Split (1)

train · 26.9k rows

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17,586	157,113	51972	Discharge summary	report	Unit No: [Numeric Identifier 107586] Admission Date: [2177-6-24] Discharge Date: [2177-8-4] Sex: M Service: CSU CHIEF COMPLAINT: Vocal hoarseness and dysphagia. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 107587] is an 84-year-old man with hoarseness and left vocal cord paralysis. Chest x- ray revealed a mediastinal mass. A CT showed density at the aortic arch just distal to the left subclavian consistent with a thoracic aneurysm. He had a catheterization done in [2177-5-10] that showed an EF of 60%, a 40% LAD, 95% RCA ostial and 60% distal. Aortogram showed an irregular arch with an aneurysm which was not well seen. PAST MEDICAL HISTORY: Significant for hypertension, depression, syncope, vocal hoarseness with left cord paralysis, and sinus surgery. MEDICATIONS AT HOME: Hydrochlorothiazide 25 daily, enalapril 20 daily. ALLERGIES: He is intolerant to indapamide and atenolol. FAMILY HISTORY: Noncontributory. OCCUPATION: Retired small engine mechanic. SOCIAL HISTORY: Tobacco: Quit at age 50. Smoked for 20 years prior to that. Lives alone. No heavy alcohol use. PHYSICAL EXAM: Pulse is 54, blood pressure is 165/79, respiratory rate 20. Height is 5 feet, 8 inches, weight is 122 pounds. General: Is in no acute distress. Skin is scattered excoriated areas in the right leg and foot. HEENT is unremarkable. Neck is supple. Chest is clear to auscultation bilaterally. Heart is regular rate and rhythm without murmur. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema, no varicosities. Neuro is grossly intact on focal exam. Pulses: Femoral 2+ bilaterally, dorsalis pedis and posterior tibial 1+ bilaterally, and radial is 2+ bilaterally. No carotid bruits. LABS: White count 8.8, hematocrit 41.9, platelets 339. INR is 1.0. Sodium 135, potassium 4.8, chloride 97, CO2 25, BUN 20, creatinine 1.1. AST 22, alkaline phosphatase 68, total bilirubin 1, albumin 3.8. EKG is sinus rhythm at a rate of 61 with LVH. Chest x-ray: With a known thoracic aneurysm, no CHF. UA is negative. Echocardiogram showed a normal EF with 1+ AR, no MR, 1+ TR, aortic root that was mildly dilated, ascending aorta that is also mildly dilated with [Doctor First Name ] PA pressures, no pericardial effusion. Carotid studies showed less than 40% stenosis on the right and less than 40% stenosis on the left with antegrade flow in both vertebrals. HOSPITAL COURSE: Patient was a direct admission to the operating room on [6-24] where he underwent an aortic-to- innominate bypass with a 12 mm Dacron graft, a TAG stent placed across the aortic arch, and a coronary artery bypass with saphenous vein graft to the LAD. The bypass time was 99 minutes with a crossclamp time of 66 minutes. Patient tolerated the procedure and was transferred from the operating room to the cardiothoracic intensive care unit with a mean arterial pressure of 82 in a sinus rhythm at 88 beats per minute. At that time, he was on Neo-Synephrine and propofol infusion. He also had a lumbar drain placed that was kept at the time of transfer. Patient did well in the immediate postoperative period. He remained hemodynamically stable throughout the day of surgery, but did remain sedated throughout that 1st operative day. On the morning of postoperative day 1, the patient continued to be hemodynamically stable. His sedation was discontinued, and he was weaned from the ventilator, unsuccessfully extubated. Additionally, the patient's lumbar drain was also removed. Throughout the day the patient was noted to have frequent periods of atrial fibrillation which required continued Neo- Synephrine drip to maintain adequate blood pressure. Patient remained hemodynamically stable on postoperative day 2; although, did continue to require Neo-Synephrine for his blood pressure. He had a bedside swallow evaluation on bed 2 and failed; and therefore, was kept NPO at that time. Additionally, the patient's chest tubes were removed on postoperative day 2. On day 3, the patient was hemodynamically stable. By then, he had weaned off his Neo-Synephrine drip. He remained in sinus rhythm, and he was transferred from the ICU to the cardiac stepdown floor for continuing postoperative care and cardiac rehabilitation. It should be noted that the patient was placed on amiodarone for his intermittent episodes of atrial fibrillation. Over the next several days, the patient did well. His activity level was increased with the assistance of the nursing staff. Patient did well once on the floor. It was noted on postoperative day 5 that the patient had an edematous left upper arm. He had a duplex scan that showed a DVT and therefore, he was begun on heparin as well as Coumadin at that time. On postoperative day 7, the patient complained of acute onset chest pain as well as tachypnea and diaphoresis with associated hypotension. His physical exam at the time was unremarkable. He was given a liter of saline which helped to improve his blood pressure. Cardiology consult was obtained at that time. An echocardiogram done showed a lateral hypokinesis with a pericardial effusion. He, additionally, had some lateral EKG changes. He was brought to the catheterization lab, where a cardiac catheterization showed that his coronaries were all patent and his pericardial effusion was drained following which he was transferred to the cardiothoracic ICU for continued monitoring. During the night of postoperative day 7, the patient went into a cardiac arrest with a rhythm that was PEA. He was intubated and resuscitated with multiple shocks ultimately ending up on dobutamine, epinephrine, and Neo-Synephrine. The following morning the patient was brought to CAT scan, where it was discovered that the patient had a leak at the anastomosis of his aortic-to-innominate bypass graft, and he was brought emergently to the operating room where he underwent a mediastinal exploration and repair of the proximal aortic-to-innominate anastomosis as well as evacuation of right and left pleural hematomas. He tolerated this well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, he was on Neo-Synephrine at 0.3, dobutamine at 5 mcg per kilogram per minute, and propofol at 30 mcg per kilogram per minute with a heart rate of 62, sinus rhythm and a mean arterial pressure of 54. Patient remained hemodynamically stable throughout that surgical day. On postoperative day 1, he continued to be hemodynamically stable. His dobutamine wean was begun. His propofol was weaned to off. The ventilator was weaned, and the patient was successfully extubated. Patient did go back into atrial fibrillation during the course of postoperative day 1 from his 2nd surgery. On day 2, he was begun to be diuresed. Over the next several days, the patient struggled from a pulmonary standpoint working to bring up thick secretions and ultimately on postoperative days 13 and 5, he was reintubated for respiratory distress. It should be noted that following the patient's 2nd surgery, he also had worsening renal function with a creatinine that got as high as 2.7 and a BUN in the 70s. The renal service was consulted. Patient was gently hydrated and ultimately diuresed. Additionally, he was treated for a Pseudomonas pneumonia at that time. By postoperative days 17 and 9, it was felt that the patient may be able to be weaned again from the ventilator which was therefore weaned, and patient was again extubated on postoperative days 20 and 12. He, again, struggled from a pulmonary standpoint for several days. On postoperative days 22 and 14, the patient had a PEG placed. Again, for several days, the patient struggled from a pulmonary standpoint, but remained extubated. He did not tolerate his tube feeds during this period of time. On postoperative day 27, he was brought to the interventional radiology suite to have a Dobbhoff placed through his existing PEG to try to advance to a postpyloric tube. This maneuver failed and ultimately, his PEG was lost during the procedure following which he was brought emergently to the operating room where he underwent an exploratory laparotomy as well as an open G-J tube placement and an open tracheostomy. Patient tolerated the surgery well and was transferred from the operating room back to the cardiothoracic intensive care unit. The patient recovered from his open laparotomy and the G-J tube was attempted to be used. However, the patient, again, did not tolerate his tube feeds. Several days was spent waiting for the patient's bowel function to return. Was able to wean to tracheostomy collar during this period. After several days, nursing staff was noting that they were getting tube feeds back in the gastric residual. A KUB showed that the jejunostomy tube had recoiled and this was sitting in the stomach. Patient was, again, brought to interventional radiology where he had advancement of the jejunostomy tube back to a postpyloric position. Additionally on the [6-28], the patient underwent a thoracentesis for 1.2 liters of serosanguineous fluid. At this time, the patient is tolerating tube feeds at full strength, and he has weaned from the ventilator having gone on tracheostomy collar for greater than 24 hours; however, he continues to have ventilator backup in his room incase there is any need for pressure-support ventilation at night or during periods of respiratory distress. It is felt that the patient is ready and stable for transfer to a rehabilitation facility for continuing respiratory care as well as nutrition management. At the time of this dictation, the patient's physical exam is as follows: Temperature 98.7, heart rate 88 sinus rhythm, blood pressure 106/52, respiratory rate 22, O2 saturation 99% on 40% tracheostomy mask. Lab data: White count 16, hematocrit 32, platelets 99. Sodium 136, potassium 4.1, chloride 104, CO2 26, BUN 32, creatinine 1.2, glucose 147. ABG: pH 7.44, CO2 40, PO2 90. General: In no acute distress. Alert and responsive to voice. Chest is regular rate and rhythm. Lungs are coarse with bilateral rhonchi. Abdomen is soft, nontender with active bowel sounds and a G-J tube in place that is clean and dry. Extremities are warm. They are well perfused with 1+ lower extremity edema. Patient is to be discharged to rehabilitation. DISCHARGE DIAGNOSES: Aortic aneurysm status post endovascular stent with aortic-to-innominate bypass status post coronary artery bypass grafting x1 with a saphenous vein graft to the posterior descending artery, pericardial tamponade status post pericardial drain, status post re- exploration with repair of aortic-to-innominate anastomosis leak, respiratory failure status post tracheostomy, exploratory laparoscopy with an open gastrostomy-jejunostomy tube placement, hypertension, depression, and vocal cord paralysis. FO[Last Name (STitle) 996]P: Patient is to have followup with Dr. [Last Name (Prefixes) ] 2 weeks after his discharge from rehabilitation. Follow up with Dr. [Last Name (STitle) 1391] in [3-14] weeks and follow up with Dr. [Last Name (STitle) 35888] 1 month following his discharge from rehabilitation. DISCHARGE MEDICATIONS: Heparin 5000 units subcutaneously t.i.d., Atrovent nebulizer q.4h. as needed, albuterol nebulizers q.4h. as needed, lansoprazole suspension 30 mg daily, ferrous gluconate 300 mg daily, ascorbic acid 500 mg b.i.d., cefepime 2 grams every 24 hours x3 weeks with the last dose being on [8-21], and Roxicet elixir 5 mL every 4-6 hours as needed for pain 1 b.i.d. Patient is currently tolerating tube feeds with ProBalance at 55 cc per hour. ACTIVITY: Restrictions for the next 6 weeks include 10 pound lifting limit. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2177-8-4] 12:48:57 T: [2177-8-4] 13:30:58 Job#: [Job Number 107588]	[ "414.01", "427.5", "V09.0", "427.31", "998.11", "420.90", "746.89", "482.41", "518.5", "482.1", "453.8", "285.1", "478.31", "441.2", "996.1", "584.5", "511.8" ]	icd9cm	[ [ [] ] ]	[ "88.42", "36.11", "37.23", "88.72", "00.40", "39.61", "38.93", "34.91", "00.14", "31.1", "96.6", "96.72", "43.11", "39.41", "34.51", "88.57", "99.60", "37.0", "96.04", "97.51", "46.39", "39.73", "88.56", "00.17", "39.23", "38.18", "99.00" ]	icd9pcs	[ [ [] ] ]							943, 1006	10407, 11234	11258, 12033					2481, 10385							817, 926					1135, 2463																								147, 180											209, 658																681, 795	1023, 1119
41,403	158,816	7827	Discharge summary	report	Admission Date: [2105-9-17] Discharge Date: [2105-10-13] Date of Birth: [2031-3-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: intubation, tracheostomy, peg tube placement History of Present Illness: Patient is a 74 yo F with ? history of seizure who was sleeping the night of admission when her husband awoke and found her to be son[Name (NI) 7884] and AMS. He was reportedly concerned about seizure and called EMS. EMS found her to be in respiratory failure, attempted intubation in field but failed. Went to [Location (un) ] ED. At [Location (un) ] ED, she was intubated and a CT head negative and found to have a UTI. Recieved 1g Ceftriaxone. Transferred to [Hospital1 18] with continued AMS and concern of CT negative stroke vs post-ictal state. Intially started on Esmolol gtt for hypertension to 180s. CXR obtained with wide medistinum. Given failed intubation in field, obtained CTA that revealed a Type A dissection, goes to descending aorta, does not extend into coranaries. Stops at R innominate arterty. With Esmolol gtt, SBP decreased from 180 to 140. Thoracic surgery wanted MR head to assess for further etiology of neurological changes. MRI revealed two small strokes. Given versed and then propofol throughout the day, so medication effect suspected as playing a role in continued AMS. Neurology was consulted and recommended further evaluatoin with an EED. Her exam was non-focal. Her labs are remarkable for a leukocytosis and left shift with a lactate of 3.0 now. Her labs are remarkable for a leukocytosis and left shift with a lactate of 3.0. Given question of underlying neurological status, CT surgery was hesistant to pursue emergent repair. Thus, she was admitted to the MICU for further monitoring and care. Upon arrival, patient is minimally responsive to sternal rub and cannot answer questions further. Husband confirms story as above and states understanding about both her strokes and aortic dissection. Past Medical History: HTN L5 fusion - several years ago L1-4 b/l laminotomies - one month prior to admission neurosurgery with ? cauterizing CN IX vs X for 'throat seizures' thoracic aortic aneursym coronary disease abnormal nuclear stress test with an anterior apical defect bilateral hip replacements knee replacement hypothyroidism Social History: No tobacco or EtOH use Family History: Noncontributory Physical Exam: Vitals: T: 100.1 P: 101 R: 16 BP: 190/130 SaO2: 100% on AC General: intubated, off sedation HEENT: NC/AT, no scleral icterus noted, ET in place Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally anteriorly Cardiac: nl S1 S2, no murmur Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+ pedal edema bilaterally Skin: no rashes or lesions noted. Neurologic: Minimal withdrawing to pain, mild grimace to sternal rub but no purposeful movements Pertinent Results: [2105-9-17] 06:10AM BLOOD WBC-15.9* RBC-4.66 Hgb-13.9 Hct-40.2 MCV-86 MCH-29.9 MCHC-34.7 RDW-13.8 Plt Ct-238 [2105-9-17] 06:10AM BLOOD Neuts-85.0* Lymphs-11.0* Monos-3.6 Eos-0.2 Baso-0.2 [2105-9-17] 06:10AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.1 [2105-9-17] 06:10AM BLOOD Glucose-136* UreaN-19 Creat-0.7 Na-141 K-3.2* Cl-102 HCO3-27 AnGap-15 [2105-9-17] 06:10AM BLOOD ALT-14 AST-19 CK(CPK)-67 AlkPhos-75 Amylase-25 TotBili-0.3 [2105-9-17] 06:10AM BLOOD Lipase-14 [2105-9-17] 06:10AM BLOOD cTropnT-<0.01 . CT Chest [2105-9-17]: Type-A aortic dissection with extensive intramural hematoma involving the proximal aspects of all the great vessels and the aortic arch. Dissection does not involve the origins of the coronary arteries. Focal stenosis of the left subclavian vein at the level of the first rib with multiple chest wall venous collaterals. Endotracheal tube in appropriate position. Stable appearance of L4-L5 vertebral fusion hardware and bilateral femoral hip arthroplasty. . MRI Brain [2105-9-17]: Multifocal acute infarcts, the largest located within the right caudate head with partial involvement of the right basal ganglia. The multifocality suggests the central embolic source. Only the distal left vertebral artery is visualized, which may fill by retrograde flow. The proximal left vertebral artery may be hypoplastic or occluded. . EEG [2105-9-18]: Abnormal EEG due to the slow background. These findings suggest a mild encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no clearly epileptiform features. . Echo [2105-9-18]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. There is a 2 cm intramural hematoma in the posterior aortic root at the level of left and noncoronary sinuses of Valsalva, with a contiguous dissection flap extending into the noncoronary sinus of Valsalva all the way to the aortic valve. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is no pericardial effusion. Brief Hospital Course: Ms. [Known lastname 28263] was admitted to the MICU with a type A aortic dissection and acute CVAs. She was intubated and initially placed on an esmolol drip to control blood pressures to systolics 100-120. This was stopped and she had an episode of atrial fibrillation with RVR. She was given diltiazem to control this but became hypotensive and this was switched to metoprolol. She had no further episodes of atrial fibrillation. Cardiothoracic surgery was consulted regarding her type A aortic dissection and felt that she was not a surgical candidate due to her mental status changes. Neurology was consulted as well to manage her acute infarcts. She was started on a heparin drip for management of her embolic disease and also for a right upper extremity DVT. She was extubated briefly and then reintubated for increased oxygen requirements. She had an LP on [2105-9-22] which did not show evidence of infection. She had a thoracentesis on [2105-10-1] showing an exudative effusion. She continued to be febrile and grew MRSA in her sputum and was treated with Vancomycin X 14 days. She was unable to be weaned from the ventilator and had a tracheostomy and PEG tube placed on [2105-10-9]. She had persistently labile blood pressures with episodes of hypotension alternating with hypertension. On [2105-10-9], CT surgery stated again that she was not a surgical candidate. On [2105-10-13], she suffered a PEA arrest and was not able to be resuscitated. An echo done during the code showed cardiac tamponade and RV collapse, a known complication of aortic dissection. Medications on Admission: Levoxyl 125 mcg daily Gabapentin 300 mg b.i.d. Cartia XT 180 mg daily Aspirin 81 mg Skelexin 800mg [Hospital1 ] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired	[ "997.31", "276.8", "599.0", "511.9", "V43.65", "423.3", "441.01", "300.00", "414.01", "453.8", "428.0", "434.11", "427.31", "518.81", "276.0", "V43.64", "427.5", "V45.4", "345.90", "041.12", "244.9", "263.9" ]	icd9cm	[ [ [] ] ]	[ "03.31", "96.72", "31.1", "43.11", "38.93", "99.04", "34.91", "96.6", "93.90" ]	icd9pcs	[ [ [] ] ]	7507, 7516	5700, 7312	337, 383	7570, 7582	3146, 5677	7641, 7654	2577, 2594		7478, 7484		7537, 7549		7338, 7455			7606, 7618										2609, 3127																								276, 299											411, 2185																2207, 2521	2537, 2561
63,866	108,244	42385	Discharge summary	report	Admission Date: [2192-1-8] Discharge Date: [2192-1-13] Date of Birth: [2145-9-30] Sex: M Service: MEDICINE Allergies: aspirin Attending:[First Name3 (LF) 1899] Chief Complaint: dyspnea/ chest pain Major Surgical or Invasive Procedure: Pericardiocentesis, pericardial drain placement and removal [2192-1-8] History of Present Illness: Mr. [Known lastname 24927] is a 46 year old male transferred from OSH with pericardial effusion. Patient has experienced both dull and sharp chest pain, centered around left chest, but radiating to substernal area and left shoulder, for past 5 weeks. Pain was sometimes so severe that he had to take vicodin to relieve it. Pain is also associated with shortness of breath that comes and goes, with no specific alleviating or exacerbating factors. Patient was seen 5 weeks ago when he first experienced the pain at OSH. The pain was [Known lastname ] but did worsen at times. He had an extensive work up at OSH including a CTA which excluded aortic dissection, pericardial effusion and pulmonary embolus. He was seen in the ED by a cardiology attending who thought there was a very low probability of atherosclerotic CAD. He was ruled out by 3 cycles of cardiac enzymes, all of which were negative, and he was discharged. Since then, he has seen his primary care doctor [First Name (Titles) ] [Last Name (Titles) ] dyspnea, gotten several CXR at OSH all of which were negative for abnormality, and has been prescribed flovent and albuterol, and recently a Zpack, none of which have provided any relief. His left sided chest pain was assessed to be MSK by an orthopedist, and he has been receiving muscular massages by a massage therapist, as well as taking vicodin for his pain. He presented to OSH today with similar symptoms, was found to be febrile to 102.7F and on Echo was found to have a pericardial effusion. He was transferred to the [Hospital1 ] for further evaluation. On ROS, patient notes extreme fatigue and loss of appetite. He does not believe he's lost weight, but his wife does. [Name2 (NI) ] endorses frequently feeling fevers/chills, but until today has not taken his temperature. He has drenching night sweats at times. He has also had some upper respiratory symptoms including cough, white phlegm production and sore throat. He denies lightheadedness, dizziness, confusion, abdominal pain or distension, changes to his bowel habits, dysuria or frequency, muscular weakness or sensory changes besides pain in left shoulder and extreme fatigue. He denies easy bruising, bleeding while brushing his teeth or overt bleeding from elsewhere in his body. He denies rashes, joint swelling, or joint pain. He denies cold intolerance, proximal muscle weakness, or weight gain. . Cardiac review of systems is notable for absence of chest paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, patient was found to have pulsus 10. Cardiology fellow bedside echo confirmed pericardial effusion and early tamponade physiology. He received 1L NS and levaquin for fever and pleural effusion. He received tylenol for his fever.170cc fluid taken out during pericardiocentesis and drain left in place. Most Recent Vitals prior to transfer: 99.1 101 121/71 18 98%2L Past Medical History: hand surgery for tendon release sebaceous cysts on his head borderline hypertension, hyperlipidemia Social History: He works as a contractor and has had asbestos exposure in the past, but always with a mask. He has also worked with various plumbing solvents and has had exposure to dust in atticks. - Tobacco history: 15 pack-year smoking hx - ETOH: rare - Illicit drugs: none Family History: Father had an MI at age 56 and died during CABG at age 72. Uncle had MI in late 50s. Grandmother had GI cancer. Daughter has mild ebstein's anomaly and accessory pathways - treated with ablation. History of DM. No hx of autoimmune or rheumatologic conditions. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: T=98.9 BP=137/75 HR=109 RR=27 O2 sat=100(RA) GENERAL: NAD. Orientedx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis or petechia of the oral mucosa. oropharynx without erythema or exudate. No cervical or axillary lymphadenopathy. No thyroid enlargement or goiters. NECK: Supple with JVP of 13 cm, no Kussmaul's sign. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. +friction rub. no murmurs. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: normoactive bowel sounds, soft, nondistended. pain in epigastrum with abdominal pressure. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or rashes. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ PHYSICAL EXAM ON DISCHARGE: Vitals - Tm/Tc: 97.2/97.5 HR:59-85 BP:99-123/57-84 RR:18 02 sat:100% RA GENERAL: 46 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 rubs. ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding. EXT: wwp, no edema. NEURO:5/5 strength in U/L extremities. PSYCH: A/O Pulsus [7-13] Pertinent Results: Labs on Admission: [2192-1-8] 04:45PM BLOOD WBC-12.1* RBC-3.94* Hgb-11.5# Hct-34.1# MCV-87 MCH-29.2 MCHC-33.7 RDW-12.7 Plt Ct-320 [2192-1-8] 04:45PM BLOOD Neuts-74.1* Lymphs-19.5 Monos-6.2 Eos-0.1 Baso-0.2 [2192-1-8] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Burr-1+ [2192-1-8] 04:45PM BLOOD PT-19.8* PTT-29.2 INR(PT)-1.9* [2192-1-8] 04:45PM BLOOD Fibrino-904* [2192-1-8] 10:15PM BLOOD FDP-40-80* [2192-1-9] 05:02AM BLOOD ESR-83* [2192-1-8] 04:45PM BLOOD Ret Aut-1.6 [2192-1-8] 04:45PM BLOOD Glucose-117* UreaN-17 Creat-1.3* Na-135 K-3.8 Cl-99 HCO3-24 AnGap-16 [2192-1-8] 04:45PM BLOOD ALT-21 AST-14 LD(LDH)-208 AlkPhos-74 TotBili-0.6 [2192-1-8] 04:45PM BLOOD Lipase-71* [2192-1-8] 04:45PM BLOOD cTropnT-<0.01 [2192-1-9] 05:02AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [2192-1-8] 04:45PM BLOOD Albumin-3.6 UricAcd-4.6 [2192-1-8] 10:15PM BLOOD Iron-14* [2192-1-8] 04:45PM BLOOD Hapto-445* [2192-1-8] 10:15PM BLOOD calTIBC-196* Ferritn-934* TRF-151* [2192-1-8] 04:45PM BLOOD TSH-1.6 [2192-1-8] 04:48PM BLOOD Lactate-1.1 Cardiac Cath [1-8]: FINAL DIAGNOSIS: 1. Pericardial Tamponade with sucessful removal of 160 cc of bloody pericardial fluid via a sub-xiphoid approach. 2. Reduction in pericardial pressure from 25 mmHg to 13 mmHg after pericardiocentesis. TTE [1-8]: The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%), although there is beat to beat variation in the ejection fraction due to abnormal septal motion. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is a moderate sized pericardial effusion. There is brief right ventricular diastolic collapse and significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling and early tamponade physiology. IMPRESSION: Moderate circumferential pericardial effusion with early tamponade physiology. Normal biventricular function with abnormal septal motion. TTE [1-8]: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. IMPRESSION: Small residual pericardial effusion without echocardiographic signs of tamponade. Labs on Discharge: [2192-1-13] 06:55AM BLOOD WBC-6.3 RBC-4.41* Hgb-12.5* Hct-37.7* MCV-86 MCH-28.3 MCHC-33.1 RDW-12.7 Plt Ct-466* [2192-1-13] 06:55AM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-141 K-5.1 Cl-105 HCO3-29 AnGap-12 [2192-1-13] 06:55AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.3 Brief Hospital Course: Primary Reason for Hospitalization: Mr. [Known lastname 24927] is a 46M with no signficant PMH who is transfered from an OSH for evaluation of a pericardial effusion and found to have tamponade physiology. . # PERICARDIAL EFFUSION: Patient has had intermittent chest pain since [Month (only) 404]. At that time, there was no EKG evidence of pericarditis or low voltage suggestive of effusion. He was observed and sent home after three set of negative cardiac enzymes. He now represents with dyspnea and chest pain, this time found to have effusion with early tamponade physiology. Pulsus was 10 in ED. Patient was sent directly to cath lab for fluoro-guided pericardiocentesis. He drained 160 ccs of pericardial fluid, after which his drain was pulled. Repeat echo on HD#2 showed increase in pericardial effusion, pulsus 12. His chest pain was initially managed with IV dilaudid and tylenol. He then underwent ASA desensitization (given h/o eye swelling with ASA), after which he was started on indomethacin and colchicine for pericarditis. His symptoms improved significantly with these treatments. DDx for pericardial effusion included viral, TB, post-MI, uremia, hypothyroidism, malignancy or collagen vascular disease. Initially most concerned for either malignancy (given recent weight loss, fatigue, night sweats, new anemia) or viral (given recent URI, fever, leukocytosis with left shift). Pt ruled out for MI. Pericardial fluid cell count had 12:1 ratio of RBC:WBC, with left shift. Pericardial fluid cytology negative for malignant cells. Pericardial fluid culture (including acid fast) and gram stain were negative. [Doctor First Name ], anti-DS DNA and complement panel were checked to screen for lupus and other collagen vascular diseases. [Doctor First Name ] and anti-DS DNA were negative. C3 and C4 were mildly elevated at 191 and 59. ESR was markedly elevated at 83 (ref range 0-15). CT chest/[Last Name (un) 103]/pelvis with contrast was performed to work up for occult malignancy, and showed mild non-pathologic mediastinal lymph node enlargement more concerning for infection. HIV test was negative. TSH WNL. Other viral cultures checked were negative. Based on these studies and clinical picture, it was found that pericardial effusion was most likely due to a viral etiology. Patient received a cardiac MRI that showed some restrictive physiology. . # Elevated INR: Patient's INR was 1.1 in [Month (only) 404], now 1.9. Patient does not take coumadin. PTT is not prolonged. Differential includes nutritional deficiencies, liver synthetic dysfunction, DIC. After receiving vitamin K 5mg on HD#2, INR remained elevated at 2. LFTs are not significantly elevated, nor is albumin low, to suggest liver synthetic dysfunction. DIC labs negative. Blood smear showed no schistocytes. INR came down by itself to 1.3 by discharge. . # Anemia: Patient's Hct was 44 in [Month (only) 404], but now is 34, signifying a 10 pt drop within the last month. Patient has pericardial effusion, but otherwise has no overt evidence of bleeding. Hemodynamically stable. His iron studies shows possible anemia of chronic disease, but extremely elevated ferritin levels are difficult to interpret in the setting of high inflammation (acute phase reactant). Hemolysis labs signify no hemolysis. . # [Last Name (un) ]: Cr 1.3, up from baseline 1.0. Differential includes pre-renal vs. intrinsic renal failure from systemic disease. After IV fluids, creatinine improved to 0.9, indicating pre-renal etiology. . # Fevers: Differential includes infectious, malignant, vs. auto-immune. Patient's history and CXR with effusions does not make it seem infectious; therefore azithromycin was discontinued. Bloody pericardial effusion, night sweats, and fatigue were concerning for malignancy, although CT chest/abdomen/pelvis did not show any gross evidence of malignancy. Auto-immune disease also a possibility, but not consistent with patient's clinical picture; also ESR elevated but [Doctor First Name ], anti-DS DNA and C3/C4 were normal. Patient remained afebrile starting HD#3. Transitional Issues: Patient was discharged to rehab. He will continue indomethicin for 2 weeks and colchicine for 2 years. His oxygen levels were noted to be low overnight, so he was recommend to obtain an outpatient sleep study to evaluate for sleep apnea. Medications on Admission: tylenol prn pain flovent prn dyspnea (stopped bc not helping) albuterol inhaler prn dyspnea (stopped bc not helping) azithromycin 250 daily (today is day [1-6]) vicodin prn pain Discharge Medications: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 1 weeks. Disp:42 Capsule(s) Refills:0 3. indomethacin 25 mg Capsule Sig: One (1) Capsule PO three times a day for 1 weeks. Disp:21 Capsule(s) Refills:2 4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Anemia Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a pericardial effusion or a collection of fluid in the sac around your heart. We think this is because of a virus and we have sent many tests to make sure it is not for another reason. All of these tests are negative and a few cultures are still not finalized. You had a cardiac MRI top further assess your heart and the fluid. There is still some fluid that we hope will be absorbed over time. You have been started on some medicines, indomethicin and colchicine to help decrease the inflammation of the lining around your heart and help to prevent the fluid from reaccumulating. You should take the indomethicin, 50 mg (2 25 mg tablets) three times a day for one week and then decrease to 25 mg (1 pill) three times a day for one week. At that time, you will see Dr. [First Name (STitle) ] again and can discuss your medicines. Colchicine will be taken twice daily for at least one year. You will also take prilosec (omeprazole) twice daily as these medicines can irritate your stomach. Please call Dr. [First Name (STitle) ] if your chest pain worsens and call the Heartline for any urgent symptoms you may have at home. You will get an echocardiogram during the appt with Dr. [First Name (STitle) ] on [1-26]. You had a low blood count or anemia during your hospital stay. You should have your blood studies rechecked in a few weeks to see if there is any need to treat or do further testing. Your kidneys function declined but have now normalized. Followup Instructions: PCP [Name Initial (PRE) ]:Wednesday, [Month (only) 956] the 15th at 11am With:[First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ],MD Location: [Hospital ] MEDICAL ASSOCIATES, P.C. Address: [Location (un) 21638], [Location (un) ],[Numeric Identifier 21639] Phone: [Telephone/Fax (1) 21640] Department: CARDIAC SERVICES When: THURSDAY [2192-1-26] at 11:40 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1905] Completed by:[2192-1-14]	[ "272.4", "285.29", "420.91", "584.9", "V74.1", "V07.1", "423.3", "780.60", "V15.84", "790.92" ]	icd9cm	[ [ [] ] ]	[ "37.0", "99.12" ]	icd9pcs	[ [ [] ] ]	13645, 13651	8554, 12675	288, 365	13743, 13743	5436, 5441	15395, 16170	3772, 4036		13167, 13622		13672, 13722		12961, 13144		6652, 8239	13894, 15372										4051, 4072															4975, 5417			12696, 12935						228, 250						8258, 8531					393, 3351								5455, 6635	13758, 13870							3373, 3474	3490, 3756
32,766	152,525	2333	Discharge summary	report	Admission Date: [2189-2-21] Discharge Date: [2189-2-25] Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 603] Chief Complaint: abdominal pain mental status change Major Surgical or Invasive Procedure: none History of Present Illness: 89 F with pmhx afib, CVA x 2, dementia, hypothyroidism who was originally admitted [2-21] to the SICU after noting abdominal pain x 4d and decreased responsiveness. In the SICU she was found to have have thrombus in L atrium, left renal artery, and SMA. Radiographic L renal infarction, but bowel "looked good, no sign peritonitis." . She was managed conservatively given lactate was relatively low and interpreted as no evidence of mesenteric ischemia, with NGT, heparin gtt, and pain control. Decision was made by family and pt not to pursue aggressive intervention. . Pt was started on anticoagulation and empiric antibiotics and was going to be transferred to the medicine floor when she was noted to be anuric and unresponsive to verbal stimuli. [2-21] ABG=7.5/28/100. Per report, this family was called to discuss goals of care. They essentially do not want anything aggressive done including further scans and want her to be comfortable but did not want to completely withdraw care at this time. . Pt transferred from MICU service to medical service for ongoing management of SMA infarction, [Name Prefix (Prefixes) ] [Last Name (Prefixes) 2966], mental status changes felt likely [3-7] repeat CVA, and ?PNA (on levaquin/flagyl for PNA, not for abdominal process per MICU team) Past Medical History: 1. CVA - x 2, most recently [4-10]. 2. Atrial fibrillation, on coumadin. 3. Hyperlipidemia 4. Hypothyroidism 5. Dementia - per daughter at baseline pt is able to converse. Social History: Emigrated from [Country 3587]. Lives with her daughter. Smokes a pipe every month. No etoh/drugs. Occasionally attends an elder day care program. Daughter works during the day so patient is occasionally unsupervised. Family History: No history of stroke, diabetes, coronary artery disease. Physical Exam: PE: General: unresponsive to sternal rub VS: 99.3 HR 97(97-146) 132/91(108-181/70-106) HEENT: NCAT, anicteric, no injections, MMM Neck: no LAD or thyromegaly Chest: tacchy, nl s1s2 no mgr lungs: clear anteriorly ABD: +bs, softly distended, no masses, nontender Ext: no cce Neuro: responsive to pain with withdrawl, cold Pertinent Results: [2189-2-21] 08:16PM TYPE-ART PO2-100 PCO2-28* PH-7.50* TOTAL CO2-23 BASE XS-0 [2189-2-21] 08:16PM LACTATE-1.0 [2189-2-21] 06:01PM PTT-133.3* [2189-2-21] 09:03AM TYPE-[Last Name (un) ] PO2-129* PCO2-34* PH-7.46* TOTAL CO2-25 BASE XS-1 COMMENTS-GREEN TOP [2189-2-21] 09:03AM LACTATE-1.4 [2189-2-21] 09:03AM freeCa-1.07* [2189-2-21] 08:52AM PT-21.6* PTT-150* INR(PT)-2.1* [2189-2-21] 07:00AM GLUCOSE-132* UREA N-17 CREAT-1.2* SODIUM-135 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 [2189-2-21] 07:00AM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-2.1 [2189-2-21] 07:00AM WBC-22.6* RBC-4.31 HGB-11.0* HCT-34.1* MCV-79* MCH-25.7* MCHC-32.4 RDW-14.6 [2189-2-21] 07:00AM NEUTS-84* BANDS-3 LYMPHS-10* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2189-2-21] 07:00AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ TARGET-1+ BURR-OCCASIONAL ACANTHOCY-OCCASIONAL [2189-2-21] 07:00AM PLT COUNT-345 [2189-2-20] 10:19PM PT-16.1* PTT-26.3 INR(PT)-1.4* [2189-2-20] 08:14PM LACTATE-3.8* [2189-2-20] 08:00PM GLUCOSE-167* UREA N-22* CREAT-1.5* SODIUM-134 POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-24 ANION GAP-20 [2189-2-20] 08:00PM estGFR-Using this [2189-2-20] 08:00PM ALT(SGPT)-46* AST(SGOT)-59* CK(CPK)-29 ALK PHOS-177* AMYLASE-55 TOT BILI-0.7 [2189-2-20] 08:00PM LIPASE-16 [2189-2-20] 08:00PM CK-MB-NotDone cTropnT-<0.01 [2189-2-20] 08:00PM ALBUMIN-3.9 CALCIUM-10.4* PHOSPHATE-2.5* MAGNESIUM-1.5* [2189-2-20] 08:00PM URINE HOURS-RANDOM [2189-2-20] 08:00PM URINE GR HOLD-HOLD [2189-2-20] 08:00PM WBC-23.4# RBC-5.15 HGB-13.4 HCT-40.7 MCV-79 MCH-25.9* MCHC-32.8 RDW-14.7 [2189-2-20] 08:00PM NEUTS-78* BANDS-4 LYMPHS-10* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2189-2-20] 08:00PM URINE GRANULAR-[4-8]* HYALINE-[4-8]* [2189-2-20] 08:00PM URINE RBC-[4-8]* WBC-[4-8] BACTERIA-FEW YEAST-NONE EPI-0-2 [2189-2-20] 08:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2189-2-20] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.027 . . . STUDIES: * [2-20] CT abd/pelvis: Thrombus in the left atrium. Thrombosis of the proximal superior mesenteric artery with distal reconstitution probably through collateral flow. No evidence of small or large bowel wall thickening or adjacent inflammatory change to suggest ischemia. Thrombosis of the left renal artery and associated infarction of the left kidney. Wedge compression deformities of L1 and L3 are probably chronic. * [2-20] CXR: NG tube in good position. Stable cardiomegaly, mild left lower lobe atelectasis. No evidence of pneumonia or CHF. * [2-20] Head CT: No acute intracranial hemorrhage or mass effect. Overall similar appearance of the brain compared to [2188-10-19] with multiple areas of old infarction demonstrated. Please note that MR [First Name (Titles) 151] [Last Name (Titles) 3631]-weighted imaging is more sensitive for evaluation of acute infarction if this is a significant clinical concern. Brief Hospital Course: a/p: 89 yo female with afib, CVA x2, dementia, now with SMA clot, [Name Prefix (Prefixes) ] [Last Name (Prefixes) 2966], non-enhancing kidney on CT and anuria with unresponsiveness. . # abdominal pain/hypotension - pt admitted to the surgical service, and found to have thrombus in left renal artery (with complete left renal infarction), and superior mesenteric artery. She had radiographic L renal infarction. serial lactates were trending down, and pt was without peritonitis. She was treated conservatively with antibiotics and NGT decompression and heparin gtt. she was not felt to require surgical intervention. her abdominal pain resolved. She was awaiting transfer to the medical service when her mental status acutely declined as below. . # Altered mental status: Per family, patient's mental status has been declining ever since her last CVA. Admission CT HEAD showed no acute bleeding, but could not exclude embolic event. She has known clot in SMA, left renal artery and LEFT atrial thrombus (seen on CT superior cuts of CT abd/pelvis) despite anticoagulation with coumadin. She was placed on heparin during this hospitalization for concern for SMA and renal artery thrombosis. However on [2-22] pt's mental status acute declined. She was no longer able to communicate reliable. Concern was for recurrent stroke given her history of atrial fibrillation and left atrial thrombus as above, in spite of heparin anticoagulation. Given her acute mental status decline, despite anticoagulation, decision was made with family to change goals of care to DNR/DNI. Pt's mental status failed to improve after transfer to the MICU, and given goals of care did not include BIPAP or invasive lines or procedures, she was [Last Name (un) 4662] to the medical floor. Her mental status remained poor. She was continued on empiric antibiotics for concern for PNA, though CXR was unremarkable. . On [2-23], mental status had failed to improve. After extensive discussion with both pt's HCP [Name (NI) ] [Name2 (NI) ] [Telephone/Fax (1) 12149] and her son [Name (NI) 12150] [Name2 (NI) ] [Telephone/Fax (1) 12151], decision was made to change goals of care to comfort measures only, as it was felt that she had likely suffered a recurrent stroke in spite of heparin anticoagulation. Family clearly did not desire PEG tube placement, and agree that further anticoagulation would not likely alter her prognosis. Her coumadin was discontinued. Her urine output declined quickly. She was evaluated by the pain and palliative care service, placed on a regimen or oral morphine elixir prn, though she did not complain of signficant pain. she was placed on scopolamine patch to manage secretions. . Arrangements were made to transfer her to an hospice facility. . # Atrial fibrillation: h/o atrial fibrillation with known left atrial thrombus despite coumadin, pt was treated with heparin gtt and rate controlled with metoprolol, these were discontinued given her goals of care as above. . # Oliguria: likely due to poor po intake, and poor prognosis as above. decision was made not to pursue PEG tube feeding or intravenous hydration as it was not felt likely to alter her prognosis. Over the course of [2104-2-25] her urine output continue to decline to neglible levels. . # Hypothyroidism: pt initialy continued on 75 mcg levothyroxine, this was d/c'd at discharge given goals of care. . # Contact: [Name (NI) ] [Name2 (NI) ] [Telephone/Fax (1) 12149] (health care proxy) and her son [Name (NI) 12150] [Name2 (NI) ] [Telephone/Fax (1) 12151] (english speaking). . # CODE STATUS: pt is DNR/DNI, she is comfort measures only. . # DISPO: pt was discharged to hospice facility [2-25] after discussion with [Month/Year (2) 12150] at [Doctor Last Name ] who confirmed discussion with his mother [Name (NI) 382] at 3PM and confirmed that she will meet pt at the hospice facility. Medications on Admission: (per most recent discharge summary) 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. [Name (NI) 10687] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Valsartan 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 650 units/hr Intravenous ASDIR (AS DIRECTED). 15. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg Discharge Medications: 1. [Name (NI) 10687] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 5. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 6. Morphine 10 mg/5 mL Solution Sig: [2-4] PO Q1HR PRN () as needed for titrate to pt comfort (air hunger). Discharge Disposition: Extended Care Facility: [Doctor Last Name 1495] Josph Rehabiliation and Nursing Care Center Discharge Diagnosis: stroke superior mesenteric artery thrombosis renal artery thrombosis Discharge Condition: poor, comfort measures only, being discharged Discharge Instructions: pt was discharged with plan for hospice care. Followup Instructions: pt being discharged with plan for hospice care.	[ "593.81", "557.0", "427.31", "584.9", "272.0", "507.0", "345.90", "434.91", "244.9", "429.89", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11706, 11804	5681, 6454	253, 259	11917, 11964	2462, 5284	12058, 12108	2048, 2106		11045, 11683		11825, 11896		9683, 11022			11988, 12035										2121, 2443																								178, 215											287, 1593				5293, 5658					6469, 9657							1615, 1793	1809, 2032
3,107	114,669	24794	Discharge summary	report	Admission Date: [2137-9-18] Discharge Date: [2137-10-21] Date of Birth: [2058-9-23] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: Biliary colic Major Surgical or Invasive Procedure: laproscopic cholecystectomy, ERCP with sphincterotomy, repair of duodenal perforation History of Present Illness: The patient is a 78-year-old female who was admitted under the care of Dr. [Last Name (STitle) 468] on [9-18] following an ERCP procedure. During a sphincterotomy and common bile duct extraction by Dr. [Last Name (STitle) ], a duodenal perforation became apparent. Past Medical History: biliary colic Social History: none Family History: none Physical Exam: General- no apparent distress Lungs: clear to ascultation bilaterally Heart: regular rate and rhythum, normal S1S2 Gastrointestinal: soft, diffusely tender, mildly distended Neurologic: alert and oriented X3 Pertinent Results: [2137-9-19] 12:32AM BLOOD WBC-19.4* RBC-5.18 Hgb-16.3* Hct-46.7 MCV-90 MCH-31.4 MCHC-34.8 RDW-13.2 Plt Ct-243 [2137-9-21] 10:30AM BLOOD WBC-14.4* RBC-4.50 Hgb-13.8 Hct-41.2 MCV-92 MCH-30.6 MCHC-33.4 RDW-13.9 Plt Ct-247 [2137-9-24] 04:44PM BLOOD WBC-12.4* RBC-4.08* Hgb-12.4 Hct-36.4 MCV-89 MCH-30.5 MCHC-34.1 RDW-13.8 Plt Ct-276 [2137-9-25] 06:35AM BLOOD WBC-14.3* RBC-3.96* Hgb-11.8* Hct-35.3* MCV-89 MCH-29.9 MCHC-33.5 RDW-14.0 Plt Ct-266 [2137-9-30] 12:30AM BLOOD WBC-11.9* RBC-3.30* Hgb-10.0* Hct-29.6* MCV-90 MCH-30.2 MCHC-33.8 RDW-14.0 Plt Ct-380 [2137-10-3] 04:53AM BLOOD WBC-9.4 RBC-3.28* Hgb-9.7* Hct-29.3* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.8 Plt Ct-438 [2137-10-8] 06:00AM BLOOD WBC-9.4 RBC-3.15* Hgb-9.3* Hct-28.3* MCV-90 MCH-29.6 MCHC-33.0 RDW-14.3 Plt Ct-400 [2137-10-14] 08:40AM BLOOD WBC-7.7 RBC-3.03* Hgb-8.9* Hct-27.1* MCV-89 MCH-29.3 MCHC-32.9 RDW-15.4 Plt Ct-411 [2137-10-21] 08:30AM BLOOD WBC-4.5 RBC-3.24* Hgb-9.6* Hct-29.6* MCV-91 MCH-29.6 MCHC-32.3 RDW-16.0* Plt Ct-215 [2137-9-29] 04:00PM BLOOD Neuts-87.8* Bands-0 Lymphs-6.8* Monos-4.4 Eos-0.9 Baso-0 [2137-10-11] 05:55AM BLOOD Neuts-78.8* Lymphs-11.7* Monos-2.7 Eos-6.6* Baso-0.3 [2137-9-24] 04:44PM BLOOD PT-13.3 PTT-28.2 INR(PT)-1.2 [2137-9-28] 04:55AM BLOOD Plt Ct-355 [2137-9-28] 02:40PM BLOOD PT-15.5* INR(PT)-1.6 [2137-9-30] 12:30AM BLOOD Plt Ct-380 [2137-9-30] 02:36PM BLOOD PT-12.8 PTT-31.0 INR(PT)-1.1 [2137-10-2] 10:20PM BLOOD Plt Ct-426 [2137-10-15] 05:35AM BLOOD Plt Ct-340 [2137-10-21] 08:30AM BLOOD Plt Ct-215 [2137-9-19] 12:32AM BLOOD Glucose-128* UreaN-9 Creat-0.5 Na-134 K-3.6 Cl-96 HCO3-24 AnGap-18 [2137-9-19] 06:05AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-132* K-3.6 Cl-95* HCO3-23 AnGap-18 [2137-9-26] 06:00AM BLOOD Glucose-88 UreaN-8 Creat-0.5 Na-137 K-4.2 Cl-101 HCO3-27 AnGap-13 [2137-10-2] 02:58AM BLOOD Glucose-138* UreaN-7 Creat-0.4 Na-131* K-3.7 Cl-100 HCO3-26 AnGap-9 [2137-10-5] 06:00AM BLOOD Glucose-164* UreaN-9 Creat-0.4 Na-133 K-4.6 Cl-98 HCO3-30 AnGap-10 [2137-10-10] 08:13AM BLOOD Glucose-122* UreaN-12 Creat-0.5 Na-133 K-3.2* Cl-100 HCO3-27 AnGap-9 [2137-10-13] 06:40AM BLOOD Glucose-683* UreaN-11 Creat-0.6 Na-112* K-3.4 Cl-87* HCO3-22 AnGap-6* [2137-10-17] 12:50AM BLOOD Na-131* K-3.6 Cl-98 [2137-10-21] 08:30AM BLOOD Glucose-105 UreaN-14 Creat-0.6 Na-134 K-3.5 Cl-97 HCO3-31 AnGap-10 [2137-9-19] 12:32AM BLOOD ALT-58* AST-32 AlkPhos-121* Amylase-66 TotBili-0.9 [2137-9-19] 06:05AM BLOOD ALT-53* AST-30 AlkPhos-116 Amylase-62 TotBili-0.9 [2137-9-29] 04:58AM BLOOD Amylase-35 [2137-10-13] 06:40AM BLOOD ALT-18 AST-22 LD(LDH)-185 AlkPhos-174* Amylase-81 TotBili-0.4 [2137-10-14] 08:40AM BLOOD ALT-20 AST-22 AlkPhos-188* Amylase-76 TotBili-0.5 [2137-10-17] 05:47AM BLOOD AST-33 [2137-10-21] 08:30AM BLOOD ALT-28 AST-35 LD(LDH)-167 AlkPhos-286* Amylase-44 TotBili-0.4 [2137-9-19] 12:32AM BLOOD Calcium-8.8 Phos-2.3* Mg-1.5* [2137-9-29] 04:58AM BLOOD Calcium-7.5* Phos-2.3* [2137-10-1] 05:14PM BLOOD Calcium-6.7* Phos-2.7 Mg-1.8 [2137-10-5] 06:00AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.9 [2137-10-11] 12:35PM BLOOD Calcium-7.5* Phos-2.2* Mg-1.8 [2137-10-21] 08:30AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7 [2137-9-23] 09:12AM BLOOD Type-ART pO2-60* pCO2-36 pH-7.49* calHCO3-28 Base XS-4 [2137-10-1] 01:33AM BLOOD Type-ART pO2-91 pCO2-35 pH-7.44 calHCO3-25 Base XS-0 [2137-10-3] 05:19AM BLOOD Type-ART Temp-38.2 pO2-66* pCO2-37 pH-7.47* calHCO3-28 Base XS-3 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] Brief Hospital Course: The patient is a 78 year old female who was admitted to the care of Dr. [Last Name (STitle) 468] after she had an ERPC with sphincterotomy that resulted in a perforated duodenum. A CT scan from the date of her admission showed bilateral pleural effusions and retroperitoneal free air. The patient was treated conservatively at first, with serial examinations, pain medications, and intravenous fliuds, as well as Levofloxacin and Flagyl intravenously and a nasogastric tube for decompression. On hospital day five, the patient was doing well clinically and her NG tube was discontinued and her diet was advanced slowly. A repeat CT scan from [9-23] demonstrated new large bilateral pleural effusions, small non-specific pulmonary nodules in the right middle lobe, and persistent retroperitoneal free air, consistent with known duodenal perforation, as well as interval development of large amount of retroperitoneal fluid, as well as fluid in the root of the mesentery. A repeat CT scan on [9-26] demonstrated a large, mainly fluid-attenuating collection in the right retroperitoneum extending from the lateral paraduodenal and hepatorenal fossa to the anterior right pelvis. In addition, there were multiple air locules in the paraduodenal component in keeping with recent local perforation. These collections have not shown interval size change. Also, there were moderate right basal pleural effusion that had shown some interval reduction in size. Also, there was a possible 3 mm nonobstructing gallstone in the distal end of the CBD with no intrahepatic biliary dilatation. On [9-30], the patient underwent an exploratory laparotomy with retroperitoneal exploration and debridement, exploration of lesser sac, drainage of lesser sac and retroperitoneum, gastrostomy tube placement, jejunostomy tube placement, and colotomy with primary repair for aspiration of colon. This was done for retroperiotnela sepsis. The patient then spent four days in the surgical intensive care unit. She was started on tube feeds and total perenteral nutrition during that time period. Cultures from her abscess grew out enterococcus, coagulase negative Staphylococcus, and [Female First Name (un) 564] Albicans. She was started Vancomycin and Fluconazole in addition to her previous antibiotic regime. The patient continued to spike fevers however. A CT scan from [10-7] deonstrated marked interval reduction in the size of the right posterior abdominal/right retroperitoneal collections, small residual collections along the right posterior abdomen/retroperitoneum and in the small bowel mesentry to the left of midline, moderate right basilar smaller left basilar pleural effusion with posterior bibasilar atelectasis, more marked on the right side,unchanged in the interval. A CT from [10-14] demonstrated interval regression in the size of the right pararenal and retroperitoneal fluid-attenuating collections. In addition, there was moderate right basal pleural effusion has shown some interval reduction in size. Posterior bibasilar atelectasis and a small effusion at the left base were unchanged. The remainder of her hospital course was uneventful except for continuous spiking of fevers of unknown origin. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 6. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for Hyponatremia. 7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 8. Loperamide 1 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 12. Prochlorperazine 10 mg IV Q6H:PRN nausea 13. Fluconazole 200 mg IV Q24H 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 15. Morphine Sulfate 2 mg IV Q2H:PRN 16. 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. 17. Vancomycin HCl 1000 mg IV Q 12H Start: [2137-10-2] 18. Pantoprazole 40 mg IV Q24H 19. Piperacillin-Tazobactam Na 4.5 gm IV Q8H Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Hospital Discharge Diagnosis: duodenal perforation, biliary colic, choledocholithiasis Discharge Condition: good, but spiking fevers of unclear origin despite thouough work-up Discharge Instructions: -Please follow up with Dr [Last Name (STitle) ] in two weeks -Swallow evaluation before seeing Dr [Last Name (STitle) ] Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4340], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2137-11-19] 10:30 Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks Completed by:[2137-10-21]	[ "511.9", "568.0", "530.81", "574.51", "998.2", "564.7", "733.00", "780.6", "518.0", "567.2", "787.91" ]	icd9cm	[ [ [] ] ]	[ "54.91", "51.85", "54.59", "54.4", "96.08", "43.19", "96.6", "45.03", "99.15", "46.39", "51.88" ]	icd9pcs	[ [ [] ] ]	9446, 9507	4664, 7909	329, 417	9608, 9678	1047, 4641	9854, 10151	798, 804		7932, 9423		9528, 9587					9702, 9831										819, 1028																								275, 291											445, 723																745, 760	776, 782
5,865	186,505	45270	Discharge summary	report	Admission Date: [2192-8-25] Discharge Date: [2192-8-30] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 678] Chief Complaint: bleeding Major Surgical or Invasive Procedure: Right internal jugular central venous catheter placed and removed Blood transfusions Red Blood cell scan History of Present Illness: 88 y.o. male with history of AVMs and diverticulosis who noted frank blood with a bowel movement yesterday. Patient denies chest pain, shortness of breath, palpitations, lightheadedness or syncope, F/C, N/V with this bleeding. He does however note diarrhea the week prior to presentation, but says that this diarrhea was short-lived (relieved with Immodium) and non-bloody. He also reports an approximate 20 lb. weight loss over the past 3 years. As mentioned, patient has a history of GIB with multiple hospitalizations and is s/p a remote right hemicolectomy in [2176] for colon cancer. . Patient presented to the [Hospital1 18] ED where he was noted to have a Hct drop from 39 to 32 with a SBP drop from 167 to 100. A CTA abdomen showed extravasation of constrast from the sigmoid colon and patient was admitted to the MICU for further management. Upon arrival, he was rapidly given 3 units of PRBCs and taken to IR where an angiogram showed no bleeding. He was then brought back to the MICU for further observation, with the plan to involve GI and surgery and proceed to a tagged RBC scan if bleeding recurred. Past Medical History: 1)Colon cancer ([Location (un) ] A) s/p R hemicolectomy in [2176] 2)Multiple AVMs with 15 year history of recurrent GIB 3)CAD s/p stent to LAD in [10-8] 4)Hypertrophic cardiomyopathy 5)HOCM 6)GERD 7)h/o jejunal lipoma in [2176] 8)Hypertension 9)Hyperlipidemia . Past Surgical History: 1)s/p cholecystectomy in [2178] 2)s/p prostatectomy 3)L inguinal hernia repair [2179] Social History: Married 61 years, lives in [Location ] with his wife. They have three sons, two grandchildren, and three greatgrandsons. He and his wife were [Name2 (NI) ] in [Country 3399], and moved to the US in the 60's. He previously worked as an accountant, and his wife worked as a dressmaker. They have been retired for 20 years. He previously smoked, but quit 40 years ago. Denies any EtOH. His activity at home is limited by his spinal stenosis and resultant R leg neuropathic pain Family History: His father died elderly of lung cancer; his mother had hypertension, and died at age 67 of a CVA. Physical Exam: General: Awake, alert, NAD HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous Neck: Supple, no LAD Chest/CV: S1, S2 nl, III/VI systolic murmur heard best at apex w/ radiation into axilla Lungs: CTAB Abd: Soft, tender to palpation throughout without rebounding or guarding, + BS, no organomegaly Rectal: Frankly bloodly stool Ext: No c/c/e Pertinent Results: CBC: [2192-8-30] WBC-11.0 RBC-5.28 Hgb-16.3 Hct-45.6 Plt Ct-197 [2192-8-25] Hct-33.0* [2192-8-25] Hct-37.5* Plt Ct-149* [2192-8-25] WBC-19.5# RBC-3.55 Hgb-11.4* Hct-30.8* Plt Ct-112* [2192-8-28] Hct-44.4 [2192-8-29] WBC-11.3* RBC-5.33 Hgb-16.2 Hct-46.4 Plt Ct-193 . Chemistry: [2192-8-30] Glucose-97 UreaN-14 Creat-0.9 Na-137 K-3.3 Cl-102 HCO3-26 AnGap-12 [2192-8-30] Calcium-8.8 Phos-2.2* Mg-1.8 . CXR [8-26]: No definite pneumothorax or pneumoperitoneum, but this study is limited in semiupright position. Compared to prior study performed a day earlier, mild intersitial pulmonary edema has almost completely resolved. Mild cardiomegaly is stable. There are no enlarging pleural effusions. Improved low lung volumes. Left lower lobe opacity persists consistent with atelectasis. Right IJ catheter sheath is in place. CTA [8-25]: IMPRESSION: 1. Active extravasation of contrast in the sigmoid colon, likely related to a diverticular bleed. An AVM is also possible in this patient with a history of duodenal AVM. These findings were discussed with Dr. [First Name4 (NamePattern1) 2031] [Last Name (NamePattern1) ] [Doctor Last Name ] and the interventional radiology team at the time of the exam. 2. Slightly increasing size of mesenteric soft tissue masses with tethering of adjacent bowel loops. There are also new soft tissue masses elsewhere in the mesentery. These findings are nonspecific and may represent confluent lymphadenopathy related to lymphoma or other process, a primary mesenteric mass such as carcinoid or desmoid tumor, or mesenteric fibrosis. Biopsy may be beneficial as the process is progressive . RBC scan [8-25]: IMPRESSION: Findings consistent with active bleeding, within the sigmoid colon, probably corresponding to area of hemorrhage noted on recent CT evaluation. Findings and possible angiographic intervention were discussed with Drs. [First Name (STitle) ], and [Name5 (PTitle) ] by Dr. [First Name (STitle) 7747] at the time of interpretation. Brief Hospital Course: 88 y.o. male with history of recurrent GIBs in the setting of known AVMs and diverticulosis, who presents with a chief complaint of hematochezia. . # LGIB: presented with hematochezia as above. Pt has a history of AVMs and diverticulosis. Pt was admitted to the intensive care unit where he was transfused 12 units of blood. Initially question/concern for perforation given CT findings & tender abdomen. Surgery was consulted, but eval and intervention refused by the patient. Tagged red cell scan confirmed sigmoid colon source: active bleeding seen there. Pt taken for angio, however, by that time, no bleeding was seen and no intervention was done. The bleeding stopped on its own. Empiric antibiotics were started for GI coverage. Hematocrit never dipped below 30, and remained stable (>40) when the bleeding stopped. . # Lymphadenopathy: Pt found to have progressive mesenteric lymphadenopathy on CT. Recommend follow up and possible biopsy as outpatient. . #h/o colon cancer. Pt closely followed by his outpatient gastroenterologist Dr. [Last Name (STitle) 3315] during this admission. Pt had concerning symptoms (weakness and long term weight loss) and CT scan with worsening mesenteric LAD and matting concerning for metastasis of his prior malignancy. Currently no plan for scope given recent significant bleed but may be reconsidered as outpatient. . # CAD: s/p stent (unsure of what kind) and not on Plavix/ASA. Currently without chest pain, SOB and EKG unremarkable. . # ARF: Creatinine to 1.7 on presentation, improved with IVF/PRBCs, supporting pre-renal/hypovolemia in the setting of GIB. Pt got bicarb and NAC following arteriogram. Creatinine stablalized. . # Cellulitis: Patient developed erythema and warmth of the foot near the first MTP joint. Concern for gout vs. cellulitis. He was started on vancomycin x 1 dose with some improvement. Full and currently painless joint ROM, unlikely to be septic arthritis. Given improvement with antibiotics, a course of dicloxacillin will be given. He has no MRSA risk factors or past history; therefore empiric vancomycin was not given but his foot should be reassessed daily to monitor for worsening which might suggest need for MRSA coverage. . # Hypertension: Blood pressure meds held initially given concern for potential hemodynamic instability with large GI bleed. These were gradually reintroduced as BP tolerated. He is currently on his home regimen with the exception of being on 50 mg daily of atenolol. His BP meds may need further titration at rehab. . # GERD. Continued PPI and sucralfate. . . Medications: All home medications were continued. New medications were as follows: Ciprofloxacin 750mg PO q12, Flagyl 500mg PO TID, Dicloxacillin 250mg PO q6. The flagyl and ciprofloxacin course will be completed on [9-2]. The dicloxacillin will be completed on [9-5]. Medications on Admission: Atenolol 100 mg PO QD Clonazepam 0.5 - 1mg PO BID PRN: anxiety Fluorouracil 5% cream HCTZ 25 mg PO QD Lansoprazole 30 mg PO QD ?double PPI coverage Lidocaine 5% TD QD Nitroglycerin 0.3 mg SL PRN Omeprazole 40 mg PO QD Phenobarb-Belladona Alkaloids 16.2 mg PO BID Simvastatin 20 mg PO QHS Spironolactone 12.5-25 mg PO QD Sucralfate 1 gram PO QID Tolterodine 2 mg PO QD Ferrex 150 mg PO BID Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 4 days: to be completed [2192-9-2]. 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days: to be completed [2192-9-2]. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 90. 9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 90 or hr < 55. 10. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO QID (4 times a day) as needed. 11. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: to be completed [2192-9-5]. 12. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp < 90. 16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Lower GI bleed Acute blood loss anemia Hypertension Cellulitis Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for a GI bleed. At first you went to the Intensive Care Unit. You required 12 units of blood while you were there. A bleeding scan showed that you had some bleeding in the colon. It was thought to be either a diverticula or an AVM. The bleeding stopped on its own. You wer started on Antibiotics for a small concern of bacteria moving from your gut into your blood. Your vital signs were stable and as there was no evidence of re-bleeding you were transfered to a general medical floor. On the floor you remained stable and were restarted on your home medications. . Your right toe developed what appeared to be an infection although it may also be a first episode of gout. You were started on antibiotics for that. Your blood pressure medications were intially held butwere slowly restared. . Medication changes: Resume all of your home medications. Antibiotics: Flagyl for 7 day course to be completed on [2192-9-2] Ciprofloxacin for 7 day course to be compelted on [2192-9-2] Dicloxacillin for 7 day course to be completed on [2192-9-5] Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN, CS Phone:[Telephone/Fax (1) 250] Date/Time:[2192-9-24] 9:40 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2192-10-22] 11:30 Dr. [Last Name (STitle) 3315]: [10-12] at 8:40 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684]	[ "578.9", "V10.05", "530.81", "285.1", "414.01", "584.9", "401.9", "682.7", "425.1", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.47" ]	icd9pcs	[ [ [] ] ]	9868, 9938	5021, 7892	270, 377	10045, 10054	2946, 4998	11198, 11618	2469, 2568		8333, 9845		9959, 10024		7918, 8310			10078, 10916									1852, 1947	2583, 2927																						10936, 11175		222, 232											405, 1529																1551, 1829	1963, 2453
4,590	106,413	25506	Discharge summary	report	Admission Date: [2168-8-11] Discharge Date: [2168-8-11] Date of Birth: [2093-1-7] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 330] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: none History of Present Illness: 75yoW with salivary cancer metastatic to lungs, bone, liver, kidneys brought to [Hospital1 18] ED after cardiac arrest. Patient reportedly found down for 30minutes and intubated in the field for airway protection. On arrival to [Hospital1 18] no BP or HR, K 6.8, lactate 17.9. She was treated with epinephrine/atropine x2, pronounced dead, but then regained HR and pulse. BP 58/31, right femoral line placed, and she was started on dopamine. She received calcium gluconate and insulin/D50 for hyperkalemia. Currently HR 128, BP 113/99. ABG 7.08/45/432. She is not responsive to pain or verbal stimuli. Past Medical History: previous care at [Hospital3 ] - metastatic cancer, thought to be salivary gland primary Social History: patient lives with her daughter. two daughters involved in her care. Family History: non-contibutory Physical Exam: T 92.4 HR 128 BP 113/99 RR 16 A/C TV 400 RR 16 FiO2 100% PEEP 5 ABG 7.08/45/432 Gen: comatose HEENT: pupils fixed 5mm, anicteric, ETT, OG tube with bloody output CV: tachycardic, regular, no mrg Resp: coarse bilaterally Abd: thin, no bowel sounds, soft, large palpable masses RLQ/RUQ/LLQ Ext: muscle wasting, 1+ radial pulses B, decreased DP pulses Neuro: nonresponsive to pain, pupils nonreactive, doll's eyes Pertinent Results: [2168-8-11] 12:56PM TYPE-ART PO2-432* PCO2-45 PH-7.08* TOTAL CO2-14* BASE XS--16 [2168-8-11] 12:56PM K+-3.8 [2168-8-11] 12:25PM GLUCOSE-571* LACTATE-17.9* NA+-139 K+-3.9 CL--100 TCO2-15* [2168-8-11] 12:05PM UREA N-23* CREAT-0.9 [2168-8-11] 12:05PM CK(CPK)-36 [2168-8-11] 12:05PM AMYLASE-125* [2168-8-11] 12:05PM CK-MB-NotDone cTropnT-0.02* [2168-8-11] 12:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2168-8-11] 12:05PM URINE HOURS-RANDOM [2168-8-11] 12:05PM URINE HOURS-RANDOM [2168-8-11] 12:05PM URINE GR HOLD-HOLD [2168-8-11] 12:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2168-8-11] 12:05PM WBC-21.0* RBC-4.02* HGB-8.7* HCT-30.3* MCV-75* MCH-21.6* MCHC-28.7* RDW-16.3* [2168-8-11] 12:05PM PLT COUNT-404 [2168-8-11] 12:05PM PT-15.6* PTT-58.4* INR(PT)-1.6 [2168-8-11] 12:05PM FIBRINOGE-432* [2168-8-11] 12:05PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2168-8-11] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2168-8-11] 12:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [2168-8-11] 12:05PM URINE AMORPH-FEW [2168-8-11] 11:44AM TYPE-[Last Name (un) ] PO2-32* PCO2-69* PH-7.15* TOTAL CO2-25 BASE XS--7 [2168-8-11] 11:44AM K+-6.8* Brief Hospital Course: 75yo woman with history of metastatic cancer, primary thought to be salivary, presented after cardiac arrest, intubated in the field, rescuscitated in the ED by PEA ACLS protocol. CT head revealed a large posterior fossa intracranial hemorrhage. Neurologic exam demonstrated brain death. Neurosurgery and Neurology consults were called for confirmation. Initial exam was done with the patient hypothermic. She was warmed with a warming blanket, and repeat exam again demonstrated brain death. The family was notified that patient was brain dead. The organ donation team was notified. The family declined organ donation. The ventilator was withdrawn. The medical examiner was called and declined evaluation. Medications on Admission: percocet prn Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	[ "198.0", "431", "276.7", "198.5", "276.2", "142.9", "197.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "00.17", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	3938, 3947	3125, 3842	309, 315	3999, 4009	1659, 3102	4066, 4077	1180, 1197		3905, 3915		3968, 3978		3868, 3882			4033, 4043										1212, 1640																								255, 271											343, 962																984, 1077	1093, 1164
27,593	113,219	1862	Discharge summary	report	Admission Date: [2142-9-14] Discharge Date: [2142-9-21] Date of Birth: [2070-7-26] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 800] Chief Complaint: Generalized Malaise w/Fevers x 2 weeks, Hypoxia, and pancytopenia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 72 y/o M with a history of CAD, HTN, and BPH who reports having fevers at home x2 weeks as well as urinary urgency x 2 weeks that is new for him. Prior to the onset of the patient's fevers, he reports being bitten by a long green bug while in the parking lot of [Company 10414]. The bite area became indurated, erythematous, but never necrotic. The day following the bite, the patient reported feeling generalized malaise, then began developing fevers, mainly at night, but continued working throughout the day. Given his symptoms, the pt went to see his PCP 3 times over the last week, and was prescribed Ciprofloxacin on [2142-9-11] for his symptoms. He underwent an abdominal CT as well as blood testing, which showed new pancytopenia as well as splenomegaly on CT. Lyme serology sent as an outpatient was negative. In addition, the pt's PCP had noted the pt's BP to be slowly downtrending over the last week, and several of his anti-hypertensives were held. The patient was then referred to the ED to be evaluated for his persistent fevers, malaise and new pancytopenia Past Medical History: CAD s/p stent placement in '[35] off Plavix/ASA -->Exercise MIBI in [2-19]: IMPRESSION: 1. Moderate size and intensity reversible perfusion defect in the LAD territory. 2. Mild hypokinesis in the area of decreased perfusion, consistent with post-stress stunning. Calculated EF 47%. HTN BPH Hematuria Infraaortic aneuysm: 3.4 x 3.2 cm Social History: Works as a psychologist. Divorced, but dating two women, which has apparently become a stressful situation. Denies illicit drug use, drinks 3-4 alcoholic drinks daily. No history of ETOH withdrawl or seizures. 20 pk year history of tobacco, quit 20 years ago. Family History: none, one brother healthy Physical Exam: Vitals: T:97.4 BP:119/75 P:76 RR:24 O2Sat: 93%3L Gen: Somewhat diaphoretic appearing, pleasant, elderly gentleman HEENT: PERRL, EOMI, mild scleral icterus, pale conjunctiva. NECK: supple, no LAD appreciated CV: Regular, nl S1/S2 without audible murmur. No carotid bruits. LUNGS: [Hospital1 ]-basilar crackles without wheezing. ABD: softly distended. No tenderness to palpation. Normal bowel sounds. No hepatomegaly. Spleen tip not palpable. No ascites. EXT/SKIN: No asterixis, no rashes, no petechiae. Skin appears slightly jaundiced. No splinter hemorrhages, no [Last Name (un) ] lesions. Extremities warm, well perfused without lower extremity edema. GU: Dried blood and external hemorrhoids visualized. Prostate smooth and somewhat tender on exam. Guaiac +. Pertinent Results: [2142-9-13] 01:05PM BLOOD WBC-4.4 RBC-3.57* Hgb-11.0* Hct-30.6* MCV-86 MCH-30.8 MCHC-35.9* RDW-15.5 Plt Ct-57* [2142-9-19] 05:45AM BLOOD WBC-4.5 RBC-2.44* Hgb-7.3* Hct-21.5* MCV-88 MCH-30.0 MCHC-34.1 RDW-16.4* Plt Ct-112* [2142-9-19] 04:38PM BLOOD Hct-27.9# [2142-9-21] 06:50AM BLOOD WBC-8.1 RBC-2.87 Hgb-8.5* Hct-25.4* MCV-89 MCH-29.8 MCHC-33.7 RDW-16.6* Plt Ct-197 [2142-9-20] 05:50AM BLOOD Neuts-72.9* Lymphs-22.4 Monos-3.6 Eos-1.0 Baso-0.2 [2142-9-13] 01:05PM BLOOD Neuts-70 Bands-4 Lymphs-14* Monos-10 Eos-0 Baso-2 Atyps-0 Metas-0 Myelos-0 [2142-9-14] 03:54PM BLOOD PT-14.4* PTT-66.4* INR(PT)-1.3* [2142-9-17] 11:00AM BLOOD PT-13.4 PTT-32.1 INR(PT)-1.2* [2142-9-16] 04:15AM BLOOD Fibrino-536* [2142-9-15] 08:28AM BLOOD Parst S-POS [2142-9-20] 05:50AM BLOOD Parst S-THICK SMEAR REVIEWED [2142-9-15] 01:13AM BLOOD Ret Aut-0.6* [2142-9-18] 05:25AM BLOOD Ret Aut-0.7* [2142-9-14] 10:05AM BLOOD Glucose-137* UreaN-44* Creat-2.0* Na-136 K-3.2* Cl-99 HCO3-26 AnGap-14 [2142-9-21] 06:50AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-138 K-4.1 Cl-104 HCO3-29 AnGap-9 [2142-9-13] 01:05PM BLOOD ALT-45* AST-99* AlkPhos-34* TotBili-2.1* DirBili-0.8* IndBili-1.3 [2142-9-17] 11:00AM BLOOD ALT-276* AST-389* LD(LDH)-999* AlkPhos-40 TotBili-1.8* [2142-9-20] 05:50AM BLOOD ALT-180* AST-116* LD(LDH)-574* AlkPhos-41 Amylase-68 TotBili-1.3 [2142-9-14] 03:54PM BLOOD Calcium-7.2* Phos-2.9 Mg-2.1 [2142-9-21] 06:50AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8 [2142-9-15] 01:13AM BLOOD calTIBC-164* Hapto-<20* Ferritn->[2134] TRF-126* [2142-9-14] 10:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM HAV-NEGATIVE [2142-9-15] 01:13AM BLOOD Type-ART Temp-37.5 O2 Flow-52 pO2-68* pCO2-31* pH-7.51* calTCO2-26 Base XS-1 [2142-9-18] 12:18AM BLOOD Type-ART pO2-68* pCO2-34* pH-7.54* calTCO2-30 Base XS-6 . CXR [9-15] No acute intrathoracic process. Low lung volumes. [9-16] Low lung volumes. Bibasilar atelectasis. [9-17] In comparison with study of [9-16], there is substantial increase in the thick streaks of atelectatic change at both bases. The upper zones are essentially clear. No evidence of pleural effusion or vascular congestion [9-18] In comparison with study of [9-17], some decrease in the thick streaks of atelectasis at both bases. However, some significant atelectasis persists in this patient with even lower lung volumes . CT abdomen 1. Interval development of splenomegaly with a linear/wedge-shaped peripheral hypodensity, most consistent with a perfusion abnormality. Clinical correlation is recommended. Given the patient's history of fever, the enlargement of the spleen may be secondary to a viral process. 2. Abdominal aortic aneurysm measuring 3.6 x 3.4 cm in size. 3. Colonic diverticulosis. 4. Enlargement of the prostate gland. 5. Atherosclerosis with involvement of the coronary arteries. . LE US There is normal compressibility, augmentation, color Doppler signal, and Doppler waveform within the common femoral vein, superficial femoral vein, popliteal vein bilaterally. Tibial and peroneal veins also demonstrate normal signal and compression. . ECHO The left atrium is normal in size. 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 mildly dilated with normal free wall contractility. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Pt presented to the Ed from PCP office with fever, confusion, down-trending BP pancytopenia and CT evidence of splenomegaly. He also was found to have an oxygen saturation of 89%. . He was admnited to the MICU where he was found to have babesiosis on peripheral smear. Lyme and Erlichia serologies were sent. Lyme serology was negative, Elrichia is still pending. ID and Hem/Onc consultations were obtained. He was started on quinine, doxy and clindamycin. He was also found to have hemolytic anemia, elevated liver enzymes and acute renal failure. During his stay in the MICU the patient experineced dyspnea and had cracles on PE. An echo showed EF of 55 and no other acute processes. After two days in the MICU, the patient admited to symptomatic improvement and he was transfered to the floor. Both his pancytopenia, elevated liver enzymes and the number of parasites on the smear were improved at this point in time. . In the [Hospital1 ] the patient was switched from quinine/clindamycin to atovoquine/azithromycin. . The patient's leucopenia and thrombocytopenia continued to improve, yet his HCT was trending down. His reticulocyte count at this time was 0.9, while LDH was trtending down. The patient was started on Folate and B12 to assist the marrow response. The pateient reached a nadir HCT of 21.5 reuiring transfusion of 1 unit pRBCs. This lead to HCT elevation to 27.9, which then stabilized at 25-26. The patient's ARF remained stable in this setting, while his liver function test improved. . The patient's dyspnea improved with inhaled Albuterol and Ipratropium bromide, as well as gentle diuresis. The patient had bilateral LE U/S, negative for DVT. He was able to saturate in the mid 90's in the absence of oxygen, and while ambulating prior to discharge. . The patient is to continue atovoquine and azithromycin and Doxycycline as outpatient therapy. . The patient is recommended to have outpatient follow up to determine resolution of his anemia and ARF. Medications on Admission: Metoprolol 25 mg b.i.d. - reduced to 25mg daily Lisinopril 20 mg daily - on hold Lipitor 40 mg daily HCTZ 25mg daily - on hold Lorazepam prn Cialis prn . Discharge Medications: 1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2 times a day) for 11 days. Disp:22 Doses Refills:0 6. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 doses. Disp:11 Tablet(s) Refills:0 7. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 Inhaler Refills:3 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:1 Inhaler Refills:3 10. Outpatient Lab Work Blood draw: CBC, ferritin, iron, TIBC, Vitamin B12, Folate. To be drawn at the time of your outpatient follow-up apppointment on [2142-9-26]. Discharge Disposition: Home Discharge Diagnosis: Babesiosis Discharge Condition: Stable Discharge Instructions: You were admited with fever and hypotension and found to have Babesia infection and may also have Ehrlichia - both tick borne illnesses. You were started on an antibiotic regimen and your infection is getting beter. Please complete a course of antibiotics for this problem. Take Azithromycin and Atovaquone until [2142-10-1] and Doxycycline until [2142-9-24]. You also had shortness of breath which is also getting better with fluid removal. This likely was due to fluid overload plus a component of reactive airway disease. You may continue to take an albuterol and ipratropium inhaler as necessary for shortness of breath. Please discuss this issue further with your primary care doctor. Your infection was complicated by anemia, which we attributed to blood cell destruction secondary to infection. You required transfusion of red blood cells while in the hospital. You must have your blood checked early next week to monitor your blood count to further work-up your anemia. Please call your regular doctor or return to the ED if you develop: fevers chills shortness of breath chest pain fatigue lightheadedness bleeding or any other symptom that is unusual for you. Followup Instructions: Please make sure to follow up with your regular doctor. [First Name (Titles) 6] [Last Name (Titles) 10415]t has been scheduled for you with Dr [Last Name (STitle) 2903] on Wed, [9-26]. Please call the office on Monday to determine the time of appointment. Please have your blood drawn at that appointment to monitor for anemia and further work-up this problem. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811] Completed by:[2142-9-21]	[ "414.01", "789.2", "441.4", "088.82", "799.02", "401.9", "284.1", "283.9", "600.00", "584.9", "288.50", "578.1", "V45.82", "287.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10053, 10059	6706, 8690	337, 344	10114, 10123	2965, 6683	11353, 11888	2131, 2158		8894, 10030		10080, 10093		8716, 8871			10147, 11330										2173, 2946																								232, 299											372, 1468																1490, 1838	1854, 2115
58,128	162,764	16582	Discharge summary	report	Admission Date: [2177-7-8] Discharge Date: [2177-7-18] Date of Birth: [2121-2-13] Sex: M Service: MEDICINE Allergies: Penicillins / Keflex / Ketamine Attending:[Doctor First Name 3290] Chief Complaint: Fevers Major Surgical or Invasive Procedure: none History of Present Illness: 56 y/o M with recent prolonged ICU stay at [Hospital1 18] for right foot osteomyelitis s/p 6 weeks of dapto/cefepime (last dose supposed to be today), but complicated by newly diagnosed CML with BCR-ABL rearrangement (late [Month (only) ]) on gleevac until [6-19] when anemia and thrombocytopenia developed, multifactorial respiratory failure s/p trach but weaned off vent support, renal failure now on HD (due tomorrow), AFib on Coumadin presents from [Hospital ] rehab to [Hospital ] clinic today and found to have temp to 99.5 in office, lungs wet sounding, and osteomyelitis looked worse so sent to ED. Per wife the patient has had several issues over the last few days including the following: 1. He had a chronic indwelling foley for urinary retension complicated by recurrent UTIs. Wife noted at rehab on Sunday that he no longer had foley in so requested insertion of foley. Per EMS today foley had hematuria and per rehab physicians possibly also pus. Wife also saw the hematuria but did not know about pus. 2. His mental status seems to be getting worse. PRior to leaving [Hospital1 18] he had waxing/[Doctor Last Name 688] MS but was able to hold a conversation more often than he is now. Per wife sometimes she can talk to him now but most of the time he is delirious. In addition he has declined in his ability to feed himself and do other ADLs. 3. Wife thinks the right heel wounds look worse than they did before he left here and is not sure if he ever had pressure ulcers on his back before. 4. On Sunday at rehab he had a yellowish pus coming out of trach site and it was cleaned off. No one did cultures of it to her knowledge. He presented to [Hospital ] clinic today and because of fevers and AMS was referred to ED. In ED, temp98.6 HR 80 BP 105/46 RR 20 O2Sat98. On exam right heel wound draining fluid with eschar and erythema (7X7cm) around it. Patient also got Foley placed yesterday now draining [Hospital ] with [Hospital ] coming from meatus. Trach site erythematous. Anasarca as well. ID was called and recommended continuing dapto 600mg Q48H and cfp 1gm IV Q24H for now. Received CFP and vancomycin in ED given may have lung infection and dapto wouldnt cover lung source. CXR ordered. Also renal was called and are aware of admission->likely to get HD in AM, anasarca is baseline. Onc aware of admission, Dr. [Last Name (STitle) ] is his oncologist, fellows plan was to give gleevac 100mg after HD tomorrow. . VS prior to transfer to floor: T 99.4 HR 70 112/55 95 trach collar with RR 15 . On the floor, patient complained of pain but is unable to tell me where the pain is located. . Wants to be suctioned. . Review of systems: unable given altered mental status. [Name8 (MD) ] RN lots of secretions suctioned. Past Medical History: CAD CML with BCR-ABL followed by Dr. [Last Name (STitle) ] initially received leukophoresis and hydrea then gleevac which was stopped on [2177-6-19] given nl WBC count and anemia/thrombocytopenia. Osteomyelitis of right foot treated with dapto/cfp until [2177-7-8] when course was supposed to finish HTN diastolic HF Chronic Foley for BPH with recurrent UTI ESRD on HD (T/T/S) MS [First Name (Titles) ] [Last Name (Titles) 3781] interactive but unable to follow commands NGT but able to swallow pureed foods (no pills) CAD s/p MI with stent in [2161] Atrial fibrillation on Coumadin Diabetes Type 2 on Insulin Hypertension Hyperlipidemia CML (new diagnosis) Peripheral [Year (4 digits) 1106] disease s/p R SFA stent angioplasty and L SFA stent placement Lower extremity cellulitis with surgical debridement/VAC intradural tumor compressing spinal cord at C1/C2 and s/p anterior cervical decompression at C5/6 fusion ([8-29]) and extradural tumor removal of C1 intradural tumor (meningioma) ([8-30]) Gastroporesis Neuropathy Congenital Pulmonic Stenosis s/p surgery at 2 and 9years old Chronic indwelling foley. Depression diagnosed at [Hospital3 ], refused SSRIs Social History: Nonsmoker, no alcohol consumption Family History: No history of renal failure or disease. Mother with ? [Name2 (NI) ] dyscrasia Heart disease in unspecificed family members. Physical Exam: Vitals: T:98.6 BP:114/71 P:74 R: 18 O2:96% on 35% trach mask General: somnolent but arousable. Unable to answer questions appropriately but gives vague or incoherent answers. does not follow commands. Anasarca HEENT: Sclera anicteric, dry MM, oropharynx clear Lungs: Coarse BS bilaterally CV: Regular rate and rhythm, normal S1 + S2, [2-1] SM RUSB (heard on exam in past) no rubs, gallops Abdomen: soft, non-tender, partly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley scrotal edema Ext: warm, 3+ pitting edema bilateral lower extremities, right heel bandaged, chronic venous stasis changes on bilateral lower extremities. BACK: eschar on coccyx with surrounding erythema Discharge Exam: V 98.8, BP 121/60, HR 77, RR 20, 98% on 3.5 L Gen: comfortable, pleasant affect, alert and awakre, trached, hypothenar atrophy Cardiac: irregular rate, holosystolic murmur at left and right upper sternal border Chest: bilateral scattered rhonchi, bilateral breath sounds ABd: soft, non tender, non distended, pos bs GU: has foley in place Ext: 3+ pitting edema of bilatera LE. LE wounds are dressed, dry and in tact. Has air-boots on. Back: coccygeal ulcer wrapped Neuro: A+O x3, weakness of UE bilaterally Pertinent Results: [2177-7-8] 12:00PM [Month/Day/Year 3143] WBC-108.0# RBC-3.60# Hgb-11.7# Hct-33.3# MCV-93 MCH-32.4* MCHC-35.0 RDW-21.0* Plt Ct-141* [2177-7-8] 12:00PM [Month/Day/Year 3143] Neuts-54 Bands-10* Lymphs-1* Monos-2 Eos-1 Baso-2 Atyps-0 Metas-12* Myelos-18* [2177-7-8] 12:00PM [Month/Day/Year 3143] Hypochr-NORMAL Anisocy-3+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-2+ [2177-7-8] 02:30PM [Month/Day/Year 3143] PT-25.3* PTT-40.3* INR(PT)-2.4* [2177-7-10] 12:26PM [Month/Day/Year 3143] Fibrino-433# [2177-7-8] 02:30PM [Month/Day/Year 3143] ESR-30 [2177-7-8] 12:00PM [Month/Day/Year 3143] UreaN-47* Creat-4.0# Na-130 K-4.2 Cl-92* HCO3-26 AnGap-16 [2177-7-8] 12:00PM [Month/Day/Year 3143] ALT-14 AST-35 AlkPhos-108 TotBili-0.6 [2177-7-8] 02:30PM [Month/Day/Year 3143] Calcium-9.4 Phos-0.7* Mg-2.6 [2177-7-8] 02:30PM [Month/Day/Year 3143] CRP-23.8* [2177-7-8] 02:54PM [Month/Day/Year 3143] Glucose-148* Lactate-1.1 Na-129* K-4.3 Cl-93* calHCO3-26 DISCHARGE LABS: Hematology COMPLETE [Month/Day/Year 3143] COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2177-7-18] 05:41 80.5* 3.27* 9.9* 31.0* 95 30.2 31.9 20.3* 139* Source: Line-PICC DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos Promyel [2177-7-18] 05:41 601 12* 4* 4 1 0 0 8* 6* 5* Source: Line-PICC 200 CELL DIFF RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Stipple [2177-7-18] 05:41 NORMAL 2+ NORMAL 2+ NORMAL 1+ OCCASIONAL Source: Line-PICC BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [2177-7-18] 05:41 139* Source: Line-PICC Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2177-7-18] 05:41 1321 24 2.4* 137 4.7 97 30 15 Source: Line-PICC IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2177-7-18] 05:41 439* Source: Line-PICC CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2177-7-18] 05:41 9.1 4.1 2.0 5.7 Source: Line-PICC .............................. Micro: Source: Endotracheal. FINAL REPORT [2177-7-13] GRAM STAIN (Final [2177-7-10]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2177-7-13]): SPARSE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. CEFTAZIDIME , CHLORAMPHENICOL , AND TIMENTIN sensitivity testing performed by Microscan. CHLORAMPHENICOL = <=8 MCG/ML = Sensitive. TIMENTIN = 16 MCG/ML = Sensitive. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| CEFTAZIDIME----------- 8 S LEVOFLOXACIN---------- 1 S TRIMETHOPRIM/SULFA---- <=1 S Urine Culture [2177-7-9]: No growth ................................... [2177-7-8] CXR: 1. Support lines and tubes in place as described above. 2. Left lower chest opacity likely representing left pleural effusion,with associated atelectasis; an underlying infectious process cannot be ruled out. . [2177-7-8] Lumbo-Sacral X-ray: Six markedly suboptimal bedside (& possibly intraoperative) radiographs of the lumbar spine with lateral images apparently obtained with cross-table technique lying supine. There is possible displaced fracture of L5 vertebral body. However, this appearance does not correlate with the history provided & fracture or destruction of this body was not seen on more satisfactory CT of this area done [2177-6-9]. Clinical correlation might be helpful. . [2177-7-8] R Foot X-ray: Minimal interval change with findings suggestive of distal 5th metatarsal osteomyelitis. Probable secondary reflex sympathetic osteodysrophy. . [2177-7-8] CT Head W/Out Contrast: 1. Enlarged ventricles which is new when compared to [2176-8-30], although exact age is indeterminate. This may represent underlying communicating hydrocephalus, and an MRI with CSF flow study could be performed for further evaluation, if warranted on clinical grounds. 2. No evidence of mass or mass effect. . [2177-7-9] L Foot X-ray: No definite radiographic evidence for osteomyelitis. Marked osteopenia along the medial distal fifth metatarsal head again noted. No obvious fracture. Given the degree of osteopenia, subtle abnormalities may not be radiographically apparent. As such, bone scan or MRI may help for further assessment. . [2177-7-9] MRI Head: 1. Small, area of diffusion abnormality in the anterior right parietal lobe.This may be due to subacute infarct. However, in absence of gadolinium enhancement, other processes could not be excluded. Gadolinium enhance study can be obtained if clinically indicated following consultation with renal service. 2. No hydrocephalus. 3. Remote suboccipital craniectomy with residual deformity of craniocervical junction. [2177-7-11] Swallowing Video: FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was intermittent aspiration of thin liquids. For further details, please refer to speech and swallow division note in OMR. IMPRESSION: Penetration and aspiration of thin liquids. Brief Hospital Course: 56yo M with DM2, PVD, CHF, chronic osteomyelitis admitted to the MICU for increased sputum, persistent osteomyelitis, fevers and decreased mental status. Pt recently had a long hospitalization course for osteomyeltitis complicated by multifactorial respiratory failure s/p trach/peg, renal failure on HD now, new diagnosis of CML now on gleevac, and persistent AMS of unclear etiology. #Fevers: Started on broad antibiotic coverage with linezolid , bactrim and meropenem to cover osteomyelitis of right foot, stenotrophomonas pna (from prior sputum cultures as well as repeat sputum culture from this admission), and UTI (rehab center reports pus in urine). Patient's symptoms improved, afebrile, more lucid, less secretions, and antibiotics were switched to Daptomycin and Meropenem, per ID reccomendations. Patient will be on dapto/[Last Name (un) 2830] for 6 weeks (start date [2177-7-8]) followed by PO antibiotics for osteomyelitis suppression. Patient was transfered to the medical wards after stablilized. #Osteomyelitis: Pt has osteomyelitis of right heel as well as ulcers and infections of left foot and coccyx. Was initially on linezolid and meropenem for coverage and then switched to Daptomycin and Meropenem (start date: [2177-7-8]). ID followed pt and reccomended 6 weeks of dapto/[Last Name (un) 2830] followed by daily PO suppressive therapy. Pt found to have coccygeal ulcers and was followed by wound care with daily dressing changes. . # CML: Pt was recently diagnosed with CML in [2177-4-29]. He was given hydrea and gleevac on last admission. Gleevac was briefly stopped at rehab and counts came back up. On this admission, pt was re-started on gleevac 200mg daily along with allopurinol. Hematology followed pt and [Hospital1 ] tumor lysis labs were performed to carefuly monitor response. WBC still continued to be high in the 80-120s with mildly elevated LDH (550-650) and elevated Uric Acid (4-7.5 range). Pt will continue current gleevac regimen for CML suppression until he decides to focus on comfort measures only. This dose of gleevac (pill is crushed into liquid form) is sufficient to make patient comfortable until he withdraws care. When he focuses on immediate end of life care, he will likely want to stop taking this medication. . # Altered Mental Status: On prior admission, pt had AMS thought to be secondary to intracranial leukostasis from CML, although symptoms did not improve with leukoparesis. On this admission, patient was initialy found to have AMS and had CT and MRI workup. Infection was likely the source of his AMS since he became significantly more lucid with antibiotics. # Hydrocephalus: Unclear etiology but patient has h/o spinal surgeries for meningioma in [10-7]. There was concern that pt had obstruction of drainage from either septic or malignant mass given complicated history of osteo and CML. However, MRI done on [2177-7-9] showed no hydrocephalus. Mental status cleared and symptoms of AMS were attributed to infection. . # Nutrition: Nutrition consulted and recommended nectar thick, and sips of thins; as pt??????s primary goal is his comfort. Pt also written for soft diet. He initially had a dopoff tube in place for meds and tube feeds which was discontinued after long discussion with patient about deciding to eat food despite aspiration risks. Patient aware of his very poor prognosis and elected to eat food that he desires, despite the risks. Pt's preference of food was given in small bites while patient sitting up. . # Pain: Pt had bony pain from leukocytosis assoc w/CML, ulcers, as well as chronic pain from neuropathies, meningiomas, osteomyelitis. Pt was given dilaudid every 2 hrs and gabapentin for pain control. Palliative care was closely involved in pain managment. Went home on 4-6mg PO dilaudid every 2 hrs for pain. He was also written for IV dilaudid 0.75mg as needed for pain if he can not take PO. He still had pain on this regimen but preferred to be alert. This regimen will unlikely be sufficient when patient decides to focus on end of life and comfort. . # Decreased hearing: Left ear's with erythema and pt reported some decreased hearing. He was given daily ciprodex. # Respiratory: Pt was trached as of last admission. He was on 3.5L O2 and given neb treatments all through his trach. On admission he was noted to have increased secretions which decreased with antibiotics. Sputum culture grew stenotrophomonas- sparse growth, and patient was briefly treated with bactrim. Stenotrophomonas thought to be more likely contaminate or colonization, given the sparse growth and reccurent positive cultures. . # Oliguria/ESRD/anasarca: Pt originally came in with foley which was d/c'ed for possible UTI. Pt's urethral meatus oozed some dark [Year (4 digits) ] and urology was consulted. New foley was placed to drain old [Year (4 digits) ] in bladder. Foley was flushed several times a day and no clots were seen. Pt was found to be oliguric, urinated 50-200cc/day. Received HD every T/T/S as well as ultrafiltration 2 days a week to remove extra fluid for anasarca. Renal closely followed patient throughout hospitalization. All medications were renally dosed. Pt will have HD at rehab center every T/Th/Sat. He does not need further ultrafiltration at this point unless his clinical status changes. He will get his Daptomycin (q 48 hrs) and Meropenem (q 24 hrs). On HD days, he will get these meds after HD. Of note, patient phosphorus levels fluctuated. At times he required neutrophos supplements for low phos. # Coagulopathy: Pt found to have elevated INR and coumadin for A. fib was held. DIC panel was negative. INR trended down. . # A. Fib: Pt was rate controlled with metorpolol. Coumadin was held initially for an elevated INR and was then discontinued because pt has poor prognosis and end stage disease and history of GI bleeds on coumadin. . # Goals of Care: Pt was told if his poor prognosis. Case management/social work/palliative care were all active in helping patient and family coordinate care and goals. It was decided that patient wanted to be transfered to [Hospital ] Hospital (In [Location (un) ], ultimately) close to home so he could see his mother and son and then become comfort measures only. He requested to stop HD at that point and to have pain control for comfort. He described that he felt that stopping HD would be the most peaceful way to go. However, it is important to note that pt said he would be willing to go back to the hospital, should he become acutely sick again, if he has not yet seen his mom. It is very important to him to stay alive to see his mom and son. [Name (NI) ] is still DNR/DNI and this was discussed at legnth. After he sees his mother and son, he has made it clear that he would like to focus on comfort measures. While inpatient, he decided that he did not want tube feeds anymore and was willing to take the risks so he can eat food that he enjoys. He will be going home on whatever food he wishes to eat. He is very aware of the risks of aspiration and pneumonia. He eats food in small bites with one-to-one assistance and sitting upright. In terms of pain, he will be going to rehab on dilaudid 4-6mg every 2 hrs for pain. At this point, he would like to keep this pain regimen so he can be alert for his family. However, when he decides to focus on comfort, he will likely need more medication. He will continue his gleevac, meropenem, daptomycin, hemodialysis, wound care until he sees his mother and son. After that, he would like to stop hemodialysis and focus on pain control and comfort. Medications on Admission: 1. Simvastatin 10 mg Tablet [Name (NI) ]: Two (2) Tablet PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet [Name (NI) ]: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet [Name (NI) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain, headache. 4. Therapeutic Multivitamin Liquid [Name (NI) ]: Five (5) ML PO DAILY (Daily). 5. Insulin Lispro 100 unit/mL Solution [Name (NI) ]: 2-8 units Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 6. Gabapentin 300 mg Capsule [Name (NI) ]: One (1) Capsule PO Q24H (every 24 hours). 7. Fentanyl 100 mcg/hr Patch 72 hr [Name (NI) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Metoprolol Tartrate 25 mg Tablet [Name (NI) ]: One (1) Tablet PO TID (3 times a day). 9. Daptomycin 500 mg Recon Soln [Name (NI) ]: Six Hundred (600) mg Intravenous q48 hours for 13 days: LAST DOSE [2177-7-8]. 10. Cefepime 1 gram Recon Soln [Month/Day/Year ]: One (1) gm Injection once a day for 13 days: ON HD DAYS, GIVE AFTER HD. LAST DAY = [2177-7-8]. 11. Coumadin 5 mg Tablet [Month/Day/Year ]: One (1) Tablet PO once a day. 12. Docusate Sodium 50 mg/5 mL Liquid [Month/Day/Year ]: One Hundred (100) mg PO BID (2 times a day). 13. Senna 8.6 mg Tablet [Month/Day/Year ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day/Year ]: One (1) injection Injection TID (3 times a day): please discontinue once INR >2. 15. Lactulose 10 gram/15 mL Syrup [Month/Day/Year ]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 17. Hydromorphone 4 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 18. Epogen 10,000 unit/mL Solution [Last Name (STitle) ]: 5500 (5500) units Injection qHD. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID PRN as needed for Constipation. 3. Insulin Lispro 100 unit/mL Solution [Last Name (STitle) ]: One (1) Subcutaneous ASDIR (AS DIRECTED): Follow Insulin Sliding Scale regimen. 4. Gabapentin 300 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 6. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO TID PRN as needed for constipation. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Allopurinol 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. Imatinib 400 mg Tablet [Last Name (STitle) ]: [11-30] Tablet PO DAILY (Daily): Patient receives Gleevac in specially formulated liquid form. 200mg daily, several hours before bed. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Month/Day (2) ]: One (1) Inhalation q 6hr PRN as needed for wheezing . 11. Miconazole Nitrate 2 % Powder [Month/Day (2) ]: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash . 12. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Hydromorphone 4 mg Tablet [Hospital1 ]: 1-1.5 Tablets PO q 2hr PRN as needed for pain: 4-6mg PO every 2 hrs for pain. 14. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 15. Lidocaine HCl 2 % Solution [Hospital1 ]: One (1) ML Mucous membrane TID PRN as needed for throat pain. 16. Meropenem 500 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 5 weeks: Start date=[2177-7-8] for total 6 week course. On HD days, please give dose AFTER HD. . 17. Daptomycin 600 mg IV Q48H On HD days, please give dose after dialysis, thanks 18. HYDROmorphone (Dilaudid) 0.75 mg IV ONCE MR1 pain Duration: 1 Doses Discharge Disposition: Extended Care Facility: [Hospital1 ] [Location (un) 686] Discharge Diagnosis: PRIMARY: 1)Osteomyelitis 2)Chronic Myelogenous Leukemia 3)Renal Failure 4)Pneumonia SECONDARY: 1)Heart failure 2)Anasarca Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: I was a pleasure providing care for you during your hospitalization. You were admitted for fevers and osteomyelitis (an infection of the bones in your feet). You were given antibiotics through your vein to treat the infection. You had daily dressing changes for the wounds on your buttox and feet. You were found to have a very high white [Location (un) ] cell count, likely from your leukemia (CML) and an infection. You were given Gleevac for the leukemia and seen by leukemia doctors. You had [Location (un) ] checked often to make sure that your electrolytes were repleted. You had hemodialysis for your renal failure and for the water that was in your legs. You met with Palliative care to discuss end of life goals and pain control. You requested to go to [Hospital1 ] facility where you could spend time with your family and ultimately focus on being comfortable. The following changes were made to your medications: -Coumadin was stopped -Gleevac 200mg daily was re-started -Dilaudid 4-6mg PO every 2 hrs for pain was started You will be on the antibiotics: Daptomycin (every 48 hrs) and Meropenem (every 24 hrs) for a total 6 week course. For now, you will continue the chemotherapy, the antibiotics, until you see your family. It was a priviledge to take care of you. Followup Instructions: You may contact the [Hospital1 ] if you have questions about your antibiotics regimen. You will continue dapto/[Last Name (un) 2830] for total of 6 weeks (began [2177-7-8]), followed by oral suppressive antibiotic therapy.	[ "536.3", "V44.0", "486", "707.15", "300.4", "585.6", "584.9", "707.03", "V45.11", "205.10", "331.3", "427.31", "357.2", "730.17", "428.0", "V44.1", "403.91", "V58.61", "250.60", "428.33", "707.25", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.95", "38.93", "39.95" ]	icd9pcs	[ [ [] ] ]	23255, 23322	11331, 13636	299, 306	23488, 23488	5832, 6875	24948, 25186	4419, 4548		20997, 23232		23343, 23467		18979, 20974			23625, 24925			6891, 11308							4563, 5288							5304, 5813													3036, 3125				253, 261											334, 3017									23503, 23601							3147, 4352	4368, 4403
26,868	104,454	52919	Discharge summary	report	Admission Date: [2163-6-20] Discharge Date: [2163-6-22] Date of Birth: [2090-1-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 73 year old woman with history of ESRD on HD, hypertension, severe PVD s/p bilateral BKA, and LVH with LVOT who is presenting with acute shortness of breath. She was in her usual state of health until earlier this evening when she noticed that she "just didn't feel right." When she went to lay down, she noted the onset of shortness of breath. She denied chest pain or palpitations. She had her last HD session on Friday. She denies eating salty food or missing medications . In the ED her initial vital signs were 220/110 120 RR 40 and 100% on BIPAP. She continued on BIPAP with improvement in her oxygenation. An EKG was interpreted as unchanged from prior. Nitro-paste was administered for blood pressure control. A left femoral central line was placed for IV access. Both cardiology and nephrology were consulted who recommended urgent dialysis for volume control. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . * Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: - Diastolic CHF with LVOT obstruction at rest - Chronic 2L NC at night - Hypertension - Diabetes - Peripheral vascular disease status post bilateral knee amputations in [2146] (L) and [2157] (R) - GERD - Hypercholesterolemia - ESRD on hemodialysis M,W,F. Receives dialysis at [Location (un) ] hemodialysis center in [Location (un) ]. - Paroxysmal atrial flutter, s/p failed ablation with subsequent a. fib - Peptic ulcer disease - Hypertrophic obstructive cardiomyopathy - Mild mitral stenosis (MVA 1.5-2.0 cm2) - Secondary Hyperparathyroidism - Diastolic Congestive Heart Failure Social History: Social history is significant for the presence of current tobacco use (1 pack per week), and [12-22] PPD x 50 years. There is no history of alcohol abuse. Lives in [Hospital3 ] facility and uses a mobile wheelchair or a walker. Family History: Her father died in his 90s and mother at the age of 102. Patient unable to specify cause of death. She has one living sister and 6 sisters and one brother who passed away. Her family history is significant for coronary artery disease, cancer, and diabetes. Physical Exam: VS: T 97.3, BP 121/69, HR 78, RR 18, O2 99% on 4L Gen: thin elderly, African American female. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. right pupil 2mm->1, left surgical pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP to angle of jaw. gauze in place from LIJ line placement w/o hematoma CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at LLSB/apex Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles and rhonchi to [12-22] way up back. Abd: flat, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. b/l BKA. left femoral TLC Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit Left: Carotid 2+ without bruit; Femoral 2+ without bruit Pertinent Results: [2163-6-20*] 12:00AM BLOOD WBC-16.1# RBC-4.34 Hgb-12.5 Hct-41.2 MCV-95 MCH-28.9 MCHC-30.4* RDW-18.8* Plt Ct-350 [2163-6-22] 04:54AM BLOOD WBC-7.8 RBC-4.16* Hgb-12.0 Hct-38.9 MCV-93 MCH-29.0 MCHC-31.0 RDW-17.8* Plt Ct-324 [2163-6-20] 12:00AM BLOOD PT-17.6* PTT-94.2* INR(PT)-1.6* [2163-6-22] 04:54AM BLOOD PT-27.2* PTT-38.1* INR(PT)-2.7* [2163-6-20] 12:00AM BLOOD Glucose-182* UreaN-74* Creat-8.1# Na-140 K-5.6 Cl-100 HCO3-26 AnGap-20 [2163-6-20] 11:30AM BLOOD K-6.4* [2163-6-22] 04:54AM BLOOD Glucose-100 UreaN-65* Creat-6.9# Na-135 K-5.0 Cl-98 HCO3-27 AnGap-15 [2163-6-20] 12:00AM BLOOD CK(CPK)-49 [2163-6-20] 06:24AM BLOOD CK(CPK)-53 [2163-6-20] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.05 [2163-6-20] 06:24AM BLOOD CK-MB-NotDone cTropnT-0.05* [2163-6-20] 06:24AM BLOOD Calcium-8.7 Phos-6.4* Mg-2.7* [2163-6-20] 08:00PM BLOOD Calcium-8.6 Phos-2.8# Mg-2.0 [2163-6-22] 04:54AM BLOOD Calcium-8.7 Phos-5.6# Mg-2.5 Brief Hospital Course: The patient is a 73 year old woman with history of ESRD on HD, severe PVD, LVH with LVOT obstruction presenting with shortness of breath and pulmonary edema. . # CAD: Although patient has with multiple CAD risk factors, prior non-invasive and invasive testing showed no significant obstructive coronary disease. A troponin of 0.04 in the context of normal CK and EKG with no ST-T changes was likely demand ischemia secondary to hypertensive heart disease. Admission EKG did not show signs of active ischemia and the patient was monitored on telemetry and continued on aspirin and statin. . # CHF: The pt's hypoxia was attributed to CHF and not pneumonia as she denied any cough, and was afebrile and lacking a consolidate on chest xray. Pulmonary embolism was also unlikely as the patient is on chronic anticoagulation. Due to chronic diastolic congestive heart failure and a physiologic HOCM that leads to hypotension during dialysis sessions, it is most likely that the patient developed pulmonary edema in the setting of volume status change while receiving dialysis. Her oxygenation status improved significantly following blood pressure and rate control and a dialysis session. There are no PFT's to support the diagnosis of COPD, but marked hyperinflation on CXR and notable smoking history indicated strong possibility of COPD contributing to patient's symptoms so patient was treated with home dose of spiriva and albuterol as needed. The patient was weaned on BiPap and began to breathe comfortably on room air following dialysis. . # Atrial fibrillation: The pt was anticoagulated with coumadin and rate controlled with metoprolol and diltiazem for her history of atrial fibrillation. . # Hypertension: The patient's hypertension was also controlled with diltiazem and metoprolol and following a successful dialysis session her lisinopril and irbesartan were restarted. . # Diabetes: For her diabetes the patient was continued on her home dose of NPH with an insulin sliding scale. . # Hyperkalemia: The patient has end stage renal disease and receiving HD. The patient was orginally volume overloaded and on day two of admission developed hyperkalemia to a K of 6.7. She had no peaked T waves or QT prolongation on EKG and received calcium carbonate and D5/insulin as well as dialysis. Her electrolytes were monitored closely with subsequent K between 4.1 and 5.0. # Heme: On admission labs the patient was erythrocytotic. Prior evaluations had not shown renal mass that could contribute to over production of erythropoietin and on [2163-5-30] the epo level was low normal which would suggest a MPD such as [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. Patient would benefit from heme follow up as an outpatient. Medications on Admission: Nephro-cap 1 capsule daily Warfarin 2 mg Daily Brimonidine 0.15 % Drops DAILY Latanoprost 0.005 % Drops HS Tiotropium 18 mcg DAILY Ranitidine HCl 150 mg DAILY Lisinopril 30 mg DAILY Insulin NPH 4 [Hospital1 ] Albuterol 90 mcg 1 puff:q6hours Aspirin 325 mg daily Simvastatin 80 mg daily Diltiazem HCl SR 120 mg DAILY Irbesartan 150 mg daily Metoprolol Tartrate 100 mg [Hospital1 ] Sevelamer HCl 800 mg TID Discharge Medications: 1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 13. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) units Subcutaneous twice a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: [Location (un) 86] [Location (un) 269] Discharge Diagnosis: Primary: Acute diastolic Heart Failure End stage renal disease on hemodialysis . Secondary: Peripheral Vascular disease Atrial Fibrillation on Coumadin Hypertension Discharge Condition: stable Discharge Instructions: You were admitted with shortness of breath and acute diastolic heart failure. This has been treated with dialysis & aggressive blood pressure control. . We have not made any changes to your medications, please make sure to adhere to a low salt diet and keep all your follow up appointments as shown below. . If you develop any worsening shortness of breath, chest pain, weakness or any other general worsening of condition, please call your PCP or come directly to the ED. . It is very important that you adhere to a low sodium diet. Followup Instructions: 1. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2163-7-14] 12:40 . 2. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2163-8-29] 11:40am . 3. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2163-12-7*] 1:40pm	[ "V58.67", "428.33", "518.82", "250.70", "V49.75", "272.0", "428.0", "585.6", "530.81", "289.0", "250.40", "588.81", "403.91", "V15.82", "440.20", "V58.61", "427.31", "583.81", "V45.1" ]	icd9cm	[ [ [] ] ]	[ "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	9356, 9433	4875, 7632	333, 339	9642, 9651	3876, 4852	10234, 10693	2613, 2872		8095, 9333		9454, 9621		7658, 8072			9675, 10211										2887, 3857																								274, 295											367, 1723																1745, 2343	2359, 2597
13,778	153,317	44140+58684	Discharge summary	report+addendum	Admission Date: [2133-6-3] Discharge Date: [2133-6-5] Date of Birth: [2051-10-9] Sex: M Service: SURGERY Allergies: Tetanus,Diphther Toxoid Adult / Aggrenox Attending:[First Name3 (LF) 2597] Chief Complaint: in graft stenosis Major Surgical or Invasive Procedure: OPERATION PERFORMED: 1. Ultrasound-guided puncture of left common femoral artery. 2. Contralateral second-order catheterization of right dorsalis pedis artery. 3. Serial arteriogram of the right lower extremity. 4. Angioplasty of right vein graft to dorsalis pedis artery anastomotic stenosis. History of Present Illness: This is an 81-year-old man with severe peripheral arterial disease. He is status post a right common femoral to dorsalis pedis artery vein graft bypass. He has since had 2 percutaneous interventions for distal anastomotic stricture. On surveillance duplex he was found to have a distal anastomotic stricture once more. In addition, he has developed an ulcer in the medial aspect of his first toe. Given these findings the patient was consented for a leg angiogram possible angioplasty for limb salvage. Past Medical History: Gout MRSA/Enterococcal (not VRE) UTI [7-8] * DM type 2 complicated by neuropathy & retinopathy, Hgb A1c 6.8% in [9-8] * CAD s/p 4v CABG ([2119]) * PVD s/p bypass grafting (s/p L popliteal to DP bypass w/ R arm vein ([8-3]) ; failed - s/p revision ([3-4]); RLE claudication - s/p R SFA to DP saphenous vein bypass ([5-5]) ; stenosed distal graft - s/p atherectomy ([9-5])) * 2nd & 3rd degree AV block s/p pacemaker in [2123] * hypertension * s/p L carotid endarterectomy in [2128] * hyperlipidemia * known infrarenal aortic aneurysm s/p graft repair ([12/2119]) * anxiety/depression * osteoarthritis * chronic back pain * cataracts * chronic renal insufficiency (recent creatinine values 1.3-2.1) * H/o intermittent slurred speech with CVA diagnosed in [9-/2129] * H/o vertigo, uses meclizine occasionally as outpatient Social History: Patient is a retired carpenter who lives with his wife. [Name (NI) ] has a 30-pack-year smoking history, but quit about 30 years ago. He does not drink alcohol. He denies h/o illicit drug use. He uses a walker to ambulate due to leg pain. He receives home VNA. Family History: Mother with CAD,HTN and stroke. 2 brothers with CAD s/p CABG. Physical Exam: Physical Exam: Vitals: T: 96.4 P:71 R: 16 BP:141/53 SaO2: 98 General: Awake, cooperative, NAD. Obese man, pleasant, slighlty anxious. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: Dressing in Right groin from angio, mulitple scars on legs from vascular procedures. Covered wound on base of R great toe. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [Doctor Last Name 1841] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [3-4] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: Right pupil large, irregular, surgical not reactive, left pupil small round surgical minimal reaction. Left [Last Name (un) 8491] cut, R fundus appeared normal, could not see left III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Decreased to LT, pinprick and temperature at feet to knees. No extinction to DSS. -DTRs: [Name2 (NI) ] elicitable reflexes. Toes mute bilaterally. -Coordination: No intention tremor, normal FNF Pertinent Results: [2133-6-5] 06:15AM BLOOD WBC-6.3 RBC-2.99* Hgb-9.6* Hct-28.7* MCV-96 MCH-32.1* MCHC-33.4 RDW-13.4 Plt Ct-241 [2133-6-3] 06:11PM BLOOD PT-13.0 PTT-43.3* INR(PT)-1.1 [2133-6-5] 06:15AM BLOOD Glucose-90 UreaN-40* Creat-2.2* Na-139 K-3.8 Cl-102 HCO3-23 AnGap-18 [2133-6-4] 04:57PM BLOOD CK(CPK)-91 [2133-6-5] 06:15AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.3 [2133-6-4] 06:03AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 URINE Blood-MOD Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM URINE RBC-[6-11]* WBC-21-50* Bacteri-FEW Yeast-NONE Epi-0 URINE CastHy-[3-6]* Brief Hospital Course: [Known lastname ],[Known firstname 94726] Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that she would undergo: OPERATION PERFORMED: 1. Ultrasound-guided puncture of left common femoral artery. 2. Contralateral second-order catheterization of right dorsalis pedis artery. 3. Serial arteriogram of the right lower extremity. 4. Angioplasty of right vein graft to dorsalis pedis artery anastomotic stenosis. Prepped, and brought down to the endo suite room for surgery. Intra-operatively, was closely monitored and remained hemodynamically stable. Tolerated the procedure well without any difficulty or complications. Post-operatively, transferred to the PACU for further stabilization and monitoring. Was then transferred to the VICU for further recovery. While in the VICU, received monitored care. When stable was delined. Diet was advanced. When stabilized from the acute setting of post operative care, was then transferred to floor status. While on the floor he had a syncopical event. Neuro was called. Head CT hegative. R/O for stroke. He recovered rapidly. Unknown etiology. On the floor, remained hemodynamically stable with pain controlled. Continues to make steady progress without any incidents. Discharged home in stable condition. Received preoperative hydration. On DC the creatinine is stable. Medications on Admission: Allopurinol 100", plavix 75' METOPROLOL 25", lasix 40mg'', Diovan 160', simvistatin 80', HUMULIN N 45 u in am and 40 units in pm procrit, Doxercalciferol 2.5 mcg QOD, Tramadol 50 TID, Trazadone 50 HS Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Humulin N 100 unit/mL Suspension Sig: One (1) As directed by PCP Subcutaneous twice [Name Initial (PRE) ] day. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Right lower extremity ischemia with ulceration. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? If instructed, take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [2-4] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [3-5] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [Telephone/Fax (1) 1237]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2133-7-2] 10:30 Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) ] Phone:[Telephone/Fax (1) 721] Date/Time:[2133-7-2] 2:30 Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2133-7-3] 10:40 [2133-7-9] 04:50p [Last Name (LF) 1111],[First Name3 (LF) 1112] B. LM [Hospital Unit Name ], [Location (un) ] VASCULAR SURGERY (SB) [2133-7-9] 04:15p VASCULAR [Apartment Address(1) ] ([Doctor First Name ]) LM [Hospital Unit Name ], [Location (un) ] VASCULAR LMOB (NHB Completed by:[2133-6-5] Name: [Known lastname ],[Known firstname 4327] R Unit No: [Numeric Identifier 14967] Admission Date: [2133-6-3] Discharge Date: [2133-6-5] Date of Birth: [2051-10-9] Sex: M Service: SURGERY Allergies: Tetanus,Diphther Toxoid Adult / Aggrenox Attending:[First Name3 (LF) 1546] Addendum: Pt with stage IV CKD Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1548] MD [MD Number(1) 1549] Completed by:[2133-7-15]	[ "V45.01", "V45.81", "285.9", "272.4", "357.2", "428.0", "250.50", "585.4", "362.01", "440.23", "996.74", "250.60", "707.15", "274.9", "403.90", "414.00", "250.40" ]	icd9cm	[ [ [] ] ]	[ "00.40", "88.48", "39.50" ]	icd9pcs	[ [ [] ] ]	12225, 12388	5462, 6901	316, 624	8213, 8213	4786, 5439	10965, 12202	2346, 2410		7152, 8092		8142, 8192		6927, 7129			8364, 10368	10394, 10942						3637, 4767			2440, 3006																								259, 278											652, 1157									8228, 8340							1179, 2046	2062, 2330
22,120	196,321	29094	Discharge summary	report	Admission Date: [2120-10-6] Discharge Date: [2120-10-9] Date of Birth: [2074-11-6] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 330] Chief Complaint: thrombosed lt. ue fistula with hyperkalemia and urgent need for dialysis given this Major Surgical or Invasive Procedure: TPA infusion to AV fistula for clearance History of Present Illness: 45 y/o man with DM, CAD, depression, who lives at the [Hospital ] Rehab, is blind, bedridden, and on HD for ESRD who was found to have a clotted lt. UE fistula at [Last Name (un) ], K of 7 (no ECG changes), transferred to the [Hospital1 ] for urgent HD. Past Medical History: 1. ESRD [1-4] ?diabetes; on HD for approx 1 year. 2. CAD s/p 4 MI's. further hx not available 3. ?Pericardial effusions vs pericarditis? 4. OSA/asthma. Has been on bipap at night; stopped [1-4] panic attacks 5. "Liver disease;" pt does not know etiology. Has q2 week paracenteses. 6. s/p CVA resulting in L-sided weakness. Resolved 7. s/p toe amputation 8. hypothyroidism 9. sacral decubiti 10. blindness 11. memory loss Social History: Lives at the [Hospital ] Rehab Social History: No smoking, occasional alcohol, no drug use. Family History: NC Physical Exam: VS: 98.4 105/68 77 13 97 ra GEN: chronically ill-appearing gentleman with anasarca; NAD HEENT: EOMI, anicteric, MMM dry; corneal opacifications OU NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l with few [Hospital1 ]-basilar cracles; BS decreased overall, esp at bases CV: RR, S1 and S2 wnl, +S4 gallop. No flow or bruit heard over HD cath site. No JVD appreciable (stiff neck) ABD: firm, distended with very tense/firm and inturated skin on flanks. Otherwise abdomen non-tender. + BS. EXT: tense edema,tender, + erythema B LE and questionable warmth from tibial plateau to ankles; chronic venous stasis changes, feet warm and well-perfused, very slight ulceration on rt shin - no purulence or erythema. SKIN: Legs as above; rt trunk with very tense and hard skin; skin over back with papules and several areas of brownish crusts. Large decubiti with + bleeding/stage I break-down. Appears clean-based, no purulence. NEURO: AAOx3. Cn II-XII intact. 4/5 strength throughout. Pertinent Results: [2120-10-6] 02:10AM PT-15.3* PTT-27.6 INR(PT)-1.4* [2120-10-6] 02:10AM PLT COUNT-213 [2120-10-6] 02:10AM HYPOCHROM-3+ ANISOCYT-1+ MACROCYT-3+ [2120-10-6] 02:10AM NEUTS-80.5* LYMPHS-10.6* MONOS-6.1 EOS-2.4 BASOS-0.4 [2120-10-6] 02:10AM WBC-7.6 RBC-2.95* HGB-9.3* HCT-30.4* MCV-103* MCH-31.7 MCHC-30.7* RDW-16.4* [2120-10-6] 02:10AM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-2.8* [2120-10-6] 02:10AM GLUCOSE-114* UREA N-54* CREAT-4.8* SODIUM-131* POTASSIUM-6.7* CHLORIDE-96 TOTAL CO2-25 ANION GAP-17 [2120-10-6] 06:30AM ALBUMIN-3.2* [2120-10-6] 06:30AM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-288* TOT BILI-0.3 [2120-10-6] 06:30AM POTASSIUM-6.4* [2120-10-6] 06:38AM K+-6.3* [2120-10-6] 01:00PM CALCIUM-8.9 PHOSPHATE-5.4* MAGNESIUM-2.7* [2120-10-6] 01:00PM GLUCOSE-87 UREA N-60* CREAT-5.2* SODIUM-132* POTASSIUM-6.3* CHLORIDE-95* TOTAL CO2-26 ANION GAP-17 [2120-10-6] 08:49PM GLUCOSE-96 UREA N-37* CREAT-3.8# SODIUM-142 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-17 Brief Hospital Course: Pt. was admitted to [Hospital Ward Name 121] 10 Hepatorenal service and went to IR for placement of a temporary HD catheter ("Quinten" catheter placed to the Rt. Subclavian vein). He then underwent HD without complication. He was subsequently evaluated by IR through fistulography which confirmed a thrombosis. Catheters were introduced to the fistula, and a TPA infusion was begun, necessitating ICU admission for monitoring. He received the TPA thougout the night of [10-7]-7, and repeat fistulography was performed the next day - the fistula was clear of thrombosis. He suffered no complication of the TPA infusion. Otherwise, he was maintained on his usual outpatient medications without complication or incident. He was discharged back to [Last Name (un) ] on [10-9]. Medications on Admission: coreg 3.125 [Hospital1 ] phoslo 667; t caps w/ meals nephrocaps QHS iron 325 kayexalate 120cc daily sorbitol on days off HD synthroid 200 mcg daily SSI (2U regular for each 50 over 200); no long-acting insulin seen combivent q4 hrs zoloft 100 daily wellbutrin SR 150 daily risperidone 0.5mg po QHS Ambien 5mg QHS fentanyl patch 100mg q 72 hrs biascodyl po and pr prn senna colace MOM prn Discharge Medications: 1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-4] Puffs Inhalation Q4H (every 4 hours) as needed. 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: as per sliding scale units, insulin Injection ASDIR (AS DIRECTED): as per sliding scale (included). 11. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 12. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 14. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 15. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 19. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 20. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [Last Name (un) ] Center - [Location (un) 701] Discharge Diagnosis: Chronic renal failure with failure (thrombosis) of Lt. UE AV fistula Discharge Condition: Stable Discharge Instructions: Take all your medications as prescribed Followup Instructions: With your usual dialysis providers at the [Hospital *] Rehab.	[ "536.3", "244.9", "585.6", "996.73", "493.90", "403.91", "412", "276.7", "250.40", "250.60", "E878.2", "707.03" ]	icd9cm	[ [ [] ] ]	[ "99.10", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	6602, 6683	3413, 4210	355, 398	6796, 6805	2344, 3390	6893, 6961	1277, 1281		4653, 6579		6704, 6775		4236, 4630			6829, 6870										1296, 2325																								232, 317											426, 693																715, 1146	1214, 1261
907	133,125	43049	Discharge summary	report	Admission Date: [2163-10-1] Discharge Date: [2163-10-2] Date of Birth: [2107-6-29] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Aspirin / Levofloxacin / Bactrim Attending:[First Name3 (LF) 14802] Chief Complaint: Nausea/ vomiting Major Surgical or Invasive Procedure: Placement of External Ventriclar Device. History of Present Illness: Ms. [Known lastname ] is a 56F with history of lupus, renal insufficiency, and hypertension who presents to the ED with nausea and vomiting for several hours. While in triage, patient became unresponsive and was noted to only have movement in her bilateral upper extremities. Patient was emergently intubated and taken to CT scan. Per family, patient has been in usual health and felt ill this afternoon. Her lupus has been well controlled, though she has been hypertensive in office visits. She does not use any anti-coagulation. Past Medical History: #Type IV Lupus Nephritis x 8 years - on prednisone, cellcept (s/p cytoxan in past) - baseline Cr - 1.9-2.0 #HTN #H/O Klebsiella ESBL UTI #H/O Asymptomatic Bacturia #H/O Necrotizing Fasciitis #H/O ARDS #H/O Anemia Social History: Cantonese speaker who is a homemaker and lives with husband and 2 children. Family History: FH: sister with lupus and mother with HTN. No CAD, CA Physical Exam: Deceased Pertinent Results: [2163-10-1] 10:29PM PT-9.9 PTT-25.6 INR(PT)-0.9 [2163-10-1] 10:13PM GLUCOSE-161* LACTATE-2.0 NA+-144 K+-3.6 CL--118* TCO2-19* [2163-10-1] 10:13PM HGB-9.7* calcHCT-29 [2163-10-1] 10:00PM GLUCOSE-171* UREA N-43* CREAT-1.8* SODIUM-145 POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-19* ANION GAP-15 [2163-10-1] 10:00PM estGFR-Using this [2163-10-1] 10:00PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-1.9 [2163-10-1] 10:00PM WBC-14.4# RBC-3.18 HGB-9.7* HCT-30.3* MCV-95 MCH-30.7 MCHC-32.2 RDW-12.8 [2163-10-1] 10:00PM NEUTS-63.3 LYMPHS-31.9 MONOS-3.6 EOS-0.9 BASOS-0.3 [2163-10-1] 10:00PM PLT COUNT-239 Brief Hospital Course: Ms. [Known lastname ] is a 56F with history of lupus, renal insufficiency, and hypertension who presents to the ED with nausea and vomiting for several hours. While in triage, patient became unresponsive and was noted to only have movement in her bilateral upper extremities. Patient was emergently intubated and taken to CT scan. The CT showed an ACA aneurysm with very high intracranial pressure. Emergent EVD placed in ICU with elevated ICPs in the 30s. She was admitted to the neurointensive care unit for aggressive critical care. Given patient's poor prognosis, the patient's family withdrew care. She was extubated and passed shortly. Medications on Admission: Medications prior to admission: Plaquenil 200 mg every other day Calcitriol 0.25 mcg daily Lisinopril 10 mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Subarachnoid hemorrhage secondary to aneurysm rupture intracranial hemorrhage COMA respiratory failure Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2163-10-2]	[ "430", "585.9", "348.5", "710.0", "582.81", "V49.86", "331.4", "348.4", "403.90", "V58.65" ]	icd9cm	[ [ [] ] ]	[ "96.71", "02.21", "96.04" ]	icd9pcs	[ [ [] ] ]	2889, 2898	2047, 2695	330, 372	3044, 3054	1384, 2024	3106, 3140	1284, 1339		2860, 2866		2919, 3023		2721, 2721			3078, 3083										1354, 1365											2753, 2837													273, 292											400, 937																959, 1174	1190, 1268
24,607	197,631	19247	Discharge summary	report	Admission Date: [2142-2-21] Discharge Date: [2142-4-6] Date of Birth: [2069-11-24] Sex: M Service: Vascular Surgery CHIEF COMPLAINT: Acute mesenteric ischemia. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old nondiabetic white male without any significant medical history, who smokes two packs of cigarettes per day, who developed upper abdominal pain after eating six months prior to admission. This resulted in a 50-pound weight loss. An upper gastrointestinal series was negative. Abdominal computed tomography at an outside hospital showed extensive calcification. The patient also complained of bilateral calf claudication for the previous two years. Initially, his right calf cramped and then left calf claudication developed as well. The patient was referred to Dr. [Last Name (STitle) 1391] and was seen on [2142-2-2] in [Location (un) 5028]. Esophagogastroduodenoscopy by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] was requested and reportedly showed erosion/ulcerations. A mesenteric arteriogram done as an outpatient at [Hospital1 69] on [2142-2-20] via the right brachial artery (after unsuccessful left brachial and bilateral femoral punctures) showed left subclavian occlusion, celiac artery occlusion, infrarenal aortic occlusion, superior mesenteric artery with high-grade stenosis which reconstitutes the internal mammary artery, and high-grade right proximal renal artery stenosis, and uptake in the left renal artery. The patient was discharged home post angiogram on [2142-2-20]. At midnight that same night the patient began to have severe abdominal pain. He was admitted to a local hospital, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital in [Location (un) 5028], where a noncontrast computed tomography scan showed pneumatosis suggesting acute mesenteric ischemia. The patient was transported by medical flight to [Hospital1 346] for further evaluation. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Vasectomy 40 years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Tylenol as needed. FAMILY HISTORY: Mother died secondary to congestive heart failure. Brother had "open heart" surgery. No history of diabetes. SOCIAL HISTORY: The patient lives with his wife. [Name (NI) ] ambulates independently. He smokes two packs of cigarettes per day. He has one or two beers per day. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs with a temperature of 97.7, his pulse was 84, his respiratory rate was 18, his blood pressure was 167/64, and oxygen saturation was 100% on 2 liters via nasal cannula. In general, an alert, cooperative, thin, white male in no acute distress. Head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric. Pupils were equal and round. The neck was supple. No lymphadenopathy or thyromegaly. Chest examination revealed heart with a regular rate and rhythm without murmurs. The lungs with wheezes present. The abdomen was mildly tender with guarding and rebound. Rectal examination showed no masses. Stool was guaiac-positive. Extremities revealed feet equally cool. On pulse examination, carotids were palpable bilaterally. Radial pulses were 2+ bilaterally. Femoral pulses were palpable bilaterally. Pedal pulses had monophasic Doppler signals. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 15.9, his hemoglobin was 11, his hematocrit was 34.2. Prothrombin time was 15.6, partial thromboplastin time was 40, and INR was 1.6. Sodium was 143, potassium was 4.2, chloride was 114, bicarbonate was 24, blood urea nitrogen was 17, and creatinine was 1. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus rhythm at a rate of 80. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the hospital on [2142-2-21]. He was taken emergently to the operating room to have an aortobifemoral bypass and a superior mesenteric artery to aorta bypass by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391] followed by an exploratory laparotomy and small-bowel resection by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (General Surgery). At the time of procedure, because of ongoing ischemia, Dr. [Last Name (STitle) ] planned a second look exploration on [2142-2-22]. During exploration, the patient had washout, ileocecectomy, and ileocolostomy. Postoperatively, the patient developed a fever and elevated bilirubin. On [2142-3-4], the patient had successful placement of a percutaneous cholecystostomy tube with ultrasound guidance. Placement yielded 80 cc of nonpurulent dark green inspissated bile. The patient remained extremely jaundiced. Cultures of the bile grew methicillin-resistant Staphylococcus aureus. The patient was treated with a course of vancomycin and Zosyn. The patient's sputum cultures grew [Last Name (LF) 23087], [First Name3 (LF) ] the patient was treated with a course of fluconazole. The patient was pan-cultured for a fever spike on [2142-3-30]. Once set of blood cultures grew two kinds of Klebsiella pneumoniae which were pan-sensitive; including levofloxacin. The Klebsiella was resistant to Unasyn. The anaerobic bottle grew Enterobacter which was resistant to Unasyn and Zosyn, but otherwise sensitive to other antibiotics including levofloxacin. Levofloxacin was started on [2142-4-1]. Length of course will be determined at discharge. The patient failed a bedside swallowing study in early [Month (only) 958]. He continued to remain nothing by mouth. A percutaneous endoscopic gastrostomy tube was placed to start tube feedings. Several days later, a double lumen Hickman catheter was placed in the left subclavian vein for long-term total parenteral nutrition. Tube feeds consisted of half-strength Criticare which reached a goal of 20 cc per hour. The total parenteral nutrition goal was 33 kilocalories per kilogram. The patient had a follow-up bedside swallow examination which seemed to indicate the patient was aspirating. However, a video swallow study done on [2142-4-3] showed that the patient's swallowing had improved significantly and there was no aspiration. Recommendations included starting pureed solids and thin liquids on [2142-4-4]. It was also recommended to stop the tube feeds prior to transfer to the rehabilitation facility. After placement of the percutaneous endoscopic gastrostomy tube in early [Month (only) 958], the patient was noted to have blood in the tubing, and he also passed liquid guaiac-positive stools. His hematocrit was 26. He was transfused to keep his hematocrit greater than 30 several times. The patient was taken for an esophagogastroduodenoscopy by Gastroenterology on [2142-3-19]. At that time, gastritis versus portal gastropathy was considered. Also, two lesions of angiectasis (one in the stomach and one in the proximal duodenum) were cauterized. The patient still continued to have blood draining into his rectal tube. A repeat esophagogastroduodenoscopy was normal, but a possibility of bleeding from the surgical anastomosis was considered. The following day, a colonoscopy was done and an ulcer was seen in the right colon near the anastomosis. There was no active bleeding seen. A computed tomography angiogram of the abdomen done did not show an abscess. No surgical exploration was considered unless the patient developed active bleeding. He was transfused intermittently, and his hematocrit has remained stable. The patient's cholecystotomy tube fell out in the early morning hours of [2142-4-2]. There was no significant drainage, and the tube was not replaced. Physical Therapy evaluated the patient for full weightbearing ambulation. The patient was easily fatigued but cooperative. At the time of this dictation, the patient's abdominal and groin incisions were clean, dry, and intact without surgical staples in place. The patient's feet were equally warm with palpable dorsalis pedis pulses and dopplerable posterior tibialis pulses bilaterally. He has a double lumen Hickman catheter in his left subclavian vein and a percutaneous endoscopic gastrostomy tube. At the time of this dictation, the patient's nutrition plan will be started per recommendations from the Nutrition Service. The patient will start a pureed diet and thin liquids with supervision. Total parenteral nutrition is at goal, and cycling will start today at 16 hours from 6 p.m. to 10 a.m. Stopping the tube feeds has been recommended but has not been decided upon. Liver function tests will be ordered as requested. Total parenteral nutrition will be dextrose 325 grams, amino acid 100 grams, and lipids 45 grams per 2 liters. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg intravenously q.24h. (length of treatment to be determined at discharge). 2. Lopressor 12.5 mg by mouth/PEG twice per day (hold for systolic blood pressure of less than 100, heart rate of less than 55). 3. Ursodiol 300 mg by mouth/PEG tube three times per day. 4. Protonix 40 mg intravenously q.12h. 5. Loperamide 2 mg by mouth twice per day. 6. Ferrous sulfate 5 mL by mouth twice per day. 7. Oral solution of morphine sulfate 10 mg to 15 mg by mouth/NGT q.6h. 8. Mucomyst 20% 1 mL to 10 mL via nebulizer q.4-6h. as needed. 9. Chlorhexidine gluconate 15 mL by mouth three times per day as needed. 10. Dulcolax suppository at hour of sleep as needed. 11. Artificial Tears 1 to 2 drops both eyes four times per day as needed. 12. Tylenol 650 mg to 100 mg by mouth/per rectum q.4-6h. as needed. 13. Regular insulin sliding-scale q.6h. DISCHARGE DISPOSITION: Rehabilitation facility. CONDITION AT DISCHARGE: Satisfactory. PRIMARY DISCHARGE DIAGNOSES: 1. Acute mesenteric ischemia. 2. Aortobifemoral bypass graft and superior mesenteric artery to the aorta on [2142-2-21] by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391]. 3. Exploratory laparotomy and small-bowel resection on [2142-2-21] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. 4. Second look exploration, washout, ileocecectomy, and ileocolostomy on [2142-12-23] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. SECONDARY DISCHARGE DIAGNOSES: 1. Blood loss anemia; status post multiple transfusions. 2. Bleeding from ulcer next to right colon anastomosis; resolved. 3. Jaundice with placement of percutaneous cholecystostomy tube. 4. Malnutrition; placement of percutaneous endoscopic gastrostomy tube, double lumen Hickman catheter placed on [2142-3-20]. 5. Klebsiella and Enterobacter bacteremia. 6. [Year (4 digits) ] pneumonia. 7. Methicillin-resistant Staphylococcus aureus cultured from bile. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern1) 3954] MEDQUIST36 D: [2142-4-4] 15:43 T: [2142-4-4] 15:49 JOB#: [Job Number 52432]	[ "276.1", "444.89", "518.5", "112.4", "276.3", "557.1", "276.2", "790.7", "576.1" ]	icd9cm	[ [ [] ] ]	[ "39.29", "45.23", "99.04", "54.63", "38.91", "45.73", "96.72", "43.41", "43.11", "89.64", "39.25", "96.07", "96.04", "45.62" ]	icd9pcs	[ [ [] ] ]	9800, 9836						2206, 2318	10442, 11188				8898, 9776	2169, 2189												2079, 2142											3883, 8871						9851, 9874								167, 195											224, 2025																2048, 2055	2335, 3854
9,754	145,043	8818	Discharge summary	report	Admission Date: [2187-2-1] Discharge Date: [2187-3-9] Date of Birth: [2124-6-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6565] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: Mr. [Known lastname 8467] is a 62m with metastatic prostate ca, cad, osa, and a history of mild doe with an unrevealing work-up who came to oncology clinic today with complaints of worsening doe over the past 5-6 days. He states it began this past weekend with no clear precipitant; he'd felt fine all last week. Whereas normally he could walk 80-90 feet on level ground before feeling dyspneic, now it occurs at half that distance. He describes the sensation as one of having to work harder to [Last Name (LF) 1440], [First Name3 (LF) ] increased effort. There's been minimal cough, minimal sputum production, no hemoptysis, no wheezing, no orthopnea/pnd, no chest pain or palpitations, no uri sx. He also has no sick contacts, no exposure to dusts or other strange environmental phenomenon, no recent travel; his volunteer activities does include work with the homeless, but a large portion of this is office-related work, and he does not think anyone he's been around has had a cough. He further denies f/c (though had one temp to 100.1 at home), abd pain, n/v/d/c, melena/hematochezia, hematuria/frequency. His appetite has been decreased for the past few weeks but he's kept up with oral hydration. In the oncology clinic, hi o2 sats were in the mid 90's on room air at rest but he desatted to mid 80's with ambulation. Past Medical History: -Metastatic prostate CA -- Diagnosed [2178] after developing back pain, and his PSA came back at 1567. He has multiple osseous metastases. The cancer is hormone refractory, and he was initially treated with lupron; when disease progression was demonstrated on this regimen, he underwent 28 cycles of taxotere/estramustine. Then in [12/2185] he got mitoxantrone and prednisone. Most recently he's had taxotere and carboplatin for 12 cycles with good response though complicated by acute colitis. As he continued to progress off chemotherapy, he was started on the ARIAD trial in 1/[2186]. -HTN -CAD -- NSTEMI [2179], MIBI in [2183] with mild, fixed defects -OSA Social History: Mr. [Known lastname 8467] lives in [Location ] with his wife and son. [Name (NI) ] formerly worked for [Company 2676] as a software engineer, working on the guidance system for the Patriot missile; prior to that he was in the Air Force. He has an undergraduate degree in MIS and an MBA. He smoked 1ppd for 20 years but quit 20 years ago, has a glass of wine occasionally with dinner, and has never used illicit/injection drugs. He has a labrador retriever. Family History: His mother seems to have a malignancy but bx's have been unrevealing thus far. Physical Exam: t 99.4, bp 160/88, hr 80, rr 18, spo2 96%ra gen- pleasant, mod obese male, looks slightly older than age, non-toxic, nad heent- anicteric sclera, op clear with mmm neck- no jvd/lad/thyromegaly cv- rrr, s1s2, 2/6 systolic murmur at ursb (no radiation) pul- no resp distress/accessory muscle use; moves air well, normal i:e, no w/r/r abd- soft, nt, nd, nabs, no hepatosplenomegaly back- no cva tenderness, no sacral edema, mild mid-thoracic vert pain (baseline per pt) extrm- no cyanosis/edema, warm/dry nails- no clubbing, no pitting/indentations, mildly discolored derm- erythematous, confluent rash on elbows, hands, feet neuro- a&ox3, no focal cn/motor deficits Pertinent Results: Admission Labs: [2187-2-1] 10:44AM BLOOD WBC-4.5 RBC-3.87* Hgb-10.9* Hct-31.0* MCV-80* MCH-28.0 MCHC-35.0 RDW-16.0* Plt Ct-163 [2187-2-1] 10:44AM BLOOD Neuts-66 Bands-4 Lymphs-15* Monos-7 Eos-5* Baso-2 Atyps-1* Metas-0 Myelos-0 [2187-2-1] 10:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr[Last Name (STitle) 833] [2187-2-1] 10:44AM BLOOD Plt Smr-NORMAL Plt Ct-163 [2187-2-1] 10:44AM BLOOD Ret Aut-0.7* [2187-2-1] 10:44AM BLOOD Glucose-123* UreaN-21* Creat-1.4* Na-132* K-3.8 Cl-100 HCO3-24 AnGap-12 [2187-2-1] 10:44AM BLOOD ALT-34 AST-69* LD(LDH)-626* CK(CPK)-145 AlkPhos-67 TotBili-0.9 DirBili-0.2 IndBili-0.7 [2187-2-1] 10:44AM BLOOD CK-MB-2 cTropnT-<0.01 [2187-2-1] 08:00PM BLOOD CK-MB-2 cTropnT-<0.01 [2187-2-2] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 [2187-2-1] 10:44AM BLOOD TotProt-5.5* Albumin-3.2* Globuln-2.3 Calcium-7.4* Phos-2.3* Mg-1.7 Cholest-213* [2187-2-1] 08:00PM BLOOD Iron-35* [2187-2-1] 08:00PM BLOOD calTIBC-229* VitB12-1354* Folate-14.6 Ferritn-693* TRF-176* [2187-2-1] 10:44AM BLOOD Triglyc-230* . [2-1] CXR: Subtle right lower lobe posterior basilar opacity, which may be due to atelectasis or early pneumonia. Followup chest radiographs would be helpful. Linear retrosternal upper lobe opacity, likely atelectasis. . [2-1] Head CT: 1. New 2.0 x 1.3 cc cm focus of hypointensity in the right inferior frontal lobe. The appearance is nonspecific and contusion or age indeterminate infarction cannot be excluded. MRI is recommended for further correlation. . [2-2] LENIs: No evidence of deep venous thrombosis. . [2-2] CTA Chest: 1. Multiple segmental pulmonary emboli. 2. Patchy bilateral ground-glass opacities, likely consistent with pulmonary edema from congestive heart failure. An infectious process cannot be fully ruled out. . [2-2] Renal U/S: 1. No hydronephrosis. 2. Possible tiny crystal in the mid portion of the right kidney. . [2-2] CXR: Interval worsening of multifocal bilateral hazy (ground glass) opacities, which is likely due to asymmetrical pulmonary edema or atypical infection. Differential diagnosis includes hemorrhage and drug toxicity. . [2-5] Echo: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a very small pericardial effusion (seen posteriorly). There are no echocardiographic signs of tamponade. . [2-7] CXR: No evidence of pneumothorax. Slight worsening of parenchymal opacities. . [2-7] Bronchial Washings: negative for malignant cells. . [2-9] CXR: Slight improvement in bilateral pulmonary opacities. . CTA Chest [2187-2-21]: CT OF THE CHEST WITH CONTRAST, FINDINGS: Current studies viewed in conjunction with the prior exam of [2187-2-11]. There are diffuse ground glass opacities throughout both lung fields, most marked in the upper lobes. There is relative sparing of the right lower lobe. There is no evidence of pulmonary embolism. There are no effusions appreciated. Again appreciated is some scattered mediastinal lymphadenopathy. Bone windows reveal some rarified areas within scattered vertebral bodies raising the question of metastatic foci, unchanged compared to the prior exam. Small bilateral pleural effusions are appreciated and appear new since the prior study. . IMPRESSION: 1. No evidence of pulmonary embolism. 2. Marked progression in diffuse ground glass infiltrates with relative sparing of the right lower lobe. This is associated with development of new small bilateral effusions. 3. Study is otherwise unchanged including multiple areas within the thoracic vertebral body raising the question of bony involvement by this patient's underlying malignancy. . Wedge biopsies of lung, two: I. (Right upper lobe): a. Patchy organizing pneumonitis with features of bronchiolitis obliterans-organizing pneumonia (BOOP). b. Marked accumulation of intraalveolar macrophages. c. Subpleural fibrosis with intimal thickening of pulmonary arteries. . II. (Right middle lobe): a. Metastatic adenocarcinoma consistent with prostate origin, microscopic focus (slide G). Tumor cells are positive for PSA and keratin cocktail and negative for PSAP, keratin 7 and 20. b. Patchy organizing pneumonitis with features of bronchiolitis obliterated-organizing pneumonitis (BOOP). c. Marked accumulation of intraalveolar macrophages. d. Subpleural fibrosis with intimal thickening of pulmonary arteries. . Brief Hospital Course: Shortness of [Date Range ]: This was initially felt to be [1-18] PE given CTA findings on admission. Initial work up ruled out cardiac ischemia with a normal EKG and negative cardiac enzymes. Infectious etiologies were also considered, including bacterial pneumonia, PCP (given that that the patient had been on chemotherapy), fungal infections, and tuberculosis. Initially, the patient was treated with levofloxacin for community acquired pneumonia. This was discontinued at the recommendation of the infectious diseae service as it has some anti-TB activity, and we did not want to give monotherapy for TB until it was formally ruled out. When the patient continued to be febrile, ceftriaxone and azithromycin were started for community acquired pneumonia, and coverage was then broadened to zosyn and vancomycin to cover nosocomial pneumonia as the patient's infiltrates on chest xray were worsening while the patient was hospitalized. A viral antigen screen was negative, ruling out influenza and several other viral infections. . The pulmonary service was consulted, and a bronchoscopy with BAL was performed. The gram stain from the BAL showed no organisms, and the respiratory culture grew oropharyngeal flora. PCP and AFB were negative. However, the PCP screen in patients with malignancy is not always reliable, so bactrim and steroids were started to cover PCP. [Name10 (NameIs) ] patient was also continued on isolation precautions for TB until additional sputum samples could be obtained, for similar reasons. He was eventually ruled out for TB with 3 negative AFBs. After PCP was ruled out steroids were d/ced. . Thoracic surgery was consulted for a VATS procedure to obtain tissue to help confirm the diagnosis. The main concern, other than the above differential, was lymphangitic spread of his tumor, which could be confirmed with tissue, as well as BOOP, which was a concern given recent chemo therapy with tor-inhibitor, which has a known association with BOOP. Thoracics recommended repeat Chest CT before considering VATS, and when this showed improvement in GGO they recommended continuing antibiotics and steroids and deferring VATS. . However pt had an episode of respiratory decompensation, requiring a transfer to the [Hospital Unit Name 153] and non-invasive ventilation with BiPAP. Pt. did not require intubation. It was felt that this decompensation was [1-18] flash pulmonary edema. After pt. was stabilized and transferred back to the floor VATS was again considered given uncertainty in the diagnosis (repeat CTA had showed resolution of PEs, however pt. was still very SOB, and the team was not confident that his SOB could be contributed to pulmonary edema and PE alone) It was also noted that pt's decompensation happened after steroids were d/ced, and so a steroid responsive process like BOOP was considered. . On [3-1] pt. was taken for VATS. Pathology showed BOOP + evidence of metastatic prostate CA in the lung. . In the end pt's SOB was felt to be multifactorial, from PE, lung mets from prostate CA, BOOP, which was most likely [1-18] pt's recent chemotherapy regimen, and from CHF with diastolic dysfunction. Pt. improved with steroids and diuresis, and was discharged home with home O2 and close follow up with Dr. [Last Name (STitle) ], his oncologist. Pt. was discharged on Prednisone, Lovenox and Coumadin, a BB and ACE, and home O2. . #Acute renal insufficiency: Pt. had 2 episodes where his Cr became elevated. [Last Name (un) ] firt, shortly after admission was felt to be pre-renal and improved with hydration. A Renal US at that point showed no obstruction. The second happened several days after Bactrim was tarted and was felt to be [1-18] AIN from Bactrim and resolved with discontinuation of this. Cr was stable around 1 for several days prior to discharge. . #CAD -- The patient was ruled out for MI on admission. He was monitored on telemetry for a few days with no significant events. We continued aspirin and ACE inhibitor per his outpatient regimen, and added a beta blocker for better BP control. . #HTN -- We continued lisinopril, and doxazosin, which the patient was on as an outpatient, and added a beta blocker for better BP control, particularly given the patient's history of coronary artery disease. . #Anemia -- The patient's creatinine ranged in the high 20s, down from his baseline of mid to high 30's. There was no obvious source of blood loss or hemolysis. In the past, had no b12/fe/fol deficiency. The anemia was microcytic with a low retic count. The most probable cause seemed to be AOCD with a contribution from chemotherapy. Laboratory studies were consistent with this etiology. Given the patient's hypoxia, it was decided to transfuse the patient to maintain hct around 30. He received 1 unit of PRBC on [2-3] and another on [2-9]. . #Hyponatremia -- This was considered to be likely SIADH, given the ongoing pulmonary process. Improved with fluid restriction. . #Skin rash -- This was secondary to chemotherapy. We continued with silvadene [Hospital1 ] per outpatient regimen. . #Pain -- Continued the usual outpatient regimen. Celebrex was initially held due to elevated creatinine, but was restarted after a few days. Medications on Admission: -EC-aspirin 325 mg daily -omeprazole 20 mg daily -fentanyl patch 50 mcg every 48 hours -Ditropan 10 mg b.i.d. -doxazosin 8 mg b.i.d. -lisinopril 20 mg daily -multivitamin daily -Aldactone 50 mg b.i.d. -Lupron every 3 months -Percocet b.i.d. -Celebrex 200 mg b.i.d. -Silvadene cream twice daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 8. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:21 Capsule(s) Refills:0 10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 12. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:90 Tablet(s) Refills:0 13. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:0 14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 15. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:24 mL Refills:0 16. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:90 Tablet(s) Refills:0 17. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 19. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous [Hospital1 ] (2 times a day). Disp:14 mL Refills:0 22. Carvedilol 3.125 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). Disp:240 Tablet(s) Refills:2 23. Home Oxygen 3L continuous O2 NC- O2 98% on 3L, 83-84% on RA Discharge Disposition: Home With Service Facility: Care Centrix Discharge Diagnosis: Metastatic Prostate Cancer Pulmonary Embolus Bronchiolitis Obliterans Organizing Pneumonia (BOOP) Flash Pulmonary Edema Hypertension CHF with Diastolic Dysfunction, preserved EF (65-70%) Obstructive Sleep Apnea Discharge Condition: Improved- breathing comfortably on 3L oxygen Discharge Instructions: If you experience fever, chills, shortness of [Hospital1 1440], chest pain, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. . Please take all medications as prescribed. . Please attend all followup appointments. . Please limit your sodium intake to 2 g/day and your fluid intake to 2L per day. Followup Instructions: Oncology: Please call Dr. [Last Name (STitle) ] and Dr.[Name (NI) 30779] office at [Telephone/Fax (1) 22] about your follow up appointment next Thursday. . Pulmonology: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office at [Telephone/Fax (1) 612] to set up a follow up appointment . Primary Care: Please call Dr.[Name (NI) 29254] office at [Telephone/Fax (1) 250] to set up a follow up appointment in the next 2-4 weeks. . Please have your INR checked at a lab by your house and have the results faxed to Dr. [Last Name (STitle) 13933] at [Telephone/Fax (1) 13345]. [First Name4 (NamePattern1) 2946] [Last Name (NamePattern1) ] MD [MD Number(1) 3218] Completed by:[2187-5-7]	[ "327.23", "516.8", "285.29", "253.6", "415.19", "402.91", "786.3", "693.0", "733.90", "584.9", "412", "518.82", "225.2", "V10.46", "198.5", "428.31", "E933.1", "V58.65", "197.0" ]	icd9cm	[ [ [] ] ]	[ "33.24", "93.90", "99.04", "99.07", "32.29" ]	icd9pcs	[ [ [] ] ]	16618, 16661	8754, 14044	333, 347	16916, 16963	3723, 3723	17374, 18166	2942, 3023		14389, 16595		16682, 16895		14070, 14366			16987, 17351										3038, 3704																								273, 295											375, 1721				5121, 8731	3740, 5112											1743, 2431	2447, 2926
50,384	166,688	35927	Discharge summary	report	Admission Date: [2195-1-30] Discharge Date: [2195-2-4] Service: MEDICINE Allergies: Morphine / Codeine / Bactrim Attending:[First Name3 (LF) 2009] Chief Complaint: right flank pain Major Surgical or Invasive Procedure: nephrostomy History of Present Illness: 85 y.o. woman with h/o CAD s/p IMI 30 yrs ago, DM, presenting initially w/ right flank pain associated with nausea. At [Hospital 882] Hospital, CT showed right sided hydronephrosis w/o renal stones. At [Hospital1 882], BP= 200/96 with ekg showing ST depressions across precordium, in addition to STE and Q waves in II, III, aVF which were initially thought to be new (now known to be old). CE negative X1 at OSH. The patient was transferred to [Hospital1 18] where ED vitals were 98.1 178/84 64 98% 4L, and ekg was initially thought to be showing evolving STEMI. Received aspirin, plavix 600mg X1, and integrillin. Integrillin was later discontinued, when Q waves identified as old. Her blood pressure was persistently in the 160-180's while on nitro gtt and labetolol IV boluses. In the ED. Her nitro gtt was eventually titrated up 100mcg/hr, and after receiving a total of three boluses of labetolol her blood pressure decreased to 155/71. Repeat EKG showed persistent ST depressions across precordium. She was admitted to the CCU for hypertensive emergency. Labs on admission show troponin 0.07 (later rising to 0.11, with CKs in 40s) and creatinine of 1.3. In ED, spiked a temp to 101.4. She received urine and blood cultures and was given cipro. In the CCU, it was thought that she did not have STEMI instead it appeared her clinical picture was due to demand ischemia in the setting of hypertensive to 200s systolic. She was initially on a labetalol gtt but was discontinued 6am [2195-1-30] after 4 hours on it when systolics were in the 100s. BP regimen was held due to low systolics Urolog was consulted and right perc nephrostomy tube was placed by IR [1-30]. She was started on cipro/gent day 1= [1-29]. She was febrile overnight to 102.7. On [1-31], pt was re-started on half of her home atenolol. On [2-1], she developed assymptomatic 4 second pauses on telemetry. Of note, the pt has a baseline RBBB, LAFB, and prolonged PR interval. Currently denies chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. No abdominal pain, N/V, no headache/dizzyness. Endorses feeling slightly confused, also endorses weakness at home and frequent falls. Past Medical History: Type II Diabetes Hypothyroidism Hyperlipidemia TIA GERD CAD, s/p MI in [2164] inferobasal ischemia, echo [2187] w/ posterior wall hypokinesis w/ aneurysm Depression Anxiety Anemia unspecified Diabetic retinopathy Cataract extract Osteoarthritis Pulmonary fibrosis on 2L home oxygen Social History: -Lives w/her daughter. [Name (NI) ] a walker at home, but does not walk much. -Tobacco history: 40 pack years -ETOH: occassional -Illicit drugs: none Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: T=100.6 BP= 149/72 HR= 66 RR= 12 O2 sat= 94% 6L GENERAL: WDWN female in NAD. oriented to name, knew she was in hospital, knew year but did not know date. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not elevated. 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: dry crackles throughout both lung fields b/l (Pt has interstitial fibrosis) ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ =========================== At time of discharge, nephrosotomy tube in place, pt afebrile, and BP=, remainder of physical exam not significantly changed. Pertinent Results: LABS ON ADMISSION: [2195-1-29] [2195-1-29] 08:45PM WBC-10.3 RBC-3.17* HGB-11.4* HCT-33.3* MCV-105* MCH-35.8* MCHC-34.1 RDW-15.1 [2195-1-29] 08:45PM NEUTS-92.8* LYMPHS-5.5* MONOS-1.5* EOS-0.1 BASOS-0.1 [2195-1-29] 08:45PM PLT COUNT-152 [2195-1-29] 08:45PM PT-15.0* PTT-103.6* INR(PT)-1.3* [2195-1-29] 08:45PM GLUCOSE-190* UREA N-28* CREAT-1.3* SODIUM-144 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-20 [2195-1-29] 08:45PM CK(CPK)-44 [2195-1-29] 08:45PM cTropnT-0.07* LABS AT TIME OF DISCHARGE: [2195-2-4] 07:10AM BLOOD WBC-5.9 RBC-2.63* Hgb-9.6* Hct-28.1* MCV-107* MCH-36.5* MCHC-34.2 RDW-14.0 Plt Ct-151 [2195-2-4] 07:10AM BLOOD Glucose-116* UreaN-24* Creat-0.9 Na-142 K-4.4 Cl-104 HCO3-29 AnGap-13 [2195-2-4] 07:10AM BLOOD Mg-1.9 Other Laboratories: [2195-1-30] 03:45AM BLOOD ALT-12 AST-24 LD(LDH)-258* CK(CPK)-47 AlkPhos-65 TotBili-0.6 [2195-1-30] 03:45AM BLOOD CK-MB-NotDone cTropnT-0.11* [2195-1-31] 04:30AM BLOOD calTIBC-189* VitB12-GREATER TH Folate-18.6 Ferritn-230* TRF-145* [2195-1-29] 08:45PM BLOOD Triglyc-187* HDL-49 CHOL/HD-3.6 LDLcalc-91 [2195-1-30] 03:45AM BLOOD Digoxin-0.7* EKG: [2195-1-29]: Sinus rhythm. The P-R interval is prolonged. Left axis deviation. Right bundle-branch block with left anterior fascicular block. There are Q waves in the inferior leads consistent with prior myocardial infarction. Non-specific ST-T wave changes. No previous tracing available for comparison. CXR [2195-1-29]: No prior comparisons. Allowing for technique, cardiomediastinal contours are probably within normal limits. Pulmonary vascularity is normal. Diffuse reticular opacity is seen throughout both lungs, suggestive of underlying chronic lung disease/fibrosis. There is no sign of a superimposed pneumonia. There is no pleural effusion or pneumothorax. Echocardiogram: [2195-1-30]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is an inferobasal left ventricular aneurysm. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %) secondary to iferior akinesis (with inferobasal aneurysm) and posterior hypokinesis. The apex is also hypokinetic. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Microbiology: Blood Cultures 1/16 x 4, [2-2] x 2 - no growh to date Urine culture [2-3] - no growth to date [2195-1-30] 8:39 am URINE Source: Catheter. FINAL REPORT [2195-2-1] URINE CULTURE (Final [2195-2-1]): CITROBACTER FREUNDII COMPLEX. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 85-year-old woman with a history of CAD, DM presented with right flank pain, was found to have right-sided hydronephrosis and hypertensive emergency. . Pyelonephritis/Hydronephrosis: At the outside hospital the patient underwent abdominal CT scan which showed hydronephrosis and pyelonephritis. No obstructing stones were seen. She was initially started on ciprofloxacin and received one dose of gentamicin. Urine culture grew pansensitive citrobacter and she will complete a two week course of ciprofloxacin. She underwent percutaneous nephrostomy tube placement on admission to this hospital which she tolerated well. This tube will remain in place for two weeks until she follows up in the department of urology for further management. If further nephrostomy tube supplies are needed or if there are questions pertaining to the maintenance of this tube, call interventional radiology at [Telephone/Fax (1) 53983] or [Telephone/Fax (1) 9387]. . Acute Renal Failure: Patient's creatinine on admission was 1.3 from unclear baseline in the setting of pyelonephritis and hydronephrosis. On discharge her creatinine had returned to 0.9. Her renal function will need to be monitor closely as an outpatient, particularly in the setting of initiation of an ace-inhibitor. . Intermittent complete heart block: The patient was transferred to the cardiology service after she was noticed to have 4 second pauses on telemetry. Telemetry showed evidence of AV nodal blockade. Her atenolol and digoxin were discontinued. She was seen and evaluated by the electrophysiology consult service. They recommend that all AV nodal blocking agents be held indefinitely. She will be reevaluated by electrophysiology after her acute infection has cleared. She may need a pacemaker in the future in order to be able to tolerate a beta-blocker for her coronary artery disease. . Hypertensive emergency: The patient presented with blood pressures in the 200s systolic in the setting of acute infection and renal obstruction initially requiring a labetolol drip. Her blood pressures stabilized after percutaneous nephrostomy tube was placed. As above, her nodal blocking agents were discontinued because of her intemittent heart block. In this setting her blood pressure increased again. She was started on lisinopril 20 mg daily in addition to her home lasix and isosorbide dinitrate. Her renal function will need to be rechecked as an outpatient. Her lisinopril can be titrated up as tolerated by her primary care physician. [Name10 (NameIs) ] additional blood pressure agents are required, would recommend against all nodal blocking agents. . Coronary artery disease: There was concern at the OSH for ST elevations and Q waves in the inferior leads. On transfer to this hospital her ECG changes were more consistent with demand ischemia in the setting of hypertensive emergency with no signs of ongoing coronary ischemia. She had no chest pain during this admission. She was continued on atorvastatin and plavix. Her beta blocker was discontinued as above. . Congestive heart failure: An echocardiogram revealed EF 40-50% with inferior akinesis, posterior hypokinesis, apical hypokinesis, which were consistent with her history of inferior myocardial infarction. It was unclear why this patient was on digoxin and in the setting of intermittent heart block this medication was discontinued as was her beta blocker. She was started on lisinopril 20 mg daily for her blood pressure and this can be titrated up as an outpatient as renal function and blood pressure tolerate. . Interstitial pulmonary fibrosis: Patient wears 2L oxygen at home. She had no respiratory difficulty during her hospital course. . Depression/anxiety: No active issues. She was continued on sertraline and alprazolam PRN. . History of TIA: She was continued on plavix. . Type II Diabetes: Her metformin was held during this admission and her blood sugars were controlled with a humalog sliding scale. Her oral agents were restarted on discharge. . Hypothyroidism: She was continued on her home dose of levothyroxine. . Anemia: Unclear etiology. Her hematocrit ranged 28 to 30 during this admission. Laboratories were notable for a low iron and elevated ferritin consistent with an inflammatory anemia. She was continued on her home iron and cyanocobalamin. This may need further workup as an outpatient. . Her hospitalization was discussed with her PCP by phone. Medications on Admission: Medications on Admission: Lipitor 20 mg daily Synthroid 112 mcg daily Atenolol 25 mg daily Metformin 1500 mg daily Lasix 20 mg daily Ranitidine 150 mg [Hospital1 ] Plavix 75 mg daily Zoloft 50 mg daily Isosorbide Dinitrate 20 mg TID Digoxin 0.125 mg daily Alprazolam 0.25 mg daily:PRN Iron 325 mg daily Cyanocobalamin 500 mg [Hospital1 ] Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Outpatient Lab Work Please check BUN, creatinine and potassium on [2195-2-9]. She has recently been started on lisinopril. Discharge Disposition: Extended Care Facility: [Location (un) 169] of [Location (un) 1411] Discharge Diagnosis: Pyelonephritis (new) Hydronephrosis (new) Intermittent Complete Heart Block (new) Hypertensive Emergency Acute Renal Failure ===================== Interstitial pulmonary fibrosis Coronary Artery disease Discharge Condition: Medically stable for discharge Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to an outside hospital with flank pain and were transfrerred to [Hospital1 18]. Here, a tube was placed to help drain urine from your kidney which had become infected. You have been receiving antibiotics for this infection. The tube will have to stay in place at least until you are seen by urology as an outpatient. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Please take ciprofloxacin 500 mg two times a day for 10 more days 2. Please DO NOT take atenolol or digoxin. These medications slow your heart rate. 3. Please take lisinopril 20 mg daily for your blood pressure While you were here, we noticed that your heart ocasionally skips beats, for this reason atenolol has been stopped. Several other changes have been made to your medications. The list of medications you should be taking now is attached. Please review this with your primary care doctor when you are discharged from rehab. Please seek medical attention if you experience dizziness, change in vision, weakness, shortness of breath, or chest pain. Let your doctors know if [Name5 (PTitle) ] are having fevers and chills. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2.5 Liters Followup Instructions: The following appointments with specialists have been made for you: Urology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770] on [2-23] at 1:20pm at [Location (un) ], [Hospital Ward Name 23] Building [Location (un) ] ([Telephone/Fax (1) 164]) Electrophysiology (Cardiology): Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2357] on [3-6] at 1:20 PM. The clinic is in the [Hospital Ward Name 23] Center on the [Location (un) ]. The office phone number is [Telephone/Fax (1) 62]. Please make an appointment with your primary care provider when you are discharged from rehabilitation. Completed by:[2195-2-5]	[ "300.4", "414.01", "V12.54", "426.0", "584.9", "041.85", "250.50", "272.4", "590.10", "244.9", "348.30", "428.0", "591", "362.01", "401.0", "285.9", "412", "515" ]	icd9cm	[ [ [] ] ]	[ "55.03", "99.20" ]	icd9pcs	[ [ [] ] ]	14365, 14443	8371, 12831	252, 265	14690, 14723	4081, 4086	16124, 16821	3054, 3114		13227, 14342		14464, 14669		12883, 13204			14747, 16101										3129, 4062																								196, 214											293, 2552								4100, 8348								2574, 2866	2882, 3038
27,576	113,975	34514	Discharge summary	report	Admission Date: [2116-6-6] Discharge Date: [2116-6-26] Date of Birth: [2044-11-20] Sex: M Service: MEDICINE Allergies: Celebrex Attending:[First Name3 (LF) 613] Chief Complaint: Right sided weakness Major Surgical or Invasive Procedure: Required a G-tube([6-15]) and Intubation for respiratory distress ([6-17]) History of Present Illness: Mr [Known lastname 8147] is a 71yo R handed man with hx of severe OSA on CPAP, OA who was found down per roommate 10pm [6-5] and brought to outside hospital where he was found to have R MCA stroke. Per family/roommate, pt has been complaining of fatigue for several days including the day of admission - pt took an afternoon nap and was found to be in his usual state at 6pm. Then around 9pm, pt was noted to have difficulty using his L leg and getting up but it was assumed to be secondary to his chronic L knee pain (s/p knee replacement). At 10pm - about an hour later, pt was found down on the floor per roommate with no movements in L leg plus slurred speech and L facial droop. EMS was called and pt was trasported to outside hospital where he was given ASA 325mg in the ED but no lytics given that pt arrived in ED outside the 3hr window for tPA. Pt's initial vitals per EMS was 154/80 for BP and HR 58~60. Then while in ED, SBP ranged from 154~189 with DBP 73~86. Pt remained afebriel. Pt had CT scans which showed hypodensity in the R perieto-occipital lobes with no evidence of hemorrhage and R dense MCA sign. MRI and MRA were also done which showed large defects involving both R frontal, temporal, parietal and parieto-occipital lobes with no evidence of hemorrhagic transformation. FLAIR showed mild evidence of mass effect on R lateral ventricle but all ventricles were patent. MRA showed absent beginning of R ICA at the petrous portion and absence of distal flow of R MCA. On Neurology service, the patient had a RIGHT hemiplegia. With bulbar dysfunction, he underwent PEG [2116-6-15]. He continued to use nightly CPAP at outpatient pressures. Past Medical History: 1. OSA - CPAP at 16/8 at night 2. Asthma 3. GERD 4. BPH 5. s/p L knee repair and replacement 6. s/p ventral hernia repair 7. s/p L hand surgery after fracture 8. s/p L elbow surgery Social History: SH: Quit smoking in [2074] and sober for 7 years. Works as full-time maintenance person at [Hospital1 11485] School in [Location (un) 2624]. Has three children and sevral grandchildren. Family History: FH: Father died of CAD and mother died of stomach cancer. No FH of strokes, seizures and bleeding issues. Physical Exam: O: Vitals: T 98.8 (Tmax 100.2), BP 146/52, HR 66, RR 20, SpO2 91% FiO2 0.3, heparin rate 1300, +10L (+753/24 h) General: CPAP mask on, looks edematous CVS: JVD 9 cm, S1+2 no added sounds Resp: Coarse crackles B/L GI: slighly distended abdomen w normal BS Neurological Examination: MS-Follows simple commands. Speech not assessed (on CPAP). CN-PERRL, EOMI, nods "yes" when asked whether he perceives soft touch on his face Motor-R UE and LE [4-6] w/ normal tone. L UE 0/5, L LE [12-7] w/ nox stim only. Sensation difficult to assess on the arms and legs, but appears to be in tact throughout. Reflexes-(no change from previous note) L/R bic [2-2], tri [1-4], pat [2-2]+, Ach [1-3] Brief Hospital Course: Pt admitted from OSH with large R MCA stroke, treated only with aspirin. Was monitored on the neurology floor and began physical therapy. He continued his nighttime home CPAP regimen of 18/6. Was not changed from his home settings while in the hospital. . MRI/MRA showed large defects in R frontal, temporal and parietal with no evidence of hemorrhagic transformation. No flow in dital R MCA. Had no midline shift and no hydrocephalus. . Pt failed a speech and swallow study and had a GJ tube placed. It was initially hard to thread the tube into the jejunum, so it had to be revised. The patient now was a G tube and J tube. The G tube was clogged while in the SICU, and there was concern for ileus, but with motility agents, the residual volume decreased and the patient started having bowel movements. . Was being treated on the floor for significant Left hemiplegia with bulbar dysfunction. Had PEG placement on [2116-6-15], and was using CPAP as he had been doing at home. Overnight the [Date range (1) 21036] pt was noted to have O2 sat in 70s with tachypnea. Sats increased with stimulation. ABG showed mile hypercarbia (48). WBC 15.8 and CXR showed worsening atelectasis. CE normal x1. Intubated that night in the SICU for increased work up breathing likely secondary to aspiration pneumonitis. . The patient was then found to have bilateral PE on CT of chest. Heparin therapy was initiated and 3 days before discharge, coumadin therapy with started with 5 mg. His INR is subtherapeutic now. We recommend increasing his coumadin to 7.5 mg (he is likely having interaction with his antibiotics, especially the erythromycin he was on for motility). Continue to monitor INR and when therapeutic over 2.0, can take off heparin drip. . Pt also developed what was thought to be ventilator acquired pneumonia. Was treated with one day of vanco and a course of zosyn. He was 2 days remaining of his 8 day zosyn course. He is clinically improving and maintaining high saturations on between 2-3 L NC. His leukocytosis is resolving. . Pt was extubated on [6-23] in the SICU. Pt did well overnight. Can talk in short sentences. Continues to have L sided neglect and L hemiplegia. Follows commands. Obviously snores loudly even when just resting. . Pt is discharge with a central line still in place for the heparin drip. He has difficult access, so we felt central line was appropriate and the rehab facility could decide if a PIV would work. Pt also has working GJ tube in place and has a tube feed regimen that has been reevaluated by nutrition today. He is in stable condition and his ongoing medical issues now just include completing a course of zosyn for the next two days, and reaching a therapeutic INR and removing the heparin drip. . Physical therapy should be started for his stroke deficits. He should have repeat speech and swallow evaluation in one to two weeks to determine if he can start taking food and medicines PO. Medications on Admission: flomax 0.4 mg qHS advair 100/50 [Hospital1 ] prilosec 40 mg daily Discharge Medications: 1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Enalapril Maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please continue heparin drip until INR >2.0, then can stop and just anticoagulate on coumadin. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 13. Zosyn 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 2 days: Please complete 8 day course of zosyn. Thanks. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: 1. R MCA stroke 2. Aspiration pneumonitis 3. Pneumonia 4. Bilateral Pulmonary embolism . Secondary Diagnosis: 1. GERD 2. Obstructive Sleep Apnea Discharge Condition: Patient afebrile three days, currently breathing during the day on 2-3L NC with saturations in high 90s, using CPAP at night at his home settings, systolic blood pressures in 130s-140s. Pt has L sided hemi-paralysis from the stroke. Is communicative and appropriate in short sentences. Nutrition support from a GJ tube. Discharge Instructions: You were transferred to [Hospital1 18] from an outside hospital for a severe stroke. The left side of your body is now paralyzed, but the physical therapists have seen you and started working with you for rehabilitation. . While in the hospital you had a tube placed into your intestine so we could continue to give you nutrition. You are not able to swallow safely due to your stroke. . While on the floor, you seemed to aspirate some gastric contents into your lungs and develop a pneumonitis (an inflammation of your lungs). It made you work so hard at breathing, that we needed to intubate you. While you were intubated, we also found some pulmonary embolisms in both lungs. We started treating you with a blood thinner to break up the clots. You also developed a pneumonia while on the ventilator. We treated you with antibiotics and you improved. You still need O2 during the day, and use your CPAP at night. . You are being transferred to a rehabilitation facility with hospital level care, and you'll be continually cared for. In the near future, we hope to get your INR therapeutic on coumadin and take off the heparin drip. You will also complete 2 more days of Zosyn for your pneumonia. . Please return to the hospital for worsening respiratory status, chest pain, shortness of breath, increasing weakness, bleeding in your stool or urine or any other problems. Followup Instructions: You will go to a rehabilitation facility where they have 24 hour doctor supervision. He will continue to monitor your INR and your breathing. . Neurology Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2116-7-24] 1:00 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2116-6-26]	[ "530.81", "342.82", "501", "518.82", "600.00", "V11.3", "V15.82", "518.0", "V16.0", "327.23", "V43.65", "415.19", "486", "493.90", "432.9", "278.00", "263.8", "433.11", "E879.8", "V64.1", "507.0", "434.91", "V17.3", "348.5" ]	icd9cm	[ [ [] ] ]	[ "93.90", "38.93", "45.13", "96.6", "96.04", "43.19", "33.24", "96.72" ]	icd9pcs	[ [ [] ] ]	7945, 8017	3385, 6359	289, 373	8225, 8550		9985, 10479	2530, 2639		6479, 7922		8038, 8038		6385, 6456			8574, 9962										2654, 3362																								229, 251											401, 2090			8167, 8204				8057, 8146									2112, 2296	2312, 2514
51,275	118,170	34083	Discharge summary	report	Admission Date: [2104-10-14] Discharge Date: [2104-10-27] Date of Birth: [2021-11-18] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 3913] Chief Complaint: Fever Abdominal pain [2104-10-18] Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Lysis of adhesions. 3. Transverse loop colostomy. History of Present Illness: The patient is an 82yo woman with low grade non-Hodgkin's lymphoma complicated by aplastic anemia following treatment wtih fludarabine, followed by Dr. [Last Name (STitle) ] since [5-25]. She was admitted from the Emergency Department today with a neutropenic fever. The patient reports developing a dry cough approximately three days ago. Because of the cough, her planned admission for ATG/cyclosporine for her aplastic anemia was delayed, and a CXR was performed which showed no evidence of pulmonary infection. She felt feverish today and took her temperature, which was 100.4. After calling [First Name8 (NamePattern2) 3235] [Last Name (NamePattern1) 3236], she was advised to seek evaluation in the Emergency Department. In addition to her cough and feverishness, she has experienced rhinorrhea over the past several days. She has had no dyspnea, skin rash, or joint pain and denies recent bleeding and bruising. She has recently been in close contact with her daughter, who has an upper respiratory infection. In the Emergency Department, she was noted to be febrile, with T 104.1 degrees. Her WBC was 1.1 and ANC 792. Blood cultures, a urinalysis, and a chest xray were obtained, revealing no clear source of infection. She was empirically started on cefepime 2g IV and was admitted for further management. Past Medical History: PMH: 1. Colon cancer [2099] (adenocarcinoma) - S/p diverting colostomy, reversed in [2100] 2. Lymphocytic lymphoma, diagnosed in [10/2103] - S/p fludarabine/rituximab x 4 cycles started [2103-12-18] at [Location (un) ], complicated by aplastic anemia in [5-25]. 3. Aplastic anemia: followed by Dr. [Last Name (STitle) ]. 3. Hypertension PSH: Left colectomy '[98] colostomy takedown '[99] open cholecystectomy '[00] appendectomy and tubal ligation '[51] R subclavian port [10-25] ([Doctor Last Name ]) Social History: Widowed for 12 years. She had 4 sons 1 daughter and several grandchildren. Lives with son [Name (NI) ] in [Location (un) 16843], MA. Independent all IDL's. Denied smoking, recreational drugs. No alcohol. Family History: Father with stroke at 77. Mother heart and renal failure. No history of cancer. Physical Exam: VITAL SIGNS: 99.4, 82, 139/65, 20, 99%RA GENERAL APPEARANCE: The patient is a pleasant woman who appears well. HEENT: Pupils are equal, round, and reactive to light. Lens implantations noted. Sclerae are nonicteric. Extraocular muscles are intact, and the mucous membranes are well hydrated. NECK: There is no cervical or supraclavicular lymphadenopathy. LUNGS: Clear bilaterally without crackles or wheezes. HEART: S1, S2. no m/r/g ABDOMEN: Midline incition wound clean, with staples. Mildly distended and with mild pain on deep palpation. Bowel sounds present and adequate colostomy output. No Hepato-splenomegaly. EXTREMITIES: No edema, adequate pulses, warm. SKIN: No skin rashes. Pertinent Results: On Admission: [2104-10-13] 11:55AM WBC-1.3* RBC-2.61* HGB-8.1* HCT-22.3* MCV-86 MCH-31.2 MCHC-36.5* RDW-16.7* [2104-10-13] 11:55AM NEUTS-76* BANDS-0 LYMPHS-7* MONOS-14* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-2* [2104-10-13] 11:55AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ [2104-10-13] 11:55AM PLT SMR-RARE PLT COUNT-18# [2104-10-13] 11:55AM UREA N-25 CREAT-0.8 SODIUM-140 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 [2104-10-13] 11:55AM ALT(SGPT)-76* AST(SGOT)-50* LD(LDH)-386* ALK PHOS-87 TOT BILI-1.0 [2104-10-13] 11:55AM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-2.1 [2104-10-14] 08:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2104-10-14] 08:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2104-10-14] 08:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2104-10-14] 08:10PM LACTATE-1.2 Urine culture: Negative Blood culture: Negative Rapid viral screen: negative CR CHEST ([2104-10-16]): 1. Mild generalized bronchitis. Study did not include assessment of small airway obstruction. 2. No lung nodule other than calcified granuloma. 3. Top normal size ascending thoracic aorta could be related to aortic stenosis in the presence of aortic valvular calcification. Clinical correlation advised. 4. Atherosclerotic calcification predominantly aorta, head and neck vessels and splenic artery, not coronaries. 5. Transfusion related hyper-attenuation in the liver and splenomegaly. 6. Suggest ultrasound to exclude thyroid nodule. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST 11/1/08IMPRESSION: 1. High-grade large bowel obstruction with a transition point located at the level of distal descending colon near the prior site of surgical anastomosis. Possible etiologies include colorectal carcinoma recurrence, post surgical stricture or diverticular disease.. 2. No lymphadenopathy or splenomegaly. No other site of recurrence is noted. 3. Fibroid uterus. 4. Unchanged 3mm right middle lobe nodule. Brief Hospital Course: #. Bronchitis: Patient admited with neutropenic fever. She received neupogen and was started on cefepime. Azythromicin was added for concern for atypical bacteria with CAP. CXR was unremarkable, but CT scan was suggestive of bronchitis. Cefepime was stopped in day 2, when patient's ANC >1000, and pt completed a 5-day course of Azythromycin. Patient's cough improved. Patient did not require oxygen and is being discharged breathing comfortably in room air. . #. Aplastic anemia: Patient with HCT <25, will get blood. [Month (only) 116] do ATG/CSA when patient recovers from surgery. Pt's HCT was followed in the hospital requiring multiple transfussions (6 RBC). Patient's platelets are in low range 15-40,000 range during hosptialization and required 2 units in the peri-surgical days. . #. Abdominal obstruction: Pt with abdominal distention and decreased bowel sounds and CT scan showed complete obstruction of the descending colon, close to prior surgery site. Was taken to the OR in [10-18]. Perioperatively, she received both packed red blood cells and platelets. Following an uncomplicated exploratory laparotomy,lysis of adhesions, and transverse loop colostomy, the patient was admitted to the surgical ICU for further management. She was transferred to the floor on [10-21]. Primary care was transferred to the BMT service on [10-23]. Patient will need close follow up and work up for recurrent colonic cancer. . #. Hypertension - Continue atenolol, HCTZ. . #. FEN - Regular diet . #. Access - PIV . #. PPx - -Bowel regimen -Pain management with . #. Code - Full code . #. Dispo - Home with follow up in clinic within 3 days. Medications on Admission: Atenolol 25mg qHS HCTZ 25mg Daily MVI Filgristim 300mcg SC daily Folic acid 1mg Daily Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin Flush 10 unit/mL Kit Sig: One (1) Syringe Intravenous once a day. Disp:30 Syringes Refills:2 6. Line Care Please do line care per protocol. 7. Colostomy Please do colostomy care per protocol. Discharge Disposition: Home With Service Facility: Diversified VNA Discharge Diagnosis: Primary Diagnsois: Bronchitis. Large bowel obstruction. . Secondary Diagnosis: Hypertension History of colon cancer s/p resection and colostomy with re-anastomosis. Aplastic anemia History of lymphocytic lymphoma s/p chemotherapy with fludarabine/rituximab now in remission. Discharge Condition: Stable, tolerating PO, deambulating. Discharge Instructions: You were seen at the [Hospital1 18] for fever. Your signs and symptoms were compatible with viral infection in your upper airways and bronchi. Your CT scan of the chest was compatible with bronchitis. You were started on antibiotics to cover for possible bacteria and improved. You were found to be very distended and to have difficulty moving your bowels. Your abdominal pain persisted, despite moving your bowels. You had a CT of your abdomen, that showed obstruction in your distal colon, close to where you had prior surgery. You needed to have emergent surgery, where they decompressed your large bowel and did a colostomy. Your post-op course was normal. Now you are discharged home. You will need a nurse to help you clean yor colostomy site and look at your wounds. You will also need close follow up to monitor you blood levels and may require frequent transfusions. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] this Friday [10-31] at the [Hospital1 18] [Location (un) 620] at 2:00 PM. You can call to her office at [Telephone/Fax (1) 2998] for more information. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[Telephone/Fax (1) 2998] Date/Time:[2104-10-31] 2:00 Please come to the [Hospital1 18] [Hospital Ward Name 1826] building [Location (un) 436] at the Heme/Onc outpatient unit for follow up and blood tests on Wednesday [2104-9-28] at 10 AM. Provider: [Name Initial (NameIs) 455] 3-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2104-10-29] 10:00	[ "V10.05", "284.89", "E933.1", "440.8", "568.0", "466.0", "401.9", "560.9", "202.80" ]	icd9cm	[ [ [] ] ]	[ "99.05", "46.03", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	7864, 7910	5565, 7223	322, 404	8229, 8268	3404, 3404	9198, 9890	2590, 2672		7360, 7841		7931, 7989		7249, 7337			8292, 9175										2687, 3385																								245, 284											432, 1766			8010, 8208					3418, 5542								1788, 2344	2360, 2574
49	190,539	24743	Discharge summary	report	Admission Date: [2186-11-21] Discharge Date: [2186-11-28] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Fatigue and dyspnea on exertion Major Surgical or Invasive Procedure: [2186-11-21] - AVR 25mm St. [Male First Name (un) 923] Porcine Valve History of Present Illness: Splendid 80 year old gentleman who has severe aortic stenosis. He sustained and inferior wall MI on [2-/2178] followed by a PTCA. He recently had a colonic tumor/polyp removed in [Month (only) 216] and developed chest pain as well as dyspnea perioperatively. A cardiac catheterization was performed which revealed sever aortic stenosis and no flow limiting disease. His ejection fraction was preserved. Past Medical History: S/P Colonic polyp removal [8-25] Left TKR [2178] PTCA [2178] IMI [2178] HTN AS Hyperlipidemia COPD CRI Depression Erectile dysfunction Social History: Has not seen the dentist in 3 years. No tobacco, infrequent alcohol use. Lives alone. Wife in nursing home. Family History: Mother [Name (NI) 62389] of endocarditis Father died of accident Physical Exam: GEN: NAD, WDWN, 134/81 62 NSR HEART: RRR, IV/VI systolic murmur LUNGS: Clear ABD: Benign Pulses: No carotid bruits, no edema pulses intact Pertinent Results: [2186-11-27] 06:10AM BLOOD Hct-32.3* [2186-11-26] 06:05AM BLOOD WBC-7.0 RBC-3.50* Hgb-10.9* Hct-31.0* MCV-89 MCH-31.1 MCHC-35.0 RDW-15.4 Plt Ct-235 [2186-11-26] 06:05AM BLOOD Plt Ct-235 [2186-11-27] 06:10AM BLOOD UreaN-26* Creat-1.3* K-5.0 [2186-11-26] CXR Borderline cardiac enlargement has decreased, comparable to the preoperative appearance on [10-23]. Thickening of the right costal and apical pleural margin is probably due to fat deposition, not fluid, although a tiny volume of layering pleural fluid is present bilaterally. No pneumothorax. No pneumonia. [2186-11-22] EKG Sinus rhythm Consider left atrial abnormality Probable inferior myocardial infarction, age indeterminate Inferolateral ST-T wave changes with slight ST segment elevation - cannot exclude in part ischemia/injury Clinical correlation is suggested Since previous tracing of [2186-11-21], first degree A-V delay absent and further lateral ST-T wave changes seen [Last Name (NamePattern4) 4125]ospital Course: Mr. [Known lastname 62390] was admitted to the [Hospital1 18] on [2186-11-21] for elective surgical management of his aortic stenosis. He was taken directly to the operating room where he underwent an aortic valve replacement utilizing a 25mm St. [Male First Name (un) 923] porcine valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, he awoke neurologically intact and was extubated. He was initially slightly confused requiring a sitter however his mental status slowly cleared. Later on postoperative day one, he was transferred to the cardiac surgical step down unit for monitoring. He was gently diuresed towards his preoperative weight. Beta blockade was discontinued for low blood pressure. The physical therapy service was consulted to help increase his postoperative strength and mobility. Mr. [Known lastname 62390] developed atrial fibrillation which converted spontaneously back into normal sinus rhythm. Mr. [Known lastname 62390] continued to make steady progress and was discharged to rehabilitation on postoperative day six. He will follow-up with Dr. [Last Name (Prefixes) ], his cardiologist and his primary care physician as an outpatient. Beta blockade should be resumed as an outpatient when his blood pressure can tolerate. Medications on Admission: Lopressor 25mg daily Lasix 40mg daily Celexa 20mg daily Zocor 60mg daily Aspirin 325mg daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: Take for three days then stop. 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [1-22] Tablets PO Q6H (every 6 hours) as needed for severe pain. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) Discharge Disposition: Extended Care Facility: [Hospital ] Health Care Discharge Diagnosis: Aortic Stenosis Hyperlipidemia PAF HTN COPD IMI PTCA [2178] Postop confusion Left TKR Colonic polyp removal CRI Depression Erectile Dysfunction Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours. 4) Take lasix for 3 days until reach preop weight of 225 pounds and then stop or as insturcted by physician. [Name10 (NameIs) ] potassium with lasix and stop when lasix stopped. 5) Please resume lopressor and or an ace inhibitor when blood pressure can tolerate. 6) Call with any questions or concerns. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. ([Telephone/Fax (1) 1504] Follow-up with cardiologist Dr. [Last Name (STitle) 13175] in 2 weeks. Follow-up with primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 51257] in 2 weeks. ([Telephone/Fax (1) 32468] Completed by:[2186-11-28]	[ "496", "293.9", "311", "412", "V45.82", "427.31", "272.4", "403.90", "564.09", "428.0", "424.1" ]	icd9cm	[ [ [] ] ]	[ "35.21", "88.72", "99.04", "39.61" ]	icd9pcs	[ [ [] ] ]	4686, 4740		302, 381	4932, 4939	1380, 2355		1136, 1206		3893, 4663		4761, 4911		3776, 3870			4963, 5468				5519, 5860						1221, 1361														2406, 3750										231, 264											409, 821																843, 995	1011, 1120
31,079	122,279	51148	Discharge summary	report	Admission Date: [2144-2-14] Discharge Date: [2144-2-17] Date of Birth: [2065-1-18] Sex: F Service: MEDICINE Allergies: Amoxicillin / Nitroimidazole Derivatives / Lisinopril / Chlorophyllin (Chlorophyll) Analogues / Chlorhexidine Gluconate / Dextrose 0.5%-Water / IV Dye, Iodine Containing / Clonidine Attending:[First Name3 (LF) 2297] Chief Complaint: CC: "weakness" Reason for MICU transfer: drop in Hct, guiac positive Major Surgical or Invasive Procedure: None History of Present Illness: This is a 79 yo F with h/o hypertension, CVA in [2131] with residual left-sided weakness, epilepsy and Afib on Couamdin, now brought in today by daughter because of worsened generalized weakness and lethargy for the last one week. At baseline, pt is verbal, conversant, oriented, gets around in a wheelchair. Pt with decreased PO intake as well. . In the ED, initial VS were T 97.5 HR 70 BP 143/62 RR 20 O2 sat 100%. CT head was neg. Patient intermittently tender on abd exam so a CT abd was performed which showed no acute process. Labs revealed a Hct of 22.5 (down from 35.7 2 months ago). Pt was guiac positive with green stool. EKG showed NSR 63, LVH and a prolonged QTc. UA was neg for infection. GI evaluated pt and recommended 2U pRBCs, PPI gtt and checking iron studies and hemolysis labs. Pt was also ordered for 2 bags of FFP given INR of 3.4. Pt has 2 PIVs. On transfer, VS were HR 54 BP 132/48 RR 17 O2 94% on RA. . Upon arrival to the ICU, pt is somnelent, not arousable to voice, midly responsive to sternal rub. Daughter at bedside who provided history. Denies bloody stools, dark stools, dysuria, URI symptoms, constipation. Does endorse 3 bowel movements for the last 2 days, but only one today. Denies seizure activity (last seizure was 1 1/2 months ago). . ROS: as per HPI, denies CP, SOB, HAs, acute visual changes, nausea/vomiting, dysuria. Endorses weight loss last few weeks but not able to estimate how much. endorses mild diarrhea as above. Past Medical History: - PVD s/p multiple stents of the superficial femoral artery and balloon angioplasty of the tibial peroneal trunk; then found to have restenosis of SFA s/p angioplasty with stent placement [2140-9-23] - s/p CVA [2131] with residual left sided weakness - Seizure disorder with partial seizures. Usually left arm symptoms only. - Stage III CKDz - Hypertension - Hyperlipidemia - Type 2 diabetes - CHF with preserved LVEF - Atrial fibrillation on anticoagulation - s/p hysterectomy - s/p CCY - h/o adenomatous polyp on colonoscopy [2136] - h/o Grade 2 internal hemorrhoids on colonoscopy [2136] Social History: Patient lives with her 88 yo spouse in a [Location (un) ] handicap accessible apartment. She has a daughter in the area who is her HCP. She has home PCA. Pt denies ETOH, smoking (quit 30 years ago) or drug use Family History: Mother died of a stroke in 80??????s. No FH PE, DVT, early CAD. Physical Exam: VS: Temp: 97.6 BP: 144/70 HR: 64 RR: 15 O2sat 97% on RA GEN: sleepy, nonrousable but later awake, uncooperative with exam HEENT: left pupil oval shaped but reactive to light, blind in right eye, anicteric, dry MM, OP without lesions Neck: no LAD, no JVD, no masses RESP: bibasilar crackles, no wheezes CV: irregular rhtyhm, regular rate, S1 and S2 wnl, no m/r/g ABD: soft, nondistended, nontender EXT: no edema SKIN: +hyperpigmentation in bilat lower ext, no rashes NEURO: AAOx2 (name, "hospital"). CNII-XII intact. 2/5 strength in LUE, LLE. 5/5 strength in RUE, RLE. sensation intact. Pertinent Results: [2144-2-14] 01:35PM BLOOD WBC-7.8 RBC-2.37# Hgb-7.6# Hct-22.5# MCV-95 MCH-31.8 MCHC-33.5 RDW-14.8 Plt Ct-198 [2144-2-15] 04:28AM BLOOD WBC-7.6 RBC-3.29 Hgb-10.4* Hct-29.9* MCV-91 MCH-31.6 MCHC-34.8 RDW-16.5* Plt Ct-176 [2144-2-16] 06:25PM BLOOD WBC-13.5* RBC-3.21* Hgb-10.5* Hct-30.8* MCV-96 MCH-32.7* MCHC-34.0 RDW-16.1* Plt Ct-195 [2144-2-14] 01:35PM BLOOD PT-33.9* PTT-34.9 INR(PT)-3.4* [2144-2-16] 04:12AM BLOOD PT-33.3* PTT-32.4 INR(PT)-3.4* [2144-2-14] 01:35PM BLOOD Ret Aut-4.1* [2144-2-14] 01:35PM BLOOD Glucose-160* UreaN-44* Creat-1.8* Na-148* K-3.7 Cl-111* HCO3-25 AnGap-16 [2144-2-16] 08:14PM BLOOD Glucose-176* UreaN-49* Creat-1.9* Na-151* K-5.3* Cl-113* HCO3-23 AnGap-20 [2144-2-16] 04:12AM BLOOD proBNP-5168* [2144-2-14] 01:35PM BLOOD Phenyto-19.8 [2144-2-15] 09:15AM BLOOD Phenyto-20.5* Phenyfr-2.0 %Phenyf-10 [2144-2-15] 04:28AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2144-2-14] 01:35PM BLOOD calTIBC-260 VitB12-622 Folate-GREATER TH Hapto-177 Ferritn-64 TRF-200 [2144-2-16] 06:21PM BLOOD Type-ART pO2-62* pCO2-67* pH-7.24* calTCO2-30 Base XS-0 [2144-2-16] 10:53PM BLOOD Type-ART pO2-65* pCO2-71* pH-7.20* calTCO2-29 Base XS--1 Brief Hospital Course: This is a 79 yo F with h/o hypertension, CVA in [2131] with residual left-sided weakness, epilepsy and Afib on Couamdin, who now presents with weakness and found to have Hct drop who subsequently developed hypoxic respiratory failure. . # Anemia: Unclear if anemia was acute or subacute. It is presumably related to GI blood loss since she was guaiac positive, however, could also be Fe def [2-12] poor nutrition. Hemolysis labs negative. She was satrted on PPI drip then transitioned to PPI IV BID. GI was consulted and planned to scope her once INR trended down. She received 2 units PRBCs. . # Lethargy/generalized weakness: Unclear etiology but most likely secondary to hypovolemia and anemia. Throughtou her hosptial course, however, she never became interactive or alert as she develoepd profound hypoxemia. Hypernatremia likely also contributed to lethargy. . #. Hypoxic hypercarbic respiratory failure: Pt wasinitially 97% on RA on arrival to MICU but became progressively more hypoxic. She had witnessed aspiration event on [2-15] and CXR was consistent with bilateral airspace opacities and likely pulmonary edema. We attempted to diurese her but she did not respond to lasix up to 80mg IV and was not awake enough to tolerate BiPap. She became more lethargic and unresponsive and was not effectively ventilating. ABG was 7.20/67/62 on 100% NRB. Given her progressive decline and her wishes to be DNR/DNI, her family was contact[Name (NI) ] and she was made [Name (NI) 3225]. They were at her bedside when she expired at 2:05am on [2144-2-17]. Progressive hypoxic respiratory failure was attributed to development of pulmonary edema or TRALI related to blood transfusions or ARDS/[Doctor Last Name ] related to aspiration event. . # Diarrhea: likely viral etiology but has h/o c diff - check c diff, stool studies . # Afib: Warfarin held and she was given FFP given supratherapeutic INR. . # Seizure d/o: Phenytoin level monitored . Medications on Admission: 1. amlodipine 10 mg DAILY 2. clopidogrel 75 mg DAILY 3. famotidine 40 mg Q24H 4. fluticasone 50 mcg/Actuation Spray One Spray [Hospital1 ] 5. furosemide 80 mg DAILY 6. gabapentin 400 mg [Hospital1 ] 7. insulin regular 8 Units twice a day 8. NPH 16 Units SC qam 9. NPH 12 Units SC at bedtime 10. hydralazine 150 mg [Hospital1 ] 11. lorazepam 0.5 mg at bedtime as needed for anxiety 12. phenytoin sodium extended 100 mg 4 times a day 13. rosuvastatin 40 mg DAILY 14. sertraline 100 mg DAILY 15. sotalol 80 mg 2 times a day 16. valsartan 320 mg DAILY 17. ferrous sulfate 300 mg (60 mg Iron) DAILY 18. multivitamin DAILY 19. spiranolactone 25mg daily 20. warfarin 4mg daily except 3mg on Tues Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: None	[ "729.89", "507.0", "518.81", "780.79", "276.0", "584.9", "345.90", "008.8", "438.89", "V46.3", "455.0", "280.0", "V49.86", "578.9", "276.52", "250.80", "428.0", "V58.61", "790.92", "403.90", "428.32", "427.31", "585.3" ]	icd9cm	[ [ [] ] ]	[ "38.99" ]	icd9pcs	[ [ [] ] ]	7599, 7608	4842, 6818	512, 518	7659, 7668	3585, 4819	7720, 7727	2898, 2963		7570, 7576		7629, 7638		6844, 7547			7692, 7697										2978, 3566																								403, 474											546, 2018																2040, 2650	2666, 2882
19,937	199,611	51090	Discharge summary	report	Admission Date: [2125-6-7] Discharge Date: [2125-6-13] Date of Birth: [2063-1-15] Sex: F HISTORY OF PRESENT ILLNESS: This patient was transferred to our service from the medical Intensive Care Unit. Briefly, 63-year-old female with end stage renal disease, status post cadaveric kidney transplant who was recently discharged from arrived at rehabilitation facility and was found unresponsive. She was not reacting to deep sternal rub, and appeared to be in respiratory arrest. Upon arrival in the MICU, the patient remained unresponsive. She had mild reaction and to Narcan. There was also no evidence to suggest that she receive any narcotics. As previously said, patient remained unresponsive for the first 8-12 hours in the MICU regained consciousness and became conversant. Her arterial blood gases in the MICU revealed hypercapnia and acidosis. In addition pt with worsening renal failure. Pt put on bipap for OSA and obesity hypoventilation syndrome c/b hypercarbia. Pt remianed lethargic but improved over presentation. Her ABGs remained abnormal with PH which was 7.13 and 7.18 and PCO2 between 50 and 80. Her other medical systems were stable and she was transferred to our floor. PAST MEDICAL HISTORY: 1) End stage renal disease. Had a cadaveric transplant in [2115] 2) Sleep apnea. The patient has refused to go for sleep apnea study but has presumptive diagnosis of obstructive sleep apnea. 3) Obesity, hypoventilation syndrome. 4). HTN 5). DM 6) recurrent respiratory failure requiring intubation X3 over past month presumed due to OSA/Obesity hypoventilation. 7) SVC syndrome due to clots from repeated IV access lines and possible uinderlying hypercoaguable state. 8) recent hematoma in right groin due to femoral line requiring transfusion. SOCIAL HISTORY: The patient lives alone in [Hospital1 1474], has 6 children who are all very close to her and see her fairly frequently. The baseline patient was able to ambulate and ride an exercise bike in [Month (only) 547] although reportedly had increasing daytime somnolence for several months prior to admit. FAMILY HISTORY: Noncontributory. MEDICATIONS: Upon transfer from the MICU included RenaGel 1,600 po tid, insulin sliding scale, Prednisone 10 mg po q d, Epogen 4,000 units subcu three times a week, Calcitriol 0.25 mcg po q d, Colace 100 mg po bid, Dulcolax 10 mg po prn, Tylenol prn, Protonix 40 mg q d, Lopressor 25 mg po bid and Imuran 100 mg po q d. ALLERGIES: No known drug allergies. LABORATORY DATA: White count 5.9, hematocrit 29.6, platelet count 288,000, PT 13.2 with INR 1.2, PTT 29, sodium 149, potassium 6.6, hemolyzed, chloride 117, CO2 23, BUN 120, creatinine 6 .5. Repeat potassium was 4.6. She also had calcium of 9.7, phosphorus 3.8 and magnesium 2.3. ALT was 8, AST 8, alkaline phosphatase 90 and total bilirubin .7. Latest arterial blood gas showed PH 7.17, PCO2 62, PO2 142. HOSPITAL COURSE: Upon transfer to our service, it was deemed that patient would require dialysis fairly soon. We therefore obtained an ultrasound of her lower extremities to evaluate the possibility of any patent vessels which might be used for AV graft. Unfortunately, ultrasound revealed no patent vessels. It was therefore felt that patient was a very poor candidate for hemodialysis given lack of access. Meanwhile her mental status continued to deteriorate with lethargy/confusion. She was difficult to arouse. There was ?new left facial droop so Head CT was performed and this was negative for actue bleed/cva. Repeat labs showed persistent acidosis with Ph 7.11 and worsening renal failure. her acidosis appeared to be combined metabolic and respiratory. Her respiratory status continued to worsen. Consultation with pulmonary was obtained and it was felt that her respiratory compromise was a combination of sleep apnea and obesity hyperventilation syndrome. It was now felt that the patient's respiratory and renal function were steadily worsening and there was no clear solution to her worsening status. Her prognosis was extremely poor given a lack of IV access for dialysis and ongoing hypoventilation and refusal to use BIPAP. A family meeting was therefore held. The family felt that the best option was to make the patient comfort measures only as there was no apparent way to improve her renal or respiratory compromise (short of tracheostomy with cpap/mechanical ventiation as needed). The patient was made comfort measures only on [6-12]. She was started on sublingual Morphine which she did not tolerate very well. She was therefore switched to IV Morphine 2 mg q 4-6 hours prn. The patient expired on [2125-6-12] at 8:20 a.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3022], M.D. [MD Number(1) 3023] Dictated By:[Doctor Last Name 22847] MEDQUIST36 D: [2125-6-14] 18:43 T: [2125-6-17] 20:00 JOB#: [Job Number ]	[ "276.2", "250.40", "583.81", "780.09", "584.9", "518.81", "401.9", "V42.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							2146, 2935							2953, 4967																																															146, 1229																1252, 1803	1819, 2129
3,682	135,236	51431+51432	Discharge summary	report+report	Admission Date: [2170-1-22] Discharge Date: [2170-3-19] Service: THORACIC SURGERY CHIEF COMPLAINT: A 77-year-old patient with remote percutaneous transluminal coronary angioplasty of RCA, referred for outpatient cardiac catheterization due to exertional symptoms. HISTORY OF PRESENT ILLNESS: A 77-year-old priest with a remote history of percutaneous transluminal coronary angioplasty of his RCA on [2158-4-19] done well over the years until last [Month (only) 205] when he began noticing burning in his throat and upper chest after walking a quarter of a mile. Admitted to [Hospital1 ] at the time where he underwent a stress test which was remarkable for 0.5 to [Street Address(2) 28585] depressions inferiorly in V4 through 6. Imaging did not detect perfusion defects at that time, as ejection fraction was noted to be 50%. He was told at that time the symptoms were attributable to reflex and he was started on Prilosec at that time. He has since that limited his level of activity because of persisting symptoms. He is now uncomfortable with the sensation in his chest and throat after walking as little as [Age over 90 ] yards. The past week, he has taken nitroglycerin with complete relief of symptoms. He denies claudication, orthopnea, edema, paroxysmal nocturnal dyspnea and lightheadedness. His height is 5 feet 8 inches and his weight is 185 pounds. PAST MEDICAL HISTORY: 1. Hypercholesterolemia 2. Hypertension 3. Paroxysmal atrial fibrillation 4. Gastroesophageal reflux disease 5. Coronary artery disease 6. Hypothyroidism 7. Bladder cancer that was treated with surgery. 8. Crohn's disease, last bleeding noted in [2159] 9. Low testosterone levels 10. Status post TNA and mastoid surgery ALLERGIES: THE PATIENT STATES ALLERGIES TO PROTAMINE, SHELLFISH AND DYE. ADMISSION MEDICATIONS: 1. Aspirin 81 mg qd 2. Amiodarone 200 mg qd 3. Pindolol 5 mg qd 4. Nifedipine 60 mg qd 5. Prilosec 20 mg [Hospital1 ] 6. Lipitor 10 mg qd 7. Dyazide 37.5/25 mg qd 8. Coumadin 2 mg on Monday, Wednesday, Friday, 3 mg on Sunday, Tuesday, Thursday, Saturday 9. Levoxyl 100 mcg qd 10. Vitamin D ADMISSION LABS: White count 8.1, hematocrit 40, platelets 257. Sodium 140, potassium 4.4, chloride 101, Co2 29, BUN 13, creatinine 1.1 and an INR of 1.9. ADMISSION PHYSICAL EXAM: GENERAL: No acute distress. LUNGS: Clear. HEART: Regular rate and rhythm, S1, S2. ABDOMEN: Benign. EXTREMITIES: No edema. OP: Normal. HOSPITAL COURSE: The patient was brought to catheter lab. Please see catheter report for full details. In summary, catheter showed low normal ejection fraction, LAD with 80% stenosis, left circumflex with an 80% to 90% stenosis and an RCA with a 90% stenosis. CT surgery was consulted following cardiac catheterization. The patient was seen by cardiac surgery and accepted for coronary artery bypass grafting. On [1-23], the patient was brought to the Operating Room. Please see the Operating Room for full details. In summary, the patient had a coronary artery bypass graft x3 with left internal mammary artery to the LAD, saphenous vein graft to OM and a saphenous vein graft to the distal RCA. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well on the immediate postoperative period. Hemodynamically, he was stabilized. Following his, his anesthesia was reversed and he was weaned from the ventilator, at which point he was successfully extubated. On postoperative day 1, the patient continued to do well. He was transferred from the cardiac surgery recovery unit to Far Six for continuing postoperative care and cardiac rehabilitation. On postoperative day 3, the patient was noted to have a fever of 100.1?????? along with high O2 requirements. A chest x-ray was done which at that time showed a right lower lobe infiltrate. At that time, he was started on Levaquin for presumed pneumonia. Sputum cultures were also sent at that time. On the night of postoperative day #5, the patient was noted to have acute episodes of desaturation and shortness of breath. Further chest x-ray was done and his antibiotic coverage was expanded to include levofloxacin as well as ceftriaxone. During the next several days, the patient remained on the floor. He was noted to continue to have episodes of shortness of breath and desaturation. He was aggressively diuresed, however on postoperative day 10 despite these efforts the patient showed no improvement and he was transferred back to the Intensive Care Unit for more aggressive pulmonary therapy. On postoperative day 11, the patient was reintubated. At that time, the patient's chest x-ray showed right sided infiltrates as well as some congestive heart failure. Chest CT done following his transfer to the Intensive Care Unit showed ARDS versus amiodarone fibrosis or a combination of both. Bronchoscopy at that time showed small amount of blood and erythema with no endobronchial lesions. Cultures were sent for cytology, microbiology and cell counts. The following day, the patient self extubated following which he was reintubated. On postoperative day 16, the patient experienced episodes of rapid atrial fibrillation with a ventricular rate of 150. Following amiodarone load, the patient was cardioverted back to a normal sinus rhythm. Over the next several days, the patient was maintained on a ventilator. He was noted to be coming increasingly hypoxic. On postoperative day 20, he was chemically paralyzed and changed to pressure control ventilation. Also at that time he was noted to have increasing fever with a white count of 14.3. Fever work up was done. Sputum cultures from that time showed gram positive cocci as well as yeast for which the patient was started on appropriate antibiotics. The patient continued to have pulmonary problems over the next several weeks. He remained in the Intensive Care Unit chemically paralyzed and on pressure control ventilation throughout that period of time. In addition to his ARDS, the patient also experienced recurrent episodes of atrial fibrillation on more than on one occasion requiring electrical cardioversion. On [3-1], the patient began to show a slight improvement in his pulmonary status. At that time, he underwent an open tracheostomy at the bedside. The patient continued to show slow progression in his pulmonary status and on [3-5], postoperative day 37, the patient's paralytics were discontinued. He remained on pressure control ventilation, however his respiratory rate and driving pressures were slowly turned down. On postoperative day 38, the patient was again noted to spike a temperature to 101.8?????? with a white blood cell count of 24,000. Fever work up at that time showed positive blood cultures. His lines were re-sited. Sputum with Enterobacter was treated with appropriate antibiotics and sinusitis for his OG an nasogastric tubes were removed. The patient responded well to these therapies. He continued to show slow pulmonary progress and on postoperative day 41 he was switched from pressure control ventilation to intermittent mandatory ventilation which he tolerated well. Also, on postoperative day 41 a PEG tube was placed. Over the course of the past week, the patient's ventilatory requirements have continued to improve. He currently is on continuous positive airway pressure with pressure support of 25 and PEEP of 5, 40% FIO2. His respiratory rate is in the mid 20s and his tidal volumes are 380 to 420. The patient will be transfered to rehab, responding to commands, afebrile, and hemodynamically stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft x3 with left internal mammary artery to the LAD, saphenous vein graft to OM and saphenous vein graft to distal RCA. 2. Status post tracheostomy 3. Status post PEG tube placement 4. Adult respiratory distress syndrome 5. Paroxysmal atrial fibrillation 6. Gastroesophageal reflux disease 7. Hypothyroidism 8. Hypertension 9. Hypercholesterolemia 10. Crohn's disease 11. Hypo-testosterone 12. Bladder CA treated with surgery [80]. Mastoid surgery DISCHARGE MEDICATIONS AS WELL AS PHYSICAL EXAM will be addressed in a subsequent addendum discharge summary. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2170-3-13] 15:05 T: [2170-3-13] 15:09 JOB#: [Job Number 106640] Admission Date: [2170-1-22] Discharge Date: [2170-3-19] Service: Cardiothoracic Surgery ADDENDUM: The patient remained in the Cardiothoracic Intensive Care Unit throughout that period. His condition continued to slowly improve. From a pulmonary standpoint, he was placed on pressure support during the day hours with a pressure support of 28 and 40% FIO2 and during the night time hours he was placed on an IMV with a tidal volume of 400, rate of 14 and 40% FIO2, 5 PEEP. With that, his blood gases were in the range of 7.44, 58, 74, 96% saturated. His tube feeds during that time were also changed to a 1.5 calorie per cc low carbohydrate pulmonary tube feed. Hemodynamically, he remained stable from an infectious disease standpoint. He continued on vancomycin and gentamicin. Those two are to be continued through Wednesday, [3-21]. Neurologically, Father [Name (NI) ] continued to show slow improvement. By postoperative day 53, the patient was nodding his head appropriately to questions. He continued to be unable to purposefully move his arms or lower extremities. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft x3 complicated by ARDS 2. Status post trach 3. Status post PEG tube 4. Paroxysmal atrial fibrillation 5. Gastroesophageal reflux disease 6. Hypothyroid 7. Bladder CA 8. Crohn's disease 9. Hypo-testosterone 10. Hypertension 11. Hypercholesterolemia 12. Mastoid surgery ALLERGIES: AMIODARONE AND CONTRAST DYE DISCHARGE MEDICATIONS: 1. Lipitor 10 mg qd 2. Lacrilube to both eyes tid 3. Colace 100 mg [Hospital1 ] 4. Aspirin 325 mg qd 5. Levoxyl 100 mcg qd 6. NPH insulin 10 units q 12 hours 7. Captopril 12.5 mg q8h 8. Heparin 5000 units subcutaneously q 12 hours 9. Vancomycin 1 gm q 12 hours through Wednesday, [3-21]. 10. Gentamicin 120 mg intravenous q8h through Wednesday, [3-21]. 11. Santyl ointment to left calf wound [Hospital1 ] 12. Lopressor 25 mg [Hospital1 ] 13. Prevacid elixir 30 mg qd 14. Sliding scale regular insulin qid 15. Prednisone 10 mg qd 16. Procainamide 625 mg q4h 17. Combivent metered dose inhaler q4h and prn VENTILATOR SETTINGS AT THE TIME OF TRANSFER: During the day, pressure support of 28 with PEEP of 5 and FIO2 of 40%. With that, he maintains a tidal volume of 320 cc. At night, he is switched to an IMV, 40% FIO2, tidal volume of 400, rate of 10 with 5 PEEP. FOLLOW UP: The patient is to have follow up care one month following discharge from rehabilitation with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. He is also to see his primary care physician within two to three weeks following discharge from rehabilitation. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2170-3-19] 09:27 T: [2170-3-19] 09:43 JOB#: [Job Number 106641]	[ "414.01", "790.7", "515", "518.5", "998.4", "428.0", "285.9", "427.31", "486" ]	icd9cm	[ [ [] ] ]	[ "96.6", "86.05", "39.61", "99.15", "43.11", "37.22", "36.15", "36.12", "31.1" ]	icd9pcs	[ [ [] ] ]				9753, 9761				9782, 10170	10193, 11088					2512, 7696				1867, 2171								2353, 2494									11100, 11643															120, 286											315, 1413					2188, 2338											1435, 1844
12,073	182,965	28688	Discharge summary	report	Admission Date: [2102-6-26] Discharge Date: [2102-6-30] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: s/p fall down stairs Major Surgical or Invasive Procedure: none History of Present Illness: 85 F found at bottom of stairs in pool of blood, questionable LOC, pt unable to recall details of event. Past Medical History: Diabetes Mellitus hypertension a-fib h/o stroke Social History: non-contrib Family History: lives with husband Physical Exam: VS 96 139/87 18 95% on NRB HEENT: airway intact, PERRL, large occipital laceration CV: irreg rhythm (a-fib) Chest: BS equal bilat Abd: soft, nt, FAST(-) Pelvis: stable Back: non-tender rectal: guiac (-), nL rectal tone Ext: moving all extremities Pertinent Results: CXR([6-26])- no effusion, no rib Fx, no PTX Pelvic x-ray([6-26])- no Fx CT c-spine([6-26])- no Fx or malalignment CT abd/pelvis([6-26])- neg CTA head ([6-27])- bilateral foci of SAH (L>R); no aneurysm or flow abnormality Carotid duplex: no stenosis Brief Hospital Course: Neuro: Patient was admitted with a SAH. Initially she was confused and seemed to have a waxing-[Doctor Last Name 688] MS, however her MS improved closer to baseline at time of discharge. Patient was loaded with dilantin and will complete 10 day course. CV: Patient was in a-fib (HR in 80s-100s) on admission and remained in a-fib during hospital course, with intermittent ventricular ectopy. In concert with her primary care physician, [Name10 (NameIs) ] was discontinued. Rate control was continued with atenolol. Patient was unsteady walking and medical and PT team felt she would be best served by a short stay in a rehabilitation center. Medications on Admission: Atenolol 50 mg [Hospital1 ] Dyazide -one tab PO daily avapro 150 mg po daily [Hospital1 ] 2.5 mg PO daily trazadone 50 mg PO daily nitroquick 0.4 mg SL (daily vs prn?) Discharge Medications: 1. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual prn as needed for chest pain. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO qd (). 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 7 days. 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED) as needed for hyperglycemia: sliding scale. 8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: 1) subarachnoid hemorrhage 2) scalp laceration Discharge Condition: Good, tolerating POs. Discharge Instructions: You have suffered a subarachnoid hemorrhage (a small bleed into your brain tissue) and a laceration (cut) to your head following a fall down the stairs. You should return to the ED or [Name6 (MD) 138] [Name8 (MD) ] MD if you develop worsening headaches, vision changes, neurologic deficits (numbness or weakness in your arms or legs; change in your mental status - i.e. confusion, behavioral changes), chest pain, difficulty breathing, nausea/vomiting, fever/chills, or any other symptoms that are concerning to you. You should take all medications as prescribed. Your [Name8 (MD) ] (blood thinner) has been stopped and at this time should NOT be restarted; this has been discussed with your primary care physician. [Name10 (NameIs) ] will complete a 10 day course of dilantin (an anti-seizure medication) - you should take this medication until [7-6]. You should follow-up with the trauma clinic (see below) and your primary care physcian. Followup Instructions: Follow-up at trauma clinic in [11-21] weeks (call [Telephone/Fax (1) 6439] to make an appointment). Follow-up with your primary care physician within one week of discharge from the rehabilitation center. Completed by:[2102-6-30]	[ "V58.61", "E880.9", "250.00", "V12.59", "873.0", "401.9", "427.31", "852.00", "298.9" ]	icd9cm	[ [ [] ] ]	[ "86.59" ]	icd9pcs	[ [ [] ] ]	2765, 2845	1136, 1791	281, 288	2936, 2960	843, 1113	3974, 4217	538, 558		2018, 2742		2866, 2915		1817, 1995			2984, 3951										573, 824																								221, 243											316, 422																444, 493	509, 522
63,944	187,913	41660	Discharge summary	report	Admission Date: [2121-7-21] Discharge Date: [2121-8-7] Date of Birth: [2054-7-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: Abd pain, leg pain, ? ASA toxicity Major Surgical or Invasive Procedure: L subclavian line CVL placement Arterial line placement Intubation Percutaneous chole drain History of Present Illness: Mr. [Known lastname 90564] is a 67 year-old Spanish-speaking male with history of sCHF (EF of 20% as per OHS report), HTN who presented to an OSH with leg pain, and abdominal pain and was found to have [Last Name (un) ] and acidosis. He states that his leg pain has been ongoing for the last several years, but worsening in the last few weeks. He has been taking on average 12 ibuprofen and ASA for his pain for several years and in the last 3 days he was several tablets per day without much resolution of his symptoms. Yesterday he felt worse to the point that he came to the ED at [Hospital3 15402]. He initially had US of his LE as per report it was negative. He labs and was found to have a Cr of 7.1, ASA level of 15.9, and bicarb of 8. He was transferred to [Hospital1 18] for urgent HD. . In the BIMDC ED, his initial VS were 97.5 76 116/53 28 97%. He remained tachypneic and repeat labs which showed low bicarb of 6, BUN 91/Creatine of 7.8. Serum Osms:292 UricA:15.2/VBG was pH 7.23/ pCO2 18/ pO2 80/ HCO3 8. His ASA level was 15 and there was concern for aspirin intoxication, toxicoloy was consulted and recommended giving fomepizole, although they thought this was less likely to be due to true intoxication giving levels. Renal consult was also called. He was given 1L of NS, and D50 (for hypoglycemia) and admitted to the [Hospital1 12145]. . Currently he is very drowsy, but responsive. Ox 3. Jaundice with increase in resp rate to 30s. He denies having any pain or discomfort, able to answer most questions appropriately. Renal is present to place HD line. He was given 2gm of calcium gluconate (freeCa:0.75) and 1 amp of bicarb (bicarb of 11). Review of systems: (+) Per HPI, + nausea, generalized body aches and pain. (-) 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. All other review of systems are negative. Past Medical History: - sCHF (reportedly EF of 20%) - Hypertension - Hyperlipidemia - History of alcohol abuse , denies drinking in the last 6 years Social History: From Guatamala, he has a brother [First Name8 (NamePattern2) 71] [Name (NI) 90564]) who lives in [Name (NI) 392]. History of alcohol use (6 beers per day, but stopped many years ago), no drugs. He smokes, but unable to quantify. Family able to state that he has stopped drinking EtOH for past 5 years Family History: Unclear Physical Exam: ADMISSION General: Middle-aged male, drowsy but easily arousable by verbal stimuly HEENT: Sclera icteric,PERRLA - 2mm, MMdry, oropharynx clear Neck: supple, JVP at 7cm, no LAD Lungs: Clear to auscultation bilaterally, except for crackles on right LLL CV: Regular rate and rhythm,normal S1 + S2, Tachy, no murmur, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no palpable HSM Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Drowsy but able to answer questions appropriately, Ox person/place. He was able to give me his brother's phone #. PERRLA, + Asterix. Moving all extremeties Pertinent Results: LABS: Na 130/ K 3.4/ Cl 89/ Bicarb 6 /BUN 91/ Cr 7.8 /Glu 62 Ca 5.8/ Mg 3.0 /Phos 8.3 ALT 432 AST 537 AP 247 Tbili 4.7 Alb 3.3 Lip 61 serum ASA 15.5 serum tylenol, alcohol, other tox - negative Sosm 292 uric acid 15.2 WBC 5.8 Hct 32.2 Plt 123 N 86.5% L 11.5% M 1.3% PT 15.1 PTT 42.1 INR 1.3 VBG 7.23/18/80 Lactate 4.7 free calcium 0.74 Urine: Sp [Last Name (un) ] 1.025, pH 6.0, prot 30+, lg blood neg nitr, leuk, glu, ketones, uro, bili UNa 47 . microscopy: muddy brown casts, large number of nondysmorphic RBC's, renal tubular epithelial cells . IMAGING: CXR:There is cardiomegaly. No focal consolidation, no pleural effusion or pneumothorax. . EKG: NSR, rate 65, Q waves in III and aVF consistent with prior, TWI on aVL (new), Biphasic T waves on V2-V3 (sl more pronounced than prior), ST depression w/ TWI on V3-V6 (similar to earlier done on [7-20]). No earlier EKG for comparison. Micro: [2121-8-2] 10:22 am SPUTUM Source: Endotracheal. ACID FAST SMEAR (Final [2121-8-4]): Reported to and read back by [Last Name (LF) 611],[First Name3 (LF) ] @ 14:00, [2121-8-3]. Reported to and read back by [Last Name (LF) 90565],[First Name3 (LF) ] @ 14:15, [2121-8-3]. ACIDFAST BACILLI. FEW seen on direct smear. MODERATE seen on concentrated smear. ACID FAST CULTURE (Preliminary): GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Final [2121-8-7]): POSITIVE FOR M. TUBERCULOSIS BY MTD. Identified by State Laboratory [2121-8-6]. Reported to and read back by [Last Name (LF) ],[First Name3 (LF) ] AND DR.[Last Name (STitle) ],MATTEW @ 14:00, [2121-8-6]. IMAGING: Brain MRI IMPRESSION: Multiple FLAIR and T2 hyperintense lesions in bilateral frontal and parietal periventricular white matter and right cerebellar hemisphere showing slow diffusion. The etiology of the lesions is unclear and the location of the lesions is unusual for septic emboli. Consider the possibility of vasculitis perhaps in combination with hypotension leading to infarction. Abdominal MRI: IMPRESSION: 1. Non-occlusive non-circumferential plaque projecting into the lumen of the infrarenal abdominal aorta. Findings favor ulcerated plaque versus chronic penetrating ulcer, possibly with hemorrhage within the wall of the aorta. No definite vasculitis. If clinical suspicion for for ongoing infection within this region, then a radionuclide-labeled white cell scan may be helpful. 2. New splenic lesions concerning for either septic emboli or areas of infarction. 3. Moderate bilateral pleural effusions. ' CT Chest: IMPRESSION: 1. Compared to the prior study, there has been further progression of dense consolidation in both lower lobes. Findings are consistent with ARDS. 2. New multiple low-attenuation splenic lesions. These are difficult to completely characterize without IV contrast. However, differential diagnosis could include infarcts versus abscesses. Malignancy cannot entirely be excluded, although much less likely. Clinical correlation is advised. 3. Stable loss of paraaortic fat plane as described above. This may be secondary to enlarged lymph nodes, vasculitis, or retroperitoneal inflammation. 4. Colonic wall thickening as described above. Differential diagnosis would include infectious or ischemic etiologies. Evaluation for ischemia is very limited due to the lack of IV contrast. 5. Tubes and lines in good position. Brief Hospital Course: Mr. [Known lastname 90564] [Last Name (Titles) 12145] course was complicated by multiorgan failure with ARDS, ARF requiring CVVH, active TB with cavitary lesion, splenic and brain lesions concerning for infection vs thromboembolic disease, liver failure of unknown etiology, hypotension thought to be from sepsis, acholic cholecystitis, bilateral pneumothoraces, peripheral ischemic necrosis in the setting of pressor use. The initial insult was never identified, though it was initially speculated that Mr. [Known lastname 90564] developed acute renal failure from toxic injestion of medications... ? Aspirin toxicity: With metabolic acidosis and respiratory alkalosis; however his ASA level was normal at 15 (unclear where he was on the curve with this though). He was concurrently taking a large amount of Ibuprofen which could have contributed to his renal failure and metabolic acidosis. His serum Osm gap was 1 making other ingestions less likely. In speaking with his family, who he was not very close with, they said that he had been having abdominal and leg pain for a long time and a few weeks of fevers/chills and weight loss, and was taking "handfuls" of different meds. They broguht in a bag full of bottles which were mostly vitamins but also many empty bottles of Aspirin and Ibuprofen. The patient had a HCO3 of 6 on arrival to [Known lastname 12145]. Renal was consulted and on arrival was started on HD. He received aggressive HCO3 IV, and actually was iatrogenically put into metabolic alkalosis, however this quickly resolved. He was continued on hemodialysis/UF through his admission course with interruptions only for hypotension when he required pressors. ARDS/ PTX: On the first day of [Known lastname 12145] admission, he began developing hypoxia with CXR's showing bilateral infiltrates, notably without pleural effusions and CT chest strongly suggested ARDS. He was intubated and given ARDSnet ventilation given that his minute ventilations were very high and he was breathing very heavily. He was heavily sedated and paralyzed to facilitate low tidal volume ventilation. After his controlled ventilation and paralytics were weaned, he again started to breath very heavily such that he developed a respiratory alkalosis. Sputums did grow out moderate MSSA and sparse Enterobacter however unclear is this was ever clinically a real PNA. He was treated with a full course of broad spectrum antibiotics for 8 days. These antibiotics were continued due to development of persistent fevers without a source. Otherwise, AFB concentrated smears, Legionella, mycolytic blood cultures, RPR, malaria Ag and smear, acute CMV, acute EBV, respiratory viral culture, bile from perc chole drain, Cdiff, and all other blood cultures were negative. His vent was eventually weaned, however he remained too sedated to breath enough on his own to be extubated (see below). Eventually, he developed bilateral pneumothoraces which were treated with bilateral chest tubes. M. Tuberculosis: A cavitary lesion was noted on chest CT. The patient underwent bronchoscopy in the setting of ARDS which was negative for AFB. He was taken off respiratory precautions. He continued to spike fevers despite 8 days of broad spectrum antibiotics. He then had induced sputums x 2 which were both positive for M. Tuberculosis. He was placed back on respiratory precautions. His HIV status is unknown given he was not consented to check for HIV. Late in the course of his [Known lastname 12145] stay, Mr. [Known lastname 90564] was started on antituberculosis quadruple therapy with rifampin, INH, ethambutol, pyrazinamide. Brain/spleen lesions: Mr. [Known lastname 90564] was noted to be too sedated to wean from his ventilator. He also developed persistent fevers without a source after completing 8 days of broad antibiotics. A torso and brain CT scan was performed which showed multiple hypodense lesions in the brain and spleen concerning for mets versus thromboembolism/mycotic embolism. Given he had no known cancer, it was thought that these lesions were unlikely to be mets. His blood cultures remained negative and TTE/TEE were negative for endocarditis but did reveal a patent foramen ovale. He had a known LUE DVT and may have broken off clot to cause embolic lesions, however he was not started on anticoagulation given the brain lesions. He developed cushingoid physiology with abrupt bursts of hypertension with relative bradycardia concerning for increased intracranial pressure, therefore he did not undergo diagnostic LP. He was breifly started on mannitol and hypertonic saline with improvement in mental status. However, repeat imaging did not show increasing brain edema and given he was intermittantly on CVVH and HD, it was thought that this should be stopped. The patient was continued on broad antibiotics including antifungals with no improvement in mental status. Acute renal faliure: Muddy brown casts on microscopy consistent with ATN. ? NSAID/ASA induced as above. No crystals in the urine to suggest ethylene glycol use. He received HD through his course. He then received CVVH when dialysis was limited by hypotension. He developed persistent acidosis in the setting of sepsis and was eventually started on a bicarb gtt as he developed worsening hypotension requiring three pressors. Hypotension: On pressors off and on through [Known lastname 12145] admission. Unclear etiology as blood cultures were negative. He was given an 8d course of stress dose steroids. Eventually able to wean pressors, however he devloped refractory hypotension again requiring three pressors. Transaminitis: pt may have also been taking tylenol for his pain likely leading to transaminitis, but Tylenol levels were negative. His family was able to state that he has not drank in the pats 5 yrs. Hepatitis panels were negative as were [Doctor First Name ]. His mildly elevated LFT's had a spike in his Tbili on [7-25], and so repeat RUQ u/s was concerning for acalculous cholecystitis, for which IR was consulted and a percutaneous chole drain was placed. The pt's bilirubin remained persistently elevated. Lter in the course his transaminases increased acutely again, but this was thought to be related to sepsis/shock liver. Atherosclerotic vs mycotic aneurysm: CT torso showed an infrarenal aneurysmal dilatation called as athersclerotic vs mycotic aneurysm, however after discussion with Vascular who looked at the films, felt infectious mycotic aneurysm less likely. Blood cultures were also negative. Thrombocytopenia: Felt to likely be a combination of ABx, critical illness, and liver disease. HITT felt not likely. These were trended. No schistocytes were seen on peripheral smear. Ischemic L foot with distal digit necrosis: Vascular was consulted and this was felt to be most likely due to high pressor requirements and not an acute thrombotic event. As we were able to wean pressors, his foot became warmer, pulses were again Dopplerable and this improved. Globally hypokinetic LV: pt had an echo which showed global hypokinesis of his LV, ? reverse Takutsubo's. Likely a stress cardiomypathy, but per OSH reports pt also with h/o sCHF with EF 20%, unclear if due to prior MI given Q waves seen on III and aVF. He did make low level of Tropnins, and positive MB's were likely due to elevated overall CK given low MB index. His cardiac condition was monitored but felt likely due to severe underlying illness, so HF specific Tx's were not given (BB, ACEi, etc). Eventually the patient developed severe hypotension requiring three pressors, lactic acidosis of > 15, acidemia, and very poor prognosis with multiple organ failure with no identified source of systemic infection or unifying cause of disease. His mental status was poor with brain lesions of unknown etiology. A family meeting was held and his goals of care were changed to comfort measures only. His pressors and CVVH were stopped. His breathing tube was left in place to minimize transmission of active TB. His blood pressure soon dropped and he became pulseless within 30 minutes. He was declared deceased at 7:10 pm. Medications on Admission: Advil, tylenol, and aspirin as above- 12 tablets per day Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased	[ "276.1", "287.5", "428.0", "434.91", "575.0", "275.41", "272.4", "348.89", "038.9", "584.5", "518.81", "E850.3", "707.21", "E879.8", "512.1", "401.9", "E928.8", "428.20", "728.88", "518.89", "276.2", "785.4", "011.23", "570", "965.1", "V49.86", "785.52", "995.92", "707.07", "745.5" ]	icd9cm	[ [ [] ] ]	[ "39.95", "88.72", "33.24", "96.6", "96.72", "34.04", "51.01" ]	icd9pcs	[ [ [] ] ]	15651, 15660	7337, 15514	338, 431	15712, 15722	3844, 5173	15779, 15790	3126, 3135		15622, 15628		15681, 15691		15540, 15599			15746, 15756										3150, 3825					5210, 7314															2161, 2627				264, 300											459, 2142																2649, 2779	2795, 3110
19,940	198,694	20889	Discharge summary	report	Admission Date: [2121-11-15] Discharge Date: [2121-11-25] Date of Birth: [2061-6-15] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Hurricaine Attending:[First Name3 (LF) 2641] Chief Complaint: Fever. Major Surgical or Invasive Procedure: Removal of screws from left foot from previous fusion. History of Present Illness: The pt. is a 60 year-old female with multiple medical problems who was recently admitted from [2121-10-28] to [2121-11-13] for repair of a charcot foot complicated by respiratory distress, subsequent wound infection and a long hospitalization. She was discharged to [Hospital 100] Rehab with a PICC line for long-term antibiotics. She did well during her first two days at the rehab facility but developed a fever to 104 degrees and there was also concern over a "drug rash." In the ED, the pt. was noted to have a temperature of 100.3 degrees rectally. Her initial blood pressure was 150/85, however it suddently dropped to 70's systolic. This prompted insertion of a femoral line and the administration of 4 liters of normal saline. The pt. also required levophed for blood pressure support. She was placed on three liters of oxygen via nasal cannula and was somnolent but following commands and maintaining her airway. She was empirically started on unasyn, vancomycin and levofloxacin. She was also given one unit of packed red blood cells for a low hematocrit. She was noted to have T-wave inversions in the lateral leads. Her cardiac enzymes were drawn and were not suggestive of acute myocardial infarction. She was admitted to the MICU for possible sepsis. Past Medical History: -HTN -hyperlipidemia -diabetes mellitus, type 2 -diastolic CHF -CRI, baseline creatinine 1.5 -COPD -OSA on BiPAP -psoriasis -hypothyroidism -positive PPD -s/p bilateral mastectomy -peripheral neuropathy -hyponatremia of uncertain etiology with baseline Na of 130 Social History: The pt. is divorced and lives in an apartment in [Location (un) 1110]. 35 year history of cigarette smoking, 1-2 packs per day. Denied use of EtOH or illicit drugs.Her sister, [Name (NI) 335] [Name (NI) 55586], is her health care proxy. Family History: Non-contributory. Physical Exam: Vitals: T: 100.3F rectal P: 80 R: 26 BP: 148/85 SaO2: 93% on 3L O2 via NC General: somnolent, falls asleep before completes sentences HEENT: PERRL, anicteric sclerae, no lesions in OP Neck: obese, no JVD Pulmonary: bibasilar rales L>R, no wheezes, no use of accessory mm. Cardiac: RRR, S1S2, no m/r/g Abdomen: soft, NT/ND, NABS Extremities: VAC drain in place on L foot Neurologic: somnolent, uncooperative with exam Skin: + facial erythema, otherwise no rashes or lesions noted. Pertinent Results: Labs on admission: [2121-11-15] 11:15PM CK(CPK)-36 [2121-11-15] 11:15PM CK-MB-NotDone cTropnT-<0.01 [2121-11-15] 11:15PM OSMOLAL-276 [2121-11-15] 11:13PM TYPE-ART TEMP-39.3 RATES-/35 O2-50 O2 FLOW-12 PO2-99 PCO2-37 PH-7.36 TOTAL CO2-22 BASE XS--3 INTUBATED-NOT INTUBA [2121-11-15] 11:13PM LACTATE-0.8 [2121-11-15] 06:15PM GLUCOSE-89 UREA N-21* CREAT-1.4* SODIUM-135 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-8 [2121-11-15] 06:15PM ALT(SGPT)-30 AST(SGOT)-34 LD(LDH)-194 ALK PHOS-62 TOT BILI-0.1 [2121-11-15] 06:15PM CORTISOL-21.6* [2121-11-15] 06:15PM CRP-7.18* [2121-11-15] 06:15PM WBC-4.4 RBC-3.37* HGB-9.1* HCT-27.1* MCV-80* MCH-27.1 MCHC-33.6 RDW-16.1* [2121-11-15] 06:15PM NEUTS-76.1* LYMPHS-14.3* MONOS-2.2 EOS-7.2* BASOS-0.2 [2121-11-15] 06:15PM ANISOCYT-1+ MICROCYT-1+ [2121-11-15] 06:15PM PLT COUNT-526* [2121-11-15] 06:15PM SED RATE-114* [2121-11-15] 05:30PM PO2-63* PCO2-44 PH-7.30* TOTAL CO2-23 BASE XS--4 COMMENTS-GREEN TOP [2121-11-15] 05:15PM URINE HOURS-RANDOM UREA N-482 CREAT-70 SODIUM-45 POTASSIUM-26 [2121-11-15] 04:00PM URINE HOURS-RANDOM [2121-11-15] 04:00PM URINE GR HOLD-HOLD [2121-11-15] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 [2121-11-15] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2121-11-15] 04:00PM URINE EOS-NEGATIVE [2121-11-15] 02:34PM GLUCOSE-66* UREA N-23* CREAT-1.5* SODIUM-125* POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-23 ANION GAP-13 [2121-11-15] 02:34PM CK-MB-NotDone cTropnT-<0.01 [2121-11-15] 02:34PM WBC-5.1 RBC-3.14* HGB-8.6* HCT-25.2* MCV-80* MCH-27.4 MCHC-34.2 RDW-15.9* [2121-11-15] 02:34PM NEUTS-80.6* LYMPHS-10.6* MONOS-3.1 EOS-5.6* BASOS-0.1 [2121-11-15] 02:34PM MICROCYT-1+ [2121-11-15] 02:34PM PLT COUNT-547* [2121-11-15] 02:34PM PT-13.6 PTT-34.7 INR(PT)-1.2 [2121-11-15] 02:26PM GLUCOSE-69* LACTATE-1.1 Labs on Discharge: [2121-11-25] 05:17AM BLOOD WBC-7.3 RBC-3.66* Hgb-9.9* Hct-30.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-19.6* Plt Ct-447* [2121-11-25] 05:17AM BLOOD Plt Ct-447* [2121-11-25] 05:17AM BLOOD Glucose-144* UreaN-15 Creat-1.0 Na-131* K-3.7 Cl-96 HCO3-28 AnGap-11 [2121-11-25] 05:17AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9 Brief Hospital Course: MICU Course: 1. ? Septic Shock: The pt. was admitted with a presumptive diagnosis of sepsis (the source was initially thought to be secondary to pneumonia vs PICC line infection vs heal ulcer). Levophed was quickly weaned off over the first night that the patient spent in the MICU. A TEE was performed on [11-17] that was negative for endocarditis or abscess. The pt was pan-cultured, including PICC and femoral line tips, but nothing grew out. She was maintained on zosyn and levofloxacin. [Month/Year (2) ] did not feel that the screws in her L foot were a likely source for continued infection. A cortisol level was low, so hydrocortisone and fludricortisone were started for adrenal insufficiency in the face of her critical illness. The steroids were subsequently weaned off shortly after transfer to the floor. 2. Acute methemoglobinemia: During the TEE procedure (on [11-17]), hurricaine spray triggered an episode of methemoglobinemia, with MetHb 58% on ABG done at the time. Methylene Blue was administered with rapid clinical response and resolution of cyanosis. Further ABGs after administration of methylene blue revealed MetHb 7% shortly thereafter and later down to 1%. Hurricaine Spray was added to the list of allergies. In addition, the pt. was treated for her diabetes mellitus, coronary artery disease, and pulmonary disease (?pulmonary fibrosis and obstructive sleep apnea) during her six day MICU course. On [2121-11-20], the pt. was transferred to the floor. She was treated for the following issues: 1. Left foot infection/possible osteomyelitis: The pt. had the hardware removed by the [Date Range ] service on hospital day #7. In addition, necrotic bone and surrounding soft tissue was also debrided at the time. An Xray of the pt's. foot was performed which did not show definite evidence of osteomyelitis. A VAC dressing was placed in the wound with instructions for q3day dressing changes. The pt. was maintained on vancomycin and zosyn during the hospital stay and will be on this course of antibiotics until such time as her wound fully granulates in. It is expected that this will take approximately six weeks post-discharge. The pt. was scheduled for a follow-up appointment with [Date Range ] for one week after discharge. 2. Type 2 diabetes mellitus: The pt. was noted to have good glycemic control during the hospital stay on a sliding scale of regular insulin. Her usual dose of glipizide was added prior to discharge. 3. Coronary artery disease: The pt. was chest-pain free for the duration of the hospital stay. She was maintained on aspirin, a beta blocker, a statin and an ACE inhibitor. 4. Hyponatremia: The pt. was noted to have serum sodium of 128-133 over the course of the hospital stay. The pt's. serum sodium is noted to be between 130-133 at baseline. A strict one liter fluid restriction was instituted with some effect in maintaining the serum sodium in the range of 131-135. This fluid restriction should be maintained in the long term. All of the pt's. other medical problems were inactive during this admission. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 12. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 13. Quetiapine Fumarate 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 14. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Metoprolol Tartrate 25 mg Tablet Sig: [1-3] Tablet PO twice a day. 16. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 8 days. 17. Zosyn 2-0.25 g Recon Soln Sig: One (1) Intravenous every six (6) hours for 8 days. Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation [Hospital1 ] (2 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 14. Vancomycin HCl 10 g Recon Soln Sig: one-tenth Recon Soln Intravenous Q12H (every 12 hours). 15. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 20. Glipizide 5 mg Tablet Sig: one-half Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: -Left charcot ulcer complicated by osteomyelitis -obstructve sleep apnea -hypertension -diastolic heart failure -hyponatremia of uncertain etiology -hypothyroidism Discharge Condition: The pt. was tolerating a p.o. diet, she was breathing easily on nasal cannula by day and CPAP at night. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 liter per day Please continue to take all of your medications as prescribed. Please be sure to attend all of your follow-up appointments. If you experience any concerning symptoms, please call your primary care doctor or come to the Emergency Department for evaluation. Followup Instructions: You should follow up with an endocrinologist to further evaluate your adrenal glands.Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2122-1-9] 11:00 Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2122-1-9] 12:00 Provider: [Name10 (NameIs) ] [Last Name (STitle) ]/DR [Last Name (STitle) ] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 5091] Date/Time:[2122-1-9] 12:15 Provider: [Name10 (NameIs) 1947],[Name11 (NameIs) 5446] [Hospital 1947] CLINIC Where: CC-2 [Hospital 1947] UNIT Phone:[Telephone/Fax (1) 3153] Date/Time:[2121-12-3] 10:10	[ "713.5", "486", "730.27", "428.30", "995.91", "515", "244.9", "276.1", "780.57", "250.60", "998.59", "496", "428.0", "038.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "78.67", "38.93" ]	icd9pcs	[ [ [] ] ]	11421, 11494	5169, 8286	294, 351	11702, 11807	2773, 2778	12248, 13038	2238, 2257		9739, 11398		11515, 11681		8312, 9716			11831, 12225										2272, 2754																								247, 256						4827, 5146					379, 1668								2793, 4807								1690, 1954	1970, 2222
11,112	161,594	17281+17282	Discharge summary	report+report	Admission Date: [2123-2-10] Discharge Date: [2123-3-1] Date of Birth: [2069-4-3] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 53-year-old female with a history of breast cancer, status post chemotherapy treatment leading to myelodysplastic syndrome and subsequently to acute myelogenous leukemia, who is now at day plus 97 status post allogeneic peripheral stem cell transplant, who presents with a history of fevers and a new radiologic finding of a left upper lobe nodule. The patient was evaluated at the clinic on [2-9] for a fever to 100.3. She noted a history of a nonproductive cough, persistent upper respiratory infection symptoms with sneezing that causes a left upper chest discomfort and slight pleuritic pain. She noted a decreased appetite in the past few days with nausea. No vomiting. She notes right upper quadrant discomfort after eating her meals (approximately one hour after) in recent days. She noted a new bilateral back pain that has increased in the sitting position and worse with some movements. She denies diarrhea, abdominal pain, or sore throat. This back pain has lasted one week. She has no dysuria or urinary frequency. PAST MEDICAL HISTORY: 1. Secondary myelodysplastic syndrome leading to acute myelogenous leukemia by bone marrow biopsy in [2122-1-28]; now at day plus 97 status post allogeneic peripheral stem cell transplant from a [7-4] matched sibling donor. The course has been complicated with an admission for diarrhea in [2122-12-28] with cytomegalovirus colitis/graft-versus-host disease diagnosed. 2. History of breast cancer diagnosed in [2117]; status post right mastectomy and right axillary lymph node dissection; status post CALGB chemotherapy regimen subsequently leading to myelodysplastic syndrome (as described above). 3. Depression. 4. Gastroesophageal reflux disease. 5. Psoriasis. 6. History of Sweet syndrome; treated with prednisone in the past. 7. Cytomegalovirus colitis; treated with ganciclovir. 8. Graft-versus-host disease (grade 2); treated with prednisone. 9. History of suspected Aspergillus with a video-assisted thoracic surgery done in [2122-9-28] which showed evidence of bronchiolitis obliterans-organizing pneumonia. ALLERGIES: CEFEPIME (causes a rash). MEDICATIONS ON ADMISSION: 1. Cyclosporine 120 mg once per day continuous intravenous. 2. AmBisome 180 mg intravenously every other day. 3. Methylprednisolone 30 mg by mouth once per day. 4. Protonix 40 mg by mouth once per day. 5. Ativan 0.5 mg by mouth q.6h. as needed (for nausea). 6. Folic acid 1 mg by mouth once per day. 7. Potassium chloride 20 mEq by mouth twice per day. 8. Magnesium sulfate 3 grams intravenously once per day. PHYSICAL EXAMINATION ON PRESENTATION: Flat affect, pale, very thin, slightly cachectic woman in no acute distress. Vital signs revealed her temperature was 99.4 degrees Fahrenheit, her blood pressure was 126/80, her respiratory rate was 16, and her heart rate was 88. Head, eyes, ears, nose, and throat examination revealed extraocular muscles were intact. The sclerae were anicteric. The pupils were equal, round, and reactive to light. The mucous membranes were moist. The neck was supple. There was no lymphadenopathy. The lungs were clear to auscultation bilaterally. Heart was tachycardic with a regular rhythm. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. No masses. Extremities revealed no clubbing, cyanosis, or edema. Distal pulses were 2+ bilaterally. Neurologic examination revealed cranial nerves II through XII were intact. Skin with no rashes and no lesions. Back revealed bilateral costovertebral angle tenderness to palpation with mild perivertebral tenderness. PERTINENT LABORATORY DATA ON PRESENTATION: Her white blood cell count was 2.2, her hematocrit was 30.2, and her platelet count was 44. Absolute neutrophil count was 1590. Electrolytes revealed sodium was 135, potassium was 4.2, chloride was 104, bicarbonate was 22, blood urea nitrogen was 20, and creatinine was 1.2. Her albumin was 3.4, magnesium was 4, and calcium was 8.9. Cyclosporine level from [2-9] was 502. Viral culture was negative for influenza A/B. Viral antigen negative for respiratory syncytial virus. PERTINENT RADIOLOGY/IMAGING: A chest computed tomography with contrast revealed (1) slightly speculated 1.4-cm left upper lobe nodule which had arisen since the prior chest computed tomography in [2122-10-28]; given the patient's fever this most likely represents an infectious process, consider Aspergillosis; (2) probable radiation changes at the right apex unchanged; and, (3) persistent right-sided pleural effusion which had decreased in size since previous chest computed tomography on [2122-11-23]. A chest x-ray revealed a new ill-defined nodular opacity in the left upper lobe concerning for atypical infection, stable appearance of the chest with right apical pleural opacity and right-sided volume loss. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. LEFT UPPER LOBE LUNG MASS ISSUES: The left upper lobe lung mass was highly suspicious for an infection. The Pulmonary team was consulted on hospital day two. They determined that a bronchoscopy was not indicated as the lung lesion was in too peripheral a location for an adequate bronchoalveolar lavage to be accomplished. The Interventional Radiology team was then consulted who determined that the location of the lesion was not accessible by computed tomography scan biopsy due to obstruction by surrounding vessels. Therefore, the Cardiothoracic Surgery team was consulted for a video-assisted thoracic surgery. Also on [2-12], the Infectious Disease team was consulted who agreed with the plan for a video-assisted thoracic surgery and had recommendations for cultures to be sent in addition to pathology. They had other recommendations; including obtaining a magnetic resonance imaging of the thoracic spine to rule out the possibility of a paraspinal or epidural abscess accounting for her ongoing new back pain and to consider an echocardiogram to rule out the small possibility of septic embolus from the vegetation. No change in her antibiotic regimen was made prior to the video-assisted thoracic surgery. On [2-13], the patient was prepared for a video-assisted thoracic surgery by Cardiothoracic Surgery; however, in the hour prior to the operation, the patient's blood cultures came back with coagulase-negative Staphylococcus bacteremia. It was unclear if this represented contamination or true bacteremia. Therefore, the patient's video-assisted thoracic surgery was cancelled and a course of vancomycin was initiated in addition to levofloxacin and AmBisome. Subsequent surveillance cultures were unrevealing. On [2-15], a repeat chest computed tomography was done to re-evaluate the lung nodule which had shown a slight increase in appearance. At that time, AmBisome was increased to once per day from every other day but was returned to every other day within one day due to concerns about renal function. Caspofungin was approved by the Infectious Disease team on [2-17] as there were ongoing concerns about the possibility of aspergillosis by the primary team. It was decided to hold on initiating Bactrim for the possibility of tachycardia. The patient did finally go to have video-assisted thoracic surgery on [2-20]. She was continued on vancomycin, and caspofungin, and AmBisome while her cultures were pending. On [2-23], the cultures from the video-assisted thoracic surgery grew out nocardia. At that time, intravenous Bactrim was intubated per the recommendations of the Infectious Disease team. The patient also had her chest tube removed on this day which was postoperative day three from the video-assisted thoracic surgery. At the time of this dictation, the patient had been afebrile on Bactrim but was having complications of nausea with this therapy. The patient did develop a new oxygen requirement of 2 liters which was thought to possibly be related to her worsening right pleural effusion but was still being evaluated at the time of this dictation. 2. GRAFT-VERSUS-HOST DISEASE ISSUES: The patient was continued on cyclosporine continuous intravenous throughout her hospital stay. She had been maintained on 120 mg of continuous intravenous per day but was decreased by 12 on several occasions. At the time of this dictation, she had been receiving cyclosporine at 72 mg once per day. Her prednisone dose was also tapered to 10 mg of prednisone once per day during her hospital stay. The patient did not have any diarrhea or skin lesions to suggest active graft-versus-host disease. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient required at least 3 grams of intravenous magnesium repletion each day while on cyclosporine. Her oral intake worsened during her hospital stay to a point where she was transitioned to total parenteral nutrition on [2-26] after having several days with minimal intake. She was continued on total parenteral nutrition at the time of this dictation. 4. DERMATOLOGIC ISSUES: The patient was noted to have an unusual 1.5 cm purple erythematous lesion on the right lateral aspect of her lower leg. This lesion was suspicious for a septic embolus, and a Dermatology consultation was obtained and a biopsy was done. The biopsy with associated cultures did show microabscesses but did grow out gram-positive rods consistent with nocardia. This further raised the possibility of disseminated nocardia. 5. NEUROLOGIC ISSUES: The patient was found to have a left upper lobe nodule that nocardia growth and Dermatology biopsy that had nocardia growth. Given the 40% chance of central nervous system involvement and the patient's worsening mental status on the dates of [2-25] and [2-26], a magnetic resonance imaging was done which did show two lesions that sere suggestive of infection; likely to be nocardia given this clinical scenario. The magnetic resonance imaging showed a small 5-mm ring enhancing lesion in the left occipital lobe with associated edema and a small 3-mm lesion within the right cerebellar hemisphere. Also, bilateral changes of mastoiditis were noted. The patient was continued on intravenous Bactrim as a single [Doctor Last Name 360] (per the Infectious Disease team) for treatment of this disseminated nocardia. 6. HEMATOLOGY/ONCOLOGY ISSUES: On [2-26], the patient was noted to have blasts in her peripheral blood smear. This finding was worrisome for the possibility of recurrence. The patient was planned to have a subsequent bone marrow biopsy to further evaluate this finding. During her hospital stay, the patient did receive 2 units of packed red blood cells on [2-22] for ongoing anemia. 7. RENAL ISSUES: The patient's creatinine did worsen throughout her hospital stay; at times reaching as high as a creatinine of 2. This worsening renal function was thought to be related to medications; in particular AmBisome and cyclosporine were suspected to be causing renal insufficiency. The patient did initially respond to a decrease in her cyclosporine and adjustment of some of her medications; however, at the time of this dictation, her creatinine remained at 2 despite serial decreases in her cyclosporine. The possibility that intravenous Bactrim was contributing to her renal insufficiency was being explored. Her fractional excretion of sodium was calculated at 5%. A urine protein creatinine ratio was pending at the time of this dictation. 8. ORTHOPAEDIC ISSUES: The patient did fall to her coccyx on [2-25] and had a resulting hematoma at the site. Imaging of the area was not done, and her pain was controlled with a patient-controlled analgesia. The patient did report improvement in this painful site, and the hematoma was resolving with conservative management. 9. RESPIRATORY ISSUES: The patient was stable on room air throughout her hospital stay until [2-27] when she developed a new oxygen dependence of 2 liters. A chest x-ray was done at the time of this new oxygen requirement and showed multifocal infiltrates; one of which, in the right upper lobe, appeared larger, and the remaining infiltrates were without significant change. The right pleural effusion did persist. At the time of this dictation, the patient had been started on meropenem, and the possibility of a pleural effusion thoracentesis was being considered. NOTE: Please see subsequent Discharge Summary Addendum for the remaining hospital course, discharge plan, and discharge medications. [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 31111], M.D. [MD Number(1) 31112] Dictated By:[Last Name (NamePattern1) 1615] MEDQUIST36 D: [2123-3-1] 12:19 T: [2123-3-2] 07:22 JOB#: [Job Number 48403] Admission Date: [2123-2-10] Discharge Date: [2123-3-20] Date of Birth: [2069-4-3] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 53 year old with secondary MDS/AML status post allo BMT 97 days ago, with history of breast cancer, who presents with new radiologic findings of left upper lobe nodule. The patient was evaluated at home yesterday for a fever of 100.3. She noticed non- productive cough and recent URI symptoms, which were persistent, left sided chest discomfort, and slight pleuritic pain. She noticed decreased appetite over the past two days, accompanied by nausea, no vomiting. She noticed right upper quadrant mild discomfort with eating meals. She noticed bilateral back pain which worsened in the sitting position. No diarrhea. No dysuria, hematuria or frequency. The patient states that the back pain lasted approximately 1 week. PAST MEDICAL HISTORY: 1. Secondary MDS transformed to AML on biopsy in [2122]. Status post allo BMT from matched sibling donor, complicated by CMV colitis and GVHD. 2. Breast cancer, diagnosed [2117], status post right mastectomy, right axillary lymph node dissection, status post chemotherapy with subsequent MDS. 3. Depression. 4. GERD. 5. Psoriasis. 6. Sweet syndrome treated with prednisone. 7. CMV colitis. 8. GVHD grade 1. CURRENT MEDICATIONS: Cyclosporin, ambazone, methylprednisolone, Protonix, Ativan, folic acid, potassium chloride, magnesium sulfate. ALLERGIES: Cefepime produces rash. PHYSICAL EXAMINATION: Vital signs 99.4, 126/80, 88, 16. HEENT examination - Extraocular movements intact. Anicteric. No lymphadenopathy. Lungs clear to auscultation bilaterally. Heart - Normal S1 and S2, no murmurs, rubs or gallops. Abdominal examination - Soft, nontender, nondistended. Positive bowel sounds. Extremities - No cyanosis, clubbing or edema. Neurologic - Cranial nerves II-XII intact. Skin - No rash. Back - No costovertebral angle tenderness. LABS ON ADMISSION: White count 2.2. Differential: Neutrophils 73.5, lymphocytes 17.6, monocytes 7.8, eosinophils 0.5, basophils 0.6. Hematocrit 30.2, platelets 44, absolute neutrophils 1590. Sodium 135, potassium 4.2, chloride 104, bicarbonate 22, BUN 20, creatinine 1.2, glucose 94. ALT 38, AST 22, LDH 233, alkaline phosphatase 77, total bilirubin 0.8, albumin 3.4, phos 4.0, magnesium 1.6, calcium 8.9. Cyclosporin level within normal limits. Blood cultures, urine cultures, influenza A and B cultures, CMV viral load pending. Chest CT with contrast - Slight spiculated 1.4 cm left upper lobe nodule which is new since prior CT, most likely consistent with infectious process. Probable radiation changes at the right apex which are unchanged, and persistent right sided small pleural effusion. Chest x-ray - New, ill-defined opacity in left upper lobe concerning for atypical infection. Stable appearance of chest, with right apical pleural opacity and right sided volume loss. HOSPITAL COURSE: The patient was admitted to the oncology service, given the fact that she had a lung nodule which was most likely infectious in etiology. The patient also was followed closely by ID consultants, who ended up diagnosing a Nocardia pulmonary infection, which was treated with linezolid per ID. They also added minocycline throughout her stay, for worsening pulmonary infiltrates and respiratory decompensation. The patient, due to this, was taken to the ICU and needed intubation. The patient also had hypotension responsive to fluid and transient pressor requirements. Due to the patient's need for volume, given her hypotension, she inevitably developed congestive heart failure. The course was complicated, as well, due to biliary sepsis, which was thought secondary to acalculous cholecystitis, based on abdominal ultrasound findings, though there was also some concern that, given the patient's prior history of GVHD, that the patient could have had some graft versus host disease occurring in the liver as well. "Levoflagyl" was added to the patient's other antibiotics at that time. The patient was placed on voriconazole as well, given the patient's pulmonary infection and worry for pulmonary aspergillosis, although this was not substantiated on invasive testing. After discussion with the family, the patient's code status was changed to "comfort measures only," given the dire situation, the patient's volume status, persistent problems with oxygenation and hypotension. The patient was placed on a fentanyl and Versed drip. The patient passed away comfortably on [2123-3-20]. The patient's oncologist and pulmonary attending were made aware of the patient's passing. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 48404] Dictated By:[Last Name (NamePattern1) 48405] MEDQUIST36 D: [2124-5-26] 11:37:00 T: [2124-5-26] 12:04:04 Job#: [Job Number 48406]	[ "996.62", "038.9", "996.85", "285.9", "205.00", "584.9", "039.1", "511.9", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "51.02", "96.04", "86.11", "38.93", "00.14", "41.31", "22.01", "32.29", "99.04", "96.71", "99.15" ]	icd9pcs	[ [ [] ] ]													2339, 5066	15974, 17914																								5100, 13119	14532, 14975																			14359, 14509			13148, 13886								14990, 15956								13908, 14337
29,690	171,419	48363	Discharge summary	report	Admission Date: [2203-10-28] Discharge Date: [2203-11-10] Date of Birth: [2134-12-21] Sex: F Service: MEDICINE Allergies: Lipitor / Lisinopril / Iodine / Paper Tape Attending:[Last Name (NamePattern1) 1167] Chief Complaint: foot pain Major Surgical or Invasive Procedure: None History of Present Illness: 68y/o F with PMH of CAD s/p 4 vessel CABG and recent stent to graft, ischemic cardiomyopathy EF 20-30, s/p ICDm just discharged from [Hospital Unit Name 196] service for CHF exacerbation (in CCU on dopa and lasix gtt) now presenting with chest pain. Since discharge, patient has been seen by VNA at home and today was noted to be hypotensive to SBP of 70s with lightheadedness and dizziness. Shortly thereafter she experienced fleeting chest pain, lasting approximately one minute and then resolved. She denies worsening of baseline SOB, palpitations, F/C, N/V/D, dysuria/hematuria. Patient was mostly concerned with left foot pain that started the night prior to admission. Patient denies any injury to her foot and likewise denies swelling or redness. She reports that the foot was extremely painful to touch and even bedsheets hurt her. She denies and history of foot or joint problems, specifically gout. Given the continued pain, she presented to the ED for further evaluation. . In the ED, vitals were notable for a SBP in the 70s with arm cuff and patient was given a 250 cc bolus. Her blood pressure was rechecked in the thigh and found to be 122/57. Patient was chest pain free and reportedly even denied ever having chest pain. EKG was unchanged from prior and CXR showed stable cardiomegaly without pulmonary edema. Given the foot pain, foot films were obtained and were unremarkable. Patient was also noted to have acute on chronic renal failure with creatinine of 2.1, up from 1.6 and down trending, but positive Troponin of .55 (1.09 on [10-22]). Patient was then admitted for further management of chronic cardiac disease. . Upon arrival to the floor, patient was sleeping comfortably, denying chest pain or foot pain. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of ankle edema, syncope or presyncope. Past Medical History: 1. CAD s/p 4v CABG in [1-14] with LIMA-LAD, SVG-Diag (known occluded), SVG-OM1, and SVG-RCA; non-sustained VT on tele s/p CABG, had intervention to the LIMA-LAD anastamosis in [7-20] with Cypher stent at the anastomosis; cath'd most recently in [6-20] with instent restenosis of LIMA-LAD prior Cypher stent that was successfully treated with Taxus stent. 2. DM2 since [2189] 3. Hypercholesterolemia 4. Osteoarthritis: b/l shoulder, knee arthritis with intermittent effusions, RF +; also DJD of both knees and L thumb, s/p TKR of L knee [10-15] 5. Dyspnea on exertion x years, followed by cardiology and pulmonology, thought to be most likely related to ischemic cardiomyopathy and CAD 6. CHF (EF 20-30%) [2202-6-13]. 1+ MR, 1+TR. Small atrial secundum defect 7. Hypertension 8. Asthma 9. Uterine fibroids, has had peri-menopausal spotting, received HRT 10. History of occult blood positive stool 11. Myelodysplastic syndrome 12. Cataracts 13. ICD [12-21] Social History: Social history is significant for the absence of current tobacco use. She previously smoked ~1 ppd but quit 10 years ago. She drinks alcohol rarely, about once every two weeks. She lives with her husband. They previously owned a restaurant called Pit Stop BBQ. She has four children, one of whom is deceased. Family History: Mother had DM and CAD, but died at 79 from lung CA. Father died of an accidental death, but had a h/o CAD. Physical Exam: VS: T - 98.5, BP - 122/70 (thigh), HR - 53, RR - 18, O2 - 100% RA GENERAL: WDWN, African-American female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, 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. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c; trace edema. No overlying erythema of bilateral feet. Nontender, full ROM of toes and feet. No asymmetry SKIN: Multiple areas of hyperpigmentation involving entire body 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: Ankle/Foot Films (R/L) - no acute fractures, effusions. L foot films: IMPRESSION: 1. No fracture. 2. Hallux valgus/metatarsus varus deformity with bunion formation. R foot films: FINDINGS: Three views show no evidence of acute bone or joint space abnormality. There is a small inferior and moderate posterior calcaneal spurring. BL ankle films: FINDINGS: No evidence of acute bone or joint space abnormality. Small calcifications and soft tissues could be within phlebolith. Abdominal Ultrasound: FINDINGS: The liver is normal in echotexture. No focal lesion is identified. There is no intrahepatic biliary dilatation. The gallbladder wall is again mildly thickened. Son[Name (NI) 493] [Name2 (NI) ] sign is absent. In comparisons with ultrasound of [2203-10-22], there is no significant interval change. The main portal vein is patent with appropriate direction of flow. The spleen is unremarkable and normal in size. A tiny amount of perihepatic free fluid is visualized. IMPRESSION: No hepatosplenomegaly. Tiny amount of perihepatic ascites, unchanged. [2203-10-28] 09:10PM GLUCOSE-159* UREA N-88* CREAT-2.1* SODIUM-134 POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-27 ANION GAP-19 [2203-10-28] 09:10PM CK(CPK)-33 [2203-10-28] 09:10PM cTropnT-0.55* [2203-10-28] 09:10PM CK-MB-NotDone proBNP-[Numeric Identifier 101876]* [2203-10-28] 09:10PM URIC ACID-21.0* [2203-10-28] 09:10PM WBC-2.1* HCT-30.0* [2203-10-28] 09:10PM NEUTS-60 BANDS-0 LYMPHS-29 MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-2* NUC RBCS-124* [2203-10-28] 09:10PM PLT SMR-LOW PLT COUNT-86* [2203-10-27] 05:30AM GLUCOSE-114* UREA N-85* CREAT-1.6* SODIUM-135 POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-29 ANION GAP-16 [2203-10-27] 05:30AM MAGNESIUM-2.0 [2203-10-27] 05:30AM WBC-1.8* HCT-29.0* [2203-10-27] 05:30AM PLT COUNT-83* Brief Hospital Course: A/P: 68 yo M w/ CAD, ischemic cardiomyopathy, and OA and multiple admissions for CHF exacerbation with multiple diuretic changes/increases including HCTZ who presents with bilateral ankle pain and developed acute on chronic CHF. . # Cardio/pulmonary arrest: Pt had end-stage CHF. Pt's wishes and prognosis were discussed at a family meeting with Dr [First Name (STitle) 437], palliative care, and [Doctor First Name 1258]. Decided to be DNR/DNI, goal to be comfortable at home. Pt was transitioned to CMO, and pt's ICD was turned off on [11-9]. Pt became hypotensive overnight down to 80s/60s and a fluid bolus was given overnight. In the AM it was clarified that vitals were to be discontinued and to only to be given bolus if symptomatic. Plan was to transfer to home hospice tomorrow, but today [11-10] at about 12:00 pt became more SOB and then apneic and died of cardio-pulmonary arrest. # Acute on Chronic Systolic HF: (EF 20%) In the [Name (NI) ] pt was hypotensive in 70s, and given a 250ml bolus and responded to 122/57. Pt was initially euvolemic and w/o orthopnea, PND, or DOE on the floor, but later to become volume overloaded. Pt was treansferred to the CCU for milrinone since unable to tolerate fluid challenge for renal failure. Pt continued to devleop hypotension [1-15] CHF. Started milrinone and lasix gtt which was increased to 20mg/hr and 0.75mcg/kg/min, and given 2 doses diuril. On [11-6] pt was diuresed enough to stop the milrinone drip and was switched to PO lasix and was euvolemic in the CCU. Pt was transferred back to the floor, and became slightly overloaded and went up to lasix to 80mg [Hospital1 ], goal was to keep pt even. When pt became CMO this was changed to 30mg IV BID. # Acute on Chronic Renal Failure: Pt's baseline Cre usually 1.6-1.8. Prerenal [1-15] CHF possibly leading to intrarenal ATN. No contrast administered recently. Pt's Cr was trended and intially her diruetics were held, these were restarted once her [Doctor First Name 48] improved. On transfer back from the CCU her Cr was still elevated at 2.3. # Hypotension: Initially thought to be in the setting of overdiuresis. No evidence of sepsis, but in the end thought to be [1-15] end-stage CHF, managed with fluid bolueses and above. # CAD: s/p CABG with recent stent of LIMA to LAD. No chest pain or palpitations currently. EKG unchanged from previous w/o acute ischemic changes. Trops were elevated [1-15] renal disease and remained flat. Continued ASA, Plavix, statin, BB until pt became CMO. # Rhythm: Pt occasionally had NSVT, but would remain asymptomatic. Pt's AICD was eventually turned off on [11-9]. . # Asthma: cont albuterol, spiriva, fluticasone # Myelodysplastic syndrome: Pt's Hct ~30 at baseline. U/S requested by Heme-onc shows no interval change in HSM. Stop danazol. Pt received epo while in house (3000 U 3x/week), and transfused 1 unit on [11-5]. # DM: diet controlled at home. HISS while in house. # Ankle pain: Likely gout in setting of new onset HCTZ use. (Uric acid 21.0) Atypical joint for gout (ankles). No evidence of fracture on L foot films taken in ED. Unlikely infection (no fevers, leukocytosis, or open ulcers.) Bilateral ankle films to assess for effusions, but no signficant effusion was found. Pt's HCTZ was held. Tylenol/Tramadol was given for pain Medications on Admission: 1. Digoxin 125 mcg PO Q MWF 2. Torsemide 40 mg PO BID 3. Metoprolol Succinate 25 mg PO QD 4. Aspirin 325 mg PO QD 5. Clopidogrel 75 mg PO QD 6. Spiriva 7. Fluticasone 110 mcg 2 puffs [Hospital1 ] 8. Isosorbide Mononitrate SR 30 mg PO QD 9. Pravastatin 40 mg PO QHS 10. Albuterol 90 mcg 2 Puffs PRN 11. Multivitamin 12. Nitroglycerin 0.3 mg SL PRN 13. Trazodone 25 mg PO QHS PRN: insomnia 14. Epoetin Alfa Injection 15. Docusate Sodium 100 mg PO BID PRN 16. Aranesp SureClick -Polysorbate 25 mcg QWeek per outpatient hematologist Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 2. Clopidogrel 75 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for foot pain. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Aranesp SureClick -Polysorbate 25 mcg/0.42 mL Pen Injector Sig: One (1) injection Subcutaneous once a week: to be administered by hematologist. 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [12-15] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain: if chest pain does not resolve with tablets, please call 911. 10. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:2 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 12. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for Shortness of Breath/Wheezing. 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for Insomnia. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital 3005] Hospice Discharge Diagnosis: Gout Acute on Chronic Renal Failure Chronic Systolic Heart Failure CAD Ischemic cardiomyopathy Myelofibrosis Discharge Condition: Pt died on [11-10] around 12:00 Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2203-11-10]	[ "V45.81", "584.9", "274.9", "427.5", "250.00", "238.75", "403.90", "428.0", "425.4", "585.9", "V66.7", "414.00", "428.23", "493.90", "458.9", "715.91", "V45.02", "V45.82", "715.96", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	12467, 12525	6926, 10286	324, 331	12678, 12715	5021, 6903	12767, 12802	3900, 4008		10870, 12444		12546, 12657		10312, 10847			12739, 12744										4023, 5002																								275, 286											359, 2547																2569, 3557	3573, 3884
8,061	133,667	29075	Discharge summary	report	Admission Date: [2148-12-3] Discharge Date: [2148-12-17] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: none History of Present Illness: 84 yo man transferred from [Hospital1 1562] via [Location (un) ] for respiratory distress and platelet count of 2. Pt reports that his symptoms began approximately 2 months ago when his wife called 911, because he had sweats, dizziness and felt week. He was found to have a bleeding gastric ulcer that was cauterized ([2148-10-2]) in [Hospital1 1562]. He subsequently felt better and had a return to "normal brown stools". Recently he noted that his urine was dark, it would start dark and then lighten up. He has bruised easily for "years", the rash (petechial) on his extremities began "today, prior to the blood draws". He has tired easily and been short of breath for weeks. He's noted numbness in his fingers. He has had a cough for 1 year, that has progressively worsened. He saw a pulmonologist at [Hospital 1562] hospital, unclear final dx, but did not require home O2. He denied any hemoptysis. He's felt cold, but denies fevers, chills or night sweats. Has had a decreased appetite and a 30 pound weight loss over the last 8 months. He's otherwise felt well with no preceeding infections or sick contacts. Past Medical History: -pulmonary fibrosis -diet controlled diabetes -s/p hemrrhoidectomy -hypothyroidism -constipation -tinnitus Social History: retired dentist (never wore a mask), married, quit etoh [2148-9-29] after gastric ulcer, had glass of wine with lunch, quit smoking in [2103]-1ppd x20years. No other drug use Family History: M: CAD -F: Pancreatic CA no bleeding disorders, no hematologic malignancies Physical Exam: VS T 96.7 HR 75 BP 108/48 100% AC PEEP 5 FiO2 80% GEN: Intubated, sedated HEENT: no scleral icterus, cataracts bilaterally, L-surgical pupil CV: tachy RESP: diffuse rhonchi/crackles ABD: Soft ND/NT, No splenomegaly, +BS EXT: no edema skin: large ecchymoses on upper extremities, fine petechial rash over extremities, dense petechial rash on left upper extremity with cut-off across bicep Pertinent Results: [2148-12-2] 10:30PM BLOOD WBC-15.9* RBC-3.38* Hgb-11.1* Hct-29.6* MCV-87 MCH-32.7* MCHC-37.5* RDW-16.4* Plt Ct-5* [2148-12-17] 03:06AM BLOOD WBC-33.9* RBC-2.44* Hgb-7.5* Hct-21.3* MCV-87 MCH-30.8 MCHC-35.2* RDW-16.4* Plt Ct-129* [2148-12-17] 03:06AM BLOOD Neuts-97.5* Bands-0 Lymphs-1.3* Monos-0.9* Eos-0.3 Baso-0 [2148-12-2] 10:30PM BLOOD Neuts-91.7* Bands-0 Lymphs-4.8* Monos-2.6 Eos-0.8 Baso-0.1 [2148-12-2] 10:30PM BLOOD Plt Smr-RARE Plt Ct-5* [2148-12-3] 12:40AM BLOOD Plt Ct-46# [2148-12-3] 04:43AM BLOOD Plt Ct-17# [2148-12-3] 08:27AM BLOOD Plt Ct-80# [2148-12-17] 03:06AM BLOOD Plt Smr-NORMAL Plt Ct-129 Brief Hospital Course: 84 yo man presents with fever, respiratory distress and thrombocytopenia. . #. Respiratory Failure: He has known pulm fibrosis, does not require home O2, however progressively worsening cough x1 year. No hemoptysis but in ED found to be profoundly hypoxic w/O2 sat 54% RA and in respiratory distress. Pt intubated for airway protection, ? pulm hemorrhage vs. PNA (however b/l diffuse infiltrates) vs. ARDS. A broncheoalveolar lavage was preformed and frank blood was returned, indicating a diffuse alveolar hemmorrhage. Blood cultures and sputum cultures were negative throughtout his hospital stay. His respiratory status steadily improved, and he was weaned to CPAP with pressure support. on hospital day 14, he had a succcessful spntaneous breathing trial, and was extubated. His mental status failed to clear throughout intermittant sedation. . #. Thrombocytopenia: differential includes infection/sepsis, underlying myelodysplastic syndrome/leukemia, or ITP with possible alveolar hemorrhage. No shistocytes are seen, TTP-HUS, DIC are unlikely. HCT initially stable, dropped steadily on subsequent days. He received multiple transfusions of platelets, ffp, and packed RBCs. Through multiple testing, the patient was found to have a warm antibody hemolytic anemia. A bone marrow biopsy was attempted by the hematology service, but was unsuccessful. Possibility of underlying malignancy remains considering patient's consistently high WBC count, although the differential did not show atypical cells. . # ? Fever: Pt w/initial ED rectal temp 103, however rectal probe left in for several minutes, so ? accuracy of that measurement. Following Temps in ED not-febrile. Pt also normotensive in ED (except w/propofol use for intubation), not tachycardic, therefore Sepsis less likely. Fever may be due to pulm hemorrhage (more likely given PLT 2 and frank blood coming out of ETT and OGT) vs. PE (PE less likely as pt w/low PLTs and not tachycardic nor hypotensive). The patient's fever resolved after hospital day 2. . #. ARF: Unclear what his baseline Cr is, at OSH Cr was 2.6. Likely pre-renal in setting of poor PO intake vs. renal process. The patient's Cr peaked at 4.5. He continued to make urine and diuresed large amounts of the total fluid given. . #. Hypothyroidism: TSH-normal. synthroid was continued . #. CODE: FULL was changed to DNR on hospital day 13. On hospital day 14, the patient was made CMO and extubated. He was placed on a morphine and midazolam drip. After a few hours extubated, he became bradycardic and asystolic on the monitor and passed away. His family was present. . Medications on Admission: thyroid replacement, lactulose prn, lipitor (started ~2months ago), prilosec Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: patient deceased in house Discharge Condition: . Discharge Instructions: . Followup Instructions: .	[ "287.31", "518.81", "786.3", "276.0", "283.0", "518.4", "250.00", "515", "584.5", "244.9", "585.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "00.17", "99.04", "96.04", "99.05", "96.6", "33.24", "38.91", "96.72" ]	icd9pcs	[ [ [] ] ]	5755, 5764	2990, 5601	284, 290	5833, 5836	2313, 2966	5886, 5890	1811, 1888		5729, 5732		5785, 5812		5627, 5706			5860, 5863										1903, 2294																								224, 246											318, 1463																1485, 1594	1610, 1795
1,725	190,024	20512	Discharge summary	report	Admission Date: [2135-5-31] Discharge Date: [2135-6-15] Date of Birth: [2076-12-1] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ibuprofen Attending:[First Name3 (LF) 1505] Chief Complaint: 3-vessel CAD presenting as dyspnea and L shoulder pain. Major Surgical or Invasive Procedure: 1. CABG x3 (LIMA-LAD, SVG-ramus, SVG-RCA) History of Present Illness: 58F initially admitted to [Hospital1 ]-[Location (un) 620] with symptoms of SOB and L shoulder pain. Found to be in CHF and Afib, developed a LBBB. Echo showed EF 55% and basal inferior hypokinesis. Put on integrillin and IV heparin and transferred to [Hospital1 ]-[Hospital1 ] for emergent cardiac cath, which showed 3-vessel CAD. Past Medical History: 1. Atypical dementia 2. CAD 3. NIDDM 4. HTN 5. PVD 6. h/o CVA 7. Hypercholesterolemia 8. ? obstructive sleep apnea 9. s/p bilateral CEA Social History: Married. Retired secretary. 40 pack year smoking, quit [5-25]. 1 glass EtOH per week. No drugs. Family History: + CAD + stroke Physical Exam: Afebrile, VSS NAD, alert Neck: soft, + bilat bruits, well healed scars Heart: RRR, no murmurs Lungs: CTAB Abd: soft, NT, ND, + BS Ext: no edema Pertinent Results: [2135-6-13] 09:05AM BLOOD WBC-11.7* RBC-3.49* Hgb-10.5* Hct-32.1* MCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 Plt Ct-416 [2135-6-10] 04:55AM BLOOD PT-12.9 PTT-26.5 INR(PT)-1.1 [2135-6-12] 05:00AM BLOOD UreaN-37* Creat-1.4* Na-133 K-4.1 HCO3-27 [2135-6-9] 08:00PM BLOOD ALT-19 AST-19 AlkPhos-102 Amylase-56 TotBili-0.4 Brief Hospital Course: 58F initially admitted to [Hospital1 ]-[Location (un) 620] with symptoms of SOB and L shoulder pain. Found to be in CHF and Afib, developed a LBBB. Echo showed EF 55% and basal inferior hypokinesis. Put on integrillin and IV heparin and transferred to [Hospital1 ]-[Hospital1 ] for emergent cardiac cath, which showed 3-vessel CAD. She was taken to the OR [2135-6-2] for CABG x3 (LIMA-LAD, SVG-ramus, SVG-distal RCA). Post-op, she was transferred to the CSRU. She was extubated on POD 0-1. She developed rapid afib which had a negative effect on her hemodynamics, with a drop in her cardiac index and mixed venous oxygen saturations. Pt. was started on amiodarone and managed conservatively. She improved over the next several days with diuresis with improving pa catheter numbers and hemodynamics. She was transferred to the floor on POD 5. She was anti-coagulated with coumadin for a short time, but was taken off after she converted to sinus rhythm on POD 7, secondary to high fall risk. She had a brief transient rise in her creatinine that resolved with decreased lasix doses. Neurology commented that the patient has very limited rehab potential based on atypical dementia and worsening gait function. Medications on Admission: 1. Integrillin gtt 14 mcg/min IV infusion 2. Heparin gtt 1350 units/h IV infustion 3. Metoprolol 4. ASA 325 mg po daily 5. Lipitor 6. Gemfibrozil 7. Trileptal 8. Lexapro 9. Prevacid 10. Valsartan 11. Digoxin 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. Oxcarbazepine 300 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:0 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:0 11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): f/u c PCP or cardiologist for duration. Disp:120 Tablet(s) Refills:2 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:10 Tablet(s) Refills:0 13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: 1. CAD 2. NIDDM 3. Atrial fibrillation 4. HTN 5. PVD 6. h/o CVA 7. Obstructive sleep apnea 8. Atypical dementia Discharge Condition: Good Discharge Instructions: 1. Medications as directed. 2. Call office or go to ER if fever/chills, drainage from sternum, chest pain, shortness of breath. Followup Instructions: PCP, 2 weeks, please call for appointment. Cardiologist, 2 weeks, please call for appointment. Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month	[ "274.9", "780.39", "305.1", "410.71", "414.01", "428.0", "250.00", "290.12", "780.57", "428.30", "427.31", "272.0", "443.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.53", "36.12", "37.22", "99.20", "36.15", "88.56", "39.61" ]	icd9pcs	[ [ [] ] ]	4939, 5084	1611, 2852	346, 390	5239, 5245	1262, 1588	5421, 5680	1066, 1083		3110, 4916		5105, 5218		2878, 3087			5269, 5398										1098, 1243																								251, 308											418, 769																791, 928	944, 1050
56,001	128,689	4123	Discharge summary	report	Admission Date: [2160-10-20] Discharge Date: [2160-10-23] Date of Birth: [2076-1-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: S/P Fall with splenic laceration Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] was transferred from [Hospital1 ] with a splenic laceration and multiple rib fractures. He fell at home on [2160-10-18] and on [2160-10-19] was taken to the ER as his blood sugar was 560 and he was hypotensive. Mr. [Known lastname ] lives at home with his son who takes care of him 24/7. Upon further investigation his hematocrit was 25 and he received 1 unit of packed red blood cells. His stool guiac was negative and he subsequently underwent CT of abd and pelvis which showed a splenic laceration and fractures of left ribs [9-5]. There was also some free fluid in the pelvis prompting transfer to [Hospital1 18]. Past Medical History: PMH 1. Dementia 2. IDDM 3. Hypertension 4. CHF 5. CAD 6. UTI 7. Left heel pressure ulcer 8. urinary incontinence PSH 1. S/P CABG '[47] 2. S/P ICD placement 3. S/P ORIF right hip '[51] 4. S/P ORIF left hip '[56] Social History: Widowed, lives at home with his son who cares for him 24/7 Family History: non contributory Physical Exam: Temp 99 BP 133/59 HR 79 RR 26 O2 sat 99% RA HEENT NCAT PERRLA Neck non tender Chest Clear and equal breath sounds, no deformities COR RRR Abd soft, diffusely tender especially LUQ, no rebound Ext left lateral heel ulcer 1x5 cm with minimal depth, mod yellow green drainage no edema, palpable PT's bilaterally Pertinent Results: [2160-10-19] 11:32PM WBC-14.7* RBC-2.89* HGB-8.1* HCT-23.7* MCV-82 MCH-28.0 MCHC-34.2 RDW-15.8* [2160-10-19] 11:32PM PT-12.2 PTT-25.6 INR(PT)-1.0 [2160-10-19] 11:32PM PLT COUNT-220 [2160-10-19] 11:33PM GLUCOSE-203* LACTATE-3.3* NA+-138 K+-4.2 CL--97* TCO2-28 [2160-10-19] 11:32PM UREA N-39* CREAT-1.0 [2160-10-19] 11:32PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.031 [2160-10-19] 11:32PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [2160-10-19] 11:32PM URINE RBC-0-2 WBC-[11-14]* BACTERIA-OCC YEAST-NONE EPI-<1 [2160-10-19] Head CT : 1. No acute intracranial process. 2. Left phthisis bulbi. 3. Extensive atherosclerotic disease. [2160-10-20] Abd CT : 1. Limited study due to patient motion and extensive artifact. Within this limitation, there is a splenic laceration with focal area of hyperdensity within the spleen, which may represent a dilated varix and less likely a pseudoaneurysm. Splenic Doppler ultrasound should be performed to discern if this is arterial or venous. Extensive hemoperitoneum surrounding the spleen, liver, right paracolic gutter and within the pelvis is unchanged when compared to prior exam. No active bleeding is seen. 2. Extensive amount of collaterals seen along the left flank. This is suggestive of a more central stenosis, perhaps subclavian or brachiocephalic vein. 3. No definite liver or bowel injury, however evaluation limited due to aforementioned limitations. 4. Multiple left-sided rib fractures. 5. Seminal vesicles hypodensities which may represent cysts. [2160-10-20] CXR : The heart size is normal. The patient is after median sternotomy and CABG. Mediastinal position, contour, and width are unremarkable. The pacemaker leads terminate in right atrium and right ventricle. An abandoned third pacemaker lead is noted. The pacemaker is in the left hemithorax. There is left basal opacity most likely consistent with atelectasis giving its new appearance compared to prior study obtained on [2160-10-19]. The known rib fractures are partially obscured by the projection of the pacemaker. There is no evidence of pneumothorax, and there is no evidence of pulmonary edema. Brief Hospital Course: Mr. [Known lastname ] was evaluated by the Trauma team in the ER and subsequently admitted to the Trauma ICU for further management and treatment. He had some left upper quadrant abdominal pain and his hematocrit on admission was 25. He was transfused with 2 units of packed red blood cells and his hematocrit rose to 30. His blood pressure was in the 130/80 range throughout. The abdomenal and pelvic CT from [Hospital1 ] was reviewed by the radiology department and was felt that there was no extravasation of fluid in the pelvis. The splenic laceration was also very small. They recommended following serial hematocrits and should they fall he may need an angiogram with subsequent embolization. His hematocrit was followed closely for 48 hours and remained in the 30 range. His blood pressure was stable and his abdominal pain resolved. He was transferred to the Trauma floor for further management. Of note, he had a foley catheter placed 5 weeks ago as his son was having a difficult time caring for him with his urinary incontinence, especially with daily lasix. Unfortunately a urine culture was done at [Hospital1 ] which grew out Proteus Mirabilis sensitive to Cefazolin. He was initially on IV Kefzol and then switched to Keflex orally. The catheter was removed on [2160-10-22] but bladder scanned after eight hours for 600 cc's. The catheter was then replaced and another voiding trial should be done when he is more ambulatory. Flomax was also started. His blood sugars were out of control on admission and his Lantus was resumed along with a tight sliding scale for coverage QID. His son manages his care and adjusts his insulin as he sees fit with the assistance of Dr. [Last Name (STitle) 1380]. This will need to be followed closely. The Physical Therapy service was involved for a full evaluation and felt that rehab would benefit him over time as his mobility is compromised by his muscle weakness. He will need teaching in transferring to a wheel chair and as well as balance training. The hope is that he will be able to return home with his son. Medications on Admission: Lantus insulin 18-30 units sc Daily at noon ( pt's son decides dose based on BS trends) Humulin regular insulin pre meal and hs ASA 81 mg PO Daily Niacin 250 mg PO BID Quinipril 10 mg PO Daily Atenolol 25 mg PO Daily Lexapro 10 mg PO Daily Discharge Medications: 1. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day. 7. Insulin Lispro Subcutaneous 8. Insulin Regular Human Subcutaneous 9. Insulin Lispro 100 unit/mL Solution Sig: 2-12 units Subcutaneous four times a day: Per sliding scale coverage. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Niacin 250 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day: Thru [2160-10-27]. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 5176] Discharge Diagnosis: S/P Fall 1. Left rib fractures [9-5] 2. Splenic laceration 3. Acute blood loss anemia Secondary diagnosis 1. Hypertension 2. IDDM 3. CAD 4. CHF 5. UTI 6. left heel ulcer Discharge Condition: Stable hemodynamics, able to eat a diabetic diet, ambulating with assistance. 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, 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) 18052] for a follow up appointment in 2 weeks. Call Dr. [Last Name (STitle) 1380] for a follow up appointment in 2 weeks. Completed by:[2160-10-23]	[ "V45.81", "414.00", "707.23", "401.9", "E849.0", "788.30", "865.00", "599.0", "428.0", "707.07", "E000.9", "284.9", "250.00", "285.1", "V45.02", "E888.9", "807.09" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	7624, 7702	4054, 6160	348, 354	7920, 8000	1757, 4031	8962, 9182	1395, 1413		6450, 7601		7723, 7899		6186, 6427			8024, 8939										1428, 1738																								276, 310											382, 1056																1078, 1303	1319, 1379
18,629	146,627	19199	Discharge summary	report	Admission Date: [2204-5-30] Discharge Date: [2204-6-4] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: RUQ, epigastric pain Major Surgical or Invasive Procedure: [First Name3 (LF) ] w/placement of 7cm by 10FR Cotton [Doctor Last Name ] biliary stent History of Present Illness: 85 yo M with h/o CAD s/p 2 vessel CABG, s/p bioprosthetic AVR, HTN, HL, and CRI who presents with RUQ and epigastric pain X 1 week. Pt reports that 1.5 weeks ago pt awoke with RUQ and epigastric pain and subjective fevers. He describes his pain as constant burning with sharp pains, rating [5-6], no radiation, worse after eating (up to [9-6]), and relieved with vomiting. Pt had seen his NP who recommended treatment for GERD with Maalox, Zantac, and Tums. The following day, pt develop nausea and vomiting (nonbloody, ?bilious) with any attempt with po intake. He has not been able to eat or take his medications for a week. He returned to see the NP and was prescribed omeprazole, to which he developed an itchy rash and was discontinued. He denies any constipation, diarrhea, or BRBPR. He reports 2 dark stools over the weekend. He also endorses dark urine, low urine output, and "wooziness." Without improvement, pt presented to [Hospital1 ] [Location (un) 620] ED. Upon arrival to [Hospital1 ] [Name (NI) 620] [Name (NI) ], pt was found to be in afib with RVR to rate of 170s, tolerated by BP in 110s/60s. Tmax of 102.6 with shaking chills. Labs notable for WBC 12.5 with left shift, lactate 7.5, AST 212, ALT 318, AlkPhos 703, and TBili 10.48. CK 87, CK MB 1.7, TropT 0.027. Pt received cipro, flagyl, and zofran. Given suspicion for biliary related sepsis and need for [Name (NI) ], pt was transferred to [Hospital1 ]-[Location (un) 86]. In the ED, initial VS were: T99.2, 160, 107/88, 14, 94% on 4L. Repeat labs notable for lactate 1.9, AST 172, ALT 228, AlkPhos 470, TBili 9.8, CK 308, MB 26, MBI 8.4, Trop 0.57. He was given zosyn 4.5 gm IV X 1, morphine 4 mg x1. EKG with afib with RVR. Pt was given ASA and diltiazem 15 mg IV X 1 with improvement in HR from 150s to 100s but also dropped his SBPs to 60s briefly, which came up to 80s. Pt was given reversal with IV calcium gluconate, RIJ TLC placed, and started on norepinephrine gtt. Currently in NSR with HR in 80s. He was reportedly mentating during this episode. Cardiology consulted for positive CEs, who felt this was more demand related and did not recommend heparin gtt. [Location (un) ] and surgery were both contact[Name (NI) ] who recommended admission to [Hospital Unit Name 153] with [Hospital Unit Name ]. He received 3 L NS in the ED. Currently patient denies any abdominal pain, N/V. He only complains of a dry mouth. ROS: As above. Pt denied any headaches. He reported some rhinorrhea but no cough, sob. No chest pain, palpitations. No orthopnea, PND, pedal edema. Past Medical History: CAD s/p 2 vessel CABG and bioprosthetic AVR in [2198]: left internal mammary artery to the left anterior descending coronary artery, reverse saphenous vein graft from the aorta to the obtuse marginal coronary artery. HTN Hypercholesterolemia Chronic renal insufficiency (baseline 1.6 - 1.9) h/o rheumatic heart disease Asthma Chronic anal fissure disease Seasonal allergies L cataract s/p surgery Social History: Patient lives with his wife and acts as her caretaker as she has mild dementia. He was trained as a merchant [Hospital1 ] but worked in construction after he got married. He previously smoked [1-31] ppd x30 years, quit in [2164]. He has 3 alcoholic drinks a year. No recreational drug use. Family History: Pt is adopted. Physical Exam: 99.0 97 104/60 18 98% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL, non-icteric HEENT: Atraumatic/Normocephalic Cardiovascular: RRR no M/G/R Resp: CTAB no wheezes/crackles/rubs Abdominal: Soft/NT/ND, Ext: no clubbing/cyanosis/edema Pertinent Results: from [Hospital1 ] [Location (un) 620] [2204-5-29]: WBC 12.5 Hct 39.2 Plts 269 N 91 B 1 L 3 M 4 Eos 1 Na 138 K 5.1 Cl 98 HCO3 22 BUN 45 Cr 1.8 Glu 170 AST 212 ALT 318 AlkPhos 703 TBili 10.48 CK 87 MB 1.70 Trop-T 0.027 Lactate 7.5 --> 1.9 at [Hospital1 18]/[Location (un) 86] ED Bld Cx X 2 E.Coli pan sensitive STUDIES: RUQ U/S: Cholelithiasis without evidence for cholecystitis or biliary ductal dilatation. CXR: No new focal consolidation or edema. Possible right heart failure or portosystemic shunting. EKG: NSR at 75. RBBB. STD in V1, TWI in V1 (old), TWI in III. No STE. TTE: The left atrium is mildly dilated. 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The aortic valve prosthesis cannot be adequately assessed (leaflets not well seen duet o acoustic shadowing). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. At least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. At least moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior report of [2199-2-12], a bioprosthetic AVR is now seen. LVEF has normalized. [Year (4 digits) ]: A single periampullary diverticulum with large opening was found at the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. A mild diffuse dilation was seen at the main duct with the CBD measuring 10mm. A single 6mm round stone was seen at the biliary tree. A 7cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed successfully using a Oasis 10FR stent introducer kit. Good flow of thick and purulent bile was noted following biliary stent placement. Normal limited pancreatogram. Brief Hospital Course: 85 yo M with h/o CAD s/p CABG and AVR, HTN, and CRI who presents with RUQ pain, sepsis, elevated LFTs in an obstructive pattern, and positive CEs. . #) Sepsis/Cholangitis/Bacteremia - In setting of elevated WBC, tachycardia, hypotension (although this was in setting of getting IV diltiazem), initial elevated lactate, and likely source for infection. RUQ U/S in ED did not reveal any CBD dilation; however, given clinical concern for cholangitis, the pt underwent an urgent [Doctor Last Name ] in which a 6 mm CBD stone was visualized along with diffuse dilation of the CBD up to 10 mm. The CBD stone was extracted, biliary stent placed, and sphincterotomy was not performed given concern about the pt's cardiac enzymes and possible need for anti-coagulation (see below). He was initially given cipro, flagyl at the OSH ED and was given zosyn, cipro upon arrival to [Hospital1 18]. He was continued on IV cipro/zosyn overnight without further fevers. Blood cxs showed pan-sensitive E. coli. He was initially on levophed gtt for hypotension, which was easily weaned off upon arrival to the ICU without need for further IVF boluses. As pt remained HD stable overnight, he was transferred to the surgery service for further care by hospital day 2. Per surgery, the pt will need a cholecystectomy in the future. . #) Positive cardiac biomarkers: Likely secondary to demand ischemia in the setting of biliary sepsis and developement of atrial fibrillation with RVR to 150s. Troponin peaked at 0.63, CK peaked at 434. EKG without specific changes to suggest ischemia. Cardiology was consulted and pt was placed on aspirin, high dose statin. He was not placed on heparin gtt given thought that cardiac enyzme leak was not secondary to primary ACS. After the pt's pressor requirement was weaned off, he was started on metoprolol, which will need to be titrated up as tolerated. A TTE revealed a preserved LVEF with 2+ MR [First Name (Titles) ] [Last Name (Titles) 114]e pulmonary HTN. He continued to convert in and out of atrial fibrillation, as such the decision was made to anticoagulate. The cardiology team advised not to bridge with lovenox, and to followup with them as an outpatient to determine if long term anticoagulation would be necessary . #) Afib with RVR: The patient has no prior history of atrial fibrillation and likely that arrhythmia was secondary to sepsis. Was back in NSR at the time of arrival to the [Hospital Unit Name 153]. Cardiology was consulted who recommended using amiodarone or digoxin in the future if the pt redevelops afib with RVR as he dropped his blood pressures significantly with use of IV diltiazem in the ED. He was kept on telemetry monitoring with an 8 beat run of assymptomatic NSVT overnight in the ICU. He continued to convert in and out of atrial fibrillation, as such the decision was made to anticoagulate. The cardiology team advised not to bridge with lovenox, and to followup with them as an outpatient to determine if long term anticoagulation would be necessary . #) Hct drop - Hct 39.2 on presentation to [Location (un) 620], then 31.2 upon arrival to [Hospital Unit Name 153] but in setting of obtaining 5L IVFs and possibly hemoconcentrated on admission. Hct continued to trend down slightly during ICU course without outward signs of GI bleed. His stools were guaiac'd, pt was type and crossed, and LDH was not elevated suggesting absence of hemolysis. . #) Chronic renal insufficiency - Cr within recent baseline of 1.6 - 1.9. His kidney function was monitored closely, meds were renally dosed, and nephrotoxins were avoided. . #) CAD s/p CABG - With positive cardiac enzymes as above. Course as above. . #) Chronic systolic CHF: ECHO showed EF of 35-40% peri-MI in [2198]. TTE on arrival to [Hospital Unit Name 153] showed LVEF 55%. His azygos vein did appear prominent in his CXR and TTE also did reveal 2+ MR and mod pulm HTN. The pt did complain of subjective shortness of breath briefly during hospital day 2. His fluid status was monitored closely to ensure that he did not go into decompensated CHF. . #) s/p AVR - Bioprosthetic, pt not on anti-coagulation as an outpatient. . #) Hypercholesterolemia - Continued home statin at high dose. . #) FEN/GI - The patient was initially made NPO, amylase and lipase were checked following [Hospital Unit Name ] and the patients diet was advanced. #) Ppx - continue home dose H2 blocker, hep sq tid, bowel regimen At the time of discharge the patient was tolerating a regular diet, his LFTS were normalizing, his amylase and lipase were stable and down trending. He was ambulating without assistance, voiding, afebrile and had a normal WBC. Medications on Admission: HCTZ 25 mg [Hospital1 ] Lisinopril 5 mg daily Metoprolol 25 mg [Hospital1 ] Pravastatin 20 mg daily ASA 81 mg daily Ropinirole 0.5 mg [Hospital1 ] Flovent 110 mcg inh prn Promethazine 12.5 mg prn Ranitidine 150 mg daily (Omeprazole 20 mg daily)--developed rash Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last dose [2204-6-13]. Disp:20 Tablet(s) Refills:0 5. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for HR<60 BPS<90. 7. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: cholangitis Discharge Condition: stable Discharge Instructions: Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-6] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [Name Initial (PRE) ]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [Name5 (PTitle) ] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [Location (un) 2831] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8318], MD Phone:[Telephone/Fax (1) 2998] Date/Time:[2204-6-11] 10:45 Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2204-7-12] 12:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2204-7-12] 12:00 Dr. [Last Name (STitle) 49718] [Name (STitle) 766] [2204-6-18] at 11:30am [Hospital 197] Clinic at [Location (un) 620] Cardiology Thursday [6-6],[2203]...[Doctor Last Name ] will call you tomorrow to set up a time ([Telephone/Fax (1) 10413]) Completed by:[2204-6-4*]	[ "414.00", "493.90", "038.9", "428.0", "585.9", "995.92", "V42.2", "410.71", "V45.81", "576.1", "427.31", "272.4", "428.32", "403.90", "574.21" ]	icd9cm	[ [ [] ] ]	[ "51.87", "51.88" ]	icd9pcs	[ [ [] ] ]	12482, 12488	6609, 11304	281, 378	12544, 12553	4132, 6586	17316, 18013	3807, 3823		11627, 12459		12509, 12523		11330, 11604			12577, 17293										3838, 4113																								221, 243											406, 3037																3059, 3469	3485, 3791
26,356	138,517	9900+9934	Discharge summary	report+report	1 1 1 DR Name: [Known lastname ], [Known firstname 275] J Unit No: [Numeric Identifier 33208] Admission Date: [2134-6-18] Discharge Date: [2134-6-25] Date of Birth: [2058-8-29] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male transferred in from an outside hospital. CT of his abdomen showed distended loops of small and large bowel with an apple core lesion at the splenic flexure with a near complete obstruction. The patient was thus taken to the operating room on [6-19]. Pre-operative diagnosis was chronic obstruction. Postoperative diagnosis also chronic obstruction. Procedure was a subtotal colectomy with ileostomy formation. Attending surgeon, Dr. [Last Name (STitle) ]. Findings were a markedly dilated right transverse colon and small bowel. No palpable liver mass. DR.[Last Name (STitle) 844],[First Name3 (LF) 843] 02-333 Dictated By:[Last Name (NamePattern1) 33209] MEDQUIST36 D: [2134-6-24] 12:09 T: [2134-6-29] 09:56 JOB#: [Job Number ] Admission Date: [2134-6-18] Discharge Date: [2134-6-25] Date of Birth: [2058-8-29] Sex: M Service: Surgery, Purple Team PREOPERATIVE DIAGNOSIS: Colonic obstruction. POSTOPERATIVE DIAGNOSIS: Colonic obstruction. HISTORY OF PRESENT ILLNESS: CT of the abdomen at an outside hospital done on [6-17] showed distended loops of small and large bowel with a lesion of the splenic flexure, a near complete obstruction with minimal fluid in the bilateral gutters. The patient also complained of gas-like crampy abdominal pain. HOSPITAL COURSE: Based on these findings, the patient was to the operating room on [2134-6-19]. The patient underwent a subtotal colectomy with ileostomy. Surgeon was Dr. [First Name (STitle) ] [Name (STitle) ]. Findings were markedly dilated right transverse colon and small bowel. No palpable liver mass. The patient was transferred to the Intensive Care Unit for fluid management. The patient was put on perioperative Flagyl and ceftriaxone. As of [6-22], the patient had excellent fluid management and was diuresing very well. He was transferred to the floor. As of [6-24], the patient was changed over completely to all p.o. medications. He was back on all of his home medications. He was taking Percocet for pain. He was tolerating a regular diet, and he was learning ostomy care. His Foley was discontinued at midnight on [6-24], and on the morning of [6-25], the patient was stable for discharge to home with [Hospital6 407] care to help him with his ostomy. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg p.o. b.i.d. 2. Accupril 20 mg p.o. q.d. 3. Lasix 20 mg p.o. q.d. 4. Folate 1 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. 6. Flomax 0.4 mg p.o. q.d. 7. Avandia 4 mg p.o. b.i.d. 8. Prandin 2 mg p.o. b.i.d. 9. Vitamin E 400 IU p.o. q.d. Note: The patient had a CEA level of 1.9 that was taken on [2134-6-19]. [Name6 (MD) 843] [Name8 (MD) 844], M.D. [MD Number(1) 845] Dictated By:[Last Name (NamePattern1) 33293] MEDQUIST36 D: [2134-6-24] 12:14 T: [2134-6-29] 08:56 JOB#: [Job Number 33294]	[ "V45.81", "250.00", "414.01", "153.8", "560.89", "401.9", "276.5", "799.4", "197.7" ]	icd9cm	[ [ [] ] ]	[ "45.79", "46.21" ]	icd9pcs	[ [ [] ] ]												2809, 3395		1697, 2703																												2718, 2783																			1395, 1679
16,789	126,298	3855+55514	Discharge summary	report+addendum	Admission Date: [2187-9-18] Discharge Date: [2187-11-8] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: 83F w/ mild DOE Major Surgical or Invasive Procedure: s/p L carotid->innominate/CABGx1(SVG->PDA)/innominate->ascending aorta/aortic valve resuspension/ascending aorta replacement/endovascular stent of arch and descending aorta [2187-9-19] s/p L subclavian->carotid transposition [2187-9-27] s/p trach s/p open G tube s/p tunnelled dialysis catheter History of Present Illness: 83F w/ h/o CAD, infrarenal AAA, found to have an ascending aortic aneurysm of 7cm and descending aorta which measures 4.3 cm. She was referred for aortic repair. Past Medical History: CAD CVA left parietal infra [Doctor First Name ] aaa PVD with r iliac stent intermittant claaudication HTN NIDDM increase chol gout appy tonsillectomy r cataract surgery Social History: Lives alone rare alcohol neg illicit drug use pos smoker Family History: Pos CAD Physical Exam: Gen: Elderly WF in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign, +dentures Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+=bilat. without bruits. Lungs: Clear to A+P CV: RRR without R/G/M, nl S1, S2 Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E, pulses 1+ = bilat. throughout Neuro: nonfocal Pertinent Results: [2187-11-6] 03:18AM BLOOD WBC-11.4* RBC-2.76* Hgb-8.9* Hct-27.2* MCV-99* MCH-32.3* MCHC-32.8 RDW-18.8* Plt Ct-233 [2187-11-6] 03:18AM BLOOD PT-16.4* INR(PT)-1.8 [2187-11-6] 03:18AM BLOOD Glucose-100 UreaN-74* Creat-3.9* Na-144 K-4.7 Cl-104 HCO3-27 AnGap-18 [2187-10-22] 01:10PM BLOOD ALT-43* AST-21 LD(LDH)-303* AlkPhos-298* Amylase-26 TotBili-0.3 [2187-11-6] 03:18AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.6 [2187-10-29] 11:59AM BLOOD Type-ART pO2-144* pCO2-38 pH-7.36 calHCO3-22 Base XS--3 Brief Hospital Course: The patient was admitted on [2187-9-18] and underwent L common carotid bypass to inominate artery/CABGx1(SVG->PDA)/inominate to ascending aorta bypass, aortic valve resuspension, asc. aorta repalcement/endovascular stent of arch and descending aorta on [9-19]. She tolerated the procedure well and was transferred to the CSRU on Milrinone and NTG. She received multiple blood products. On POD#1 she was having seizures and neurology was consulted. She was started on Dilantin and the seizures resolved. She was unresponsive and unable to move her left side, and was found to have watershed emboli on MRI. She was started on tube feeds on POD#3, and was more alert on POD#5. She was weaned off her cardiac drips and was progressing. She has a progressively ischemic LUE and underwnet R carotid subclavian transposition on [9-27]. Her arm improved immediately. She was unable to wean from the vent quickly and underwent trach and open G tube on [10-5]. She was followed by [Last Name (un) ] for DM and was on Lantus insulin. ON [10-4] she becan moving her L side to command. She had temps and was started on Vanco and Cefipime on [10-14]. Her lines were changed and she was fully cultured. She eventually grew out MSSA from a line tip and was treated with Vanco. Her BUN and creat. began to rise on [10-18] and renal was consulted. She became progressively lethargic and eventually unresponsive. She had another head CT and MRI which was unchanged. She was started on hemodialysis and eventually became more responsive. She was on hemodialysis for 4 weeks and remained anuric. She and her family were very discouraged with the pt's prognosis as she never wanted to live on dialysis. There were many discussions with the patient, the family, and Dr. [Last Name (STitle) 4261] of the ethics service, and the decision was made by the patient that she wanted to go home with hospice and discontinue dialysis. Medications on Admission: Diltiazem 120 mg PO daily Atenolol 50mg PO q AM, 25mg PO q PM HCTZ 25 mg PO daily Diovan 80 mg PO q AM, 40 mg PO q PM ASA 81 mg PO daily Plavix 25 mg PO daily Lipitor 20 mg PO qhs Colchicine PRN Folic Acid 400 mcg PO daily Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: Two (2) mg PO every four (4) hours as needed for pain: Mild pain or resp. distress give 2mg.via GT Mod. resp. distress give 5 mg . Severe resp. distress or pain give 10 mg. Disp:1 bottle Refills:0 2. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 4-6 hours as needed for secretions. Disp:50 tablets Refills:0 3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:30 Tablet(s) Refills:0 4. O-2 Suspensory Misc Sig: 40% trach mask Miscell. continuous. Disp:1 canister Refills:2 Discharge Disposition: Home With Service Facility: HOSPICE,VISTA CARE Discharge Diagnosis: HTN Aortic dilitation DM s/p L CVA R CVA PVD s/p R iliac stent Gout Discharge Condition: Critical Discharge Instructions: Follow medications on discharge instructions. Followup Instructions: Home with hospice. Completed by:[2187-11-7] Name: [Known lastname 2747],[Known firstname ] Unit No: [Numeric Identifier 2748] Admission Date: [2187-9-18] Discharge Date: [2187-11-8] Date of Birth: [2104-9-16] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 674] Addendum: The patient signed out AMA and was sent home with the following medications: ASA 81 PO daily Prilosec 30 PO daily Lopressor 25 mg PO daily Amiodorone 200 mg PO daily RISS Albuterol MDI 1-2 puffs QID PRN Keppra 500 mg PO BID Discharge Disposition: Home With Service Facility: HOSPICE,VISTA CARE [Doctor Last Name ] [Last Name (Prefixes) ] MD [MD Number(1) 681] Completed by:[2187-11-8]	[ "434.11", "263.9", "518.5", "441.7", "438.20", "997.2", "424.1", "427.31", "414.01", "250.00", "435.1", "584.5", "435.2", "997.02", "780.39" ]	icd9cm	[ [ [] ] ]	[ "39.95", "36.11", "39.71", "39.73", "35.11", "38.45", "39.61", "39.23", "39.59", "43.19", "38.95", "33.21", "31.1", "96.6" ]	icd9pcs	[ [ [] ] ]	5798, 5983	2003, 3957	284, 589	5003, 5014	1470, 1980	5108, 5775	1070, 1079		4231, 4819		4912, 4982		3983, 4208			5038, 5085										1094, 1451																								229, 246											617, 781																803, 979	995, 1054
30,601	197,881	8308	Discharge summary	report	Admission Date: [2141-5-27] Discharge Date: [2141-6-14] Date of Birth: [2088-2-4] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: 53M with h/o HTN presents after neighbor called EMS because they had not seen patient come out of the house for 1 week. When EMS arrived, he was in bed, from which he had not moved, even to eat or drink, for several days due to severe L knee pain. He was disheveled and covered in his own stool. Major Surgical or Invasive Procedure: L knee arthocentesis CVL [2141-6-4] - laparoscopically assisted right colectomy History of Present Illness: 53M with h/o HTN presents after neighbor called EMS because they had not seen patient come out of the house for 1 week. When EMS arrived, he was in bed, from which he had not moved, even to eat or drink, for several days due to severe L knee pain. He was disheveled and covered in his own stool. He is very tangential as a historian and repeatedly brings up a planned trip to [Country 149] that he cancelled this past week, almost to the point of perseverating. In the ED, a large L knee effusion was tapped and copious, "milky" material aspirated. Central line placed for access. Labs notable for ARF, with BUN 153 and Cr 6.3; leukemoid WBC of 46.8; anion gap acidosis (gap 29). Bld Cx sent and pt received CTX 1 gram. Received banana bag + 4L NS and Cr down to 4.6. ED spoke to [Hospital3 ] pcp [Name9 (PRE) ] [First Name8 (NamePattern2) ] [Name9 (PRE) ], who reported that he has 3-drug HTN; sometimes c/o nonspecific leg pain; last seen 2wks ago for reg visit, no specific complaints at that time. . ROS: Constitutional: Fatigue, No(t) Fever Eyes: No(t) Blurry vision, No(t) Conjunctival edema Ear, Nose, Throat: Dry mouth, No(t) Epistaxis Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema, No(t) tachycardia, No(t) Orthopnea Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, No(t) Diarrhea, No(t) Constipation Genitourinary: No(t) Dysuria, Foley Musculoskeletal: Joint pain, No(t) Myalgias Integumentary (skin): No(t) Jaundice, No(t) Rash Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure Psychiatric / Sleep: No(t) Agitated, very tangential historian Pain: [1-11] Minimal . Past Medical History: HTN DJD of R hip Gout Cirrhosis Social History: divorced in [2122], has lived alone since. drinks 5 drinks/day, usually rum and coke; remote tobacco use, "back when he was a kid." denies illicit/ivda. works as a taxi driver. Family History: pt unsure. Physical Exam: Tmax: 35.5 ??????C (95.9 ??????F) Tcurrent: 35.5 ??????C (95.9 ??????F) HR: 78 (78 - 93) bpm BP: 106/69(79) {88/65(70) - 106/69(79)} mmHg RR: 17 (13 - 17) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 64.3 kg (admission): 64.5 kg Height: 65 Inch . General Appearance: Thin Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, scaphoid Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: Unable to stand, cannot weight bear [2-11] pain in L knee Skin: Warm, No(t) Rash: , painless nodules in flexor tendon both wrists, achilles tendons, and elbows Neurologic: Attentive, Responds to: Not assessed, Oriented (to): hospital, person, Movement: Not assessed, No(t) Sedated, Tone: Not assessed, tangential, borders on confabulatory . At Discharge: Vitals: T-98.3, HR-71, BP-134/80, RR-16, O2 sat-98% GEN: NAD, A/Ox3 CV: RRR RESP: CTAB ABD: +BS, ND, appropriately tender Incision: Midline, abdominal, portion packed with gauze Extrem: no c/c/e Pertinent Results: [2141-6-11] 06:35AM BLOOD WBC-14.2* RBC-2.96* Hgb-9.0* Hct-26.3* MCV-89 MCH-30.5 MCHC-34.3 RDW-15.6* Plt Ct-198 [2141-5-27] 08:50AM BLOOD WBC-46.8* RBC-2.05* Hgb-7.7* Hct-22.0* MCV-107* MCH-37.5* MCHC-34.9 RDW-18.0* Plt Ct-658* [2141-6-6] 06:20AM BLOOD PT-15.2* PTT-28.3 INR(PT)-1.3* [2141-6-11] 06:35AM BLOOD Glucose-108* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-30 AnGap-10 [2141-5-27] 08:50AM BLOOD Glucose-146* UreaN-153* Creat-6.3# Na-123 K-4.8 Cl-84* HCO3-10* AnGap-34* [2141-6-4] 02:55PM BLOOD ALT-37 AST-43* LD(LDH)-281* AlkPhos-119* Amylase-36 TotBili-0.6 [2141-5-27] 08:50AM BLOOD ALT-15 AST-70* LD(LDH)-233 CK(CPK)-752* AlkPhos-230* TotBili-1.3 [2141-6-11] 06:35AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.5* [2141-5-28] 02:52AM BLOOD Albumin-2.8* Calcium-8.0* Phos-4.8* Mg-1.9 [2141-5-27] 08:50AM BLOOD Calcium-9.7 Phos-10.6* Mg-2.8* UricAcd-16.9* Iron-25* [2141-6-1] 04:00PM BLOOD Folate-8.0 [2141-5-27] 06:26PM BLOOD VitB12-840 [2141-5-27] 08:50AM BLOOD calTIBC-242* Hapto-583* Ferritn-936* TRF-186* [2141-5-27] 06:26PM BLOOD TSH-1.2 [2141-6-1] 04:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [2141-5-27] 08:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2141-6-1] 04:00PM BLOOD HCV Ab-NEGATIVE . [2141-6-10] 7:10 am SWAB Site: NOT SPECIFIED Source: wound 1 CHARCOAL SWAB SENT. GRAM STAIN (Final [2141-6-10]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. . Rads: [6-1] KUB - ileus [6-2] - Abd U/S - no ascites, possible cirrhosis [6-2] - CT abd - Small bowel dilatation up to 4.2 cm with relatively decompressed distal loops of small bowel and colon - pSBO vs. ileus, cholelithiasis [6-4] - KUB/CXR - free air under L hemidiaphragm and dilated SB up to 5 cm with decompressed loops distally. . Pathology Examination Procedure date [2141-6-4] DIAGNOSIS: Ascending colon, segmented resection: 1. Cecal perforation, 6.0 cm, with associated transmural inflammation and serositis. 2. Remainder of specimen, including colonic and ileal margins is viable. 3. Diverticulosis, focal. 4. Partial fibrous obliteration of appendix. Clinical: Free air viscus perforation, perforated typhlitis. Brief Hospital Course: 53M with acute polyarticular arthritis and acute renal failure, also 3-drug hypertension and alcoholism . Acute Polyarticular Arthritis: although joint distribution is not classic, polys and needle shaped crystals and negative gram stain on microscopy of joint fluid is c/w gout. Due to ARF, NSAIDs and colchicine avoided early in admission. pt not complaining of pain at time and says he wants to avoid medications; rheumatology consulted, as presentation is atypical. - Rheum recommended IV solumedrol 24mg IV x1 and reassessing daily. Gout symptoms persisted, and worsened. Continued on IV methylprednisolone 10mg IV BID post-op [Date range (1) 29428]. Gout symptoms improved, decreased swelling and pain. Transitioned to PO Prednisone taper on [2141-6-13]. . Leukemoid reaction: suspect stress response from several days of acute inflammatory illness. Liquid tumor is less likely, but must be considered, especially if WBC not responding to managements directed at inflammation. Patient's WBC count initially trended down. Infectious work-up non-revealing. Had some loose stool so sent for C. Diff although abdominal exam benign, and no known recent antibiotic exposure prior to presentation. More concerning possibility was for underlying malignancy. Differential notable for left shift without significant predominance of abnormal forms. Leukocyte alkaline phosphatase was elevated - not c/w CML. SPEP/UPEP sent given ARF and anemia and were... . Acute renal failure: BUN:Cr ratio > 20:1 and pt has not been taking adequate po x5 days, highly suggestive of prerenal azotemia. Cr decreased with aggressive fluid hydration. Metabolic acidosis and hyperphosphatemia likely secondary to renal failure with inadequate acid secretion also resolved with hydration. Continued to improve with IV fluids. Fluid ajusted according to labwork. Hyponatremia: hypovolemic, improved with IVF's. . Anemia: Hct low despite significant volume contraction. macrocytic, no signs of active/obvious bleeding. Stools all guaiac negative. Suspect alcohol bone marrow suppression + iron deficiency. Transfused for Hct <21 with appropriate increase to 25%. Will need outpt colonoscopy--concern for underlying malignancy given anemia, and leukocytosis. . Alcoholism: 5 drinks per day, last drink was 5 days prior to admission. pt with odd affect and seems confabulatory, so will empirically replete thiamine, folate. check ed TSH, B12. monitored per CIWA scale protocol- no signs of withdrawal noted during admission. Scale discontinued after 11 days. . HTN: antihypertensives held durign early admission due to hemodynamic instability. restarted once full volume resuscitation achieved and stable. . On [2141-6-4] General Surgery consulted for complaints of abdominal distension and emesis - treated as an ileus with an NGT and had dark bilious output from the NGT - put out 1-2 liters per day. Today with free air under the diaphragm per CT scan. Abdomen was benign at the time, but steroid managment makes abdominal exam unreliable. Also had elevated WBC, which was trended down from 40. Heme-Onc attributed elevated WBC as reactive leukocytosis. He was pre-op consented for exploratory laparoscopy/laparotomy with Dr. [Last Name (STitle) 1120]. . His operative course was uncomplicated. He was routinely observed in the PACU, and transferred to 12 [Hospital Ward Name 1827]. POD1-He continued with NGT, NPO, IV fluid hydration, and PCA for pain control. IV steroids continued for managment of gout. His abdominal dressing remained CDI. Attempt per nursing staff to assist patient OOB to chair. Due to gout flare and associated pain, patient had difficultly mobilizing. Both Physical and Occupation therapy were consulted, and recommended short term Rehab. Foley remained in place for an extra day due to compromised mobility of upper extremities. Foley removed POD3, patient failed to urinate, scanned bladder for >500cc of urine. He was catheterized, and was able to urinate thereafter using urinal. He continued with NGT in place for days due to increased NGT output, and prolonged ileus. NGT was removed once bowel function improved, and output decreased. He reported flatus, and tolerated a regular diet. Ensure supplements were added with each meal. His abdominal incision developed some mild erythema, and serous drainage. Incision was opened at bedside on [2141-6-12], packed with moist gauze. Erythema decreased. There was no increase in WBC or development of fever. On [2141-6-13], patient reports gout pain to have resolved. He was started on PO Prednisone, and Colchicine. He was screened for Rehab placement, and was transferred for continue rehabilitation. He was advised to follow-up with PCP for colonoscopy in the future, and with Rheumatology in [2-12] weeks for continued management of Gout. Medications on Admission: amlodipine 5mg daily atenolol 50mg daily triamterene/HCTZ 37.5/25 [Hospital1 ] Discharge Medications: 1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO BID (2 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO QD () for 3 doses: [Date range (1) 29429]/08. 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 3 doses: [Date range (1) 29430]/08. 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 3 doses: [Date range (1) 29431]/08. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 5 doses: [Date range (1) 29432]. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Discharge Diagnosis: Primary: Typhlitis with perforation. Post-op ileus Gout flare Post-op urine retention Post-op surgical wound cellulitis . Secondary: HTN, DJD of Right hip, gout, Cirrhosis Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . Incision Care: Pack open area of incision with moist gauze in normal saline. Changed twice a day, and as needed. You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your follow-up appointment. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please call the office of Dr. [Last Name (STitle) 1120] to make a follow up appointment in [2-12] weeks [Telephone/Fax (1) 29433]. . 2. Please make a follow-up appointment with Rheumatology [Telephone/Fax (1) ] in [2-12] weeks for further management of gout. . 3. Follow-up with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 17362] [Name (STitle) ] [Telephone/Fax (1) ] as needed. You will require a colonoscopy in the near future for routine screening and to assess all possible causes of anemia. Completed by:[2141-6-14]	[ "274.0", "540.0", "276.1", "285.9", "997.4", "560.1", "288.62", "571.2", "998.59", "682.2", "303.91", "276.52", "788.20", "E878.6", "584.9" ]	icd9cm	[ [ [] ] ]	[ "47.01", "99.15", "99.04", "45.72", "81.91", "38.93" ]	icd9pcs	[ [ [] ] ]	12589, 12642	6682, 11517	609, 695	12858, 12936	4209, 5820	14156, 14745	2787, 2799		11651, 12566		12663, 12837		11543, 11628			12960, 13791								13806, 14133		2814, 3979																3993, 4190								274, 571				5855, 6659							723, 2518																2540, 2573	2589, 2771
47,413	142,057	39618	Discharge summary	report	Admission Date: [2173-7-23] Discharge Date: [2173-7-30] Date of Birth: [2131-7-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Cath - POBA/DES to LAD History of Present Illness: 41 yo M h/o hypercholesterolemia and two prior MIs, 1st at age 37, the second at age 40 presents with after a STEMI. Patient was out to dinner with friends for his birthday party. Had one drink plus one shot of alcohol, afterwards developed shortness of breath and left arm numbness. This was followed by [9-26] crushing chest pain that radiated to the jaw, left arm, and back. Profusely diaphoretic at the time. Called friend and was taken to [Hospital1 18] [Name (NI) ]. He had his first MI at age 37, after a [11-20] barbecue, woke up in the middle of the night with left arm pain and chest pain. Was taken to [Hospital 1474] Hospital, then transferred to [Hospital1 2177] where he had a catheterization. He does not remember what was stented. His next MI was at age 40, where the patient says he was awake for many hours and again developed left arm pain with crushing chest pain. This MI was treated at [Hospital 3278] medical center. Of note, the patient has not had insurance for 2 years as he did not renew it because he "felt ok." He had not taken his medications for at least two years. Those included lipitor, aspirin, and nitroglycerin. He does admit to having anginal symptoms on exertion for the past few months. When he walks distances of a few blocks, runs, or lifts heavy things, he develops a "pinch" in his chest as well as dyspnea. In the ED, initial vitals were HR: 96 BP: 127/77 RR: 32 O2 Sat: 100 %. He was given Integrillin, morphine, ASA 81 x4, Plavix (300 vs. 600?), heparin gtt and nitro gtt. He vomited after receiving the Plavix and aspirin, and received his aspirin dose PR. EKG showed ST elevations in V1-V4 with reciprocal depressions in II, III, aVF, V5, V6. Patient was taken emergently to the cath lab. On the way, developed V fib arrest and was defibrillated once with return of sinus rhythm. Patient underwent cardiac cath which showed thrombotic total occlusion at the prior LAD stent in the mid portion of the vessel. The Cx had a total occlusion after a large OM1. The RCA had a total occlusion in the mid vessel. The clots were aspirated and a DES was placed distal to his original stent in his LAD. The patient arrived to the floor in stable condition. He currently denies chest pain, shortness of breath, nausea, vomiting. His vitals were Tc: 97 HR: 94 BP: 145/93 RR: 16 O2: 100% 2L NC. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, [Hospital ] 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: Cardiac cath in [2167] and [2170] per patient, stenting of LAD in one of prior procedures. Social History: - Owned chinese restaurant, closed it 1 week ago. -Tobacco history: quit smoking 2 years ago, 1ppd for 22 years -ETOH: occasional -Illicit drugs: marijuana use Family History: Father with first MI in 50s, also with hyperlipidemia. Denies diabetes, [Year (4 digits) ] problems, clotting problems, or cancers. Physical Exam: GENERAL: WDWN chinese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: moist oral mucosa. NECK: Supple with no JVD appreciated when supine. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3, S4. LUNGS: CTA bilaterally on anterior exam. ABDOMEN: Soft, NTND. EXTREMITIES: No femoral bruits. 2+ DP/PT pulses. minimal tenderness to palpation at cath site, Mild ecchymosis. No hematoma, induration. Left vein site wtih drsg [Name5 (PTitle) ] [Name5 (PTitle) ] [Name5 (PTitle) ], no hematoma. Pertinent Results: [2173-7-23] 10:35PM GLUCOSE-131* UREA N-18 CREAT-1.4* SODIUM-143 POTASSIUM-2.9* CHLORIDE-108 TOTAL CO2-17* ANION GAP-21* [2173-7-23] 10:35PM estGFR-Using this [2173-7-23] 10:35PM CK(CPK)-268 [2173-7-23] 10:35PM cTropnT-<0.01 [2173-7-23] 10:35PM CALCIUM-9.7 PHOSPHATE-1.7* MAGNESIUM-2.3 Brief Hospital Course: 42 y/o male with PMHx hyperlipidemia s/p 2 MI at age 37 and 40 who presents with STEMI. s/p cardiac cath with POBA and stenting of LAD with restoration of normal flow. # STEMI - While being transported to the Cath lab, the patient went into V fib arrest and became unresponsive. He recieved a 200J biphasic shock from the defibrillator which converted him back to a junctional rhythm and restoration of conciousness. In the cath lab, the patient had a Promus stent placed distal to his first stent in his LAD after thrombus extraction and POBA. He came to the CCU stable and chest pain free. He was initially started on prasugrel, atorvastatin, metoprolol, lisinopril, and aspirin. Due to his lack of insurance, the patient was switched to clopidogrel from prasugrel and from atorvastatin to simvastatin. He had an echocardiogram which showed akinesis of his anterior/septal/apical LV walls with an EF of 25%. Because of the risk of thrombus formation with his akinesis, he was started on coumadin. A heparin gtt was started to bridge him over until he was therapeutic on coumadin. He was instructed to take his medications daily as his non-compliance was the reason for his stent thrombosis. He showed his understanding in the importance of taking his medications every day, even if he feels well. He should also undergo plavix sensitivity testing as an outpatient to see if he responds. If not, then he should be switched to prasugrel. Pt does not qualify for Lifevest. Positive EP study wtih VT and VF induced; ICD was placed and pt will have EP follow-up. # Hyperlipidemia - The patient's lipid panel was obtained while in house. It showed an LDL of 152 as well as total cholesterol of 232. His goal should be an LDL < 70 as he is a high-risk patient with history of STEMI. Initiated lipid control with statin coverage - simvastatin 80mg and continue as an outpatient. # Hypertension - The patient was hypertensive while in the CCU with SBPs in the 150s. He was started on low-dose lisinopril and metoprolol with normal blood pressures after. Continue these meds as an outpatient. # Lack of insurance - Social work was consulted to see if they could help set the patient up with services, including health insurance and a new PCP. [Name10 (NameIs) ] to follow up with [Hospital1 ] center/new pcp and Dr. [Last Name (STitle) 911] as an outpatient cardiology. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] associates following for Mass Health/HSN application. He will be given a free week supply of meds through Care Plus Pharmacy. Advised pt to apply for unemployment benefits as above, pt familiar with local unemployment office. Medications on Admission: Lipitor, aspirin, nitroglycerin - denies taking for 2 years Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Coronary Artery Disease Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and a dangerous heart rhythm called ventricular fibrillation that needed to be shocked in to a normal rhythm. The heart attack was because of a blocked stent, this was opened again and another stent was placed in the left anterior artery. You will need to take aspirin and Plavix every day for one year. You risk another heart attack and death if you do not take these medicines. Don't stop taking Aspirin and Plavix unless Dr. [Last Name (STitle) 911] tells you to stop them. Your heart function is very weak after this heart attack. We hope it will improve over the next 4-8 weeks. In the meantime, you will need to watch yourself closely for fluid overload which may cause swelling in your arms or legs, a cough, trouble breathing or inablility to lie flat at night. Please weigh yourself every morning and call Dr. [Last Name (STitle) 911] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. . New medicines: 1. Start taking aspirin (325 mg) and Plavix daily to keep the stents open and prevent another heart attack. You will take Plavix twice a day for another 2 days, then decrease to once daily after that on [8-2]. 2. Start Coumadin to prevent blood clots and strokes from your weak heart muscle. You will need to take this medicine every day and get your blood checked frequently to prevent the blood level from being too high or too low. Goal blood level is 2.0-3.0. [First Name8 (NamePattern2) ] [Name8 (MD) 2716], RN with Dr. [Last Name (STitle) 911] will monitor your blood level and tell you how much coumadin to take every day. 3. You will need to inject Lovenox twice daily until your coumadin level is > 2.0. [First Name8 (NamePattern2) ] [Location (un) 2716] will tell you when it's Ok to stop the Lovenox. 4. Start taking Simvastatin every day to lower your cholesterol 5. Start taking Metoprolol and Lisinopril to help your heart pump better. These medicines will help prevent fluid buildup. 6. Start Cephalexin (Keflex), an antibiotic to prevent infection at the pacer site. 7. Start Hydrocodone/Acetaminophen as needed for the pain at the pacer site, this pain should get better every day. Followup Instructions: Name: [Last Name (LF) 5240],[First Name3 (LF) 5241] Location: [Hospital6 5242] CENTER Address: [Location (un) 5243], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 798] Appointment: Wednesday [2173-8-4] 10:40am Department: CARDIAC SERVICES When: TUESDAY [2173-9-14] at 3:00 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: CARDIAC SERVICES When: WEDNESDAY [2173-9-1] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "427.41", "412", "V45.82", "305.21", "V60.2", "414.01", "272.4", "E878.1", "996.72", "410.11", "V15.82", "401.9", "V15.81" ]	icd9cm	[ [ [] ] ]	[ "00.40", "37.21", "88.56", "00.45", "00.66", "99.20", "36.07", "99.62" ]	icd9pcs	[ [ [] ] ]	7502, 7508	4704, 7391	321, 353	7624, 7624	4364, 4681	9990, 11028	3683, 3822				7529, 7603		7417, 7479			7775, 9967										3837, 4345			3350, 3489																					276, 283											381, 3270									7639, 7751							3292, 3330	3505, 3667
20,340	123,577	10991+56199	Discharge summary	report+addendum	Admission Date: [2192-5-8] Discharge Date: [2192-5-16] Date of Birth: [2136-10-8] Sex: F Service: [Hospital Unit Name 196] HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old female with a history of metastatic colon CA who was transferred from [Hospital3 3583] for pericardiocentesis. The patient reports a two to three week history of shortness of breath and pleuritic chest pain, which started all of a sudden, was not associated with any concurrent illnesses. The patient was evaluated at an outside hospital ED three weeks prior to admission at [Hospital6 2018] and was discharged to home with the diagnosis of musculoskeletal pain, per report. Since this time, the patient continued to experience shortness of breath, marked dyspnea on exertion, and overall fatigue. Given worsening symptoms, the patient returned to the Emergency Department three days prior to this admission. The patient was evaluated at [Hospital3 3583] Emergency Department. In the Emergency Department, the patient was noted to have supraventricular tachycardia and shortness of breath. Evaluation at [Hospital3 3583] revealed a large pericardial effusion and the patient was transferred to [Hospital6 1760] for pericardiocentesis. Upon arrival, the patient underwent cardiac catheterization. The patient was noted to have equalization of diastolic pressures. Given organization, this effusion was unable to be drained. The patient was subsequently transferred to the [Hospital Unit Name 196] Service for concern of constricted pericarditis. Upon examination, the patient continued to complain of left-sided pleuritic chest pain. The patient also reported dyspnea on exertion and orthopnea. The patient also complained of palpitations and lightheadedness. The patient denied any PND, lower extremity edema, or syncope. The patient reports relief of shortness of breath upon sitting up. PAST MEDICAL HISTORY: 1. Colon cancer diagnosed in [2187] with liver mets. The patient underwent chemotherapy with 5-FU, methotrexate, and leucovorin. The patient also had liver resection for metastases. The patient is no longer undergoing any therapy for her cancer. 2. Depression. ADMISSION MEDICATIONS: 1. Effexor 75 mg p.o. b.i.d. 2. Amiodarone 400 mg p.o. b.i.d. 3. Ursodiol 300 mg p.o. q.i.d. 4. Ceftriaxone 1 gram. 5. Oxycontin 80 mg p.o. b.i.d. 6. Oxycodone 5 mg q. six hours p.r.n. ALLERGIES: Compazine. SOCIAL HISTORY: The patient is married. She is a restaurant owner. She has two children. She was a former smoker. FAMILY HISTORY: Her mother had a history of coronary artery disease and colon CA. Her father had a history of coronary artery disease. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: There is no temperature recorded at admission. The patient's current heart rate was 100, blood pressure 150/70, respirations 12, saturating 92% on 2 liters nasal cannula, pulses were noted to be 20 mmHg. General: The patient was a well-developed, well-nourished female lying in bed in mild respiratory distress. HEENT: The pupils were equal, round, and reactive to light. Extraocular motor muscles were intact. The oropharynx was clear. Jugular venous distention was not assessed as the patient was supine status post procedure. Cardiac: S1, S2, regular rate and rhythm. There were no murmurs, no S3, no S4. Abdomen: Benign. Extremities: There was no clubbing or cyanosis. The patient had 2+ DP pulses bilaterally. Neurologic: The patient was grossly intact without focal deficits, moving all extremities, and with normal speech. LABORATORY/RADIOLOGIC DATA: The data upon admission to the outside hospital revealed a Chem-7 within normal limits, creatinine 0.7, hematocrit 32.5. CK 22, troponin less than 0.02. CEA 133. ALT 39, AST 40, albumin 3.6, INR 1.1, TSH 1.4. EKG on admission revealed sinus tachycardia at 95 beats per minute, nonspecific T wave inversions in the lateral leads. There were no PR depressions noted. From the outside hospital, the patient also had one tracing with atrial fibrillation and one with bigeminy. Echocardiogram from the outside hospital revealed a left ventricular ejection fraction greater than 55% with 1+ MR, small to moderate pericardial effusion without tamponade. A chest CT performed on [2192-5-6] from the outside hospital revealed a large pericardial effusion, right pleural effusion, small left-sided pleural effusion, right lower lobe atelectasis, and hepatomegaly with biliary stent. A V/Q scan performed at the outside hospital on [2192-5-5] was read as low probability. On [2192-5-8], cardiac catheterization upon admission at [Hospital6 256] revealed the following hemodynamics: Right atrium pressures of 28/32 with a mean pressure of 25, right ventricular pressure of 50/28, PA pressure 50/28/36, pulmonary capillary wedge pressure of 30/34 with a mean pressure of 29, cardiac output 4.82, cardiac index 3. ASSESSMENT: The patient is a 55-year-old female with metastatic colon CA without known coronary artery disease presenting with progressive dyspnea on exertion, shortness of breath, and palpitations secondary to pericardial effusion with organization complicated by tamponade who underwent unsuccessful pericardiocentesis. Thus, the patient was admitted to the [Hospital Unit Name 196] Service for the concern of constrictive pericarditis. HOSPITAL COURSE: 1. PERICARDIAL EFFUSION/CONSTRICTIVE PERICARDITIS: Given the concern of ongoing pericardial effusion and constrictive pericarditis, the CT Surgery Service was consulted for evaluation of pericardial window or pericardial stripping procedure. For further evaluation and to better define the effusion, the patient underwent a transthoracic echocardiogram which revealed a continuous moderate effusion with right ventricular and right atrial clot. The patient also underwent a cardiac MRI which revealed tethering of the pericardium, suggestive of constriction, with small semisolid effusions. On further discussion with Cardiac Surgery as well as the patient, the patient opted for a minimally invasive procedure and did not want to undergo a full sternotomy for pericardial stripping. On hospital day number five, the patient underwent a pericardial window and drainage of pleural effusions. Intraoperative findings reported a very thickened pericardium that appeared inflamed. There was no obvious tumor nodules. There was serous fluid seen within the pericardium, measures at approximately 150 to 200 cc. There were also loculations seen within the pericardium. In the left pleural space, there was a pleural effusion that was noted to be serous. Fluid approximated 200-300 cc that was evacuated from the left pleural space. On the right, there were multiple adhesions from the right pleural space. There was unsuccessful drainage of the right-sided pleural effusion. Per op report, there was also a 3 by 2 inch window in the anterior pericardium that was made. A chest tube was inserted through the pericardium. There were also chest tubes placed within the pleural spaces. Status post procedure, the patient was transferred to the CCU for further monitoring. The drainage was serous both the pleural and pericardial space. The patient was no longer at acute risk of tamponade. However, the patient was still with constrictive pericardial disease. In the CCU, the patient continued to remain hemodynamically stable. Chest tubes were removed and the patient was transferred back to the [Hospital Unit Name 196] Service for followed care. Upon transfer, the patient continued to remain hemodynamically stable. The patient is at risk of subacute tamponade given constrictive pericarditis. Her blood pressure remained stable without any evidence of compromise. Of note, cytology of the pleural fluid was negative and was noted to be blood only. At the time of dictation, pathology of pericardial tissue remains pending. 2. ATRIAL FIBRILLATION: The patient was noted to have atrial fibrillation at the outside hospital and was started on an Amiodarone load. The hospital course at the [Hospital6 1760] was complicated by recurrent episodes of atrial fibrillation. The patient was initiated on a beta blocker. While continuing on this regimen, the patient continued to experience episodes of atrial tachycardia; however, the patient overall remained well controlled. The patient is to be discharged on beta blocker and on Amiodarone 200 mg p.o. t.i.d. for a total of three weeks and should be titrated down to 200 mg p.o. q.d. as of [2192-6-2]. Given the initiation of Amiodarone, the patient will be discharged with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Heart monitor. 3. CONGESTIVE HEART FAILURE: Status post procedure, the patient developed bilateral crackles on examination with peripheral edema secondary to perioperative fluid resuscitation. The patient was subsequently diuresed throughout the remainder of this hospital stay. The patient continues to have CHF at the time of discharge. The patient will be discharged on 40 mg p.o. q.d. of Lasix and home 02. The patient should be followed closely and should continue with diuresis and oxygen supplementation as needed. Home VNA should assist in monitoring of daily weights and I&Os until the patient is no longer with signs of heart failure. 4. ONCOLOGY: The patient has a history of metastatic colon cancer. She is not seeking any further therapy at this time. In time, the patient should be transitioned over to hospice care as needed. 5. PAIN: Upon admission, the patient experienced focal left-sided chest pain thought to be secondary to pericardial disease and effusion. The patient was transitioned on a PCA Dilaudid strip for pain control. The patient was subsequently transitioned to Oxycontin and Fentanyl. However, the patient displayed decreased mental status on the Fentanyl patch and subsequently Fentanyl was discontinued. The patient is to be discharged to home on Oxycontin 80 mg p.o. b.i.d. and Oxycodone as needed. The patient is also to continue on Ibuprofen 400 mg p.o. q. six to eight hours given for pericardial disease. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSIS: 1. Pericardial effusion. 2. Constrictive pericarditis. 3. Metastatic colon cancer. 4. Chronic pain. 5. Atrial fibrillation. DISCHARGE MEDICATIONS: 1. Oxycodone 80 mg p.o. b.i.d. 2. Ibuprofen 400 mg tablets p.o. q. eight hours. 3. Metoprolol 50 mg p.o. b.i.d. 4. Amiodarone 200 mg t.i.d. until [2192-6-2], at that time the patient should be transitioned down to 200 mg p.o. q.d. 5. Venlafaxine 75 mg tablets p.o. b.i.d. 6. Oxycodone 5 mg tablets 5-10 mg p.o. q. six hours p.r.n. 7. Senna/Docusate 8.6 to 50 mg tablets, two tablets p.o. b.i.d. 8. Ursodiol 300 mg tablets p.o. q.i.d. 9. Lasix 40 mg tablets p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient is to be discharged to home with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Heart monitor. The patient should record the [Doctor Last Name ] of Heart at times of events and also one time q.a.m. to monitor for QRS list. 2. The patient is to follow-up with PCP or Cardiology as discussed. 3. The patient should continue on home 02. [Doctor First Name 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D. Dictated By: [First Name4 (NamePattern1) 35644] [Last Name (NamePattern1) ], M.D. MEDQUIST36 D: [2192-5-16] 10:44 T: [2192-5-19] 08:21 JOB#: [Job Number 35645] Name: [Known lastname 5347], [Known firstname 634] Unit No: [Numeric Identifier 6351] Admission Date: [2192-5-8] Discharge Date: [2192-5-16] Date of Birth: [2136-10-8] Sex: F Service: DISCHARGE MEDICATIONS: Lasix 40 mg po q day to 40 mg po bid until lower extremity edema is decreased and patient may reduce this to q day dosing. FOLLOW-UP INSTRUCTIONS: 1. The patient is to followup with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6352] for followup early next week. 2. The patient is to send daily [Doctor Last Name ] of Hearts monitor strips to him to monitor for Q-T interval. 3. The patient is to continue on O2 nasal cannula at 2 liters for documented ambulatory on room air sat of 84%. [Doctor First Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 5817] Dictated By:[Last Name (NamePattern1) 6353] MEDQUIST36 D: [2192-5-16] 13:56 T: [2192-5-16] 17:31 JOB#: [Job Number 6354]	[ "424.0", "V10.05", "197.7", "511.9", "423.2", "427.31" ]	icd9cm	[ [ [] ] ]	[ "88.55", "34.04", "37.12", "37.21" ]	icd9pcs	[ [ [] ] ]							2615, 2757		11965, 12089		10335, 10465			5453, 10240		10993, 11941		2263, 2479																																																			2772, 5435					12113, 12775			1969, 2240	2496, 2598	10265, 10314
20,060	141,899	12651	Discharge summary	report	Admission Date: [2156-10-18] Discharge Date: [2156-10-26] Date of Birth: [2076-4-27] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: nausea, vomiting, dysequilibrium Major Surgical or Invasive Procedure: [10-20] Right Craniotomy for Tumor resection History of Present Illness: This is an 80 year old right handed man with a 3week hisotry of n/v/HA/gait anomalies. This worsened in the 24 hours prior to presentation. He was taken to [Hospital3 3383] hospital where a CT showed a right cerebellar mass. He was transfered to [Hospital1 ] for further evaulation. Past Medical History: DM, HTN, bypass surgery [55] years ago, appendectomy, cataract surgery Social History: Tob: 1ppd for his "entire life", recently down to 2 cigarettes a day. EtOH 1 glass of wine with dinner Family History: NC Physical Exam: On Admission: O: T: 98.1 BP: 148/78 HR: 71 R: 18 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [3-10], IOLs OU EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place. Language: Speech slow with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-13] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Normal bilaterally Toes downgoing bilaterally Coordination: dysmetria, mild dysdiadochokinesis, normal heel to shin Handedness: Right Physical Exam upon discharge: awake, alert. oriented to self/hospital PERRL, EOMI face symmetric, tongue midline MAE's with good strengths following all commands incision- C/D/I Pertinent Results: [2156-10-18] MRI head with and without contrast: There is confirmation of an ovoid, irregularly rim-enhancing mass measuring 23 x 32 mm within the right cerebellar hemisphere. There is extensive surrounding edema, including compression of the fourth ventricle. No other areas of pathological enhancement are identified. The lesion exhibits very low diffusion, which would argue against an inflammatory process such as an abscess. The motion degraded FLAIR images suggest a very minor degree of T2 hyperintensity within the white matter of both cerebral hemispheres, becoming confluent in the periatrial regions bilaterally. Given the patient's age, chronic small vessel infarction would appear the most likely diagnosis. [2156-10-18] CTA head: No definite hypervascularity is seen in relationship to the cerebellar mass. [2156-10-18] CT chest/abd pelvis: IMPRESSION: 1. No primary tumor identified to account for metastasis. 2. There is interstitial lung disease with a basilar predominance and subpleural cysts consistent with interstitiell lung disease. Centrilobular emphysema is present. A nodule within the lingula measures 7 mm and is non- specific. Follow- up in 3 months is recommended, alternatively this could be compared to prior studies to ensure stability 3. A 3-mm nodule within the left lobe of the thyroid is noted 4. Diverticulosis without evidence of diverticulitis. CT HEAD W/O CONTRAST [2156-10-21] Status post resection of right cerebellar mass, with expected postoperative changes, and no evidence of large hematoma,increased mass effect, or larger vascular territorial infarction [2156-10-22]: MRI brain with and without contrast: minimal amount of blood product within the postoperative bed. No overt evidence of residual mass. Brief Hospital Course: Mr. [Known lastname ] was admitted to the neurosurgery service for work up of a right cerebellar lesion. He was started on antiemetics and steroids which improved his symptoms of nausea and vomiting. MRI was obtained to better evaluate the lesion. CT Torso was performed for metastatic workup but was negative for obvious signs of primary disease. After discussion with the patient and the patient's son and Healthcare proxy, [Name (NI) ], the decision was made to proceed with resection of the mass. A pre-op work up was done. He required >400 units of Insulin twice during the day of [10-20] and his RISS was adjusted. He was made NPO at midnight in anticipation of surgery. MRI wand study was ordered for surgical planning. On [10-21] the patient underwent a right suboccipital craniotomy for resection of right cerebellar tumor. Post operatively patient remained stable on examination. Post op head CT showed post surgical changes, no acute hemorrhage, mass effect or acute infarct. On [10-22], he was transferred to the floor and his diet advanced. MRI Brain demonstrated no acute infarct. He was seen and evaluated by physical therapy and occupational therapy who fet that he would benefit from acute rehab. On [10-24] and [10-25] the patient's Serum Na dropped to 130 and BUN bumped, trending up to 36. The hyponatremia responded to NS fluid boluses and Serum Na improved to 133. Labs were followed closely. On [10-26] Na and K were WNL. BUN was improving. He was neurologically stable and cleared for discharge. Medications on Admission: unknown Discharge Medications: 1. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/fever. 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Right Cerebellar mass Intersitial Lung Disease Emphysema Thyroid nodule Diverticulosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions/Information ?????? 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 3 days after your surgery. Your wound closure uses dissolvable sutures and the suture material will fall out on its own - do not pull the sutures or scrub the incision. Do not leave wet bandages or wet towels on the incision. ?????? 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. ?????? Continue to take your Keppra (Levetiracetam) as prescribed. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [Hospital 341] Clinic on [2156-11-8] at 10:30am. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 5074] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ** You must call registration before [11-5] at noon in order to be seen in clinic to update your insurance information and referral. The phone number for registration is [Telephone/Fax (1) 10676]. You should call them as soon as possible, do not wait until [11-5]. There were several abnormal findings on the CT scan we did of your chest. You must see your PCP within the month to discuss the findings of emphysema, thyroid nodule and diverticulosis. You need to have the CT chest repeated in 3 months. You should get a copy all your medical records to bring to your PCP. Completed by:[2156-10-26**]	[ "198.3", "401.9", "276.1", "305.1", "250.00", "V45.81", "414.00", "199.1", "348.4", "492.8", "562.10", "515", "241.0" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]	6764, 6822	4321, 5884	343, 394	6953, 6953	2520, 4298	9127, 10202	952, 956		5942, 6741		6843, 6932		5910, 5919			7138, 9104										971, 971																								271, 305							2352, 2501				422, 715	1489, 2322							985, 1249	6968, 7114							737, 814	830, 936
67,992	124,765	5883	Discharge summary	report	Admission Date: [2139-4-21] Discharge Date: [2139-4-24] Date of Birth: [2062-11-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4891] Chief Complaint: Birght red blood per rectum Major Surgical or Invasive Procedure: Celiac, SMA, [Female First Name (un) 899] angiography Colonoscopy Capsule endoscopy History of Present Illness: 76 year old male with history of hyperlipidemia, gout, sciatica and previous lower GI bleed (presumed diverticular, source never elucidated in [2136]) who presents with bright red blood per rectum. The patient had been taking a transcontinental flight when he developed abdominal cramping and when to the lavatory where he passed significant amounts of bright red blood per rectum. [Initials (NamePattern4) ] [Last Name (NamePattern4) 533] physician on board evaluated the patient and described him as "stable," although with ongoing dizzyness when attempting to stand. He arrived in [Location (un) 6692] Airport where EMS brought him to the [Hospital1 18] ED. Enroute, the patient was reportedly pale, diaphoretic with ongoing BRBPR (~[1-1] pints) and abdominal crampiness. The patient does endorse recent constipation with straining to have bowel movements. . In the [Hospital1 18] ED, initial VS were: T98.0, HR110, BP122/86, RR 15, 99% on RA. The patient did have one episode of SBP80s (?vasovagal) en route via EMS without syncope and received two units pRBC and 2L normal saline IVF in the ED. NG lavage was performed and was clear. GI was consulted and recommended consulting IR if the NG lavage was clear. General Surgery was also consulted and concurred (IR). The patient received pantoprazole 80mg IV (although bleed appeared more small-large intestinal), two large bore IVs placed (14 and 18 gauges). IR evaluated the patient in the ED with plan for angiogram tonight. VS on transfer were afebrile, HR84, BP134/53, RR15, 98% on RA. . On arrival to the MICU, the patient was resting comfortably in bed and had not had any more BRBPR since arrival to the ED (although describes significant maroon stools en route). Denies abdominal pain, shortness of breath, chest pain. . ROS: Patient denies fevers, chills, dysuria, urinary urgency. He denies SOB, chest pain, syncope, pre-syncopal symptoms. Denies rectal pain. Past Medical History: * Lower GI bleed ([2136], unclear source despite colonoscopy and tagged RBC, 5 pRBC) * Gout * Hyperlipidemia * Sciatica * Peripheral neuropathy, not on medications * Right hip replacement ([2131]) * Left inguinal hernia repair ([2132]) * Circumcision for balanitis ([2126]) * Colonoscopy: Diverticulosis of the sigmoid colon, distal descending colon and proximal ascending colon. Polyp in the proximal ascending colon (polypectomy). Otherwise normal colonoscopy to cecum (12/[2136]). Social History: Lives with wife in [Name (NI) 912], near [Location (un) ]; has a cottage. Retired from insurance company. Denies tobacco or illicits. Two alcoholic beverages a day (1 shot vodka mixed w/ water), [4-3] days/week. Family History: Mother with rheumatoid arthritis and [Name (NI) 4522] Disease (alive). Father died of rheumatic heart disease and coronary artery diseaseat 52 years old. Physical Exam: On admission: VS: Temp: 99.7 BP: 125/72 HR: 74 RR: 14 O2sat 98% on RA GEN: Pleasant, comfortable except for NGT, NAD HEENT: PERRL, EOMI, MMM, conjunctiva not pale, no lymphadenopathy RESP: CTA b/l with good air movement throughout CV: Regular rate and rhythm, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, non-distended, +BS, soft, no masses EXT: No cyanosis/ecchymosis/edema SKIN: No rashes orlesions NEURO: Alert and oriented. CN 2-12 grossly intact. Strength and sensation grossly intact. . Discharge physical exam: VS: Temp: 97.8 BP: 129/87 HR: 72 RR: 18 O2sat 100 on RA GEN: Pleasant, appropriate, no acute distress HEENT: PERRL, EOMI, conjunctiva not pale or injected, no carotid bruits RESP: Clear to auscultation bilaterally CV: RRR. soft S1, S2, no murmurs auscultated ABD: Nontender, non-distended, +BS, soft, no masses or hepatosplenomegaly EXT: Radial pulses 1+, pedal pulses 2+ SKIN: No rashes. Seborrheic keratoses on back/chest. -IR site in right groin with very small hematoma. No bruits over site. Dressing removed now. NEURO: Alert and oriented. Pertinent Results: Admission labs: [2139-4-21] 11:06PM HCT-35.6* [2139-4-21] 07:18PM HCT-37.2* [2139-4-21] 04:22PM LACTATE-1.9 [2139-4-21] 04:15PM GLUCOSE-129* UREA N-27* CREAT-1.2 SODIUM-137 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12 [2139-4-21] 04:15PM WBC-9.9 RBC-4.24# HGB-14.2# HCT-40.6# MCV-96 MCH-33.5 MCHC-35.0 RDW-13.5 [2139-4-21] 04:15PM NEUTS-67.8 LYMPHS-25.6 MONOS-4.3 EOS-1.6 BASOS-0.6 [2139-4-21] 04:15PM PLT COUNT-171 [2139-4-21] 04:15PM PT-12.7 PTT-21.5* INR(PT)-1.1 . Discharge labs: [2139-4-24] 06:58AM BLOOD WBC-6.2 RBC-4.17* Hgb-14.0 Hct-39.6* MCV-95 MCH-33.5* MCHC-35.3* RDW-14.0 Plt Ct-122* [2139-4-24] 06:58AM BLOOD Glucose-169* UreaN-13 Creat-1.0 Na-141 K-3.4 Cl-107 HCO3-25 AnGap-12 . EKG: Normal sinus rhythm, HR81, normal axis, QTc 446, no ST elevations or TW inversion. . [2139-4-23] EKG: Sinus rhythm. Low QRS voltage. Delayed R wave progression is non-diagnostic but cannot exclude possible prior septal myocardial infarction. Findings are non-specific. Clinical correlation is suggested. Since the previous tracing of [2137-4-20] no significant change. . [2139-4-21] Arteriogram: 1. No evidence of active arterial extravasation. 2. Brisk filling of dilated venous plexus at the anal canal (left wall) = hemorrhoids. . Colonoscopy [2139-4-23]: Findings: Protruding Lesions Medium non-bleeding internal hemorrhoids were noted. Excavated Lesions Multiple non-bleeding diverticula with mixed openings were seen in the whole colon. Diverticulosis appeared to be of moderate severity. Impression: Diverticulosis of the whole colon Grade 2 internal hemorrhoids Otherwise normal colonoscopy to cecum Recommendations: No blood or bleeding source indentified. Suggest capsule endoscopy. Brief Hospital Course: 76 year old male with history of hyperlipidemia, gout, sciatica and previous lower GI bleed (presumed diverticular, source never elucidated in [2136]) who presents with bright red blood per rectum. . # Lower GI bleed: Most likely given negative NG lavage and relative hemodynamic stability despite significant amount of BRBPR. The patient has a history of prior lower GI bleed in [2136] and although source was never elucidated (colonoscopy, tagged RBC), may have been due to known diverticuli. IR took patient for angiography, with possibility of intervention but did not find active arterial extravasation along celiac, SMA and [Female First Name (un) 899] branches although brisk filling of dilated venous plexus (left anal canal wall) suggestive of hemorrhoids. This raises question of possible hemorrhoidal bleeding instead although this would be venous and not seen bleeding during IR procedure. GI and ACS followed patient in house. Colonoscopy on [2139-4-23] showed diverticulosis of the whole colon, grade 2 internal hemorrhoids, and otherwise normal colonoscopy to cecum. Given lack of bleeding from hemorrhoids, surgery was deferred. Subsequent capsule study was performed but no images were captured. The patient will follow as an outpatient to determine if capsule endoscopy should be repeated. His hematocrit has been stable and no further episodes of bleeding. . # Hyperlipidemia: Continued patient's home Crestor, but held his aspirin [Doctor Last Name ] to bleeding. . # Sciatica: Stable and patient had no complaints. Medications on Admission: * Aspirin 81mg daily * Crestor 5mg daily * Colchicine - two pills daily PRN Discharge Medications: 1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Lower gastrointestinal tract hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 23264], It was a pleasure participating in your care at [Hospital1 771]. . You were admitted because you were having bleeding from your lower gastrointestinal tract. You were briefly in the Intensive Care unit to replace some blood and fluids. You receive a study of your abdominal arteries that showed no active bleeding but hemorrhoids. You received a colonoscopy that showed diverticulosis (pouches off of your colon) and internal hemorrhoids. No active bleeding was seen during the colonoscopy, but the source of your bleeding may have been either the diverticuli or the hemorrhoids or both. You also had a capsule endoscopy, but the pictures were not transmitted. Your blood counts were stable by the time of discharge, so it was felt that you were no longer bleeding. . The gastroenterology department will be in touch with you next week on Tuesday about the possibility of another capsule endoscopy. You also have a follow up appointment set up with Dr. [Last Name (STitle) 6880]. If you would prefer, however, to get GI care at a facility closer to your home, you may cancel this appointment. Just be sure to get some follow up, and definitely see your primary care physician on Wednesday, [4-29]. . We have added a prescription for a stool softener, docusate. We stopped your aspirin because you were bleeding. . You should have a discussion with Dr. [Last Name (STitle) 1728] about the risks and benefits of aspirin therapy. Followup Instructions: Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4961],MD Specialty: Primary Care Address: [Street Address(2) ], 2 WEST, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 14148] When: Wednesday, [4-29] at 11:30am Department: GASTROENTEROLOGY When: WEDNESDAY [2139-5-6] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6970], MD [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "V43.64", "578.9", "272.4", "443.0", "455.0", "V10.83", "355.8", "V12.72", "562.10" ]	icd9cm	[ [ [] ] ]	[ "88.47", "45.23", "45.29" ]	icd9pcs	[ [ [] ] ]	8143, 8149	6263, 7821	332, 422	8233, 8233	4464, 4464	9884, 10470	3189, 3349		7948, 8120		8170, 8212		7847, 7925			8384, 9861			5006, 6240							3364, 3364																								265, 294											450, 2403					4480, 4990			3378, 3867	8248, 8360							2425, 2931	2947, 3173			3892, 4445
81,671	113,722	7244	Discharge summary	report	Admission Date: [2198-9-30] Discharge Date: [2198-10-2] Date of Birth: [2164-11-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4654] Chief Complaint: Melena Major Surgical or Invasive Procedure: Upper endoscopy x 2 History of Present Illness: Mr. [Known lastname 26808] is a 33 year old male without any significant past medical history who was in his usual state of health until the day prior to admission. He reports that he awoke around 1 am, at which time he had a loose, black bowel movement. Shortly thereafter, he felt nauseus and began to vomit bright red blood with clots. He felt slightly lightheaded and drove himself to the emergency room. He denies any associated abdominal pain at the time or in the weeks prior to hematamsis/melena - just occ vague ache associated with hunger that was slightly stronger than previously. Of note, patient had been taking 2 full strength aspirin every 4-6 hours for relief of discomfort from a cold sore that began over two weeks ago, and had taken this dosing for about 10 days. He last took aspirin about 10 days ago. In the emergency room, his presenting vital signs were temperature 97.0, heart rate 77, blood pressure 144/86, respiratory rate of 17, and 100% on room air. As laboratories were being drawn, the patient became acutely diaphoretic and his heart rate went down to the 40's. His blood pressure dipped to a systolic of 90. Two 18 gage peripheral IV's were placed, and a NG tube was placed, at which time the patient vomitted bright red blood. NG lavage was completed with bright red blood and clots that did not clear. Rectal exam was notable for melena in the vault. He was given a bolus of protonix 80 mg and then continued on a protonix drip. He was type and crossed for 4 units of packed red blood cells. Upon arrival to the ICU, he received 4 units pRBC's, fluids and IV protonix infusion. EGD performed by GI: Diffuse friability, erythema and congestion of the mucosa were noted in the whole stomach. A single ulcer was found in the stomach body with evidence of a visible vessel. Epinephrine 1/[Numeric Identifier 961] injections and cauterizations were applied for hemostasis with success. A second endoscopy was performed the next day which revealed sucessful hemostasis. The patient had no further melena or hematemasis. He currently reports feeling well. Past Medical History: 1)Hyperlipidemia 2)Status post tonsillectomy [5-/2197] Social History: Patient works in the bio-technology field. He has a supportive husband who is at the bedside. He does not smoke or use ilicit drugs. He drinks a [12-27] alcoholic drinks a few nights a week, sometimes more on a weekend while out with friends. [Name (NI) ] enjoys gardening. Family History: Non-contributory. Physical Exam: VS 96.9 120/65 71 20 99% RA General: Pleasant male, in NAD, resting comfortably in bed. HEENT: NC/AT. MMM, clear oropharynx, no scleral icterus. PERRL Neck: Supple Cardiac: Regular rate & rhythm, no rubs or gallops, possible soft systolic murmur, although not heard consistently Lungs: CTAB no w/r/r Abdomen: Soft, NT, ND, +BS Extr: Warm, well perfused, capillary refill WNL Neuro: A&Ox3, CN's sym and intact. Speech fluent and coherent Skin: No lesions or rashes Pertinent Results: [2198-9-30] 08:15AM BLOOD WBC-5.4 RBC-4.50* Hgb-14.0 Hct-38.3* MCV-85 MCH-31.1 MCHC-36.6* RDW-12.3 Plt Ct-225 [2198-10-1] 12:10AM BLOOD WBC-10.1 RBC-3.20# Hgb-10.6# Hct-27.7* MCV-87 MCH-33.2* MCHC-38.3* RDW-12.3 Plt Ct-205 [2198-10-2] 07:00AM BLOOD Hct-33.2* [2198-9-30] 08:15AM BLOOD PT-12.7 PTT-22.5 INR(PT)-1.1 [2198-9-30] 08:15AM BLOOD Glucose-116* UreaN-28* Creat-0.8 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [2198-9-30] 08:15AM BLOOD ALT-13 AST-15 AlkPhos-52 TotBili-0.4 [2198-9-30] 08:15AM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.8 Mg-1.9 Relevant Imaging: 1)Cxray ([9-30]): NG tube is in the first portion of the duodenum. Cardiomediastinal contours are normal. The lungs are clear. There is no pleural effusion. 2)EGD: [2198-9-30]: Mixture of red and clotted blood was seen in the stomach. Extensive washout was performed to obtain better visualization. Residual clot remained, but we were able to see the majority of the gastric mucosa by repositioning patient. Diffuse friability, erythema and congestion of the mucosa were noted in the whole stomach. Excavated Lesions A single ulcer was found in the stomach body with evidence of a visible vessel. [2198-10-1]: Gastritis in the entire stomach. Non-bleeding gastric ulcer s/p cautery from previous EGD. Brief Hospital Course: Mr. [Known lastname 26808] is a 33 year old male without past medical history who presents with hematemesis and melena in setting of significant aspirin use 10 days ago. 1)Upper GI Bleed: Patient presented with melena and NG lavage in the ED was positive. Likely in the setting of Aspirin use. Hct on admission was 38.3 but dropped to 27.7. He received a total of 4 units pRBCs. He was initially transferred to the MICU for closer monitoring. An IV PPI was started at this time. GI was consulted and the patient underwent an upper endoscopy which revealed gastritis with a single bleeding ulcer, which was cauterized. He was rescoped the next day which showed no further bleeding. H. pylori serologies were sent and returned positive. He was started on Prevpak. IV PPI was transitioned to PO and his diet was advanced. Hct at time of discharge was approximately ~33. He is scheduled in [Hospital ] clinic for follow-up in 3 weeks with Dr. [Last Name (STitle) 4539]. 2)Positive blood cultures: [12-29] blood culture bottles positive for GPC's in clusters. Thought to be a contaminant but he was started on Vancomycin which was stopped the next day. He has no murmurs on exam and no other focal findings. Repeat blood cultures were obtained prior to discharge. Patient is scheduled for follow-up in [Company 191] at the end of this week. In addition, he will be contact[Name (NI) ] day after discharge to inform him of his results. Medications on Admission: Aspirin 650mg PO q4-6 hours for 10 days, last taken about 1-1.5 weeks ago Acyclovir (only recently for cold sore) Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 2. PrevPak Please use as directed for 14 day course. Dispense 1 pack, no refills. Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI Bleed H. Pylori infection Discharge Condition: Stable Discharge Instructions: 1) You were admitted because you were found to have an upper gastrointestinal bleed likely due to Aspirin use. You had an upper endoscopy which showed a single bleeding ulcer within your stomach. The bleeding was stopped via cauterization and on repeat endoscopy the following day, there was no evidence of additional bleeding. Due to the fact that you've had a GI bleed, you are to avoid using aspirin or NSAIDs (ibuprofen, naproxen). 2) You were also diagnosed with H. pylori, which is an infection of the lining of your stomach. For this infection, you were started on two antibiotics, amoxicillin and clarithromycin along with an anti-acid medication. 3) As part of your laboratory evaluation, blood cultures were obtained. You were found to have bacteria in one of the blood cultures. We believe that this may be a contaminant. As a precaution, an additional set of blood cultures were obtained immediately prior to discharge. However, you should call your primary care physician's office tomorrow ([2198-10-3]) for the results of the first set of blood cultures. You will need to follow-up the results of the most recent set of blood cultures at your follow-up appointment with your primary care physician on Thursday, 10/09/[Numeric Identifier 12623]. 4) You were started on several new medications during your hospital course. You were started on pantoprazole which you should continue taking until you are seen in follow-up by your gastroenterologist. You were also started on two antibiotics for your H. pylori infection, which you will continue taking for 14 days. Please take all other medications as listed below. 5)Please attend all appointments as listed below. 6) If you have shortness of breath, difficulty breathing, chest pain, fevers, chills, or any other concerning symptoms, please seek immediate medical attention. Followup Instructions: 1) You will need to follow-up the results of the 1st set of blood cultures by calling your primary care physician's office tomorrow ([2198-10-3]). 2) You have a follow-up appointment with your primary care physician on Thursday, [2198-10-4] at 2:20 pm. 3) You have a follow- up appointment with your gastroenterologist, Dr. [Last Name (STitle) 4539], on [2198-10-23] at 2:00 pm. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8718], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2198-10-23] 2:00 [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658]	[ "458.9", "427.89", "535.50", "041.86", "780.8", "531.40", "E935.3", "272.4" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13", "44.43" ]	icd9pcs	[ [ [] ] ]	6618, 6624	4710, 6167	323, 344	6712, 6721	3384, 3954	8630, 9293	2865, 2884		6332, 6595		6645, 6691		6193, 6309			6745, 8607										2899, 3365																								277, 285		3972, 4687									372, 2467																2489, 2550	2566, 2849
49,922	148,473	35622	Discharge summary	report	Admission Date: [2122-10-5] Discharge Date: [2122-10-8] Date of Birth: [2054-8-7] Sex: F Service: MEDICINE Allergies: Bee Pollen Attending:[First Name3 (LF) 2485] Chief Complaint: fever, dyspnea Major Surgical or Invasive Procedure: Intubation Bronchoscopy [2122-10-5] A line Central line, RIJ [2122-10-6] History of Present Illness: 68F with COPD, chronic systolic CHF, and metastatic pancreatic CA on paclitaxel admitted from rehab with fever to 101 and dyspnea. Recent admission to [Hospital1 18] [Date range (1) 81061] for hypoxemia attributed to COPD exacerbation, reported acute on chronic systolic CHF, and community-acquired PNA treated with 14 days of moxifloxacin (ended [9-27]) and a prednisone taper. Per her daughter, she was doing well at rehab and was even able to go outside yesterday with only 1.5L nasal canula. Overnight she started not feeling well, became progressively short of breath, developed a productive cough with increased sputum. Denies fever/chills, lightheadedness, abdominal pain, nausea/vomitting, dysuria, change in bowel movements. Her daughter noticed that she has developed new confusion today. In the ED, initial V/S 99.7 142 146/60 24 95% 3L NC. WBC# 23.5 (81%PMN, 16% bands), lactate 5.9 INR 1.5 Na 132 Cl 91. CXR showed large R-sided infiltrate. Blood Cx drawn. Given vanc/cefepime, methylpred 125 mg IV, nebs x3. Blood pressure nadir 82/36. Got 1300 cc NS, started on levophed gtt. V/S prior to transfer 104 82/36 99%2L. Past Medical History: -Pancreatic CA with liver & skin mets, s/p gemcitabine and erlotinib, then enrolled in CAPOX trial, currently on paclitaxel, on hold since last admission - per onc has relatively low disease burden -COPD (FEV1 39% pred, FEV1/FVC 56% pred in [3-23]) -Chronic systolic heart failure (unknown EF) - [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (onc) she had episode of flash pulmonary edema with low EF which resolved and most recent EF was 50% although no ECHO available in OMR -Chronic macrocytic anemia baseline, hct mid-high 30's Social History: Resident of [Hospital1 ] Senior Healthcare of [Location (un) 1439] since her discharge [9-29]. Previously was living with her daughter and son and grandchildren, was independently mobile and iADL and ADL independent, was previously driving and could climb a flight of stairs. Was married but her husband has since passed away. History of smoking 30+ pack years, no ETOH, no drug use. Her daughter is her HCP. Family History: Brother died of colon cancer Physical Exam: Physical on Arrival to [Hospital Unit Name 8113]: NAD, coughing frequently, oriented to name, not place or time HEENT: flat JVD, very dry mucus membranes, PERRL, EOMI, no cervical LAD RESP: rhonchi bilaterally anteriorly, egophony on right posteriorly, breath sounds distant, no crackles, no wheezes CV: RRR, no M/R/G, no thrills/lifts ABD: soft, ND, NT, liver edge ~2cm below costal margin, no splenomegaly, no masses, +BS, eccyhmoses on abdomen EXT: no edema, ecchymoses on UE b/l NEURO: CN2-12 intact, no sensory deficits, 5/5 strength b/l Pertinent Results: [2122-10-5] 11:00AM BLOOD WBC-23.5# RBC-3.41 Hgb-11.7* Hct-34.5* MCV-101* MCH-34.2* MCHC-33.8 RDW-16.4* Plt Ct-194 [2122-10-5] 11:00AM BLOOD Neuts-81* Bands-16* Lymphs-2* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2122-10-5] 11:00AM BLOOD PT-16.8* PTT-34.1 INR(PT)-1.5* [2122-10-5] 11:00AM BLOOD Glucose-104* UreaN-19 Creat-1.0 Na-132* K-4.0 Cl-91* HCO3-25 AnGap-20 [2122-10-5] 11:00AM BLOOD ALT-35 AST-29 AlkPhos-163* TotBili-1.4 [2122-10-5] 11:00AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.3* [2122-10-5] 03:24PM BLOOD VitB12-404 Folate-9.9 [2122-10-5] 11:17AM BLOOD Glucose-105 Lactate-5.9* Na-132* K-3.9 Cl-89* calHCO3-27 [2122-10-5] 06:19PM BLOOD Type-ART pO2-103 pCO2-48* pH-7.24* calTCO2-22 Base XS--6 Intubat-NOT INTUBA [2122-10-7] 03:35AM BLOOD Lactate-2.1* [2122-10-5] 04:00PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2122-10-5] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2122-10-5] 04:00PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 [2122-10-5] 04:00PM URINE CastHy-7* [2122-10-5] 04:00PM URINE Mucous-RARE [2122-10-5] 04:00PM URINE Hours-RANDOM UreaN-394 Creat-86 Na-23 K-58 Cl-24 [2122-10-5] 04:00PM URINE Osmolal-414 [2122-10-6] 03:36AM OTHER BODY FLUID Polys-94* Lymphs-0 Monos-6* [2122-10-7] 03:20AM BLOOD WBC-9.6 RBC-2.80* Hgb-9.6* Hct-29.1* MCV-104* MCH-34.3* MCHC-33.0 RDW-16.7* Plt Ct-103* [2122-10-8] 01:37AM BLOOD WBC-6.6 RBC-2.89* Hgb-9.9* Hct-31.0* MCV-107* MCH-34.3* MCHC-31.9 RDW-16.7* Plt Ct-86* =============== MICROBIOLOGY =============== [2122-10-5] - Blood cx [12-16]: Pending - Urine cx: Negative - Urine legionella: Negative - Rapid viral screen (prelim): negative--- - MRSA- positive [2122-10-6] - BAL (prelime): 3+ PMN, no microbes seen, Staph aureus coag +, no legionella--- [2122-10-7] - Blood cx: Pending ================== IMAGING ================ [2122-10-5] CXR: FINDINGS: Endotracheal tube ends 5 cm above the carina. Nasogastric tube courses into the stomach and out of view. Right Port-A-Cath is in the low SVC. The right lower lung is now well aerated with minimal residual atelectasis. Dense alveolar consolidation of the right upper lobe is seen and more confluent than on the study from [10-5] at 11:02 a.m. Cardiomediastinal silhouette is unremarkable. There are no pleural effusions or pneumothorax. IMPRESSION: Improved right lower lobar collapse with slightly worsened right upper lobe pneumonia. [2122-10-8] CXR: FINDINGS: In comparison with the study of [10-7], there is little overall change in the combination of asymmetric edema and pneumonia in the right hemithorax, somewhat obscured by obliquity of the patient. The monitoring and support devices remain in place. Left lung remains essentially clear. Brief Hospital Course: 68F with COPD, chronic systolic CHF, metastatic pancreatic CA, recent admission for COPD exacerbation in the setting of community-acquired pneumonia admitted with septic shock from healthcare-associated pneumonia. . The patient expired from respiratory and hemodynamic complications of septic shock. The below issues were active during her hospitalization: . #Septic shock: Most likely health care associated pneumonia in the setting of severe COPD, for which the patient required intubation. Patient had negative viral screens and sputum grew coagulase positive staph aureus. The infection was treated with Vancomycin, Cefepime and Ciprofloxacin, as well as Hydrocortisone for stress dose steroids. On [10-8], the patient was no longer able to maintain blood pressure on pressors despite fluid resuscitation. Family decided to make patient CMO; she was subsequently extubated and expired. . #Chronic systolic CHF: The patient had a h/o flash pulmonary edema in setting of low EF, most recent EF ~50% prior to admission. Although there was intermittent concern that the patient's worsening respiratory status and hypotension were a result of poor forward flow in the setting of cardiogenic shock, her CVP and exam were not consistent with this. Small doses of Lasix were unsuccessful in improving her hemodynamics. . #COPD: The patient was continued on her home nebulizer treatments with hydrocortisone and antibiotics as mentioned above during her hospitalization. . # Pancreatic cancer: The patient presented with known pancreatic cancer with mets to liver and skin and pulm nodules seen on CT in [2122-6-14]. She had evidence of compromised liver synthetic function with slightly elevated INR. Chemotherapy was held in the setting of her acute illness. . #Hyponatremia- Suspected to be secondary to hypovolemia based on dehydration on exam and labs. Patient was fluid resusciatation as described above. . #Macrocytic anemia - HCT at baseline throughout hospitazliation without evidence of active GI bleed. . Medications on Admission: 1. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. senna 8.6 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. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. sodium chloride 0.65 % Aerosol, Spray Sig: [11-15] Sprays Nasal QID (4 times a day) as needed for dry nose. 11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB or Wheeze. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q3H (every 3 hours). 16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 17. petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for dry skin. 18. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 19. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): taper: 40 mg qd x 3d, then 30mg qd x 3d, then 20mg qd x 3d, then 10mg qd x 3d, then 5mg qd x 3d then stop. 20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Indwelling Port (e.g. Portacath), non-heparin dependent: Flush with 10 mL Normal Saline daily, PRN, and when de-accessing, per lumen. 21. Ondansetron 4 mg IV Q8H:PRN nausea 22. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 23. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "785.52", "428.0", "276.1", "518.89", "486", "157.9", "197.7", "496", "038.9", "198.2", "518.81", "995.92", "428.22" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.04", "96.71", "33.24", "38.91", "96.6" ]	icd9pcs	[ [ [] ] ]	10655, 10664	6130, 8152	285, 368	10715, 10724	3229, 6107	10780, 10790	2616, 2646		10616, 10632		10685, 10694		8178, 10593			10748, 10757										2661, 3210																								231, 247											396, 1543																1565, 2158	2174, 2600
19,248	120,823	6044	Discharge summary	report	Admission Date: [2166-6-13] Discharge Date: [2166-6-19] Date of Birth: [2097-1-10] Sex: M Service: [Hospital 12145] TRANSFERRED TO [Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: Per MICU house officer admission note. A 69-year-old male with past medical history of coronary artery disease, status post myocardial infarction, and status post CABG x3 in [2154]. He was transferred here from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital for chest pain in the setting of renal failure. For the past three weeks, the patient has been noticing increased difficulty urinating. Previous diagnosis of benign prostatic hypertrophy, but chose not to intervene. Three days prior to admission, the patient became anuric. By the day of admission, he was also experiencing shortness of [Last Name (LF) 1440], [First Name3 (LF) ] he went to the hospital, Foley was placed, and 900 mL of urine came out with continuous flow afterwards. Renal ultrasound was performed which showed no hydronephrosis. Creatinine on admission was 5.5, and it was 2.9 by the day of transfer on [2166-6-13]. Otherwise, the patient had two episodes of chest pain while moving around in bed, substernal 10-20 minutes relieved with nitroglycerin. Unclear if it was "gas pain or musculoskeletal". Patient complained of uncomfortable bed. Specifically, the patient has left apical chest pain every 2-3 weeks with exertion, main anginal equivalent, and shortness of [Year (4 digits) 1440]. Cannot walk to mail box and driveway without getting shortness of [Year (4 digits) 1440]. He does complain of orthopnea and paroxysmal nocturnal dyspnea as well as left lower extremity swelling. His usual Lasix dose was 80 mg po q day so worsening over the past year. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2154] with saphenous vein graft to diag, LIMA to left anterior descending artery, saphenous vein graft to PDA, anteroseptal myocardial infarction, catheterization [2165-12-13] which showed RA 10, P.A. 42/18, pulmonary capillary refill wedge pressure of 16, cardiac output 7.4, cardiac index 3.0, systemic vascular resistance [11-5], A-V gradient 4, A-V area 2.1, left ventricular ejection fraction 36%, akinetic inferior wall, hypokinetic posterior wall, three vessel native disease, total occlusion saphenous vein graft to PDA, patent saphenous vein graft to diag, LIMA to left anterior descending artery. 2. Abdominal aortic aneurysm 4.5 cm intrarenal. 3. Diabetes mellitus type 2, hemoglobin A1C 5.5. 4. Status post pacemaker placement in [2154] here at [Hospital1 1444] after CABG for asystole, Medtronics 9790 Spectrax rate 50 interviewed 1196, on [2166-5-7]. 5. Sigmoid diverticulosis. 6. Peptic ulcer disease. Duodenal ulcer/melena, [2165-12-13], H. pylori negative. 7. Restless leg syndrome. 8. Hiatal hernia. 9. Remote alcohol history. 10. Left renal vein occlusion. 11. Hypertension. 12. Hypercholesterolemia. 13. Parkinson's disease. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Lasix 80 mg IV bid. 2. Diazepam 5 q6h prn. 3. Pergolide 25 tid. 4. Digoxin 0.25 q day. 5. Protonix 40 q day. 6. Imdur 30 q day. 7. Carbidopa 50/200 one [Hospital1 ]. 8. Toprol XL 25 q day. 9. Lisinopril 10 q day. 10. Ambien 5 prn. 11. MSSR 15 po bid. PHYSICAL EXAM ON ADMISSION: Vital signs: 148/70, 65, 14, and 96 on 4 liters. General: Obese male in mild distress while talking. Pupils are mildly reactive, left side is greater than right side, congenital. Neck: Jugular venous distention to earlobe. Cardiac: Regular, rate, and rhythm, systolic murmur left sternal border. Pulmonary: Inspiratory wheezes, crackles at right base. Abdomen: Positive bowel sounds, faint hypoactive, soft, mild tenderness in suprapubic area, nondistended. Extremities: No clubbing, cyanosis, or edema. Decreased pulses, venous stasis changes. Neurologic is alert and oriented times two, date [2166-5-31]. LABORATORIES ON ADMISSION: White blood cells 9.5, hematocrit 36.9, platelets 173, INR 1.2, PTT 46.6. Chem-7: 142, 4.8, 109, 22, 73, 2.3. CK at outside hospital on [6-11]: 207, MB 12.5, index 6, troponin 0.3. On [6-12] CK at outside hospital 183, MB 10.1, troponin less than 0.3 with index of 5.5. [6-12] CK 140, MB 7.4, index 4.9, troponin not done. On admission, CK 114, MB 6, troponin less than 0.3. ELECTROCARDIOGRAM: Normal sinus rhythm at 57, normal axis, IVCD of left bundle morphology, normal P-R, QTC, and small Q's in II and F, poor R-wave progression, nonspecific T-wave flattening inferolaterally, no acute ST-T wave changes compared to electrocardiogram on [2-14], inferolateral T-wave flattening is more pronounced. CHEST X-RAY: Heart is significantly enlarged, a few basilar interstitial morphology increased, mild cephalization of pulmonary vasculature. HOSPITAL COURSE: Patient was transferred from outside hospital directly to the Intensive Care Unit for acute renal failure and rule out myocardial infarction. He was transferred on a Heparin drip. On night of admission, the patient had ruled out for a myocardial infarction. His Heparin drip was stopped, also given his history of significant bleed, patient had been started on Integrilin and Heparin in [2165-8-12] and had a subsequent bleeding ulcer melena requiring 10 units of blood, therefore he had subsequently not been started on any anticoagulants or antiplatelet agents. On admission to the MICU, he was noted to have severe epistaxis. Otolaryngology was consulted, who recommended Afrin, ice, and pressure for 45 minutes and packing. He packed his nose without complications. He was started on Keflex which was continued for 48 hours while the packing was in place. Packing was discontinued for 48 hours, and the patient had no further episodes of nosebleeding, his hematocrit remained stable not requiring any blood transfusion. Also in the MICU, he had further episodes of chest pain overnight, and was given sublingual nitroglycerin times many with good relief of the chest pain. He also had episodes of bradycardia into the 30s which were asymptomatic, but noted on Telemetry. He was called out to the [Hospital Unit Name 196] service on [2166-6-14]. The remainder of his hospital course will be summarized by systems: 1. Cardiology. A. Coronary artery disease: The patient has a history of coronary artery bypass graft and catheterization revealing occlusion of the saphenous vein graft to the PDA. Ongoing intermittent chest pain certainly sounded atypical and pain was noted to be worse with palpation, and he ruled out for a myocardial infarction with enzymes with two negative at an outside hospital and one set negative here. He had a Persantine MIBI done on [2166-6-16] which revealed an ejection fraction of 43% and moderate fixed myocardial perfusion defect in the inferior wall and the inferior aspect of the lateral wall. Given that this defect was fixed, it was decided to medically manage the patient for his coronary artery disease. He was continued on isosorbide mononitrate, which was increased to his home dose of 60 mg po q day. He was continued on a low dose beta blocker. He was not started on an ACE inhibitor given his acute renal failure and relative hypotension, and he was not started on aspirin given his bleeding issues in the past. B. Pump: The patient has a history of congestive heart failure with ejection fraction of 36% by catheterization. He was monitored for volume overload and Lasix was temporarily held due to overdiuresis at the outside hospital, which was restarted at his home dose of 80 mg po q day on the day of discharge. His ACE inhibitor was held secondary to renal failure and he was continued on low dose beta blocker. C. Rate and rhythm: Patient clearly had a pacemaker malfunction as his pacer was not responding to episodes of bradycardia in the Medical Intensive Care Unit. His outpatient Electrophysiologist, Dr. [Last Name (STitle) 73] felt that this was not clinically significant. He is also noted to have several episodes of a wide complex rhythm at normal rate which Dr. [Last Name (STitle) 73] is aware of. He will follow up with a pacemaker interrogation and followup with Dr. [Last Name (STitle) 73] on [7-25]. 2. Pulmonary: Patient has a history of obstructive-sleep apnea, but he has never had sleep studies or used CPAP or BiPAP before. He was treated with albuterol and Atrovent if needed which he responded well on his first day in the Medical Intensive Care Unit, however, he did not need these subsequently, and further workup was not pursued. The patient had a chest x-ray which showed a question of a right upper lobe opacity. However, this was not seen on subsequent chest x-ray. Radiology recommended get a P.A. and lateral as an outpatient to rule out any pathology. 3. Renal: Patient was admitted to outside hospital for acute renal failure with creatinine of 5.0 from baseline of 1.5 felt due to postrenal failure from benign prostatic hypertrophy. Foley was placed and creatinine continued to improve to 2.1 on [2166-6-14]. Renal was consulted, who recommended initiating Flomax and consulting Urology for benign prostatic hypertrophy. 4. Urology: The patient was seen by Urology service under Dr. [Last Name (STitle) ], who felt that his picture was consistent with benign prostatic hypertrophy. Recommended that Foley remain in place until followup as an outpatient on [2166-6-24], and continue Flomax. 5. Infectious Disease: Patient had no signs of infection during the hospital course. 6. Gastrointestinal: The patient with a history of massive GI bleed secondary to anticoagulation, however, his hematocrit remains stable, and he had no blood loss. He was continued on high dose proton-pump inhibitor. 7. Neurologic: He was continued on his anti-Parkinsonian medications. He was initially monitored on a CIWA scale for alcohol use, but did not require any benzodiazepines. 8. Epistaxis: The patient had no further epistaxis after nose packing. His Keflex was discontinued once the packing was discontinued 48 hours later. 9. Left hand cellulitis: Patient noted increased redness from the peripheral IV site on his left hand. The IV was discontinued, and the site was monitored. On date of discharge, it was more erythematous with swelling over the left hand consistent with cellulitis. He was started on dicloxacillin to followup with his primary care physician. DISCHARGE DIAGNOSES: 1. Chest pain, not otherwise specified. 2. Congestive heart failure. 3. SA node dysfunction, sick sinus, sinus bradycardia. 4. Acute renal failure, not otherwise specified. 5. Urinary retention. 6. Benign prostatic hypertrophy. 7. Right hand cellulitis. MEDICATIONS ON DISCHARGE: 1. MSSR 50 mg po q12h. 2. Carbidopa/levodopa one tablet [Hospital1 ]. 3. Pergolide 0.25 mg po tid. 4. Nitroglycerin sublingual prn. 5. Protonix 40 mg po q12h. 6. Colace 100 mg po bid. 7. Tamsulosin 0.4 mg po q24h. 8. Isosorbide mononitrate 60 mg po q24h. 9. Toprol XL 25 mg po q24h. 10. Dicloxacillin 500 mg po q6h x7 days. 11. Lasix 80 mg po q day. FOLLOW-UP INSTRUCTIONS: The patient is to followup for SMA-7 by primary care physician. [Name10 (NameIs) ] was discharged home with VNA services for congestive heart failure teaching and for Foley catheter management. CONDITION ON DISCHARGE: Good. [Doctor First Name 900] [Name8 (MD) 901], M.D. [MD Number(1) 2144] Dictated By:[Last Name (NamePattern1) 2918] MEDQUIST36 D: [2166-6-19] 12:24 T: [2166-6-23] 08:55 JOB#: [Job Number 23735]	[ "428.0", "412", "682.4", "584.9", "996.62", "V45.81", "427.81", "788.20", "600.0" ]	icd9cm	[ [ [] ] ]	[ "21.01" ]	icd9pcs	[ [ [] ] ]								10654, 10909				10935, 11290		4988, 10633																																															222, 1825								4101, 4970					11315, 11515		3157, 3430	1847, 3132		11540, 11802
15,226	132,205	13424	Discharge summary	report	Admission Date: [2156-12-19] Discharge Date: [2156-12-22] Date of Birth: [2113-10-24] Sex: F Service: CCU REASON FOR ADMISSION: Transfer from outside hospital with unstable angina. HISTORY OF PRESENT ILLNESS: The patient is a forty-three-year-old female with a history of coronary artery disease, status post coronary artery bypass graft on [2156-11-16], LIMA to LAD, SVG to PDA, SVG to D1 who developed intermittent left mid arm pain on [2156-12-15]. The patient was instructed by her primary care physician to take sublingual Nitroglycerin at home and if the pain recurred, to go to the Emergency Department. The pain did recur on the night prior to admission to outside hospital and the patient presented for evaluation at [Hospital1 ], Nishoba, where labs are notable for hematocrit of 29, Troponin of 0.43. The patient was admitted and ruled out for myocardial infarction with creatine kinase of 55, 49 and 39, Troponin of 0.43, 0.54, 0.62 and 0.65. Electrocardiogram serially showed a stable pattern of [Street Address(2) 4793] elevations in lead III and T wave inversions in V2 with one showing a T wave inversion in V3, which corrected shortly thereafter. The patient then underwent a nondiagnostic ETT on [2156-12-17] with nuclear imaging showing a reversible large anterior defect per report. The patient had persistent left arm pain that was responsive only to increased titration of intravenous Nitroglycerin. The patient was started on Aggrestat and Lovenox and transferred to [Hospital1 188] for catheterization. PAST MEDICAL HISTORY: 1) Coronary artery disease as above. In addition to multiple PCI's prior to coronary artery bypass graft. 2) Insulin dependent diabetes mellitus. 3) Hypertension. 4) Gastroesophageal reflux disease. 5) Tooth abscess. 6) Dyslipidemia. MEDICATIONS: Medications on transfer, Lovenox 60 mg subcutaneous twice a day, Imdur 60 mg twice a day, Penicillin VK 250 mg four times a day, Atenolol 25 three times a day, Prednisone 40 mg times three doses for allergy to IV contrast, aspirin 325 mg every day, Protonix 40 mg every day, Effexor 37.5 mg twice a day, insulin pump, Aggrestat drip, Colace 100 mg by mouth twice a day, Cipro 500 mg by mouth twice a day, Plavix 75 mg every day, Iron Sulfate 325 mg every day, Diovan 80 at 12.5 every day and Nitro drip. ALLERGIES: Allergies include IVP dye. SOCIAL HISTORY: The patient is a nonsmoker and nondrinker. FAMILY HISTORY: Family history is significant for diabetes and a son who died at eighteen months of hypoplastic heart. PHYSICAL EXAMINATION: In general, she was pain free. She had no jugular venous distension or carotid bruits. The patient's lungs were clear to auscultation bilaterally. The patient's heart examination was normal S1, S2, regular rate and rhythm without audible murmur. The patient's abdomen was benign. The patient had 2+ distal pulses without edema. LABORATORY DATA: Electrocardiogram on admission in the CCU revealed normal sinus rhythm at 73 with stable changes as described above. HOSPITAL COURSE: 1) Cardiac, the patient was admitted to the CCU as stated above for cardiac catheterization. The patient was taken to catheterization on [2156-12-20], which revealed mild plaquing of the left main coronary artery. The LAD showed proximal diffuse disease with mid occlusion after the S2, there was no antegrade filling through the prior stent. Left circumflex revealed luminal irregularities. Ramus and high diagonal showed approximately 70% occlusion with competitive flow seen from and into the SVG. The RCA showed that the PDA had a 40% proximal lesion and a 70% distal lesion. There was competitive flow seen into the SVG with anastomosis, just distal to the 40% stenosis. SVG to the diagonal was patent with back filling of the left main and LAD. SVG to the RCA had proximal mild disease, large caliber distal vessel was somewhat mismatched into the smaller PDA. The LIMA to LAD revealed a patent graft with multiple kinks and bends with an 80% hazy anastomotic lesion, no back filling into the native mid LAD or prior stent, diffuse disease in the native vessel downstream of the anastomosis. The patient had a patent proximal left subclavian. The anastomotic lesion was treated with balloon angioplasty and the patient was placed on Aggrestat to be continued for eighteen hours after angioplasty. The patient tolerated the catheterization well and was called out to the floor shortly thereafter at which time, she was started on vitamins B6, B12 and Folic acid in addition to the Plavix and Aggrestat post-catheterization. Approximately 10:30 the next morning, the patient developed epistaxis thought to be secondary to all of her anticoagulants, especially to Aggrestat. The Aggrastat was stopped at that time and pressure was applied to the nose for approximately fifteen minutes. Bleeding continued. The patient was then given multiple sprays of Afrin hoping to cause vasoconstriction in the nose and help to stop the bleeding, however, the bleeding persisted for approximately five hours. At that point, ENT was formerly consulted who came and applied Merocel packing to the left nostril. Bleeding stopped immediately. A stat hematocrit had been checked that morning, which showed that it was 34. Hematocrit is stable at the time of discharge at 29. The patient had no further chest pain after catheterization and will be discharged to home on Toprol XL 50 mg every day, vitamin B6, B12 and Folate as above, Plavix 75 mg by mouth every day, aspirin 325 mg by mouth every day. 2) Infectious Disease, the patient presented with a dental abscess, all ready being treated with Penicillin VK, The Pen-VK was continued until the time of the Merocel packing placed in the nose. At that time, the Penicillin was changed to Keflex to cover for staph. This will be continued until the packing is removed, five days after its placement. 3) Endocrine, the patient was continued on her insulin pump, which she managed herself, based on her fingersticks. DISCHARGE DIAGNOSES: LIMA to LAD anastomotic lesion, status post PTCA. Coronary artery disease as described above. Type 1 diabetes. Nosebleed, secondary to Aggrastat. DISCHARGE MEDICATIONS: Toprol XL 50 mg by mouth every day, vitamin B6 10 mg by mouth every day, vitamin B12 400 mcg by mouth every day, Folic acid 1 mg by mouth every day all of which to be taken for six months, Plavix 75 mg by mouth every day, Keflex 500 mg by mouth every six hours times seven days, ibuprofen 400 mg by mouth three times a day as needed, aspirin 325 mg by mouth every day. FOLLOW-UP: The patient will follow-up with Ears, Nose and Throat in her local area to have removal of the packing in five days. The patient will arrange to have follow-up herself. The patient is also instructed to follow-up with her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27542] at her earliest convenience. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Doctor Last Name 26904] MEDQUIST36 D: [2156-12-22] 11:54 T: [2156-12-27] 05:30 JOB#: [Job Number ]	[ "250.01", "411.1", "996.72", "285.9", "414.01", "784.7", "401.9", "E878.8", "E934.2" ]	icd9cm	[ [ [] ] ]	[ "37.22", "99.20", "36.05", "21.02", "88.56" ]	icd9pcs	[ [ [] ] ]							2472, 2576	6067, 6406	6429, 7452					3079, 6035																									2598, 3062																						239, 1582																1604, 2396	2412, 2456
55,015	194,868	13277	Discharge summary	report	Admission Date: [2158-8-1] Discharge Date: [2158-8-17] Date of Birth: [2098-1-29] Sex: F Service: MEDICINE Allergies: aspirin / Penicillins / ibuprofen Attending:[First Name3 (LF) 1973] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 60yoF with Hepatitis C cirrhosis, with mechanical aortic, tricuspid, mitral valves on Coumadin, h/o afib, h/o upper GI bleed in the past [3-15] Dieulfoy lesion presenting with hematemesis. The patient reportedly awoke the morning of presentation to find her pillow soaked with blood, unclear whether she coughed up or vomited the blood. She reports epigastric abdominal pain and nausea, and she took Maalox for her pain with improvement. She presented to [Hospital3 17163] where she reportedly coughed blood in ED with a stable Hct of 31.6 -> 32.9 and BP 110 near her baseline. She was transferred to [Hospital1 18] for further evaluation of her hematemesis vs hemoptysis. She denies recent fevers, abdominal pain, nausea/vomiting, diarrhea (although she does endorse frequent stools since her last hospitalization), denies chest pain, dizziness, shortness of breath. Of note, the patient reportedly has had several GIB's in the past due to a Dieulafoy lesion including a recent episode in [2158-6-7] during which she was intubated with a hct 20 and 500cc bloody NGT output. She had an EGD at [Hospital3 17162] at that time which showed a Dieulfoy lesion with active bleeding which was clipped x2, and she was discharged on PPI for chronic suppressive therapy. She reports that since her discharge, she has experienced continued nausea but denies any abdominal pain or hematemesis. In [Hospital1 18] the ED, initial VS: 98.0 70 96/62 16 97% 2L Nasal Cannula The patient was found to have mild abdominal discomfort and on rectal exam, had brown, guiac positive stool. Her Hct was stable from the findings at [Hospital3 17163], and her BP's remained at her baseline in the 100's. INR was 3.5. NG lavage revealed flecks of blood which were guiac positive, and subsequently put out 200cc of bright red blood mixed with stomach contents. The NG tube reportedly put out another 200cc of bright red blood prior to clearing on suction. She did not have any further episodes of emesis subsequently. GI was consulted and recommended Octreotide gtt, Protonix gtt, and Ceftriaxone. She was transferred to the MICU for further management. On transfer, VS were: 105/47 65 98% 2L NC. On arrival to the MICU, the patient reported continued abdominal pain but denied nausea, hematemesis, hematochezia, chest pain, shortness of breath, lightheadedness. Past Medical History: - Hepatitis C cirrhosis - h/o GIB with Dieulafoy lesion - Mechanical Aortic, Mitral, and Tricuspid valves replacement [3-15] endocarditis, on Coumadin - Afib s/p pacemaker - CHF, presumed diastolic (most recent TTE [6-5] @OSH with EF 55-60%, moderate Aortic regurg) - COPD - Renal insufficiency - Anxiety with panic attacks - s/p appendectomy - s/p cholecystectomy - s/p hysterectomy Social History: - Tobacco: Previously smoked ~30 pk-years, quit 30 years ago - EtOH: Denies. Previously drank socially on occasion. - Illicit Drugs: Denies current use. Previously h/o IVDU including Heroin, as well as crack cocaine and speed. Lives alone at home but son checks in on her. Patient reports being native american and that being part of this community is very important to her Family History: NC Physical Exam: ADMISSION EXAM: VS: 96.5 74 88/51 11 92% 2L NC GEN: Pleasant, comfortable, alert, interactive, NAD HEENT: Muddy conjunctiva, EOMI, sclera anicteric, MMM, JVP <9cm, NGT in place. CV: Irregularly irregular, prominent S1 and S2 clicks, GIII systolic murmer at RUSB, GIII holosystolic murmer at LSB and apex RESP: Coarse inspiratory rales at bases b/l, fair air movement throughout, no wheezes or rhonchi ABD: Soft, asymmetrically distended with multiple well healed surgical wounds, moderate to significant tenderness at epigastrum, RLQ and RUQ without rebound with voluntary guarding, +b/s, no masses or hepatosplenomegaly though limited exam [3-15] pain EXT: WWP, no c/c, trace pitting edema of ankles b/l SKIN: No rashes/no jaundice NEURO: AAOx3. Moving all extremities. DISCHARGE EXAM: VS: Gen: HEENT: Lungs: Cardiac: Abdomen: Skin: Extremities: Neuro: Pertinent Results: [2158-8-10] 06:15AM BLOOD WBC-10.8 RBC-3.50* Hgb-11.3* Hct-36.1 MCV-103* MCH-32.2* MCHC-31.3 RDW-16.3* Plt Ct-302 [2158-8-8] 07:37AM BLOOD WBC-12.1* RBC-3.69* Hgb-12.0 Hct-37.7 MCV-102* MCH-32.4* MCHC-31.7 RDW-16.4* Plt Ct-288 [2158-8-5] 06:00AM BLOOD WBC-10.3 RBC-3.70* Hgb-12.0 Hct-37.4 MCV-101* MCH-32.3* MCHC-31.9 RDW-16.5* Plt Ct-297 [2158-8-3] 06:18AM BLOOD WBC-8.3 RBC-3.49* Hgb-11.5* Hct-35.7* MCV-102* MCH-32.9* MCHC-32.1 RDW-17.1* Plt Ct-292 [2158-8-2] 05:17AM BLOOD WBC-10.5 RBC-3.56* Hgb-11.5* Hct-36.8 MCV-103* MCH-32.3* MCHC-31.3 RDW-17.5* Plt Ct-315 [2158-8-2] 01:01AM BLOOD WBC-9.1 RBC-3.47* Hgb-11.4* Hct-36.5 MCV-105* MCH-32.7* MCHC-31.1 RDW-17.0* Plt Ct-349 [2158-8-1] 09:28PM BLOOD WBC-13.5* RBC-3.33* Hgb-10.9* Hct-35.6* MCV-107* MCH-32.6* MCHC-30.5* RDW-16.4* Plt Ct-368 [2158-8-1] 06:00PM BLOOD WBC-11.1* RBC-3.37* Hgb-11.4* Hct-35.3* MCV-105* MCH-33.8* MCHC-32.2 RDW-16.5* Plt Ct-342 [2158-8-10] 06:15AM BLOOD Neuts-53.1 Lymphs-27.3 Monos-13.3* Eos-5.2* Baso-1.0 [2158-8-1] 06:00PM BLOOD Neuts-45.5* Lymphs-39.7 Monos-9.7 Eos-4.0 Baso-1.0 [2158-8-17] 08:25AM BLOOD PT-28.1* PTT-71.8* INR(PT)-2.7* [2158-8-15] 07:10AM BLOOD PT-22.5* PTT-94.6* INR(PT)-2.1* [2158-8-11] 06:10AM BLOOD PT-23.2* PTT-84.8* INR(PT)-2.2* [2158-8-9] 06:41AM BLOOD PT-20.0* PTT-99.1* INR(PT)-1.8* [2158-8-7] 05:59AM BLOOD PT-17.7* PTT-89.9* INR(PT)-1.6* [2158-8-5] 06:00AM BLOOD PT-25.7* PTT-30.4 INR(PT)-2.4* [2158-8-3] 06:18AM BLOOD PT-52.0* PTT-41.1* INR(PT)-5.6* [2158-8-2] 05:17AM BLOOD PT-37.1* PTT-38.1* INR(PT)-3.7* [2158-8-1] 06:00PM BLOOD PT-35.1* PTT-34.7 INR(PT)-3.5* [2158-8-9] 06:41AM BLOOD Glucose-102* UreaN-10 Creat-0.8 Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [2158-8-4] 05:05AM BLOOD Glucose-107* UreaN-16 Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-22 AnGap-14 [2158-8-1] 06:00PM BLOOD Glucose-72 UreaN-15 Creat-1.0 Na-141 K-4.9 Cl-109* HCO3-25 AnGap-12 [2158-8-3] 06:18AM BLOOD ALT-23 AST-46* AlkPhos-356* Amylase-77 TotBili-0.5 [2158-8-1] 06:00PM BLOOD ALT-30 AST-58* AlkPhos-418* TotBili-0.5 [2158-8-9] 06:41AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8 [2158-8-5] 06:00AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.9 [2158-8-4] 05:05AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.7 [2158-8-1] 06:00PM BLOOD Calcium-7.9* Phos-4.4 Mg-2.1 [2158-8-7] 05:59AM BLOOD AMA-NEGATIVE [2158-8-1] 06:00PM BLOOD Digoxin-0.7* [2158-8-2] 12:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2158-8-2] 01:01AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2158-8-2] 01:01AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2158-8-2] 01:01AM URINE RBC-7* WBC-11* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 RenalEp-<1 [2158-8-2] 01:01AM URINE CastHy-3* [2158-8-1] 9:16 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2158-8-7] MRSA SCREEN (Final [2158-8-6]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S TTE (Complete) Done [2158-8-3] at 4:00:00 PM Conclusions The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 65%). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. The ascending aorta is mildly dilated. A bileaflet aortic valve prosthesis is present. The transaortic gradient is significantly higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. There is a tricuspid valve prosthesis, the nature of which is not evident on the basis of this study. However, leaflet motion of this prosthesis appears to be restricted, and the inflow gradients are much higher than expected for this type of prosthesis. Tricuspid regurgitation is present (?mild-to-moderate) but could not be quantitated with certainty. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] Significant pulmonic regurgitation is seen. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. Impression: the markedly elevated antegrade pressure gradients across prostheses in the tricuspid and aortic positions suggest a mechanical abnormality such as immobilized leaflet (pannus ingrowth vs valve thrombosis); consider transesophageal echocardiography to better define ABDOMEN U.S. (COMPLETE STUDY) Study Date of [2158-8-3] 8:28 AM IMPRESSION: 1. Patent main portal vein. 2. No ascites. Trace pleural effusions seen bilaterally. 3. Nodular hepatic architecture with no focal liver lesion identified. 4. The gallbladder has been surgically removed and the spleen could not be identified. Perhaps the spleen has also been removed. 5. Malrotated atrophic right kidney. Small bilateral simple cyst seen in each kidney. ECG Study Date of [2158-8-4] 6:05:18 PM Atrial fibrillation. Prolonged Q-T interval. Delayed precordial R wave progression. ST-T wave abnormalities. Compared to the previous tracing of [2158-8-2] the rhythm now appears to be atrial fibrillation. Suggest repeatingtracing at double standard in an attempt to distinguish an artifact and true P waves. Intervals Axes Rate PR QRS QT/QTc P QRS T 65 0 94 476/484 0 -24 -18 EGD [2158-8-2] Findings: Esophagus: Protruding Lesions 4 cords of grade I varices were seen in the esophagus. Stomach: Lumen: A large hernia was seen with a potentially para-esophageal component. Protruding Lesions A single 4 -5 mm polypoid lesion was found in the stomach body. Duodenum: Normal duodenum. Impression: Esophageal varices Polyp in the stomach body Hiatal hernia Otherwise normal EGD to third part of the duodenum Brief Hospital Course: MICU COURSE: 60yoF with Hepatitis C cirrhosis, with mechanical aortic, tricuspid, mitral valves on Coumadin, h/o afib, h/o upper GI bleeds in the past [3-15] Dieulfoy lesion presenting with hematemesis. #. Acute Blood Loss Anemia due to GI Bleeding (Duelifoy's Lesion): Pt was admitted after noting some blood on her pillow that was thought to be [3-15] GI bleed given the presence of blood on gastric lavage. She underwent an EGD which showed 4 cords of grade I esophageal non bleeding varices, large hernia with possible para-esophageal component, protruding 4 -5 mm polypoid lesion in the stomach body. No active signs of bleeding were noted, her GI bleed was thought to be [3-15] Dieulafoy lesion that intermittently will bleed, hence her prior history of GI bleeds. The polyp was not biopsied given the patient's elevated INR and she will need a repeat polypectomy. Following her EGD her octreotide gtt was discontinued and her PPI was switched to [Hospital1 ]. She was also started on Levo/Flagyl (PCN allergy) for SBP ppx. She was then called out to the floor after her Hgb/Hct were noted to be stable. She had no further bleeding during her admission #. Coagulopathy, s/p Mechanical Valves x3: Patient with aortic, mitral, tricuspid valves due to endocarditis, INR goal between 2.5-3.5 with current INR goal closer to 2.5 given GIB weighed against risk of thrombus given her three mechanical valves. Her INR was not reversed. She was bridged using IV Heparin once her coumadin was held, and her INR went subtherapeutic. It was a long time to re-coumadinize her as we eventually found out that her supplement (Ensure) had a large amount of vitamin K. #. Atrial Fibrillation: Patient with pacemaker on Digoxin, presumably for afib. Her Coumadin was supratherapeutic so it was held. She initially had her Metoprolol held given her GI bleed, which were eventually restarted. #. Chronic Hepatitis C: Pt with h/o Hepatitis C, likely [3-15] past IVDU. Her LFTs were trended daily, MELD scores were obtained. She will follow up with the hepatology service. #. Acute on Chronic Diastolic CHF: Pt has a history of CHF, prior to her leaving the ICU she was noted to have more pulmonary vascular congestion and bilateraly effusions with the rt effusion being larger. Unclear as to the etiology given pt received very little in the name of fluid and PRBCs. An Echo was obtained which showed as above. #. COPD: No evidence of an acute exacerbation, Atrovent and Albuterol nebs were continued #. Depression/Anxiety: Continued on home regimen of Prozac 40mg daily Medications on Admission: - Digoxin 0.125mg daily - Prozac 20mg qhs - Coumadin 6.5mg daily or as directed - Fosamax 70mg po qweekly on Fridays - Advair 250/50 1 puff q12h - Atrovent duonebs qid prn dyspnea - Albuterol nebs q2h prn dyspnea - Remeron 15mg qhs - Zolpidem 5mg po daily - Klonopin 1mg po tid prn anxiety - Colace 100mg daily -Hydroxyzine [Doctor First Name 1052] 50mg 1 cap po every 6 hrs prn for anxiety -Omeprazole 20mg po 1 tab [Hospital1 ] -tramadol 50 mg po take 1-2 tabs po TID as needed -seroquel 12.5 mg po q 6 hours -ropinirole 0.5mg take 1 tab po qhs -ferrous sulfate 160mg po bid Discharge Medications: 1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze, shortness of breath. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:2 5. digoxin 125 mcg 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. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for itching/anxiety. 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 12. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 14. mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 16. Coumadin 2 mg Tablet Sig: Three (3) Tablet PO once a day for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Healthcare Discharge Diagnosis: Primary Upper gastrointestinal bleed Secondary Mechanical heart valves with aortic stenosis Pleural effusion Depression Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 33419] [Last Name (Titles) ] were transferred to our hospital because you were vomiting blood and they were concerned you were going to lose too much blood. During your time in the intensive care unit, you did well and did not have any further episodes of bleeding. The gastroenterologists perfomed and endoscopy (looked inside your stomach with a camera) and saw a vessel that was not bleeding. They did not do anything at that time because your blood was thin from your coumadin and they did not want you to bleed from the procedure. You were transferred to the regular medicine [Hospital1 ], where we started you on a regular diet and you tolerated this well and we restarted all of your home medications. The gastroenterologists would like to still perform a procedure on the vessel in your stomach that caused the bleeding. You declined to have this done while as an inpatient and recommend that you have this done as an outpatient. You have a follow-up appointment scheduled with them (see below). During your hospital stay you developed more shortness of breath and a chest xray showed a pleural effusion on the right side. This was after you had received a lot of fluids in the intensive care unit and given your heart condition probably led to the effusion. We gave you some medicine to get the fluid out and this worked and you had no further symptoms. Because of this we got a transthoracic echocardiogram (ultrasound of your heart) which showed some changes in your mechanical heart valves. We spoke with your cardiologist who reported that these were stable from before and did not require anything to be done at this time. You will follow-up with your cardiologist (see below) Because one of the antibiotics we gave you during your bleeding (to prevent an infection) increased your blood thinning from the coumadin, we stopped your coumadin, and we waited for your INR to trend down to the normal range of 2.5-3.5. However it dropped too low and this required you to be put on a continuous Heparin IV drip to keep you anticoagulated while we waited for your INR to increase to 2.5. At the time of your discharge your INR=2.6 (in the goal range). You will need to have your INR checked after you leave on Friday [2158-8-18] by the visiting nurse The following changes were made to your medications: Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital 5503] Medical Associates Address: [Doctor Last Name 40418], [Location (un) ],[Numeric Identifier 40419] Phone: [Telephone/Fax (1) 40420] Appointment: Monday [8-21] at 3:45PM Department: DIV. OF GASTROENTEROLOGY When: THURSDAY [2158-9-7] at 3:00 PM With: [Initials (NamePattern4) ] [Last Name (NamePattern4) 11716] [Name8 (MD) 11717], 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	[ "285.1", "V02.54", "428.33", "424.1", "305.63", "427.31", "428.0", "300.4", "V15.82", "496", "530.82", "E934.2", "790.92", "070.70", "211.1", "V45.01", "V43.3", "300.01", "593.9", "571.5", "553.3", "305.53" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	16206, 16263	11360, 13946	305, 310	16440, 16440	4427, 11337	19005, 19735	3529, 3533		14582, 16183		16284, 16419		13972, 14559			16623, 18982										3548, 4324							4340, 4408																	254, 267											338, 2706									16455, 16599							2728, 3121	3137, 3513
29,777	118,179	34040+57883	Discharge summary	report+addendum	Admission Date: [2177-6-27] Discharge Date: [2177-7-3] Date of Birth: [2097-1-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: Painless jaundice Major Surgical or Invasive Procedure: [2178-7-3] External Biliary Drain Placement & Tissue Sampling [2177-6-28] EGD with cauterization [2177-6-27] ERCP with sphincterotomy Intubation x's 2 History of Present Illness: HPI: 80yo W w PMH of alzheimer's dementia, HTN, osteoporosis who underwent endoscopy yesterday for evaluation of painless jaundice. The patient was initially seen at [Hospital 1562] Hospital for evaluation of jaundice and pruritis x 2 days. She had been in her usual state of health at [Hospital3 ] facility when staff noted jaundice. She did not have any associated abdominal pain, nausea, vomiting, diarrhea, fever, or chest pain. She was taken to [Hospital 1562] Hospital for further evaluation. She was noted to have a bilirubin of 11.6 and abdominal ultrasound which showed dilation of the common bile duct and intrahepatic bile ducts c/w common bile duct obstruction. MRI showed high grade obstruction at the junction of the left and right hepatic ducts and neck of the gallbladder with a normal caliber distal common bile duct. Findings were consistent with a tumor arising from the neck of the gallbladder or from the common bile duct. She was transferred to [Hospital1 18] for ERCP. . During ERCP successful deep cannulation could not be obtained inspite of a small pre-cut sphincterotomy. Plan was for ERCP on Monday. Patient was stable post procedure and monitored on general medical floor. Per report, patient developed dark stools overnight. This morning, ICU team was called after patient had persistent guaiac positive dark stools and 250cc of hematemesis. Pt's blood pressure dropped to 80/60 during this time. Her sats dipped to the low 90s on RA, 100% on 2L. Her mental status was at baseline throughout. A second IV was placed and patient was transferred to the [Hospital Unit Name 153] for closer monitoring. EGD was done in the ICU and found blood in the stomach body, pylorus and antrum, with active bleeding from the ampulla. She was injected with epinephrine and cauterized. She was transfused with 3 units of PRBC. Per GI IV ciprofloxacin was started for a 7 day prophylactic course. Past Medical History: 1. Hypertension 2. Alzheimer's disease 3. Anxiety 4. Osteoporosis 5. Peripheral vascular disease with left ICA stenosis 6. Recurrent falls 7. s/p surgical repair of right wrist fracture. Social History: Lives in Atria Woodbriar in [Hospital3 ]. Quit smoking 25 yrs ago. No ETOH, NO illicits. Widowed. Retired band worker and worked for Catholic Social Services. . ADLs/IADLs: needs assistance for shower but she is able to dress, feed, and ambulate herself to the dining facility. ALF provides medications. She is active with the choir and enjoys day trips with the ALF. Also enjoys TV. Assistive Device: walker without wheels Family History: Mother: CVA age 82 Father: brain tumor age 80 Physical Exam: Admission exam: ============== VS: T BP 87/45 HR 80 O2Sat 100% on 2L GEN: Elderly woman sitting up in bed, anxious HEENT: EOMI, PERRL, +icteric sclera NECK: Supple CHEST: CTABL, no w/r/r CV: RRR, S1S2, no m/r/g ABD: Soft/NT/ND + BS EXT: no c/c/e SKIN: jaundiced, no rashes Discharge exam: ============== VS: T:96.5, BP: 114/57, HR: 67, RR: 18, O2Sat: 96 (3L) Wt: 60.2 kg, Pain: [3-17], generalized discomfort. Gen: elderly F. lying in bed, drowsy HEENT:, EOMI, sclera icteric, MMM Neck: supple Chest: clear throughout CV: RRR, S1S2, no murmur Abd: +BS, soft, NT, bile duct drain in RUQ, draining greenish-yellow fluid (125cc/24 hrs) Ext: +PP, warm, no edema Skin: jaundice, no rash, multiple ecchymoses MS: Arousable, drowsy, pleasant, confused Pertinent Results: Admission labs: =============== OSH [2177-6-25]: WBC: 5.9 Hb:12.7 HCT:38 Plt 189 Ast: 60 ALT 50 Alk Phos 354 T Bili 12.5 INR 1.0 [Hospital1 18] [2177-6-28]: 136 106 43 141 AGap=12 4.0 22 0.8 estGFR: 69 / >75 (click for details) ALT: 42 AP: 192 Tbili: 11.2 Alb: AST: 59 LDH: Dbili: TProt: [Doctor First Name ]: 282 Lip: 50 95 CBC: 9.2 >7.7<189 23.7 Imaging: ========= Abd US at OSH [6-25] showed dilated common bile duct and intrahepatic bile ducts consistent with common bile duct obstruction. CT Abd [6-26] at OSH showed distended gallbladder and intrahepatic ductal dilitation consistent with a biliary obstruction. MRI/Abdomen [6-26] at OSH showed high grade obstruction at the junction of the left and right hepatic ducts and neck of the gallbladder with a normal caliber distal common bile duct. The findings are compatible with a tumor either arising from the neck of the gallbladder or from, the common bile duct. CXR [6-28] Endotracheal tube terminates 3.8 cm above the carina, and nasogastric tube courses below the diaphragm within the stomach. Cardiomediastinal contours are within normal limits for technique. Small bilateral pleural effusions are present with adjacent basilar atelectasis. Questionable ascites in the upper abdomen. EGD [6-28]: Blood in the stomach body, pylorus and antrum Active bleeding from the ampulla. [Hospital1 ]-CAP Electrocautery was applied with a gold probe for hemostasis at the apex of the ampulla. Subsequently 5 cc.epinephrine (1/[Numeric Identifier 961]) was successfully injected submucosally at the apex of the ampulla to obtain complete hemostasis. ERCP [6-27]: The major papilla looked normal. Cannulation of the biliary duct was attempted. Successful deep cannulation could not be obtained inspite of a small pre-cut sphincterotomy. [2177-7-3] WBC-9.7# RBC-3.33* Hgb-10.4* Hct-29.7* MCV-89 MCH-31.2 MCHC-34.9 RDW-16.8* Plt Ct-176 [2177-7-3] Plt Ct-176 [2177-7-2] PT-12.2 PTT-28.6 INR(PT)-1.0 [2177-7-3] Glucose-94 UreaN-6 Creat-0.6 Na-131* K-3.3 Cl-97 HCO3-23 AnGap-14 [2177-7-3] ALT-72* AST-96* LD(LDH)-246 AlkPhos-252* TotBili-22.1* [2177-7-3] Calcium-8.4 Phos-3.2 Mg-1.8 [2177-7-1] CEA-2.3 [2177-7-1] Result Reference CA [88]-9 320 H 0-37 SEE NOTE Brief Hospital Course: 80 yo W with PMH of alzheimer's dementia, HTN, osteoporosis who underwent EGD and attempted biliary cannulation now with hematemesis and dark stools. GIB: after a ERCP for painless jaundice the patient had hematemesis and dark stools. She underwent a repeat EGD that revealed blood with clot at site of sphincterotomy making this the likely source of bleeding. Site was cauterized and injected with epi with no visible residual bleeding. No evidence of PUD, gastritis, AVMs so other etiologies can be ruled out. The patient's OG tube initially was suctioning dark red / brown blood which was very likely old blood. She was transfused 3 units of blood and her hematocrit increased appropriately (nadir of hematocrit was 23). Her HCT was checked q6 hours and was stable. Per GI the patient was given 7 days of cipro(started on [6-28]) for prophylaxis. She is on PPI daily. The patient was intubated for ERCP (although she was DNR/DNI the patient's code status was reversed for the procedure and then reverted back to DNR / DNI post ERCP after the patient was extubated). Current CODE STATUS is DNR / DNI. She underwent biliary drain placement and tissue bx on [2177-7-2]. The drain has greenish/yellow fluid output of about 100cc/shift. Oncology consult felt she [Last Name (un) ] likely has cholangiocarcinoma or possibly pancreatic, or periampullary. In any event surgery will not be an option and her care will be palliative. The pathology is pending and will need to be followed up. Please email [University/College 78559] to check on results. Her family requests a follow up appointment with oncology and this will be arranged with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 13006]. Hypokalemia: serum potassium was 3.3 on [7-3]. She was given one dose of KCl 40 meq PO. She has not been receiving Lasix. Respiratory: Intubated for airway protection. Extubated post procedure. She has been on O2 prn and has been without it all day today. Her O2sat decreased to 92% with ambulation today. Hypotension: Initially hypotensive s/p bleed, given 3 liters IVF and 3 units of PRBC, BP stable. Alzheimer's: Namenda was discontinued per Geriatric consult and Aricept was continued. There is no added benefit to using Namenda unless dementia is severe and to decrease the pill burden it has been discontinued. Zyprexa 2.5 mg [Hospital1 ] prn for agitation can be utilized. Osteoporosis: On fosamax, calcium, vit D. Contact: [Name (NI) ] [Name (NI) 449] [Name (NI) 10321] ([Telephone/Fax (1) 78560] Daughter [Known firstname ] [Last Name (NamePattern1) 1557] ([Telephone/Fax (1) 78561] (cell), ([Telephone/Fax (1) 78562] (home) Both son and daughter are HCP, per report Medications on Admission: Fosamax 70mg q week ASA 81mg q day Calcium Furosemide 40mg daily PRN edema Alprazolam 0.25mg q6hrs prn anxiety Vicodin Ibuprofen Celexa 10mg daily Namenda 10mg po bid Aricept 10mg daily Zyprexa 5mg po daily Discharge Medications: 1. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for throat discomfort. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Citalopram 20 mg Tablet Sig: 0.5(10mg) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet(2.5 mg) PO Q4H (every 4 hours) as needed for pain. 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Agitation. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: for 2 more days, last date: [7-5]. Discharge Disposition: Extended Care Facility: [Male First Name (un) 4542] Nursing Center - [Hospital1 1562] Discharge Diagnosis: Primary Diagnosis: Obstructive Jaundice GIB . Secondary Diagnosis: Alzheimers disease HTN PVD with Left ICA stenosis Osteoporosis Anxiety Discharge Condition: Stable Discharge Instructions: [Hospital1 1501] for care of drain and pain management. Followup Instructions: Call your Primary Care Provider [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD, [Telephone/Fax (1) 23860] to get an appt. within 2 weeks. You have an appointment with Dr. [Last Name (STitle) ], Hematology/Oncology, ([Telephone/Fax (1) 694], [7-23] Wed at 3pm, [Hospital Ward Name 23] [Location (un) ], [Hospital1 1535]. Completed by:[2177-7-3] Name: [Known lastname 12634],[Known firstname 7506] E Unit No: [Numeric Identifier 12635] Admission Date: [2177-6-27] Discharge Date: [2177-7-3] Date of Birth: [2097-1-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1981] Addendum: While in the hospital a CEA and CA19-9 were done. Carcinoembyronic Antigen (CEA) 2.3 ng/mL (0 - 4). CA19-9: 320 H (0-37). It is recommended that oncology review these results on her follow up visit on [7-23]. Discharge Disposition: Extended Care Facility: [Male First Name (un) 12636] Nursing Center - [Hospital1 2946] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1983] MD [MD Number(2) 1984] Completed by:[2177-7-4]	[ "V15.82", "443.9", "733.00", "294.8", "276.1", "458.9", "155.1", "576.2", "V12.54", "300.00", "578.9", "294.10", "331.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "44.43", "51.12", "51.87", "51.85", "87.54", "99.04" ]	icd9pcs	[ [ [] ] ]	11812, 12065	6371, 9128	332, 497	10661, 10670	3973, 3973	10778, 11789	3139, 3187		9385, 10360		10500, 10500		9154, 9362			10694, 10755										3202, 3476							3492, 3954																	275, 294											526, 2462			10567, 10640		3989, 6348		10519, 10546									2484, 2675	2691, 3123
60,833	161,850	9485	Discharge summary	report	Admission Date: [2129-3-3] Discharge Date: [2129-3-5] Date of Birth: [2050-7-7] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2777] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 78 y/o F with h/o CAD s/p stenting and HTN who was transferred from OSH for a finding of focal right carotid dissection on CT scan. Pt initially presented to OSH last night after developing chest pain that was minimally relieved by 3 doses of sublingual nitro. On the day prior to admission, pt did have an episode of chest pain that was relieved by one dose of sublingual nitro. Pt states that pain felt like pressure and radiated across her chest. Pt denies shortness of breath. Pt states that she also has had episodes of right neck pain over the past few days. She states that she has had chronic neck pain since she developed a tooth abscess a year and a half ago and needed a root canal but the neck pain was worse over the past few days. Pt also has had complaints of numbness and tingling in her left hand over the past several weeks. She denies focal weakness or vision changes. No fevers, chills, lightheadedness, dizziness, cough, abd pain, nausea/vomiting, or dysuria. Past Medical History: CAD s/p stent htn hyperlipidemia anxiety Social History: Smoked 2 ppd for 18 years, quit smoking 40 years ago, no etoh. Family History: Parents had CHF, DM, and CAD Physical Exam: T 97.8 P 56 BP 162/65 R 18 SaO2 100% Gen: nad Neck: supple Heent: non-icteric Lungs: clear heart: RRR Abd: soft, nontender, nondistended, no pulsatile mass Extrem: palpable femoral, popliteal, and DP/PT pulses bilaterally Pertinent Results: Labs on admission: [2129-3-3] 11:55PM BLOOD WBC-8.8 RBC-4.06* Hgb-12.4 Hct-37.3 MCV-92 MCH-30.6 MCHC-33.3 RDW-13.6 Plt Ct-300 [2129-3-3] 11:55PM BLOOD PT-14.5* PTT-122.7* INR(PT)-1.3* [2129-3-3] 11:55PM BLOOD Glucose-133* UreaN-14 Creat-0.8 Na-138 K-4.2 Cl-104 HCO3-25 AnGap-13 [2129-3-3] 11:55PM BLOOD Calcium-9.3 Phos-4.0 Mg-2.5 Labs prior to discharge: [2129-3-4] 07:46AM BLOOD PT-13.7* PTT-60.1* INR(PT)-1.2* [2129-3-4] 07:46AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-137 K-4.2 Cl-103 HCO3-24 AnGap-14 Imaging: CAROTID SERIES COMPLETE PORT Study Date of [2129-3-4] 10:44 AM Right ICA stenosis <40%. Left ICA stenosis <40%. KUB: Non-obstructive bowel gas pattern Brief Hospital Course: 78 y/o F with CAD who now presents with chest pain and question of focal right carotid dissection on OSH CT scan. Scans reviewed and we concluded that she did not have any evidence suggestive of a right or left carotid dissection. Her symptoms are most consistent with typical angina and not a carotid dissection. Carotid ultrasound showed unimpressive bilateral carotid stenoses. Patient remained asymptomatic without chest pain or neuro symptoms during her hospital stay. Patient was afebrile with stable vital signs. Labs unremarkable. Patient is scheduled for an outpatient stress test. She will follow up with her PCP and cardiologist. Discharged home today in good condition tolerating POs and ambulating well. Medications on Admission: asa 81 zetia 10 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Chest pain Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([9-1] lbs) until your follow up appointment. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 2 weeks. Please follow up with your cardiologist and primary care physician this week. Have your outpatient stress test as scheduled. Completed by:[2129-3-5]	[ "300.00", "401.9", "723.1", "786.50", "414.01", "564.00", "272.4", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	3430, 3436	2485, 3213	279, 286	3491, 3498	1765, 1770	4782, 5003	1473, 1503		3289, 3407		3457, 3470		3239, 3266			3522, 4759										1518, 1746																								229, 241											314, 1312								1784, 2462								1334, 1377	1393, 1457
27,798	169,588	34337+57916	Discharge summary	report+addendum	Admission Date: [2138-7-23] Discharge Date: [2138-8-13] Date of Birth: [2082-3-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement with a size 21 St. [Male First Name (un) 923] Regent mechanical valve and Aortic root enlargement with bovine pericardial patch and Coronary artery bypass graft times two; left inframammary artery to left anterior descending artery and saphenous vein graft to obtuse marginal. [2138-7-25] Bronchscopy [2138-7-29], [2138-7-30] Pacemaker generator change and lead revison on [2138-8-13]. History of Present Illness: 56 year old male presented to outside hospital with dyspnea on exertion and palpitations, found to be in rapid atrial fibrillation. Underwent cardiac catherization that revealed coronary artery disease and was transferred for surgical evaluation Past Medical History: Diabetes mellitus Atrial fibrillation Sick Sinus Syndrome s/p PPM Obesity Blindness Restrictive lung disease Obstructive sleep apnea Hypertension Diabetic retinopathy Behavioral Dysfunction Social History: Lives independently in [Location (un) 79013]Denies tobacco Denies ETOH Family History: Both parents deceased from myocardial infarction Physical Exam: General HR 59, RR 22 b/p 144/61 wt 266 #, ht 5'2" Neck supple Full ROM Chest CTA bilat Heart irregular 3/6 SEM Abd soft, NT, ND, +BS Ext warm well perfused trace LE edema Neuro intact, blind Pertinent Results: [2138-7-23] 05:10PM PT-13.8* PTT-52.7* INR(PT)-1.2* [2138-7-23] 05:10PM WBC-8.9 RBC-4.72 HGB-13.5* HCT-40.5 MCV-86 MCH-28.5 MCHC-33.3 RDW-15.0 [2138-7-23] 05:10PM ALT(SGPT)-79* AST(SGOT)-48* LD(LDH)-130 ALK PHOS-119* TOT BILI-0.7 [2138-7-23] 05:10PM GLUCOSE-255* UREA N-13 CREAT-0.9 SODIUM-137 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 [2138-7-25] ECHO PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-18]+) mitral regurgitation is seen. Dr.[Last Name (STitle) ] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and epinephrine and is being v paced. 1. A well-seated mechanical valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 18 mmHg). No aortic regurgitation is seen. 2. LV function is slightly depressed (global). LVEF= 45% 3. Aorta is intact post decannulation. 4. Moderate Mitral regurgitation persists. 5. Very poor image quality. [2138-8-2] ECHO 1. The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is mildly depressed (LVEF= 55 %). with normal free wall contractility. 3. There are simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. [The amount of regurgitation present is normal for this prosthetic aortic valve.] 4. The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. Eccentric posterior directed jet. 5. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. POST EVACUATION: Pericardial fluid has been evacuated. No residual loculated effusion. Ventricles appear better filled. [2138-8-6] CXR 1. No pneumothorax following chest tube removal. 2. Persistent cardiomegaly and mild pulmonary vascular congestion. Unchanged left greater than right pleural effusions. Brief Hospital Course: Transferred in from outside hospital for cardiac surgical evaluation. Underwent preoperative workup that included pulmonary evaluation Transferred to the operating [**] and underwent coronary artery bypass graft, aortic valve replacement, and aortic root enlargement with patch, see operative report for further details. He was transferred to the intensive care unit for hemodynamic monitoring. He remained on vasoactive medications and fluid for decreased blood pressure and cardiac output. Was then started on milirone POD 2 for decreased cardiac output with improvement. He was weaned from the ventilator and extubated POD 3 without difficulty. He was then reintubated for LLL collapse, with left chest tube insertion and bronchscopy that revealed left main bronchus occlusion with thick secretions. He was weaned from pressors but remained on ventilatory support. He was bronched again [7-30] for thick secretions right and left bronchus, BAL sent and started on antibiotics. On POD 8 the patient became hemodynamically compromised, an echocardiogram at that time revealed signs of tamponade and he was brought back to the operating room for exploration and evacuation with releif of tamponade symptoms. He tolerated the operation well and was again brought to the cardiac surgery ICU post-op. Over the next several days he remianed hemodynamically stable was weaned from his inotropes and pressors and was extubated. He was started on intravenous heparin for mechanical valve, but coumadin being held until pacer revision. During this period he was aggressively diuresed, he remained in the ICU for continued pulmonary toilet and hemodynamic monitoring. On POD 13/5 he was stable enough to be transferred to the stepdown floor to await a pacer generator change. Patient was brought to the EP lab on [2138-8-12] and had an uneventful generator change and lead revision. He was restarted on Coumadin and Heparin the evening of the 26th for mechanical aortic valve. INR 1.2 on [2138-8-13], plan to transfer to LTAC in [Location (un) 1110] so that he may have IV Heparin while his INR becomes therapeutic. Medications on Admission: Digoxin 0.125 mg daily Lasix 40 mg daily Sotalol 120 mg [Hospital1 ] Actos 15 mg daily Aspirin 81 mg daily metformin 1000 mg in am 500 mg in pm Discharge Medications: 1. Citalopram 20 mg Tablet [Hospital1 *]: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:0 2. Prednisone 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:0 4. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:240 ML(s) Refills:0 6. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 7. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Glipizide 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) for 2 doses: Pt to have 6 total doses. As of [2138-8-13] at noon he has had 4. Please continue two more doses. Disp:2 Tablet(s) Refills:0 11. Ipratropium Bromide 17 mcg/Actuation Aerosol [Date Range ]: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:1 inhaler Refills:0 12. Cephalexin 500 mg Capsule [Date Range ]: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:20 Capsule(s) Refills:0 13. Warfarin 5 mg Tablet [Date Range ]: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 14. Atorvastatin 10 mg Tablet [Date Range ]: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 15. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Date Range ]: 1450 (1450) units Intravenous ASDIR (AS DIRECTED): for goal ptt of 55-80 until INR reaches goal of [1-19]. Disp:qs units Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic stenosis s/p AVR Klebsiella pneumonia Diabetes mellitus Atrial fibrillation Obesity Blindness Restrictive lung disease Sick sinus syndrome w/ PPM Obstructive sleep apnea Hypertension Diabetic retinopathy Behavioral dysfunction 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 [First Name8 (NamePattern2) 1787] [Last Name (NamePattern1) 43699] in 1 week Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 32255] in [1-19] weeks Need a wound check of the pacemaker insertion site on [8-20], [2137] Wound check appointment [Hospital Ward Name 121] 6 as instructed by nurse ([Telephone/Fax (1) 3071]) [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2138-8-13] Name: [Known lastname 12719],[Known firstname 5084] S Unit No: [Numeric Identifier 12720] Admission Date: [2138-7-23] Discharge Date: [2138-8-13] Date of Birth: [2082-3-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Pt has PICC line in right upper arm. It was pulled back to not interfere with his pacemaker. It has 27cm outside of the body and 21cm inside the body. It is not a central line. Discharge Disposition: Extended Care Facility: [Hospital3 2215] Northeast - [Location (un) 437] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2138-8-13]	[ "327.23", "423.3", "250.50", "424.1", "V53.31", "427.31", "414.01", "482.0", "420.90", "362.01", "278.01", "401.9", "512.1", "440.0" ]	icd9cm	[ [ [] ] ]	[ "89.64", "34.03", "35.22", "37.75", "36.15", "88.72", "39.61", "96.04", "39.56", "34.04", "33.24", "96.72", "37.87", "36.11" ]	icd9pcs	[ [ [] ] ]	11335, 11538	4645, 6783	340, 773	9618, 9625	1649, 4622	10136, 11312	1372, 1422		6981, 9201		9328, 9597		6809, 6958			9649, 10113										1437, 1630																								281, 302											801, 1049																1071, 1263	1279, 1356
57,901	150,712	31980	Discharge summary	report	Admission Date: [2166-3-15] Discharge Date: [2166-3-26] Date of Birth: [2090-6-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4891] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy x 2 with cautery of local artereo-venous malfomations resulting from radiation proctitis, with successful hemostasis Blood transfusion of 4 units of PRBC History of Present Illness: 75 y/o man with hormone refractory, metastatic, prostate cancer reported BRBPR and anemia of chronic blood loss. Past Medical History: Prostate cancer: [Doctor Last Name ] 7, PSA 9.7 on [2163-11-4], mets to hips, initially tx with Lupron [2163-12-20], s/p radiation to left hip between [Month (only) 116] and [2164-7-2] due to persistent pain. Has become resistant to hormone tx due to side effects. PSA 41 as of 1/[2166]. Bone scan positive in both hips, but also w/ severe OA Osteoarthritis: severe; currently controlled with morphine E.R. 100 mg [Hospital1 ] and oxycodone 15 mg [5-7] tab qd. Stool incontinance: Since [9-/2165] Chronic liver disease Left hip replacement hypertension, benign Social History: recently quit smoking tobacco; previously 60 pack year hx past alcohol abuse for 10-15 years, quit drinking [2160] denies drugs widowed; retired truck driver and Korean War Veteran Has 4 children Family History: not relevant Physical Exam: VS: 97.8/97.8 60 11 128/52 95%2Lnc Gen: Elderly gentleman in NAD HEENT: PERRL, eomi, sclerae anicteric. CV: Nl S1+S2 Lungs: Mild expiratory wheezes bilaterally. Bibasilar crackles GI: S/NT/ND +bs Ext: Trace edema bilaterally Neuro: AOx3, CN II-XII intact. Pertinent Results: OLD Report: [2162-12-17]: HIP UNILAT MIN 2 VIEWS: IMPRESSION: 1. Bipolar prosthesis in the left hip with heterotopic ossification in the soft tissues. 2. Moderate-to-severe osteoarthritis of the right hip. [2166-3-20] 02:50AM BLOOD WBC-5.9 RBC-3.36* Hgb-10.4* Hct-32.1* MCV-96 MCH-30.9 MCHC-32.3 RDW-16.6* Plt Ct-214 [2166-3-19] 06:00PM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.3* [2166-3-20] 02:50AM BLOOD Glucose-103* UreaN-11 Creat-0.6 Na-142 K-3.5 Cl-108 HCO3-27 AnGap-11 [2166-3-20] 11:15AM BLOOD CK-MB-4 cTropnT-0.04* [2166-3-20] 02:50AM BLOOD CK-MB-4 cTropnT-0.05* ECG ([3-20]): Sinus with 1:1 conduction. NA, IVCD. No acute ST-T wave changes. CTAP: Preliminary Report !! WET READ !! 1. No evidence of large amount of free air. Small microperforation (at the transverse colon, 2;39) cannot be completely excluded, but is unlikely. 2. Large amount of fluid-density ascites. 3. Moderate left and large right pleural effusions with bibasiar opacities c/w atelectasis or aspiration (pat aspirated per Dr. [Last Name (STitle) 3315]. 4. liac, sacral and spine mets. Fx of the left inferior pubic ramus of indeterminate age. 5. Gallstones CXR: As compared to the previous radiograph, there is an increase in interstitial structures, diameters of pulmonary vessels, and interstitial markings and in bilateral pleural effusions. In addition, the size of the cardiac silhouette is larger than before. Overall, this is consistent with increasing interstitial lung edema. No other abnormalities. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] for bright red blood per rectum. This continued in the hospital and his hematocrit fell to 20. He was transfused 4 U of PRBC with improvment. He underwent colonoscopy which revealed radiation proctitis. Multiple AVMs were cauterized with hemostasis. Following his colonoscopy, Mr. [Known lastname ] developed severe abdominal pain and respiratory distress concerning for perforation of the bowel. He was admitted to the intensive care unit. Imaging did not reveal perforation, and his pain improved. His dyspnea continued, however, and he was found to have evidence of congestive heart failure and bilateral pleural effusions. Diuresis for acute diastolic heart failure was iniated, and he refused diagnostic and therapeutic thoracentesis. He responded to gradual diuresis during the admission. The patient was found to be very weak, malnuourished (cachectic), and had anasarca and marked dependent edema (4+ = leakage of serum through skin). PT evaluated his mobility and recommended rehabilitation hospital stay. Patient and family expressed wishes to transition oncologic care to the [Hospital1 18], to obtain a second opinion following discharge. This process was initiated. Based on the information they receive, they will decide as a family about transitioning to hospice care. Palliative care consultation was obtained to assist the family and team in determining a safe discharge plan and in further discussions of the above issue. The patient and family preferred to transition to home, but were aware that he may benefit from a hospice home or other facility given his deconditioning and care needs. Home medications for blood pressure and prostate cancer were continued, as well as for depression and GERD. Medications on Admission: morphine sulfate 100 mg E.R. [Hospital1 ] oxycodone 15-30 mg q3h prn pain celexa 10 mg QHS omeprazole 20 mg daily potassium chloride 10 mEq 5 times daily lasix 80 mg [Hospital1 ] (recently doubled from 40 for increasing peripheral edema) atenolol 50 mg daioy Terazosin 10 mg QHS Chantix 1 mg po BID ketoconazole 200 mg 1 po TID percocet 10-325mg 1 po q4-6h prn pain hydrocortisone 10 mg 1 po TID Discharge Medications: 1. ketoconazole 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Maximum of 2 grams per day. 3. morphine 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 4. oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 5. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer dose Inhalation every six (6) hours as needed for sob,wheezing. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer dose Inhalation every four (4) hours as needed for sob,wheezing. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 11. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Home oxygen 1-2L continuous, with pulse dose portability. Patient congestive heart failure and COPD. 13. Celexa 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. terazosin 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 15. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO three times a day. 16. carbamide peroxide 6.5 % Drops Sig: Five (5) Drop Otic [Hospital1 ] (2 times a day) for 4 days: Please continue these drops at home and discuss with your PCP about further options. Disp:qs 1 month Refills:0 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for c: Continue this stool softener while on morphine. Disp:qs 1 month Refills:0 18. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO five times a day. 19. morphine 30 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO twice a day: This dose is decreased from your original dose. Disp:180 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: Bayada Nurse Discharge Diagnosis: Metastatic prostate cancer Radiation proctitis with gastrointestinal bleeding with resultant anemia of acute blood loss Likely underlying chronic liver disease due to history of alcohol abuse Malnutrition, moderate Tobacco use, over 60 years, quit several weeks prior to admission Chronic pain of the hips/pelvis from metastatic disease Deconditioning due to above, with anasarca and dependent edema and pleural effusions, bilateral Venous stasis dermatitis of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816] Deconditioning due to the above Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr [Known lastname ], It was a pleasure to care for you during your admission. As you know, you were originally admitted to the ICU and underwent GI procedures to stop the bleeding from your intestine. You were also received blood transfusions to help improve your anemia temporarily. You should discuss with your doctor about the possible need for future transfusions, if that is something that you and your family think is in keeping with your wishes. Your breathing has improved, but you will be sent home on new home oxygen, especially for when you walk. We suspect that your smoking and the fluid in your lungs made you short of breath, but you may need further workup as an outpatient about your lung function. You have received the equipment and should use this as directed. It is imperative that you never smoke while on oxygen, as oxygen is highly flammable. We hope that you will continue not to smoke, and will discuss with Dr [Last Name (STitle) 17025] regarding smoking cessation maintenance. We have changed the following medications: 1. Your chantix was held while you were here. You can discuss with Dr [Last Name (STitle) 17025] regarding restarting it when you see him tomorrow. 2. We decreased your long acting morphine (MS Contin) to 90mg from 100mg, because you were a little sleepier in the afternoons. 3. We started miralax (polyethelyne glycol) for a stool softener. Followup Instructions: PCP [Name Initial (PRE) ]:Thursday, [3-27] at 2:45pm With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 275] [Last Name (NamePattern1) ],MD Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 6698] Phone: [Telephone/Fax (1) 6699] Gentourinary Oncology Group Appointment: CALL [Telephone/Fax (1) 10784] *To transfer your care to the [Hospital1 18] Gentourinary Oncology Group you must 1st have the following records sent from your current oncologists office to the following FAX NUMBER: [Telephone/Fax (1) 74923]. The following items are needed: Complete PSA History, prostate pathology report, all MD [First Name (Titles) 12883] [Last Name (Titles) 74924]g to the prostate cancer diagnosis and all recent imaging reports(scans and etc.). Please have the fax go to the attention of [Doctor First Name ]. She says there is availability in the Clinic with either Dr. [Last Name (STitle) ]. Bubly, Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ], or Dr. [Last Name (NamePattern4) 74925] in the next 2 weeks if you get the documents faxed this week (The patient's daughter [Name (NI) **] is aware of this plan, and has notified the primary oncologist's office to fax the needed materials to the above number)	[ "338.3", "V43.64", "305.03", "285.1", "401.1", "569.85", "569.49", "428.33", "428.0", "799.4", "459.81", "530.81", "211.4", "338.29", "571.2", "198.5", "185", "569.3", "789.59", "788.39", "511.9", "263.0", "V15.82", "715.95", "789.09", "311", "E879.2" ]	icd9cm	[ [ [] ] ]	[ "45.43", "48.36", "45.23" ]	icd9pcs	[ [ [] ] ]	7767, 7810	3348, 5154	332, 501	8413, 8413	1801, 3325	10032, 11412	1496, 1510		5608, 7744		7831, 8392		5180, 5585			8598, 10009										1525, 1782																								265, 294											529, 643									8428, 8574							665, 1263	1279, 1480
75,796	188,976	41269	Discharge summary	report	Admission Date: [2198-5-29] Discharge Date: [2198-6-5] Date of Birth: [2125-8-3] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 1253] Chief Complaint: Hypercarbic respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation [2198-5-29], self-extubated [2198-5-30] History of Present Illness: 72 year-old woman with history of COPD on home O2, atrial fibrillation, DM, OSA and CKD who presents to the hospital with respiratory failure. Per the patient's daughter, the patient had been feeling relatively well since her last discharge on [5-21] until yesterday, when she started having some mild difficulty breathing but per her daughter declined to go see the doctor. Of note, during that admission she had hypoxia that was thought to be secondary to flash pulmonary edema. This morning, the patient developed severe respiratory distress and EMS was called. By report of them they were called to the house for a female with increasing shortness of breath, who found her with poor air exchange, lethargic, with normal blood pressure in 150's and hr<100, but with poor air exchange, increasingly lethargic, and after a trial with CPAP, failed and EMS proceeded with intubation with sedative without paralytic, first pass success but reportedly difficult intubation. In the ED, initial VS were: afebrile 60 140/70 100% on vent. She received levofloxacin, solumedrol and was placed on propofol for sedation. Her first ABG on arrival showed marked respiratory acidosis with hypercarbia, ABG was 7.22/107/59/46. Her vent settings on transfer were assist control, FiO2 40%, 400, 22 and 10. On arrival, these were adjusted to FiO2 40%, 350, 20 and 5. Her repeat ABG showed marked improvement of her hypercarbia, and was 7.44/56/132/39. On arrival to the MICU, patient's VS were 97.6 67 138/86 14 100%. Review of systems: Unable to obtain but per the family the patient had no sick contacts, fever or chills prior to admission. Past Medical History: - COPD on home oxygen-dependent - Obstructive sleep apnea with BiPAP at night - Type 2 diabetes mellitus, on insulin - Atrial fibrillation on coumadin - Diastolic congestive heart failure - Diverticulitis s/p colostomy, then s/p reversal - OSA, on BiPAP - Obesity - Anemia of chronic disease - Pedal edema - Hypertension - Dyslipidemia - Chronic kidney insufficiency stage III in f/u renal [Hospital1 18] - GERD Social History: Lives with husband. Used to be school bus driver. Denies alcohol, smoking, or illicit drug use. Never smoked, significant second hand smoke exposure, no alcohol or drugs. Lives in [Location (un) 538] with husband and usually granddaughter, multiple kids in local area, HHA cleans, daughter feels needs more help at home. Family History: No history of CKD, lung disease, or malignancies. Physical Exam: ADMISSION EXAM: Vitals: 97.6 67 138/86 14 100% on 40% FiO2 General: Intubated, sedated, no acute distress. HEENT: Sclera anicteric, MMM, slight anisocoria with pupil 4mm on left, 2mm on right, Asymmetric [Doctor First Name 2281] on left c/w recent cataract surgery. Neck: Supple, JVP could not be assessed. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Significant rhonchi bilaterally, otherwise with good air movement bilaterally. Abdomen: Soft, mildly distended, midline laparotomy scar. No hepatosplenomegaly detected. GU: Foley Ext: Warm, well perfused, 1+ pulses, minimal edema. Neuro: Withdraws from pain, babinski downgoing bilaterally. Discharge: VS: Afebrile 138/70 P71 R20 99% 1L NC GEN: comfortable, non-toxic. RESP: Breathing comfortably, speaking full sentences. No WRR. CV: RRR. Pertinent Results: ADMISSION LABS: [2198-5-29] 05:25AM BLOOD WBC-6.7 RBC-3.26* Hgb-8.6* Hct-30.4* MCV-93 MCH-26.4* MCHC-28.3* RDW-14.4 Plt Ct-413 [2198-5-29] 10:13AM BLOOD Neuts-89.7* Lymphs-7.3* Monos-2.5 Eos-0.5 Baso-0.1 [2198-5-29] 05:25AM BLOOD PT-19.4* PTT-43.6* INR(PT)-1.8* [2198-5-29] 05:25AM BLOOD Fibrino-662* [2198-5-29] 10:13AM BLOOD Glucose-76 UreaN-50* Creat-1.8* Na-143 K-4.7 Cl-99 HCO3-39* AnGap-10 [2198-5-29] 05:25AM BLOOD ALT-25 AST-26 AlkPhos-126* TotBili-0.3 [2198-5-29] 05:25AM BLOOD cTropnT-0.03* [2198-5-29] 10:13AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.7 [2198-5-29] 05:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICROBIOLOGY: [2198-5-29] 5:40 am BLOOD CULTURE FINAL REPORT [2198-6-2] Blood Culture, Routine (Final [2198-6-2]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final [2198-5-30]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2198-5-30] 9:00AM. Anaerobic Bottle Gram Stain (Final [2198-5-31]): Reported to and read back by [Doctor Last Name 10502] @ 14:54 ON [2198-5-31]. GRAM POSITIVE ROD(S). [2198-5-29] BLOOD CULTURE: PENDING [2198-5-29] URINE CULTURE: Negative [2198-5-29] MRSA screen: Negative [2198-5-30] SPUTUM CULTURE: RESPIRATORY CULTURE (Final [2198-6-1]): SPARSE GROWTH Commensal Respiratory Flora. [2198-5-30] URINE LEGIONELLA ANTIGEN: Negative [2198-5-30] BLOOD CULTURE: PENDING [2198-5-31] BLOOD CULTURE: PENDING [2198-6-2] BLOOD CULTURE: PENDING [2198-6-3] BLOOD CULTURE: PENDING IMAGING: [2198-5-29] ECG: Baseline abnormalities. Probable sinus rhythm. Left atrial abnormality. Left anterior fascicular block. Lateral T wave abnormalities. Since the previous tracing of [2198-5-18] the rate is now slower. Otherwise, there may be no significant change. [2198-5-29] CHEST XRAY (portable): Moderate pulmonary edema with small right pleural effusion. [2198-6-1] CHEST XRAY (PA and lateral): In comparison with the study of [5-30], there has been improvement in the pulmonary vascular congestion. Some elevation of pulmonary venous pressure persists. The area of increased opacification in the left perihilar region has almost completely cleared. Mild atelectatic changes are seen at the left base. [2198-6-3] 08:00AM BLOOD WBC-9.3 RBC-3.09* Hgb-8.2* Hct-27.4* MCV-89 MCH-26.6* MCHC-30.1* RDW-14.9 Plt Ct-401 [2198-6-2] 07:18AM BLOOD PT-20.5* INR(PT)-1.9* [2198-6-3] 08:00AM BLOOD PT-19.9* INR(PT)-1.9* [2198-6-4] 06:46AM BLOOD PT-21.3* INR(PT)-2.0* [2198-6-5] 07:17AM BLOOD PT-21.5* PTT-37.6* INR(PT)-2.0* [2198-6-2] 05:10PM BLOOD Glucose-375* UreaN-74* Creat-2.3* Na-138 K-4.7 Cl-93* HCO3-38* AnGap-12 [2198-6-3] 08:00AM BLOOD Glucose-115* UreaN-77* Creat-2.1* Na-142 K-4.0 Cl-97 HCO3-40* AnGap-9 [2198-6-4] 06:46AM BLOOD Glucose-131* UreaN-77* Creat-2.2* Na-140 K-4.1 Cl-97 HCO3-36* AnGap-11 [2198-6-5] 07:17AM BLOOD Glucose-129* UreaN-78* Creat-2.1* Na-142 K-4.4 Cl-98 HCO3-38* AnGap-10 [2198-6-4] 06:46AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0 MICRO: [2198-5-30] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2198-5-30] URINE Legionella Urinary Antigen -FINAL INPATIENT [2198-5-30] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2198-5-29] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2198-5-29] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2198-5-29] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] [2198-5-29] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] PENDING: [2198-6-3] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2198-6-2] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2198-5-31] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Brief Hospital Course: 72 year-old woman with COPD, diastolic heart failure who presented with hypercarbic respiratory failure which required intubation [2198-5-29]. She self-extubated on [2198-5-30]. She was initially on Levaquin, but antibiotic coverage was broadened when blood cultures returned positive. She rapidly improved with regard to her respiratory status. Sputum culture ultimately showed respiratory commensal flora and blood culture showed typical skin contaminants (Corynebacterium and coagulase negative Staph aureus), so antibiotics were discontinued on [2198-6-1] because actual infection was very questionable given her well appearance. She was monitored off antibiotics and surveillance cultures drawn. She demonstrated no signs of worsening or infection. Of note, last admission [2198-5-21], her HCTZ and Furosemide were discontinued. On this admission, she had evidence of volume overload and received intermittent doses of IV furosemide for volume overload. PROBLEM LIST: # Hypercarbic respiratory failure due to mild COPD exacerbation and pulmonary edema. A diagnosis of pneumonia was initially considered, but was later felt unlikely. Sputum Cx showed respiratory flora. Legionella negative. Pt received 3 days of antibiotics and 5 days of Prednisone 60 mg. She continued albuterol and Ipratropium nebulizers, and she was resumed on her home Advair at the time of discharge. It may be that she had a more significant component of volume overload given that her regular diuretics (HCTZ and Furosemide) were discontinued at discharge [2198-5-21]. Her respiratory status is now back to baseline and she is having good oxygen saturation. She was noted to have persistently elevated bicarbonate, which remained near her baseline. Due to the concern of hypercarbia, her home oxygen flow (2L O2/min) was decreased to 1L O2/min). At the time of discharge, her oxygen saturation was 99% on 1 L NC. She continued her regular CPAP at night. She was provided a prescription and referrals for outpatient pulmonary rehab after discharge. # Blood culture positive, 1 set, on [2198-5-29] showing Corynebacterium and Coagulase negative Staph aureus (common skin contaminants). She was briefly treated with antibiotics, but infection was subsequently felt unlikely, so they were discontinued on [6-1]. She was monitored off of antibiotics, and surveillance blood cultures while off antibiotics have been no growth to date. # Acute kidney injury on stage 3 CKD, baseline Cr 1.8. Intermittent doses of IV Furosemide were given for acute on chronic dCHF. She was subsequently resumed on her home lasix dose of 20 mg po q day. Her Cr remained above her previous baseline at the time of discharge. # Acute on chronic diastolic CHF Pt has a known history of chronic diastolic heart failure, with history of flash pulmonary edema. It was felt that acute on chronic dCHF likely contributed to her presentation of hypercarbic respiratory failure. She received intermittent doses of IV Furosemide, and she was transitioned to her home dose of Furosemide 20mg PO daily prior to discharge. She will require close follow-up with PCP for volume status assessments and she should monitor daily weights at home. It is noted that there is concern about possible medication and dietary non-compliance contributing to her decompensation. # Hypertension, stable. Blood pressure is poorly controlled at home and often reports that she runs very high with systolics in the 180s. The patient had an episode of flash pulmonary edema during her last admission. As such, it will be extremely important to keep her blood pressure under good control as this could cause worsening of her CHF. She received lisinopril 40mg during the hospitalization considering benazepril is non-formulary. She was resumed on home benazepril at the time of discharge. She was started on oral hydralazine TID during the hospitalization, with improvement in blood pressure. She will continue this after discharge. She continued amlodipine. # Anemia, normocytic, chronic. Likely related to CKD and diabetes. HCT stable in mid-high 20's. # Diabetes mellitus, type II, uncontrolled, with possible diabetic nephropathy. Continue home lantus, sliding scale insulin. Lantus was decreased while she was intubated and returned to 60 units after extubation. While on prednisone she received 62 units daily. # Atrial fibrillation, rate controlled, in sinus rhythm. Continued anticoagulation with Warfarin. Her warfarin dose remained 6 mg po q 1600 for several days prior to discharge. # Glaucoma: Continued latanoprost, apraclonidine # S/p cataract surgery: Continued prednisolone # DVT prophylaxis: Warfarin with therapeutic INR # Communication: family - HCP is daughter [Name (NI) 19948] # [Name2 (NI) 7092] status: Full code Transitional Issues: 1. COPD with hypercarbia: She remains hypercarbic with high bicarbonate, which may predispose her to future episodes of failure. She was provided a prescription for pulmonary rehab. Wean oxygen as tolerated during the day, for goal SpO2 >90-92%. Encourage compliance with CPAP, and consider interrogation of her home CPAP device to assess compliance. Consider referral to Pulmonary Medicine. 2. dCHF: Recommend close volume status monitoring, and titration of lasix as needed to maintain euvolemia. Good blood pressure control, medication compliance, and low-salt diet were stressed to patient to minimize exacerbations. She may benefit from Social Work involvement to further assess barriers to compliance. 3. Atrial fibrillation: INR currently therapeutic at INR for past 2 days. Recommend close INR follow up. 4. Chronic renal failure: Her creatinine is currently above her previous baseline, but I am uncertain whether her current Cr (2.1) may represent a new baseline. Recommend close follow up of renal function. 5. Pending results: there are several blood cultures remaining pending, although my suspicion for blood stream infection is currently very low. Medications on Admission: - Albuterol 90mcg 1-2puffs inhaled q4h prn SOB/wheeze - Amlodipine 10mg PO daily - Benazepril 40mg PO daily - Famotidine 20mg PO BID - Fluticasone-salmeterol (DISCONTINUED BY PCP [Last Name (NamePattern4) ] [2198-5-25]) - Furosemide 20 mg PO daily (DISCONTINUED last hospitalization [2198-5-21]) - Gemfibrozil 600mg PO BID - HCTZ 50 mg PO daily (DISCONTINUED last hospitalization [2198-5-21]) - Prednisolone 1% 1gtt LEFT EYE daily - Latanoprost 0.005% 1gtt RIGHT EYE qhs - Apraclonidine 0.5% 1gtt LEFT EYE daily - Lantus 60units SC daily - Ipratropium-albuterol 0.5mg-3mg(2.5mg base)/3ml nebs inhaled q4h prn SOB/wheeze - Metoprolol 50mg PO daily - Tiotropium 18mcg inhaled daily - Warfarin 6mg PO daily - Home O2 continuous 2L/min by nasal canula Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 6. Lantus 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. 7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) unit Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. 10. apraclonidine 0.5 % Drops Sig: One (1) Drop Left Eye Ophthalmic DAILY (Daily). 11. latanoprost 0.005 % Drops Sig: One (1) Drop Right Eye Ophthalmic HS (at bedtime). 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [1-15] INH Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) INH Inhalation twice a day. 14. warfarin 6 mg Tablet Sig: One (1) Tablet PO Q 4 pm. 15. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:0 16. Home Oxygen 1 Liter/min 17. Outpatient Pulmonary Rehab 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY DIAGNOSES: - Respiratory failure - COPD, mild exacerbation - Acute on chronic diastolic heart failure - Obstructive sleep apnea SECONDARY DIAGNOSES: - Chronic kidney disease, stage III/IV - Diabetes mellitus, type II - Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the ICU with respiratory failure and required the support of a ventilator. There was initially a question of whether or not you had an infection in your lungs or in your blood stream. It was determined that you were not likely to be infected, so antibiotics were stopped. After a few days in the ICU, your condition improved and you were transferred to the medical floor. Your breathing issues were probably from a combination of having a COPD flare and perhaps excess fluid in your lungs. You improved with Prednisone and with some diuresis with Lasix. It is important that you weigh yourself each day. If you find that you have gained [2-16] pounds above your baseline weight, you should call your doctor to advise. You should also wear elastic compression stockings on your legs to mobilize fluid from your skin back into your blood vessels. Keeping your legs elevated when you are not standing is also helpful to decrease leg swelling. Followup Instructions: Department: BIDHC [Location (un) ] When: THURSDAY [2198-6-7] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 607], MD [Telephone/Fax (1) 608] Building: 545A Centre St. ([Location (un) 538], MA) None Campus: OFF CAMPUS Best Parking:	[ "790.92", "584.9", "V46.2", "327.23", "491.21", "365.9", "530.81", "285.9", "403.90", "V58.67", "585.3", "427.31", "428.33", "428.0", "486", "518.81", "250.00" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	16571, 16628	8148, 9127	298, 371	16920, 16920	3761, 3761	18098, 18389	2838, 2889		14977, 16548		16649, 16786		14189, 14954			17103, 18075										2904, 3742		16807, 16899																12993, 14163		1933, 2040				227, 260											399, 1913					3777, 8125	9141, 12972			16935, 17079							2062, 2479	2495, 2822
4,966	199,069	12728	Discharge summary	report	Admission Date: [2153-2-3] Discharge Date: [2153-2-20] Date of Birth: [2108-1-21] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 45-year-old male status post Roux-en-Y gastric bypass at an outside hospital in [2152-5-10]. Postoperative course was complicated by pancreatitis, duodenal stump leak, stricture. She had a gastric bypass revision and hepatic jejunostomy at [Hospital1 1444] in [2152-12-10]. The patient returned to [Hospital1 69] with a temperature of 104, complaining of rigors. Denies nausea, vomiting. Denies pain. Denies jaundice. PAST MEDICAL HISTORY: 1. Obesity. 2. Malnutrition, chronic TPN. PAST SURGICAL HISTORY: 1. Status post Roux-en-Y and gastric bypass. 2. Pancreatitis, status post biliary stricture. 3. Status post gastric bypass revision [12-11]. 4. Status post biliary drain secondary to stricture. ALLERGIES: No known drug allergies. MEDICATION: 1. TPN. 2. Augmentin 835 mg twice a day. PHYSICAL EXAMINATION: Pleasant, cooperative in acute distress. Temperature 102.1, heart rate 114, blood pressure 108/50. Respiratory rate 20. 97% on room air. Alert and oriented times three, no jaundice, no icterus. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Clear to auscultation bilaterally. Regular rate and rhythm with no murmurs. Port-a-cath site clean, dry and intact. Abdomen soft, nontender, nondistended. LABS: White blood count 6.9, neutrophils 90%, no bands. Hematocrit 30, platelets 170, sodium 137, potassium 4.2, chloride 101, bicarbonate 24, BUN 20, creatinine .8. Blood sugar 177. Calcium 9.2, mag 1.7, phos 27, AST 24, ALT 27, alk phos 536, total bili 1.6, amylase .47, lipase 17, total protein 6.4. Chest x-ray: No effusions. HOSPITAL COURSE: The patient was admitted to surgery service. He was started on broad spectrum antibiotics including Vancomycin, Zosyn and Tobramycin. He was pan cultured. Surgery was consulted with a presumed diagnosis of cholangitis. The patient was also moved to Intensive Care Unit. [2153-2-4] the patient's biliary drain was changed without complications. On [2153-2-7] the patient was transfused two units of packed red blood cells for anemia in preparation. The patient was taken to the operating room on [2153-2-8]. Diagnosis of small bowel obstruction. Exploratory laparotomy, revision of biliary limb Roux-en-Y bypass and resection of gastric pouch, lysis of adhesion was performed. Operation went without complications. The patient was transferred to Post Anesthesia Care Unit in stable condition. Postop day one the patient is afebrile, vital signs stable. Continued on TPN. Starting to ambulate. Continue broad spectrum antibiotic per ID team. Biliary culture started growing yeast and he was started on Fluconazole. Postop day three the patient had Upper Gastrointestinal, small bowel follow through which showed no leak. The patient is ambulating. LFTs are improving. He was started on stage diet which he is tolerating well. Postop day four afebrile, vital signs stable. Progressed to Stage II diet, patient is tolerating well. Postop day five the patient is afebrile, vital signs stable. The patient was switched to p.o. meds, Foley was discontinued. Postop day six the patient's G-tube was capped without complications. His tube feeds were increased to 50 cc's an hour which the patient was tolerating well. His TPN was discontinued. The patient was advanced to Stage III diet. On [2153-2-16] the patient had an episode of emesis, no prodrome. He had another swallow study, small bowel follow through which showed dilated jejunum, bile refluxing. The patient was started on Erythromycin, Reglan and bowel regimen which he is tolerating well. He had another episodes of bilious vomiting the next day but otherwise was tolerating Stage IV diet, ambulating, no fever, no chills. Tobramycin was discontinued followed by Zosyn and Erythromycin per ID recommendation. Postop day 16 the patient is afebrile, vital signs stable,tolerating Stage IV diet. His tube feeds are cycled at night which he is tolerating well. Wound is clean, dry and intact. G-tube is capped. No nausea, vomiting in two days. No concerns of an active issue. Projected discharge on [2153-2-20]. CONDITION ON DISCHARGE: Stable. DISPOSITION: The patient is discharged home. The patient a will continue tube feeds with ProMod at night 100 cc's an hour for 14 hours. The patient will contact Dr. [First Name (STitle) ] and Dr.[Name (NI) 39264] office for postoperative follow-up. MEDICATIONS: 1. ProMod 100 cc's an hour for 14 hours at night. 2. Benadryl 25 mg one to two tabs p.o. q 6 hours p.r.n. 3. Dilaudid 224 mg q 4 to 6 hours p.r.n. for pain 4. Bisacodyl suppository 10 mg p.r. q day p.r.n. 5. Zantac 150 mg p.o. twice a day 6. Reglan 10 mg one tab p.o. three times a day for seven days. DISCHARGE DIAGNOSIS: 1. Small bowel obstruction, status post gastrojejunostomy revision, cholangitis, biliary sepsis, anemia, malnutrition, hypocalcemia, hypomagnesemia, hypokalemia, hypovolemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Dictator Info ] MEDQUIST36 D: [2153-2-19] 16:40 T: [2153-2-19] 16:05 JOB#: [Job Number ]	[ "996.62", "560.81", "997.4", "285.9", "276.9", "576.1", "785.6", "579.3", "117.9" ]	icd9cm	[ [ [] ] ]	[ "54.59", "38.93", "87.54", "99.77", "96.6", "86.05", "99.15", "45.62", "44.39", "40.24", "46.39" ]	icd9pcs	[ [ [] ] ]											4990, 5428			1829, 4347											703, 1000														1023, 1811																						159, 613																635, 680		4372, 4969
28,716	190,667	10757+10758	Discharge summary	report+report	Admission Date: [2145-10-28] Discharge Date: [2145-11-3] Date of Birth: [2111-6-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: low back pain Major Surgical or Invasive Procedure: none History of Present Illness: 34 y/o M with hx of AVR after IVDU associated endocarditis in [2140] has presented several times over the past month for multiple complaints. Past admissions include: . [Date range (1) 35164] - in the ED for chest pain after drug use, d/c'ed. [Date range (1) 35165] - admitted for SI, d/c'ed to [Hospital 1680] rehab [Date range (1) 35166] - admitted to ICU for ? etoh withdrawl seizure, left AMA the same day [Date range (1) 35167] - admitted for back pain, possible pyelonephritis or UTI and increased creatinine, left AMA [Date range (1) 35168] - admitted for back pain and LOC after using inhalants, again left AMA . Then after leaving AMA that day, he went home, drank approx a half pint of vodka at 10am on [10-27], used some inhalants, and then returned to the ED with complaints of chest pain, low back pain and the hope to get into rehab. . This morning, the patient denies any chest pain, shortness of breath, headache, changes in his vision. He only complains of low back pain and denies having chest pain yesterday. His back pain is low back, bilaterally paraspinally with slight midline tenderness. He had no numbness or tingling or weakness in his legs. No fevers, chills, weight changes or other problems. Past Medical History: 1) s/p aortic mechanical valve replacement in [2139] for endocarditis secondary to IVDU. - Patient has a cardiologist at [Hospital1 2177], but he infrequently follows care; INR range is supposed to be between 2.5-3.5 but patient is noncompliant with coumadin. In the past, he has been a patient of the [Hospital1 2177] coumadin clinic. 2) +Hepatitis B and C 3) H/o EtOH withdrawal seizures - Says he's never had seizures out of the context of alcohol withdrawal. 4) history of suicide attempt [6-5] while in Police custody, admitted to the Trauma service, intubated x days, ultimately recovered and went to inpatient Psych service on [Hospital1 ]-4 x 3 days where he was determined to have no evidence for depression. He was discharged at that time to Police custody. Social History: Smokes cigarettes-recently only [3-3] cigs/day -Etoh - onset of problem drinking 15 y/o, ~10 detox, h/o w/d seizures, denies h/o DTs, longest periods of sobriety were 6 months in '[31] (? if in jail during this time) and also reports recently sober X 8 months earlier this year, last drink yesterday - Marijuana - none recently. - Cocaine - "a couple of times/week", smoked or IV, last use was 1 month ago. - Heroin - last used approx 4 wks ago - inhales Dust-Off on a regular basis (done yesterday) - Denies any other illicit substance use or prescription med misuse. - Homeless - Formerly lived with his parents. Has a teenage son. Mr. [Known lastname 35160] parents and the boy's other grandparents reportedly share custody of him. Family History: DM in mom and sister. Denies CAD, stroke. Grandparents died of lung CA. Patient denies family medical history of mental illness. Physical Exam: PE the morning of admission: Vitals - Tm 98.3, BP 146/96, P 76, R 20, 100% on RA Gen - in bed, slightly anxious, but with good attention and calm and cooperative, NAD HEENT - abrasions on top of L forehead, moist mucous membranes, supple neck, no LAD of JVD CV - RRR, mechanical systolic click, no other murmurs appreciated Lungs - CTA B Back - tender to palpation paraspinally above gluteus muscle, no midline tenderness to palpation Abd - soft, NT, ND, no hsm, hyperactive bowel sounds Ext - warm, well perfused, blisters on R palm Neuro - CN intact, no nystagums, mild intention tremor with hands outstretched, cerebellar functions intact, strength 5/5 throughout, reflexes 2+ throughout except R patellar which was 1+, [Last Name (un) 36] and motor grossly intact . Pt [Doctor Last Name ] btw [7-8] on CIWA scales for sweating, anxiety, tremors. Pertinent Results: Pertinent Results: . INR the day of discharge: 2.5 . MRI of back: CLINICAL INDICATION: 34-year-old male with history of IV drug use, endocarditis requiring mechanical valve, now presenting with fevers, low back pain, and spinal tenderness. Please evaluate for epidural abscess. TECHNIQUE: MR images of the cervical, thoracic, and lumbar spine were obtained including T2 sagittal, T1 sagittal, sagittal STIR, axial GRE, sagittal STIR, and axial T2 sequences. This exam is limited by patient motion, with the GRE sequences quite limited by pulsation artifact, and no axial images of the lower lumbar spine or lumbar STIR sequence. Finally, the patient declined additional imaging, including post-contrast sequences. FINDINGS: Within the cervical spine, the vertebral body height and alignment are normal. There is normal cord signal and morphology. The paraspinal soft tissues are normal. At C2/3, there is no evidence of disc herniation, spinal stenosis, or neural foraminal narrowing. At C3/4, there is a mild disc bulge with no spinal stenosis or neural foraminal narrowing. At C4/5, there is a disc bulge that is eccentric to the left that abuts the left ventral cord. There is mild left neural foraminal narrowing. At C5/6, there is a left paracentral disc bulge with effacement of the left ventral cord and left neural foraminal narrowing. The right neural foramen is patent. At C6/7, there is a broad-based central disc herniation that effaces the ventral thecal sac. The neural foramina are patent. At C7/T1, there is no evidence of disc herniation, spinal stenosis, or neural foraminal narrowing. THORACIC SPINE: The vertebral body height, alignment, and bone marrow signal of the thoracic spine are normal. There is no abnormal cord signal or morphology. There is no disc herniation, spinal stenosis, or neural foraminal narrowing. There is no evidence of abscess. Sagittal STIR sequence demonstrates no abnormal signal. LUMBAR SPINE: The vertebral body height and alignment are normal. The conus has normal signal and morphology and terminates at L1. Axial images of the lower lumbar spine were not performed due to patient not wanting to continue with the exam. The paraspinal soft tissues demonstrate no abnormality. Sagittal T1 sequence demonstrates a shallow disc protrusion at L5/S1 with associated annular tear. The remainder of the sagittal images demonstrates no evidence of disc herniation. IMPRESSION: 1. No non-contrast evidence of discitis, vertebral osteomyelitis or epidural abscess in the cervical, thoracic, or lumbar spine. 2. The evaluation of the leptomeninges and nerve roots is quite limited due to the lack of gadolinium contrast. 3. Multilevel cervical spondylosis, with ventral canal and neural foraminal narrowing, most marked at the C4/5 through C6/7 levels. 4. Shallow disc protrusion at L5/S1 with associated annular tear. Brief Hospital Course: 34 y/o M with hx of AVR and many recent admissions related to etoh/drug use presents with continued back pain after leaving AMA two days ago. Has subtherapeutic INR, on hep gtt. . # Back pain - continues to be the same, decided to decrease pain medicines from narcotics over the course of the admission and try to control better with tyelnol. Will not discharge home wtih narcotics, so need to start weaned off. Patient was ambulating and has no neuro findings. Avoided NSAIDS because of slight rise in creatinine. . # ETOH / risk of withdrawl - kept on CIWA scale during admission and scored during first few days of admission then stopped requiring benzos. . # AVR - needs a INR 2.5 to 3.5, INR today 2.0; continued heparin gtt until therapeutic and was discharged the day his INR was 2.5. Patient threatened to leave AMA several times, but ended up staying until he was therapuetic. Had long discussions about importance of coumadin and following up as scheduled because of risk of stroke and death. He seemed to understand. . # Anxiety - saw psych during admission, has had previous relationship with them before,l started gabapentin for pain and started citalopram for now per psych recs. . # Renal insufficiency - improved over course of admission. We avoided nephrotoxic drugs like NSAIDs during his admission. . Medications on Admission: coumadin 7.5 mg daily (not taking since leaving hospital on [10-27]) Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:48 Tablet(s) Refills:0 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:0 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:0 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:8 Tablet(s) Refills:0 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:15 Capsule(s) Refills:0 7. Outpatient Lab Work Please check PT and INR. Forward results to Dr. [First Name (STitle) ]. Thank you. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Subtherapeutic INR with mechanical atrial valve 2. Alcohol abuse and withdrawl Discharge Condition: vital signs stable, mild low back pain, therapeutic INR Discharge Instructions: You were admitted to the hospital for low back pain and a subtherapeutic coumadin level. We determined that your back pain was likely due to musculoskeletal causes An MRI of your back was done and showed no infection or nerve problems. [Name (NI) ] can treat the pain with tylenol and ibuprofen. We monitored your INR and restarted your coumadin, but had to keep you on heparin while you were an inpatient. This is necessary because on your mechanical valve. It is very important that you take your coumadin every day and follow up in clinic. You should also seek help at a dual-diagnosis treatment center for alcohol use. The psychiatrists here saw you and recommended that you start citalopram and gabapentin. Please take these medicines as prescribed and talk with Dr. [First Name (STitle) ] about continuing them at your next office visit. Please return to the hospital for any increasing back pain with fevers or chills, chest pain, shortness of breath, weakness, headaches, changes in vision, seizures or any other concerns. Please avoid mixing alcohol or other drugs with your prescribed medicines. Followup Instructions: Please follow up with your primary care doctor [First Name8 (NamePattern2) ] [Last Name (Titles) ]. His phone number is [Telephone/Fax (1) 14315]. [11-18] at 3:15. . Please go to Dr.[Name (NI) 35169] office this Friday to have your INR checked. He will follow up your level. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2146-1-24] Admission Date: [2145-11-3] Discharge Date: [2145-11-9] Date of Birth: [2111-6-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: s/p Chemical burn to face and right hand Major Surgical or Invasive Procedure: None History of Present Illness: 34 yo male who presents s/p dust-off explosion in right hand and left cheek, approximately two hours after discharge from [Hospital1 18]. He reports that after being discharged he was "left to my own devices" and began having "EtOH withdrawal" which agrees were, cravings as he walked by the nearby liqour store. Because he did not have enough money for EtOH he decided he would inhale dustoff, and the can exploded in his hand. He is admitted to the ED for further management. Past Medical History: 1) s/p aortic mechanical valve replacement in [2139] for endocarditis secondary to IVDU. - Patient has a cardiologist at [Hospital1 2177], but he infrequently follows care; INR range is supposed to be between 2.5-3.5 but patient is noncompliant with coumadin. In the past, he has been a patient of the [Hospital1 2177] coumadin clinic. 2) +Hepatitis B and C 3) H/o EtOH withdrawal seizures - Says he's never had seizures out of the context of alcohol withdrawal. 4) history of suicide attempt [6-5] while in Police custody, admitted to the Trauma service, intubated x days, ultimately recovered and went to inpatient Psych service on [Hospital1 ]-4 x 3 days where he was determined to have no evidence for depression. He was discharged at that time to Police custody. Social History: Smokes cig - 1 ppd -Etoh - onset of problem drinking 15 y/o, ~10 detox, h/o w/d seizures, denies h/o DTs, longest period of sobriety was 6 months in '[31] (? if in jail during this time), last drink 2 days ago -Marijuana - as a kid, none recently. -Cocaine - "a couple of times/week", smoked or IV, last use was 1 month ago. -Heroin - last used approx 4 wks ago -inhales Dust-Off on a regular basis -Denies any other illicit substance use or prescription med misuse. -Homeless -Formerly lived with his parents. Has a teenage son. Mr. [Known lastname 35160] parents and the boy's other grandparents reportedly share custody of him. Family History: From OMR in d/c summary from [2143-10-13], DM in mom and sister. Denies CAD, stroke. Grandparents died of lung CA. Patient denies family medical history of mental illness. Physical Exam: Upon admission: 97.3, P 92, BP 107/76, RR 21 99%RA. White male resting in bed, left cheek raw & red and right hand bandaged. Patient appears to be in a great deal of pain, but he was cooperative with the interview. Appears sedated. Speech spontaneous, no dysarthria. Mood is "depressed" with a restricted, but tearful affect. Thoughts organized, no unusual content. Denied thoughts of suicide, but does struggle with fleeting thoughts of hopelessness. Insight into problems with substances remains limited, but he is asking for help now. Please see Dr. [Last Name (STitle) 5261] note for full details. Pertinent Results: [2145-11-3] 11:04PM GLUCOSE-186* LACTATE-4.0* NA+-138 K+-4.2 CL--97* TCO2-22 [2145-11-3] 11:00PM UREA N-19 CREAT-1.4* [2145-11-3] 11:00PM WBC-10.2 RBC-4.71 HGB-14.3 HCT-41.0 MCV-87 MCH-30.3 MCHC-34.9 RDW-14.3 [2145-11-3] 11:00PM PT-25.1* PTT-31.8 INR(PT)-2.5* [2145-11-3] 11:00PM PLT COUNT-342 [2145-11-3] 11:00PM FIBRINOGE-496* [2145-11-4] Radiology CT SINUS/MANDIBLE/MAXIL IMPRESSION: Soft-tissue swelling and reticulation as described above without underlying fracture. Minimal sinus disease. Brief Hospital Course: He was admitted to the Trauma service. Psychiatry and Plastic Surgery were immediately consulted. His wounds were irrigated and dressed; dressing changes to his right hand consisting of Bacitracin and Xeroform gauze were started. Silvadene is being applied to facial burns. He will follow up in [Hospital 3595] clinic on the Tuesday after discharge. Given his history with Depression and Polysubstance abuse Psychiatry was consulted and made several recon recommendations pertaining to his medications. His Celexa was restarted with recommendations to increase to 20 mg after several days on the 10 mg; Neurontin was added to address his impulsivity. He was given Percocet and Ibuprofen prn for pain. Social work was closely involved throughout his hospital stay assisting with issues surrounding being homeless and for substance abuse. Medications on Admission: Coumadin Celexa Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Based on INR goal 2.5-3.0. Disp:30 Tablet(s) Refills:2 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Apply topically as directed. Disp:1 Jar Refills:2 7. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Must take with food. Disp:120 Tablet(s) Refills:1 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p Chemical burn to left face and right hand (2nd degree) Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Your INR's are usually managed by your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] [Telephone/Fax (1) 14315]. An appointment was scheduled for you during your last hosptial stay for [11-18] at 3:15. Dressing changes will be performed by: [Street Address(1) ] Inn Mon-Fri [First Name9 (NamePattern2) 35170] [Doctor Last Name ] House Sat & Sun You will need to go to these facilities to have the dressings changed twice daily Wear the splint on your right hand as instructed. Followup Instructions: Please call the [Hospital1 18] Plastics Hand clinic at [Telephone/Fax (1) 3009] to set up an appointment for the Tuesday following discharge. Follow up with your outpatient mental health providers upon discharge from rehab. Follow up with you primary care doctor for your Coumadin and INR monitoring. Completed by:[2145-11-9*]	[ "305.91", "V43.3", "V60.0", "944.23", "V58.61", "E924.1", "301.7", "303.90", "948.00", "944.25", "070.70", "941.27" ]	icd9cm	[ [ [] ] ]	[ "86.28" ]	icd9pcs	[ [ [] ] ]	16754, 16760	14876, 15721	11476, 11482	16863, 16943	14308, 14853	17526, 17868	13480, 13658		15787, 16731		16781, 16842		15747, 15764			16967, 17503										13673, 13675																								11396, 11438											11510, 11993							9334, 9420	13689, 14289								12015, 12806	12822, 13464
77,826	109,289	54997	Discharge summary	report	Admission Date: [2181-8-20] Discharge Date: [2181-8-27] Date of Birth: [2111-10-9] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 1515] Chief Complaint: Aortic Valve stenosis presenting for COREVALVE Major Surgical or Invasive Procedure: COREVALVE History of Present Illness: Mr. [Known lastname 112298] is a 69 year old man with severe aortic stenosis, CAD s/p stent to mid-LAD and D1 ([2172]), HTN, HLD, diabetes, afib, and CKD, who presented for Corevalve. Initial workup of his aortic stenosis revealed critical disease with [Location (un) 109] 0.45cm2, mean gradient 55mmHg, EF 55-60%. Cardiac cath revealed nonobstructive CAD and patent stent. He was initially referred for surgical AVR, and 9 weeks ago underwent sternotomy, where epiaortic ultra sound revealed prohibitively calcified aorta and procedure was aborted. He was then referred to [Hospital1 2025] for evaluation for TAVR and was found to have large annulus. He was referred to [Hospital1 18] for treatment options. He was again deemed not a surgical candidate due to heavily calcified aorta. He met all inclusion criteria for COREVALVE/TAVR and was admitted on [2181-8-19] for the procedure. Upon admission he endorsed SOB after walking [12-11] mile and climbing 4 stairs, lightheadedness when getting out of bed, and chest pressure when loading the car. COREVALVE procedure took place the morning on [2181-8-20]. The procedure went well aside from development of LBBB. On arrival to the floor, patient was intubated and stable. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -Critical aortic stenosis -Stent to mid-LAD and D1 in [2172] -Afib (sotalol, warfarin) 3. OTHER PAST MEDICAL HISTORY: -CKD Past Surgical History: -sternotomy ([2181-6-19]) -rt index finger reattachment s/p trauma Social History: Married, lives with wife. Two children. Retired owner of distributing company (doors and windows). Frequents summer home in NH. Warfarin managed by [Hospital3 ] at [Hospital3 ] Center, [Hospital1 1559]. Has own INR machine at home. Independent in ADLs. Race: caucasian Last Dental Exam: dental clearance obtained - Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 112299] (Highland St, [Hospital1 1559] MA) Lives with: wife Occupation: retired company owner Tobacco: 60 pack years, quit 20yrs ago ETOH: [1-12] scotch/day Family History: Father died age 69- emphysema. Mother Died age 89 of MI, No heart disease before age 65. 1 nephew with congenital HD Physical Exam: ADMISSION EXAM: VS:T 98, HR 60 (paced) 121/52, RR 15, O2 sat 100% on GENERAL: WDWN male in NAD, lying comfortably in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Left eye with injected conjuctiva. Visual acuity intact bilaterally, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without JVP, pacer wire present in right IJ. CARDIAC: irregular rate, normal S1, S2. Late Systolic murmur heard at RUSB radiating thoroughout the precordium. No thrills, lifts. No S3 or S4. LUNGS: Well healed sternotomy scar. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. + BS No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. No hematoma at access sites SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ DISCHARGE EXAM: Pertinent Results: ADMISSION LABS: [2181-8-20] 01:10PM WBC-6.0 RBC-3.84* HGB-11.9* HCT-37.7* MCV-98 MCH-31.0 MCHC-31.5 RDW-14.0 [2181-8-20] 01:10PM PLT COUNT-153 [2181-8-20] 01:10PM BLOOD Glucose-92 UreaN-30* Creat-1.1 Na-136 K-4.6 Cl-104 HCO3-25 AnGap-12 [2181-8-20] 01:10PM ALBUMIN-4.3 [2181-8-20] 01:10PM CK-MB-3 proBNP-5523* [2181-8-20] 01:10PM PT-18.5* PTT-35.3 INR(PT)-1.7* [2181-8-20] 01:10PM ALT(SGPT)-23 AST(SGOT)-28 CK(CPK)-86 ALK PHOS-71 TOT BILI-1.0 2-D ECHOCARDIOGRAM [2181-8-21]: Prevalve Implant Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Drs [Last Name (STitle) ] and [Name5 (PTitle) ] were notified in person of the results. Postvalve implant Corevalve seen in the aorticv position. It appears well seated. There is mild perivalvular leak. Moderate mitral regurgitation persists. The mean gradient across the mitral valve is 4 mm Hg. There is some turbulence noted in the LVOT. Rest of the examination is unchanged DISCHARGE LABS: Brief Hospital Course: ASSESSMENT AND PLAN: 69 yo man with critical symptomatic aortic stenosis, history of CAD s/p stent to midLAD and D1 [2172], HLD, DM, CKD, afib, HTN deemed not a surgical candidate for conventional AVR due to heavily calcified aorta, now s/p Corevalve. 1. Severe aortic stenosis admitted for COREVALVE. Procedure went well, no complications, pt was extubated in CCU post-operatively without complications. Right IJ was removed on POD#2, patient was stable and called out to regular cardiology floor. His post-op course was overall uncomplicated. However, he spiked a fever to 101.1 on [8-23], blood and urine cultures were sent and were no growth to date on the day of discharge. Post-op ECHO on [8-27] showed a mildly dilated LA, markedly dilated RA, moderate symmetric LVH. Hyperdynamic LV systolic function(EF>75%). There is a mild resting LVOFT obstruction. A mid-cavitary gradient is identified. An aortic CoreValve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mild (1+) AR/MR, mild PAH. There is no pericardial effusion. He will follow-up as planned with Dr. [Last Name (STitle) ] as an outpatient. 2. Diastolic heart failure - NYH Class II, LVEF >55%. BNP 55K. Losartan was restarted once patient was extubated and off pressors. He was discharged on Losartan, aspirin, simvastatin, and zetia. Standing diuretic not ordered as hypertrophic heart. Oral fluids to be encouraged. 3. Atrial fibrillation: went into LBBB and afib during procedure, but now natively conducting without narrow complex QRS. Sotalol was held for bradycardia and was not restarted prior to discharge. He was started on heparin drip while holding coumadin. The heparin gtt was discontinued, warfarin was restarted at home dose and he was treated with Aspirin and plavix until INR therapeutic and then plavix can be stopped. 4. CAD - (stent to midLAD and D1 [2172], patent), losartan, ASA, vytorin and plavix as above. 5. HLD - continue ezetimibe/simvastatin, and heart healthy diet. Simvastatin dose was reduced secondary to med interaction. 6. HTN - as noted above, he was initially on nitro gtt for elevated blood pressures and then Losartan was restarted as above. Plan to resume home benicar dose on discharge. 7. CKD - metformin held during hospitalization, and all meds were renally dosed. Glipizide 2.5mg started in place of metformin. Patient to monitor blood glucose at home. BUN/Cr to be drawn on [8-29]. 8. DM - home metformin held, and he was started on insulin sliding scale while hospitalized. Glipizide 2.5mg started in place of metformin. Patient to monitor blood glucose at home. BUN/Cr to be drawn on [8-29]. 9. Eye Pain: When patient was extubated, he complained of eye pain, likely due to corneal abrasion. Ophthalmology was consulted and noted corneal abrasion he was tx with Bacitracin/Polymyxin B Sulfate and Latanoprost 0.005%. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Vytorin [9-29] NF (ezetimibe-simvastatin) 10-20 mg Oral daily 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. olmesartan NF 40 mg Oral Daily 5. Sotalol 60 mg PO BID 6. Warfarin 2.5 mg PO DAILY16 7. Ascorbic Acid 500 mg PO DAILY 8. Aspirin EC 81 mg PO DAILY 9. Vitamin D 800 UNIT PO DAILY 10. coenzyme Q10 NF 50 mg Oral daily 11. flaxseed oil NF 1,000 mg Oral daily Discharge Medications: 1. Ascorbic Acid 500 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 4. Vitamin D 800 UNIT PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN pain 6. Clopidogrel 75 mg PO DAILY Start: In AM day of surgery. Do not give if direct aortic approach - GIVE PRIOR TO GOING TO OR RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:1 7. GlipiZIDE XL 2.5 mg PO DAILY RX glipizide 5 mg 0.5 (One half) tablet(s) by mouth each morning Disp #15 Tablet Refills:3 8. coenzyme Q10 NF 50 mg Oral daily 9. flaxseed oil NF 1,000 mg Oral daily 10. Vytorin [9-29] NF (ezetimibe-simvastatin) 10-20 mg Oral daily 11. Warfarin 2.5 mg PO DAILY16 check INR daily until stable 12. Outpatient Lab Work basic chemistry (potassium, sodium, chloride, serum bicarb, BUN, creatnine) - please draw on Wednesday [2181-8-29] 13. olmesartan NF 40 mg Oral Daily 14. Artificial Tear Ointment 1 Appl LEFT EYE PRN eye pain 15. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN eye discomfort/dryness 16. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE Q8H Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: 1. Aortic stenosis s/p CoreValve AVR [2181-8-21] 2. CAD s/p PCI to mid-LAD and D1 ([2172]) 3. HTN 4. Hyperlipidemia 5. Paroxysmal atrial fibrillation (warfarin) 6. T2DM 7. CKD 8. s/p sternotomy ([2181-6-19]) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Groin restrictions - no lifting >10 lbs x 1 month post procedure Discharge Instructions: Mr. [Known lastname 112298], It has been a pleasure working with you in the treatment of your severe aortic stenosis. You had a prior sternotomy at an outside hospital in [Month (only) 205] of this year for a planned surgical aortic valve replacement, but was found to have a heavily calcified aorta upon closer examination. Your surgery was unable to be done. You were then referred for aortic valve treatment options and were found to be a candidate for Corevalve/TAVR. You underwent your procedure on [2181-8-21]. Postoperatively you demonstrated some changes on your EKG [Location (un) 1131]. Electrophysiology specialists were consulted, an EP study was done which demonstrated no indication for further intervention. You have progressed nicely and are now ready for discharge to home with arrangements made for visiting nurses. You have been provided with separate discharge instructions regarding the corevalve procedure. It is important to weigh youself daily! Notify the doctor if you gain more than 3 lbs in 2 days, or 5 lbs in 5 days. Followup Instructions: I understand you already have an appt to see Dr [Last Name (STitle) 112300] on [9-4]. I understand you already have an appt to see your cardiologist, Dr [Last Name (STitle) 47403]. We will contact you to with information regarding your 30day followup with Dr [Last Name (STitle) ]. You will also have an echocardiogram with that visit.	[ "272.4", "585.9", "428.32", "V15.82", "428.0", "414.01", "426.3", "427.89", "424.1", "V45.82", "250.00", "E849.7", "440.0", "E928.9", "780.62", "365.9", "403.90", "427.31", "V70.7", "918.1" ]	icd9cm	[ [ [] ] ]	[ "39.64", "35.05", "37.26" ]	icd9pcs	[ [ [] ] ]	10287, 10336	5597, 8565	318, 329	10600, 10600	3660, 3660	11918, 12273	2547, 2665		9151, 10264		10357, 10579		8591, 9128			10816, 11895			5574, 5574						1883, 1955	2680, 3623			1732, 1823				3641, 3641																	232, 280											357, 1622					3677, 5556				10615, 10792		1854, 1860					1644, 1712	1971, 2531
23,244	142,858	46292	Discharge summary	report	Admission Date: [2201-3-8] Discharge Date: [2201-3-16] Date of Birth: [2135-10-8] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1493] Chief Complaint: hypotension and hypothermia with diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 15499] is a 65 y.o. F s/p liver [Known lastname ] in [2196-6-5] for primary biliary cirrhosis, now admitted for hypotension, near syncope, vomiting, and hypothermia. The patient is not a good historian, but she reports that she went to a coffee shop today before she wanted to run some errants. In the coffee shop she started to feel fatigued, lightheaded and weak. She went to the bathroom, but had trouble to get up from the toilet. She then walked out of the bathroom and asked for help. She reports vomiting only if she gets probed about it and reports nausea preceeding the vomiting. She states that she vomits bilious vomitus about once daily. She denies any blood in her vomitus. She also reports intermittent abdominal pain in her lower abdomen, that she associates with Lactulose intake. The patient reports that she might have missed some of her Lactulose and immunosupressive medications. . Of note, she has been recently hospitalized twice in [8-13] and [11-13] for hepatic encephalopathy. . In the ED, VS: 96.6 78 109/56, initially. Pt then became hypothermic with a temperature to 34.8 rectally. Her pressure continued to rise and was 186/83 on discharge from the ED. The patient received cefepime, vancomycin, and dexamethasone. Urine culture and blood cultures were sent. A CXR showed no evidence of acute cardiopulmonary process. Preliminary results of a CT torso showed no evidence of a septic source or other etiology for deompensated status; few nonspecific ground glass foci in the right lung with a large amount of fluid in the esophagus to level of thoracic inlet. She was also evaluated by [Month/Year (2) ] surgery, which did not feel that there was anything acute to recommend or intervene upon. . Currently, Ms. [Known lastname 15499] feels fine and has no particular complaints. . ROS: Denies CP, SOB, arthralgias, myalgias, headache, vision cahnges, confusion, dysuria, abdominal pain (out of the ordinary). She reports lighter stools and darker urines recently. She also denies cough. She reports fever, but when asked when she states "when in the coffee shop last time" and then "when here in the hospital". She reports weight loss, but is unsure how much. Past Medical History: - Insulin dependent Diabetes - Primary biliary cirrhosis s/p orthotopic liver [Known lastname ] [Month (only) ] [2196](followed by Dr. [Last Name (STitle) 497] c/b recurrence of PBC, multiple episodes of acute rejection, CMV viral infection and anastomotic biliary stricture s/p balloon dilatation and stent via ERCP [11-12] (AST 71 in [3-13], ALT 62) - Hypothyroidism - Osteoporosis (followed by Dr. [Last Name (STitle) ] currently off Boniva since [2200-4-11] - Secondary hyperparathyroidism due to low dietary vitamin D and calcium - Pulmonary artery hypertension (mild, gradient ~ 32 mm Hg) - Hypertension - Delayed gastric emptying on Reglan Social History: She lives by herself in [Location (un) ], and her nearest family lives in [State 2748]. Her sister-in-law is her HCP. She does not have any children. She denies current tobacco, ethanol, or drug use, but previously smoked 1 ppd x many years. She is retired but formerly worked at the [Hospital ] Medical Library for over 40 years. Walks with a cane at baseline. Family History: Noncontributory Physical Exam: Vitals - T: 97.6 BP173/86: HR:81 RR:18 02 sat:99RA GENERAL: NAD, alert oriented x 3 HEENT: mmm, clear OP, mild icteric sclera CARDIAC: S1S2, no m/r/g RRR LUNG: clear to auscultation bilaterally ABDOMEN: soft, mild tenderness in epigastrium and LLQ. no rebound. EXT: no edema. Left hand edema- mild erythema. NEURO: AAOx3. + asterixis. Pertinent Results: [2201-3-8] 09:07PM LACTATE-2.7* [2201-3-8] 06:00PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.026 [2201-3-8] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG [2201-3-8] 06:00PM URINE RBC-0-2 WBC-[3-11] BACTERIA-OCC YEAST-NONE EPI-0-2 TRANS EPI-[3-11] [2201-3-8] 06:00PM URINE HYALINE-[3-11]* [2201-3-8] 06:00PM URINE MUCOUS-FEW [2201-3-8] 05:57PM TYPE-[Last Name (un) ] PO2-51* PCO2-26* PH-7.27* TOTAL CO2-12* BASE XS--13 [2201-3-8] 05:57PM GLUCOSE-175* LACTATE-5.6* NA+-142 K+-3.2* CL--111 [2201-3-8] 05:45PM GLUCOSE-191* UREA N-20 CREAT-1.3* SODIUM-143 POTASSIUM-3.2* CHLORIDE-110* TOTAL CO2-11* ANION GAP-25* [2201-3-8] 05:45PM estGFR-Using this [2201-3-8] 05:45PM ALT(SGPT)-49* AST(SGOT)-57* CK(CPK)-49 ALK PHOS-393* TOT BILI-2.0* [2201-3-8] 05:45PM LIPASE-60 [2201-3-8] 05:45PM CK-MB-NotDone cTropnT-<0.01 [2201-3-8] 05:45PM CALCIUM-9.8 PHOSPHATE-5.0# MAGNESIUM-2.0 [2201-3-8] 05:45PM TSH-55 [2201-3-8] 05:45PM T4-8.8 FREE T4-1.1 [2201-3-8] 05:45PM WBC-7.2 RBC-4.66 HGB-14.5 HCT-44.4 MCV-95 MCH-31.0 MCHC-32.5 RDW-15.3 [2201-3-8] 05:45PM NEUTS-69 BANDS-0 LYMPHS-23 MONOS-5 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2201-3-8] 05:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [2201-3-8] 05:45PM PLT SMR-NORMAL PLT COUNT-316 LPLT-3+ PLTCLM-1+ [2201-3-8] 05:45PM PT-13.4 PTT-35.1* INR(PT)-1.2* Brief Hospital Course: In Brief, this is a 65 y/o F s/p liver [Year/Month/Day ] [2196] for PBC, hypertension, hypothyroidism who presented with hypotension and hypothermia to the ED on [2201-3-8]. ON arrival, VS T 92, HR 73, Bp 74/58, RR 27 sats 100 2l. She was initially admitted to the ICU. Broad spectrum antibiotics were given vancomycin, cefepime and Decadron. IV fluids were given ~ 3 L obtaining good response. Her initial WBC 7 with no bands, second value WBC 8.6 with 19 bands. Blood CX and urine CX were obtained. Chest x ray with no clear infiltrates although Ct torso showed R lower Lobe ground glass attenuation (this has to be followed up in one month by repeat CT). Ct abdomen with no acute intraabdominal pathology but with a distended fluid filled esophagus. . In the unit she was never hypotensive - instead hypertensive into the 170's. IV fluids were continued, antibiotics as well. she was found with persistent diarrhea up to 6-7 episodes a day. She was started on Flagyl [2200-3-9] for ? c Diff. C Diff sent x 1 negative. r/o for MI. TSH was elevated but free T4 was normal. She also had metabolic acidosis, with low bicarb, thought to be due to diarrhea. Currently she feels well, no clear complaints. she has been tolerating PO's. . # diarrhea: significant improvement, now bowel movement x4 on lactulose, stool negative for C-Diff x3 and no other pathogen could be identified. Given sudden leukopenia, thought to be consistent with viral gastroenteritis. # s/p Liver Transplantation: continued tacrolimus with decreased dose from 1.5 Q12H to 1 mg Q12H, as trough levels were on the upper normal range. Continued Bactrim SS 3x/week prophylaxix. . # hepatic encephalopathy: resolved with lactulose and rifaximin. . # HTN: BPs remained elevated. Switched back to captopril 50 mg [Hospital1 ] and low dose BB started (metoprolol 12.5 [Hospital1 ]). . # Depression: continued Sertraline . # Hypothyroidism: continue Levothyroxine Medications on Admission: MEDICATIONS: per [Name (NI) ] pt does not recall - on admission Captopril 50 mg po BID Ergocalciferol (Vitamin D2) 50,000 units po weekly Nexium 40 mg po BID Lactulose 30 ml po TID Levothyroxine 75 mcg po daily Metoclopramide 10 mg po TID Sertraline 50 mg po daily Sucralfate 1 gm po QID Tacrolimus 1.5 mg po BID Bactrim SS 1 tablet po q Mon/Wed/Fri Ursodiol 600 mg po BID Calcium carbonate 500 mg po BID Ferrous Sulfate 325 mg po BID Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Levothyroxine 25 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR) (). 10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week: Tuesdays. 13. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 ] CENTER Discharge Diagnosis: 1. Hepatic encephalopathy 2. Gastroenteritis Primary biliary cirrhosis s/p orthotopic liver [Hospital6 ] [Month (only) ] [2196](followed by Dr. [Last Name (STitle) 497] c/b recurrence of PBC, multiple episodes of acute rejection, CMV viral infection and anastomotic biliary stricture s/p balloon dilatation and stent via ERCP [11-12] (AST 71 in [3-13], ALT 62) Systemic hypertension Pulmonary artery systolic hypertension Diabetes mellitus Depression Osteoporosis Colonic adenoma in [2196] Hypothyroidism Secondary hyperparathyroidism [2-7] low dietary vitamin D and calcium Discharge Condition: Good Discharge Instructions: You were admitted with acute mental status change, hypotension, and diarrhea. You were given lactulose, fluids and antibiotics and your condition improved. We decreased the dose of your Tacrolimus to 1 mg evert 12 hours. . Please call your doctor or 911 if you feel confused, have diarrhea, fever or any other health concerns. Followup Instructions: Please follow up with your appointments: - Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2201-4-1] 9:20 - Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2201-4-28] 9:00 blease arrive 20 minutes prior to test	[ "276.8", "E878.0", "244.9", "996.82", "V58.67", "V15.82", "571.6", "V15.81", "008.8", "276.2", "536.3", "252.02", "733.00", "416.8", "311", "E849.0", "572.2", "250.60" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9382, 9432	5727, 7681	336, 343	10083, 10090	4111, 5704	10465, 10779	3723, 3740		8171, 9359		9453, 10062		7707, 8148			10114, 10442										3755, 4092																								255, 298											371, 2609																2631, 3315	3331, 3707
5,209	164,089	13900	Discharge summary	report	Admission Date: [2102-5-15] Discharge Date: [2102-5-17] Date of Birth: [2051-2-6] Sex: M CHIEF COMPLAINT: Chief complaint was question choreoathetosis. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old patch 50 mcg per hour, who states he took Benadryl the evening prior to admission and subsequently had uncontrollable arm and leg movements. He went to [Hospital3 15174]. Per the notes there, the patient had complained of back pain and "itchy feet" that resolved. The patient was noted to have athetosis. A Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], and it was felt that the patient could have been having an adverse reaction to the Fentanyl and Benadryl as a rare side effects of these medications is athetosis. The patient was initially treated with Benadryl prior to them discovering that this may have been causing his symptoms with worsening of his symptoms. He then was given Ativan for a total of 26 mg. He also received morphine, Narcan, and 5 mg of intravenous Valium. The patient was noted to have some improvement in his movements, but also developed agitation requiring four-point restraints. He was then transferred to [Hospital1 69] where he was admitted to the Medical Intensive Care Unit. On arrival here, his temperature was 99.2. His other vital signs were stable. It was decided to stop using Ativan for his movement disorder, and he was changed to droperidol to block dopamine. At the time of arrival, he denied any pain, and he was unable to recall the events of the evening prior. PAST MEDICAL HISTORY: 1. History of Vicodin abuse in the past; subsequently on a Fentanyl patch. 2. Depression. 3. Chronic low back pain. 4. Question of hepatitis C; which the patient states he obtained secondary to a blood transfusion during parotid surgery. MEDICATIONS ON ADMISSION: Medications at home included a Fentanyl patch 50 mcg. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is currently staying with his mother [Name (NI) 41643] [Name (NI) 41644] (telephone number [Telephone/Fax (1) 41645]), as he states he is afraid to stay in his own apartment secondary to fears about the insulation causing all of his health problems. [Name (NI) ] smokes one pack of cigarettes per day. He denies any alcohol use. He states that he smoked marijuana in the remote past but denies any current use. He denies any history of intravenous drug use. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 101, blood pressure of 135/66, heart rate of 85, oxygen saturation of 96%. In general, the patient was somnolent but easily arousable to voice. Head, eyes, ears, nose, and throat showed the sclerae to be anicteric. Pupils were equal, round and reactive to light. Extraocular movements were intact. The oropharynx was slightly dry. The neck was supple. There was no jugular venous distention, and no lymphadenopathy. The lungs were clear to auscultation bilaterally. The heart had a regular rate and rhythm. No murmurs, rubs or gallops. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. There was no hepatosplenomegaly. The extremities were without clubbing, cyanosis or edema. Neurologic examination showed the patient to be somnolent but easily arousable. He was oriented to "[Hospital3 ]" and [2102-5-15]." He answered simple questions and moved all extremities. Cranial nerves II through XII were grossly intact. His toes were downgoing bilaterally. Deep tendon reflexes were 2+ throughout. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from the outside hospital showed a white blood cell count of 7.8, hematocrit of 46.8, platelets of 213. Sodium of 139, potassium of 4.1, chloride of 101, bicarbonate of 27, blood urea nitrogen of 16, creatinine of 0.7, blood sugar of 108. Calcium of 9.4, albumin of 3.8, ALT of 119, AST of 45, alkaline phosphatase of 68. Creatine kinase of 451, with a MB index of 1. On arrival to [Hospital1 69] the patient's sodium was 144, potassium of 4, chloride of 109, bicarbonate of 24, blood urea nitrogen of 15, creatinine of 0.6, blood sugar of 84. ALT was 95, AST was 76, amylase of 41, alkaline phosphatase of 59. Creatine kinase of 2526, lipase of 6. Lithium level was less than 0.2. Toxicology screen was positive for barbiturates and opiates. A strychnine level was pending at the time of admission. RADIOLOGY/IMAGING: A head CT showed no acute process. HOSPITAL COURSE: In summary, the patient is a 51-year-old male who was admitted to the [Hospital1 188] with what was felt to be an adverse reaction to Fentanyl and Benadryl administration. He was originally admitted to the Medical Intensive Care Unit for observation after he had received a lot of benzodiazepines as well as droperidol. In the Medical Intensive Care Unit, the patient was noted to have rising creatine kinases with a negative MB index and an elevated temperature. He was transferred out to the general medical floor on the second hospital day in stable condition with a decreased temperature, and no further abnormal movements. 1. NEUROLOGY: A Neurology consultation was obtained when the patient was first admitted given that he had fever and mental status changes. It was felt that the patient's abnormalities were most likely secondary to a medication reaction, as they promptly resolved after withdrawal of the offending agents. The question of a lumbar puncture was raised, but given the patient's lack of neurologic findings, lack of meningeal signs, and quick resolution of fever without antibiotics, no lumbar puncture was ever obtained. The question of possible neuroleptic malignant syndrome was considered given the patient's clinical presentation. However, the patient adamantly refused taking any neuroleptic medications. The patient's primary care physician was not aware of the patient taking any current neuroleptic medications as well. 2. PSYCHIATRY: As stated, the patient was exhibiting delusional behavior. He was preoccupied about formaldehyde insulation that was present in his subsidized apartment. He denied any auditory or visual hallucinations. He stated that he felt like he was depressed but denied any active suicidal ideation, but stated that he did think about hurting himself from time to time but could "never do it." He indicated that he had, in the past, been under the care of a psychiatrist. His primary care physician was [Name (NI) 653] regarding his baseline mental status, and it was found that this has been a long-term issue for him, and that she has seen him three times in the past, and he has exhibited this same type of behavior at her office. In fact, he even brought a sample of powder which he said was the offending [Doctor Last Name 360] into her office at one point. A Psychiatry consultation was called to assess for the patient's safety to be discharged on the third hospital day. They felt the patient did seem paranoid and delusional but was not at risk of harm to himself or others and was safe to be discharged. They recommended outpatient psychiatric treatment if the patient would agree to it. I spoke to the patient's primary care physician, [Name10 (NameIs) ] she stated that she would attempt to get the patient into a program given the findings above. 2. GASTROINTESTINAL: The patient also reported a history of hepatitis C that he stated was secondary to a blood transfusion that he received. Hepatitis serologies and ultimately came back showing him to indeed be hepatitis C positive. In addition, serologies were consistent with past exposure to hepatitis B with hepatitis B surface antibody and hepatitis B core antibody both positive; but hepatitis B surface antigen negative. The patient's AST and ALT were mildly elevated while admitted. He also described a history of a 40-pound to 50-pound weight loss over the past one to two years as well as anorexia and chronic nausea and vomiting. He did not have any stigmata of chronic liver disease on physical examination, however. Given his weight loss and long-term history of hepatitis with elevated liver enzymes, there was concern for hepatoma. I spoke with the patient's primary care physician and informed her of the hepatitis serology results as well as the fact that his liver enzymes were elevated. She stated she would get the patient referred to Gastroenterology. 3. INFECTIOUS DISEASE: As stated, the patient had a temperature at the time of admission after he had significant agitation and muscular rigidity secondary to his presumed drug reaction. He never had an elevated white blood cell count. He had been afebrile for more than 24 hours at the time of this Discharge Summary. There was concern for possible urinary tract infection, as a urine sample which had been sent while a Foley was in place showed a significant amount of blood with white blood cells present. However, there were no bacteria seen, and there was a significant amount of red blood cells consistent with trauma from the Foley. A repeat urinalysis was sent when the Foley was removed, and this showed still blood present but no nitrites and no leukocyte esterase. There were no bacteria seen on microscopy. It was felt that his urine findings were most likely secondary to trauma from the Foley and not infection. His cultures have remained negative. Blood cultures have remained negative as well. Stool cultures were negative for Clostridium difficile, Salmonella, and Shigella. 4. RENAL: The patient did have a rise in his creatine kinase amount after having his initial episode of agitation and significant thrashing about with injury to his arms and legs when he was in the four-point restraints. His creatine kinases peaked at 8868 on the second hospital day, and on the third hospital day they were trending down. At the time of this Discharge Summary the most recent creatine kinase was 5569. There was another creatine kinase pending for this afternoon. If it is still trending down, the patient will be discontinued from his intravenous fluids. His renal function had remained stable with a stable blood urea nitrogen and creatinine. 5. COMMUNICATIONS: The patient's primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 41646] (at telephone number [Telephone/Fax (1) 41647]) was [Telephone/Fax (1) 653] throughout the [Hospital 228] hospital stay and informed of the events which occurred. CONDITION AT DISCHARGE: Condition on discharge was stable. MEDICATIONS ON DISCHARGE: The patient was to be given a prescription for Vicodin one to two tablets p.o. q.6h. p.r.n. for back pain. He was given a prescription for 10 pills. DISCHARGE FOLLOWUP: The patient was to follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 41646], within one week following discharge. He will need further evaluation for pain control and possibly a chronic pain unit consultation to help manage his back pain. In addition, he will need follow up for his hepatitis C and elevated liver enzymes. He also needs psychiatric followup of his likely delusional disorder. DISCHARGE DIAGNOSES: 1. Choreoathetosis secondary to Fentanyl/Benadryl. 2. Hepatitis C. 3. Chronic low back pain. 4. Delusional disorder. [First Name11 (Name Pattern1) 4283] [Last Name (NamePattern4) 4284], M.D. [MD Number(1) 7551] Dictated By:[Last Name (NamePattern1) 6859] MEDQUIST36 D: [2102-5-17] 13:47 T: [2102-5-18] 08:34 JOB#: [Job Number 27843] cc:[Numeric Identifier 41648]	[ "292.0", "333.5", "E933.0", "996.76", "304.00", "070.54", "297.9", "E935.2", "728.89" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								11346, 11781				10705, 10856	1885, 1994	4562, 10627																												10642, 10678								135, 182					10878, 11325						211, 1593																1615, 1858	2011, 4544
73,843	158,983	54826	Discharge summary	report	Admission Date: [2135-5-31] Discharge Date: [2135-6-7] Date of Birth: [2094-7-18] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 495] Chief Complaint: Feeling unwell Major Surgical or Invasive Procedure: IJ CVL placement History of Present Illness: 40 yo male with history of heroin abuse, Hepatitis C, and recently diagnosed diabetes mellitus who presented to an OSH as he was feeling unwell. He reports a recent diagnosis of diabetes, after classic symptoms of polydipsia, polyuria, and 20lb weight loss with thrush of his oral cavity and his genitalia. He then reports fevers, nausea, nonbloody bilious vomiting, myalgais, and rash on his left ankle over the past few days. He was feeling unwell so he tried to treat his diabetes by having carbohydrates, so he had multiple popsicles and liters of soda. This did not help his symptoms so his brother brought him to [Name (NI) ] [Last Name (NamePattern1) ] Hospital. At the OSH, he reportedly presented with a heroin overdose and was lethargic on their initial exam. He initially responded to narcan with return to baseline mental status. He was noted to have a blood sugar of 1200. He was given 1L of fluid and started on insulin drip and vancomycin given concern for celluitis because of several erythematous areas on his body. Enroute per EMS patient became more altered and started having hallucinations. OSH labs: K 2, Bicarb 13, Cr 1.8, Osm 336, serum tox positive for opiates otherwise negative, urine ketones positive. He was transferred to [Hospital1 18] as there were no ICU beds available at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. On arrival at [Hospital1 18], he complained of being extremely thristy. He admits to heroin abuse today. He also reported SI. He states he was recently diagnosed with type 2 diabetes but has continued to eat a high carbohydrate diet at home. Initial V/S on arrival: 140 28 109/52 100% on RA. A right IJ was placed. This was confirmed on CXR w/ no obvious PTX. He was given 4L IVF NS, and 1L with potassium. He received 15units of insulin and then an insulin drip at 12 units/hour. Mental status A&Ox3. V/S prior to transfer: 98.6 136 149/73 28 100% on RA. On arrival to the MICU, he is thirsty, hungry, and notes left ankle pain. Past Medical History: DM Hepatitis C Social History: Smokes 10cigs/day for 24 years, quit 1 month ago. No EtOH abuse, +IVDU with heroin, last use yesterday. Family History: Brother with DM2, mother died of heart disease, father is healthy. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMdry, oropharynx clear, EOMI, PERRL, 5mm bilateral pupils Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended GU: +foley Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema, warm tender erythematous patch on left inner ankle, multiple tattoos, left axillary pustule, right axillary erythematous papule, multiple track marks on bilateral arms Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: [2135-5-31] 12:52AM BLOOD WBC-12.0* RBC-4.18* Hgb-12.3* Hct-35.0* MCV-84 MCH-29.4 MCHC-35.1* RDW-13.6 Plt Ct-209 [2135-5-31] 12:52AM BLOOD Neuts-88.1* Lymphs-6.4* Monos-5.1 Eos-0.2 Baso-0.1 [2135-5-31] 12:52AM BLOOD PT-12.6* PTT-25.9 INR(PT)-1.2* [2135-5-31] 12:32PM BLOOD ESR-114* [2135-5-31] 12:52AM BLOOD Glucose-524* UreaN-19 Creat-1.4* Na-141 K-2.7* Cl-108 HCO3-20* AnGap-16 [2135-5-31] 12:52AM BLOOD ALT-25 AST-17 AlkPhos-91 TotBili-0.5 [2135-5-31] 05:54AM BLOOD Lipase-30 [2135-5-31] 04:46PM BLOOD CK-MB-3 cTropnT-<0.01 [2135-5-31] 12:52AM BLOOD Albumin-2.9* Calcium-8.3* Phos-1.3* Mg-2.2 [2135-6-3] 03:36AM BLOOD %HbA1c-13.6* eAG-344* [2135-5-31] 04:02AM BLOOD Osmolal-306 [2135-5-31] 05:29AM BLOOD PTH-32 [2135-6-1] 09:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2135-6-1] 02:48AM BLOOD [Doctor First Name ]-NEGATIVE [2135-5-31] 12:32PM BLOOD CRP-GREATER THAN 300 [2135-5-31] 12:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2135-6-1] 09:30PM BLOOD HCV Ab-POSITIVE* [2135-5-31] 12:56AM BLOOD Lactate-2.6* Micro: [2135-5-31] 2:52 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2135-5-31] 7:34 am BLOOD CULTURE Source: Line-CVL. FINAL REPORT [2135-6-3] Blood Culture, Routine (Final [2135-6-3]): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN >2 MCG/ML. STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 350-8155C [2135-5-31]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- 4 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [2135-5-31]): GRAM POSITIVE COCCI IN CHAINS. Reported to and read back by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ON [2135-5-31] @ 1010 PM. Aerobic Bottle Gram Stain (Final [2135-6-1]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [2135-5-31] 7:28 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2135-6-3] Blood Culture, Routine (Final [2135-6-3]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 350-8155C [2135-5-31]. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. STAPHYLOCOCCUS LUGDUNENSIS. SECOND MORPHOLOGY. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS LUGDUNENSIS \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- 2 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [2135-6-1]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by DR. [Last Name (STitle) 13480] [Name (STitle) 3078] PAGER# [Serial Number 3079] @ 0620 ON [2135-6-1]. Anaerobic Bottle Gram Stain (Final [2135-6-1]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS [2135-6-1] 2:03 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2135-6-3] C. difficile DNA amplification assay (Final [2135-6-2]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [2135-6-3]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2135-6-3]): NO CAMPYLOBACTER FOUND. Imaging: TTE: The left atrium is elongated. 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. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No significant regurgitant valvular disease seen. Study is technically suboptimal to exclude a small vegetation. BLE LENIs: No son[Name (NI) 493] evidence of deep venous thrombosis within the bilateral lower extremities. 3V LEFT ANKLE: 1. Mild degenerative changes of the tibiotalar joint. 2. No subcutaneous air is noted. Please clinically correlate as radiographs cannot exclude the presence of necrotizing fasciitis. CTA CHEST: 1. No evidence of pulmonary embolism or acute aortic syndrome. Subsegmental arteries could not be assessed as the study was technically inaequate due to respiratory motion artifact. 2. Multiple pulmonary lesions, some of which shows probable early cavitation, are concerning for septic emboli with incipient pulmonary abscess formation. Other less likely diagnoses are metastatic disease or multifocal pneumonia secondary to atypical mmicroorganism such as fungi or mycobacteria. 3. Extensive bibasilar atelectasis, with nearly complete collapse of the left lower lobe. RUE U/S: Limited exam of the right IJ and small segment of the proximal right subclavian vein due to patient's noncooperation and overlying bandage overlying the central venous catheter. The more peripheral central venous structures are patent. [2135-6-7] 05:34AM BLOOD WBC-16.9* RBC-3.98* Hgb-11.3* Hct-33.3* MCV-84 MCH-28.4 MCHC-33.9 RDW-14.0 Plt Ct-387 [2135-6-6] 03:04AM BLOOD WBC-15.6* RBC-4.12* Hgb-11.9* Hct-34.5* MCV-84 MCH-28.8 MCHC-34.4 RDW-14.3 Plt Ct-408 [2135-6-5] 03:53AM BLOOD WBC-12.0* RBC-3.93* Hgb-11.4* Hct-32.9* MCV-84 MCH-29.0 MCHC-34.7 RDW-14.3 Plt Ct-283 [2135-6-4] 03:39AM BLOOD WBC-13.7* RBC-4.20* Hgb-11.9* Hct-35.0* MCV-83 MCH-28.4 MCHC-34.0 RDW-14.3 Plt Ct-255 [2135-6-3] 03:36AM BLOOD WBC-12.3* RBC-4.20* Hgb-12.0* Hct-34.5* MCV-82 MCH-28.6 MCHC-34.8 RDW-14.1 Plt Ct-216 [2135-6-7] 05:34AM BLOOD Neuts-83.7* Lymphs-11.3* Monos-4.1 Eos-0.5 Baso-0.3 [2135-6-7] 06:12AM BLOOD PT-14.2* PTT-27.5 INR(PT)-1.3* [2135-6-7] 05:34AM BLOOD Glucose-223* UreaN-4* Creat-0.6 Na-136 K-3.4 Cl-98 HCO3-24 AnGap-17 [2135-6-6] 07:30AM BLOOD Na-134 K-3.7 Cl-100 [2135-6-6] 03:04AM BLOOD Glucose-237* UreaN-4* Creat-0.7 Na-139 K-4.0 Cl-102 HCO3-25 AnGap-16 [2135-6-5] 06:41PM BLOOD Na-133 K-3.3 Cl-97 [2135-6-7] 05:34AM BLOOD ALT-19 AST-19 AlkPhos-91 TotBili-0.4 [2135-6-5] 03:53AM BLOOD LD(LDH)-262* [2135-6-4] 03:39AM BLOOD ALT-22 AST-22 LD(LDH)-359* AlkPhos-100 TotBili-0.4 [2135-6-3] 03:36AM BLOOD ALT-24 AST-25 AlkPhos-85 TotBili-0.5 [2135-6-7] 05:34AM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.2 Mg-1.7 [2135-6-6] 03:04AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 [2135-6-5] 03:53AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9 [2135-6-4] 06:07PM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0 [2135-6-7] 06:12AM BLOOD Vanco-28.1* [2135-6-6] 07:30AM BLOOD Vanco-21.8* [2135-6-6] 05:43PM BLOOD HIV Ab-NEGATIVE [2135-6-3] 12:03PM BLOOD Type-CENTRAL VE pO2-29* pCO2-35 pH-7.47* calTCO2-26 Base XS-0 Brief Hospital Course: 40 yo male with history of Hepatitis C and IVDU with recent diagnosis of diabetes who presented with profound hyperglycemia, new diagnosis of DM, narcotic withdrawal, LLE cellulitis, pulmonary nodules presumed to septic emboli, and GBS and staph bacteremia. 1. GBS and Staph lugdenesis bacteremia complicated by pulmonary nodules presumed to be septic emboli. Unsure of the source. Normal TTE and TEE. Wanted to consider CT abdomen for source though he decided to leave understanding the risks. He was started on ampicillin/vancomycin. He was subsequently switched to vancomycin as all of his bugs were covered with IV vancomycin. He decided to leave the hospital understanding the risk of not treating his infection against medical advice. --> Discharge recommended IV vancomycin 1250 q6. Presumed treatment for at least four weeks for endocarditis. No growth from BC from [2135-6-2]. # Sinus tachycardia: Likely due to withdrawal. He was not in pain or anxious. There was low clinical concern for pontine hemorrhage or pulmonary embolism. # Self terminating torsades: Likely multifactorial from electrolyte imbalance to Haldol QTc effect. --> High risk for Haldol in the future. # Heroin withdrawal: Patient with less signs of withdrawal and clinically was not withdrawing on exam. # Diabetes mellitus: HgbA1c 13.6. AG closed [2135-5-31]. Likely overlap of DKA (with classic symptoms of polyuria, polydipsia, and dehydration, AG metabolic acidosis, and ketosis) and HHNK (with extreme hyperglycemia, dehydration, and [Last Name (un) ]). Appropriate glucose control with lantus and sliding scale insulin. Diabetic teaching given by nursing prior to DC/AMA. # Thrush: In the setting of newly diagnosed diabetes. HIV negative. # Hep C: Untreated. Patient currently not a candidate to undergo therapy. # Suicidal ideation: denied . # Left the hospital against medical advise. MICU and Pysch team evaluated him and he understood the risks detrimental to his life of leaving his medical care here. He was deemed ok to leave AMA. Thyroid U/S as outpt Medications on Admission: Topical nystatin Discharge Medications: None given since he left AMA Discharge Disposition: Home Discharge Diagnosis: Opioid withdrawal Polymicrobial bacteremia Pulmonary septic emboli Diabetes DKA Discharge Condition: 1. GBS and Staph bacteremia Discharge Instructions: You decided to leave against medical advise. We strongly encourage you to talk to PCP or admission to hospital next to you for treatment of your infection Followup Instructions: You decided to leave against medical advise. We strongly encourage you to talk to PCP or admission to hospital next to you for treatment of your infection	[ "593.9", "070.54", "415.12", "038.0", "038.12", "733.6", "V49.87", "682.6", "112.0", "292.0", "787.91", "250.13", "276.8", "427.1", "304.01" ]	icd9cm	[ [ [] ] ]	[ "81.91", "94.65", "38.97", "88.72" ]	icd9pcs	[ [ [] ] ]	15305, 15311	13106, 15185	325, 343	15434, 15463	3294, 4497	15666, 15823	2585, 2654		15252, 15282		15332, 15413		15211, 15229			15487, 15643										2669, 3275						4541, 13083																		271, 287											371, 2409																2431, 2447	2463, 2569
68,780	185,579	53538	Discharge summary	report	Admission Date: [2170-6-19] Discharge Date: [2170-6-30] Date of Birth: [2087-11-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization [2170-6-21] Cardiac catheterization [2170-6-22], impella supported with drug eluting stents placed to left main and LAD PICC placement [2170-6-23] Right Femoral Dialysis Catheter placement [2170-6-25] History of Present Illness: 82-year-old woman post NSTEMI (infero-lateral ST dep and TWI TnT 6.41 presenting as CHF post L THR on [2170-2-12] and at angiography there was evidence of two vessel coronary artery disease including a 90% proximal stenosis and a 30% mid-vessel stenosis and occluded RCA. The proximal LAD lesion was stented with a bare metal stent. In addition, there was evidence of biventricular diastolic dysfunction and mild pulmonary arterial hypertension. Following her operation, she had a period of rehabilitation and was back to her baseline by [2170-5-8] at which point she was able to walk 50ft with a cane. By [2170-5-30] she became progressively short of breath such that prio to admition she had difficulty mobilizing to the bathroom. Her shortness of breath was more sever over the past 2 weeks although she denied any SOB at rest. In adition, she developed worsening orthopnea (4 pillows) with previously no requirement of no greater than 1 pillow. She noted increasing lower extremity edema and an increase in her weight from 112lb to 119lb. She initially was on 40mg od of furosemide which was increased to 40mg [Hospital1 ] and latterly metolazone was added. Due to hypotension which was otherwise asymptomatic (SBP in 80s) her lisinopril was reduced from 5mg to 2.5mg daily. Due to her symptoms, she presented for a repeat echocardiogram on [6-19] which showed significant worsening of cardiac function, an EF of 15%, significant AS, and moderate to severe MR. She was admitted for repeat coronary angiography. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She noted a four day history of dull epigastric discomfort at night that started [5-28] which was attributed to heartburn, however not relieved by ranitidine, that spontaneously resolved before planned assessment with U/S. No urinary complaints. There were no other positive symptoms. . Cardiac review of systems revealed no evidence of chest pain, palpitations, syncope or presyncope. Past Medical History: CARDIAC RISK FACTORS:(+)Dyslipidemia,(+)Hypertension PERCUTANEOUS CORONARY INTERVENTIONS: Stent to LAD [2170-2-5] . 1) Hypertension 2) Hyperlipidemia 3) Hx of L breast ca s/p lumpectomy [2150] no chemo/XRT 4) R THR [2166] - no complications 5) L THR complicated by NSTEMI as above 6) Abdominal shingles [2169-1-8] 7)Placed on warfarin for apical hypokinesis and concern of thrombus formation 8)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]. 9)History of diabetes type II, although most recent HgA1c was 5.8 ([2-/2170]) off of all medications 10) Depression Social History: Tobacco history: Denies. ETOH: denies. Illicit drugs: denies. Originally Hungarian. Current teacher of science and art to pre-school children. Prior to her discharge to rehab, she lived at home with her husband and was independent in her ADLs, IADLs and very functional. Previous exercise tolerance 50ft ? accurate. Recently limited by SOB using 1 cane post hip surgery, and limited to 3ft. 16 steps into house. Family History: Mother - angina. Father unknown - killed in concentration camp. Physical Exam: VS: T=97.2 BP=104/64 HR=91 RR=20 O2 sat= 90% RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP elevated at 6 cm. CARDIAC: PMI located in 5th intercostal space with mild displacement. RR, normal S1, S2. ESM and PSM with radiation to axilla and carotids (mild). No thrills, lifts. No S3 or S4. LUNGS: Lumpectopmy scar, no scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasal crackles worse on right with markedly decreased breath sounds bibasally associated with dullness to percussion. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. No ascites. EXTREMITIES: No c/c. No femoral bruits. Bilateral lower extremity pitting edema (2+) to knees. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ (but difficult given lower ext edema) Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ (but difficult given lower ext edema) NEURO: GCS 15/15. Upper and lower limb examination normal. Cranial nerves II-XII intact no fundoscopy performed but fields normal. Pertinent Results: Admission Labs: [2170-6-19] 03:04PM BLOOD WBC-6.2 RBC-3.92* Hgb-12.1 Hct-37.6 MCV-96 MCH-30.7 MCHC-32.0 RDW-14.4 Plt Ct-258 [2170-6-19] 03:04PM BLOOD PT-21.3* INR(PT)-2.0* [2170-6-19] 03:04PM BLOOD UreaN-52* Creat-1.2* Na-139 K-4.5 Cl-99 HCO3-29 AnGap-16 [2170-6-19] 03:04PM BLOOD CK(CPK)-240* [2170-6-19] 03:04PM BLOOD CK-MB-6 cTropnT-0.18* [2170-6-20] 05:31AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.4 Other Notable Labs: [2170-6-26] 01:36AM BLOOD WBC-11.9* RBC-2.50* Hgb-8.0* Hct-23.7* MCV-95 MCH-31.9 MCHC-33.6 RDW-17.3* Plt Ct-169 [2170-6-25] 03:59AM BLOOD PT-34.4* PTT-74.2* INR(PT)-3.5* [2170-6-25] 12:45PM BLOOD Glucose-203* UreaN-82* Creat-4.4* Na-131* K-5.5* Cl-93* HCO3-16* AnGap-28* [2170-6-26] 10:20PM BLOOD Lactate-2.0 [2170-6-28] 04:44AM BLOOD ALT-152* AST-182* CK(CPK)-577* AlkPhos-108* TotBili-0.8 [2170-6-27] 10:15AM BLOOD ALT-126* AST-137* CK(CPK)-331* AlkPhos-112* [2170-6-25] 03:59AM BLOOD ALT-29 AST-41* LD(LDH)-281* AlkPhos-73 TotBili-0.5 [2170-6-23] 05:22AM BLOOD CK(CPK)-80 [2170-6-27] 10:15AM BLOOD CK(CPK)-331* [2170-6-27] 03:52PM BLOOD CK(CPK)-294* [2170-6-28] 04:44AM BLOOD CK(CPK)-577* [2170-6-28] 10:03AM BLOOD CK(CPK)-612* [2170-6-28] 02:22PM BLOOD CK(CPK)-505* [2170-6-29] 04:08AM BLOOD CK(CPK)-271* [2170-6-29] 10:06AM BLOOD CK(CPK)-303* [2170-6-28] 10:03AM BLOOD CK-MB-10 MB Indx-1.6 cTropnT-0.50* [2170-6-28] 02:22PM BLOOD CK-MB-9 cTropnT-0.47* [2170-6-29] 10:06AM BLOOD CK-MB-9 cTropnT-0.47* Discharge Labs: [2170-6-29] 04:08AM BLOOD WBC-10.0 RBC-3.21* Hgb-10.2* Hct-31.5* MCV-98 MCH-31.7 MCHC-32.2 RDW-20.3* Plt Ct-215 [2170-6-29] 10:06AM BLOOD PTT-91.5* [2170-6-29] 04:08AM BLOOD PT-18.4* PTT-150* INR(PT)-1.7* [2170-6-29] 04:08AM BLOOD Glucose-117* UreaN-18 Creat-1.0 Na-131* K-4.0 Cl-93* HCO3-22 AnGap-20 [2170-6-29] 10:06AM BLOOD CK(CPK)-303* [2170-6-29] 04:08AM BLOOD ALT-174* AST-182* LD(LDH)-313* CK(CPK)-271* AlkPhos-107* TotBili-1.4 [2170-6-29] 10:06AM BLOOD CK-MB-9 cTropnT-0.47* [2170-6-29] 04:08AM BLOOD Calcium-9.8 Phos-2.2* Mg-2.1 [2170-6-29] 10:36AM BLOOD Type-[Last Name (un) ] pO2-30* pCO2-48* pH-7.38 calTCO2-29 Base XS-0 Comment-PERIPHERAL [2170-6-29] 10:36AM BLOOD freeCa-0.95* [2170-6-29] 04:08AM BLOOD ALT-174* AST-182* LD(LDH)-313* CK(CPK)-271* AlkPhos-107* TotBili-1.4 [Month/Day/Year ] [2170-6-19]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15 %) secondary to akinesis of the entire interventricular septum, anterior free wall, inferior free wall, and apex. The only segments of the left ventricle that are not akinetic or severely hypokinetic are the basal segments of the posterior and lateral walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. There are focal calcifications in the aortic arch. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2170-2-19], left ventricular contractile function is markedly further decreased; mitral regurgitation is significantly increased. [Year (4 digits) ] [2170-6-23]: LVEF 20%, moderate 2+ MR. [Last Name (Titles) ] [2170-6-25]: RV systolic function appear slightly worse, LEVF 25%, 3+ MR. [Last Name (Titles) ] [2170-6-27]: RV function appears slightly improved and estimated pulmonary artery pressure is lower. LVEF 20-25%, 3+ MR. [Month/Day/Year ] [2170-6-29]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = [9-21] %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2170-6-27], LV systolic dysfunction remains severely depressed. RV systolic function is now significantly depressed. ECG on admission [2170-6-19]: Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of [2170-2-26] no definite change. ECG [2170-6-28]: Sinus rhythm. Left bundle-branch block. Intermittent wide complex beats of different morphology that may be late-cycle ventricular premature beats versus possible changing pattern of intraventricular conduction delay showing left axis deviation. Since the previous tracing of [2170-6-27] there is no significant change. CXR on admission [2170-6-19]: Allowing for differences in patient positioning, large left and moderate right pleural effusions are not substantially changed. Together with basilar atelectasis, there is obscuration of the heart borders. Mild-to-moderate pulmonary edema is not changed. There is no pneumothorax. Aortic calcifications are noted. CXR [2170-6-26]: Progression of venous congestion with moderately large bilateral pleural effusions. Brief Hospital Course: 82F s/p NSTEMI [2-/2170] with stent to LAD who presented with worsening CHF, echo demonstrated significant worsening in LV function (LVEF 15%, most recent EF=20-25% [6-27]) and MR, s/p cardiac catheterization [2170-6-21] which revealed in-stent restenosis of proximal LAD and worsened atherosclerotic disease of left main stem. Impella with stenting of LMA lesions on [2170-6-22]. Her post-catherization recovery had been complicated by [Last Name (un) ], hypotension, and respiratory distress due to pulmonary edema. She developed left limb ischemia likely secondary to contrast nephropathy in addition to hypotension and her condition progressivly deteriorated and she died on [2170-6-30] after being made for comfort measures only on [6-29]. . # Systolic heart failure: Worsening SOB, increased pulmonary edema and bilateral pleurel effusions thought to be secondary to either worsening MR [First Name (Titles) ] [Last Name (Titles) ] cardiomyopathy on admission. Echo on day of admission revealed diminished LVEF for 15% and moderate 3+ MR. Cardiac cath on [2170-6-21] revealed 90% instent restenosis of the LAD stent as well as left main disease, and the patient underwent impella-supported PCI on [2170-6-22] with stenting of left main. She was electively intubated for the procedure following an episode of hypoxia the night of [2170-6-21] in which she temporarily required a non-rebreather and CPAP to maintain O2 sats. She was able to be extubated shortly after returning to the CCU. Repeat echo [2170-6-22] showed improved LVEF of 20% and reduced MR, 2+. The patient had a PICC line placed and was briefly started on dopamine, however she did not torelate this and it was discontinued. She later developed acute renal failure post-procedure with anuria likely due to a combination of low BP and contrast induced nephropathy requiring CVVH for which she was dependent. Her SBP was consistently low with SBP in 80s and was closely monitord. She started to recieve blood pressure support with Norepinephrine which she initially tolerated well and at highr levels was associated with increasingly [Month/Day/Year ] appearance of her left [Last Name (un) 5355] and she was eventually weaned off only to be restarted on the morning of [6-29]. Patient remained on oxygen via nasal cannula 3-4L, and maintained her O2 sats on this. She started heparin gtt ([6-28]) for both for her cardiac hypokinesis and any potential arterial embolism of her left leg after her INR decreased to subtherapeutic levels. By [6-29], her SBP ropped into tteh 70s and norepinephrine wa restarted although her [Month/Year (2) ] limbs became worse and her BP was only able to be maintained in the high 70s/low 80s. On [6-29] after discussion with her family, she was made for comfort measures only and an echo on [6-29] revealed a significantly decreased LVEF of only 10-15%, in addition to worse RV systolic function. She died on [6-30]. . # CAD: The patient had an NSTEMI in [2-/2170] s/p L THR surgery, and it was thought that an [Year (4 digits) ] cardiomyopathy may be the etiology for her current presentation. There was a question of whether her LAD stent had thrombosed, given significant worsening of LV function (EF 30-35% in [2170-2-19] to EF of 15% on admission [6-19]). The patient underwent a cardiac cath on [2170-6-21] to evaluate her coronary arteries, which revealed 90% in-stent restenosis in the proximal LAD, worsened atheresclerotic disease of the left main (ostial 70% left main lesion), and complete occlusion of the RCA with the distal RCA perfused via collaterals. The patient did not wish for surgical intervention, and then underwent an impella-supported PCI with stenting of the left main stem on [2170-6-22]. She was electively intubated for the procedure after a brief episode of hypoxia the night prior to the cath. After the interventional catherization her asprin, plavix was continued. She recieved simvastatin which was discontinued [6-28] given increasing LFTs. Metoprolol held given her hypotension. She was placed on heaprin drip after her INR became subtherapeutic on [6-28]. . # Acute Renal Failure: The patient's Cr trended up from 1.2 on admission to 3.0 on [2170-6-24]. A renal consult was called. Likely secondary to contrast nephropathy, as well as renal compromise in setting of hypotension. Patient remained anuric x6 days. Started CVVH [6-26], with goal of removing 50-100mL of fluid per hour through a femoral dialysis line. Electrolytes were closely monitored and repleted as needed. Hemodynamics and respiratory status were closely monitored. Resipratory status greatly improved with removal of fluid by dialysis but she remained anuric and was initially due to have a permanent dialysis catheter placed but was too unstable to go for the procedure so CVVH was continued with her femoral dialysis line. She developed progressive cardiovascular instability and she required furtehr inotropic support. She was made for comfort measures only on [6-29] and died on [6-30]. . # Hypotension - BP was hypotensive on admission, likely multifactorial and secondary to diuresis, anti-hypertensives and poor CO. SBP range generally 70s-90s with several SBP readings as low as 60s following administration of IV metoprolol which was held on most of the admission. Her BP was also felt to be contributory to her acute renal failuer which occurred post-cath and was felt to be in combination with contrast-induced nephropathy following two catheterisations and a high contrast burden. Norepinephrine was used intermittengly for blood pressure support and she was able initially to be weaned off this post-catheterisation however due to persistent severe hypotension on [6-29] this was restarted. She was made for comfort measures only on [6-29] and died [6-30]. . # Hyperlipidemia - She was continued on her home simvastatin until [2170-6-28], when it was stopped in setting of rising LFTs and elevated CK. . # [Month/Day/Year ] lower limbs in context of hypotension: On admission there were faintly palpable peripheral pulses in both feet left worse than right. Her left foot to the mid-shin was noted to be mottled since vasopressors were requierd to support her BP. She was reviewed daily by vascular who felt no acute intervention was needed but recommended a heparin infusion which was commenced on [6-28]. Leg appearance initially improved with weaning norepinephine and using bear-hugger to warm extremities however worsened with decreasing SBPs. Pulses in the feet were intermittently present on doppler in the right foot and absent on the left but this also varied as to being detectable. She also had considerable [Month/Year (2) ] limb pain requiring increasing levels of IV hydromorphoen with associated sedation. We continued the warming blanket which seemed to help her leg appearance and potentially pain. CK levels were trended in case of compartment syndrome following re-perfusion injury but generally decreased. By [6-29], both legs appeared [Month/Year (2) ], worse on the left with on pulses present on doppler and greatly decreased capillary refill worsening with falling BP. She was made for comfort measures only on [6-29] and died on [6-30]. . #Increasing LFT??????s ??????Possibly caused by hypoperfusion because of the diminished cardiac output from her [Month/Year (2) ] disease. Also could have been drug related. The AST/ALT levels were 182/174 respectively, and not remarkable enough for [Month/Year (2) ] liver. No signs of abdominal tenderness were seen on physical exam. We discontinued her statin and restarted tylenol only after increasing lower extremity pain. We trended her LFT's. . # Run of VT. On admission, patient was in sinus rhythm with LBBB (partial) and infero-lateral [Month/Year (2) ] changes on ECG. The patient had episodes of PVC??????s 15-20 beats intermittently at increasing frequency, and had several runs of NSVT. There was an episode of ?VT on [6-28] VT which EP felt rhythm more likely to be VT than SVT with aberrancy. Patient started on amiodarone infusion on [6-28]. Arrhythmia could be due to [Month/Year (2) ] ventricular tissue/reperfusion of injured ventricular tissue, or electrolyte imbalance. We trended electrolytes and repleted as needed. We held Metoprolol given her hypotension. She had no furtehr episodes of VT until her death on [6-30]. . #Thrush ??????observed on physical exam on [6-27]. Possibly caused by prolonged usage of facial oxygen mask and NC which can dry the mucous membranes. Admistered Nystatin swish and swallow which was administered by a tongue sponge. . # Leukocytosis- WBC trended down, after initially being elevated and patient was afebrile with no clinical signs of infection. However, given decline in hemodynamic stability, we monitored closely for signs of infection/sepsis. We followed up blood cultures and continue to trend WBC which was trending down. She did not require any antibiotics. # Confirmation of death - Dr [First Name8 (NamePattern2) 714] [Last Name (NamePattern1) ] [2170-6-30] Called to see patient at 0216. Patient's code status changed to comfort measures only earlier today, and she has been on morphine gtt titrated to patient's comfort. Patient seen and examined. Pupils fixed and dilated. No heart sounds or breath sounds auscultated. Carotid and radial pulses absent bilaterally. Telemetry monitor reveals asystole. Patient expired with husband at beside, daughter and son in waiting room. Family has declined autopsy. Attending Dr. [First Name (STitle) 437] notified. I hearby proclaim the patient, [Known firstname 110041] [Known lastname 6522], deceased. Time of death 02:35, [2170-6-30]. Medications on Admission: 1. Aspirin 325 mg daily 2. Clopidogrel 75 mg daily 3. Multivitamin1 tab daily 4. Lisinopril 2.5mg daily recent decrease from 5mg on [6-12] 5. Simvastatin 80 mg daily 6. Leuteine 6mg daily 7. Trazodone 50 mg QHS prn insomnia 8. Coumadin 5 mg daily 9. Furosemide 40mg [Hospital1 ] last dose on [6-18] 10. Acetaminophen Extra Strength 1000 mg TID PRN 11. Metoprolol Succinate 12.5 mg daily 12. Metolazone 2.5mg daily alt days. Discharge Medications: Morphine Sulfate 2-20 mg/hr IV DRIP Lidocaine 5% Patch 2 PTCH TD DAILY left foot, 12 hrs on, 12 hrs off Acetaminophen 650 mg PO/PR TID Lorazepam 0.5-1 mg IV Q4H:PRN Anxiety Capsaicin 0.025% 1 Appl TP TID Sarna Lotion 1 Appl TP [Hospital1 ]:PRN itching Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent. Discharge Disposition: Expired Discharge Diagnosis: patient has passed away Discharge Condition: patient has passed away Discharge Instructions: patient has passed away Followup Instructions: patient has passed away	[ "428.0", "584.5", "412", "426.0", "459.89", "414.01", "401.9", "427.1", "790.01", "785.51", "424.0", "E878.2", "E944.4", "996.72", "E879.0", "715.90", "997.1", "428.23", "427.31", "E849.7", "416.8", "300.4", "272.4", "458.29", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "88.56", "89.64", "00.66", "36.07", "37.22", "38.95", "39.95", "88.42", "38.93", "37.68", "00.41", "00.46", "39.64" ]	icd9pcs	[ [ [] ] ]	22184, 22193	11445, 21341	343, 588	22260, 22285	5394, 5394	22357, 22383	4061, 4126		21828, 22161		22214, 22239		21367, 21805			22309, 22334			6930, 11422							4141, 5375																								284, 305											616, 2834					5410, 6914											2856, 3615	3631, 4045
72,039	113,103	50505+59263	Discharge summary	report+addendum	Admission Date: [2114-8-10] Discharge Date: [2114-8-18] Service: MEDICINE Allergies: Vicodin Attending:[First Name3 (LF) 896] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Intubation History of Present Illness: The patient is an 89-year-old woman with a recent history of myelodysplastic syndrome requiring transfusions, presenting after experiencing abdominal pain at home. and not feeling well over the previous two days. The patient is a transfer from [Hospital1 ]. She was being worked up in their Emergency Room for a likely pancreatitis ("foggy" pancreas on CT with distended gallbladder). When she returned from the CT, she developed respiratory distress and tachypnea. She was treated with Benadryl duonebs. The patient was then intubated and sedated, after which she was transferred to [Hospital1 18] for additional care. She had received at least one dose of Zosyn at [Location (un) 620]. Upon originally arriving in the Emergency Department, she was not opening her eyes but she was following simple commands. The initial blood gas was 7.38/32/200/20, based on which the Emergency Department was willing to lower the FiO2 to 40%. The patient was also provided fentanyl for pain; propofol as her sedating [Doctor Last Name 360]. Surgery was consulted, but the patient was not felt to be a candidiate for cholecystectomy. The patient received 4 liters of fluid during her stay in the Emergency Department. She had a fever to 101.3 in the ED, for which she received Tylenol. The patient's vitals upon leaving the Emergency Department were HR 92 BP 111/53 RR 18 97% saturation on vent Fi O2 40 PEEP 5 Tv 500 with peak flow 20. . On arrival to ICU, patient was intubated and sedated but appeared comfortable. Her blood pressure dropped to 80s/50s, so she was bolused 1L of NS to which BP responded to 100s systolic. Daughter and granddaughter at bedside. Past Medical History: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT, HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR): -no current outpatient treaters, previously followed by Dr. [Last Name (STitle) 46087] [Name (STitle) 105194] hx of MDD -previous trials of imipramine, lithium, and outpatient ECT -previous trial of celexa in [2112] per OMR -1 previous inpatient hospitalization she reports she did not find helpful -denies hx of SA PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): hx of hyperthyroidnow now w/hypothyroidism treated w/ synthroid hx of breast CA s/p lumpectomy hx of paroxysmal a fib hx of MI hx of HTN hx of emboilism to right eye after arteriogram for MI hx of diverticular perforation, status post bowel resection Social History: She is widowed. She lives at [Location ] on the [Doctor Last Name ] in independent living. She has rare alcohol. No smoking. Lives independently. Gets help with housework. Does not walk with a walker. Family History: FAMILY PSYCHIATRIC HISTORY: Denies family hx of mental illness inlcuding depression, bipolar, schizophrenia -denies family hx of suicide attempts Physical Exam: On Admission: Vitals: BP: 103/43 P: 67 R: 17 18 O2: FiO2 40% General: Intubated, sedated, responds to voice, does not follow commands HEENT: Sclera anicteric, intubated Neck: Supple, no LAD Lungs: Diffuse rhonchi and expirtaory wheeze CV: S1, S2, systolic ejection murmur Abdomen: soft, distended, bowel sounds very quiet, no apparent rigidity GU: Foley in place Ext: warm, well perfused, 2+ radial pulses, edema of lower extremities Pertinent Results: On Admission: [2114-8-10] 03:45AM BLOOD WBC-5.4 RBC-2.17# Hgb-6.5# Hct-19.6# MCV-90# MCH-30.0 MCHC-33.3 RDW-20.5 Plt Ct-15# [2114-8-10] 03:45AM BLOOD PT-13.0 PTT-22.6 INR(PT)-1.1 [2114-8-10] 03:45AM BLOOD Glucose-122 UreaN-19 Creat-1.0 Na-138 K-3.6 Cl-111* HCO3-17* AnGap-14 [2114-8-10] 03:45AM BLOOD ALT-28 AST-31 LD(LDH)-407* AlkPhos-49 TotBili-1.1 [2114-8-10] 03:45AM BLOOD Lipase-1579* Studies: CXR [8-13]-Confluent lower lobe opacities with a left effusion, small, likely represent atelectasis. Echo [8-10]-Mild regional left ventricular systolic dysfunction, c/w CAD. Calcific aortic valve disease with minimal stenosis/mild regurgitation. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. RUQ US-IMPRESSION: Distended gallbladder with gallbladder wall edema, pericholecystic fluid with a small amount of sludge and tiny stones visualized in the gallbladder. There is however no evidence of intra- or extra-hepatic biliary ductal dilatation. Although cholecystitis cannot be fully excluded, although these findings are likely related to inflammatory changes from adjacent pancreatitis. Brief Hospital Course: Ms. [Known lastname ] was an 89 year old female who suffered from transfusion dependent myelodysplastic syndrome that was transferred from [Hospital1 18] [Location (un) 620] to [Hospital1 18] on [8-10]. She had initially presented to [Hospital1 18] [Location (un) ] with abdominal pain where she was found to have pancreatitis. In their emergency department, she developed respiratory distress and was intubated necessitating transfer to [Hospital1 18]. Ms. [Known lastname ] arrived at [Hospital1 18] intubated and sedated. She was able to follow simple commands and appeared comfortable. She was followed by the ERCP team who believed the pancreatitis was due to a passed gallstone and that no intervention was necessary. Ms. [Known lastname ] outpatient hematologist confirmed that the patient had likely moved from MDS to AML and that the family was declining chemotherapy. At [Hospital1 18] she had 20% blasts on peripheral smear and required intermittent platelet and PRBC transfusions. Following one platelet transfusion, the patient became difficult to ventilate and had a drop in her BP. CXR showed new opacities bilaterally and effusions. The primary team consulted with the blood bank/pathology and a diagnosis of TRALI was suspected. On [8-14] the patient was on pressure support ventilation and was no longer sdedated. A family meeting was held during which it was decided that when the patient was extubated, she would not be reintubated. She was extubated on the 27th. Following extubation the patient immediatly began to show signs of increased work of breathing. Attempts were made to improve the patient's respiratory status including diuresis and supplemental oxygenation. However, by the afternoon of the 27th it became clear that the patient was not going to be able to maintain her oxygenation. Family was called to bedside. Palliative care was called and were also at bedside. After discussion, family consensus was to move forward on comfort measures only On [8-17] the patient was transferred to a private room on a medical floor. She was placed on a morphine drip and a scopalamine patch. With family at bedside, she expired on [8-18]; time of death 15:52. Medications on Admission: ATORVASTATIN - (Not Taking as Prescribed: pt stopped) - 10 mg Tablet - 1 Tablet(s) by mouth daily CLONAZEPAM - (Prescribed by Other Provider: [Name Initial (NameIs) 3532]) - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a day DANAZOL - 200 mg Capsule - three times a day - No Substitution LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth daily LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day PHYSICAL THERAPY - - gait training and general reconditioning -- eval& treat SERTRALINE - 25 mg Tablet - 1 Tablet(s) by mouth daily CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg Tablet, Chewable - 1 Tablet(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable Name: [Known lastname ],[Known firstname 17121] Unit No: [Numeric Identifier 17122] Admission Date: [2114-8-10] Discharge Date: [2114-8-18] Date of Birth: [2025-4-2] Sex: F Service: MEDICINE Allergies: Vicodin Attending:[First Name3 (LF) 3046] Addendum: Clarification: there are inconsistencies in documentation on daily progress notes. Patient did not have sepsis. . [First Name8 (NamePattern2) 1239] [Last Name (NamePattern1) 17123] PGY-1 [Pager number 17124] Discharge Disposition: Expired [First Name11 (Name Pattern1) 394] [Last Name (NamePattern4) 3047] MD [MD Number(2) 3048] Completed by:[2114-9-21]	[ "244.9", "518.7", "584.5", "785.50", "205.00", "599.0", "300.4", "284.1", "V49.86", "401.9", "412", "V66.7", "518.81", "414.01", "V10.3", "E934.7", "427.31", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.72", "38.97" ]	icd9pcs	[ [ [] ] ]	8863, 9032	4853, 7113	229, 241	8191, 8200	3677, 3677	8263, 8840	3060, 3208		8092, 8108		8161, 8170		7139, 8069			8224, 8240										3223, 3223																								175, 191											269, 1941								3691, 4830								1963, 2815	2831, 3044
62,296	193,576	46311	Discharge summary	report	Admission Date: [2168-10-12] Discharge Date: [2168-10-29] Date of Birth: [2085-10-29] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Erythromycin Base / Codeine / Nsaids / Aspirin / Fosamax / Zinc / Ultram Attending:[First Name3 (LF) 2485] Chief Complaint: nausea and diarrhea Major Surgical or Invasive Procedure: PEG tube placement [10-27] intubation, Mechanical ventilation History of Present Illness: Ms. [Known lastname 9480] is an 82 year-old lady with a history of malignant B-cell lymphoma, diabetes, and frequent UTIs who was admitted with a two day history of nausea and diarrhea. . In the ED, the patient's vital signs were VS: T 96.6, BP 102/43, P 90, R 16, O2 100% on 3L (99% on 2L). She had a CT abdomen performed, which did not show any acute pathology. She was found to have a leukocytosis to 18K, which decreased to 13.3 with IVFs. She was also found to have a K of 6.3, for which she was given Insulin and glucose (the patient refused Kayexelate). U/A was grossly positive for UTI. ECG showed T wave flattening. She was started on Cipro and Flagyl for possible colitis and was admitted to OMED for further evaluation. . On the floor, pt is pleasant and comfortable. She states she called the ambulance from home because she felt weak. No fall. Unable to detail further. Per records, patient came from extended care facility, not home. She states that she had no problems with Rituxan but did have diarrhea after bendamustine, including diarrhea and memory loss. She notes that she has "difficulty expressing myself." She has some nausea now and has dry heaves where the vomit "sticks in my throat, but doesn't come up." She also complains of diffuse abdominal pain that is in a "different place every day." Morphine helps and it is worse with certain foods but she is unable to detail which foods exacerbate the pain. Pt also complains of SOB x 1 year but is unable to elaborate further when asked with open and closed end questions. Finally, she has an itch on her back, which she was told is a fungal infection. She denied headache, constipation and fevers. She has lost 20-25 pounds but does not know over how long. Past Medical History: 1. Malignant Lymphoma: She was treated with whole body radiation in [2129] and because of a recurrence she had a course of Rituxan which ended on [2164-5-1]. A follow up PET scan in [Month (only) ] [2163] revealed that all of the FDG avid areas were no longer visible. During her visit of [2167-6-29] she was noted to have bilateral supraclavicular adenopathy. On [7-14] a biopsy was performed which showed: Non-Hodgkin B-cell lymphoma, follicular center cell type, grade II/III, predominantly follicular pattern (see note).She was seen in consultation by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] who recommended 4 treatments with Rituxan and then re-evaluation. This was completed on [2167-9-9] she had a restaging PET scan on [2167-10-5] which showed: 1. Marked overall improvement, with near-resolution of FDG-avid lymphadenopathy. Residual avid sub-centimeter left supraclavicular node. 2. No other FDG-avid node in chest, abdomen, or pelvis. 3. Decrease of FDG-avidity of the right parotid gland diffusely; may reflect residual of inflammatory parotitis. . She completed four cycles of Bendamustine for her non hodgkins lymphoma. A PET scan done on [2168-8-15] and it shows: 1. No new foci of FDG-avidity concerning for metastatic disease compared to the prior study. 2. Interval resolution of FDG-avid foci in the liver and right lower neck. 3. Interval decrease in FDG-avidity in the indeterminant focus in the lower left neck. 4. Interval resolution of FDG-avidity in the right temple and bilateral parotid glands. 5. Moderate size hiatal hernia, unchanged. . 2. Insulin Dependent Diabetes: She used to attend a [Hospital 982] Clinic at the [Hospital6 33] but recently has been managing it by herself. 3. Hypothyroidism: On thyroid replacement with no problems 4. Spinal Stenosis: Has been seen in the pain clinic and epidural steroid injections have relieved her pain to a substantial degree in the past but recent injections have been less successful 5. Dyspnea: Interstitial Lung Disease followed by pulmonary 6. Hypertension: Controlled with medication 7. Frequent UTIs 8. Hyperlipidemia Social History: Mrs. [Known lastname 9480] is still able to live alone. Widowed x 13 years [Known firstname 335] is fiercely independent and loves her present living arrangement. She has equipped her house with various equipment so she can cook, wash dishes etc. while seated. A housekeeper comes in once per week to clean and do the shopping. She continues to find this arrangement satisfactory. She has two chidlren- one in [Location (un) ] and one in [Hospital1 1474]. She has six grand children. . Family History: Family history of melanoma and history of coronary artery disease Physical Exam: PHYSICAL EXAM: Vitals - T: 96.2 BP: 111/54 HR: 107 02 sat: GENERAL: NAD SKIN: rash on posterior shoulders bilaterally with excoriations, no open sores but multiple scabs in various stages. mild erythema under left breast without excoriations. HEENT: EOMI, PERRLA, anicteric sclera, MMM, supple neck, sore in R lower jaw. CARDIAC: RRR, S1/S2, no mrg LUNG: diffuse crackles bilaterally ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREM: moving all extremities well, 2+ pitting edema half way up calves, feet cool. NEURO: CN II-XII intact (difficulty with head turn due to central line but shoulder shrug nl), 5/5 strength in UE bilaterally, 3/5 strength in LE bilaterally, sensation intact and symmetric [Hospital Unit Name 60075] EXAM VS: Afebrile, BP: 124/52 (on levophed), HR: 87 SaO2: 100% on mech vent settings GEN: ill-appearing elderly woman intubated, sedated, not responsive to voice or painful stimuli HEENT: b/l chemiosis, PICC line in place CV: regular rate and rhythm, no appreciable murmurs LUNGS: coarse, ventilated breath sounds anteriorly ABD: hypoactive BS, no rebound/guarding EXT: cool, cyanotic, darkened nail beds, poor peripheral pulses, anasarca, [2-3]+ pitting edema B/L UE and LE Neuro: unable to assess as intubated, sedated Pertinent Results: [2168-10-13] 12:00AM GLUCOSE-239* UREA N-83* CREAT-3.3* SODIUM-136 POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-15* ANION GAP-25* [2168-10-13] 12:00AM ALT(SGPT)-73* AST(SGOT)-40 LD(LDH)-307* CK(CPK)-11* ALK PHOS-1605* TOT BILI-0.5 [2168-10-13] 12:00AM CK-MB-4 cTropnT-0.04* [2168-10-13] 12:00AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-4.5 MAGNESIUM-2.1 [2168-10-13] 12:00AM AMA-NEGATIVE [2168-10-13] 12:00AM WBC-13.7* RBC-3.22* HGB-10.6* HCT-33.9* MCV-106* MCH-32.8* MCHC-31.1 RDW-20.1* [2168-10-13] 12:00AM NEUTS-93* BANDS-0 LYMPHS-1* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2168-10-13] 12:00AM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL MACROOVAL-OCCASIONAL TEARDROP-OCCASIONAL [2168-10-13] 12:00AM PLT COUNT-178 [2168-10-13] 12:00AM PT-14.5* PTT-28.4 INR(PT)-1.3* [2168-10-12] 09:03PM LACTATE-2.4* [2168-10-12] 05:00PM GLUCOSE-126* UREA N-81* CREAT-3.2* SODIUM-137 POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-17* ANION GAP-23* [2168-10-12] 05:00PM CK-MB-4 cTropnT-0.05* [2168-10-12] 05:00PM ALT(SGPT)-75* AST(SGOT)-50* LD(LDH)-335* CK(CPK)-20* ALK PHOS-1658* TOT BILI-0.5 [2168-10-12] 05:00PM ALBUMIN-2.7* CALCIUM-8.6 PHOSPHATE-4.4# MAGNESIUM-2.1 . [2168-10-19] BLE veins: IMPRESSION: [Doctor Last Name ] scale images are limited secondary to patient's body habitus. No definite evidence of deep venous thrombosis in bilateral lower extremity veins. Left posterior tibial veins could not be visualized. . Upper GI Series : [2168-10-18] Significant esophageal dysmotility with multiple nonpropulsive tertiary contractions and corkscrew configuration of the esophagus. 2. Lack of passage of barium tablet beyond distal esophagus, which is likely due to esophageal dysmotility as described above. No evidence of fixed strictures, stenosis, or extrinsic mass compression to indicate esophageal obstruction . Brief Hospital Course: Inpatient Oncology Service brief hospital course: Ms. [Known lastname 9480] is a 82 yo woman with h/o low grade B cell lymphoma, initially treated with radiation in the [2128], recurred in [2166] and then treated again with chemo, who presented with failure to thrive, nausea, and diarrhea. She was at a rehab facility where she was transferred after a recent admission for colitis when she developed altered mental status, vomiting, and diarrhea. On admission she was found to have an elevated AlkPhos (1600), acute renal failure, and a UTI. Her UTI was treated with antibiotics without issue. Her elevated AlkPhos was investigated with a liver Bx which did not show B cell lymphoma. Her ARF was treated with aggressive fluids complicated by peripheral edema and pulmonary edema. She also suffered from significant dysphagia. She was found to have diffuse esophageal dysmotility. Of note, she has a history of achalasia s/p dilations. As a result, she was unable to tolerate POs. Albumin of admission was 1.8. Despite several attempts, she was unable to tolerate an NG or feeding tube. Her anasarca continued to progress to the point that she was diffusely edematous and developed worsening pulmonary edema. She was unable to maintain adequate oxygenation on the floor and was transfered to the ICU for Lasix ggt and non-invansive ventilation versus intubation. . [Hospital Unit Name 153] Course: ([Date range (1) 98467]) Upon arrival to the ICU, Ms [Known lastname 9480] was volume overloaded and having difficulty breathing due to pulmonary edema, so she was treated with lasix. A renal ultrasound was conducted to rule out hydronephrosis. She was started on broad spectrum antibiotics inluding vancomycin, cefepime and ciprofloxacin for hospital acquired pneumonia as chest x-rays were concerning for infiltrate. Additionally, due to her immunocompromised state, she was given IV Bactrim for PCP [Name Initial (PRE) 1102]. She was negative for flu. She had increasing respiratory distress after lasix gtt was stopped. ABG showed(7.33/36/184/20/-6) and CXR looked stable with perhaps slight increase in interstitial infiltrates. She was placed on face mask at 15L due to pO2 of 184, which she tolerated well for a few hours, and was then placed on a non-rebreather. She desatted on NRB with increasing respiratory distress, gas showed 7.32/39/60/21, symptoms unalleviated by 80mg IV Lasix so decision was made to intubate. On [10-28], her pulmonary and renal insufficiency worsened. Echocardiogram showed high output cardiac failure with hyperdynamic circulation and LVEF 70-80%. This could be due to septic shock. Her family decided to withdraw care. She passed comfortably on a morphine drip in the presence of her family at 0517 on [2168-10-29]. Medications on Admission: Omeprazole 20 mg daily Levothyroxine 100 mcg daily Acetaminophen 325-650 mg q6h prn ProAir HFA 90 mcg/Actuation HFA 1-2 puffs q 4-6 h prn Lasix 40 mg daily Insulin Glargine 20 U qhs Insulin Regular Human sliding scale Miconazole Nitrate 2 % Powder [Hospital1 ] Hydrocortisone 0.5 % Ointment daily Potassium Chloride 20 mEq daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary Failure to Thrive Secondary Malignant Lymphoma Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2168-10-29]	[ "349.82", "276.0", "584.9", "518.81", "401.9", "558.9", "722.70", "276.7", "041.4", "V58.67", "272.4", "287.5", "785.52", "486", "112.3", "515", "261", "250.00", "599.0", "E947.8", "202.80", "038.9", "787.29", "428.0", "285.29", "995.92", "571.8", "434.11", "428.31" ]	icd9cm	[ [ [] ] ]	[ "33.24", "38.93", "50.11", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	11582, 11591	8424, 11166	384, 451	11691, 11700	6376, 8350	11756, 11795	4958, 5025		11550, 11559		11612, 11670		11192, 11527			11724, 11733										5055, 6357																								325, 346											479, 2219																2241, 4420	4436, 4942
26,724	159,090	10032	Discharge summary	report	Admission Date: [2175-4-5] Discharge Date: [2175-4-28] Date of Birth: [2097-6-23] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 13561] Chief Complaint: Falls Major Surgical or Invasive Procedure: EMG and muscle biopsy History of Present Illness: Mr. [Known lastname 33556] is a 77 year old right handed man with a history of primary autonomic failure resulting in orthostatic hypotension and supine hypertension, who is followed by Dr. [First Name (STitle) ]. He was advised to come to the ED today after he had a fall each night for the past two nights. Mr. [Known lastname 33557] wife and daughter note that for the past week he has been talking, responding, and walking more slowly than usual. His balance has not been as good. At baseline he has a stooped, shuffling gait, and does not use a cane or walker for stabilization. He takes midodrine for the orthostasis, and has required frequent adjustments in his dosing due to the supine hypertension at night. No major adjustments have been made recently, however. He is also supposed to drink plenty of fluids and take salt tabs, but has not been drinking well for the past couple of weeks, and has not been taking the salt tabs for the past 3 days, due to edema in his legs. For the past two nights he has awoken at 3-4 a.m. to change his depends, and while in the bathroom has fallen over backwards. He notes that he did not feel dizzy or lose consciousness, but simply lost his balance. He has not hit his head, but his back has been sore after the falls. His family reports that when he falls, he does tend to fall backwards. He has not been systemically ill, although he sometimes feels dizzy in the morning, which he describes as lightheaded. He has had no headaches, palpitations, fever, shortness of breath. There have been no ill contacts at home. Review of systems: No recent fever, weight loss, cough, rhinorrhea, shortness of breath, chest pain, palpitations, vomiting, diarrhea, or rash. No diplopia, dysarthria, tinnitus, dysphagia, vertigo, weakness, numbness, paresthesias. Past Medical History: - Primary autonomic failure with orthostatic hypotension and supine hypertension, diagnosed after he had a number of syncopal episodes - GERD - Urinary frequency - Hx pancytopenia in [1-17], resolved spontaneously, negative lab w/u, has never had bone marrow bx, followed in past by Heme/Onc - OSA, dx per pt as "mild" after sleep study, did not tolerate CPAP - h/o hoarseness/cough, evaluated by ENT at OSH ?vocal cord dysfunction vs. reflux - chronic low back pain - colon polyps s/p polypectomy 5 years ago, next colonoscopy in [2-18]. Social History: Lives with his wife and [Name2 (NI) 33558], daughter also stays there. + tobacco- 5 cig/day x 10 yrs-quit [2123]. no EtOH x 1 yr, works part-time in mail office at local college. Family History: Father-colon CA. Mother-DM, dementia ?Alzheimer's Physical Exam: T 97.2 HR 59 BP 159/94 -> 193/115 sitting up s/p midodrine RR 12 Pulse Ox 98% General appearance: Thin 77 year old man sitting up in bed in NAD HEENT: NC/AT, neck supple with full ROM and no paraspinal muscle tenderness CV: Regular rate and rhythm without murmurs, rubs or gallops. No carotid bruits. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended Extremities: no clubbing, cyanosis; 2+ non-pitting edema to knees bilaterally Mental Status: Alert and oriented to person, place, and date. Speech is hypophonic and very slow, with intact naming, delayed but intact registration, comprehension. Repetition somewhat impaired, when asked to repeat "Cats [Male First Name (un) ] dogs" says "Cat [Male First Name (un) ] dog" repeatedly. Mildly inattentive. Able to recite months of year backwards with 2 errors (left out two months). Recalls 0/3 items at 3 minutes. Intact calculations. No apraxia. +snout sign, +glabellar tap, - palmomental Cranial Nerves: Pupils are equal, round and reactive to light. Visual fields are full to confrontation. Extraocular movements are full. There is no nystagmus and no ptosis. Facial sensation is intact to light touch. Face is symmetric but with somewhat decreased spontaneous mobility and his gaze is slightly intense. Hearing is intact to finger rub bilaterally. There is symmetric palate elevation and the tongue protrudes midline. Motor System: Normal muscle tone, no rigidity. Strength is full throughout. There is no pronator drift. +tongue tremor when mouth held open, and +bilateral postural tremor in the hands, but no resting tremor. Reflexes: Deep tendon reflexes are 2+ and symmetric. Plantar responses are flexor bilaterally. No [Doctor Last Name 937]. Sensory: Sensation is intact to light touch, temperature, position, and pinprick throughout. Mildly decreased distal vibration sense in feet bilaterally. Coordination: No dysmetria with finger to nose. Slow but accurate finger tapping bilaterally. Gait: Shuffling and stooped, but not festinating. Tends to retropulse. Requires 11 steps to pivot. Pertinent Results: [2175-4-5] 03:30PM NEUTS-81.4* BANDS-0 LYMPHS-13.8* MONOS-4.0 EOS-0.3 BASOS-0.5 [2175-4-5] 03:30PM WBC-3.4* RBC-4.07* HGB-11.8* HCT-36.8* MCV-90 MCH-29.0 MCHC-32.1 RDW-15.3 [2175-4-5] 03:30PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-2.3 [2175-4-5] 03:30PM CK-MB-45* MB INDX-13.6* cTropnT-<0.01 [2175-4-5] 03:30PM CK(CPK)-330* [2175-4-5] 03:30PM estGFR-Using this [2175-4-5] 03:30PM GLUCOSE-105 UREA N-22* CREAT-0.6 SODIUM-140 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-34* ANION GAP-9 [2175-4-5] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2175-4-5] 09:30PM CK-MB-36* MB INDX-13.5* [2175-4-5] 09:30PM cTropnT-<0.01 Echo: [4-6]: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mildly dilated aortic root. CXR: [4-5]: Polygonal opacity in the lingula could represent scar or atelectasis, or pneumonia. In conjunction with the small right sided pulmonary nodule, a chest CT may be of value. LLE Doppler: [4-5]: No evidence of DVT in the left lower extremity CT head: [4-5]: No acute intracranial hemorrhage. No fracture. [4-12] CT torso: 1. Bilateral lower lobe pneumonia. 2. 2.7 cm gastric wall mass, of uncertain etiology. 3. Asbestos-related pleural plaques. 4. Wedge compression fracture of L1 vertebral body of uncertain chronicity. L-spine MRI [4-5]: Compression deformity, age indeterminate, of the L1 vertebral body, and possibly of T11 and T10 as well. Please correlate with the site of the patient's pain. [4-12] EMG: Abnormal study. The electrophysiologic findings are most consistent with a mild generalized myopathy without denervating features. There is no electrophysiologic evidence for a generalized polyneuropathy affecting large-diameter nerve fibers (including [First Name9 (NamePattern2) 7816] [Location (un) ] syndrome) or for a pre- or post- synaptic disorder of neuromuscular junction transmission. Incidental note is made of a mild ulnar neuropathy at the left elbow. The reduced activation noted on needle electromyography also suggests that a component of this patient's weakness is due to a central process or poor effort. [4-21] Muscle biopsy: Mild, non-specific changes: Mild fiber size variation with occasional small, angulated myofibers and round, atrophic myofibers Occasional nuclear knots. Isolated regenerating myofiber. No significant inflammation. [2175-4-28] 05:30AM BLOOD WBC-4.3 RBC-3.14* Hgb-9.4* Hct-27.7* MCV-88 MCH-30.0 MCHC-34.1 RDW-15.3 Plt Ct-264 [2175-4-28] 05:30AM BLOOD Plt Ct-264 [2175-4-28] 05:30AM BLOOD Glucose-105 UreaN-16 Creat-0.5 Na-139 K-4.6 Cl-100 HCO3-34* AnGap-10 [2175-4-28] 05:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.8 [2175-4-6] 04:45AM BLOOD calTIBC-267 VitB12-GREATER TH Folate-9.4 Hapto-70 Ferritn-365 TRF-205 [2175-4-7] 11:54AM BLOOD Hapto-88 [2175-4-6] 04:45AM BLOOD TSH-6.0* [2175-4-6] 01:00PM BLOOD Free T4-0.92* [2175-4-7] 11:54AM BLOOD Cortsol-26.8* [2175-4-6] 04:45AM BLOOD PEP-NO SPECIFI IgG-707 IgM-59 [2175-4-7] 05:50AM BLOOD HIV Ab-NEGATIVE [2175-4-27] 04:04AM BLOOD Type-ART pO2-85 pCO2-51* pH-7.48* calTCO2-39* Base XS-12 Brief Hospital Course: Initial Neurology Course Neuro/Autonomic: - [4-6]: Midodrine was continued at the dosage schedule of 7.5 at 0800, 1100, 5mg at 1400 and 2.5mg at 1800. Vasopressin was continued and Salt tabs were restarted. Morning of [4-6] had orthostatis of 95/65 supine and 82/55 sitting up with symptoms of dizziness. Discussed with Autonomic Fellow [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] who wanted to continue current midodrine doses, continue salt tabs and IVF or 2-3 liters/day with plan to titrate as needed from here. Thought that it was likely that the patient had fallen secondary to his orthostasis despite the fact that he was never pre-syncopal or dizzy because patients with autonomic disorders are often asymptomatic of there orthostasis. MRI was unimpressive and non-acute. Orthostatics checked again later in the day on [4-6] and were 120/72 (P87) lying, 120/68 (P88) sitting, then machine could not register upon standing, but manually was 86/40 standing (P40). When checked manually while sitting was 98/72 (P82). Patient was not symptomatic at any point. STill mildly orthostatic [4-7] but asympomatic and will continue current doses midodrin, salt tabs, fluids and watch. Lumbar Puncture considered [4-6] but deferred secondary to low platelet count and poor platelet smear. -Hypothermic to 89.9 rectally on admission to floor. Was given Bair-Hugger and corrected to 93.5 over course of 6 hours. Could be related to his autonimic dysfunction but not described in his prior history. Discussed with Autonomic serivice who felt that this could be part of the autonomic dysregulation but also suggested sepsis or other systemic cause as an etiology. Lactate and ammonia levels returned within normal. Cardiovasc: CKMBI was elevated x 3 but troponins negative x 3. Echo had EF 55% and mild Mitral regurg and mild aortic root dilation. Resp: CO2 retention with ABG CO2 55 and Hc03 35. Lactate .9. Likely chronic. No history of COPD but does have history of opbstructive sleep apnea with CPAP intolerance. PNA seen in left lower lobe lingula on CXR and also associated nodule. Started Levaquin. ID later recommended D/Cing as patient not symptomatic and has known history of pulmonary scarring followed by pulmonologist at OSH. Given his history of asbestos exposure and smoking, CT with contrast ordered which showed a pneumonia, asbestos related plaques, and a 2.7 gastric wall mass. GI: Tolerated diet well. When CT Chest performed, incidentally found a gastric calcification and nodule suspicious for GIST tumor. Biopsy of this showed that it was nonneoplastic. Has mildly elevated LFTs ALT>AST with no known source, which has essentially resolved. Endo: Regular insulin sliding scale for prophyaxis. TSH and Free T4 borderline but satisfactory. He was started on levothyroxine for treatment. Heme: Pancytopenic on admission and worsened on repeat labs in AM. Consulted Heme. Recommended sepsis work up, EBV titer, HIV, PPD, Parvovirus, CMV, Coags, Cortisol, Cortistim, Lactate, SPEP, TSH, FE studies, Folate, Repeat blood cultures, HIT, Ca/Mg/Phos, LDH, B-glucan and galactomanin. Urine study: add MMP22 (urinary CA marker) TTE and maybe TEE for vegetations. CT chest. IVF and follow UOP. PPD. Possible LP. Had transiently elevated PTT of 84 on [4-7] Am labs with INR of 1.2. Heparin D/C'd and coags as well as DIC panel re-ordered stat. Second set showed PTT corrected to 45 and normal fibrinogen/haptoglobin and D-dimer around 1000. Discussed with Heme who was not impressed and thought was possibly a down stream draw from heparin flush as it corrected so quickly without treatment. Work up for pancytopneia negative at day 3 and pancytopenia beginning to spontaneously resolved. Currently still pancytopenic but not terribly far off from his baseline. If everything resolves, will still need to follow up with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 33559] in 2 weeks as OP for possible further work up including marrow. ID: Consulted given the hypothermia and concern for sepsis. They were not at all concerned for sepsis as his pressures have been stable and now at baseline temperature, also had normal lactate level. Recommended cancelling aspergillosis and fungal infection work up, and was not too concerned about Lyme or Parvovirus. Did not think that there was any significant sign of infection in the patient and that current work up in addition to CMV IgM reasonable. Did not think that TB precautions needed and thought that PPD placement not imperative but could be done and should only be done >48 hours after the cortistim test completed (would interfere). Will not pursue TEE as likelihood of endocarditis very low and no positive blood cultures as of yet. All ID work up negative at day 3 and ID has signed off. Notify ID if any cultures/antibodies return positive. ID did not feel strongly for/against LP and agreed with holding off given the poor coags. MICU course: The patient was admitted to the MICU for respiratory distress attributed to aspiration pna +/- mucus plugging. The patient arrived intubated and was started on vanc and zosyn for a 10 day course. The following issues were addressed during his MICU course: . # hypoxic and hypercarbic respiratory failure/failue to extubate: The respiratory failure was thought to be secondary to an aspiration PNA +/- mucous plugging. The patient was intubated and treated with vanc and zosyn for ten days. He was extubated on [4-10], was apneic, and subsequently emergently reintubated. The cause of his apnea was unclear. His NIFFs were very low, making a myopathy a possible cause. Hypothyroidism was also on the differential given his elevated TSH. An EMG suggested a myopathic process but a muscle biopsy was non-diagnostic. The patient's hypothyroidism was treated with synthroid and diamox was used to lower his bicarb. The patient's HCO3 fell and his NIFFs improved with time. His sputum grew out GNRs. He was eventually extubated successfully. He was placed on nocturnal BIPAP for hypoventilation during sleep. Of note, his repeat sputum cultures continued to grow out GNR and a recent CXR showed a possible consolidation in the RLL in the setting of improving respiratory function and overall clinical picture. The patient had been afebrile for >1wk with a stable and low WBC ct. Given he had no clinical signs of PNA, he was not treated with antibiotics. The patient was supported with chest PT, nebs, incentive spirometry with good effect. Because he continued to hypoventilate and have hypercarbia on ABG, he was started on nocturnal BiPap of [9-18]. Patient was transferred to the Neurology service on [4-27]. He was continued on his noctural Bipap. He has been afebrile, stable vital signs, and white count of 4.3. Recent CXR on [4-27] shows improved of original opacities. We have obtained an ESR and UA/UCx prior to discharge to ensure that he is free of any infection. Current autonomic neurology recommendations: Continue aggressive hydration with at least 2L of fluid per day and salt tablets to a goal of 10gm of salt per day. Orthostatic blood pressures should be checked. Continue Midodrine. The patient is likely deconditioned which will worsen hypotension. BP should be taken prior to PT, and if <100 mmHg, midodrine can be increased (by 2.5-5mg increments) to tolerate PT (goal SBP >100mm Hg). He should avoid being supine for several hours after Midodrine is given, thus it should not be given after 4pm. If there is supine HTN (190's-200's), the head of the bed should be elevated to 45 degrees. Continue DDAVP. Pending labs: Anti [Doctor Last Name ], Ro, La, UPEP, SSA, SSB Medications on Admission: Midodrine 7.5 mg in the AM, 7.5 mg in mid-AM, 5 mg at 2 p.m., and 2.5 mg around [6-18] p.m. (about 4 hours before he goes to sleep); desmopressin inhaler; salt tabs 1g, up to 10 per day (family titrates) Discharge Medications: 1. Midodrine 5 mg Tablet Sig: One (1) Tablet PO PRN as needed for If SBP <100 prior to physical therapy: Please check blood pressure prior to physical therapy and administer if SBP <100. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 5. Midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO AT 11 AM (). 6. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO AT 6 PM (). 7. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) Spray Nasal HS (at bedtime). 9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 15. Midodrine 5 mg Tablet Sig: One (1) Tablet PO AT 2 PM (). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Autonomic failure, s/p respiratory failure, pneumonia s/p antibiotics, pancytopenia and coagulopathy - resolved, 2.7 cm gastric wall mass - biopsy nonneoplastic. Discharge Condition: Good Discharge Instructions: Please take your medications as directed and attend your follow up appointments. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539] (Hematology) on [5-5] at 11AM. The clinic is located on [Hospital Ward Name 23] 9. The clinic's phone number is ([Telephone/Fax (1) 33560]. Please have your sutures removed around [4-29], 7-10 days after your muscle biopsy was performed. Follow up with Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ] of Autonomic Neurology on [5-10] at 3pm. The clinic is located on [Hospital Ward Name 23] 8. The clinic's phone number is ([Telephone/Fax (1) 19252].	[ "507.0", "518.81", "337.9", "244.9", "781.2", "359.9", "286.9", "935.2", "934.1", "327.23", "535.10", "401.9", "253.8", "V15.88", "284.8", "E912", "458.0", "788.41", "E915" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.6", "45.16", "83.21", "96.72", "93.90", "99.05" ]	icd9pcs	[ [ [] ] ]	17899, 17996	8487, 16230	330, 354	18202, 18208	5204, 6334	18337, 18937	2996, 3049		16489, 16576		18017, 18181		16256, 16466			18232, 18314										3064, 3530	16594, 17876																			1990, 2205				285, 292											382, 1970	4068, 5185	6343, 8464							3545, 4052							2227, 2775	2791, 2980
68,123	104,412	43996	Discharge summary	report	Admission Date: [2167-6-22] Discharge Date: [2167-7-2] Date of Birth: [2121-1-4] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Levofloxacin / Flagyl Attending:[First Name3 (LF) 2782] Chief Complaint: Chief Complaint: unresponsive Reason for MICU transfer: need for Narcan gtt Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 805] is a 46 year old woman with h/o hemorrhagic stroke with residual spasticity and weakness, seizure disorder, depression, Hepatitis C, who was brought it by EMS after being found unresponsive at home. The patient got in an argument with her mother this morning, after which she locked herself in her room and took a handful of pills -- Morphine and a muscle relaxant (patient unsure of medication name, but is prescribed Flexeril). She states that she did not expect to wake up and is quite tearful at the time of interview. She just returned home 4 days prior after being discharged from [Hospital 38] rehab. She states that her mother [Name (NI) ] is "the devil" and was trying to find another home for her because she couldn't take care of her anymore. Her family found her unresponsive in her room and called EMS. Narcan 0.4mg x1 was given in the field. Patient woke up immediately, but then became more responsive again. In the ED, initial VS were: 98.2 110 130/82 5 100%. Patient was given Naloxone 0.4mg IV x1, then started on a Naloxone gtt @ 0.3mg/hr given that she was still somnolent. Serum tox was negative, but urine tox was not obtained. On arrival to the MICU, patient's VS: P 105 BP 136/90 RR 11 O2sat 100%2LNC. The patient is alert and answering questions appropriately. She is tearful and is wondering why she is still alive. She notes some mild headache x3 days, but no vision changes or changes in weakness. Abdominal distension is old per patient, and she notes having a BM this morning. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. s/p stroke - left parieto-occipital hemorrhagic stroke in [9-11], unclear etiology, s/p craniotomy to evacuate hemorrhage, secondary herniation syndrome w subfalcine and transtentorial herniation, bilat Wallerian degeneration syndrome, quadraparesis with increasing spastic paraparesis worse on R, prox upper & both lower extremities, s/p Baclofen pump placement -Evaluated at [Hospital1 2025] by Dr [Last Name (STitle) ] in [2163] -ongoing issues with increasing spasticity -[5-15] was off Baclofen pump and PO -[2-15] on Baclofen PO (no pump), MS Contin, tizanidine -[7-18] only on MS Contin for pain management -[12-19] on Baclofen PO (no pump), MS Contin & IR PRN 2. hyperhomocysteinemia, mildly elevated, no further w/u planned 3. carries psychiatric diagnoses of OCD & depression with suicidal ideation; patient notes suicidal attempt at age 13, cut her wrists 4. sickle cell trait 5. Hepatitis C, genotype 3, viral load 799,000 in [February 2163], no plans to treat as transaminases normal, f/u planned in [2165] 6. microcytic anemia with normal iron studies 7. restrictive lung disease due to weakened resp muscles following stroke 8. GI h/o duodenitis, colitis in [July 2165], treated with abx 9. Epilepsy, during [July 2165] admission (no clear provoking factor). She has now had about six or so, her mother thinks. [Name2 (NI) ] have been in the hospital. She has had two at home: She will become agitated and non-sensical, with right gaze deviation, repetitive verbalizations: "help me", "open it", etc. Her mother says that she has had no generalized seizures at home. 10. Question of motor neuron disease (primary lateral sclerosis)raised in prior MRI findings, EMG and nerve conduction studies [12-15] provided no evidence for the diagnosis. Social History: Discharged from [Hospital 38] rehab [2167-6-18], now staying with her mother. [Name (NI) ] smoking (smoked prior to stroke in [2158]). No alcohol. Family History: Arthritis, walks with cane. Father - unknown. [Name2 (NI) ]-one with seizures. Physical Exam: Admission Physical Exam: Vitals: P 105 BP 136/90 RR 11 O2sat 100%2LNC General: Alert, orientedx2 (aware of place, but thought it was [2168-6-8]), no acute distress HEENT: Sclera anicteric, dry MM, 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, rhonchi Abdomen: firm, distended, bowel sounds present, baclofen pump in RLQ, some tenderness to palpation in bilateral lower quadrants, no rebound or guarding GU: no foley Ext: 1+ pulses, no clubbing, cyanosis or edema, LE in braces Neuro: CNII-XII intact, decreased strength in all extremities, UE contractions Pertinent Results: ADMISSION LABS: [2167-6-22] 05:10PM BLOOD WBC-8.3 RBC-4.40 Hgb-11.8* Hct-37.7 MCV-86 MCH-26.9* MCHC-31.4 RDW-15.3 Plt Ct-288 [2167-6-22] 05:10PM BLOOD Neuts-71.2* Lymphs-23.1 Monos-2.5 Eos-2.5 Baso-0.7 [2167-6-22] 05:10PM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-136 K-4.5 Cl-100 HCO3-28 AnGap-13 [2167-6-22] 05:10PM BLOOD Calcium-8.5 Phos-4.5# Mg-1.9 [2167-6-22] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . IMAGING: -[2167-6-22] CXR: CONCLUSION: Likely early developing pneumonia left base. . -[2167-6-22] KUB: IMPRESSION: Significant distention of the stomach. NG tube should be considered. No free air. . EEG pending Brief Hospital Course: discharge exam: 98.1 121/73 86-90 making eye contact, answering basic questions her pain level is unchanged, [2165-5-14] stable neurological exam data: dilantin trough: 10.3 Ms. [Known lastname 805] is a 46 year old woman with h/o hemorrhagic stroke with residual spasticity and weakness, seizure disorder, depression, Hepatitis C, who was brought it by EMS after being found unresponsive at home, after a suicide attempt . ACTIVE ISSUES: . # Acute overdose: Likely due to ingestion of Morphine, +/- Flexeril. Serum tox was negative. No evidence of active infection. Her mental status quickly improved on Narcan gtt, which was d/c'd after the pt woke up. We initially held sedating medications: morphine, seroquel, flexeril, hydroxyzine; but later restarted seroquel when pt was highly agitated. She also received tramadol as substitute for morphine for her chronic leg pain, but then refused this medication. Currently she is on morphine 5mg PO q6h. # Depression/Suicide attempt: Patient ingested morphine and other pills in a suicidal attempt after an argument with her mother. She continued to be tearful and extremely upset that she was still alive, and was refusing medications, radiology, and blood draws. She was maintained on a 1:1 sitter and suicide precautions. Psych evaluated her on [6-23], and recommended haldol IV prn as well as inpatient psychiatric hospitalization. She became agitated and yelled out at RN staffing on [6-28] and then received a dose of oral and then a dose of IV haldol. She will receive further psychiatric care in the inpatient psych setting. #Chronic Spasticity/Pain: Managed with baclofen pump as an outpatient and she is followed by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 24792], at his office address on [Street Address(2) 94477], [Location (un) 38], [Numeric Identifier 34404]. His phone number is [Telephone/Fax (1) 94478]. The chronic pain service here spoke with Dr. [Last Name (STitle) 24792] and agreed to refill her baclofen pump while she is an inpatient at [Hospital1 18] to avoid having her travel to brain tree as she remains on suidice precautions. However, intrathecal baclofen not available until [7-2] at the earliest. The chronic pain service is available to refill her pump at [Hospital1 18] if she is hospitalized at DEAC4. They will perform the refill at her bedside when the baclofen intrathecal dose is available from the pharmacy in the next few days. They can be paged by typing OUCH into the paging directory (Contact has been Dr. [Last Name (STitle) 94479] [Name (STitle) ]). Baclofen 5mg PO TID started to help diminish spasticity, as plan will be to increase intraethcal dose when it is refilled. however, If she does not have baclofen pump refill prior to [7-10], then the receiving staff should arrange for her baclofen pump to be refilled on [7-10] or [7-11] at Dr.[Name (NI) 94480] office. # Seizure disorder: Neurology followed the patient. At her last discharge she was sent to rehab on 3 AEDs including dilantin, keppra, and lacosamide. At discharge she was only continued only on dilantin for unclear reasons. Given lack of clinical seizure activity during this admission and no seizure activity on an EEG here, neurology recommended continuing her only on the dilantin alone and arranging for outpatient neurology f/u with her epilepsy specialist upon discharge from her psych admission. # Abdominal distension/vomiting: Patient initially p/w firm, tender abdomen on exam, but no rebound or guarding. Per patient, this is not new, and she had a BM after admission. She had a KUB with large gastric bubble, ?pill bezoar, urinary retention may have contributed to her abd discomfort. This improved and she had no active complaints of this symptom. # Urinary retention: Has baseline retention from her h/o CVAs and is being treated with Flomax as an outpatient. Large dose of narcotics she took may be contributing as well. Patient refused Foley placement or straight cath after admission. We continued Flomax. She underwent straight cath on [6-25] with 1400 cc of NS. She began voiding spontaneously on [6-26]. . #Possible Aspiration: CXR with increased LLL opacity, which could have represented pneumonia vs pneumonitis due to possible aspiration event while the patient was unresponsive. Given that the patient had no fever, elevated WBC count, cough, we held on treating possible PNA. CHRONIC ISSUES: # Seizure disorder: continued dilantin, level 10.3 (trough on [6-28]) TRANSITIONS OF CARE: []monitor seizure activity and adjust AEDs as indicated []further psychiatric treatment []continue treatment of chronic leg pain []REFILL BACLOFEN PUMP BEFORE [7-12] (pain fellow pager OUCH, Dr. [Last Name (STitle) ] will arrange for baclofen pump refill on the DEAC4 floor. Medications on Admission: Medications: per [Hospital 38] rehab d/c med list on [2167-6-18] Morphine 7.5mg PO q4h Seroquel 25mg PO q6h prn agitation Celexa 40mg PO daily Fosamax 70mg PO qweek Vitamin C 500mg PO q8h Oscal D Flexeril 10mg PO q12h Heparin 5000units SC BID Hiprex 1mg PO q12h Nitrofurantoin 50mg PO q6h Zyprexa 1.25mg PO q12h Dilantin 100mg PO q8h Flomax 0.4mg PO BID Hydroxyzine 50mg PO q6h prn Zofran 4mg q6h prn Vitamin D3 1000units PO daily Acetaminophen 650mg PO q6h prn Bisacodyl 10mg PR daily prn Senna 2tab PO qhs Colace 100mg PO BID Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itching. 12. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. haloperidol 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. 14. haloperidol lactate 5 mg/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day) as needed for severe agitation. 15. morphine 10 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 16. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: Suicide attempt Acute encephalopathy Seizure disorder Urinary retention Discharge Condition: requires assistance with ADLs. Discharge Instructions: You were admitted after a suicide attempt. You improved with reversal of the morphine medication. You were ultimately discharged to a psychiatric hospital TRANSITIONS OF CARE: []monitor seizure activity and adjust AEDs as indicated []further psychiatric treatment []continue treatment of chronic leg pain []REFILL BACLOFEN PUMP BEFORE [7-12] (pain fellow pager OUCH, Dr. [Last Name (STitle) ] will arrange for baclofen pump refill on the DEAC4 floor. Medication Changes []baclofen 5mg TID []morphine PRN pain Followup Instructions: You can be referred back to dr. [Last Name (STitle) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 24792], to determine any adjustments or management of your pain medication. His address on [Street Address(2) 65289], [Location (un) 38], [Numeric Identifier 34404] His phone number is [Telephone/Fax (1) 94478] YOU ARE ADVISED TO HAVE OUTPATIENT PSYCHIATRY/PSYCHOLOGY FOLLOWUP ARRANGED. PLEASE SCHEDULE VISIT WITH THE PATIENT'S [Hospital1 18] NEUROLOGIST UPON DISCHARGE, to manage your epilepsy Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Office Phone:([Telephone/Fax (1) 35413] Office Fax:([Telephone/Fax (1) 94481] Patient Location:[Hospital Ward Name 860] 4 Comprehensive Epilepsy Center	[ "070.54", "788.29", "345.90", "348.39", "270.4", "518.89", "E950.0", "787.3", "311", "975.2", "338.4", "787.03", "438.53", "E950.4", "965.09", "282.5", "344.1", "300.3", "V62.84" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12972, 13017	5944, 5944	373, 379	13132, 13164	5228, 5228	13733, 14542	4393, 4477		11459, 12949		13038, 13111		10899, 11436			13188, 13346										4517, 5209							5960, 6378													1975, 2354				274, 335			6393, 10475								407, 1956					5244, 5921					13367, 13710		10492, 10567				2376, 4196	4212, 4377
25,225	168,918	3957	Discharge summary	report	Admission Date: [2178-6-4] Discharge Date: [2178-7-1] Date of Birth: [2147-8-13] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[First Name3 (LF) 613] Chief Complaint: S. aureus bacteremia, presumed endocarditis Major Surgical or Invasive Procedure: -Hemodialysis -Femoral central line placement -External Jugular central line placement - done in interventional radiology -Dobhoff feeding tube placement History of Present Illness: 30 yo F with h/o SLE, ESRD on HD (T, Th, Sat), HTN, anemia, sickle trait, with multiple [Hospital1 18] admissions and recent MSSA endocarditis (tx w/ vanco until [5-14]) and osteomyelitis with BKA. Pt readmitted to [Doctor Last Name 1263] yesterday with generalized weakness, shaking chills, desaturation. The patient reports that on Sunday (4 days prior) she began to feel weak, shaking chills and total body aches. She reports that the symptoms progressively got worse. She was scheduled for her normal dialysis on Tuesday, but the ambulance taking her to the dialysis center felt she was too sick and took her to [Hospital 1263] Hospital. Once at the hospital she received HD, was given a dose of vancomycin, and blood cultures were sent. The patient had spiking fevers (Tmax: 104.8) while in the hospital. The blood cultures showed [1-10] S. aureus from 6/24 per [Doctor Last Name 1263] Micro-lab. They also performed a TTE that showed vegetations on the mitral valve. The patient was then transferred here to [Hospital1 18]. . Upon arrival to [Hospital1 18] she started reporting having HAs, she then had an acute decline in mental status and was found to have ICHs on CT of head, likely from septic embolic and complicated by her uremic coagulopathy and ITP. Past Medical History: - SLE diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - h/o MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [2166]. In [2173], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [8-/2175] complicated by rejection and capsule rupture 11/[2174]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [2177-6-24]. Complicated by wound./Hardware infection requiring BKA [2177-11-21] -[2178-4-2] RUE AVG excision Social History: No smoking, occasional alcohol, no drug use. Originally from [Country ], now lives in [Location 2268]. Used to work at [Hospital1 18]. Family History: Noncontributory Physical Exam: PE: T:101.0 BP:100/50 HR: 100 RR: 18 O2 91% RA --> 96% 2L Gen: NAD, Appears malaised and eyes closed HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, EJ placed, No LAD, No JVD. CV: tachy. nl S1, S2. + murmurs at apex, no rubs or [Last Name (un) 549] LUNGS: CTAB, good BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. EXT: Pt s/p L BKA, No CCE, HD access on right leg (no erythema, tenderness to palpation, swelling) SKIN: No rashes/lesions. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. PSYCH: Listens and responds to questions appropriately Pertinent Results: [2178-6-4] 07:20PM BLOOD WBC-4.6 RBC-5.20 Hgb-13.4 Hct-43.2 MCV-83 MCH-25.9* MCHC-31.1 RDW-19.3* Plt Ct-68* [2178-6-4] 07:20PM BLOOD Neuts-65 Bands-3 Lymphs-24 Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2178-6-4] 07:20PM BLOOD PT-13.7* PTT-38.0* INR(PT)-1.2* [2178-6-4] 07:20PM BLOOD Glucose-108* UreaN-26* Creat-7.0# Na-135 K-3.8 Cl-96 HCO3-26 AnGap-17 [2178-6-6] 01:10PM BLOOD ALT-30 AST-44 LD(LDH)-206 AlkPhos-124* Amylase-94 TotBili-0.4 [2178-6-6] 01:10PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.4 Mg-2.6 [2178-6-6] 01:10PM BLOOD Vanco-31.0* . Labs upon discharge: . [2178-6-26] 06:00AM BLOOD WBC-5.5 RBC-4.19* Hgb-10.9* Hct-36.0 MCV-86 MCH-26.1* MCHC-30.3* RDW-20.9* Plt Ct-126* [2178-6-27] 05:13AM BLOOD WBC-6.3 RBC-3.34* Hgb-9.0* Hct-28.4* MCV-85 MCH-27.1 MCHC-31.8 RDW-22.5* Plt Ct-109* [2178-6-28] 03:23AM BLOOD WBC-6.1 RBC-3.12* Hgb-8.3* Hct-26.5* MCV-85 MCH-26.5* MCHC-31.2 RDW-21.3* Plt Ct-98* [2178-6-29] 03:52AM BLOOD WBC-7.8 RBC-2.98* Hgb-8.2* Hct-25.5* MCV-86 MCH-27.5 MCHC-32.2 RDW-22.3* Plt Ct-94* [2178-6-27] 05:13AM BLOOD Glucose-95 UreaN-25* Creat-5.3# Na-142 K-4.0 Cl-107 HCO3-24 AnGap-15 [2178-6-28] 03:23AM BLOOD Glucose-98 UreaN-34 Creat-6.7# Na-139 K-4.1 Cl-106 HCO3-23 AnGap-14 [2178-6-29] 03:52AM BLOOD Glucose-107 UreaN-51* Creat-8.1# Na-139 K-5.3 Cl-104 HCO3-22 AnGap-18 [2178-6-26] 06:00AM BLOOD ALT-2 AST-37 AlkPhos-251* TotBili-0.2 [2178-6-29] 03:52AM BLOOD Calcium-9.3 Phos-5.4* Mg-2.7* . [2178-7-1] 05:38AM BLOOD WBC-5.8 RBC-3.15* Hgb-8.4* Hct-27.0* MCV-86 MCH-26.5* MCHC-30.9* RDW-21.0* Plt Ct-100* [2178-7-1] 05:38AM BLOOD Glucose-94 UreaN-43* Creat-7.1# Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [2178-6-26] 06:00AM BLOOD ALT-2 AST-37 AlkPhos-251 TotBili-0.2 [2178-7-1] 05:38AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.5 [2178-6-30] 05:14AM BLOOD Hapto-64 [2178-6-8] 12:05AM BLOOD Ammonia-18 [2178-6-8] 12:05AM BLOOD TSH-0.43 [2178-6-21] 05:52AM BLOOD HCG-<5 . [6-5]: TTE The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). with depressed free wall contractility. 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. There is a moderate-sized (1.0 x 0.6 cm) vegetation on the mitral valve. Mild to moderate ([12-10]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Moderate-sized vegetation on the posterior mitral leaflet. Mild-moderate mitral regurgitation. Left ventricular hypertrophy with preserved global and regional biventricular systolic function. [6-7] CT-Head IMPRESSION: 1. Large bilateral parenchymal hemorrhages in bilateral frontal lobes and left occipital lobe with surrounding edema and fluid/fluid levels. There are subarachnoid hemorrhages bilaterally, but worse on the left. Tiny hemorrhage of the left thalamus and possible tiny hemorrhage of the left cerebellum. 2. Accentuated [Doctor Last Name 352]/white matter differentiation and effacement of some sulci suggestive of diffuse edema. . [6-15] Echo - There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a 2.5cm highly mobile linear echodensity attached to the mitral leaflet c/w a vegetation. There is mild mitral regurgitation. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2178-6-8], the vegetation appears similar in length and mobility, but of much smaller diameter. The severity of mitral regurgitation has decreased. . [6-18] CT abdomen - Limited evaluation of the lung bases demonstrate bibasilar opacities, consistent with airspace disease. These appear improved when compared with the prior examination of [2176]. Again seen is hepatomegaly. There are no focal liver lesions. Within the spleen, again identified is a small hypoattenuating lesion, not significantly changed. This is nonspecific, but differential considerations could include small cyst or hemangioma. In the region of the splenic hilum, again seen are several densities, which represent splenules or varices. These are also unchanged in appearance. Pancreas is unremarkable. There is gallbladder distention presumably due to NPO status. There is no evidence of cholecystitis. The adrenal glands are unchanged, again noting a slightly lobular contour of the right adrenal gland. There has been bilateral nephrectomy. There is a small amount of free fluid inferior to the liver. This is not drainable. Intra-abdominal bowel loops are normal in caliber. PELVIS: The bladder is collapsed. Intra-pelvic bowel loops demonstrate normal caliber. As before, there are several prominent lymph nodes within the pelvis, such as a right iliac chain node measuring approximately 10 mm in short axis diameter. Bilateral inguinal lymphadenopathy is also identified. There is a left femoral venous catheter. BONE WINDOWS: No osteolytic or osteoblastic lesions. CONCLUSION: 1. No intra-abdominal abscess. 2. Gallbladder distention, presumably due to NPO status. No evidence of cholecystitis. 3. Bibasilar airspace disease, improved in extent and appearance from [2177-8-9]. . [6-18] Liver and Gallbladder US - FINDINGS: Limited views of the gallbladder demonstrate small amount of sludge. The gallbladder wall measures 3 mm. A small amount of free fluid is identified. The common bile duct measures approximately 6 mm. There is no evidence of cholelithiasis. Within the gallbladder neck, there is a small curvilinear hyperechoic structure without shadowing which may represent a fold or a tiny polyp. A son[Name (NI) 493] [Name2 (NI) 515] sign was not present. IMPRESSION: No evidence of cholelithiasis. Small amount of gallbladder sludge. Dilated common bile duct up to 6 mm. . [6-19] Ct of head FINDINGS: There has been interval evolution of multiple large bilateral parenchymal hematomas, without change in size, surrounding edema, or mass effect, consistent with evolution of hemorrhages. No new foci of hemorrhage are identified. There continues to be present sulcal effacement and S-shaped midline shift. Imaged paranasal sinuses and mastoid air cells are clear. Osseous structures are unremarkable. IMPRESSION: Interval evolution of bilateral parenchymal hemorrhage, without change in size or associated mass effect. No new intracranial hemorrhage. . [6-29] CXR - FINDINGS: In comparison with the study of [6-19], there has been placement of a right central catheter that extends to the lower portion of the SVC. Diffuse bilateral pulmonary opacifications persist, along with the strikingly prominent dilatation of the main pulmonary artery trunk indicating chronic pulmonary hypertension. IMPRESSION: Little change except for placement of new central catheter. Brief Hospital Course: A/P: This is a 30 yo F with h/o SLE, ESRD on HD (T, Th, Sat), HTN, anemia, sickle trait, with multiple [Hospital1 18] admissions and recent MSSA endocarditis (tx w/ vanco until [5-14]) and osteomyelitis with BKA admitted for S. aureus bacteremia. Had ICH likely secondary to septic embolic and underlying coagulopathy. Continues to have improving mental status, being treated for endocarditis with cefazolin, and is otherwise stable. See below for discussion of each problem... . # Acute Intracranial Hemorrhage: Pt c/o of new onset left frontal headache at ~10am on [6-6]. The patient did not have any focal neurological findings. The patient continued to c/o headache after dialysis and it did not improve with tylenol or dilaudid. The patient had increased blood pressure during the night refractory to treatment. The patient also began to have a nose bleed and a stat head CT was performed that showed large bilateral parenchymal hemorrhages in bilateral frontal lobes and left occipital lobe with surrounding edema. There were also subarachnoid hemorrhages bilaterally. The patient was transfered to the SICU and intubated. The ICHs were likely due to septic embolic from endocarditis and underlying thrombocytompenia and uremic coagulopathy. Neurosurg was unable to operate. She had two siezures and was treated with dilantin that was eventually switched to PO keppra. Neuro consult was appreciated. They advise that her prognosis is difficult to say with her ICHs. She continues to improve and is currently conversational, although not always appropriately answering questions. . # S. aureus bacteremia: Pt was transferred from [Hospital 1263] Hospital ([6-4]). Pt had blood cultures drawn at [Doctor Last Name 1263] that showed MSSA bacteremia as well as a TTE that showed vegatation on the mitral leaflet. The patient had already received vancomycin 1gm during dialysis on [6-2] and [6-4]. After the transfer to [Hospital1 18] repeat blood cultures were drawn. The cultures drawn from [6-4] and [6-5] were positive for S. aureus. ID was consulted and continued vancomycin 1gm at dialysis pending sensitivity results. A TTE was performed and confirmed the moderate vegatation on the mitral leaflet. Daily EKGs were performed on the patient that did not reveal prolongation of the PR interval. The patient then became febrile again for unknown reasons. No cultures were positive. [Month/Year (2) ] were broadened to vanco/cefepime/flagyl. Pt then stopped spiking fevers. Because no source of infection was found in cultures or CT scans, [Month/Year (2) 621] was switched again to ceftriaxone to cover MSSA on [6-24]. Pt has remained afebrile and we will complete [5-17] week course of hemodialysis dosed ceftriaxone for endocarditis. Of note, second echocardiogram during hospitalization showed interval decreased size of her vegetation. She will complete her cefazolin course and get dosed at dialysis, 2 gm M and W, 3 gm on Friday. End date is [8-3], she has follow up with ID. . # ESRD on HD: The patient had received dialysis on the day of transfer. The nephrology service was consulted at this time. Dialysis was continued throughout her stay through her temporary femoral cath until her last dialysis in which her EJ dialysis cath was used. Dialysis was given with isotonic fluids for her increased ICP from the hemorrhages. She did have some episodes of mild hyperkalemia that was resolved at dialysis. Were using kayexcelate PRN, but did not need to use it. . # ITP: The patient had a platelet level was 68 on admission. The patient had no signs of avtive bleeding or bruising. The patient was typed and crossed and continued on her home prednisone. On [6-7] the patient had a acute intracranial hemmorhage. She then was treated with IVIgx2 and IV methylpred for ITP. was also thought to have uremic plts and was given DDAVP x 1 and cryoppt. DIC labs were checked. pt was not thought to have DIC. Platelets remained low throughout the stay, set an arbitrary goal of >75,000 or active rebleeding before transfusion. Did not transfuse during hospitalization. Pt also has history of HIT so did not used heparin at all. . # Hypotension and tachycardia - has several episodes while in the MICU and one while on the floor. All were resolved with small boluses of 500 cc NS. Has had stable blood pressures the past week and a half before discharge. . # Nutrition - patient had NG tube placed after ICH and was being fed on tube feeds. When her mental status started to improved, our speech and swallow team cleared her for pureed food and thin liquids. She did pull our her NG tube once, but was replaced while she was under anesthesia for her EJ catheter. She is currently being fed and having tube feeds to meet appropriate calorie demands. If at rehab, she is able to keep up with calories on her own, the NG tube can be pulled. We discussed the option of placing a PEG tube, but since her mental status improved, we decided against it. . # Pain control - pain control has been an issue for the patient since her mental status improved. Most of her complaints revolve around her sacral wound. She also did complain about wrist and elbow pain one day. Rheumatology was consulted to answer the question if she was possibly in a lupus flair. They thought she was not in a flair. The pain resolved and she no longer has limb pain. She also complains of back pain of unknown etiology. Our concern is that there may be a central component to her pain due to the hemorrhages in her frontal load. We have continuously increased her dilaudid dose. She is currently getting 4-6 mg PO q 3 hrs with some relief. She also has a 125 mg fentanyl patch. Pain service was asked, and they recommended restarting her amitryptline, as well as adding gabapentin for neuropathic pain. We feel comfortable increasing her dilaudid as needed as long as she remains unsedated. . # Sacral stage II ulcer - remains stable, not infected. Wound care consult was called and recommended routine management of ulcer. . # Hypotension - had transitory hypotension while in the MICU which was responsive to fluid boluses. Has remained stable while on the floor, and is currently not an issue. . # Abdominal pain - had several days of abdominal pain and had a CT scan and ultrasound that was negative. Pain has since resolved. Belly labs have been normal except for consistently elevated alk phos. The elevated alk phos is likely from her bone rather than her liver due to her very severe osteodystrophy secondary to her renal failure. . # Anemia - chronic enema likely from renal failure and other multiple medical problems. After her EJ placement had an acute Hct drop to high 20s that has been stable since the procedure. Guiac negative stool. Not hemolyzing based on labwork. She is not actively bleeding at this time, and recommend continuing to follow CBC. She was not transfused during this admission. . # In general, her major issues at the time of discharge were pain control. She will need to have her main meds continually titrated for relief. She will also start needing PT/OT for strength and mobility. She is afebrile and her vital signs have been stable for about 1-2 weeks now and her mental status has been continuously improving. . Medications on Admission: Tylenol 650mg Q6prn Amitriptyline 100mg qHS ASA 81mg daily Nexium 20mg daily Fentanyl 100mcg/hr patch q3d Folic Acid 1mg Heparin 5000U SQ Q12 Dilaudid 1mg q3 Multivit Prednisone 5mg daily Senna 8.6mg [Hospital1 ] Sevelamer 1600mg at breakfast & dinner Tizanidine 2mg TID Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 3. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Lactulose 10 gram/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO BID (2 times a day). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Fentanyl 100 mcg/hr Patch 72 hr [Last Name (STitle) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): We also had a 25mg patch for a total of 125 mg q72 hrs. 7. Prednisone 5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO DAILY (Daily). 8. Levetiracetam 250 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day). 9. Acetaminophen 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 10. Cefazolin in Dextrose (Iso-os) 1 gram/50 mL Piggyback [Last Name (STitle) ]: Two (2) Piggyback Intravenous HD PROTOCOL (HD Protochol): Please give at hemodialysis. Please give 2gm on Mon, 2gm on Wed, 3gm of Friday of cefazolin. 11. Fentanyl 25 mcg/hr Patch 72 hr [Last Name (STitle) ]: One (1) patch Transdermal Q72H (every 72 hours): We use this in combination with a 100 mg patch for a total of 125 mg q 72 hr. 12. Hydromorphone 4 mg Tablet [Last Name (STitle) ]: 1 to 1.5 Tablet PO Q3H (every 3 hours) as needed. 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Last Name (STitle) ]: One (1) Adhesive Patch, Medicated Topical every twelve (12) hours as needed for back spasm. 14. Amitriptyline 50 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). 15. Lorazepam 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 16. Gabapentin 300 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1. Acute Intracranial Hemmorhage 2. MSSA Endocarditis 3. ITP 4. ESRD . Secondary: 1. Hypertension 2. Sickle cell trait 3. GERD 4. SLE Discharge Condition: stable vital signs, SBPs in 100s-120s, Dobhoff in place, sacral decub ulcer, macular rash, can answer yes/no questions, but is not always answering questions appropriately, cannot ambulate - still in bed. Discharge Instructions: You were admitted to [Hospital1 18] because of Staph. aureus bacteria infection found in your blood. We performed a ECHO of your heart and found a vegatation on your heart valve. This is conistent with endocarditis, an infection of your heart valve. You were treated with Vancomycin at dialysis for this infection, and then when you kept having fevers, we broadened your coverage. No other bacteria grew. You then stopped having fevers and the infectious disease team decided to just keep you on cefazolin as an antibiotic. . You also had a bleed in your head that was diagnosed on CT-scan. It affected your ability to communicate with us, but as time went on, you got better and were able to talk. You are still sometimes confused. The neurology team is still not able to tell how much better you will get. . You are continuing to have pain from your bed sore and your L wrist. We are trying to control your pain with dilaudid and fentanyl patch. We need to be careful with your pain medicines so we don't sedate you too much, and because your kidney does not metabolize the medicines well. . You were kept on dialysis throughout your hospital stay for kidney failure from your lupus. You will need to continue that as well. We put in an external jugular catheter for dialysis access. . You will be going to a rehab facility where they can work on your strength, ability to eat and monitor your health. . Pleae return to the hospital for changes in mental status, seizures, increasing pain, chest pain, shortness of breath, or any other concerns. Followup Instructions: Pt going to acute rehab facility - will have doctor at next facility who will continue management of care. . Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (un) 17551] phone number [Telephone/Fax (1) 250] after discharge from [Hospital ] rehabilitation. . Please see Dr. [First Name (STitle) 1075] in infectious disease at [Hospital1 18] on [8-12] at 2pm. The phone number is [Telephone/Fax (1) 457]. We will be faxing your blood work to him weekly. . Pt needs to continue dialysis on MWF schedule. Labs can be drawn at dialysis. Dialysis will also dose and give her cefazolin (2gm given after HD M and W, 3gm on F), which she will need to continue for a total of [5-17] weeks. The start date of her cefazolin was [6-22]. End date is [8-3]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2178-7-1]	[ "996.62", "530.81", "588.0", "458.9", "784.3", "430", "300.00", "V45.1", "V49.75", "263.9", "585.6", "287.5", "E879.1", "041.11", "285.21", "287.31", "780.39", "582.81", "283.0", "342.00", "789.00", "276.0", "348.30", "707.8", "276.7", "V42.0", "403.91", "421.0", "710.0", "286.9", "415.12", "518.89", "338.29", "V09.0" ]	icd9cm	[ [ [] ] ]	[ "86.05", "88.41", "39.95", "38.95", "96.6", "88.91", "99.10" ]	icd9pcs	[ [ [] ] ]	20730, 20809	11042, 18406	385, 541	20996, 21203	3510, 4095	22814, 23780	2890, 2907		18734, 20707		20830, 20975		18432, 18709			21227, 22791										2922, 3491																								301, 347										4111, 11019	569, 1875																1897, 2709	2725, 2874
80,793	122,267	34552	Discharge summary	report	Admission Date: [2163-9-18] Discharge Date: [2163-10-7] Date of Birth: [2131-5-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: motorcycle trauma Major Surgical or Invasive Procedure: L-sided chest tube placement [2163-9-18] PEG and percutaneous tracheotomy [2163-9-23] History of Present Illness: 32yo M in motorcycle accident at high-speed, reportedly doing wheelies on highway, found 100ft from his bicycle. Reportedly awake at the scene and moving all extremities. Initially brought to an OSH where he was hypotensive and hypoxic, GCS 10, then intubated and chest tubes placed BL (1 in R, 2 in L). A Head CT there was reportedly negative, and subsequently transferred to [Hospital1 18] for further mgmt and evaluation as a trauma stat. Past Medical History: ? appendectomy Social History: Construction worker. Followed at a methadone clinic. Remainder unknown. Family History: unknown Physical Exam: On arrival in trauma bay: 98.2, HR 140, BP 148/96, RR 26, O2 sat 93% intubated with ETT, BL breath sounds, bag vented pupils sluggish 3->2 BL no active head bleeding R chest tube (36Fr), L chest tube x2 (36Fr). flail chest. FAST with small subcapsular liver lac abrasion L flank, L shoulder, R knuckles prostate normal L clavicular deformity Pertinent Results: [2163-10-4] 02:18AM BLOOD WBC-9.8 RBC-3.42* Hgb-9.4* Hct-28.9* MCV-85 MCH-27.5 MCHC-32.5 RDW-14.8 Plt Ct-519* [2163-9-19] 04:42AM BLOOD PT-13.4 PTT-26.7 INR(PT)-1.1 [2163-10-4] 02:18AM BLOOD Glucose-100 UreaN-24* Creat-1.1 Na-138 K-3.9 Cl-105 HCO3-24 AnGap-13 [2163-10-4] 02:18AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1 [2163-10-6] 11:10AM BLOOD WBC-11.1* RBC-3.83* Hgb-10.4* Hct-31.9* MCV-83 MCH-27.1 MCHC-32.5 RDW-14.4 Plt Ct-558* 11:10AM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-139 K-4.3 Cl-102 HCO3-23 AnGap-18 11:10AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1 [2163-10-7] 11:53AM BLOOD ALT-28 AST-23 AlkPhos-161* Amylase-39 TotBili-0.6 DirBili-0.2 IndBili-0.4 11:53AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1 Brief Hospital Course: 32yo M presented to trauma bay as trauma stat intubated with hemodynamic stability, flail chest. CXR demonstrated persistence of L tension PTX with both L-sided chest tubes located extrapleurally. They were both removed as a new 36Fr L-sided chest tube was placed with appropriate re-expansion of the lung. Transient hypotension in the trauma bay responded to IVF and transfusion of 1u PRBC. Imaging included CT spines revealing only a T4 BL transverse process fracture. Other injuries included L rib fx's of ribs [1-18] posteriorly with displacement, ribs [5-19] anteriorly with flail chest, L clavicular fracture, and grade 1 liver laceration with subcapsular hematoma. Admitted to T-SICU under the Trauma (West3) Surgery service. A CVL was placed via R subclavian. A thoracic epidural was placed by the acute pain service for pain control and utilized until HD 5. Vent weaning was difficult due to his poor chest wall mechanics related to his rib fractures / flail. He developed a Neisseria and MSSA PNA on HD 3, manifested as a fever, and was treated with Vanco/Zosyn/Cipro. A chest CT showed bibasilar consolidations consistent with aspiration pneumonia. He continued to spike fevers up to HD 10. Work-up included re-culturing, CXR, and BAL which were unremarkable. Repeat Chest CT showed resolution of the consolidations, although with development of BL pleural effusions. The CVL was changed over a wire. Further cultures remained negative (the BAL showed coag + staph and yeast at levels below threshold for infection). WBC peaked at 19.4 on HD 11 and gradually downtrended to normal. Antibiotics were discontinued on HD 14. The R-sided chest tube was removed on HD 4. The L-sided chest tube was removed on HD 7. To facilitate his vent weaning and to provide nutritional access, a PEG and percutaneous tracheotomy (8.0 portex) were placed at the bedside on HD 6. TFs were shortly resumed and advanced to goal, tolerated with bowel function. Promitility agents (reglan and erythromycin) were added due to an episode of abdominal distension and high residuals, with resolution of symptoms, and later discontinued due to diarrhea. Eventually his mechanics improved such that he tolerated trach collars trials for a few hours at a time. Agitation then became a difficult issue. Initially managed with clonidine patch, methadone dosing that peaked at 20 [Hospital1 ], ativan prn, and occasional haldol. Psychiatry consult was obtained for guidance. Weaning of ativan and methadone was begun in order to reduce the polypharmacy. The trach was changed to a 6.0 fenestrated non-cuffed tube which he tolerated nicely. Skin care of his multiple sites of road rash was with adaptics, with gradual improvement. Pt pulled out trach on [10-5]. Occlusive dressing was placed over the tracheostomy site and trach site was observed for 24 hours. Pt maintained >95% saturations without the trach. Pt was transferred to the surgical floor and was discharged in good condition to rehab on [10-7]. Pt was afebrile, voiding, pain well controlled, and maintaining good saturations. Medications on Admission: none reported Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection of 5000 units Injection TID (3 times a day). 2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): See discharge instructions. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: 100 mg PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q6H (every 6 hours). 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Methadone 10 mg/5 mL Solution Sig: 16 mg PO TID (3 times a day) for 9 doses: Methadone 16 mg PO TID Duration: 9 Doses Start: After 18 mg tapered dose. . 10. Methadone 10 mg/5 mL Solution Sig: 14mg PO TID (3 times a day) for 9 doses: After 16 mg tapered dose. 11. Methadone 10 mg/5 mL Solution Sig: 12 mg PO TID (3 times a day) for 9 doses: After 14 mg tapered dose. 12. Methadone 10 mg/5 mL Solution Sig: 10 mg PO TID (3 times a day) for 9 doses: After 12 mg tapered dose. 13. Methadone 10 mg/5 mL Solution Sig: 8mg PO TID (3 times a day) for 9 doses: After 10 mg tapered dose. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 15. Ibuprofen 100 mg/5 mL Suspension Sig: 600 mg PO Q8H (every 8 hours) as needed. 16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: multiple rib fractures (left [1-18] laterally and [1-15] posteriorly) with flail chest respiratory failure agitation / delirium pneumonia Discharge Condition: hemodynamically stable, alternating between trach collar and ventilator support, tolerating tube feeds at goal. Discharge Instructions: [Name8 (MD) ] MD or come to ED if patient develops fever or chills; nausea, vomiting, abdominal distension, diarrhea, or constipation; chest pain, irregular heartrate, shortness of breath, worsening pulmonary performance or vent requirements, concerning pulmonary secretions; Followup Instructions: Pleaes follow-up in Trauma clinic, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], in [2-13] weeks. Call [Telephone/Fax (1) 2359] for an appointment. Completed by:[2163-12-12]	[ "E816.2", "300.00", "807.4", "862.29", "864.02", "304.01", "810.00", "495.7", "860.0", "507.0", "879.8", "518.81", "293.0", "E849.5", "805.2" ]	icd9cm	[ [ [] ] ]	[ "38.91", "33.24", "03.90", "38.93", "34.04", "96.05", "96.6", "96.72", "43.11", "31.1", "33.22" ]	icd9pcs	[ [ [] ] ]	7029, 7109	2178, 5296	331, 426	7299, 7413	1434, 2155	7741, 7955	1048, 1057		5360, 7006		7130, 7278		5322, 5337			7437, 7718										1072, 1415																								274, 293											454, 904																926, 942	958, 1032
58,167	143,486	38882	Discharge summary	report	Admission Date: [2183-1-14] Discharge Date: [2183-1-16] Date of Birth: [2109-1-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Rigid Bronch, washout History of Present Illness: 74-year-old man with history of renal cell carcinoma s/p nephrectomy and sorafenib, with lung mets s/p XRT for L obstruction presented to [Hospital ] hospital with hemoptysis, now transferred to [Hospital1 18] for further management. . Patient initially presented to [Hospital 16221] hospital with hemoptysis and acute respiratory failure and was admitted to their ICU. Chest CT reportedly showed complete left hemithorax collapse with a "small pocket of fluid." He received "aggressive pulmonary toilet" and was transferred to the floor. Due to the possibility of needing a pulmonary stent and/or a YAG laser therapy, he was transferred to [Hospital ] hospital where his pulmonologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], and his oncologist, Dr. [Last Name (STitle) 86281], practice. However, there was no YAG laser available at [Location (un) ] for one more week; therefore, patient was transferred to [Hospital1 18]. He has remained stable on [1-16] L of NC, sating in the low-mid 90s. Patient has had some bloody streaks in his sputum. He has been receiving Mucomyst nebulizers [Hospital1 ] and bronchodilators qid. He received a course of pip-tazo, which was discontinued prior to transfer to [Hospital1 18]. Sputum cx was pending. His Cr peaked at 2.2 ([2183-1-13]) from baseline of 1.4 and he has received IVF. His hemodynamics have been stable. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. FLOOR ADMISSION NOTE In summary, Mr [Known lastname 47780] is a 74M with h/o renal cell carcinoma s/p nephrectomy and sorafenib, with lung mets s/p XRT for L obstruction initially presented to [Hospital 16221] hospital with hemoptysis. Pt was admitted to ICU, chest CT revealed left hemithorax collapse. He was then transferred to [Hospital ] hospital and ultimatelly to [Hospital1 18] with plan for YAG laser therapy. Pt remained stable on [1-16] L of NC, sating in the low-mid 90s, with blood streaked sputum. Pt received nebs, zosyn, IVF for Cr 2.2 (basline 1.4). . Since arrival to [Hospital1 18] MICU, pt underwent bronch in OR on [2183-1-15], which revealed complete LUL obstruction, tumor removed, now patent. LUL and lingula were obstructed, cleaned out, but lots of blood/mucus/pus junk behind obstruction it. Got one dose Zosyn 4.5 g for this in the OR and continued overnight. Still has obstruction to LLL, could not debride. He may benefit from PDT to LLL. . Pt has also developed intermitted afib to 100s while on beta blocker. Pt was also transiently hypotensive to 80s, responded to 500cc bolus. EKG unchanged. . Past Medical History: MEDICAL HISTORY: renal cell carcinoma: s/p R nephrectomy in [2182-8-15], XRT, sorafenib cardiomyopathy with EF 40% CAD: s/p CABG AVR: [2164] HTN hyperlipidemia Social History: quit smoking and drinking 30 years ago, was athletic coach at college level, lives with wife. Family History: n/c Physical Exam: Admission Exam GENERAL: elderly man sitting up in bed in NAD, very talkative, looking comfortable HEENT: EOMI, OP moist without lesion CARDIAC: RR, normal S1/S2, 3/6 systolic click, no JVD LUNG: Decreased breath sounds on the left, no crackles, no wheezing ABDOMEN: soft, nontender, nondistended, bowel sounds present EXT: no c/c/e NEURO: oriented x 3 FLOOR PE Vitals - T: 98.6 BP: 104/56 HR: 75 RR: 20 02 sat: 95% 4L GENERAL: sleeping, easily arousable HEENT: anicteric sclera, MMM CARDIAC: RR, normal S1/S2, 3/6 systolic click, no JVD LUNG: Decreased breath sounds on the left, no crackles, no wheezing ABDOMEN: soft, nontender, nondistended, bowel sounds present EXT: no c/c/e NEURO: oriented x 3 Pertinent Results: ADMISSION LABS: . [2183-1-14] 03:42PM BLOOD WBC-8.1 RBC-4.32* Hgb-12.7* Hct-38.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-14.6 Plt Ct-249 [2183-1-15] 02:56AM BLOOD WBC-8.3 RBC-3.89* Hgb-11.4* Hct-34.9* MCV-90 MCH-29.4 MCHC-32.7 RDW-14.9 Plt Ct-271 [2183-1-14] 03:42PM BLOOD Neuts-78.6* Lymphs-11.3* Monos-6.6 Eos-3.1 Baso-0.4 [2183-1-14] 03:42PM BLOOD PT-12.1 PTT-29.2 INR(PT)-1.0 [2183-1-14] 03:42PM BLOOD Glucose-102* UreaN-22* Creat-2.3* Na-139 K-4.6 Cl-105 HCO3-26 AnGap-13 [2183-1-15] 02:56AM BLOOD Glucose-98 UreaN-24* Creat-2.0* Na-141 K-4.1 Cl-109* HCO3-23 AnGap-13 [2183-1-14] 03:42PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3 [2183-1-15] Blood Cx negative x2 [2183-1-15] sputum Cx [2183-1-15] 5:55 pm SPUTUM Source: Expectorated. FINAL REPORT [2183-1-17] GRAM STAIN (Final [2183-1-15]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2183-1-17]): MODERATE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. DISCHARGE LABS: . [2183-1-16] 06:55AM BLOOD WBC-7.9 RBC-3.78* Hgb-10.7* Hct-33.2* MCV-88 MCH-28.4 MCHC-32.3 RDW-14.6 Plt Ct-221 [2183-1-15] 02:35PM BLOOD WBC-7.4 RBC-3.84* Hgb-11.2* Hct-34.0* MCV-89 MCH-29.2 MCHC-33.1 RDW-14.5 Plt Ct-248 [2183-1-16] 06:55AM BLOOD PT-11.8 PTT-31.8 INR(PT)-1.0 [2183-1-16] 06:55AM BLOOD Glucose-93 UreaN-18 Creat-2.0* Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [2183-1-16] 06:55AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1 [2183-1-14] EVALUATION OF ANTIBODIES DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [Known lastname 47780] has a new diagnosis of Anti-D antibody. D-antigen is a member of the Rhesus blood group systems. Anti-D antibody is clinically significant and capable of causing hemolytic transfusion reactions. In the future, Mr. [Name13 (STitle) 1968] should receive D-antigen negative products for all red cell transfusions. Approximately 15% of ABO compatible blood will be D-antigen negative. A wallet card and a letter stating the above will be sent to the patient. . [2183-1-14] CXR FINDINGS: No previous images. Complete opacification of the left hemithorax with apparent cutoff of the bronchus. There is apparent shift of the mediastinum to the left. This indicates that there is substantial loss of volume in the left hemithorax, most likely relating to mucus plug or a malignancy, possibly associated with a substantial pleural fluid as well. CT is necessary to evaluate this patient further. The right lung is essentially clear. . [2183-1-15] PATHOLOGY MAINSTEM BRONCHUS DIAGNOSIS: Left mainstem bronchus tissue: The specimen consists almost entirely of blood and fibrin with a few detached bronchial epithelial cells and inflammatory cells. No definite malignancy is identified. Entire specimen submitted, multiple levels examined. Clinical: Malignant airway obstruction. . [2183-1-15] EKG Sinus rhythm with first degree A-V delay. Probable left atrial abnormality. Inferior wall myocardial infarction of indeterminate age. Non-specific anterolateral ST-T wave changes. Clinical correlation is suggested. No previous tracing available for comparison. TRACING #1 Read by: [Last Name (LF) ],[First Name3 (LF) ] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 [Telephone/Fax (3) 86282]/405 0 -19 148 . [2183-1-15] EKG Three beats of sinus rhythm. The rhythm then appears to be atrial fibrillation at 90 beats per minute. Diffuse anterolateral ST-T wave changes. Compared to tracing #1 the rhythm is initially sinus. It then appears to convert to atrial fibrillation with relatively controlled ventricular response. ST-T wave changes are slightly more prominent. TRACING #2 Read by: [Last Name (LF) ],[First Name3 (LF) ] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 92 0 108 340/396 0 3 168 . [2183-1-15] CXR SINGLE FRONTAL PORTABLE CHEST RADIOGRAPH: There is interval improved opacification of the left upper lobe with persistent dense opacification of the left lower lobe (obscuring the adjacent hemidiaphragm), which may represent atelactasis or an effusion. Sternal wires are intact. The cardiac silhouette is mildly enlarged. The mediastinal silhouette, hilar contours are normal. There is increased density along the left lateral hemithorax with complete opacification of the left apex, which may represent pleural thickening or effusion. IMPRESSION: Improved aeration of the left upper lobe. Left lower lobe atelactasis vs effusion. Left hilar and and lateral pleural opacity may represent pleural thickening or effusion. Brief Hospital Course: 74-year-old man with history of renal cell carcinoma s/p nephrectomy and sorafenib, with lung mets s/p XRT for L obstruction presented to [Hospital ] hospital with hemoptysis, tranferred to [Hospital1 18] for bronchoscopy and further management. . # Left lung collapse and hemoptysis: CXR showing complete collapse of L lung with complete cutoff of left bronchus. Was stable respiratorily and no fever or leukocytosis on admission. Went to OR with IP with bronch showing complete LUL and lingula obstruction, tumor was resected and was patent afterwards; however had blood/mucus/pus behind obstruction and so got one dose of Zosyn and Vanc, and was discharged with one week of Levaquin. An obstruction in the LLL was unable to be debrided and so IP planned for photodynamic therapy the week after admission, which was to be arranged by IP on discharge. . The pt was stable after the procedure, satting well on room air, no resp distress, ambulating without desaturation, no further hemoptysis, and discharged to follow up the week after with IP. . # Acute kidney injury: 2.2 at OSH, improved to 1.9 with IVF however trended back to 2.0 by discharge. Unclear baseline. . # Tachycardia: Atrial tach to 100s intermittently intraoperatively. Continued on beta blocker and no further issues postoperatively. . # Renal cell carcinoma: s/p R nephrectomy, XRT, and sorafenib. Pt had previously scheduled f/u with outpt oncologist. . # sCHF: EF 40%, no current evidence of heart failure. Digoxin was continued at renal dose. . # CAD: Continued on home metoprolol, aspirin, statin. Medications on Admission: MEDICATIONS ON TRANSFER: albuterol in h qid ipratropium hep SC pantoprazole 40 mg qday guaifenesin digoxin 0.125 mg PO qday (decreased from home dose of 0.25 mg qday due to [Last Name (un) ]) metoprolol 100 mg qam and 50 mg qpm rosuvastatin 20 mg qday aspirin 81 mg qday bisacodyl prn docusate sodium [Hospital1 ] N-acetylcystein nebs Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 4. Rosuvastatin 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 3 doses: To be taken: [Last Name (LF) 2974], [First Name3 (LF) 1017], and Tuesday. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left lung collapse from tumor invasion Renal cell cancer with metastases to lung systolic HF EF 40% HTN CAD s/p CABG hyperlipidemia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Dear Mr. [Known lastname 47780], It was a pleasure taking care of you. You were admitted to the hospital with left lung collapse due to tumor invasion from your cancer. You underwent bronchoscopy, where tumor was removed and part of your lung was re-expanded. However a portion of the lung was still collapsed after the procedure and remains so. You will need to complete a course of phototherapy for additional management of the tumor in the lung. The interventional pulmonary team here at [Hospital1 18] will be providing you with more information regarding this therapy. You will also complete a course of antibiotics for approximately 1 week after your discharge. . You were noted to occasionally have an irritable atrial (heart) rhythm. This is NOT the same as atrial fibrillation, and can be brought on by stressors such as infection, fever, anesthemsia, or procedures such as bronchoscopy. You should followup with your cardiologist regarding this issue, but for now no action needs to be taken. . We have made the following changes to your medications: 1.) START levofloxacin (an antibiotic) for a total of 7 days. You only need to take this once every other day, for a total of 7 days (4 doses including the one you got in the hospital). 2.) DECREASE dose of digoxin to 0.125mg daily due to your kidney function . Please keep all of your appointments as scheduled below. Please take all medications as prescribed. Followup Instructions: You have follow up with your: Interventional Pulmonology team at [Hospital1 18]: They will contact you regarding scheduling your phototherapy. In case you do now hear from them, their phone number is [Telephone/Fax (1) 3020] . Oncologist: You have a previously scheduled appointment with Dr. [Last Name (STitle) 86281] in [Location (un) ]. . Cardiologist: Please follow up with your cardiologist Dr. [Last Name (STitle) 86283]. You have an appointment [2-18], but this could be moved up if he has availability. . PCP: [Name10 (NameIs) ] [Name11 (NameIs) 86284] up with your PCP in the next 2-3 weeks. Completed by:[2183-1-17]	[ "403.90", "428.22", "V45.81", "518.0", "197.0", "427.31", "V15.82", "425.4", "786.3", "584.9", "585.9", "V10.52", "V43.3", "519.8", "272.4", "428.0", "414.00", "458.9" ]	icd9cm	[ [ [] ] ]	[ "32.01" ]	icd9pcs	[ [ [] ] ]	11755, 11761	9121, 10703	325, 348	11937, 11937	4274, 4274	13541, 14206	3532, 3537		11096, 11732		11782, 11916		10729, 10729			12085, 13126			5559, 9098							3552, 4255																			13155, 13518					275, 287											376, 3213					4290, 5543				11952, 12061						10754, 11073	3235, 3405	3421, 3516
57,449	142,986	41942	Discharge summary	report	Admission Date: [2102-10-20] Discharge Date: [2102-10-31] Date of Birth: [2074-10-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1185] Chief Complaint: Overdose AMS requiring intubation Shock requiring pressor Major Surgical or Invasive Procedure: Intubation [10-20] Right subclavian CVL [10-20] A line [10-21] Bronchoscopy [10-24] Self Extubation [10-25] History of Present Illness: history is based on record and per family 28 yo M with polysubstance abuse, bipolar and schizophrenia (per family) admitted to MICU given already intubated state [2-1] overdose medflighted to [Hospital1 18] from [Hospital6 ]. . Per wife, she last saw him on [10-19] 5PM. They had an argument and he left home and went to a friend's place. They continued to communicate through text-messaging until 8AM on [10-20]. Then, all communication between them stopped. The next time, she heard about him was when she was contact[Name (NI) ] by the hospital. Per the wife, the girl friend that he stayed with found him unresponsive with foam and blood from his mouth. There was also apparently vomitus around. In addition, he was found to have percocet, clonazepam, coke, heroin, and liquor around him. EMS was called and intubated him on the field. Per report, he remained unresponsive despite narcan and paralytics. CXR at [Hospital3 ] suggested aspiration and he was reportedly given gent/vanc/CTX/Flagyl. He was hypotensive in the 80s, and norepi and phenylephrine were started. He was found to be hyperkalemia to the [6-6] with EKG change but only received insulin and dextrose. Patient was [Location (un) ] to [Hospital1 18] and had fever up to 101. . In the ED, initial vs hr 122, bp 96/57, rr 16, O2 Sat 99% on the vent on FiO2 100%, PEEP 20, volume 450. Per report, he got a total of 6 L of NS. He got a right subclavian line. No A-line. He was found to be difficult to sedate, requiring multiple doses of midazolam and fentanyl. Tox screen + benzo, cocaine, opiates. Has leukocytosis at 12.3. CT C-spine and head were negative. CXR with diffuse opacification of right lung and left perihilar region. Vitals upon transfer were HR 114, BP 106/53, RR 24 (set), 450 VT, 100% FiO2 and PEEP 17, Satting 94%-99%. Past Medical History: per wife - history of overdose in the past without hospitalization - h/o bipolar - h/o schizophrenia - h/o suicidal attempts by cutting - h/o kidney related fever - right thigh mass that is increasing in size - s/p pencil stab to the right thigh - h/o penile infection Social History: per wife - multiple [Name2 (NI) 91043] in the past, most recently x 20 months, just got out about 1 month ago, but has been using substances since - has 5 kids of his own and 3 kids of his wife's - Tobacco: yes - Alcohol: daily binge, EtOH beer then liquor - Illicits: IV/sniff heroin, percocet and clonazepam PO, sniff cocaine, also mix other meds that she cannot recall Family History: - MGM: intestinal cancer - father: history of coke use - father's side also has a lot of psychiatric issues Physical Exam: PYHYSICAL EXAM ON ADMISSION EXAM Vitals: T: 103.1 BP: 131/66 P: 128 R: 25 O2: 98% intubated General: sedated HEENT: Sclera anicteric, mucous membrane dry, intubated Neck: supple, no LAD Chest: R IJ in place Lungs: coarse breath sounds bilaterally, R worse than left, no wheeze or rhonchi CV: tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . PHYSICAL EXAM ON DISCHARGE VSS CTAB RRR, no MRG ABD: SNT ND +BS Pertinent Results: ADMISSION LABS [2102-10-20] 06:20PM BLOOD WBC-12.3* RBC-4.96 Hgb-15.6 Hct-44.2 MCV-89 MCH-31.4 MCHC-35.3* RDW-13.8 Plt Ct-247 [2102-10-20] 06:20PM BLOOD Neuts-70 Bands-3 Lymphs-13* Monos-12* Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [2102-10-20] 06:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2102-10-20] 06:20PM BLOOD PT-16.3* PTT-28.1 INR(PT)-1.4* [2102-10-20] 06:20PM BLOOD Glucose-101* UreaN-23* Creat-2.2* Na-142 K-4.5 Cl-108 HCO3-22 AnGap-17 [2102-10-20] 06:20PM BLOOD Calcium-7.0* Phos-1.4* Mg-1.5* [2102-10-20] 06:32PM BLOOD Glucose-89 Lactate-3.8* Na-143 K-4.3 Cl-108 calHCO3-21 [2102-10-20] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2102-10-20] 06:36PM BLOOD Type-ART pO2-116* pCO2-53* pH-7.23* calTCO2-23 Base XS--5 [2102-10-20] 06:20PM BLOOD ALT-88* AST-77* LD(LDH)-255* CK(CPK)-640* AlkPhos-59 [2102-10-20] 06:20PM BLOOD CK-MB-15* MB Indx-2.3 cTropnT-0.10* [2102-10-21] 01:56AM BLOOD CK-MB-25* MB Indx-1.5 cTropnT-0.11* [2102-10-21] 10:17AM BLOOD CK-MB-23* MB Indx-1.2 cTropnT-0.12* [2102-10-21] 04:34PM BLOOD CK-MB-16* MB Indx-0.9 cTropnT-0.11* [2102-10-22] 02:28AM BLOOD CK-MB-7 cTropnT-0.09* [2102-10-20] 06:20PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2102-10-20] 06:20PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2102-10-20] 06:20PM URINE RBC-12* WBC-4 Bacteri-FEW Yeast-NONE Epi-1 [2102-10-20] 06:20PM URINE CastHy-40* [2102-10-20] 06:20PM URINE Mucous-FEW [2102-10-20] 06:20PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . DISCHARGE LABS [2102-10-31] 07:05AM BLOOD ALT-103* AST-49* AlkPhos-65 [2102-10-30] 04:50AM BLOOD Glucose-93 UreaN-12 Creat-1.2 Na-141 K-4.6 Cl-106 HCO3-26 AnGap-14 [2102-10-30] 04:50AM BLOOD WBC-9.2 RBC-4.23* Hgb-13.3* Hct-38.6* MCV-91 MCH-31.5 MCHC-34.5 RDW-13.6 Plt Ct-352 . Microbiology: [2102-10-21] URINE URINE CULTURE-Negative [2102-10-21] URINE Legionella Urinary Antigen - Negative [2102-10-21] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +} STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [2102-10-24] 12:12 pm BRONCHOALVEOLAR LAVAGE LEAKING SPECIMEN, INTERPRET RESULTS WITH CAUTION. GRAM STAIN (Final [2102-10-24]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2102-10-26]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. PERTINENT STUDIES [10-20] CT HEAD FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. The ventricles and sulci are normal in size and appearance. No concerning osseous lesion or fracture is seen. There are multiple air-fluid levels throughout the visualized paranasal sinus, commonly seen with intubation. The mastoid air cells are clear. IMPRESSION: No CT evidence of acute intracranial process. . [10-20] CT Spine FINDINGS: No acute fracture or malalignment is seen. The atlantoaxial and atlanto-occipital articulations are preserved. The prevertebral soft tissues are within normal limits. The patient is intubated and a nasogastric tube is noted in the esophagus. Air-fluid level in the right maxillary sinus is compatible with intubation. The mastoid air cells are clear. Within the visualized portions of the lung apices, opacities of the right lung are partially imaged, better seen on radiograph of the same date. IMPRESSION: No acute fracture or malalignment. . [10-20] CXR portable IMPRESSION: 1. Diffuse opacification of the right lung, and to a lesser extent within the left perihilar region. Findings may represent multifocal pneumonia, aspiration, or possibly hemorrhage. 2. Endotracheal tube and nasogastric tubes in standard positions. . [10-23] ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. 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. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. A PICC line is seen in the RA prolapsing through the tricupsid valve without any vegetations seen on the line. IMPRESSION: No valve vegetations seen. . [10-25] CXR portable FINDINGS: Frontal view of the chest. Endotracheal tube has been removed. Right subclavian catheter terminates at the cavoatrial junction. The heart is of normal size with an unchanged cardiomediastinal silhouette. Bilateral diffuse heterogeneous hazy opacities, right greater than left, have slightly improved since [2102-10-24]. No new focal opacity, pleural effusion, or pneumothorax. IMPRESSION: Interval extubation with slight improvement in diffuse hazy opacities, right worse than left. Brief Hospital Course: 28 yo M with polysubstance abuse, reported schizophrenia & bipolar, found unresponsive requiring intubation, transferred from OSH for workup and treatment and was found to have aspiration pneumonia in the setting of polysubstance overdose. . # Shock. Pt initially present with hypotension requiring 6 L IVF in the ED with upto 2 pressors in the MICU. The cause of shock is likely septic in nature, likely secondary to aspiration pneumonia. He was covered with antibiotics since admission, gent/vanco/ceftriaxone/flagyl at OSH, unasyn initially in ED of [Hospital1 ], vanco/zosyn in the MICU, clindamycin after arriving the floor and finished with augmentin for an accumulative total of 10 days. His culture was only notable for MSSA on sputum culture from the day after admission. His urine, blood culture, and BAL were otherwise negative. Upon discharge, pt was hemodynamically stable. . # Aspiration pneumonia / respiratory distress: Pt's chest x-ray on admission was concerning for multilobar pneumonia on the right side. The history of unresponsiveness and fairly rapid radiographical resolution are most consistent with aspiration pneumonia. Pt was initially broadly covered with antibiotics, which was later tailed based on the clinical course and MSSA grew from the sputum culture (See above). His MICU course was notable for hypercarbic hypoxic respiratory failure, requiring high peep (upto 18) and heavy sedation including the use of precedex. This likely developed in the setting hypoventilation secondary to sedative substance overdose. Pt's respiratory status improvement significantly after extubation. Pt maintained normal saturations without oxygenation difficulties on the hospital floor prior to discharge to [Hospital1 ] 4. . # AMS: Most likely developed because of substance overdose and pneumonia. He was intubated on the field and improved gradually. CT head/neck negative. He self extubated on [2102-10-24]. C- collar was cleared. Mental status slightly lethargic but improving upon transfer to the floor. He was alert and oriented throughout his stay on the medicine floor. He was treated with haloperidol initially and later switched to zyprexa for anxiety and agitation. . # Overdose/Polysubstance abuse: Pt came in with polysubstance abuse, with tox screen evidence of opiate, benzo, cocaine, tylenol. There is also high likelihood of alcohol abuse given the scene when pt was found. It was suspected that the overdose was a suicidal attempt. Pt was evaluate by social worker and psychiatrist during this admission. He was placed on section 12 and one-on-one watch for the concern of suicidal ideation. He received valium for alcohol withdrawal per CIWA protocol, which has been discontinued prior to discharge. Pt was also started on thiamine, folate and multivitamin. . # Transaminitis: Pt was found to have transaminitis, which likely occurred in the setting of hypotensive shock or multidrug toxicity. His ALT/AST were down trend since admission. The LFT on discharge still showed elevation of ALT/AST, which could reflect the ongoing hepatitis C infection. . # Hepatitis C: Pt was found to have positive hepatitis C antibody, suggesting infection. The potential source of infection includes tattoo and IV drug use. Of note, pt was hepatitis B negative. Pt will need hepatology followup for further evaluation and potentially treatment. Will recommend testing for HIV in the outpatient setting once the insurance situation resolves. . # NSTEMI: Pt had mildly elevated CKMB and troponin. This likely happened in the setting of hypotension and cocaine toxicity. EKG showed ST depression in inferior leads. His troponin was down trending, and CKMB returned to [Location 213]. . # Acute kidney injudry: Most likely prerenal vs ATN (in the setting of hypotension and rhabdomyolisis). His creatinine normalized after supportive care. . CHRONIC ISSUES # Psychiatric issues: [Name (NI) 1094] wife reported history of bipolar and schizophrenia, with no prior hospitalization and medication. No clear evidence of active disease was observed. Psychiatric followup after the resolution of acute medical problems was recommended. . TRANSITIONAL ISSUES Code status: full Medication changes: - STARTED thiamine 100 mg qd - STARTED folate 1 mg qd - STARTED multivitamin 1 tablet qd Follwoup: - Pt will need primary care followup after approval of Mass Health. - Please arrange hepatology followup for newly diagnosed hepatitis C. - Please check LFT in one week. - Needs clarification for potential history of bipolar and schizophrenia. Medications on Admission: None (per wife) Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for anxiety. 7. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS DIRECTED). Discharge Disposition: Home Discharge Diagnosis: aspiration pneumonia alcohol withdrawal polysubstance intoxication Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were transferred to our hospital for unresponsiveness from what appears to be an overdose of multiple drugs. You had a pneumonia, which likely happened while you were unresponsive. You were intubated by the paramedics, and required a breathing machine while in the medical ICU. We treated you with antibiotics for pneumonia and supportive care for withdrawal symptoms from the drugs and alcohol that you consumed. You have been evaluated by our inpatient psychiatry team. While your medical problems have resolved, you will spend time on the psychiatry floor to continue your treatment and healing. Please note that the following medications have been changed: - Please START to take thiamine 100 mg tablet by mouth daily. - Please START to take folic acid 1 mg tablet by mouth daily. - Please START to take multivitamin one tablet by mouth daily. - Please START the zyprexa schedule noted in your med list, though the psychiatry team may change this medicine while you are hospitalized There are no further medication changes. It has been a pleasure taking care of you here at [Hospital1 18]. We wish you a speedy recovery. Followup Instructions: - Please arrange appointment with a primary care physician once your insurance is settled, this is extremely important to maintain good health in the future. - we found a liver infection called hepatitis C, which is a longstanding and serious infection that requires monitoring by a liver doctor. Please call the liver center at ([Telephone/Fax (1) 1582] to make an appointment when you are discharged from the psychiatry floor. [Name6 (MD) ] [Name8 (MD) ] MD [Doctor Last Name 1189]	[ "291.81", "303.90", "305.50", "276.7", "E950.3", "507.0", "482.41", "292.84", "296.90", "276.0", "410.71", "785.52", "584.9", "970.81", "969.4", "518.81", "305.60", "070.70", "728.88", "E950.4", "965.01", "995.92" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.72" ]	icd9pcs	[ [ [] ] ]	14864, 14870	9640, 13883	365, 494	14981, 14981	3850, 9617	16330, 16863	3096, 3206		14313, 14841		14891, 14960		14273, 14290			15132, 16307										3221, 3831																						13903, 14247		268, 327											522, 2392									14996, 15108							2414, 2685	2701, 3080
79,548	128,799	1566	Discharge summary	report	Admission Date: [2120-3-31] Discharge Date: [2120-4-3] Date of Birth: [2057-3-12] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Droperidol Attending:[First Name3 (LF) 2108] Chief Complaint: altered mental status, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [2120-4-2] Time: 02:50 PCP: [Name10 (NameIs) 9091],[Name11 (NameIs) ] [Name Initial (NameIs) ].; [Telephone/Fax (1) 250]; [University/College 9092] The patient is a 63M with multiple ED admissions for polysubstance abuse including alcohol and nonethanol alcohols and solvents c/o diarrhea for few days without abdominal pain, decreased PO intake, initial BP for EMS 70/P. Upon arrival, he was unable to provide further history. His niece stated she left the house in the morning while he was still in bed. She called him multiple times during the day and he did not pick up. She returned at 5pm and found him in bed, covered in diarrhea. He had a normal day, the day prior. In the ED, he was alert, conversant and protecting his airway. His cousin reported that the patient had not been getting meds over the past couple of days. Initial VS: 97.2, 58, 83/47,18, 100%. FS 126. He recieved 2L-3L of IVF and was still hypotensive. A RIJ was placed at that time and norepinephrine was started at 0.08 mcg/kg/hr at 60kg and has not needed to be increased. He received a total of 4L IVF. Labs were significant for an elevated creatinine of 2.5 from baseline 1.0, Osm gap of 47 with normal anion gap. EKG showed SR 59, LAD, QTc 483, biphasic T III, F (new). He was guiaic negative. Fast ultrasound showed a left renal cyst but was otherwise negative. CT abd/pelvis, CXR, CT head were reported as unremarkable. Toxicology was consulted and recommended fomepizole 15mg/kg IV X1. Stool cdiff and blood cultures were sent. Patient was given Vancomycin 1 G (2400), Flagyl 500mg (0200), Zosyn (0100), Thiamine, Zofran 2mg, Pantoprazole 40mg (0430), and was started on norepi. He was given Fomepizole 900mg at 5:15am. VS on transfer to ICU were: 66, 166/83, 13, 98%, with a CVP of 8. He had received 4.5L IVF and UOP was 700cc. In the ICU, he denied vision changes, vomiting, dizziness or suicidality. He did report a HA. On the medicine floor, he reports insomnia, continued diarrhea since admission and abdominal pain over the past two weeks. Review of Systems: (+) Per HPI (-) All other review of systems negative. Past Medical History: - Polysubstance abuse including opiates, benzos, alcohol, and nonethanol alcohols and solvents - Hypertension - Atypical chest pain (normal stress testing done [9-1]) - Gastroesophageal reflux disease - Depression ( past hospitalizations for depression) - COPD/Emphysema - CVA in [2109] - Pancreatitis - Benign Prostatic Hypertrophy - Temporal lobe epilepsy (unclear diagnosis with 1 suggestive EEG in [2106] per OMR) Social History: - Lives alone in in [Location (un) 86] - Had VNA in past but due to conflicts with them, has had trouble keeping [Name (NI) 9093] - brother/HCP [First Name8 (NamePattern2) 4049] [Name (NI) ] [Telephone/Fax (1) 9094] who lives in [Hospital1 1474] and the sister lives in [Name (NI) 8]. - Previously worked as a field engineer for bridges and in the entertainment industry - Tobacco: Ongoing - etOH: Ongoing ; he has been drinking in large amounts off an on for many years; when he runs out of vodka, he sometimes drinks rubbing alcohol, often in times of stress - Illicits: cocaine, benzo, and rubbing alcohol abuse in the past. States last snorting of cocaine was about 30 yrs ago, but last smoking cocaine 2 wks ago. - States that he has had many stressors recently, including very close friend who died recently, caused him to start drinking this week. - States that he has not been sexually active for 30 yrs - States that he was last tested for HIV a few months ago at [Hospital1 2177] and was negative Family History: - Paternal grandfather also had epilepsy - Mother died of leukemia - Daughter drug abuser - Another niece also has leukemia - Denies any premature CAD or MI in family Physical Exam: VS: 99.0 130/75 63 17 95%RA GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates; R IJ present CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, tender to palpation in RUQ, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [3-28] motor function globally DERM: no lesions appreciated Pertinent Results: [2120-3-30] 11:00PM PLT COUNT-206 [2120-3-30] 11:00PM NEUTS-78.2* LYMPHS-17.1* MONOS-4.4 EOS-0.2 BASOS-0.1 [2120-3-30] 11:00PM WBC-10.2# RBC-3.73* HGB-12.3* HCT-35.4* MCV-95 MCH-32.8* MCHC-34.7 RDW-18.4* [2120-3-30] 11:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-3-30] 11:00PM CORTISOL-26.9* [2120-3-30] 11:00PM OSMOLAL-350* [2120-3-30] 11:00PM CALCIUM-8.9 PHOSPHATE-6.6# MAGNESIUM-2.0 [2120-3-30] 11:00PM cTropnT-<0.01 [2120-3-30] 11:00PM LIPASE-39 [2120-3-30] 11:00PM ALT(SGPT)-25 AST(SGOT)-26 ALK PHOS-60 TOT BILI-0.2 [2120-3-30] 11:00PM GLUCOSE-112 UREA N-27* CREAT-2.5# SODIUM-143 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-22 ANION GAP-17 [2120-3-30] 11:28PM GLUCOSE-109 LACTATE-2.1* NA+-146 K+-4.3 CL--109 TCO2-18* [2120-3-30] 11:53PM PT-13.3 PTT-23.8 INR(PT)-1.1 [2120-3-31] 12:09AM URINE MUCOUS-RARE [2120-3-31] 12:09AM URINE HYALINE-12* [2120-3-31] 12:09AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [2120-3-31] 12:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2120-3-31] 12:09AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.011 [2120-3-31] 12:09AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2120-3-31] 12:09AM URINE HOURS-RANDOM CREAT-127 SODIUM-70 POTASSIUM-63 CHLORIDE-99 [2120-3-31] 04:20AM OSMOLAL-334* [2120-3-31] 04:20AM CK-MB-2 cTropnT-<0.01 [2120-3-31] 04:20AM CK(CPK)-91 [2120-3-31] 04:20AM GLUCOSE-134* UREA N-24* CREAT-1.9* SODIUM-143 POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-18* ANION GAP-16 [2120-3-31] 08:16AM LACTATE-0.9 [2120-3-31] 08:16AM TYPE-ART TEMP-36.5 PO2-46* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 INTUBATED-NOT INTUBA [2120-3-31] 03:00PM OSMOLAL-321* [2120-3-31] 03:00PM CALCIUM-8.0* PHOSPHATE-3.1# MAGNESIUM-1.8 [2120-3-31] 03:00PM CK-MB-3 cTropnT-<0.01 [2120-3-31] 03:00PM CK(CPK)-104 [2120-3-31] 03:00PM GLUCOSE-98 UREA N-15 CREAT-1.3* SODIUM-143 POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-22 ANION GAP-13 [2120-3-30] pCXR: FINDINGS: Exam is limited by low lung volumes and slight rotation. Linear right basilar atelectasis is present with otherwise clear lungs. Heart size is normal and aorta is tortuous. No pneumothorax or pleural effusion is present. Several old right-sided rib fractures are present. IMPRESSION: No pneumonia. [2120-3-30] CT abn/pelvis w/o: ABDOMEN: There is minimal dependent atelectasis, particularly at the right base which is little changed from the prior study. The partially visualized heart appears normal. Evaluation of solid organs is limited by lack of IV contrast. Within these limitations, the spleen, adrenals, pancreas, and liver appear normal. There is hyperdense material within the gallbladder, likely reflecting vicarious excretion of contrast from CT examination two days prior. Two cysts are seen within the left kidney, and upper pole cyst measuring 1.5 cm and a mid pole cyst measuring 7 x 8 cm. No stones or hydronephrosis is present. The right kidney appears normal. The stomach and abdominal loops of small bowel appear normal. No free air or free fluid is present. No significant adenopathy is present. The distal esophagus is somewhat thickened, which could reflect esophagitis. PELVIS: Pelvic loops of bowel appear normal. No free air, free fluid, or adenopathy is present. There is a Foley within the bladder and the bladder does contain some air. No free air or free fluid or adenopathy is present. BONE WINDOWS: Degenerative changes are present in the thoracolumbar spine. There are several healed right-sided posterior rib fractures. IMPRESSION: 1. No acute findings in the abdomen or pelvis to explain hypotension. Some fluid within nondistended loops of bowel to account for the patient's diarrhea. 2. Left-sided renal cysts, stable. 3. New distal esophageal mucosal thickening may reflect esophagitis. The study and the report were reviewed by the staff radiologist. [2120-3-31] CT head w/o: IMPRESSION: 1. Atrophy and white matter change, but no acute intracranial findings. The study and the report were reviewed by the staff radiologist. [2120-3-31] pCXR line placement: IMPRESSION: Left IJ placement without complications. The study and the report were reviewed by the staff radiologist. [2120-4-1] RUQ U/S: FINDINGS: Normal liver echotexture without focal liver lesion. No intrahepatic biliary dilatation. Common bile duct measures 3 mm. No gallstones in the gallbladder. No pericholecystic fluid or gallbladder wall edema. The gallbladder is distended howvever appearances have improved since CT 2 days ago. There is a tiny trace of perihepatic ascites noted. Spleen measures 8 cm. Main portal vein is patent and demonstrates hepatopetal flow. IMPRESSION: 1. Gallbladder distension but no gallbladder wall edema, stones or pericholecystic fluid seen. Findings improved since CT 2 days previously. Follow-up with US recommended if symptoms persist. 2. Unremarkable appearance to the liver. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [Known lastname 805] is a 63 year old man with hx of polysubstance abuse, HTN, epilepsy; p/w hypotension and isopropyl alcohol ingestion and RUQ pain. Isopropyl ETOH Ingestion: Patient has a known history of previous isopropyl alcohol ingestion. He presented with osmolar gap and no anion gap. On further discussion, patient states that he has been very upset recently by the death of a very close friend, which caused him to start drinking vodka. When his vodka ran out, he started drinking rubbing alcohol. He is aware that these ingestions could kill him. He does state that he regrets the isopropyl alcohol ingestion and recent cocaine use and that he would like to turn his life around. He would like to be around for his grandchildren. He had no evidence of withdrawal on this admission, he stated he would like to quit but not interested in services to help with this at this time, he was seen by social work inpatient. R sided abd pain. Distended gallbladder but negative hida so not acute cholecystitis. CT abdomen otherwise negative. He will obtain his colonoscopy report from [Hospital1 2177] that he states he had a few months ago and see his PCP and gastroenterology at [Hospital1 18]. Pain was associated with diarrhea and stress, so after his full workup is complete it may be a diagnosis of IBS which is mainly a diagnosis of exclusion. Diarrhea: Stool studies negative. diarrhea resolved. Medications on Admission: Confirmed with patient (although he said he thought he was taking more medications that he can't remember) and general medicine note from [2120-2-29] 1. Finasteride 5 mg PO DAILY 2. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 3. Lisinopril 10 mg PO DAILY 4. Zonisamide 300 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Tamsulosin 0.4 mg PO HS 8. Citalopram Hydrobromide 20 mg PO DAILY 9. Hydrochlorothiazide 25 mg PO DAILY 10. Thiamine 100 mg PO DAILY Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Nizhoni VNA Discharge Diagnosis: Primary Polysubstance abuse- s/p toxic ingestion of propyl alcohol and alcohol Acute Renal failure Secondary: - Hypertension - Atypical chest pain (normal stress testing done [9-1]) - Gastroesophageal reflux disease - Depression ( past hospitalizations for depression) - COPD/Emphysema - CVA in [2109] - Pancreatitis - Benign Prostatic Hypertrophy - Temporal lobe epilepsy Discharge Condition: You were ambulating well, eating and speaking without distress. Discharge Instructions: You were admitted with a toxic ingestion of alcohol and isopropyl alcohol. You improved with hydration. You urine tox screen was also positive for cocaine. As we discussed you will die if you do not stop drinking or using drugs. You were seen by SW but you did not want to pursue treatment at this time. You were found to have a distended gall bladder. You had a gall bladder scan which was normal. Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2120-4-10] at 4:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9091], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage If your abdominal pain continues please call the gastroenterology department at the [Hospital1 18] at ([Telephone/Fax (1) 2233]	[ "577.1", "530.81", "496", "401.9", "345.40", "311", "305.90", "584.9", "276.52", "787.91", "786.50", "785.50", "980.2", "E860.3", "600.00" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	12988, 13030	10134, 11565	324, 330	13455, 13521	4875, 10111	13968, 14410	4083, 4252		12114, 12965		13051, 13434		11591, 12091			13545, 13945										4267, 4856																				2498, 2554				250, 286											358, 2479																2576, 3008	3024, 4067
30,707	146,776	31278	Discharge summary	report	Admission Date: [2149-6-25] Discharge Date: [2149-7-10] Date of Birth: [2104-4-7] Sex: M Service: SURGERY Allergies: Sevoflurane Attending:[First Name3 (LF) 1384] Chief Complaint: ruptured arteriovenous fistula aneurysm Major Surgical or Invasive Procedure: Repair of ruptured arteriovenous fistula aneurysm. Debridement of necrotic skin. Graft ligation [2149-7-4] Placement of tunneled dialysis catheter History of Present Illness: 45 year-old male with ESRD on HD, IDDM, and HTN who moved abruptly from NY about 2 weeks ago, now presents with erosion / bleeding over fistula. Bleeding began evening prior to admission. He denies pain. No fevers, +chills. No nausea or vomiting. Approximately 3weeks prior to admission, he underwent surgery on fistula for infection. Sensation in hand intact. Last HD 1 day prior to admission. Past Medical History: End Stage Renal Disease (due to Diabetes Type I), on dialysis Hypertension glaucoma, legally blind L eye s/p surgical debridement of L arm fistula [5-24] Social History: Originally from [Male First Name (un) 1056]. Separated, with five healthy children. Not currently working, but has worked for a security guard in the past. He just moved from [Location (un) 7349] to permanently stay in [Location (un) 86] with his brother. [Name (NI) ] denies current tobacco use (quit several years ago). He denies EtOH or illicit drug use. Family History: Multiple siblings with HTN and diabetes. Two sisters with a "[Last Name ] problem." No known early coronary disease or kidney disease. Physical Exam: Gen: Thin young male, NAD, walks with cane HEENT: Blind in L eye, oral mucosa pink/moist Card: RRR, no M/R/G noted Lungs: CTA bilaterally Ext: Left arm with 3 dressings, 2 from hemodialysis today and 1 covering area of concern on fistula. scabbed over, not bleeding but old blood on dressing. + Bruit/thrill. no edema noted Pertinent Results: [2149-6-25] 07:55AM POTASSIUM-4.8 [2149-7-9] 05:05AM BLOOD WBC-5.9 RBC-4.41* Hgb-13.0* Hct-39.7* MCV-90 MCH-29.5 MCHC-32.7 RDW-15.7* Plt Ct-240 On discharge: [2149-7-9] 05:05AM BLOOD WBC-5.9 RBC-4.41* Hgb-13.0* Hct-39.7* MCV-90 MCH-29.5 MCHC-32.7 RDW-15.7* Plt Ct-240 [2149-7-9] 05:05AM BLOOD Glucose-151* UreaN-47* Creat-10.0# Na-136 K-4.9 Cl-95 HCO3-26 AnGap-20 [2149-7-6] 06:00AM BLOOD Calcium-9.5 Phos-7.2* Mg-2.4 Brief Hospital Course: Admitted on [2149-6-25], received dialysis on [2149-6-27], and underwent repair of ruptured arteriovenous fistula aneurysm on [2149-6-28] in the late evening. After anesthesia induction with fentanyl and propofol, he had an episode starting at 21:40 of hypotension and bradycardia. Vitals were BP 70/40 and HR in the 50's. Per anesthesia attending's note, the patient then suffered a pulseless electrical activity event. CPR was immediately initiated, and patient was intubated. CPR was given for 8 minutes. He was given epinephrine, atropine and bicarbonate. By 21:55, his BP was 250/120 and HR was 120-140. It was determined to be reasonable to continue with the fistula revision. The patient tolerated the procedure well and was taken to the SICU post-operatively. He was sedated with propofol. During the night, a nurse found that his arms were posturing to noxious stimuli. His propofol was weaned off during the night and at 8am, a SICU nurse noted that he did not move his extremities to noxious stimuli. However, he did spontaneously lift both arms. He did not spontaneously move his arms. He was extubated at 9:30am. After extubation, he opened his eyes but was non-verbal and was not responding to commands. His head was twisted to the right, and he had a left lower facial droop. He moved both arms spontaneously. Patient was given vecuronium and propofol and was re-intubated. The stroke team was called to evaluate the patient. He received an MRI and MRA of the brain and MRA of the neck which revealed: an area of hyperintensity signal with linear extension adjacent to the left superior ependymal region with no other areas of abnormal signal noted in the brain parenchyma, the posterior aspect of the left orbital globe demonstrated heterogeneous signal, likely representing retinal hemorrhage of uncertain chronicity, normal MRA of the circle of [Location (un) 431] and neck vessels. CXR revealed moderate-to-severe cardiomegaly (longstanding and unchanged), with no pneumothorax or appreciable pleural effusion. CT head revealed a punctate area of hyperdensity in the left corona radiata, with no surrounding edema, most likely representing punctate calcification, retinal hemorrhage in the left eye, and no definite intracranial hemorrhage, mass effect, or edema. In addition to the aforementioned studies, the stroke team recommended 81mg aspirin daily. Following these studies, the patient was weaned to extubate and successfully extubated on [6-29], which he tolerated well. He received neuro checks q1hour. His mental status was noted to improve following extubation. He received dialysis on [6-30] and was transferred to the floor. He was tolerating a regular diet, ambulated independently, and able to answer questions adequately in Spanish. In the ensuing days the patient was found to have some confusion and was placed on a 1:1 sitter. He was evaluated by Psych who recommended ruling out organic causes. Seen by the neuro service in followup, they did not feel this was neurological in origin, although an EEG was obtained [7-8] which was read as within normal limits. On [7-4] the patient had spontaneous bleeding from the left arm dialysis access, which was deemed unsalvageable at that time and required ligation. A tunneled dialysis catheter was placed which has been functioning well. The sitter was discontinued, he was cleared by physical therapy. He will be discharged to [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] halfway house, and will receive hemodialysis 3x per week (TuThursSat)at [Location (un) 7503]. First HD there scheduled for Thursday [7-10]. Medications on Admission: Losartan 50 mg daily Ca Acetate 667 mg 1 q meal Folic Acid 1 mg daily Metoprolol 100 mg [Hospital1 ] Furosemide 80 mg daily Pantoprazole 40 mg daily Amlodipine 5 mg daily Discharge Medications: 1. Losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). 13. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 21 days. 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) for 3 weeks: Through [7-31]. 15. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime: Continue Humalog sliding scale also. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] House Discharge Diagnosis: Ruptured arteriovenous aneurysm Access ligation with tunneled line placement [2149-7-4] Discharge Condition: stable Discharge Instructions: Please call Dr.[Name (NI) 1381] office [Telephone/Fax (1) 673] if fevers, chills, nausea, vomiting, incision site with increased drainage/redness/bleeding or any concerns. Change dressing once daily Followup Instructions: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2149-7-14] 8:45 Opthamology followup Completed by:[2149-7-10]	[ "997.1", "E878.1", "585.6", "996.73", "997.01", "250.01", "427.5", "403.91", "V45.1", "V58.67", "996.62" ]	icd9cm	[ [ [] ] ]	[ "39.42", "39.95", "39.43", "38.95" ]	icd9pcs	[ [ [] ] ]	7738, 7840	2441, 6103	310, 463	7976, 7985	1975, 2129	8241, 8436	1476, 1616		6329, 7715		7861, 7955		6129, 6306			8009, 8218										1631, 1956																	2143, 2418							231, 272											491, 887																909, 1068	1084, 1460
63,066	175,352	52983	Discharge summary	report	Admission Date: [2142-8-24] Discharge Date: [2142-9-12] Date of Birth: [2063-7-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8104] Chief Complaint: L hemiplegia Major Surgical or Invasive Procedure: Intubation in the ED for airway protection. History of Present Illness: Patient is a 79 yo woman with PMH including HTN, hypercholesterolemia and remote hx of cervical cancer who has not seen her PCP [Name Initial (PRE) ] 2 years was found unresponsive in her bed. She lives in an [Hospital3 ] facility ([Hospital1 ] House of [Location (un) ], MA) and was last seen 48 hrs prior without any obvious signs of distress. Staff found her supine in her bed - she was mute with right sided gaze and not moving her left side. EMS was called and she had normal initial vitals including BP, HR and FSBG. EMS found her with facial droop and somnolent but was able to nod for answers and denied HA. Upon arrival at [Hospital1 18], she was "awake and nodding" but was intubated prior to CT for airway protection in the ED. She was then admitted to Neuro ICU service. Past Medical History: Last saw PCP (Dr. [First Name8 (NamePattern2) 1528] [Last Name (NamePattern1) ]) in [4-3]; refused most of screenings including mammograms and colonoscopy plus all vaccinations. 1. HTN 2. Hypercholesterolemia 3. Sciatica 4. Hx of cervical cancer s/p resection and radiation therapy in [2111] 5. Carpal tunnel syndrome 6. hx of syncope x2 - most recent in [4-3] --> normal stress test (MIBI) Social History: Lives in ALF ([Hospital1 ] House) - was homeless in the remote past per PCP. [Name Initial (NameIs) ] 2~3 cigarettes/day and no EtOH hx. Raised her grandchildren. Has [Name Initial (NameIs) 802] named [Name (NI) 32400] who was made her guardian/HCP during this admission. Family History: NC Physical Exam: T 98.1 BP 111/50 HR 111 RR 30 O2Sat 99% with 5L shovel mask HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx: ET tube in place Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic examination: MSE: Somnolent but arousable to name - stirs to name. Does follow simple commands including open your mouth and moving R side. Cranial Nerves: II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No blinks to visual threats bilaterally. III, IV & VI: Nomal oculocephalic movements - crosses midline. VII: R lower facial droop X: No gag. Motor: Diffuse, mild loss of bulk with decreased tone on L side. Moves R side antigravity but 0/5 on L side. Sensation: Grimaces to noxious stimuli bilaterally. Reflexes: +2 for biceps and brachioradialis but none for patella and 1 for Achilles. R toe mute but L toe upgoing. Pertinent Results: Microbiology: all blood cx's: negative for growth urine cx: [9-4] - pan sensitive proteus mirabilis, pseudomonas [First Name9 (NamePattern2) ] [Last Name (un) 36] to cipro and zosyn. sputum cx: mssa and proteus mirabilis [Last Name (un) 36] to ceftriaxone c. diff: negative ([9-5]) EKG: Normal sinus rhythm with atrial premature complexes. Intra-atrial conduction defect. Left ventricular hypertrophy with secondary repolarization abnormalities. Axis is plus 60 degrees suggesting a co-existent pulmonary or right ventricular disease. Since the previous tracing of [2133-3-16] diffuse ST-T wave changes and left ventricular hypertrophy are more prominent and axis has shifted rightward. Echo: The left atrium is normal in size. No atrial septal defect seen by 2D/color Doppler (cannot definitively exclude). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. 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. No 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. No vegetation seen (cannot definitively exclude). MRI/MRA: MRI IMPRESSION: 1. Acute right-sided corona radiata and periventricular infarct with acute wallerian degeneration extending to the right side of the midbrain. 2. Chronic multiple lacunes in the basal ganglia and small vessel disease. 3. Multiple microhemorrhages in the brain, suspicious for amyloid angiopathy. MRA IMPRESSION: 1. Diminished flow signal in the anterior circulation could be secondary to slow flow. 2. Non-visualization of the distal vertebral and proximal two-third of the basilar artery could be due to occlusion or slow flow from high-grade stenosis. EEG: Abnormal EEG to slow background with occasional suppressive bursts. These findings suggest a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Hypoxia is another possible explanation. Conceivably, this pattern could also be seen in a prolonged post-ictal state. Nevertheless, there were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epileptiform features. L ANKLE: Multiple vascular calcifications in the soft tissues. Duct-like calcifications projecting over the ventral frontal parts of the talus. There is an obliquely oriented lateral fracture of the malleolus, with only minimal displacement. A small fragment of bone seen along the medial aspect of the distal fibular represent a comminuted fragment. There is no other evidence of post-traumatic disease. Small plantar spur. Carotid U/S: FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. There is heterogeneous plaque in the proximal ICA and distal CCA bilaterally. There is plaque in the proximal right ECA. On the right, peak velocities are 86, 97 and 66 cm/sec in the ICA, CCA and ECA respectively. This is consistent with less than 40% stenosis. On the left, peak velocities are 104, 95 and 112 cm/sec in the ICA, CCA and ECA respectively. This is consistent with less than 40% stenosis. There is antegrade vertebral flow bilaterally. IMPRESSION: Bilateral less than 40% carotid stenosis. Head CT: IMPRESSION: 1. No definite new abnormalities. Cortical hypodensity in the frontal lobes is likely related to beam-hardening artifact. However, subtle cytotoxic edema cannot be excluded. MRI is suggested for further evaluation. This was discussed with the ordering physician by Dr. [Last Name (STitle) 21881] when the study was obtained. 2. The acute infarction in the right lentiform nucleus and corona radiata is unchanged, allowing for differences in modalities. 3. Unchanged chronic infarction in the left lentiform nucleus and internal capsule. CXR: ([8-31]) IMPRESSION: Left lower lobe consolidation with small pleural effusion is very worrisome for aspiration, a component of atelectasis/collapse is suspected.. could be due to a mucous plug. Dobhoff tube was pulled back, now ends in the stomach. CXR taken on [9-1] and [9-2] remained unchanged. Labs: CBC - Hct 48 on admission, nadirs to low 20s on [8-29] and [Date range (1) 8967] requiring blood transfusions. WBC peak to 16.0 on [8-31], which decreased to 8s with initiation of antibiotics on [9-2] and was 7.7 on discharge. Chem-10: Cre stable at 0.4 throughout admission. Na briefly low to 130s, resolved w/ decreasing free H20 boluses. K 3.5-4.0 LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [2142-8-25] 01:09AM 231* 1681 55 4.2 142 Cardiac Enzymes: CPK ISOENZYMES CK-MB MB Indx cTropnT [2142-9-2] 10:43PM 0.071 Source: Line-PICC [2142-8-28] 02:55AM 4 0.101 [2142-8-27] 03:19AM 0.111 CHEMS ADDED 11:39AM [2142-8-26] 02:19AM 9 0.171 [2142-8-25] 06:34PM 13* 0.201 [2142-8-25] 03:04PM 13 0.201 [2142-8-25] 09:19AM 14 1.5 0.261 [2142-8-25] 01:09AM 11 1.5 0.241 [2142-8-24] 11:09AM 14 1.7 0.162 HEMATOLOGIC calTIBC VitB12 Hapto Ferritn TRF [2142-9-4] 05:38AM 104 1508* [Telephone/Fax (1) 109225]* 80* TSH: 1.6 Cortisol: 16.1 neg tox screen on admission. Lactate: 2.0 (0n admission) Brief Hospital Course: A/P: 78 yo F w/ HTN, HLD found down at [Hospital3 ] facility w/ L hemiparesis, found to have R basal ganglia infarct, likely 2' to uncontrolled HTN. Neuro ICU course: Patient was intubated in the ED for airway protection and admitted to Neuro ICU where she was successfully extubated after 3 days - she remained encephalopathic with L hemiplegia. EEG was done to rule out non-convulsive status given her encephalopathy but only confirmed moderate/severe diffuse encephalopathy without evidence of focality or epilieptic activity. Per head imaging, she has evidence of old infarcts on L hemisphere as well possible explaining minimal movements on R side as recrudescence due to multiple medical issues including severe/stage IV sacral decibitus ulcer which required bedside cauterization x2 for bleeding. She required 3 units of PRBC transfusion while in ED for anemia with hct as low as 10.9 at nadir. She had repeat head imaging when her somnolence increased to rule out hemorrhage which showed no change since admission and her somnolence decreased with transfusion supporting metabolic etiology behind her encephalopathy. On admission, she was afebrile without leukocytosis but start HD #3, her WBC trended upward and she spiked with fever up to 101.7. She was pan-cultured twice while in the ICU without identification of infective organism and because she deferevesced without intervention, she was not started on empiric ABX while in the ICU. Additionally, patient had elevated troponin (crested at 0.26) without signs of renal failure plus non ST-elevated EKG changes not previously seen likely supporting NSTEMI. Also, her L ankle seemed asymmetrically more swollen that R plus given hx of patient being found down, trauma series were performed and showed L ankle, non-displaced fibular fracture. [Hospital3 1957] was consulted and patient was fitted with aircast. Although still encephalopathic, she remained hemodynamically and neurologically stable hence was transferred out to neurology floor with telemetry on HD #9. Transferred to floor on HD #10. Floor Course: #Pneumonia: Patient with hospital acquired pneumonia vs ventilator associated PNA vs. aspiration PNA in setting of CVA, placement of NG tube, and intubation for three days (CXR from [9-1] showed increasing RLL opacity) Sputum GS grew Methicillin sensitive staph aureus and pan-sensitive proteus (received 3 days of Zosyn which was switched to ceftriaxone on [9-5].) She was initially covered with Vancomycin/Zosyn for HAP, which were switched to Nafcillin/Ceftriaxone after sensitivities returned for total 8 days of treatment. She was treated with ipratroprium and albuterol nebs, guafenesin as mucolytic, chest PT, and kept on aspiration precautions. She initially required a shovel mask for oxygenation, and was eventually weaned off of oxygen. Her breathing clinically improved and she was breathing in the high 90s on room air on discharge. In addition, patient had a speech and swallow consult which deemed her unable to swallow and with multiple secretions, and at risk for aspiration. S&S recommended PEG placement. Pt received meds and TFs through NGT. Eventually had a PEG placed by interventional radiology with no complications. Pt tolerated TFs and meds through PEG on day of discharge. NGT was removed. PEG should be used as bridge for feeding and medications while patient gets speech and swallow therapy at rehabilitation. #CVA: R basal gangla infarcts. Her stroke work-up included a TTE w/o ASD, thrombus, or focal wall motion abnormality, a carotid U/S shwoing <40% narrowing of ICAs. Lipid panel c/w hypercholesterolemia, hypertriglyceridemia. L sided weakness may be recrudescence of old stroke. She was continued on a baby aspirin, metoprolol, and a statin. The encephalopathy seen during her ICU course resolved with treatment of her HAP/urosepsis, and she remained mute with L hemiplegia, she was able to nod "yes/no" to questions and move the R side of her body. She was discharged to a rehabilitation facilty for physical therapy. #Anemia: Pt had coffee ground emesis on first day of admission, which resolved. Received 3 U PRBCs during the course of her neuro ICU stay. She had a hematocrit drop to low 20s (baseline is ~26). Transfused 2 U PRBCs on [9-4] with increase in Hct to 30. No evidence of gross blood in stool. guiac negative. Fe studies show ACD, but this could be confounded by transfusion. No B12 deficiency, no evidence of hemolysis. Sacral decub ulcer was not oozing blood. GI was consulted who recommended a short course of misoprostol while in house and EGD if patient continued to have evidence of continued GI bleed. She was continued on IV Protonix and switched to Lansoprazole for her NGT/PEG. Her Hct was stable in the low to mid 30s on discharge. She should be referred to GI by her PCP for an upper endoscopy as an outpatient after discharge/rehab. #Fevers and Hypotension: Likely urosepsis. Other etiologies included decubitus ulcer and pneumonia. Had chronic NG tube, but no evidence of sinusitis on exam. MS changes/encephalopathy resolved, and patient had good U/O. Unlikely cardiogenic or obstructive (TTE neg for tamponade, EF 55%), or autonomic dysfunction related to stroke. Her hypotension resolved with fluid boluses and her beta blocker was initially held. She was treated with antibiotics for HAP (see above) and treated for her urosepsis w/ Ciprofloxacin. She became afebrile x48 hrs and her hypotension resolved. Surveillence blood cultures negative. Her BB was restarted and titrated up to 37.5 mg PO TID. . #Tachycardia: likely associated w/ urosepsis/hypovolemia. resolved with fluids and antibiotics. Pt was continued on telemetry and a beta blocker. #UTI: complicated proteus/pseudomonas UTI. replaced foley, treated with 3 days of Zosyn and 7 days of PO ciprofloxacin. She will need 2.5 days of ciprofloxacin (5 doses total) at rehabilitation (end date [2142-9-14]). #Hyponatremia: Patient was hyponatremic on transfer to floor, likely related to excessive free h20 boluses. Pt not adrenally insufficient. TSH normal. Urine osms not overly concentrated, unlikely SIADH. Resolved with halfing of free H20 boluses to 250 ccs q12H. #Sacral decub: stage III-IV, debrided in ICU by plastics. Required cauterization of bleeding vessels, remained stable afterwards with no oozing. Plastics followed the patient, and they did not see bone exposure and did not believe patient was at risk for osteomyelitis. continued wound care w/ dressing changes [Hospital1 ]. Vit A, C, and ZnSO4 for wound healing (should get 5 more days of ZnSO4 at rehabilitation, then med should be discontinued.) Pt should see plastic surgery as an outpatient for follow-up of the sacral decubitus ucler and is scheduled for an appointment. #Ankle fracture: lateral malleolus fx, comminuted distal fibular fx. L leg in air cast w/o outpatient f/u w/ Dr. [Last Name (STitle) 1005] in one month. . #Guiac positive stools: Pt has intermittently guiac positive stools in setting of heparin sq. No frank blood or BRBPR. Hct stable. Hep SQ continued given need for DVT prophylaxis. Can have non-urgent EGD as outpatient. . #Hyperglycemia: Pt was kept on HISS for tight blood sugar control in setting of improved wound healing. Pt's FS were in the low 100s near the end of her hospital stay, and her HISS was d/c-ed. #FEN: -TFs with vit A, C, ZnSO4 (x10 days) supplementation for wound healing. -repleted electrolytes aggressively to prevent refeeding syndrome -free H20 boluses (250 q12H). -Initially fed through NGT. PEG eventually placed by IR for tube feeds ad NGT removed. #PPX: lanzoprazole, bowel regimen (colace as needed), pneumoboots #Access: PICC ([9-2]) #Code: Full Code #Communication: [Name (NI) ] [Name (NI) 32400] HCP/guardian. #Dispo: to rehabilitation center Medications on Admission: 1. HCTZ (unknown dose) 2. augmentin Discharge Medications: 1. Acetaminophen 325 mg Tablet [Name (NI) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. Docusate Sodium 50 mg/5 mL Liquid [Name (NI) ]: Two (2) liquid containers PO BID (2 times a day) as needed for constipation. 3. Aspirin 81 mg Tablet, Chewable [Name (NI) ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet [Name (NI) ]: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Name (NI) ]: 5-10 MLs PO BID (2 times a day) as needed for dressing changes. 6. Heparin, Porcine (PF) 10 unit/mL Syringe [Name (NI) ]: 1-2 MLs Intravenous PRN (as needed) as needed for line flush. 7. Heparin (Porcine) 5,000 unit/mL Solution [Name (NI) ]: One (1) vial Injection TID (3 times a day). 8. Ciprofloxacin 250 mg Tablet [Name (NI) ]: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. 9. Metoprolol Tartrate 25 mg Tablet [Name (NI) ]: 1.5 Tablets PO TID (3 times a day). 10. Vitamin A 10,000 unit Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily). 11. Zinc Sulfate 220 mg Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily) for 5 doses. 12. Ascorbic Acid 90 mg/mL Drops [Name (NI) ]: Six (6) mL PO DAILY (Daily). 13. Ipratropium Bromide 0.02 % Solution [Name (NI) ]: One (1) puff Inhalation Q6H (every 6 hours) as needed. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [Last Name (STitle) ]: [4-7] MLs PO Q6H (every 6 hours) as needed for secretions. 16. Heparin, Porcine (PF) 10 unit/mL Syringe [Month/Year (2) ]: 1-2 MLs Intravenous PRN (as needed) as needed for line flush. 17. Albuterol 90 mcg/Actuation Aerosol [Month/Year (2) ]: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection PRN (as needed) as needed for line flush. 19. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection PRN (as needed) as needed for line flush. 20. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection once a day: line flush. Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: R basal ganglia stroke Secondary [Hospital 109226] Hospital Acquired Pneumonia Urosepsis Hypertension Hyperlipidemia Stage IV Sacral Decubitus Ulcer Discharge Condition: Good Discharge Instructions: You were admitted with a diagnosis of stroke to your R basal ganglia. You also had a pneumonia and a urinary tract infection, both of which was treated with antibiotics. At rehabilitation, you will need to take 5 more doses of Ciprofloxacin for treatment of your urinary tract infection (end date [2142-9-14].) You also were anemic and required 5 blood transfusions. Your blood levels were stable at the time of discharge. The following medication changes were made: -You were started on aspirin 81 mg daily and prevention of stroke -Metoprolol 37.5 mg by mouth twice a day was added for control of your blood pressure and prevention of stroke -Lipitor 10 mg by mouth daily for treatment of high cholesterol and stroke prevention -Vitamin A, Vitamin C, and Zinc Sulfate for wound healing -Ipratroprium and Albuterol as needed to improve your breathing after the pneumonia -Dextromethorphan-Guafenisen to decrease your lung secretions and make your breathing more comfortable. -Lansoprazole rapid dissolve twice a day to protect your stomach from gastritis and bleeding ulcers -Colace for constipation as needed You were discharged in stable condition. Please return to the emergency department or contact your primary care physician if you experience any of the following symptoms: paralysis, weakness, difficulty thinking or speaking, loss of bowel or bladder continence, fever > 101, shaking chills, loss of consciousness, chest, abdominal, back, or extremity pain, fall with trauma, low blood pressure, or any other symptoms not listed her that are concerning to you. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] [11-29] weeks after rehabilitation. [Last Name (LF) 5533],[First Name3 (LF) ] M. [Telephone/Fax (1) 3581]. You have an appointment scheduled for [2142-10-22] at 3:30 pm for physical exam. Your guardian/health care proxy can reschedule this appointment based on how long your rehabiliation takes. You will need a referal from your PCP for [Initials (NamePattern4) ] [Last Name (NamePattern4) 109227] upper endoscopy by a gastroenterologist as an outpatient. Please follow up with orthopedics at [Hospital1 18] in the [Hospital Ward Name 23] Center on [Hospital Ward Name 516] w/ Dr. [Last Name (STitle) 1005]. Appointment scheduled for : [10-2] at 3:15 pm. Phone # [Pager number 1228]Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2142-10-2] 3:15 Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2142-10-2] 2:55 Please follow up with plastics surgery for your sacral decubitus ulcer in [12-31] weeks time after discharge from the hospital. Their phone number is ([Telephone/Fax (1) 2868] in the cosmetic clinic. You are scheduled for Friday, [10-5] at 2:00 pm. [Hospital Ward Name 23] [Location (un) ] to see Dr. [Last Name (STitle) 23606]. Please discuss with them the continuation of your vitamin supplements for wound healing. Completed by:[2142-9-12]	[ "824.8", "790.6", "342.00", "434.91", "276.1", "790.5", "824.2", "238.71", "348.31", "707.03", "272.1", "599.70", "276.3", "368.46", "041.7", "584.9", "401.9", "707.24", "285.9", "E888.9", "287.9", "486", "599.0", "276.0", "728.88", "V10.41", "276.9", "272.0", "351.8", "041.6", "784.3", "792.1", "041.12", "724.3", "433.10", "276.52", "433.30" ]	icd9cm	[ [ [] ] ]	[ "86.22", "38.93", "96.04", "43.11", "39.98", "96.72", "96.6" ]	icd9pcs	[ [ [] ] ]	19122, 19199	8884, 16733	328, 373	19397, 19404	3141, 6848	21028, 22582	1970, 1974		16820, 19099		19220, 19376		16759, 16797			19428, 21005										1989, 2459																					8226, 8861			276, 290											401, 1212	2628, 3122			6857, 8208										2483, 2612		1234, 1647	1663, 1954
4,883	161,064	8466	Discharge summary	report	Admission Date: [2125-10-6] Discharge Date: [2125-10-9] Date of Birth: [2090-10-15] Sex: F Service: MED Allergies: Cephalosporins / Aspirin / Motrin / Iron Attending:[First Name3 (LF) 2641] Chief Complaint: headache, fever, chills, tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: This is a 34 year old female with suspected immunodeficiency being worked up as an outpatient who presented to the ED with sudden onset of headache and chills that were accompanied by tachycardia, neck stiffness, and shortness of breath. Earlier that day she started taking amoxicillin she'd been given to take as needed after she began to feel ill. She'd had a recent prior admission to the ICU for pneumococcal sepsis in [2125-5-19], complicated by acute respiratory distress syndrome, disseminated intravascular coagulopathy, acute renal failure, and fetal demise. This admission, there was initial concern for pneumoccal sepsis and so the patient was aggresively fluid resuscitated with 9L normal saline in the ED. Additionally, she received IV antibiotics (ceftriaxone, linezolide, and Pen G) and high dose steroids. She had a maximum fever of 103F and leukocytosis with maximum wbc count of 44. The patient had LP which was unremarkable, without evidence of microorganisms or neutrophils on gram stain and without growth in bacterial/fungal cultures. She was admitted to the ICU with diagnosis of sepsis; however all culture data (CSF, urine, blood, stool)was negative to date. A recent MRI of head revealed pansinusitis. Chest X ray revealed bilateral basilar infiltrates with right costophrenic angle effusion that was improving in serial films. In the ICU, she has been continued on IV Ampicillin and Ceftriaxone pre ID consult recommendation and recovered quickly and followed the hospital's gluten free diet. The day before transfer to the medicine service, she had an episode of nausea and vomiting. At the time of transfer to the medicine floor, the patient was feeling well in her usual state of health. Her only complaint was loose stools that started after hospitalization and were similar to past diarrheal episodes relieved by immodium. C.diff toxin and multiple stool cultures were negative. She has been referred to Dr. [First Name4 (NamePattern1) 27272] [Last Name (NamePattern1) 29826], [First Name3 (LF) ] allergist/immunologist at [Hospital3 1810], by her [Hospital1 112] primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 29827]. Initial evaluation has shown weak anti-pneumococcal titers, low complement levels, and high IgG count. She has received pneumovax. [Location (un) ]-Jolly bodies were seen on her peripheral smear although there has not been further evidence of splenic dysfunction. She sees a gastroenterologist for celiac sprue, which has been well managed in the past few months on a gluten-free diet. Past Medical History: pneumonia sinusitis secondary: celiac sprue asthma h/o pneumococcal sepsis complicated by ARDS, DIC, and ARF h/o nasal polypectomy one prior migraine headache with aura including diploplia, nausea, vomiting iron deficiency anemia Social History: Married with two children at home. Moved to US from [Location (un) ] in [2118]. Statistician at [University/College ] School of Public Health. Denied alcohol, tobacco, or drug use. No recent travel. Family History: Her cousin's children have CF but the patient has tested negative. Father had [Name2 (NI) 499] cancer. Brother with asthma and hayfever. No positive history for immunodeficiency. Physical Exam: T 98.3 BP 122/70 HR 60 RR 18 O2 99%RA Gen - Alert, awake, in NAD HEENT - extraocular motions intact, anicteric, MMMI Neck - supple, no jugular venous distention Chest - clear to auscultation bilaterally, no crackles/wheeze CV - Normal S1/S2, regular rate and rhythm, no murmurs, rubs or gallops, 2+ pulses throughout Abd - soft, nondistended, nontender, normoactive bowel sounds,no masses Extr - warm, no clubbing, cyanosis, or edema Neuro - AOx3, CN2-12 intact, ambulatory, no ataxia, strength 5/5 throughout, denies loss of sensation, face symmetric, tongue non-deviated Pertinent Results: [2125-10-9] 05:30AM BLOOD WBC-15.0* RBC-3.20* Hgb-9.3* Hct-29.0* MCV-91 MCH-29.1 MCHC-32.1 RDW-14.6 Plt Ct-251 [2125-10-8] 04:13AM BLOOD WBC-26.0* RBC-2.96* Hgb-8.6* Hct-27.0* MCV-91 MCH-29.0 MCHC-31.7 RDW-14.7 Plt Ct-230 [2125-10-7] 06:11PM BLOOD WBC-35.6* RBC-2.95* Hgb-8.9* Hct-27.1* MCV-92 MCH-30.1 MCHC-32.8 RDW-15.1 Plt Ct-210 [2125-10-6] 08:35PM BLOOD WBC-44.8* RBC-3.24* Hgb-9.6* Hct-29.6* MCV-92 MCH-29.6 MCHC-32.4 RDW-14.8 Plt Ct-256 [2125-10-7] 06:11PM BLOOD Neuts-88.7* Bands-0 Lymphs-6.0* Monos-2.6 Eos-2.4 Baso-0.3 [2125-10-7] 06:11PM BLOOD FDP-10-40 [2125-10-5] 11:55PM BLOOD Gran Ct-6180 [2125-10-7] 06:11PM BLOOD Lupus-PND [2125-10-9] 05:30AM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-143 K-3.6 Cl-108 HCO3-25 AnGap-14 [2125-10-7] 03:13AM BLOOD ALT-32 AST-22 LD(LDH)-159 AlkPhos-51 Amylase-19 TotBili-0.2 [2125-10-7] 03:13AM BLOOD Lipase-19 [2125-10-7] 03:13AM BLOOD Albumin-2.9* Calcium-8.3* Phos-2.9 Mg-1.9 [2125-10-7] 06:11PM BLOOD Hapto-111 [2125-10-5] 11:55PM BLOOD TSH-4.6* [2125-10-8] 04:13AM BLOOD T4-6.6 T3-88 [2125-10-5] 11:55PM BLOOD Cortsol-30.3* [2125-10-8] 04:30AM BLOOD Lactate-1.0 [2125-10-6] 02:20AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.018 [2125-10-6] 02:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2125-10-6] 02:20AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2125-10-6] 02:06AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1* Polys-0 Lymphs-96 Monos-0 Macroph-4 [2125-10-7] 08:00PM CEREBROSPINAL FLUID (CSF) ENTEROVIRUS PCR-PND [2125-10-6] CSF: CRYPTOCOCCAL ANTIGEN (Final [2125-10-8]): NOT DETECTED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. GRAM STAIN (Final [2125-10-6]): NO POLYMORPHONUCLEAR LEUKOCYTES or MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Stool:FINAL REPORT [2125-10-8] CYCLOSPORA STAIN (Final [2125-10-8]): NO CYCLOSPORA SEEN. MICROSPORIDIA STAIN (Final [2125-10-8]): NO MICROSPORIDIUM SEEN. FECAL CULTURE (Final [2125-10-8]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2125-10-8]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2125-10-7]): NO E.COLI 0157:H7 FOUND. FECAL CULTURE - R/O YERSINIA (Final [2125-10-8]): NO YERSINIA FOUND. FECAL CULTURE - R/O VIBRIO (Final [2125-10-8]): NO VIBRIO FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2125-10-7]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. OVA + PARASITES (Final [2125-10-8]): NO OVA AND PARASITES SEEN. CHARCOT-[Location (un) ] CRYSTALS PRESENT. Cryptosporidium/Giardia (DFA) (Final [2125-10-8]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. URINE CULTURE (Final [2125-10-7]): NO GROWTH. [2125-10-5] 11:55 pm BLOOD CULTURE Site: ARM 4 bottles; no growth to date CXR [2125-10-8]: Mild upper lung zone redistribution. Small bilateral effusions and bilateral lower lobe patchy opacities. The right effusion is smaller. CXR [2125-10-7]:The previously identified pulmonary edema has been resolved. There is small left pleural effusion. Patchy opacity is seen in both lower lobes. These findings most likely represent patchy atelectasis. The posterior pneumonia cannot be excluded. There is also a new patchy opacity in the right apex overlying the right 1st rib. This may represent patchy area of pneumonia ossification. CXR [2125-10-6] 4AM:Mild-to-moderate pulmonary edema, likely due to volume overload. Development of infection is unusual since the prior study 2 hours earlier did not show the presence of significant pulmonary edema. CXR [2125-10-6] 2AM:The lung volumes are low. The mediastinal and hilar contours are unremarkable. The heart size is normal. There is mild prominenc of the pulmonary vasculature. No focal area of consolidation is present. There are no pleural effusions Head MRI/MRA [2125-10-7]: 1. No significant abnormality identified within the brain. Specifically, no evidence of infarction, abnormal enhancement, or edema. 2. Extensive mucosal thickening involving all of the sinuses. 3. Meningitis cannot be excluded on the basis of this study. A lumbar puncture may be necessary for further evaluation. Head Head CT [2125-10-6]: There is no intracranial mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. The density values of the brain parenchyma are within normal limits. The [Doctor Last Name 352]- white differentiation is preserved. The surrounding soft tissue and osseous structures are unremarkable. Soft-tissue changes in ethmoid and sphenoid sinuses. Brief Hospital Course: This is a 34 year old female with celiac sprue being assessed for possible immunodeficiency or underlying collagen vascular disease who presented three days ago with acute onset fever, chills, and headache. She has concern for pansinusitis per MRI scan (without associated symptoms) and has a CXR is suggestive of pneumonia. She has not had sinus pain or drainage and her headache had resolved two days ago. She has mild burning in her frontal chest with deep inspiration and now has a mild non-productive cough with sore throat that is not bothering her enough to treat with lozenges or pain medication. Albuterol nebulizer therapy did not help these symptoms. She denies no shortness of breath, wheeze, dyspnea on exertion, and chest pain. She has not had fever or chills for the past few days. Her asthma is well managed at baseline with inhaled steroids and albuterol. She uses flonase for allergies and has had a prior nasal polyopectomy in the past. The patient does not report prior history of chronic or recurrent sinopulmonary infection. Infectious disease consult was obtained and while in the ICU, treatment with IV ceftriaxone and IV ampicillin was recommended for pneumonia and sinusitis. All culture data (CSF, urine, stool, and blood) has been negative to date. The patient has been afebrile for several days and her leukocytosis is resolving with antibiiotic therapy (44->35->26->15). Chest xray suggested improvement in [Last Name (un) 29828] bilateral pulmonary infiltrates and right small pleural effusion, determined not tappable, located in the right costophrenic angle. She reports feeling very well and is active and ambulating with ease. She was discharged in good condition with a normal lung exam. She is recommended to follow up with her primary care physician next week for a repeat chest x ray and exam to ensure resolution of the pulmonary effusion that was likely the result of aggressive fluid rehydration with 9L nasal saline in the ED. Additionally, the patient plans to follow up with her immunologist to continue diagnostic work-up for an underlying cause for susceptibility to infection. The patient also had multiple loose stools and stool leakage that began at the same time as the headache at admission. She'd had similar diarrhea at her prior admission that improved with immodium. She has known history of celiac disease and was continued on a gluten free diet. Stool cultures were negative for C. difficile and a large spectrum of microbes and parasites. In the past, the diarrhea resolved by resuming her home diet out of the hospital. She plans to follow up with her regular doctor next week. Medications on Admission: Flovent Rotadisk 250 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. Flonase 50 mcg/Actuation Aerosol, Spray Sig: [1-19] Nasal once a day. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath, wheezing. [Doctor First Name ] 60 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 13 days. Disp:13 Tablet(s) Refills:0 2. Flovent Rotadisk 250 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. 3. Flonase 50 mcg/Actuation Aerosol, Spray Sig: [1-19] Nasal once a day. 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath, wheezing. 5. [Doctor First Name ] 60 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: pneumonia sinusitis secondary: celiac sprue asthma h/o pneumococcal sepsis complicated by ARDS, DIC, and ARF h/o nasal polypectomy Discharge Condition: good Discharge Instructions: Please take all medications as prescribed. Please call your doctor or go to the ED for severe headache, fever, chills, cough, shortness of breath, or other worrisome symptoms. Followup Instructions: Please attend your follow up appointment with Dr. [Last Name (STitle) 29827] on Friday [10-19] at 2pm for repeat chest x ray to make sure your lung effusion is improving. Please follow up with your immunologist Dr. [Last Name (STitle) 29829] [Name (STitle) 29826]. Please call [Telephone/Fax (1) 29830] to make an appointment.Provider: [Name Initial (NameIs) ] Where: SC [Hospital Ward Name ] CENTER SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 15527] Date/Time:[2125-11-16] 8:45 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7167], RD Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 3681] Date/Time:[2125-12-17] 9:30	[ "787.01", "579.0", "493.90", "486", "279.3", "461.8", "511.9" ]	icd9cm	[ [ [] ] ]	[ "00.14", "03.31" ]	icd9pcs	[ [ [] ] ]	12700, 12706	9097, 11748	334, 341	12881, 12887	4265, 5978	13111, 13831	3472, 3656		12176, 12677		12727, 12860		11774, 12153			12911, 13088										3671, 4246								6011, 6123																258, 296											369, 2975																2997, 3228	3244, 3456		6155, 9074
1,207	109,003	10324	Discharge summary	report	Admission Date: [2172-11-30] Discharge Date: Date of Birth: [2109-12-21] Sex: M Service: CCU CHIEF COMPLAINT: GI bleed. HISTORY OF PRESENT ILLNESS: This is a 62 year old white male with an extensive past medical history significant for coronary artery disease requiring coronary artery bypass graft, history of inferior myocardial infarction, status post St. Jude valve for mitral valve prolapse in [2169], AICD for ventricular tachycardia, CHF with EF of 25%, history of CVA, history of ulcerative colitis, diverticulitis, abdominal aortic aneurysm, chronic renal insufficiency, occluded left RA, peripheral vascular disease, history of recent lower GI bleed. Lower GI bleed occurred in [2172-10-8] when during colonoscopy it was found that he had a cecal arteriovenous malformation. He had been recently admitted to [Hospital1 346] for interrogation of his AICD. He most recently had a lower GI bleed treated at [Hospital6 3426]. He was readmitted to [Hospital6 33] on [11-28] for pulmonary edema. He was diuresed and his symptoms resolved. However, during that admission he developed dark diarrhea with a slow drop in his hematocrit. There he had two negative CKs and troponins, but he was sent to [Hospital1 69] for further workup of his GI bleed and further treatment. At [Hospital1 190] the patient initially had no complaints. He was given two units of FFP and then was given a bowel prep with GoLYTELY. While receiving GoLYTELY, he developed chest pain on his way to the bedside commode. Chest pain resolved with two sublingual nitroglycerin and IV metoprolol. He also had brown reddish appearance to his bowel movements. He had another episode of [8-17] chest pain without radiation to his neck. It did not resolve initially with two sublingual nitroglycerin. However, he ruled out for coronary ischemia. He received 81 mg of aspirin and 5 mg of IV metoprolol. He also complained of headache and flushing. PAST MEDICAL HISTORY: Coronary artery disease status post inferior MI in [2147], status post coronary artery bypass graft times two in [2169]. CABG involved LIMA to LAD and saphenous vein graft to posterior descending artery. Mitral valve replacement with St. Jude valve in [2169]. Ventricular tachycardia status post dual chamber AICD in [2167] for ventricular tachycardia and bradycardia. History of inducible VT with old inferior scars. Status post multiple admissions. CHF with EF of 25%. Epilepsy. Stroke involving left middle cerebral artery. Diverticulitis. Benign prostatic hypertrophy status post TURP. History of gastritis H.pylori positive. Cholelithiasis. Ulcerative colitis diagnosed in [2128]. Abdominal aortic aneurysm which is 3 to 3.5 mm in diameter. Status post appendectomy in [2120]. Occluded left renal artery most likely with chronic renal insufficiency with creatinine of 2.5 to 3. Peripheral vascular disease. Lower GI bleed which last occurred in [2172-10-8]. At that time he was found to have cecal arteriovenous malformation. He had two polyps removed. He also had diverticulitis. ALLERGIES: ACE inhibitor which causes angioedema. Codeine and shellfish which cause hives. Contrast dye and iodine to which he also has reactions. MEDICATIONS: Hydralazine 75 mg p.o. t.i.d., amiodarone 200 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Klonopin 0.5 mg p.o. b.i.d., Protonix 40 mg p.o. q.d., folate 1 mg p.o. q.d., Mysoline 250 mg p.o. q.d., Colace 100 mg p.o. b.i.d., carvedilol 0.125 mg p.o. b.i.d., furosemide 80 mg p.o. b.i.d., multivitamin, Norvasc 2.5 mg q.d., Imdur 30 mg p.o. q.d. which had been discontinued because of headache, Aldactone 25 mg p.o. q.d. which was also discontinued. PHYSICAL EXAMINATION: Heart rate was 78, blood pressure 162/76, sating 97% on 2 liters, respiratory rate 20. In general, he was in moderate distress with chest pain, but alert and oriented. Pupils were equal, round and reactive to light. Extraocular movements were intact. Moist mucous membranes. Oropharynx was clear. Tongue was midline. Heart regular rate and rhythm, S1 mechanical sound above apex, 2/6 systolic murmur without radiation. Lungs were limited to the anterior. He was found to have crackles. Abdomen was soft, nontender, nondistended with positive bowel sounds. Extremities had 2 to 3+ peripheral edema, warm, no cyanosis or clubbing. Dorsalis pedis pulse was palpable. LABORATORY DATA: White count was 8.8, 82.5 neutrophils, 10 lymphocytes, 5 monocytes, 2 eosinophils, 5 basophils, hematocrit 24.9, platelets 127. Sodium was 141, potassium 3.9, chloride 108, bicarb 24, BUN 46, creatinine 2.2, glucose 99. CK was 54. INR was 2.7, PTT 26.2. UA was yellow, clear with specific gravity of 1.010, trace protein. EKG showed normal sinus rhythm at 93 beats per minute with normal axis, ST depressions and T wave inversions in aVL, 1, aVF, 2, V4, V6. Positive for left ventricular hypertrophy by voltage criteria. When he became chest pain free, he had less prominent T wave inversions. HOSPITAL COURSE: The patient was a 62 year old white male with multiple medical problems who had a GI bleed complicated by ischemic changes on his EKG. 1. Cardiac. His chest pain, along with the EKG changes, was thought to be secondary to his anemia. He has a history of chest pain with hematocrit decreases below 30. Consequently the treatment in this situation was for blood transfusion. However, because of his congestive heart failure and clinical evidence of pulmonary edema, the blood transfusion would have to be closely monitored. He required furosemide between each unit. Because of his anemic situation, his antihypertensives were held. His cardiac enzymes were cycled and were negative. Troponin was 0.4. CKs were 43, 45 and 102. No CKMB fractions were done on those CKs. Because of the setting of his acute GI bleed, aspirin was held. The goal was to keep his hematocrit above 30. On the second day of admission he had chest pain after having hematochezia. He had ST depressions on his EKG. At that time nitroglycerin drip was started. He also received metoprolol IV, morphine and aspirin. He was also diuresed with 40 mg of IV Lasix. Because of his cardiac issues, he was continued on nitroglycerin drip along with metoprolol 12.5 mg p.o. b.i.d. He was also started on hydralazine 50 mg p.o. t.i.d. for afterload reduction. His INR had initially been elevated at 2.6. Consequently because of his GI bleed, it was decided to discontinue Coumadin. Heparin was then started. However, after he had hematochezia associated with chest pain, heparin was also discontinued. He had been actually hypertensive with blood pressure between 140s and 200s despite probable bleeding from the GI tract. Hydralazine was continued and increased eventually to 75 mg p.o. b.i.d. He had colonoscopy done on [2172-12-2]. Thereafter he was started on heparin and aspirin. Metoprolol was increased to 25 mg p.o. b.i.d. Because he had been placed on carvedilol as an outpatient, he was then switched over to carvedilol 12.5 mg p.o. b.i.d. It was then increased to 25 mg p.o. b.i.d. However, these events occurred after his colonoscopy. He was also started on amlodipine and Imdur. Imdur was started at 30 mg p.o. q.d. Norvasc was started at 10 mg p.o. q.d. He continued to be diuresed because of his congestive heart failure. He required 80 mg IV b.i.d. This was transitioned to 80 mg p.o. b.i.d. which was his dose taken at home. Daily weights were measured. His edema improved gradually over time. He was transferred to the floor on [2172-12-3]. He had some nonsustained v-tach. However, his AICD was interrogated and it was found to be working well. He was continued on heparin for his mitral valve replacement. It was debated whether to start low molecular weight heparin. However, it was decided that he would be started on Coumadin. GI Fellow was consulted about this. They felt that the risk of bleeding would be low after having intervention so subsequently he was started on Coumadin 5 mg p.o. on [2172-12-6]. He will need to be continued on Coumadin with a goal INR of 2 to 3. Heparin will be continued until his INR is therapeutic. There was some discussion whether he needed cardiac catheterization. Because of his GI bleed issues and his anemia, cardiac catheterization was deferred on this admission. It will need to be reconsidered as an outpatient. 2. GI. The patient had multiple episodes of hematochezia. GI service was consulted and recommended colonoscopy. Because of his history of cecal AVM, it was felt that his new bleed was also related to cecal AVM. He had bowel movements on [2172-12-1]. At that time a nuclear medicine scan was determined to be most effective in localizing the bleed. It showed active bleeding at the cecum. Because of his anemia he was transfused multiple units of blood. GI service recommended discontinuing anticoagulants that were on board. During the procedure he was found to have a single large angiectasia that was not bleeding in the cecum. BICAP electrocautery was applied for hemostasis successfully. Two nonbleeding polyps with benign appearance and ranging in size from 3 mm to 6 mm were found in the descending colon and rectum. Nonbleeding grade 2 internal hemorrhoids were noted. Diverticula was seen in the proximal sigmoid colon. However, none of the polyps were removed. Anticoagulation was held for 24 hours after the procedure. Thereafter heparin was started. The patient had a bowel movement on [12-5] and [12-6]. Both bowel movements were guaiac negative. It was thought that his GI bleed was under control. Consequently anticoagulation would be acceptable. 3. The patient has chronic renal insufficiency. His creatinine actually increased from 2.2 to 2.5 to 2.6. He may have a renal azotemia picture. However, he has been receiving large quantities of furosemide. His creatinine was monitored. Magnesium and potassium were repleted as necessary. 4. Heme. The patient was anemic and required multiple units of blood. However, once he no longer had hematochezia his hematocrit remained stable. FOLLOWUP: The patient was originally at [Hospital6 3426]. Because of the proximity to his home, he can possibly be transferred back to the TCU at [Hospital6 3426]. Physical therapy has seen him and recommended rehab for him. He will need followup with cardiology and his primary care physician. [Name10 (NameIs) ] will most likely need followup in two weeks. DISCHARGE MEDICATIONS: 1. Lasix or furosemide 80 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. 3. Coumadin 5 mg p.o. q.d. (subject to change). 4. Heparin adjusted to PTT. 5. Aspirin 81 mg p.o. q.d. 6. Carvedilol 25 mg p.o. b.i.d. 7. Clonazepam 0.5 to 1 mg p.o. b.i.d. 8. Serax 15 mg p.o. q.h.s. 9. Tylenol 325 mg p.o. q.four to six hours. 10. Imdur XR 30 mg p.o. q.d. 11. Potassium chloride 40 mEq p.o. q.d. 12. Norvasc 10 mg p.o. q.d. 13. Hydralazine 75 mg p.o. t.i.d. 14. Levofloxacin 250 mg p.o. q.o.d. to be discontinued on [2172-12-6]. CONDITION ON DISCHARGE: Guarded, but stable. DISCHARGE STATUS: To be discharged to [Hospital6 33]. DISCHARGE DIAGNOSES: 1. Demand ischemia. 2. Arteriovenous malformation in the cecum. 3. CHF. [First Name8 (NamePattern2) 2053] [Last Name (NamePattern1) 2052], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 4523] MEDQUIST36 D: [2172-12-6] 13:03 T: [2172-12-6] 13:08 JOB#: [Job Number 34300]	[ "280.0", "414.01", "211.3", "413.9", "569.0", "569.85", "428.0", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.43", "45.23" ]	icd9pcs	[ [ [] ] ]								11290, 11629	10632, 11162					5100, 10609																									3786, 5082											139, 150											179, 1998																2021, 3763		11187, 11269
9,512	165,783	24271	Discharge summary	report	Admission Date: [2145-7-4] Discharge Date: [2145-7-12] Date of Birth: [2074-7-2] Sex: M Service: SURGERY Allergies: Amoxicillin Attending:[First Name3 (LF) 5880] Chief Complaint: Pedestrian struck by auto Major Surgical or Invasive Procedure: [2145-7-5] s/p Left IM rod tibia & closed reduction left distal radius History of Present Illness: 71 yo male pedestrian struck by auto as he was crossing street; vehicle at unknown speed taken to area hospital for obvious left leg deformity; stabilized and transferred to [Hospital1 18] for trauma care. Past Medical History: Schizoaffective disorder Mental retardation Eczema Anxiety Anemia Social History: Resdies in a nursing home for past 30 years No family in United States (has relatives in [Name (NI) 6607]) Family History: Noncontributory Physical Exam: HEENT- 4 cm laceration forehead; 0.5 cm laceration tip of nose Neck- collared Back/Spine- no stepoffs or deformities Chest- symmetrical expansion Cor- regular Abd- soft NT FAST negative GU- foley Pelvis- stable Rectum- normal tone; guaiac negative Extr- gross deformity LLE; deep laceration right foot Neuro- GCS 15 Pertinent Results: [2145-7-4] 04:55PM GLUCOSE-193* LACTATE-1.7 NA+-142 K+-4.6 CL--104 TCO2-28 [2145-7-4] 04:55PM HGB-14.8 calcHCT-44 O2 SAT-95 CARBOXYHB-1 MET HGB-1 [2145-7-4] 04:42PM UREA N-23* CREAT-1.4* [2145-7-4] 04:42PM AMYLASE-85 [2145-7-4] 04:42PM WBC-18.1* RBC-4.69 HGB-13.8* HCT-40.0 MCV-85 MCH-29.5 MCHC-34.6 RDW-13.4 [2145-7-4] 04:42PM PLT COUNT-166 [2145-7-4] 04:42PM PT-13.7* PTT-20.7* INR(PT)-1.2 [2145-7-8] 10:10AM BLOOD Hct-30.4* [2145-7-7] 12:00AM BLOOD Hct-23.4* Brief Hospital Course: Patient admitted to TSICU under care of the trauma service. Orthopedics immediatley consulted, patient taken to OR on [2145-7-5] for fixation of his left tib/fib fracture. Ortho Spine was consulted as well for cervical fracture found on CT scan (C3-C5 spinous process fracture)cervical collar recommended cervical collar for 10 days. Podiatry consulted for the injury to left foot who recommended [2-2] str betadine dsg changes [Hospital1 ], abx and NWB; no operative intervention at this time. Patient with pain control issues, currently being treated with Oxycodone prn with fairly good response, may need to be considered for longer acting narcotics. He has been evaluated by PT & OT services who have recommended post hospital rehabilitation. Discharge Medications: 1. Quetiapine Fumarate 25 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 2. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain prior to rehab session. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). 14. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Continue for 4 weeks then discontinue Discharge Disposition: Extended Care Facility: [Location (un) ] [Doctor Last Name 6641] Discharge Diagnosis: s/p Pedestrian struck by auto Forehead laceration Spinous process fractures C4-6 Anterior/posterior left rib fractures [2-4] Left tib/fib fracture Right foot plantar laceration Discharge Condition: Stable Discharge Instructions: Do not bear weight on your left upper and right lower extremities Follow up with Podiatry Followup Instructions: Follow up with Ortho, Dr. [Last Name (STitle) 1005] in [3-4] weeks [Telephone/Fax (1) 1228], call for an appointment Follow up with Dr. [First Name (STitle) 3209], Podiatry in 2 weeks, [Telephone/Fax (1) 543], call for an appointment Follow up with Dr. [First Name (STitle) 1022], Ortho Spine in 2 weeks, [Telephone/Fax (1) 7807], call for an appointment	[ "805.03", "285.9", "300.00", "892.0", "805.05", "805.04", "873.42", "E849.5", "807.05", "813.41", "E814.7", "823.20", "317", "861.21", "295.70" ]	icd9cm	[ [ [] ] ]	[ "79.36", "86.59", "79.02", "99.04" ]	icd9pcs	[ [ [] ] ]	3879, 3954	1750, 2510	295, 372	4179, 4187	1214, 1727	4325, 4711	845, 862		2533, 3856		3975, 4158					4211, 4302										877, 1195																								230, 257											400, 611																633, 700	716, 829
72,562	120,814	41050	Discharge summary	report	Admission Date: [2153-5-25] Discharge Date: [2153-6-7] Date of Birth: [2079-8-23] Sex: M Service: SURGERY Allergies: morphine / Dilaudid Attending:[First Name3 (LF) 668] Chief Complaint: Perforated cholecystitis. Major Surgical or Invasive Procedure: [2153-5-24] open cholecystectomy/subtotal ccy History of Present Illness: 73 y.o. M with h/o perforated gallbladder, treated non-operatively with perc cholecystostomy tube. Cystic duct remained occluded therefore he was scheduled for elective open cholecystectomy. Past Medical History: EtOH abuse (quit [2150]), UGI bleed (severe gastritis), Cirrhosis PSH: R gynecomastia excision; Open appy (remote); Tonsillectomy (remote), [2153-5-25] open cholecystectomy Social History: Lives w/ wife. [Name (NI) ] tobacco or EtOH (quit drinking in [2150]) Family History: noncontributory Physical Exam: 98.2 HR 73 150 A&O, Well appearing RRR clear lungs abd soft, non-tender, cholecystostomy tube to drainage Brief Hospital Course: On [2153-5-25], he underwent open cholecystectomy with partial cholecystectomy for perforated cholecystitis and cirrhosis. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please refer to operative note for details. He had an 800cc blood loss with other significant losses via ascites. He received IV fluid replacement and albumin. A JP drain was placed. He was sent to the SICU for management of low urine output and tachycardia. Postop, drain output was high. He received IV fluid replacements and standing Albumin administration. Urine output and tachycardia resolved. He was also encephalopathic and was seen by Dr. [Last Name (STitle) ] from Hepatology who started Rifaximin. Ultrasound of liver was done to evaluate the portal vein. This was found to be patent. Geriatrics was called for confusion and anxiety. It was felt that delirium was likely r/t underlying cirrhosis, prolonged hospital course and sleep disturbance. Low dose zyprexa was recommended for hyperactive features. He received zyprexia 2.5mg approximately once a day with decreased anxiety. By postop day 11, output had decreased to ~ 375ml/day. The JP was removed [6-5] and site suture. Vital signs were notable for temperature of 101.4 on postop day 9. He c/o dysuria. Blood and urine cultures were sent. Urine culture isolated >100,000 colonies of klebsiella pneumoniae for which he was started on Cipro. He remained afebrile after this time. Foley was removed on [6-2], but was replaced for urinary retention. Foley was removed again on [6-5] and he was able to urinate without difficulty. LFTs were stable. Diet was advanced and tolerated. On [6-4], an abdominal US was done to evaluate for ascites. A 2.4 x 3.7 x 20 cm collection in the midline extending from the pelvis to the mid abdomen at the incisional site was noted. Abdominal incision appeared red on [6-6]. Incision was opened ~ 4-5cm and serosanguinous fluid drained out. A normal saline damp dressing was applied. Redness resolved by [6-7]. Physical therapy worked with him and declared him safe for home with planned help at home. He was discharged to home with CareGroup VNA. . Medications on Admission: HCTZ 25', Prilosec 20' Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: UTI. Disp:6 Tablet(s) Refills:0 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Perforated gallbladder gi bleed UTI, Klebsiella pneumoniae Urinary retention Incision cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have any of the following: fever, chills, nausea, vomiting, increased abdominal pain, abdominal bloating, constipation/diarrhea, incision wound appears red or has foul smelling drainage No showering until wound healed Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2153-6-11] 10:00 Provider: [Name10 (NameIs) ] [Name11 (NameIs) 17627] [Last Name (NamePattern1) 439], [Location (un) 858]. [2153-6-12] at 10:00 Completed by:[2153-6-8]	[ "788.5", "599.0", "571.5", "788.20", "574.10", "E878.6", "041.3", "575.4", "789.59", "682.2", "458.29", "998.59", "572.3", "348.30" ]	icd9cm	[ [ [] ] ]	[ "51.21" ]	icd9pcs	[ [ [] ] ]	4103, 4161	1063, 3258	304, 356	4301, 4301		4804, 5134	896, 913		3331, 4080		4182, 4280		3284, 3308			4484, 4781										928, 1040																								238, 266											384, 576									4316, 4460							598, 783	799, 880
14,122	193,192	29746+57655	Discharge summary	report+addendum	Admission Date: [2184-1-14] Discharge Date: [2184-1-28] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2932] Chief Complaint: Found down Major Surgical or Invasive Procedure: intubation, femoral central line placement, left PICC line placement History of Present Illness: [Age over 90 ] year old woman who presented after being found down in a snow bank outside her home; she was last seen 12 hours before she was found. The daughter left for work around 6am, and when she arrived home at 6pm, she found the front door open. She saw her mother laying in a pile of snow in only a daydress, unresponsive. She asked a neighbor to help her pull her out of the snow, and then called 911. She reports that her mother goes out every day at 10 am to get the mail. When she arrived in the ED, her temperature was 28C/82.4F (rectally per report). She was intubated on arrival for airway protection. A left femoral line was placed after an unsuccessful attempt at a right femoral line. She was given 2 L of warmed NS, 2L of warmed LR, as well as 400cc of warmed NS in NG and bear huggers were placed. A trauma workup, including CT head, C-spine, CXR and CT abdomen and pelvis were only significant for bibasilar atelectasis and a right pleural effusion. ECG showed afib 52 with possible [Doctor Last Name ] waves in V4-5. She was admitted to the medical ICU for further management. Past Medical History: -s/p ORIF of left hip for intertrochanteric fracture in [2181] -"[Last Name ] problem" -osteoporosis -mild HTN -Dementia (altzheimer's) - biliary stricture - glaucoma - hearing loss Social History: No smoking, alcohol or drug use. The patient is widowed since [2147], used to work as a shoemaker, and, prior to admission, was still driving. Lives with her daughter, [Name (NI) ], who has never married and has no children or siblings. The patient has a brother who lives in [Name (NI) 108], who has little contact with her. Family History: Mother died after a fall in her late age. Father died of liver disease. Daughter is alive and well at 64. Physical Exam: Physical exam on admission to MICU: VS: T: 98.6 BP: 131/65 HR: 95 RR: 26 Sat: 96% HEENT: Forehead with small abrasion. pupils reactive. sclera anicteric. Intubated NECK: Ccollar in place. CV: Irregularly irregular. Nl S1, S2. Unable to appreciate murmurs over vent. Lungs: CTA b/l ant/lat. Abdomen: SND NABS No HSM appreciated. Ext: All digits warm. No blisters, necrosis noted. Onchomycosis of toenails. 1+ DP, 2+ radial pulses. Right lower extremity rotated inward and shortened. (+) venous stasis changes b/l. LUE multiple ecchymoses, abrasions. Skin: as above, no other rashes, petechiae. Pertinent Results: [2184-1-14] WBC-6.9 HGB-11.7 HCT-36.7 MCV-61 RDW-16.0 PLT COUNT-143 UREA N-20 CREAT-0.7 SODIUM-136 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-17 ALT(SGPT)-31 AST(SGOT)-42* LD(LDH)-319* CK(CPK)-237* ALK PHOS-117 AMYLASE-27 TOT BILI-0.8 CK-MB-11* MB INDX-4.6 cTropnT-0.18* [2184-1-28] WBC [6-2]. Hgb 9.4 Hct 31.4 Plt Ct [2-10] Radiology [1-14] CT Abd/pelvis: There is a small calcified pleural plaque noted within the left pleura. Moderate sized right-sided pleural effusion with a small left-sided pleural effusion. Areas of compression atelectasis are noted in the left base and there appears to RML collapse. Heart size appears slightly enlarged and there is mild left atrial enlargement. No focal liver lesions are identified and there is mild biliary dilatation and pneumobilia, likely related to biliary enteric tube with distal tip in the proximal jejunum. Liver parenchyma is fatty infiltrated. The gallbladder is slightly distended without evidence of wall edema or periinflammatory changes and contains a large 3 cm stone. There is a questionable small peripheral splenic infarct, with stomach, intra- abdominal bowel, and right adrenal gland all appearing unremarkable. A 1.4 x 1.2 cm left adrenal lesion is identified, incompletely characterized on current contrast enhanced study. The left kidney contains multiple simple cysts, the largest measures approximately 2.1 x 2.4 cm within the interpolar region. Right kidney appears unremarkable. There is no evidence of hydronephrosis bilaterally. No free air or free fluid is noted within the abdomen. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are identified. There is mild atherosclerotic changes within the intra- abdominal aorta and its branches, however celiac axis, SMA, and [Female First Name (un) 899] all appear patent. There is an atrophic pancreas. Intrapelvic bowel displays diffuse areas of diverticulosis with no acute diverticulitis identified. Patient appears to be status post hysterectomy. The bladder is slightly distended with no enhancing masses identified. No free fluid is noted within the pelvis and there is no pathologically enlarged pelvic or inguinal lymph nodes identified. [1-14] CT C-spine: No fractures of the cervical spine are identified. There is intervertebral disc space narrowing at multiple levels, greatest at C3/4, C4/5, and posteriorly at C5/6. Mild-to-moderate spinal stenosis in the lower cervical spine, related to small disc osteophyte complexes. The thyroid is multilobulated, particularly on the left side. Several thyroid nodules are noted, and one is concentrically calcified on the left. There is a rounded opacity at the left lung apex, and left pleural fluid noted at the apex of the chest. There are dense carotid artery calcifications bilaterally. [1-14] CT Head w/o contrast: There is no evidence of hemorrhage or shift of the normally midline structures. The ventricles and sulci are prominent, consistent with moderate involutional change. There is hypodensity of the cerebral periventricular white matter, consistent with chronic microvascular ischemia. There is a lacunar infarct of the right caudate. There is mild-to- moderate mucosal thickening within the ethmoid air cells, and rounded opacities within the posterior maxillary sinuses consistent with retention cysts. The mastoid air cells are clear. There is a sclerotic focus of the right frontal calvarium, of indeterminate etiology. [1-14] CXR: The left lung apex and chest wall are not included in the study. The endotracheal tube terminates approximately 4.3 cm above the carina. There is atelectasis in the right lower lung. No large pneumothorax is seen. There is a small right- sided pleural effusion. Tubing material is containing two metallic elements seen projecting over the lower abdomen. No fractures are apparent. [1-15] Pelvis plain film: No acute fracture or dislocation is seen. There is osteopenia which limits evaluation for a nondisplaced fracture. A left femoral vascular line is seen. Patient is status post ORIF of the proximal left femur with a dynamic hip screw. Vascular calcification is noted. Soft tissues are otherwise unremarkable. [1-15] Transthoracic echocardiogram: The left and right atria are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is moderately dilated. There is moderate global right ventricular 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 moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. [1-19] Left upper extremity ultrasound: Thrombus within the cephalic vein, a superficial vein. No deep venous thrombosis is appreciated [1-24] CXR: Single portable radiograph of the chest demonstrates persistent bilateral pleural effusions, unchanged. Cardiomediastinal contours are similar in appearance. No pneumothorax detected. Mild increased airspace opacity involving the bilateral lungs and upper lobe redistribution represent mild CHF, unchanged. Brief Hospital Course: [Age over 90 ] year old female admitted with hypothermia after being found down in the snow. In the ED, she was intubated for airway support, externally and internally warmed and transferred to the ICU. In the ICU, she was extubated successfully on [1-17]. Course was complicated by NSTEMI, MSSA septicemia, and aspiration pneumonia. Summary of hospital course following transfer to the general medical floor: 1) Sepicemia from MSSA bacteremia, pneumonia and klebseilla UTI: a) MSSA septicemia: Blood cultures from [1-15] grew [3-3] MSSA. A TTE was without evidence of vegetations, however significant valvular disease was noted (see results section). The patient's daughter/HCP declined [Name2 (NI) ] to evaluate for endocarditis; therefore, she was treated empirically with a 6 week course of antibiotics. She was initially treated with nafcillin and a PICC line was placed. However, she developed a superficial thrombophlebitis (cephalic clot, no evidence of DVT) in the left arm at the site of the PICC line. The PICC line was removed, and the infectious disease service was consulted regarding an appropriate oral antibiotic regimen. She was started on dicloxacillin, of which she will complete a 6 week course from her first negative blood culture ([1-16]), to complete [2184-2-26]. A dicloxacillin level was obtained to ensure adequate levels (pending at time of discharge), and the patient will follow-up with infectious disease as an outpatient. While on doxycycline, she should have weekly CBC/differential/LFTs faxed to the [Hospital ] clinic. If she fails to clear the infection on oral antibiotics, IV therapy (nafcillin) may need to be restarted. b) Klebsiella UTI/aspiration pneumonia: The patient completed a 7 day course of quinolones and her Foley catheter was removed. 2) NSTEMI: The patient's troponin T peaked at 0.46; this NSTEMI was felt to be secondary to profound hypothermia. She was started on aspirin, lipitor, and a beta-blocker. A TTE EF >55%, normal regional LV wall motion, moderate global RV free wall hypokinesis, 1+ MR, 4+ TR, and severe pulmonary hypertension. 3) Diastolic congestive heart failure: The patient was noted to have bilateral pleural effusions, likely due to volume resuscitation/acute illness in the setting of underlying pulmonary hypertension/valvular disease. She was started on furosemide and low dose lisinopril, which can be titrated up as tolerated as an outpatient. 4) Diarrhea: The patient developed diarrhea while on antibiotics, however 3 stool specimens were negative for C. diff toxin. Her diarrhea gradually decreased. 5) Pulmonary hyepertension: Severe pulmonary hypertension was noted on echocardiogram. Potential causes include: endocarditis (patient's HCP declined [Name2 (NI) ]), chronic PEs (O2 sat stable, patient not a good candidate for chronic anticoagulation), or sleep apnea (consider outpatient sleep study). 6) Thyroid and adrenal nodules: These were noted incidentally on abdominal and C-spine CT (see results section). Further work-up (thyroid ultrasound, serial imaging, biochemical work-up) can be pursued as an outpatient at the discretion of the patient's PCP. 7) Anemia: Hematocrit remained stable (33.4 on discharge). Iron studies revealed a low iron/TIBC, however ferritin was not consistent with iron deficiency. Vitamin B12 was elevated (MMA may be considered as an outpatient), and folate/TSH were normal. Hemoglobin electrophoresis was obtained, given patient's marked microcytosis, which was pending at discharge. 8) Hyperglycemia: The patient was noted by fingerstick's to be mildly hyperglycemic. A hemoglobin A1C was checked, which was pending at time of discharge. She was continued on a regular insulin sliding scale. 9) Dispo: The patient was discharged to a rehabilitation facility. Medications on Admission: Prednisolone eye drops 1 gtt [Hospital1 ] HCTZ 12.5mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection before each meal and bedside: If FS <150 give 0 units, if 151-200 give 2 units, if 201-250 give 4 units, if 251-300 give 6 units, if 301-350 give 8 units, if 350-400 give 10 units, if >400 give 10 units and [Name8 (MD) 138] MD. 4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 31 days: to complete [2-26] (total 6 week course). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: to groin. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): to right eye. 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-2] Drops Ophthalmic PRN (as needed). 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: hypothermia Secondary: non- ST elevation MI, coagulase positive staphylococcus septicemia, urinary tract infection, aspiration pneumonia, diastolic congestive heart failure, diarrhea, thrombophlebitis, thyroid nodule, adrenal nodule, anemia Discharge Condition: stable Discharge Instructions: 1) Please follow-up as indicated below. 2) Please come to the emergency department if you develop chest pain, shortness of breath, nausea, vomiting, abdominal pain, worsening diarrhea, fevers, chills, or other symptoms that concern you. Followup Instructions: 1) Infectious disease: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2184-2-24] 9:30 a.m. - [Hospital Ward Name ], [Hospital Unit Name ], basement 2) Primary care: Please follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 30176] ([Telephone/Fax (1) 30242]) within 1-2 weeks after discharge from the rehabilitation facility [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2184-1-28] Name: [Known lastname 11981],[Known firstname 7401] Unit No: [Numeric Identifier 11982] Admission Date: [2184-1-14] Discharge Date: [2184-1-28] Date of Birth: [2088-2-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9532] Addendum: The patient's hemoglobin electropheresis was interpreted as consistent with Beta Thalassemia trait. Discharge Disposition: Extended Care Facility: Highgate Manor [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 9533] Completed by:[2184-2-6]	[ "507.0", "428.30", "599.0", "410.71", "416.8", "038.11", "991.6", "294.10", "282.49", "511.9", "427.31", "428.0", "331.0", "E901.0", "518.0", "041.3", "995.91", "996.62", "401.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	15629, 15820	8316, 12149	273, 343	14203, 14211	2800, 8293	14496, 15606	2065, 2172		12264, 13846		13931, 14182		12175, 12241			14235, 14473										2187, 2781																								223, 235											371, 1481																1503, 1694	1710, 2049
21,558	166,816	22904	Discharge summary	report	Admission Date: [2164-3-5] Discharge Date: [2164-3-16] Date of Birth: [2128-3-9] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 35-year-old woman who was sent her primary care doctor because she was told that she had a 4-mm left ophthalmic artery aneurysm. The patient has a significant medical history of fibromyalgia and migraines, and over the last two weeks has had two episodes of bilateral central vision loss lasting 24 hours, and she was only able to see with her peripheral vision. These visual changes are not associated with headaches. She went to see her neurologist who obtained a MRI/MRA that showed the 4-mm ophthalmic aneurysm. She came directly to the Emergency Room. REVIEW OF SYSTEMS: No headache. No dizziness. No visual disturbances currently. No chest pain, shortness of breath, or abdominal pain problems. PAST MEDICAL HISTORY: Remarkable for migraines three times per week and fibromyalgia associated with increased lymph nodes and low-grade temperatures. Chronic neck, shoulder, and back pain after falling down a flight of stairs eight years ago. She also has a history of a disc herniation at L4- L5. PAST SURGICAL HISTORY: Remarkable for inguinal hernia repair a year ago, right breast benign tumor removal, and unspecified left shoulder surgery. ALLERGIES: She has allergies to CAT SCAN DYE and IODINE. MEDICATIONS ON ADMISSION: Maxalt 5 mg once daily, baclofen 5 mg once daily, verapamil 120 mg at bedtime, Elavil 50 mg once daily, amantadine 100 mg in the morning and 100 mg at noontime, Tramadol 50 mg three times daily, gabapentin 600 mg four times daily, and Naproxen 500 mg twice daily. SOCIAL HISTORY: She is married and lives with her husband. She has three children. She does smoke one pack per day times 20 years and occasional marijuana. She denies alcohol use. FAMILY HISTORY: Mother alive with diabetes and pancreatitis. PHYSICAL EXAMINATION ON PRESENTATION: The temperature was 100.4, the pulse was 92, the blood pressure was 126/83, the respirations were 20, and 100 percent on room air. She was examined in bed. Awake and an in no acute distress. The pupils were equal, round, and reactive to light and accommodation. The lungs were clear bilaterally. Heart showed a regular rate and rhythm. Normal S1 and S2. The abdomen was obese. Bowel sounds were positive. The extremities showed no edema. On neurologic examination, she was awake, alert, and oriented times three. Speech and comprehension were intact. She had no drift. The spine was symmetrical. Motor examination showed her to be [5-31] throughout the upper and lower extremities with the exception of left triceps which were [5-1], and this was secondary to her shoulder surgery and chronic pain. Deep tendon reflexes were 2 plus bilaterally. The toes were downgoing. The pupils were equal, round, and reactive to light and accommodation. The extraocular movements were full. The visual fields were intact. Sensation was intact to light touch. Cranial nerves II through XII were grossly intact. SUMMARY OF HOSPITAL COURSE: She was admitted to Neurosurgery with every 2-hour neurological testing. She had a Neurology consultation and a CTA. Neurology recommended to continue her current migraine headache prophylactic treatment. She underwent a cerebral angiogram on [2164-1-4] that showed a 65 mm medially pointing right ICA aneurysm of the right internal carotid artery with a superiorly-pointing dome which was projection in to the intradural space. She tolerated the procedure well. She then had formal visual field testing as well as a General Surgery consultation for a question of right inguinal hernia. She did need further angiography and needed bilateral femoral access. General Surgery did see the patient and did not feel that she had a recurrent inguinal hernia and did not feel it would interfere with the planned procedure. Neurology also recommended followup with Endocrinology as an outpatient for her hirsutism and menstrual disorder. It was felt that the transient central visual disturbances were likely related to her migraines and not the ophthalmic aneurysm. She was seen by Ophthalmology who also felt that if the ophthalmic aneurysm was responsible for the visual changes it would have caused a unilateral decrease in vision rather than bilateral. They agreed with treatment of aneurysm per Neurosurgery and also recommended follow-up in the [Hospital 8183] Clinic after discharge for further workup. Dr. [Last Name (STitle) 1132] did discuss with the patient her findings, and after discussion the patient it was deciced to proceed with endovascular coiling of the aneurysm. She was started on Plavix and aspirin for several days for optimal anticoagulation prior to this procedure. She continued to be neurologically intact. She did undergo angiography with coiling of the right internal carotid artery aneurysm on [2164-3-14]. She tolerated the procedure well. Post angiography her vital signs were stable. She continued to be neurologically intact. There was no hematoma at the groin site, and she had a good dorsalis pedis pulse. She was maintained on aspirin 325 mg once daily post angiography. She continued to be neurologically intact. Her diet was increased. Her activity was increased. DISCHARGE DISPOSITION: She was seen by Physical Therapy and was ambulating well, and she was discharged to home on [3-16]. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg one per day (for one week). 2. Tramadol 50 mg three times daily. 3. Colace 100 mg twice daily. DISCHARGE FOLLOWUP: She will follow up with Dr. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1132] in two weeks and will also be instructed to follow up with Endocrinology and Ophthalmology. CONDITION ON DISCHARGE: Neurologically intact. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2164-3-16] 11:41:22 T: [2164-3-17] 11:48:01 Job#: [Job Number 59186*]	[ "724.5", "723.1", "729.1", "368.41", "626.9", "346.90", "704.1", "305.1", "719.41", "437.3" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.72" ]	icd9pcs	[ [ [] ] ]	5411, 5516						1909, 3120					5542, 5657	1443, 1708												1232, 1416											3149, 5387										776, 905									5678, 5894						163, 756																928, 1208	1725, 1892	5919, 6192
373	104,540	28290	Discharge summary	report	Admission Date: [2198-8-27] Discharge Date: [2198-9-1] Date of Birth: [2164-4-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [2198-8-27] Aortic Valve Replacement utilizing a 29mm CE Perimount Magna Pericardial Valve. Replacement of Ascending Aorta utilizing a 26mm Gelweave Graft. History of Present Illness: Mr. [Known lastname 68695] is a 34 year old male who first presented with chest discomfort and tingling sensation in his left shoulder in [Month (only) 216] [2197]. Then in [2198-8-3], after playing tennis, developed vague chest discomfort associated with dyspepsia and nausea. Echocardiogram revealed a bicuspid aortic valve with moderate to severe aortic insufficiency. His ascending aorta was dilated, measuring 4.5 centimeters. His aortic root measured 2.9 centimeters. LVEF estimated at 55-60%. Subsequent cardiac catheterization confirmed moderate aortic insufficiency and dilated ascending aorta. His coronary arteries were normal and his LVEF was measured at 65%. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Biscupid Aortic Valve, Aortic Insufficiency, Dilated Ascending Aorta, History of Seizure Disorder as an infant, ?[Doctor Last Name 13621] Syndrome as a child Social History: Denies tobacco. Admits to only occasional ETOH. He is married and works as a software engineer. Family History: Father underwent CABG at age 61 Physical Exam: Vitals: BP 130/80, HR 84, RR 12 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, [2-5] diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: alert and oriented, nonfocal Pertinent Results: [2198-9-1] 04:55AM BLOOD WBC-5.7 RBC-2.61* Hgb-8.2* Hct-22.9* MCV-88 MCH-31.4 MCHC-35.7* RDW-13.9 Plt Ct-159 [2198-9-1] 04:55AM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-140 K-4.1 Cl-100 HCO3-32 AnGap-12 RADIOLOGY Final Report CHEST (PRE-OP PA & LAT) [2198-8-30] 4:01 PM CHEST (PRE-OP PA & LAT) Reason: AORTIC INSUFFICIENCY\BENTAL PROCEDURE /SDA [Hospital 93] MEDICAL CONDITION: 34 year old man s/p CABGx3/ASD REASON FOR THIS EXAMINATION: ?pneumonia CHEST, TWO VIEWS, PA AND LATERAL History of CABG and AVR. Status post median sternotomy and AVR. There is slight cardiomegaly. No evidence for CHF. There is a small left pleural effusion with minimal atelectasis at the left lung base. Mediastinal emphysema is present anteriorly in the substernal region, presumed post-surgical. No pneumothorax. DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Cardiology Report ECHO Study Date of [2198-8-27] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR, asc. Aorta repair, Height: (in) 75 Weight (lb): 180 BSA (m2): 2.10 m2 Status: Inpatient Date/Time: [2198-8-27] at 10:27 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW03-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 4.4 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 1.9 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Low normal LVEF. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic root. Moderately dilated ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets. Systolic doming of aortic valve leaflets. No AS. Moderate (2+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: PRE-BYPASS: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler, but can not completely rule out a very small PFO. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are mildly thickened. There is systolic doming of the aortic valve leaflets. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-BYPASS Normal RV systolic function. Low normal LV systolic function. EF 50-55%. A bioprosthesis is located in the aortic position. It is well seated and displays normal leaflet function. There is no aortic stenosis. There are two jets of trace aortic regurgitation. The first is clearly valvular. There is a second jet that emanates from the region of the native right coronary cusp that is directed perpendicularly to the LVOT. The nature of this jet suggests a likely perivalvular source but this can not be confirmed on 2D imaging. This jet decreased somewhat in intensity after protamine administration. Graft material is seen in the ascending aorta. The thoracic aorta is intact post-CPB. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD on [2198-8-27] 14:31. Brief Hospital Course: Mr. [Known lastname 68695] was admitted and underwent replacement of his aortic valve and ascending aorta by Dr. [Last Name (STitle) 1290]. The operation was uneventful and he transferred to the CSRU for invasive monitoring. For further surgical details, please see seperate dictated operative note. He initially experienced postoperative coagulopathy which required fresh frozen plasma and platelets. With blood products, his bleeding quickly improved and no further intervention was required. Within 24 hours, he awoke neurologically intact and was extubated. Beta blockade was initiated on postoperative day one. His CSRU course was otherwise uncomplicated and he transferred to the SDU on postoperative day two. Over several days, beta blockade was advanced as tolerated. He remained in a normal sinus rhythm. He continued to make clinical improvments with diuresis and made steady progress with physical therapy. Given his pericardial tissue valve, he will need to remain on Aspirin therapy. He was medically cleared for discharge to home on postoperative day 5.Prior to discharge, his chest x-ray showed only a small pleural effusions and no evidence of heart failure. Medications on Admission: Lisinopril Pepcid 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. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:50 Tablet(s) Refills:0 4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). Disp:180 Tablet(s) Refills:2 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. 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 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:20 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: Dilated Ascending Aorta, Bicuspid Aortic Valve, Aortic Insufficiency - s/p Aortic Valve Replacement and Replacement of Ascending Aorta, Postoperative Coagulopathy, History of Seizures Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [3-7] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 68568] in [1-5] weeks - call for appt. Local cardiologist, Dr. [Last Name (STitle) 1295] in [1-5] weeks - call for appt. Completed by:[2198-9-1]	[ "424.1", "E878.2", "998.11", "441.2" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.45", "35.21", "99.05", "99.07" ]	icd9pcs	[ [ [] ] ]	9912, 9974	7394, 8578	337, 499	10202, 10209	2038, 2403	10527, 10845	1609, 1642		8646, 9889	2440, 2471	9995, 10181		8604, 8623			10233, 10504						3022, 7371				1657, 2019																								281, 299	2500, 2996										527, 1295																1317, 1480	1496, 1593
7,009	140,738	22257	Discharge summary	report	Admission Date: [2167-9-2] Discharge Date: [2167-9-13] Date of Birth: [2119-6-10] Sex: F Service: SURGERY Allergies: Meperidine / Heparin Agents / Magnesium Sulfate Attending:[First Name3 (LF) 668] Chief Complaint: 1. Hepatic Artery Anastomotic Stenosis/Thrombosis Major Surgical or Invasive Procedure: [2167-9-8]: Hepatic artery thrombectomy and roux-en-y hepaticojejunostomy. History of Present Illness: 48 y/o female POD29 s/p orthotopic liver [Year (4 digits) ]. The patient received a liver from a donor who was HIT positive. She did not receive heparin in the post op period. On [8-9] a HIT was negative, and then a follow up on [2167-8-28] was found to be positive. On [8-11] an ultrasound found patent hepatic vasculature. She was discharged on POD 7 to home. In the interim her main complaint has been burning in her feet. She was started on gabapentin with little relief of her symptoms, and often has to plunge her feet into cold water for relief. She is otherwise doing okay, denies chest pain, shortness of breath, increased abdominal pain. She does c/o pain on her right side but has been trying to cut down on pain medication usage. Patient was to be seen in clinic today and underwent another screening ultrasound which is now reportedly showing a hepatic artery stenosis, and she is admitted for further evaluation. Past Medical History: Osteoarthritis H/o alcohol abuse Benzodiazapine abuse Alcohol-induced cirrhosis ([2157]) s/p TIPS Alcohol-induced pancreatitis Gastroesophageal reflux disease Ovarian cysts Caesarian-section x2 Appendectomy Tubal ligation Thrombocytopenia Social History: Lives with husband and 16 y/o daughter in [Name (NI) ] ME. Limited employment secondary to health. 12 pack-year smoking history, currently [12-7] ppd. ETOH abuse. benzodiazapine abuse. Family History: mother 64 died of emphysema father 67 died of ETOH related dz Physical Exam: Admission Physical Exam VS: 99.3, 110, 131/76, 18, 97%RA, 44.6 kg General: Anxious, sl tearful, otherwise looks well HEENT: sclera anicteric, mucous membranes sl dry Card: Tachy, regular rhythm Lungs: CTA bilaterally Abd: Soft, non-distended, non-tender, healing chevron incision with steri strips, bruising over right lateral portion Extr: No edema, + DPs Skin: no jaundice, no rash Neuro: A+O x3, no focal deficit, no asterixis Pertinent Results: [2167-9-12] 05:35AM BLOOD WBC-6.5 RBC-3.58* Hgb-10.8* Hct-29.5* MCV-83 MCH-30.2 MCHC-36.6* RDW-15.4 Plt Ct-132* [2167-9-10] 06:00AM BLOOD PT-13.7* PTT-25.2 INR(PT)-1.2* [2167-9-9] 12:41AM BLOOD Fibrino-458* [2167-9-13] 04:50AM BLOOD Glucose-92 UreaN-22* Creat-1.8* Na-136 K-3.9 Cl-105 HCO3-20* AnGap-15 [2167-9-13] 04:50AM BLOOD ALT-500* AST-47* AlkPhos-207* TotBili-0.3 [2167-9-5] 05:20AM BLOOD CK-MB-3 cTropnT-0.03* [2167-9-4] 07:10PM BLOOD CK-MB-3 cTropnT-0.01 [2167-9-4] 12:21PM BLOOD CK-MB-3 cTropnT-0.02* [2167-9-12] 05:35AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.5* [2167-9-13] 04:50AM BLOOD Albumin-2.8* [2167-9-13] 04:50AM BLOOD tacroFK-11.9 [2167-9-12] 05:35AM BLOOD tacroFK-8.9 [2167-9-11] 05:58AM BLOOD tacroFK-17.5 Brief Hospital Course: The patient was admitted to the [Month/Day/Year 1326] surgery service on [2167-9-2] POD29 s/p orthotopic liver [Date Range ] for EtOH cirrhosis. Patient was found to have a hepatic artery anastomotic stenosis on clinic follow up and was admitted for management. Attempted angiography was unable to negotiate the tortuous celiac axis and ultimately resulted in hepatic artery thrombosis. This was confirmed on ultrasonography and did not improve with a brief period of anticoagulation. Operative revision of the hepatic artery, thrombectomy and roux-en-y hepaticojejunostomywas performed on HD 6. The patient tolerated the procedure well. Please see operative note for details. Patient required 1 day ICU treatment for falling HCT and pressor requirements. Neuro: The patient received dilaudid with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint requiring neo postoperatively for pressure support and was weaned off on POD1. Postoperative hematocrit was decreased at 26.0 and patient was transfused 2U PRBC with approriate HCT correction to 31.4. Vital signs were routinely monitored and patient was transferred to floor on POD1 for further managment Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: Post operatively, the patient was made NPO with IVF and NGT was placed. The patient's diet was advanced when appropriate POD4, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. Lasix diureses was required for fluid overload and patient was discharged on 3 days po lasix for additional fluid diuresis. JP Drain was removed on POD8 without complication ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient was treated with Bactrim/fluconazole/valganciclovir throughout hospitalization. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Patient with increase FSBG on day of discharge at 216 covered by sliding scale. Patient was discharged with insulin Rx and appropriate materials with teaching to f/u in clinic. Patient was continued on prednisone 15mg qday. Hematology: The patient's complete blood count was examined routinely; Patient was transfused 2 units PRBC postoperatively for HCT 26.0 with appropriate response and 2 units HD5 prior to procedure for decreasing HCT. Tacrolimus dose was measured daily and dosed accordingly. Prophylaxis: No heparin was given as donor was HIT postitive. Anticoagulation was intially performed with argatroban gtt. Patient was transitioned to clopidogrel post procedure, for out patient management. Patient was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Follow up labs were scheduled, tacrolimus dosing was discussed and insulin teaching was performed. VNA services were arranged for additional home management of insuling. F/u with Dr. [Last Name (STitle) ] was scheduled as appropriate. Medications on Admission: [Last Name (un) 1724]: Fluconazole 400 mg daily, Gabapentin 300 mg TID, Lansoprazole 30 mg [Hospital1 ], MMF 500 mg QID, Zofran 4 mg ODT PRN, Oxycodone 5 mg tabs [12-7] PRN pain, Prednisone 17.5 mg daily (taper to 15 mg on [9-4]), Bactrim SS daily, Tacro 2.5 mg [Hospital1 ], trazadone 25-50 mg hs PRN insomnia, valcyte 450 mg daily, tylenol 325 mg up to 6 tabs daily, Ca/Vit D (not taking yet), colace 100 [Hospital1 ] Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 4. valganciclovir 450 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 BID (2 times a day). 6. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain/headache: Do not exceed 2g in 24 hours. 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. [Hospital1 ]:30 Tablet(s) Refills:0 9. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Hospital1 ]:20 Capsule(s) Refills:0 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). [Hospital1 ]:30 Tablet(s) Refills:2 16. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 17. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). [Hospital1 ]:120 Capsule(s) Refills:2 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. [Hospital1 ]:3 Tablet(s) Refills:0 19. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous four times a day: Please use as directed. [Hospital1 ]:1 Refills:0 20. Soft Touch Lancets Misc Sig: One (1) Miscellaneous four times a day: Use 4 times daily as directed. [Hospital1 ]:100 Refills:2 21. BD Insulin Syringe 1 mL 25 x [4-12] Syringe Sig: One (1) Miscellaneous four times a day: as directed. [Month/Day (4) ]:100 Refills:2 22. One Touch Ultra Test Strip Sig: One (1) Miscellaneous four times a day: as directed. [Month/Day (4) ]:100 Refills:2 23. Glucose Bits 1 gram Tablet, Chewable Sig: One (1) Tablet, Chewable PO PRN: Please use for Blood Glucose less than 70. [Month/Day (4) ]:15 Tablet, Chewable(s) Refills:2 24. insulin lispro 100 unit/mL Solution Sig: One (1) Units Subcutaneous QID:PRN: Please administer 2Units per Blood glucose greater than 100 in increments of 50. 100-149 -> 2Units 150-199 -> 4Units 200-249 -> 6Units 250-299 -> 8Units 300-349 -> 10Units 350-399 -> 12Units Greater than 400 Units please contact MD. [Last Name (Titles) ]:10 mL Refills:2 Discharge Disposition: Home With Service Facility: Home Health visting nurse services of Southern ME Discharge Diagnosis: Hepatic artery stenosis and thrombosis S/p liver [Last Name (Titles) ] [2167-8-6] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the [Year (4 digits) ] surgery service for stenosis of the hepatic artery. Please call your the [Year (4 digits) ] institute [Telephone/Fax (1) 673] or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. You are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed [2155] mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. Staples will be removed at your follow-up appointment. General Drain Care: Please look at the drain site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warmth, and fever). You may shower and wash the drain site gently with warm, soapy water. You may also wash with half strength hydrogen peroxide followed by saline rinse. Keep the insertion site clean and dry otherwise. Place a drain sponge for cleanliness. Avoid swimming, baths, and hot tubs. Do not submerge yourself in water. Attach the drain securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2167-9-18] 1:00 Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2167-9-25*] 1:00	[ "289.84", "998.2", "E878.0", "V58.65", "V15.82", "530.81", "E878.2", "584.9", "V58.67", "568.0", "276.69", "303.93", "444.89", "996.82" ]	icd9cm	[ [ [] ] ]	[ "87.54", "54.59", "51.37", "50.11", "39.49", "88.47" ]	icd9pcs	[ [ [] ] ]	10233, 10313	3230, 6835	355, 436	10447, 10447	2432, 3207	13388, 13697	1903, 1966		7330, 10210		10334, 10426		6861, 7307			10598, 11646								12446, 13365		1981, 2413																							11678, 12431	266, 317											464, 1409									10462, 10574							1431, 1676	1692, 1887
60,907	188,690	37331	Discharge summary	report	Admission Date: [2199-11-12] Discharge Date: [2199-11-14] Date of Birth: [2147-11-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [11-13]: Enteroscopy (EGD) [11-14]: Colonoscopy History of Present Illness: Mr. [Known lastname 83977] is a very pleasant 51-year old gentleman w/ non-Hodgkin's lymphoma s/p XRT in [2164], known CAD s/p MI and PCI x2, chronic asthma, HL and hypothyroidism who was admitted with gastrointestinal bleeding. He reports wine-coloured stools for the past couple of days. He has been worked up over the past 2 weeks for anemia and iron deficiency. He has previously had EGDs and C-scopes that showed no lesions. Recent EGD [2199-11-7] showed chronic gastritis but no source of bleeding. He was evaluated at [Hospital6 6640] in [Hospital6 ] and had CT abd which showed thickened loops of jejunum in the LUQ. Additionally, he underwent small bowel capsule study on [11-7] but results were indeterminate. He was sent home but continued to have bloody bowel movements. On [11-9], He complained of dizziness, abdominal cramps and wine-coloured stools. He re-presented to [Hospital3 ] was found to be hypotensive on exam, with a HCT of 22.3 (baseline mid 30s). He required a total of 5 units of PRBC during his hospital course (according to him, only 3 u recorded). He was transferred to [State 792]Hospital for evaluation with Dr. [Last Name (STitle) 67432] to perform small bowel enteroscopy. A tagged RBC scan at [Hospital 792]Hospital showed a potential bleeding source in the proximal jejunum. Unfortunately, Dr. [Last Name (STitle) 67432] had left to travel abroad today so he was transferred to [Hospital1 18] for small bowel enteroscopy with Dr. [First Name (STitle) ] [Name (STitle) ]. Due to his significant GI bleed and question of hemodynamic stability, he was admitted to the ICU. In the ICU, he complains of some lower abdominal cramping and foul-smelling dark maroon stools. He denies fevers, chills, difficulty breathing, chest pain, changes in urinary function or lower extremity swelling. He denies any history of hematemesis or hemoptysis and reports a normal colonoscopy in [2198]. He states this is the first time he has ever had GI bleeding of this kind. Review of systems is otherwise negative Past Medical History: 1. non-Hodgkin's lymphoma, s/p XRT (total body) [2164] 2. CAD s/p MI [2195], s/p PCI x2 3. chronic asthma 4. hyperlipidemia 5. hypothyroidism 6. gout Social History: SOCIAL HISTORY: lives at home w/ wife, no kids. Does not smoke, drink or do illicit drugs, works as electrician Family History: no hx colorectal cancers Physical Exam: GENERAL: Pleasant, well appearing middle-aged gentleman in NAD HEENT: No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: RRR . Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ DP/PT pulses SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-11]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [11-13]: EGD REPORT Nodularity in the stomach body (biopsy) Spirus enteroscopy was performed upto the proximal ileum. The entire mucosa appeared normal without any evidence of fresh or old blood. Otherwise normal EGD to proximal ileum [2199-11-12] 09:20PM WBC-13.6* RBC-3.63* HGB-10.5* HCT-32.9* MCV-91 MCH-28.8 MCHC-31.8 RDW-15.3 [11-14] COLONOSCOPY REPORT Grade 3 internal hemorrhoids Polyp in the descending colon (polypectomy) Polyp in the rectum (polypectomy) Otherwise normal colonoscopy to cecum and terminal ileum Brief Hospital Course: Mr. [Known lastname 83977] is a very pleasant 51 year-old gentleman who was transferred from [Hospital 792]Hospital to [Hospital1 18] for enteroscopy to better characterize upper GI bleed, (localized to proximal jejunum according to tagged RBC scan at [Hospital ] Hospital) admitted to ICU due to large volume blood loss and concerns for hemodynamic instability. [Hospital Unit Name 13533]: 1. GI BLEED- The likely source of Mr. [Known lastname 83978] bleed was upper given nature and description of melenic stools and evidence of source at proximal jejunum on tagged RBC scan. Possible causes of bleed include peptic ulcer disease and NSAID-induced gastritis from aspirin use, radiation enteritis from treatment for non-Hodgkin's lymphoma (although he was treated in [2164]), recurrent lymphoma and arteriovenous malformations. In the ICU, he had decreasing hematocrits and one melenic bowel movement. Gastroenterology service was notified of his admission and general surgery was also contact[Name (NI) ] so they could be aware of any potential hemodynamic changes that would warrant surgical intervention. He was transfused 1 unit of PRBCs on admission and underwent enteroscopy on [11-13]. Enteroscopy did not reveal source of bleed (just showed nodular stomach from old XRT) and bleeding was thought to be due to an ateriorvenous malformation that had blanched out. He underwent colonoscopy on [11-14] which also did not reveal a bleeding source. He had grade III internal hemorrhoids and a few polyps on colonoscopy. He was discharged with GI follow-up in [Location (un) 8545]. He was instructed to take 81mg of aspirin instead of 325mg due to bleeding risk. Aspirin and home anti-hypertensive regimen were held on admission due to GI bleed and close monitoring of hemodynamic instability. Patient's hematocrit was carefully followed and he did not require any further blood transfusions. 2. HYPERTENSION- Diltiazema and Toprol XL were held to active GI bleeding in order to better characterize volume loss and reciprocal tachycardia in response to hypotension. He will confer with outpatient GI regarding when to restart these medications. 3. HYPERLIPIDEMIA- simvastatin 10 daily was continued 4. HYPOTHYROIDISM- synthroid 100mcg daily was continued Medications on Admission: 1. diltiazem 120mg qhs 2. toprol xl 50mg qam 3. colchicine 0.6mg qam 4. allopurinol 300mg qam 5. lipitor 10mg daily 6. prilosec 40mg daily 7. synthroid 100mcg daily 8. ferrous sulfate 325mg daily 9. EC ASA 325 mg daily 10. advair 250/50 Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [Hospital1 ] (2 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: GI bleed SECONDARY: coronary artery disease, hypertension Discharge Condition: hemodynamically stable Discharge Instructions: It was a pleasure being involved in your care, Mr. [Known lastname 83977]. You were admitted to the ICU for GI bleeding and had an enteroscopy to try to figure out the source of bleeding. The exact source of bleeding was not found, and thought to be due to an AVM (arteriovenous malformation). You also underwent colonoscopy. We initially held your blood pressure medications because of GI bleeding. Your medications have not changed, but please ask your GI doctors (and cardiologist) whether to take 325mg or 81mg of aspirin. (I would recommend taking 81mg) Also, double-check with them about when to re-start your Diltiazem and Toprol XL. (we held them initially as we often do for GI bleeds) Please continue to take your other medications as you have been. Call your doctor or 911 if you experience crushing chest pain, difficulty breathing, fevers/chills, intractable nausea or vomiting, dizziness from massive blood loss or severe bleeding in your urine vomit or stool or any other concerning medical problem. Followup Instructions: Please follow-up with your outpatient GI doctors [First Name (Titles) ] [Last Name (Titles) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2199-11-15*]	[ "493.90", "211.3", "272.4", "211.1", "458.9", "276.52", "558.1", "V10.79", "414.01", "244.9", "412", "V45.82", "285.1", "909.2", "211.4", "E879.2", "537.83", "578.1", "455.0" ]	icd9cm	[ [ [] ] ]	[ "45.16", "45.42", "48.36" ]	icd9pcs	[ [ [] ] ]	7618, 7624	4137, 6445	327, 385	7735, 7760	3575, 4114	8831, 9092	2839, 2865		6733, 7595		7645, 7714		6471, 6710			7784, 8808										2880, 3556																								279, 289											413, 2510																2532, 2691	2724, 2822
76,736	113,085	35837	Discharge summary	report	Admission Date: [2167-12-19] Discharge Date: [2168-3-26] Date of Birth: [2097-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Transfer from [Hospital6 33] for cord compression Major Surgical or Invasive Procedure: XRT to spine History of Present Illness: 69 year old man with past medical history significant for htn, who was transferred from [Hospital3 ] Hosp on [2167-12-19] with concern for thoracic cord compression. The pt originally presented to his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] on [2167-12-15] with a complaint of low back pain and difficulty ambulating. He was sent for CT scan on [12-15] and CT scan showed a large bulky soft tissue mass 13x12 cm encasing the left kidney with extension into the pelvis, partially encasing left common iliac artery. The pt returned home on [12-15] with a prescription for Vicodin, but on [12-16] the pain in the pt's back became too severe and on [12-17] he presented to the [Hospital3 ] ED. The pt reported that since [Month (only) 1096] he had been experiencing anorexia, weight loss of 12 lbs, increasing abdominal bloating and drenching night sweats. . At [Hospital6 33] the pt's VS were 97.8, P103, RR 18, BP 143/99, POx 94%on RA. On labs drawn in the ED the pt had a WBC of 16.7, hct of 37.4, plts of 322, INR of 1.2, LDH of 3670, AST of 126, Cr of 2.6, calcium of 13.5 and uric acid of 16. The pt was admitted for management of acute renal failure, abdominal mass concerning for lymphoma and hypercalcemia. . During his OSH hospitalization the pt was found to have low back pain with difficulty ambulating and was evaluated by neurology which recommended MRI of the lumbar spine. MRI of lumbar spine showed marrow enhancement with evidence of cord compression from L1 to T11. The pt was then transferred on [2167-12-19] for further management of cord compression. . Past Medical History: Hypertension Social History: The pt is an electrician. He lives with his wife and has 4 adult children. He quit tobacco use 25 years ago. Family History: No family history of cancers, parents lived into 90's and died of "old age." Physical Exam: GENERAL: Middle-aged man in NAD, laying in bed, falling asleep occasionally during the interview. HEENT: Oropharyngx clear, poor dentition, EOMI, PERRLA, no cervical or clavicular LAD. CARDIAC: RRR no m/g/r S1, S2 nl LUNG: CTA anteriorly, no wheeze, rales or rhonchi ABDOMEN: soft, NT/ND, no hepatosplenomegaly, bowel sounds present EXT: warm, no clubbing, cyanosis or edema NEURO: A+O x3, CN II-XII intact Motor: Symmetric strength in upper extremities, absent pronator drift bilaterally, Diminished strength in bilateral lower extremities, legs in frog-leg position, unable to lift legs off bed, able to wiggle toes [Last Name (un) ]: Symmetric sensation bilateral upper and lower extremities. DERM: Left forehead lesion with hypopigmentation and two nevi Pertinent Results: Bone Marrow Biopsy [2167-12-19]: BONE MARROW EXTENSIVELY INVOLVED BY A HIGH-GRADE B CELL LYMPHOMA Immunophenotypic findings consistent with involvement by: a Lambda restricted B cell lymphoma that co-expresses CD10. Cytospin preparation of the FNA demonstrates a lymphoid population that consists of large atypical cells with high N:C ratio and some with cytoplasmic vacuoles. . MRI L spine [2167-12-30]: IMPRESSION: 1. Previously identified posterior, epidural lesion in the region of approximately T11 through L1 is not well evaluated on the current study. Repeat imaging at the T10 through L1 levels, with T1 and T2 pre- and post-gadolinium images is recommended. 2. Diffuse abnormal, heterogeneous signal seen throughout the vertebral bodies, most consistent with diffuse infiltration with lymphoma. 3. Low signal lesions consistent with previously seen lytic metastases identified within the iliac bones. . PE [2167-1-13] CT abdomen with contrast: IMPRESSION 1. Acute-appearing right lower lobe lobar and segmental pulmonary embolism. Please note, this examination was not tailored to evaluate the remainder of the pulmonary arterial vasculature. 2. Distended gallbladder containing multiple gallstones and mild pericholecystic fluid. These findings are suspicious for acute cholecystitis. If clinical concern remains for acute cholecystitis, a HIDA scan may be of diagnostic benefit. 3. Left retroperitoneal mass encasing the left kidney and ureter diagnosed by recent biopsy as B-cell lymphoma. Probably no interval change in extent or appearance compared to CT of [2167-12-29]. 4. Delayed left renal nephrogram concerning for poor renal function. Marked hydroureteronephrosis suggesting an obstructive component to the surrounding mass, likely near the UVJ. Areas of ureteral wall irregularity raise concern for local invasion as described. 5. Diverticulosis without evidence of diverticulitis. 6. Possible bone lesion right iliac bone. Brief Hospital Course: Mr. [Known lastname 14966] is a 70 year old man with past medical history significant for hypertension, who was transferred from [Hospital ] Hospitak on [2167-12-19] with concern for thoracic cord compression who was found to have mantle cell lymphoma, blastic variant. He ultimately died in the ICU secondary to a GI bleed. . During this hospitalization the following issues were addressed: . #. GI bleed: The patient was transferred to the ICU three times in the last week of his life. The last two transfers were for hematochezia/melena. During the first of GI bleeds, the decision was made for conservative management with platelets and RBC transfusions per the wishes of the family. Surgery and GI were consulted during the first bleed and the family was aware that EGD/colonoscopy were an option and the that IR would be an option if he began to bleed briskly. The family's goals at this time were to stabilize the patient so that he could be well enough to be discharged home to die. He was transferred back to the floor and the following evening had a large bloody bowel movement which prompted transfer back to the ICU. He had a brisk bleed and was transfused multiple units of RBCs, platelets, and FFP. He was then taken to IR for possible embolization. A family meeting took place and a decision was made for the patient to become DNR/DNI and CMO. He died later that morning of respiratory arrest with his family at his bedside. . # Mantle Cell Lymphoma, blastic variant: The pt had biopsy of his retroperitoneal mass on admission, and the biopsy revealed a high-grade lymphoma. Further pathology revealed likely Mantle Cell Lymphoma, blastic variant. On [2167-12-19] the pt was started on the [Last Name (un) ] protocol, and on [12-20] the pt started radiation to the spine. Radiation to the spine concluded on [2168-1-12], pt. was summarily started on [Hospital1 ] treatment for DLBCL. Developed febrile neutropenia, CT torso demonstrated no areas of abscess, pt. was started on neupogen, cefepime, vanc, and fluconazole. Counts steadily increased and the patient underwent the following regimen: ICE: Tolerated without significant issue Intrathecal Ara-C: After first round of intrathecal chemotherapy patient experienced altered mental status which did improve after one week. . # Tumor lysis syndrome: The pt was initially in acute renal failure likely secondary to tumor lysis syndrome. The pt received aggressive hydration and rasburicase. Over the first few days of admission the pt's electrolytes and uric acid returned to [Location 213] and the pt's renal function returned to baseline. . # Pulmonary Embolus: Pt. was complaining of pleuritic chest pain on [2167-1-13], localized to the right upper quadrant. Sent for Abdominal CT and incidentally found RLL embolus, started on heparin prior to cholecystecomy. Heparin stopped and then restarted post cholecystectomy and IVC filter on [2168-1-16]. Previous port site with hematoma on [2168-1-18], heparin stopped. Pt. developed hypoxia to 84% on RA and paO2 of 85 on NRB mask, pt. was to be sent to [Hospital Unit Name 153] but refused. Hypoxia and hypotension resolved, unclear as to etiology. . # Cholecystitis: Pt. was complaining of constant RUQ pain around the same time as his complaints of pleuritic chest pain. Surgery consulted, mass was felt on physical exam on RUQ. Cholecystecomy done on [2168-1-16] and a necrotic gallbladder was removed. Pt. was draining normally with no bilious liquid in JP drain, drain was removed and staples removed. Had an episode of bleeding from site while on heparin, but no other problems since heparin stopped. . Period reflecting [Date range (1) 81476]: Before the below chemotherapy regimen the patient was doing well on the floor. His mental status cleared completely and his left leg weakness did improve allowing him to walk several steps with assistive devices. Due to his speedy recovery, the decision was made to continue chemotherapy. Staging MRI of the spine was acquired prior to intrathecal therapy and did demonstrate an improvement. . Intrathecal Depocyt([3-13])/ICE([3-15]) # 2: Overnight [3-17] the patient developed fever, altered mental status, vomiting and poor cough. He was transfered to the ICU for intubation and supportive care. Cultures drawn 2 days prior during a febrile episode turned positive for yeast, later found to the [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 29361]. . AMS: The patient was admitted to the ICU in mid [Month (only) 547] for altered mental status and his work up revealed encephalitis likely secondary to chemo effects. He had an EEG consistent with encephalopathy, an MRI showing two small CVAs, and a negative LP. The patient returned to the BMT floor on [3-23] with mental status below baseline but improving and sufficient to protect his airway. Overnight, approximately 6 hours after his return he passed a large bloody bowel movement and was again transferred to the ICU. . # Cord Compression: Got XRT to spine for cord compr from L retroperitoneal mass on [12-20], 22, 23. [12-25] Rituxan (3 day course) started. Got Rituxan 1/23,[1-2] and [2168-1-17]. Mass decreased, seen by urology who decided against stent placement. L. hydronephrosis has been stable since the conclusion of radiation. . # Delirium: Spiked on [12-30], pansensi Pseudomonas and E Coli in UC, BC, on Cefepime. [12-31] PICC pulled, if spiking follow [Hospital1 18] F+N protocol. Pt. was switched to Zosyn post-cholecystectomy. Medications on Admission: Atenolol 50 daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2168-4-5]	[ "E878.6", "999.31", "276.1", "038.43", "293.0", "415.19", "584.5", "348.30", "403.90", "336.3", "434.91", "707.05", "591", "202.80", "E879.2", "112.5", "136.3", "707.22", "682.2", "578.1", "E879.8", "041.12", "528.09", "288.00", "780.61", "275.42", "284.1", "E934.2", "V64.41", "584.8", "574.00", "E933.1", "593.3", "590.80", "942.24", "785.59", "322.0", "995.91", "998.11" ]	icd9cm	[ [ [] ] ]	[ "88.72", "96.04", "99.25", "51.22", "38.7", "38.93", "41.31", "88.47", "92.29", "03.92", "86.07", "86.05", "03.31", "96.72", "33.24", "54.24" ]	icd9pcs	[ [ [] ] ]	10833, 10842	5103, 10732	379, 393	10894, 10904	3118, 5080	10961, 10999	2239, 2318		10800, 10810		10863, 10873		10758, 10777			10928, 10938										2334, 3099																								286, 341											421, 2061																2083, 2097	2113, 2223
54,708	172,512	49509	Discharge summary	report	Admission Date: [2143-1-12] Discharge Date: [2143-1-16] Date of Birth: [2069-5-15] Sex: M Service: MEDICINE Allergies: Zocor / lactose intolerance Attending:[First Name3 (LF) 613] Chief Complaint: - Hypoglycemia and AMS Major Surgical or Invasive Procedure: None History of Present Illness: 73M w h/o dCHF, DMII, dementia, stage IV renal insuff, HTN, recurrent DVT's on coumadin, prostate CA reffered from nursing home with hypoglycemia and AMS. . Last night in nursing home acute onset of altered mental statust, noted to be diaphoretic while sitting in a chair watching television. Patient's fingerstick at that time was noted to be 60s. Patient was given juice but he would not take it and fingerstick went down to 31. Patient was given glucagon IM which made him become more alert and he was able to drink the juice. Patient remained lethargic and minimally responsive and was sent to the ED for further evaluation. Prior to transfer from the facility he was noted to be saturating 90% on room air with heart rate in the 30s. Left fingerstick prior to transfer was 131. Patient is chronically on Coumadin. No notes of recent illness or medication changes in records. . . In the ED admission vitals 96.0 116/60, HR 48, RR 16, O2 94% on 8L. . BP down to 94/50, BG 168, hyperkalemia to 7.0, trop 0.17 with normal MB, Cr 4.0 from 2.4-2.8 baseline. . Patient got 1L NS + calcium gluconate + dextrose for hyperkalemia. . Transfer vitals 96F, HR 52, BP 108/62, 18, 99% on 8L FM. ED nursing note: "Requires jaw thrust to prevent his tongue from obstructing his airway." Past Medical History: Diabetes melitus CKD w/ h/o hyperkalemia hyperlipidemia O/A hypertension BPH h/o DVT h/o prostate CA previously with external beam radiation erectile dysfunction ex lap in [2134] in [State 531], reportedly nothing found decreased hearing, reportedly was told he needs a hearing aid but did not get one CVA - on asa 81mg daily Social History: He moved from [Country ] in [2096], family lives in the US but not [Location (un) ]. He smokes 3 cigarettes/day since his wife died in [8-8]. No etoh or illicit drug use. Family History: Cancer - unable to be specific Physical Exam: Vitals: T: 96.0 BP: 144/92 P: 65 R: 15 18 O2: 89% on 15L nasal canula General: sleepy but easily arousable, orientedX2, no acute distress, some mild upper airway collapse sounds (snoring), coughing with small amout of thick purulent sputum. HEENT: Sclera anicteric, dry MM, dentures, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: reduced bil air movement, clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: distended but non-tender, reduced bowel sounds present, no organomegaly, no flank dullness GU: no foley Ext: warm, well perfused, poor DP, good radial pulses, no clubbing/cyanosis, bil tibial edema +2 with chronic stasis dermatitis changes Neuro: CN grossly intact, lower extremities [5-4] distal, [3-4] hip gerdle, [5-4] UE, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact, mild bil UE tremmor, normal tone Discharge Exam: 97.3 140/74 HR 73 RR 20 94% RA General: alert, orientedX2 (not exact time), no acute distress HEENT: Sclera anicteric, MMM, dentures, 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: distended but non-tender, reduced bowel sounds present, no organomegaly, no flank dullness GU: no foley Ext: warm, well perfused, poor DP, good radial pulses, no clubbing/cyanosis, bil tibial edema +2 with chronic stasis dermatitis changes Neuro: CN grossly intact, lower extremities [5-4] distal, [3-4] hip gerdle, [5-4] UE, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact, mild bil UE tremmor, normal tone Pertinent Results: Admission Labs [2143-1-12] 08:16PM TYPE-ART TEMP-37.3 PO2-76* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 INTUBATED-NOT INTUBA [2143-1-12] 08:16PM LACTATE-2.3* [2143-1-12] 07:53PM GLUCOSE-233* UREA N-69* CREAT-3.8* SODIUM-139 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-22 ANION GAP-19 [2143-1-12] 07:53PM CALCIUM-8.4 PHOSPHATE-6.3* MAGNESIUM-1.5* CHOLEST-177 [2143-1-12] 07:53PM TRIGLYCER-85 HDL CHOL-68 CHOL/HDL-2.6 LDL(CALC)-92 [2143-1-12] 03:00PM VoidSpec-CLOTTED SP [2143-1-12] 02:42PM GLUCOSE-220* UREA N-68* CREAT-3.8* SODIUM-137 POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-21* ANION GAP-19 [2143-1-12] 02:42PM CK-MB-6 cTropnT-0.15* [2143-1-12] 02:42PM CALCIUM-8.5 PHOSPHATE-6.3* MAGNESIUM-1.5* [2143-1-12] 12:07PM URINE HOURS-RANDOM UREA N-238 CREAT-79 SODIUM-53 POTASSIUM-58 CHLORIDE-92 [2143-1-12] 07:42AM TYPE-ART PO2-59* PCO2-44 PH-7.30* TOTAL CO2-23 BASE XS--4 [2143-1-12] 07:42AM LACTATE-1.1 [2143-1-12] 07:42AM LACTATE-1.1 [2143-1-12] 07:42AM O2 SAT-88 [2143-1-12] 07:29AM GLUCOSE-75 UREA N-66* CREAT-3.9* SODIUM-140 POTASSIUM-5.9* CHLORIDE-107 TOTAL CO2-19* ANION GAP-20 [2143-1-12] 07:29AM CK-MB-8 cTropnT-0.16* [2143-1-12] 07:29AM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-6.8* MAGNESIUM-1.8 IRON-35* [2143-1-12] 07:29AM calTIBC-330 TRF-254 [2143-1-12] 07:29AM CORTISOL-43.6* [2143-1-12] 07:29AM CORTISOL-43.6* [2143-1-12] 07:29AM WBC-6.8# RBC-4.00* HGB-11.8* HCT-37.4* MCV-93 MCH-29.5 MCHC-31.5 RDW-17.7* [2143-1-12] 07:29AM NEUTS-84* BANDS-0 LYMPHS-14* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2143-1-12] 07:29AM PT-25.5* PTT-26.5 INR(PT)-2.4* [2143-1-12] 01:25AM URINE MUCOUS-RARE [2143-1-12] 01:25AM URINE HYALINE-16* [2143-1-12] 01:25AM URINE MUCOUS-RARE [2143-1-12] 01:00AM PT-26.9* PTT-36.3 INR(PT)-2.6* [2143-1-12] 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2143-1-12] 01:00AM CALCIUM-8.8 PHOSPHATE-6.2# MAGNESIUM-1.9 [2143-1-12] 01:00AM CK-MB-5 [2143-1-12] 01:00AM cTropnT-0.17 [2143-1-12] 01:00AM CK(CPK)-450* [2143-1-12] 01:00AM GLUCOSE-149* UREA N-63* CREAT-4.0# SODIUM-135 POTASSIUM-9.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 [2143-1-12] 01:06AM HGB-11.4* calcHCT-34 [2143-1-12] 01:06AM GLUCOSE-133* LACTATE-1.5 NA+-139 K+-7.0* CL--105 RENAL ULTRASOUND ([2143-1-12]): FINDINGS: The right kidney measures 11.3 cm and the left kidney 11.4 cm. There is no evidence of stones, masses or hydronephrosis in either kidney. The bladder is collapsed around a Foley catheter. IMPRESSION: Normal renal son[Name (NI) ]. [Name2 (NI) ] evidence of hydronephrosis. DISCHARGE LABS: [2143-1-15] 07:50AM BLOOD WBC-9.1 RBC-3.53* Hgb-10.6* Hct-31.4* MCV-89 MCH-29.9 MCHC-33.6 RDW-17.2* Plt Ct-182 [2143-1-16] 06:35AM BLOOD PT-15.0* PTT-27.6 INR(PT)-1.4* [2143-1-16] 06:00AM BLOOD Glucose-149* UreaN-81* Creat-3.3* Na-137 K-4.2 Cl-99 HCO3-27 AnGap-15 [2143-1-15] 07:50AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.8 Brief Hospital Course: PRIMARY REASON FOR ADMISSION: 73M w h/o dCHF, DMII, dementia, stage IV renal insuff, HTN, recurrent DVT's on coumadin, prostate CA reffered from nursing home with hypoglycemia and AMS and found to have AoCRF as well as pulmonary congestion. ACUTE DIAGNOSES: # Hypoglycemia: The ultimately cause of the patietnt's hypoglycemia was undetermined at the time of discharge. It was thought that he had reduced insulin clearance due to his renal failure. His insulin was held during his initial presentation. At the time of discharge he had been restarted on an insulin regimen without further episodes of hypoglycemia. # Acute on Chronic Renal Failure: The patient's creatinine was noted to be elevated from baseline on presentation. This was though to be due to a CHF exacerbation with poor effective arterial volume. A renal ultrasound was obtained that ruled out hydronephrosis. his renal failure improved after diuresis. While he was in house he was evaluated by the renal team. An upper extremity venous mapping was performed to evaluate the patient for a possible fistula in the future. He will follow up with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] nephrologist 2 weeks after discharge # Hypoxia: The patient was initially hypoxic & there was some concern for a RLL PNA. He was initially started on broad spectrum antibiotics, which were tailored down as his respiratory status improved after diuresis. He was discharged on levofloxacin, to continue the rest of his course. He was afebrile without leukocytosis throughout admission. # Delirium: The patient's initialy delirium (superimposed on dementia) was most likely secondary to hypoglycemia. His mental status improved with resolution of hypoglycemia & volume overload. An admission head CT was negative for acute intracranial process. CHRONIC DIAGNOSES: # DVT: The patient's INR was supratherapeutic on admission. His warfarin was initially held, but was restarted when his INR trended down. He will be discharged on 4 mg QD with a plan to follow his INR and redose warfarin as needed. # HTN: The patient's labetalol was initially held. Restarted nifedipine SR, tamsulosin, doxazosin and continued to hold Labetolol on transfer to the floor given controlled BP's. Pt was discharged on hydralazine and advised to discontinue labetalol & hold metolazone & torsemide until following up with his nephrologist. # HLD: LDL noted to be below 100. # Neuropsychiatric Issues: The patient was continued on fluoxetine, VPA, Gapapentin TRANSITIONAL ISSUES: # Follow-Up: The patien will follow up with his nephrologist in 2 weeks. # Code Status: DNR/DNI. Unfortunately, the patient's son does not wish to be contrted regarding his father. Medications on Admission: Aspirin 81 mg PO/NG DAILY Azithromycin 500 mg IV Q24H Duration: 5 Days Calcitriol 0.25 mcg PO DAILY Cyanocobalamin 100 mcg PO/NG DAILY Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation Doxazosin 2 mg PO/NG HS Start: in PM hold for SBP < 90 Estraderm NF (estradiol) 0.05 mg/24 hr Transdermal Q WED+SAT Fluoxetine 80 mg PO/NG DAILY FoLIC Acid 1 mg PO/NG DAILY Gabapentin 300 mg PO/NG Q24H Start: In am Torsemide 60mg once daily Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Lactulose 30 mL PO/NG DAILY Start: In am Labetalol 300 mg PO/NG [Hospital1 ] Metolazone 5 mg PO DAILY NIFEdipine CR 60 mg PO DAILY hold for SBP < 100 Sodium Polystyrene Sulfonate 30 gm PO/NG ONCE Tamsulosin 0.4 mg PO HS Valproic Acid 750 mg PO Q12H Vitamin D 400 UNIT PO/NG DAILY ISS Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): hold for SBP < 90. 6. Estraderm 0.05 mg/24 hr Patch Semiweekly Sig: One (1) Transdermal Q WED+SAT (). 7. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day: please start on [2143-1-19]. 11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. valproic acid 250 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 15. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days. 17. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 19. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 20. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 21. Outpatient Lab Work Please check chem 10 and fax results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 23926] 22. Outpatient Lab Work Please check INR on [2143-1-18] and fax results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 23926] 23. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime: and please see attached humalog sliding scale. Discharge Disposition: Extended Care Facility: [Hospital ] Rehabilitation & [Hospital ] Care Center - [Location 1268] Discharge Diagnosis: Primary Diagnosis: hypoglycemia Acute on Chronic Renal Failure Type II DM, uncontrolled with complications health care- associated pneumonia Secondary Diagnosis: chronic diastolic Congestive Heart Failure hypertension Discharge Condition: ambulatory with assistance and device oriented to person, place, time clear and coherent, alert and interactive Discharge Instructions: Mr. [Known lastname ], It was a pleasure taking care of you in the hospital. You were admitted with a low blood sugar and pneumonia. Your kidney tests were also a bit elevated. Your insulin was adjusted to help prevent more episodes of low blood sugar in the future. You will need one more day of antibiotics to finish treating the pneumonia. Your kidney tests improved over the past few days, and you will need to follow up with Dr. [Last Name (STitle) 4090], your kidney doctor, next week. The following changes were made to your medications: stop labetalol start hydralazine 75 mg three times a day changed your insulin regimen please do not take torsemide or metolazone until you see Dr. [Last Name (STitle) 4090] next week No other changes were made to your medications Followup Instructions: Name: [Last Name (LF) 4090], [Name8 (MD) 4102] MD Location: [Last Name (un) ] DIABETES CENTER/NEPHROLOGY Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3637] When: [Last Name (LF) 2974], [1-25], 8:30 AM [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "V58.61", "V10.46", "437.0", "428.0", "290.41", "507.0", "V12.51", "403.90", "272.4", "428.33", "585.4", "250.80", "V58.67", "584.9", "356.9", "276.2", "V49.86", "276.7", "311" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12982, 13091	7195, 9722	311, 317	13353, 13467	4090, 6819	14309, 14731	2202, 2234		10757, 12959		13112, 13112		9953, 10734			13491, 14286			6836, 7172							2249, 3238							3254, 4071											9743, 9927						248, 273											345, 1624			13275, 13332				13131, 13254									1646, 1981	1997, 2186
46,538	125,325	36483	Discharge summary	report	Admission Date: [2133-1-7] Discharge Date: [2133-1-18] Date of Birth: [2081-11-11] Sex: F Service: SURGERY Allergies: Morphine / adhesive tape / Protonix Attending:[First Name3 (LF) 1384] Chief Complaint: perforated bowel Major Surgical or Invasive Procedure: - [1-7]: Ex-lap, Right colectomy and ileostomy - [1-11]: Abdominal washout, placement of [Doctor Last Name ] drain, abdominal closure History of Present Illness: Patient is a 51 year old female with history of etoh/HCV cirrhosis who was transfer to BIMDC ED from [Hospital 1474] Hospital with free air on the CT scan, hemodynamically unstable on pressors. Patient was admitted to [Hospital 1474] Hospital on [2133-1-3] w/acute abdominal pain, dry heaves and on a CT scan findings of transmural thickening of the right sided colon consistent with colitis and a finding of constipation. Of note at the time of the presentation to the ED at [Hospital 1474] Hospital her bp was 72/44. [Name8 (MD) ] CRT was 1.7 from baseline of 0.9; she presented in acute renal failure. (She is diuretic dependent at baseline.) After she was admitted, she was treated w/IV cipro, colace, senna and lactulose 30 [Hospital1 ]. Patient developed upper GI bleed on HD 3 ([1-5] in the morning). She has EGD which showed bleeding from the duodenal ulcer at the bulb. The endoclip was placed. The biopsy was taken from the stomach mucosa. Patient seemed to be stable for approximately 24 hours post-EGD. On HD 4 ([1-6] in the evening), she was found to be obtunded, was intubated, started on propofol and later versed. After the propofol strated the patient became hypotensive and was resuscitated with fluids. She had a CT scan of the abdomen which showed layering of free air within the abdomen. Patient recieved unasyn 3 gm and flagyl as a response. She was subsequently transferred to [Hospital1 18] ED, as ED accepted the transfer. Upon arrival patient was levophed and has recieved a total of 6 liters of fluid since the time she was intubated. She is currently on cpap. Past Medical History: - HCV - cirrhosis - etoh abuse - esophageal varicies - ascities - COPD - HTN - s/p TIPS - cholithiasis - umbilical hernia Social History: smoke, no etoh Family History: non-contributory Physical Exam: T: 101.7F, Tm: 102.2F BP: 110/54 HR: 113 RR: 39 SaO2: 95% AC 340x30/8/60%. Intraperitoneal drain output 2L [1-14]. General: Intubated and sedated HEENT: ETT and OGT in place, sclerae icteric, no cervical LAD Neck: supple, no LAD, no thyromegaly. LIJ without erythema or fluctuance Cardiovascular: RRR, 2/6 SEM RUSB Respiratory: Coarse breath sounds anteriorly Gastrointestinal: Two intraperitoneal drains with yellow, slightly cloudy fluid. Ostomy with dark liquid stool, +bs, soft, slightly distended Genitourinary: Foley draining yellow urine Musculoskeletal: R>L pedal edema. R a-line without erythema Skin: Skin breakdown left wrist Pertinent Results: [Hospital1 18] on admission: [2133-1-7] pH 7.24 pCO2 46 pO2 136 HCO3 21 BaseXS -7 Type:Art; Intubated; Vent:Controlled; Rate:20/; TV:450; Mode:Assist/Control [2133-1-7] 02:56a Lactate:4.3 Trop-T: <0.01 Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi 154 121 60 83 AGap=18 3.5 19 1.6 Comments: Na: Notified [Last Name (NamePattern4) ] @ 0359 [2133-1-7] Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes estGFR: 34/41 (click for details) CK: 55 MB: 6 Ca: 7.6 Mg: 2.2 P: 4.8 ALT: 21 AP: 107 Tbili: 2.9 Alb: Pnd AST: 56 LDH: Dbili: TProt: Lip: 9 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative Ammonia: 121 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative 30.2 > 33.3 < 67 N:81 Band:7 L:1 M:8 E:0 Bas:0 Metas: 2 Myelos: 1 Nrbc: 2 Hypochr: OCCASIONAL Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Target: 1+ PT: 21.0 PTT: 40.6 INR: 2.0 pathology: stomach biopsy [2133-1-5] [Hospital 1474] Hospital - mild chronic inactive gastritis no h. pylori Brief Hospital Course: MICRO: [1-5] Stomach Bx (OSH): H. pylori neg; mild chronic inactive gastritis [1-7] Peritoneal Swab: 1+ GNRs, mixed bacterial types [1-9] Sputum Cx: ESCHERICHIA COLI [1-10] Sputum Cx: ESCHERICHIA COLI [1-12] Peritoneal fluid: VRE 2/23 L BAL: 1+ PMNs, neg (<1000 org) resp flora [1-16] Cdiff: negative IMAGING: - [1-6] CT A/P (OSH)CT: free air, ascities, free fluid in the pelvis simple, no free air in RP, b/l multifocal pna, LLL consolidtion - [1-5] EGD [Hospital 1474] Hospital - gastritis, portal HTN, gastropathy grade V, [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] esophagitis - [1-7] CXR: b/ilateral interstitial edema/LLL atelectasis - [1-7] CXR: LLL atelectasis - [1-8] CXR: L hilar mass and patchy b/l pulm opacities - [1-8] Hepatic Duplex: Patent TIPS shunt. Small L pleural effusion. No ascites. Splenomegaly. Sludge in GB. Mild dilatation of extrahepatic CBD. - [1-8] TTE: EF 70%, Mild functional MS due to MAC. trivial TR. - [1-9] CXR: ETT ~3.3 cm above carina; pulm edema ?slightly improved; retrocardiac opacification likely atelectasis & effusion v pulmonary consolidation - [1-10] CXR: Mod-->severe pulm edema & mod L pleural effusion incr; cardiomegaly stable. - [1-11] CXR: Predominantly bibasilar consolidation improved. The upper lungs grossly clear. - [1-12] CXR: Improved aeration in retrocardiac region @L base. - [1-13] CXR: continued diffuse opacification of b/l lungs, slightly improved at bases - [1-13] GB/liver US: Patent TIPS w/stable velocities; gallbladder is less distended and smaller than on prior u/s indicating patency of cystic duct; small amount of sludge is seen, but no gallstones are identified. No specific signs of cholecystitis. - [1-13] CTH: no acute abnormalities. - [1-14] CXR: interstitial markings may be slightly less pronounced - [1-16] LENIs: negative for DVT - [1-16] CT CAP: ?R PNA. colonic thickening. no abscess. stable appearance of liver. - [1-16] ECHO: normal EF. Preserved ventricular function. Dilated RV. Normal EF. - [1-16] CXR: engorged pulmonary vasculature. lungs otherwise clear EVENTS: [1-7]: Admit to SICU [1-7]: Ex-lap and R hemicolectomy/ileostomy for necrotic perforated colon; 2u FFP and 2u pRBCs in OR. Lactate incr:6.2 -->9.7 (on arrival to SICU), was given 1L NS bolus. Hct dropped from 33 (prior to OR) to 23.7 (in SICU). Additional 2U pRBCs. ABG 7.12/50/250/17; incr minute ventilation and given 1 amp of bicarbonate. Fent gtt to wean levophed, propofol. Vanc/zosyn/flagyl (from unasyn/flagyl). Boluses with 1/2 NS, albumin. Vigileo started. bedside echo shows no wall motion abnormality, EF>50%. Continued on bicarb gtt overnight with bolus prn pH<7.3, 1U PRBCs given, MIVF stopped when SVV / CVP showed adequate volume resuscitation. Run of AFib o/n and K/Mg gently repleted [1-8]: Duplex: patent TIPS. Formal Echo hyperdynamic 70%EF. mild MS [First Name (Titles) ] [Last Name (Titles) 82642]. transfused 2uffp for placement of L IJ. tx 1u prbc and 2u plts. sent HITT panel and stopped HSQ w/thrombocytopenia. weaning pressors AT. Renally dosing meds. [1-9]: Peripheral smear normal. Albumin 25% x 2 given. Episode of tachy and PVC: CM negative. Increasingly alkalotic: switched IVF to NS. Thrombocytopenia persists and given 1u platelets. [1-10]: TPN started; albumin x3doses given for total 37.5g; febrile to 101F and UCx/BCx sent; bronch revealed clear secretions on the R and thicker clear secretions on the L, L-side friable, traumatic ulcer (likely from suction tip) just distal to ETT at anterior trachea; difficulty weaning FiO2. [1-11]: To OR for washout and placement of additional [Doctor Last Name ] drain for management of ascites leak. albumin 25% 12.5g x 4. increased minute vent reduced FiO2, started trophic TF. TPN. [1-12]: given 2u plts->ongoing thrombocytopenia. Fever to 102: pancx, tylenol x 1. TPN. Vent settings to ARDSnet. SS insulin added. Zosyn ([12-24] thrombocytopenia) and vanco d/ced...started on ceftaz. [1-13]: Hepatic Duplex & GB US to assess patency of TIPS & ? cholecystitis; CT Head for etiology of unresponsiveness off sedation; continued albumin 25% Q6h; Dobhoff post-pyloric TFs advanced w/FWB for hypernatermia; TPN discontinued; Vancomycin restarted for enterococcus in peritoneal cx [1-14]: txfused 2u prbcs and given vit k. levophed off. Albumin prn. Continuing to wean vent support. TF restarted with MVI added. Rifamin for encephalopathy. Bronch w/thicker secretions on L, thin on R, friable tissue. Hypotension in 70s-albumin 25%, levophed restarted. [1-15]: Cont fluid repletions. TPN ordered w/trophic TFs. Pan cx for fever. +VRE in peritoneal fluid ([1-12]): tigecycline started and vanco/ceftaz stopped. ID following: B/L LE LENIs, Cdif from ostomy sent. Agitated overnight and breathing to rates in 40's -> started on prop gtt. [1-16]: B LENIS negative. lactulose PR per hepatology can't give to small bowel, mechanism of action is in colon. CT CAP no evidence of abscess ?PNA on R. TFs d/c'd. 2u FFP to change IJ. paralysis to control ventilation. Cdiff from ostomy negative. Cont TPN. [1-17]: continued TPN. Renal consult diagnosed kidney failure ATN. Family meeting held to discuss plan of care and it was decided to make CMO after arrival of daughter from out of town. [1-18]: made CMO at 0030. passed away at 0218. Chief cause of death cardiac arrest following multisystem organ failure from sepsis. Medications on Admission: advair 500/50, one puff [Hospital1 ] ventoin PRN singular 10mg qd fluconazole 100 mg qd thiamine 100 qd MV folic acid 1mg qd aldactone 300 qd lasix 140 qd neurontin 100 qd lactulose 30 [Hospital1 ] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Multi-system organ failure secondary to sepsis from perforated R colon Discharge Condition: expired Discharge Instructions: none Followup Instructions: n/a	[ "427.5", "569.83", "532.90", "572.3", "276.3", "427.31", "038.9", "286.9", "287.5", "570", "780.60", "599.0", "070.44", "557.0", "276.2", "584.5", "785.52", "401.9", "041.04", "456.21", "518.81", "424.0", "288.60", "568.89", "V09.80", "535.40", "276.1", "496", "789.59", "571.2", "482.82", "305.1", "V11.3", "567.29", "995.92" ]	icd9cm	[ [ [] ] ]	[ "54.12", "45.73", "96.6", "38.93", "96.72", "99.15", "33.24", "46.21" ]	icd9pcs	[ [ [] ] ]	9874, 9883	4060, 9590	312, 460	9998, 10008	3005, 3024	10061, 10068	2307, 2325		9846, 9851		9904, 9977		9616, 9823			10032, 10038										2340, 2986																								256, 274											488, 2113								3038, 4037								2135, 2258	2274, 2291
40,200	108,146	40263	Discharge summary	report	Admission Date: [2165-1-10] Discharge Date: [2165-1-13] Date of Birth: [2115-10-11] Sex: M Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2090] Chief Complaint: transferred to the [Hospital1 18] when discovered to have a pituitary hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: The patient recalls the onset of head discomfort three months ago. At that time he noticed a "fullness" located on the medial frontal region above the bridge of the nose. The discomfort was non-radiating. There was no clear trigger. Bending over exacerbated the discomfort, while standing upright alleviated the discomfort to some degree. The headache would last for "hours." . In the one to two months prior to presentation, the head pain increased in intensity and duration. For the syndrome, he presented to the CVS minute clinic. At first alleve was recommended. He returned to the clinic when alleve provided no relief. On the second visit he was given antibiotics for a presumed sinus infection. He had an allergic reaction to the antibiotics. He presented to his PCP who prescribed [Name Initial (PRE) ] different antibiotic. When the antibiotics failed to provide relief, he was given abortic migraine therapy (he thinks imitrex) and firoricet about 1.5 weeks prior to admission. . In about the two weeks prior to presentation, the headache again intensified and became constant. He describes the current syndrome as a "pulsing" that involves the bifrontal (L>R) region. At its worst, the pain rates [10-12]. There was no clear trigger. Lights, noise, and head movement exacerbate the discomfort, as does exertion (eg coughing and sneezing). Although the headache is not positional, it has awakened him from sleep. Alleve, excedrin, antibiotics, imitrex, and fioricet have failed to provide relief. Associated symptoms include nausea, lightheadedness, and seconds of vertigo with quick head movements. He denies similar episodes in the past. Prior to the onset of the headache months ago, he experienced occasional headaches completely responsive to tylenol. . Concerned by the intensity and persistence of symptoms, the patient presented to the [Location (un) 47] [Hospital1 1281] ED. There, an MRI of the brain revealed a pituitary hemorrhage. He was transferred to the [Hospital1 18] for further evaluation and care. Past Medical History: right knee injury (patellar fracture?) in setting of MVC, s/p surgical repair Social History: - lives with wife and two children - works as a programmer Family History: - positive for migraine - negative for stroke, seizure Physical Exam: NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Alert. Able to relate history without difficulty. * Orientation: Oriented to person, place, day, month, year, situation * Attention: Attentive. Able to name [Doctor Last Name 1841] backwards without difficulty. * Memory: Pt able to repeat 3 words immediately and recall [4-4] unassisted at 30-seconds and 5-minutes. * Language: Language is fluent without evidence of paraphasic errors. Repetition is intact. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. Prosody is normal. Pt able to name high (pen) and low frequency objects (knuckles) without difficulty. * Calculation: Pt able to calculate number of quarters in $1.50 * Neglect: No evidence of neglect. * Praxis: No evidence of apraxia. Cranial Nerves: * I: Olfaction not evaluated. * II: PERRL 3 to 2mm and brisk. Bitemporal (L>R, superior quadrant>inferior quadrant) when eyes tested individually with red pin. Fundi not well-visualized. * III, IV, VI: EOMI without nystagmus. * V: Facial sensation intact to light touch in the V1, V2, V3 distributions. * VII: No facial droop, facial musculature symmetric. * VIII: Hearing intact to finger-rub bilaterally. * IX, X: Palate elevates symmetrically. * [Doctor First Name 81]: 5/5 strength in trapezii bilaterally. * XII: Tongue protrudes in midline. Motor: * Bulk: No evidence of atrophy. * Tone: increased in the bilateral lower extremities. * Drift: No pronator drift bilaterally. * Adventitious Movements: No tremor or asterixis noted. Strength: * Left Upper Extremity: 5 throughout Delt, Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex * Right Upper Extremity: 5 throughout Delt, Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex * Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis * Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis Reflexes: * Left: brisk (3) throughout Biceps, Triceps, Bracheoradialis, 3+ to 4 Patellar, difficult to elicit Achilles * Right: brisk (3) thoughout Biceps, Triceps, Bracheoradialis, 3+ to four Patellar, difficult to elicit Achilles * Babinski: extensor bilaterally Sensation: * Light Touch: intact bilaterally in lower extremities, upper extremities, trunk, face * Pinprick: intact bilaterally in lower extremities, upper extremities, trunk, face * Temperature: intact to cold sensation throughout * Vibration: intact bilaterally at level of great toe * Proprioception: intact bilaterally at level of great toe * Extinction: No extinction to double simultaneous stimulation Coordination * Finger-to-nose: intact bilaterally * Rapid Alternating Movements: No evidence of dysdiadochokinesia Gait: * Description: Good initiation. Narrow-based with normal-length stride and symmetric arm-swing * Tandem: unable to tandem walk without difficulty * Romberg: negative Pertinent Results: [2165-1-10] 04:47PM GLUCOSE-109* UREA N-17 CREAT-1.0 SODIUM-138 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12 [2165-1-10] 04:47PM CK-MB-2 cTropnT-<0.01 [2165-1-10] 04:47PM WBC-8.5 RBC-4.30* HGB-12.6* HCT-36.5* MCV-85 MCH-29.3 MCHC-34.5 RDW-12.9 [2165-1-10] 04:00PM ALBUMIN-4.2 [2165-1-10] 04:00PM TESTOSTER-87* SHBG-12* calcFT-26* [2165-1-10] 06:55AM CORTISOL-17.5 [2165-1-9] 07:20PM PT-13.0 PTT-26.5 INR(PT)-1.1 [2165-1-9] 07:20PM WBC-11.2* RBC-4.58* HGB-14.1 HCT-39.6* MCV-87 MCH-30.8 MCHC-35.6* RDW-12.8 [2165-1-9] 07:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2165-1-9] 07:20PM T4-8.2 [2165-1-9] 07:20PM FSH-3.4 LH-1.1* TSH-3.0 [2165-1-9] 07:20PM CALCIUM-10.0 PHOSPHATE-3.0 MAGNESIUM-2.1 Brief Hospital Course: In ED, he was given dilaudid for pain and was noted to have slight visual field defecits per ED note, but patient did not notice any vision problems himself. Neurology and neurosurgery were consulted. Per neuro note "Bitemporal (L>R, superior quadrant>inferior quadrant) when eyes tested individually with red pin" on exam, but neurosurgery felt "Visual fields are full to confrontation". The recommendation was to observe him until the blood resolves in ~2 weeks prior to any surgery for possible adenoma. . He was admitted to the neurology service and while on the floor he had an event in which he became bradycardic to 38s, BP dropped to 88/66 and very symptomatic with dizzyness and diaphoresis. This was thought to be due to adrenal crisis and he was given 100 mg hydrocortisone. However, prior to giving this, his BP resolved with IV fluids. When reviewing the telemetry, he had bradycardia with 5s pause, 2 beats of a junctional escape, then return to sinus rhythm. He had no further episodes of bradycardia or hypotension. He was transferred to the floor and then discharged on [2165-1-13] with follow up scheduled for neurosurgery. Endocrinology was able to see the patient and felt that his adrenal were working correctly. Follow-up appointments were made in neurology and in endocrinology. Medications on Admission: none Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO daily. Disp:30 Tablet(s) Refills:2 2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 1 weeks. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Pituitary Hemorrhage Discharge Condition: Improved; he has normal mental status, cranial nerves, normal strengh and sensory exam Discharge Instructions: You were admitted with headaches and your brain imaging showed a pituitary hemorrhage. You should take prednisone 5mg per day and follow-up your consults. If you develop worsening headches, confusion, dizziness you should call the neurology resident on call or come to ER. You should have a repeat brain MRI in [5-8] weeks. Followup Instructions: Endocrinology: please, schedule an appoitment with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 88376] Neurology: please, schedule an appoitment along with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 19825] and Dr. [First Name (STitle) 1726]: [Telephone/Fax (1) 31415] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43] MD [MD Number(1) 2107] Completed by:[2165-1-15]	[ "252.00", "253.8", "285.9", "585.9", "296.80", "584.9", "403.90", "244.9", "250.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8346, 8352	6584, 7899	393, 400	8417, 8506	5752, 6561	8882, 9346	2693, 2750		7954, 8323		8373, 8396		7925, 7931			8530, 8859										2765, 2765																								269, 355											428, 2498	3596, 5733								2805, 3580					2790, 2790		2520, 2600	2616, 2677
18,529	189,545	51156	Discharge summary	report	Admission Date: [2145-12-29] Discharge Date: [2146-1-18] Date of Birth: [2099-12-22] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 3266] Chief Complaint: bleeding from right tonsil Major Surgical or Invasive Procedure: CVVH, placement of central lines History of Present Illness: 45yo man with h/o ESLD, cirrhosis, portal HTN [2-22] HBV, former etoh abuse awaiting OLT, recent EGD showing non-bleeding esophageal varices, who presents with bleeding from his right tonsil. The patient awoke this AM to go to the bathroom, and while going to the bathroom coughed and tasted blood in his mouth. He then coughed up about a quarter cup of blood per his estimation, and subsequently felt relief as if his "throat were opening up." According to the patient, this is the first time that he has coughed up blood although he does report a 10y h/o R tonsilar problems. These problems are characterized by soreness and swelling of his right tonsil about once per year, usually in the winter, that is relieved by him "sucking" on the tonsil until "pus" comes out. He says that he sought advice on this problem once, was told that "no one takes tonsils out anymore," and has since dealt with it himself as described. He feels that this current bleeding episode is identical to his prior episodes with the exception that the "pus" is now blood. The patient reports that he has had a sore throat and swollen right tonsil since his EGD a few days ago. He denies BRBPR, melena, fever, chills, SOB, chest pain, LH, dizziness, phlegm, cough, sinus congestion. His sore throat was accompanied by a change in pitch in his voice, described by his GF as if he "sounded like a girl," possibly higher pitched. This has resolved by the presentation today. ROS: positive for cold intolerance; DOE, "worse since EGD" Past Medical History: Cirrhosis, from HBV and etoh Hepatitis B, presumably contracted via IVDA Asthma, several hospitalizations in distant past, no intubations Social History: Single, but lives with girlfriend. [Name (NI) ] one daughter. Unemployed. Pt has a h/o of using heroin (IV and snorting), and former ETOH abuse (drank a case of beer per day). He has been abstinent for 10 years from both alcohol/heroin. He smokes [2-24] cigarettes per day. Family History: Mother with DM Physical Exam: Vitals - Gen - cachectic caucasian middle-aged man looking older than age with sunken eyes, prominent clavicles and shoulder blades HEENT - No conjunctival, sublingual or epidermal jaundice; able to express serosang fluid from R tonsil Skin - spider angiomata Neck - +cervical LAD, small rubbery nodes on L>R CV - RRR, nl S1, split S2 Lungs - decreased BS and fremitus at right base (c/w site of recurrent pleural effusions) Abd - well healed scar above pubic symphasis c/w prior appendectomy, positive rectus abdominus diasthesis, + prominent superficial abdominal veins; distended, not tense; liver edge palp 4cm below CM at midclavicular line; no splenomeg; +shifting dullness Extremities - 4+ pitting edema to groin; 1+ DP pulses Neuro - no asterixis; A+Ox3 Pertinent Results: [2145-12-29] 04:35PM HCT-26.8* [2145-12-29] 11:30AM GLUCOSE-90 [2145-12-29] 11:30AM UREA N-49* CREAT-1.5* SODIUM-134 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-30* ANION GAP-11 [2145-12-29] 11:30AM ALT(SGPT)-65* AST(SGOT)-68* ALK PHOS-107 TOT BILI-1.3 [2145-12-29] 11:30AM ALBUMIN-2.2* [2145-12-29] 11:30AM WBC-9.4 RBC-2.72* HGB-9.4* HCT-27.9* MCV-103* MCH-34.7* MCHC-33.8 RDW-15.0 [2145-12-29] 11:30AM NEUTS-70 BANDS-4 LYMPHS-9* MONOS-13* EOS-3 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2145-12-29] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2145-12-29] 11:30AM PLT SMR-VERY LOW PLT COUNT-78* [2145-12-29] 11:30AM PT-17.0* INR(PT)-1.8 Brief Hospital Course: Mr. [Known lastname 1356] is a 45 yo man with h/o ESLD, cirrhosis, portal HTN [2-22] HBV, former etoh abuse awaiting OLT, recent EGD showing non-bleeding esophageal varices, who presents after coughing up blood, possibly from his right tonsil. He was thought to have coughed blood likely [2-22] tonsil with expressible blood, though possibly [2-22] esoph varices. An ENT eval did not appreciate any abnormalities in OP; will d/w them the findings of expressible R tonsil. Esophageal varices banding and TIPS was planned. The patient became hemodynamically unstable and was intubated. CVVH was initiated for inability to remove excess fluid. THe patient was made CMO after a series of family meetings with his girlfriend and mother. [Name (NI) ] expired after being extubated on [2146-1-18]. Medications on Admission: see previous notes Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: multiorgan failure sepsis Discharge Condition: expired Discharge Instructions: expired	[ "511.9", "286.9", "572.2", "584.9", "571.2", "070.32", "276.0", "276.1", "456.0", "995.92", "518.81", "456.8", "799.4", "578.0", "038.9", "785.52", "572.3" ]	icd9cm	[ [ [] ] ]	[ "54.91", "96.6", "42.33", "39.1", "96.04", "99.04", "99.15", "00.14", "34.91", "96.72" ]	icd9pcs	[ [ [] ] ]	4859, 4868	3943, 4761	301, 335	4937, 4946	3176, 3920		2362, 2378		4830, 4836		4889, 4916		4787, 4807			4970, 4980										2393, 3157																								235, 263											363, 1885																1907, 2047	2063, 2346
4,669	155,461	21307	Discharge summary	report	Admission Date: [2129-5-7] Discharge Date: [2129-5-28] Date of Birth: [2078-1-2] Sex: M Service: CARDIOTHORACIC Allergies: Interferon Alfacon-1 Attending:[First Name3 (LF) 5790] Chief Complaint: Post intubation tracheal stenosis, DOE Major Surgical or Invasive Procedure: flexible bronchoscopy tracheal resection and reconstruction. History of Present Illness: Mr. [Known lastname 13216] is a 51-year-old gentleman, transferred from [Hospital3 ], who had been intubated following treatment of his hepatitis C with interferon. He has had progressive worsening of dyspnea on exertion and progressive hoarseness. Rigid bronchoscopy revealed a proximal tracheal stenosis in the A-frame shape suggestive of a stomal injury. Past Medical History: Hep C, interstitial pneumonitis/resp.failure from PEG-IFN, s/p trach/open J-tube placement, cirrhosis Social History: +TOB 38 yrs 1ppd Quit [2127] ETOH quit 20 yrs ago Hx of Cocaine use quit 5 yrs ago Lives alone Family History: non-contributory Physical Exam: Gen: NAD CV: RRR Chest: CTA bilaterally Abd: soft, NT, Obese Ext: + pulses Inc:CDI Pertinent Results: [2129-5-9] cardiac echo: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed with mild global hypokinesis more prominent in the mid to distal antero-lateral wall. There is no ventricular septal defect. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. CXR [2129-5-24]: IMPRESSION: Slowly improving bilateral interstitial opacities, which may be due to resolving pulmonary edema, infection or hemorrhage. Continued followup is recommended to exclude a more chronic interstitial abnormality. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2129-5-24] 06:40AM 8.9 3.84* 12.2* 34.6* 90 31.8 35.3* 15.6* 109 Brief Hospital Course: pt was admitted w/ tracheal stenosis and bronchoscopy to identify extent of lesion. The bronchoscopy was complicated by flash pul edema requiring intubation and SICU admission. Pt was diuresed and extubated to BIPAP on PPD#1/HD# 3. ON HD# 5 pt was started on vanco/levo for persistant leukocytosis and sputum w/ GM+ cocci. Transferred from ICU to floor to await tracheal surgery. On HD#7 pt had bronchoscopy which showed stable stenosis. On HD# 13 pt was taken to the OR for tracheal resection and reconstruction. guardian stitch placed in OR to amintain neck flexion and to decrease tension on anastomosis. Post operatively pt was admitted to the SICU for airway management. APS was following for pain management. Extubated on POD#1. POD#3 pt transferred from ICU to floor for ongoing post op management. POD#[5-13] [Last Name (un) ] reg diet and ambulating. Epidural d/c'd and mainatined on PCA. Bronch on POD#7-----------guardian stitch cut. Patient d/c'd home with f/u appintment. Medications on Admission: methadone 95', metoprolol 12.5', clonazepam 0.5", citalopram 20', spironolactone 100", spiriva Discharge Medications: 1. Methadone 10 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). Disp:140 Tablet(s) Refills:0 2. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for pain. Disp:1 1 Refills:1 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 4. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:70 Tablet(s) Refills:0 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Disp:30 Refills:2 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: tracheal resection and reconstruction. Discharge Condition: good Discharge Instructions: call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 170] if you develop chest pain, neck swelling, shortness of breath, fever, chills. Followup Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 170] for a follow up appointment Completed by:[2129-5-27]	[ "518.81", "041.4", "041.11", "519.19", "070.70", "786.3", "577.1", "600.00", "414.01", "466.0", "599.0", "571.2", "428.0", "278.00", "585.9" ]	icd9cm	[ [ [] ] ]	[ "33.23", "31.79", "96.04", "99.04", "96.72", "33.22" ]	icd9pcs	[ [ [] ] ]	4314, 4320	2285, 3281	325, 388	4403, 4410	1179, 2262	4600, 4723	1043, 1061		3428, 4291		4341, 4382		3308, 3405			4434, 4577										1076, 1160																								246, 287											416, 785																807, 910	926, 1027
21,784	133,182	46799	Discharge summary	report	Admission Date: [2118-8-21] Discharge Date: [2118-9-5] Service: HISTORY OF THE PRESENT ILLNESS: This 82-year-old male has a history of coronary artery disease, atrial fibrillation, type 2 diabetes, and CHF. He had the sudden onset of substernal chest pain which lasted 30 minutes and resolved spontaneously. It was similar to his usual anginal pain and he presented to the Emergency Room. His EKG in the Emergency Room revealed new ST depressions in V4-6 but his first set of enzymes were negative. He was admitted for rule out MI. PAST MEDICAL HISTORY: 1. Colon cancer, status post right hemicolectomy five years prior to admission. 2. History of noninsulin-dependent diabetes times 13 years. 3. History of atrial fibrillation. 4. History of hypertension. 5. History of CAD, status post cardiac arrest in [2108] with a positive exercise tolerance test. 6. History of CHF. 7. BPH, status post TURP times two. 8. Status post appendectomy. 9. AAA 3 cm. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Glucovance 500 mg p.o. b.i.d. 2. Toprol XL 50 mg p.o. q.d. 3. Mavik two p.o. q.d. 4. Lasix 20 mg alternating with 40 mg p.o. q.o.d. 5. Imdur 30 mg p.o. q.d. 6. K-Dur 20 mEq alternating with 40 mEq p.o. q.o.d. 7. Nitroglycerin patch 0.2. 8. Coumadin 2.5 alternating with 5 mg p.o. q.d. 9. Zocor 20 mg p.o. q.d. 10. Calcium. 11. Vitamin E. 12. Fish oil. SOCIAL HISTORY: He does not drink alcohol. He does not smoke cigarettes. FAMILY HISTORY: Unremarkable. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was an elderly white male in no apparent distress. Vital signs: Stable, afebrile. HEENT: Normocephalic, atraumatic. The extraocular movements were intact. The oropharynx was benign. The neck was supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs: Coarse breath sounds bilaterally, no wheezing. Cardiovascular: Irregular rate and rhythm with a III/VI murmur heard best at the lower sternal border radiating to the left axilla. Abdomen: Soft, nontender, positive bowel sounds. No masses or hepatosplenomegaly. Extremities: Without clubbing, cyanosis or edema. Pulses were 2+ and equal bilaterally throughout. Neurologic: Nonfocal. HOSPITAL COURSE: The patient was admitted to rule out MI and he did rule out but he continued to have resting chest pain. A stress MIBI revealed moderate lateral and inferior wall deficits which were reversible. Cardiac catheterization was performed on [2118-8-24] and revealed the left ventricle had 4+ severe mitral regurgitation with an LVEF of 35%, severe inferior hypokinesis, and moderate anterior hypokinesis. He had a 50% ulcerated left main coronary artery lesion. The LAD had a 50% proximal lesion. The left circumflex had a 40% midlesion. The RCA had a 95% ulcerated proximal lesion and he had an intra-aortic balloon placed at the time. Dr. [Last Name (STitle) 70] from Cardiac Surgery was consulted. The patient had a Dental consult which cleared him for surgery. On [2118-8-26], he underwent a CABG times three with LIMA to the LAD, reverse saphenous vein graft to the PDA and OM, mitral valve repair with a #28 band and AVR with a 23 [Last Name (un) 3843]-[Doctor Last Name ] valve. The patient was transferred to the CSRU on milrinone, Neo, and propofol. He had a large amount of chest tube drainage the night of surgery and received Protamine and FFP and platelets. The PEEP was increased. His drainage slowly decreased. He was extubated that night and was slowly weaned off his milrinone. On postoperative day number two, he was started on epi for low cardiac index. His balloon pump was discontinued on postoperative day number one. He continued to have a slow milrinone wean. On postoperative day number three, he was started on Captopril. He remained on the milrinone for several days and had intermittent confusion while in the Intensive Care Unit. The milrinone was discontinued on postoperative day number five. He continued to slowly improve. He was anticoagulated. On postoperative day number six, he was transferred to the floor in stable condition. He continued to have a stable postoperative course except his creatinine had a slight bump to 1.5. The Lasix was decreased. This will be followed closely at rehabilitation. On postoperative day number ten, he was discharged to rehabilitation in stable condition. LABORATORY DATA ON DISCHARGE: Hematocrit 33.4, white count 12,700, platelets 279,000. Sodium 136, potassium 4.4, chloride 100, C02 27, BUN 33, creatinine 1.5, blood sugar 99. PT 20.7, PTT 36, INR 2.8. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Percocet one to two p.o. q. four to six hours p.r.n. pain. 3. Glucovance 5/500 mg p.o. b.i.d. 4. Amiodarone 200 mg p.o. b.i.d. times seven days and then decrease to 200 mg p.o. q.d. 5. Captopril 12.5 mg p.o. t.i.d. 6. Aspirin 81 mg p.o. q.d. 7. Coumadin 1 mg p.o. q.d. for an INR goal of [1-16].5. He needs his INR monitored at rehabilitation as well as his creatinine. FOLLOW-UP: He will have a follow-up appointment with Dr. [Last Name (STitle) 141] in one to two weeks, an appointment with Dr. [Last Name (STitle) ] in two to three weeks, and an appointment with Dr. [Last Name (STitle) ] in four to six weeks, an appointment with Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Dictator Info ] MEDQUIST36 D: [2118-9-5] 10:42 T: [2118-9-5] 10:43 JOB#: [Job Number 99324]	[ "411.1", "401.9", "593.9", "396.3", "427.31", "250.00", "398.91", "414.01" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.12", "37.61", "88.72", "88.56", "37.23", "35.12", "88.53", "35.21", "36.15" ]	icd9pcs	[ [ [] ] ]							1525, 1561		4735, 5760					2339, 4524				1067, 1432																									4539, 4712																										1576, 2321								579, 1044	1449, 1508
29,331	109,745	34071	Discharge summary	report	Admission Date: [2134-6-3] Discharge Date: [2134-6-8] Date of Birth: [2052-1-24] Sex: M Service: NEUROSURGERY Allergies: Aspirin / Penicillins Attending:[First Name3 (LF) 78] Chief Complaint: Subdural Hematoma found on OSH head CT Major Surgical or Invasive Procedure: Left Burr hole evacuation Subdural Hematoma History of Present Illness: 82 year old male h/o HTN s/p fall 2.5 months ago with dizziness and slight gait difficulties intermittently. He had a head CT today and went to an OSH ER after it showed a large SDH. Then the patient was transferred to [Hospital1 18]. He had a repeat head CT here that was stable and was loaded with dilantin. He currently has no dizziness, headache, numbness, or tingling. The patient reports having some difficulty walking. He has no SOB or chest pain. The patient is allergic to aspirin and does not take any anticoagulation. Of note, he did have a GI bleed 3 years ago. Past Medical History: Hypertension Chronic Obstructive Pulmonary Disease Bilateral lower extremity neuropathy Upper GI bleed 3 years ago lung CA s/p R lung lobectomy Social History: lives at home with his wife has 90 pack year history of smoking but quit in [2118] Drinks one shot of EtOH per day No drug use Family History: Noncontributory Physical Exam: PHYSICAL EXAM: T:97.8 BP:128/59 HR:70 RR:17 O2Sats:95% Gen: WD/WN, comfortable, NAD. HEENT: Pupils:PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. 1+ edema bilaterally Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-10] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Pertinent Results: [2134-6-3] 05:15PM GLUCOSE-95 UREA N-15 CREAT-0.8 SODIUM-143 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13 [2134-6-3] 05:15PM estGFR-Using this [2134-6-3] 05:15PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.2 [2134-6-3] 04:24PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2134-6-3] 04:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2134-6-3] 04:10PM cTropnT-<0.01 [2134-6-3] 04:10PM WBC-8.0 RBC-4.97 HGB-14.8 HCT-44.4 MCV-89 MCH-29.8 MCHC-33.4 RDW-13.9 [2134-6-3] 04:10PM NEUTS-72* BANDS-2 LYMPHS-16* MONOS-8 EOS-1 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2134-6-3] 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2134-6-3] 04:10PM PLT COUNT-239 [2134-6-3] 04:10PM PT-11.8 PTT-28.6 INR(PT)-1.0 [2134-6-3] EKG:Sinus rhythm with ventricular premature beats. Left anterior fascicular block. Low QRS voltage in the precordial leads. No previous tracing available for comparison. Radiology [2134-6-3] Noncontrast Head CT:There is a large extra-axial collection overlying the left cerebral convexity. The collection crosses the left frontoparietal suture line, measures 2.5 cm in greatest axial dimension, and demonstrates low attenuation consistent most consistent with a subacute- to- chronic subdural hematoma. Note is made of increased attenuation of the compressed adjacent dura. There is associated 9- mm right midline shift as well as mass effect on the anterior [Doctor Last Name 534] of the left lateral ventricle. There is no evidence of acute hemorrhage. The ventricles and sulci are otherwise normal in size and configuration. The visualized paranasal sinuses are clear. No fracture is identified. IMPRESSION: Large left frontoparietal subdural hematoma of subacute-to- chronic time course with associated right lateral shift and mass effect on the left lateral ventricle. [2134-6-4] Noncontrast Head CT:The patient is status post evacuation of a large frontoparietal fluid collection, with a transfrontal catheter ending in the cavity. Small amount of fluid remains present, layering in the dependent portion of the cavity. Associated 9 mm right midline shift remains present. There is no evidence of acute hemorrhage. The ventricles and sulci are otherwise normal in size and configuration. Moderatel left maxillary mucosal thickening. IMPRESSION: 1. Status post evacuation of subacute to chronic subdural collection, with no evidence of new intracranial hemorrhage. 2. Persistent right lateral midline shift. [2134-6-5] Noncontrast Head CT:Decreased size of post-evacuation cavity over the left convexity; given attenuation differences in the fluid over the convexity raises the possibility of a new slow bleeding with layering - recommend follow up CT to assess. [2134-6-7] Noncontrast Head CT: tatus post interval removal of the left subdural drainage catheter. No gross interval change in size of the left convexity subdural hematoma with associated mass effect detailed above. Brief Hospital Course: Hospital Course [2134-6-3] large left Subdural Hematoma - Admit for q 4 hour neuro checks -Dilantin 1g loading dose,then 100mg TID - SBP < 140 - Pre-op for burr holes -Serial NC head CAT Scans -Physical Therapy Consult [2134-6-4] To Operating Room for Left frontal and parietal burr holes for evacuation of subdural hematoma. [2134-6-5] -Subdural drain for 48 hours -IV Ancef -advance diet as tolerated [2134-6-6] -Physical/Occupational Therapy Consult [2134-6-7] -D/C subdural drain today -D/C foley catheter today [2134-6-8] -Discharged home with Services for Home Physical Therapy) Medications on Admission: Lasix Lisinopril Lumigan Alphagan Klor-con Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) for 30 days. Disp:120 Capsule(s) Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:0 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: PLEASE DO NOT DRIVE WHILE ON THIS MEDICATION. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: Subdural hematoma Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: 1. Call Dr. [Last Name (STitle) ] office to set up a time to have your sutures removed in 1 week [Telephone/Fax (1) ] 2.You will need to be seen in our office in 2 weeks with a CT scan of the brain [Telephone/Fax (1) ] with Dr [First Name (STitle) ], please call for appt. 3.Follow-up with your Primary Care Physician [Last Name (NamePattern4) ] 1 week / your PCP will follow your dilantin levels. You will only need to be on this medication for seizure prevention for 30 days from a neurosurgical standpoint. Completed by:[2134-6-25]	[ "496", "782.3", "432.1", "365.9", "V10.11", "401.9" ]	icd9cm	[ [ [] ] ]	[ "01.31" ]	icd9pcs	[ [ [] ] ]	7102, 7154	5687, 6303	322, 367	7215, 7239	2531, 3659	8511, 9072	1308, 1325		6397, 7079		7175, 7194		6329, 6374			7263, 8488										1355, 1617																								243, 284											395, 975	1869, 2512			5476, 5664					1632, 1853							997, 1143	1159, 1292
11,404	119,701	25289	Discharge summary	report	Admission Date: [2103-9-19] Discharge Date: [2103-10-17] Date of Birth: [2059-3-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: Found Down Major Surgical or Invasive Procedure: Intubation for hypoxia and hypercarbia Tunneled catheter placement for HD Fasciotomy Washout of fasciotomy History of Present Illness: HPI: 44 y/o male who was found by maid at motel 6 slumped over table breathing at RR 4-5/min. He was brought to OSH given narcan and regained conciousness. He admitted to taking heroin and then methadone because he felt unwell. He also admitted to drinking vodka. Estimated time down is 2 days. At OSH there was also ? of anterior MI so patient was started on ASA, BBlocker, heparin. His Hct at the OSH was 51, WBC 29 N76 Bands 16 L 4, etoh level 2.3 and CPK [Numeric Identifier 46721]. Patient was transferred to [Hospital1 18] for more critical care managment. Patient was started on dopamine at OSH and kept on dopamine intitally in ED then weaned off. He had a lactate of 4.7 and was also hyperkalemic. He was given calcium gluconate 3g, 3 amps HCO3, 30g kayexalate, insulin with dextrose and empirically treated with vanc/levo/flagyl. His EKG on arrival showed ST elevation and peaked Ts in V2-V4 and TWI in V6 along with widened QRS. Cards saw EKG and felt that patient has LBBB and does not have MI, increased enzymes in setting of rhabdo and renal failure. Also at OSH patient was noted to have left LE pain. In the ED patient found to be waxing and [Doctor Last Name 688] mental status ABG sent which came back 7.17/74/85, decision made to intubate patient and pt went to MICU. . MICU Course: When patient admitted to MICU his respiratory acidosis was quickly corrected by increasing MV on ventilator. Patient however still hypoxic and hyperkalemic. Hypoxia was felt to be due to pulmonary congestion and hyperkalemia due to renal failure. Patient K+ did not improve once acidosis corrected so patient was started on hemodialysis. After HD patient hypoxia improved and he was quickly weaned from the ventilator. On day#4 patient was extubated and continued to do well off the ventilator. Patient had an echo which showed severe global hypokinesis with an LVEF 20-25%. Patient CK continued to trend down slowly while in the ICU and peaked at 100,000. While in the ICU patient noted to have LLE swelling. He had LENI done which was negative but his LLE continued to swell and became tense and painful. A repeat LENI was done and ortho was consulted to rule out compartment syndrome. While patient was intubated he spiked temps and was started on levo/flagyl/vanco. His urine and blood culture data was negative, but his sputum gram stain grew back gram positive cocci and rods. Patient had CT scan chest/abd which was negative for source of infection. After extubation and off propofol patient became very agitated and seemed to have alcohol withdrawal or DT. He was put on CIWA scale and initially required high doses of valium. He was started on standing Valium in addition to CIWA. His BUN/Cre did not improve even with dialysis and patient remains anuric. Past Medical History: Asthma/COPD H/O of withdrawal seizures Social History: + etoh drinks everyday + heroin + methadone Homeless. Has children. Mother lives nearby. Family History: NC Physical Exam: PE: Gen: appears well. Heent: PERRL, EOMI, sclera anicteric, OP clear, MMM Neck: No LAD Lungs: Diffuse crackles throughout Cardiac: RRR S1/S2 no murmurs Abd: Distended, soft, slight tenderness diffuse Ext: No edema,, diffuse tenderness to palpation Skin: Erythematous non-indurated lesion in left axilla, left inner thigh and right inner thigh. Patient has abrasion on left upper extremity. Neuro: Grossly intact. Pertinent Results: Labs on Transfer: [2103-9-23] 04:20AM BLOOD WBC-15.0* RBC-3.48* Hgb-11.0* Hct-31.9* MCV-92 MCH-31.5 MCHC-34.4 RDW-14.9 Plt Ct-154 [2103-9-22] 04:14AM BLOOD Fibrino-1090# [2103-9-23] 04:20AM BLOOD Glucose-98 UreaN-86 Creat-9.9# Na-141 K-5.0 Cl-101 HCO3-20 AnGap-25* [2103-9-22] 04:14AM BLOOD CK(CPK)-[Numeric Identifier ]* [2103-9-23] 04:20AM BLOOD CK(CPK)-[Numeric Identifier 63286]* [2103-9-19] 07:00PM BLOOD CK-MB->500 cTropnT-0.93* [2103-9-20] 10:15AM BLOOD CK-MB-464* MB Indx-0.5 cTropnT-0.85* [2103-9-22] 04:14AM BLOOD CK-MB-121* MB Indx-0.2 cTropnT-0.54* [2103-9-23] 04:20AM BLOOD Calcium-6.6* Phos-8.7# Mg-2.2 [2103-9-23] 04:20AM BLOOD Vanco-14.7 . . ECHO: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Systolic function of apical segments and the base is relatively preserved. Overall left ventricular systolic function is severely depressed. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is moderately dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.There is no pericardial effusion. . . CXR: [2103-9-22] Improvement of pulm edema. Operative note [2103-9-28]: PREOPERATIVE DIAGNOSIS: Left leg compartment syndrome, status post open fasciotomy. POSTOPERATIVE DIAGNOSIS: Left leg compartment syndrome, status post open fasciotomy. PROCEDURES: Irrigation and debridement left leg, second look with partial closure and reapplication of the VAC dressing. OPERATIVE INDICATIONS: Mr. [Name13 (STitle) 4643] is a 44-year-old gentleman who developed a compartment syndrome as a result of compression in the midst of a heroin overdose. I had released the compartments on [2103-9-26]. Please see the dictated operative note for details of that procedure. This was a planned second look with further irrigation and debridement and attempted closure if possible. I discussed the risks, benefits and alternatives of this procedure with the patient and he wished to proceed. OPERATIVE FINDINGS: Entire anterior compartment muscle necrosis. Viable lateral and deep posterior compartments. OPERATIVE TECHNIQUE: The patient was taken to the operating room and placed on the table in the supine position. After general endotracheal anesthesia was obtained, a small bump was placed underneath the left hip. The left lower extremity was prepped and draped in the usual sterile fashion and a time-out was performed per protocol. The prior VAC dressings had been removed prior to prepping the leg. Upon further inspection, the entire anterior compartment muscle tissue was necrotic. It was [Doctor Last Name 352] in color without any contractility using the [Last Name (un) 4161]. However, the remaining compartments all had very healthy good viable muscle with the exception of some small amount of necrosis within the soleus, in the superficial posterior compartment. After the wounds were irrigated gently with bulb irrigation, the necrotic tissue was removed. Again this included the majority of the anterior compartment musculature. The neurovascular bundle was identified and a good dopplerable pulse was obtained from the anterior tibial artery. Similarly, the posterior neurovascular bundle was also identified and found to provide a good pulse as well. The wound was then reirrigated again using gentle bulb irrigation. Attention was then turned to closure. There was an area of skin overlying the anterior compartment that was somewhat bruised, likely from a compression during the evolution of this process. It was however, still viable and did blanch and refill with compression. Thus, I was able to perform a partial closure of the lateral wound from top down and from the bottom up, leaving only a small area in the center that was left open. 2- 0 nylon stitches were used for this closure. Less of the closure could be performed for the more medial incision likely because of the presence of more viable good muscle tissue. The remaining open areas were covered with the VAC dressing and this was placed to suction with a good seal. The limb was then cleansed and placed into his multipodus boot. He was awakened and extubated in the operating room and transferred to the recovery room in satisfactory condition. All instrument, sponge and sharp counts were accurate at the end of the case x2. ESTIMATED BLOOD LOSS: 50 cc. The patient will require further irrigation, debridement and intervention from the plastic surgery team for coverage. CT abdomen/pelvis [2103-10-3]: HISTORY: White count, bandemia, complaints of diffuse abdominal pain and dropping hematocrit. COMPARISON: CT from [2103-9-20]. TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the pubic symphysis were acquired without IV contrast. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Mild atelectatic changes are noted at the lung bases. The superior aspect of the liver is excluded from the study. Imaged portion of the liver otherwise appears unremarkable without evidence of intrahepatic biliary duct dilatation or focal masses. The gallbladder, pancreas, spleen, adrenal glands, kidneys, ureters, stomach, and loops of large and small bowel are all within normal limits. The abdominal aorta is normal in caliber. There is no free air or free fluid. There is no evidence of retroperitoneal hematoma. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is seen within the bladder, which is collapsed. The pelvic loops of bowel, seminal vesicles, and prostate are otherwise unremarkable. There is no free fluid. There is no pelvic or inguinal lymphadenopathy. Within the left medial thigh musculature, lateral to the left superior pubic ramus, there is an approximately 3.0 x 8.1 cm rim-calcified fluid collection, most likely representing a subacute hematoma. Additionally, fluid is seen within the fascial planes of the left thigh as well as extensive subcutaneous fat stranding. No high-density fluid collection is present to suggest an acute hematoma. Additionally seen within the lateral musculature of the right thigh, there are linear areas of calcification seen, which may represent heterotopic/dystrophic calcification secondary to prior trauma injury. Small amount of fluis and fat stranding is also seen within the fascial planes of the right lateral thigh musculature. Irregular calcification is also noted posterior to the sacrum within the paraspinal musculature. BONE WINDOWS: No fractures are noted. No suspicious lytic or sclerotic lesions are present. IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Rim-calcified fluid collection within the medial left thigh. This likely represents subacute hematoma. Additionally, there is fat stranding and fluid surrounding the musculature and fascial planes of the left thigh, particularly laterally. 3. Small amount of fluid also demonstrated within the right thigh musculature laterally, without a focal fluid collection seen. 4. Irregular areas of ossification noted within the sacral paraspinal muscles as well as within the lateral right thigh musculature, likely representing heterotopic/dystrophic calcification secondary to trauma. Pathology report: left leg: Skeletal muscle with focal necrosis and focal acute and chronic inflammation. Brief Hospital Course: 1. Hypoxic Respiratory Distress. Patient initially developed hypoxic respiratory distress, likely secondary to pulmonary edema from volume overload with acute renal failure. Initial patient echo showed poor EF of 20-25%. His oxygen requirements were monitored closely, and did not increase. Patient was fluid restricted to 1500cc a day initially, which was d/c'd once patient's renal function recovered and patient was able to diurese. On discharge, he had oxygen saturations in the high 90s on room air. . 2. Rhabdomyolosis. Patient was in rhabdomyolysis on admission. He had creatinine kinases elevated into the 100,000s on admission, likely secondary to being found unconscious for several days per outside report. Patient was aggressively hydrated with fluids. However he went into pulmonary edema with fluid rescuscitation and was placed on hemodialysis for renal failure and volume overload. His CKs have been trending downward, but continue to remain mildly elevated. . 3. Acute renal failure. Patient developed acute renal failure likely secondary to rhabdomyolysis. He has had gradual improvement in urine output through the past several days. He was initiated on hemodialysis initially on MWF. His electrolytes were monitored carefully. He was placed on nephrocaps, sevelamer, and calcium acetate for electrolyte abnormalities associated with renal failure. His hemodialysis was terminated one week prior to discharge for improvement in renal function with good diuresis and improving creatinine. His tunneled catheter was removed. Patient is to have weekly checks of his creatinine and BUN to be followed by his PCP to assess for continued recovery of renal function. His sevelamer, calcium, and nephrocaps were all d/c'd prior to discharge due to continued improvement of his renal function. . 4. Compartment syndrome. Patient had bilateral lower extremity swelling on admission. Bilateral LENIs were negative. Orthopedics was consulted, and felt that the swelling was likely secondary to edema. After fluid removal during dialysis, patient had persistent swelling, tenderness, and limited range of motion in his left leg, and concern was raised for compartment syndrome. Patient was taken to the OR on [9-26] for evacuation of anterior fasciotomy, and repeat washout was performed on [9-28] for anterior fasciotomy with removal of large amounts of necrotic tissue. Patient was placed on a wound vac with large amounts of serosanguineous drainage. He was then taken to the OR again on [10-5] for primary closure of the lateral fasciotomy. He had decreased drainage of his medial fasciotomy throughout his hospital course, and his wound vac was d/c'd prior to discharge. He is to have wet-to-dry dressings over the site, and a 10 day course of prophylactic antibiotics. No further surgery is anticipated. Patient is to be seen by orthopedics in [12-10] weeks for follow-up. His leg exam was monitored throughout his stay. He had diminished DP pulses and weakness with dorsiflexion in his left toe, as well as decreased sensation to light touch. He had intensive physical therapy during his stay, as well as occupational therapy. He had a multipodus boot fitted, and he will need to maintain his foot in a neutral position to prevent contracture. He will need continued aggressive physical therapy at rehab to help with recovery of his muscle strength. . 5. Leukocytosis. Patient had persistent leukocytosis and fever on admission, with negative cultures. Patient's CXR and UA were negative for infection. His sputum cultures were positive for GPR and GPCP, and patient was initiated on empiric treatment for aspiration pneumonia with vancomycin, levofloxacin, and metronidazole. His final sputum, blood, and urine cultures were negative. His stool cultures for C. difficile was negative. He was continued on vancomycin due to continued leukocytosis and concern for cellulitis overlying the fasciotomy site. The vancomycin was stopped after patient's final surgery. A PICC was placed for delivery of long-term antibiotics, which remained in place. Patient is to go to rehabilitation on a 10 day course of oral cephalexin. . 6. Anemia. Patient's hematocrit decreased from 38 to 23, with no obvious source of bleeding, likely secondary to erythropoietin deficiency from renal failure, with component of acute blood loss during orthopedic procedures for fasciotomies. Patient received multiple blood transfusions to maintain his hematocrit above 30 in the context of cardiomyopathy with low EF. Due to concern for continued bleeding, patient had a CT abdomen which was negative for a retroperitoneal bleed. He continued to have serosanguineous drainage through his wound vac. Patient received IV iron and erythropoietin during dialysis, and was continued on erythropoietin until full recovery of his renal function. He will need to have his renal function monitored closely at rehab, and his erythropoietin may be d/c'd once renal function recovers and anemia resolves. . 7. Cardiomyopathy - Patient had LBBB on EKG and global hypokinesis on echo with an EF of 20-25%. Patient also had elevated CK and CK-MB, but in context of rhabdomyolysis, as well as persistent tachycardia. It was unclear whether patient had acute ischemia or dilated cardiomyopathy from chronic alcohol use. Cardiology was consulted, and felt that the patient did not have an acute ischemic event. Patient was placed on digoxin, aspirin, and metoprolol. His digoxin was subsequently d/c'd secondary to adequate rate control with metoprolol. Patient continued to have TWI on EKG, with deepening of T waves during surgeries. His EKG remained unchanged, however, and he was maintained on his beta-blocker and his ASA. He was transfused to hematocrit >30 prior to OR procedures. He had a repeat echocardiogram which showed complete recovery of ejection fraction, with only trace MR. The initial global hypokinesis was thought to be secondary to stunned myocardium in the context of being acutely ill. . 8. EtOH abuse. After sedation was removed, patient became delirious with active hallucinations, requiring high doses of valium. He improved over the next several days. Addictions and psychology were consulted. Psychiatry felt that patient was not actively suicidal and overdose was not a suicide attempt. Patient will likely need substance abuse counseling as an outpatient. . 9. Bullae. Patient had a bullae on his thenar eminence which dermatology was consulted for. They felt that it was a pressure-induced bullae. The bullae popped spontaneously, and patient applied bactroban lotion to the site daily. It appeared well-healed. . 10. Pain. Patient has a history of substance abuse, and had a period of withdrawal from heroin, methadone, and alcohol. In the past, he has used Percocet, Tylenol #3, occasionally oxycontin. Patient was placed on a fentanyl patch, with dilaudid for breakthrough pain. He was on a dilaudid PCA post-operatively for better pain control. Pain team was consulted for evaluation. His PCA was d/c'd, and he was transitioned to fentanyl 250mcg patch q72h, with dilaudid 8 mg q3-4 hours for breakthrough pain, which was an adequate regimen for his pain control. . 11. SW and addiction consults for coping, substance abuse, resources. Patient was seen by social work and by psychiatry for his substance abuse needs. . 12. Hypercalcemia. Patient developed gradual increase in calcium, likely secondary to muscle recovery after severe rhabdomylosis. Patient received aggressive fluid resuscitation, as well as multiple doses of calcitonin. He was started on pamidronate 30 mg IV, and he was placed on telemetry for continuous cardiac monitoring. His EKGs did not show interval prolongation, and he had no events on telemetry. He did develop nausea and vomiting, thought to be a side effect from the calcitonin and pamidronate injections, which was relieved by dolasetron. His LFTs, amylase, and lipase were checked and were all normal, and he had a benign abdominal exam. His calcium normalized over the course of several days. He will need to have his calcium level checked every other day at rehabilitation to assess for worsening of his hypercalcemia. . 13. Hypertension. Patient had hypertension, controlled with metoprolol 150 mg TID, amlodipine 10 mg QD, as well as isordil and hydralazine. His amlodipine may be stopped as an outpatient as his calcium improves. His metoprolol was decreased to 150 [Hospital1 ] on discharge. . 14. Constipation. Patient had severe constipation, likely related to immobility and high doses of narcotics. He was given enemas with relief. He was initiated on standing colace. . 15. Communication: Mother [Doctor First Name ] [Telephone/Fax (1) 63287] . 16. Access. Patient has left PICC line for access. This may be removed if no longer needed at rehabilitation. His tunneled catheter for hemodialysis was removed prior to discharge. Medications on Admission: Protonix 40 Albuterol Paroxetene Campral Gabapentin Mitazapine . Medication on Transfer: Protonix 40 Vanc 1000mg Q48 Levo 250 QD Flagyl 500 TID Diazepam Atrovent Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO four times a day as needed. 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical Q 24H (Every 24 Hours). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Fentanyl 100 mcg/hr Patch 72HR Sig: Two [Age over 90 1230]y (250) mcg Transdermal every seventy-two (72) hours: Please use 250mcg patch q72h. 13. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 14. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice a day. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) 8000units Injection QMOWEFR (Monday -Wednesday-Friday). 18. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days. 19. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Primary diagnoses: 1. Rhabdomyolysis 2. Acute renal failure [1-10] rhabdomyolysis 3. Anterior compartment syndome 4. Heroin, methadone, and alcohol overdose 5. Cardiomyopathy [1-10] stunned myocardium. 6. Hypertension 7. S/P anterior compartment fasciotomy for compartment syndrome 8. Pressure-induced bullae formation 9. Cellulitus 10. Acute blood loss anemia 11. Anemia associated with renal disease 12. Substance abuse 13. Hypercalcemia 14. Anxiety Discharge Condition: Stable. Discharge Instructions: If you develop shortness of breath, chest pain, confusion, swelling in your body, bleeding from your leg, lightheadedness, nausea, vomiting, or diarrhea, please call your primary care doctor or go to the emergency room. Followup Instructions: 1. Provider [First Name11 (Name Pattern1) 4224] [Last Name (NamePattern4) 4225], MD Phone:[Telephone/Fax (1) 4226]. Please follow up on.... 2. Please follow-up with your primary care doctor in [12-10] weeks. 3. Please have your creatinine, BUN, and hematocrit checked on a weekly basis, and faxed to your PCP for review. 4. Please have your calcium level checked every other day.	[ "304.70", "303.90", "401.9", "507.0", "285.1", "682.6", "518.81", "276.7", "291.0", "V60.0", "709.8", "286.9", "428.0", "728.88", "729.9", "496", "584.5", "425.4", "276.2", "275.42" ]	icd9cm	[ [ [] ] ]	[ "86.05", "83.45", "96.04", "93.59", "38.93", "96.72", "86.22", "83.09", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	22351, 22406	11586, 20487	327, 435	22910, 22920	3895, 11563	23188, 23590	3442, 3446		20700, 22328		22427, 22889		20513, 20677			22944, 23165										3461, 3876																								277, 289											463, 3256																3278, 3319	3335, 3426
5,495	142,471	7249	Discharge summary	report	Admission Date: [2145-3-3] Discharge Date: [2145-3-27] Date of Birth: [2066-7-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2279] Chief Complaint: abd pain Major Surgical or Invasive Procedure: RIJ Peritoneal Dialysis PICC line History of Present Illness: 78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD, Chronic abd/back pain and AAA who presents with worsening abdominal pain over the last 3 days as well as nausea, vomiting and tarry diarrhea. Pt initially presented to [Hospital3 417] with hypotension and mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable AAA and he was transferred to [Hospital1 18] for further care. Of note, pt was discharged on [2145-3-1] after admission for NSTEMI & PNA. During that admission, pt was taken to cath and given comorbidities only the SVG-OM2 was angioplastied. He was treated with a 10day course of Ceftriaxone/Levo for PNA and discharged to home. . In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L. CT abd was reviewed by radiology and revealed colitis adjacent to the hepatic flexure and worsening metastatic disease. Surgery and Vascular were consulted and felt there were no surgical issues. Pt had a RIJ placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and Morphine for abd pain. He was on Levophed 0.8mcg on transfer from the ED. . On arrival to the ICU, pt was complaining of diffuse abd and back pain. He denies CP/SOB but reports intermittent nausea, poor po intake and dark brown diarrhea for the last 2-3days. Past Medical History: - Carcinoid tumor with mets to liver - Hypertension - Hyperlipidemia - CAD s/p CABG x 4 in [2137], Cath [3-1] -> severe native three vessel disease with 90% lesion in SVG-OM2, which was successfully angioplastied. Also with atretic SVG-OM1, and ?obstruction of LAD. Given subclavian stenoses, central pressures noted to be 60mmHg higher than peripheral pressures. - ESRD, on PD since [6-27], s/p HD tunneled cath placement - CAD s/p bilateral carotid endarterectomies in [2132], c/b post-op seizure - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral endarterectomies and aortobifemoral bypass graft with renal artery reimplantation to aortic graft in [11-22], left renal artery stenting in [10-24], s/p right ureteral stenting in [6-27] c/b right mid-ureteral stricture with multiple stent exchanges in 07 & 08 - AAA measuring 5 cm on [1-29] CT - Sigmoid diverticulitis - Pancreatitis w/ ileus post AAA - BPH - H/o ruptured disk - S/p vasectomy, eye surgey, tonsillectomy Social History: Pt is married, lives with his wife. Social history is significant for current tobacco use. Pt quit smoking in [2137] but resumed smoking last summer, about 6 cigarettes daily. Previously, he smoked one-and-a-half pack per day for 35 years. There is no history of alcohol abuse. Family History: He has a brother with CAD s/p CABG in 70s, mother with CVA in 90s. Physical Exam: Vitals: T: 98.2 BP: 123/59 repeat 88/42 P: 95 R: 18 O2: Sats 94% 2L General: Mildly lethargic but responsive, oriented to place HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, no LAD Lungs: Scant crackles bilaterally at bases, otherwise clear CV: RRR, soft SEM gr [2-23] over RUSB, no gallop Abdomen: soft, diffusely tender to place, non-distended, bowel sounds present, no guarding, PD cath site non-tender Ext: Warm, palpable DP pulses, no edema Pertinent Results: [2145-3-3] 03:55PM BLOOD WBC-20.3# RBC-2.78 Hgb-8.5* Hct-27.2* MCV-98 MCH-30.7 MCHC-31.4 RDW-16.1* Plt Ct-251 [2145-3-4] 04:19AM BLOOD WBC-26.3* RBC-2.53* Hgb-7.8* Hct-25.4* MCV-100* MCH-31.0 MCHC-30.9* RDW-16.1* Plt Ct-285 [2145-3-5] 09:25PM BLOOD WBC-17.5* RBC-2.37* Hgb-7.4* Hct-24.0* MCV-101* MCH-31.1 MCHC-30.7* RDW-16.4* Plt Ct-243 [2145-3-8] 05:00AM BLOOD WBC-9.8 RBC-2.42* Hgb-7.6* Hct-23.5* MCV-97 MCH-31.4 MCHC-32.3 RDW-16.4* Plt Ct-231 [2145-3-3] 03:55PM BLOOD PT-14.5* PTT-28.3 INR(PT)-1.3* [2145-3-5] 09:25PM BLOOD PT-21.5* PTT-39.5* INR(PT)-2.0* [2145-3-8] 05:00AM BLOOD PT-17.2* PTT-45.4* INR(PT)-1.6* [2145-3-3] 03:55PM BLOOD Glucose-108* UreaN-31* Creat-8.2* Na-139 K-3.9 Cl-97 HCO3-29 AnGap-17 [2145-3-5] 03:23AM BLOOD Glucose-130* UreaN-42* Creat-8.9* Na-137 K-5.3* Cl-103 HCO3-16* AnGap-23* [2145-3-8] 05:00AM BLOOD Glucose-91 UreaN-50* Creat-8.1* Na-137 K-3.0* Cl-101 HCO3-23 AnGap-16 [2145-3-3] 03:55PM BLOOD ALT-9 AST-17 CK(CPK)-69 AlkPhos-64 TotBili-0.2 [2145-3-5] 03:23AM BLOOD ALT-508* AST-512* LD(LDH)-558* AlkPhos-97 Amylase-133* TotBili-0.2 [2145-3-5] 09:25PM BLOOD ALT-[2146]* AST-3222* LD(LDH)-3488* AlkPhos-128* Amylase-197* TotBili-0.3 [2145-3-6] 03:48AM BLOOD ALT-2271* AST-3566* AlkPhos-122* TotBili-0.3 [2145-3-7] 03:23AM BLOOD ALT-1777* AST-1426* LD(LDH)-750* AlkPhos-139* TotBili-0.2 [2145-3-8] 05:00AM BLOOD ALT-1127* AST-544* AlkPhos-125* TotBili-0.3 [2145-3-3] 03:55PM BLOOD Lipase-38 [2145-3-5] 03:23AM BLOOD Lipase-98* [2145-3-6] 03:48AM BLOOD Lipase-160* [2145-3-8] 05:00AM BLOOD Albumin-2.1* Calcium-7.5* Phos-6.9* Mg-1.9 [2145-3-5] 09:25PM BLOOD Hapto-364* [2145-3-3] 04:03PM BLOOD Lactate-1.2 [2145-3-4] 04:57PM BLOOD Lactate-1.5 [2145-3-6] 04:10AM BLOOD Lactate-2.2* . CT Abd/pelvis: IMPRESSION: 1. New wall thickening and inflammatory change around a short segment of right colon near the hepatic flexure. While this could represent inflammation related to diverticular disease, or other infectious or inflammatory causes, this loop of colon is situated close to multiple metastatic foci within the liver, and metastatic disease, or direct extent of tumor should also be considered. 2. Increased size of multiple hepatic metastases. 3. Free intraperitoneal air, presumably related to peritoneal dialysis. 4. Moderate right hydronephrosis, with dense material now seen in the right renal collecting system and bladder. This appearance is concerning for hemorrhage, unless there has been recent radiographic procedure with injection of contrast directly into the collecting system. 5. Cholelithiasis, without evidence of cholecystitis. 6. Grossly unchanged appearance of 5.5 cm descending thoracic and suprarenal abdominal aortic aneurysm. 7. Stable soft tissue density anterior to the right ureter, with tiny central punctate calcification. . KUB: IMPRESSION: Dilated loops of small bowel with residual air in the colon, this could be an ileus and less likely a new or incomplete SBO. Recommend followup. CXR [3-8] FINDINGS: The NG tube tip is in the proximal stomach. There continue to be dilated small bowel loops measuring up to 4.6 cm consistent with patient's known small-bowel obstruction. Right IJ line is unchanged with tip in the SVC/RA. There is some increased opacity at the right base and right mid lung consistent with infiltrate that is slightly improved compared to the prior exam. CXR [3-9] IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right basilic vein with tip in the SVC. The catheter is ready to use. U/S [3-12] IMPRESSION: 1) Occlusive thrombus in the right internal jugular vein and non-occlusive thrombus at the left subclavian vein. 2) Occlusive thrombus in the left basilic vein. CT L-spine [2145-3-15] IMPRESSION: 1. Multilevel degenerative changes, with neural foraminal narrowing and spinal stenosis, most pronounced at L4-5 level. MR is more ideal for assessemnt of intrathecal structures, unless there is a contra-indication. 2. Faint foci of sclerosis in several vertebral bodies, unchanged from the most recent prior study; however, not present in [2142] and while these can represent bone islands, given the history, also concerning for metastatic foci. Correlation with radionuclide studies can be considered. 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack of IV contrast, incompletely assessed. 4. Right hydronephrosis, double-J stent in place. 5. Upper abdominal ascites. Impressions- 3,4 &5- not compleely assessed. . CT T-spine [2145-3-16]. IMPRESSION: 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae and one involving the left eighth rib, mildly increased in size, and more conspicuous on today's study compared to the CT torso done in [2144-8-21]. Given the increase in size, these may represent metastatic lesions, though the appearance is nonspecific and resembles bone islands. No cortical discontinuity noted. 2. Lung, pleural and vascular changes as described above, incompletely imaged and characterized on the present study. CT Chest can be considered. 3. Distended bowel loops on the scout image with mildly increased diameter since the prior study scout- to correlate clinically to exclude obstructive etiology. These are not included on the other images. . CT C-spine [2145-3-16]. IMPRESSION: 1. Multilevel degenerative changes in the cervical spine as described above, causing moderate-to-severe neural foraminal narrowing as described above, and mild canal stenosis. 2. No definite sclerotic foci in the cervical spine to suggest metastases. Correlate with radionuclide studies. 3. Partially imaged T3 sclerotic focus, better assessed on the concurrent CT T spine study. 4. Significant atherosclerotic vascular calcifications as above. . CT Head [2145-3-17]. IMPRESSION: 1. No intracranial hemorrhage. Limited evaluation for intracranial metastases, though no obvious mass or edema is identified. 2. Chronic left posterior parietal infarct. . Octreotide scan. [2145-3-18]. IMPRESSION: 1. Octreotide-avid disease in a right pubic bone sclerotic lesion and increased uptake in the musculature posterior to the left greater trochanter, compatible with carcinoid. 2. Innumerable heterogeneous hepatic lesions in both lobes, some of which are subcapsular, warrant follow-up. Brief Hospital Course: 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who presents with decreased po intake, diarrhea, lethargy and hypotension found to have colitis on CT. His hospital course showed a progressive decline in function where his mental status and physical condition slowly declined despite treatment of his medical problems. . AMS: Variable course over his stay, likely multifactorial with possible etiologies including narcotics, toxic/metabolic related to renal failure. It appears to be most consistent with delirium. Had CT head with contrast on [3-17], but this does not definitively r/o brain metastases. Neuro exam is nonfocal. BUN has improved over the last 10 days. At d/c continued to be AO X 1, but has remained clear on his intentions to not escalate care with the desire to return home and be with family. Abdominal Pain/Colitis: The patient was recently admitted on [2145-3-1] for NSTEMI s/p cath and angioplasty to SVG-OM2 and also treated for PNA with a 10 day course of CTX/levo. The patient initially presented with abdominal pain to [Hospital3 417] Hospital with hypotension and a hct drop. At [Hospital3 417] the patient had a CT Abd/Pelvis scan which revealed stable AAA and colitis adjacent to the hepatic flexure and worsening metastatic disease. He was transferred to [Hospital1 18] for further care. He was evaluated by surgery and vascular who did not feel there were any acute surgical issues. The patient was hypotensive and required levophed and transferred to the MICU. He was treated initally treated with po vanco and IV flagyl for presumptive C. diff infection. He was also empirically started on Zosyn for colitis/diverticulitis and also initiated on IV vancomycin for peritonitis. The patient's peritoneal fluid was sent for analysis and was found to have elevated WBC count, however the culture showed no growth. The patient initially had a a 3 pressor requirement to maintain his BP. He was evaluated by renal who continued PD despite the concern for infection. The patient improved with antibiotics and was weaned off his pressors on [3-5]. The patient did not tolerated po diet and an NGT was placed on [3-6] and TF were attempted. On [3-7] KUB showed SBO vs ileus and TF were stopped. He was started on TPN for nutrition and bowel rest per surgery. The patient ileus resolved on [3-10] and was his diet was advanced. The patient was tolerating a regular diet and TPN was subsequently discontinued. The patient's pain was managed initially with percocet. He continued to have pain and was seen by Pain & Palliative Care. He was started on oxycontin 10mg Q12 with percocet for breakthough. He was also started on gabapentin 100mg qHS. The patient was continued on a 10 day course of Zosyn for possible diverticulitis/colitis (last day [3-12]). Additionally, the pateint was continued on Vanco per renal for suspected peritonitis (last day: [3-18]). The vancomycin was dosed by checking a vanomycin level and dosing when the level was below 15, approximately every 3 days. Additioanlly, he was continued on IV flagyl and po vancomycin for possible C. diff colitis, although stools have been negative, for 2 weeks after the patient's course of antibiotics. His IV flagyl was discontinued and he was was continued on po vancomycin for 2 weeks. His diarrhea resolved; however his baseline abdominal persisted. Peritonitis ?????? see above for course. The patient peritoneal fluid was negative for organisms. He was continued on PD despite concern for infection. He was treated with IV vancomycin for a 2 week course (last day: [3-18]). The vancomycin was dosed by checking a vancomycin level prior to dosing. Thrombus: Pt was found to have increased upper extremity swelling. He underwent U/S and found RIJ thrombus and left subclavian thrombus. His previous RIJ CVL had been removed. Additionally, his PICC line was also removed given the concern of thrombus formation and due to the fact that his PICC line was on the right side. The patient was started on heparin gtt on [3-12] and initally given 5mg coumadin. His INR became therapeutic after one dose and his coumadin was reduced to 2.5mg. On [3-14] his INR was 5.5 and his coumadin was held. His INR continued to increase and he was given 1mg po vitamin K for an INR of 7.1. His coumadin was held until his INR had come down to 2.4 and was restarted 1mg coumadin every other day. After discussion family meeting it was decided to keep pt comfortable and discontinue any medications that were unnecessary. Ileus: On [3-7] the patient had a KUB that showed dilated loops of bowel likely ileus/partial SBO. The patient had an NGT placed and made NPO. The patient slowly improved and the ileus resolved on [3-10]. He was restarted on a diet and advanced to a regular diet. Metastatic Carcinoid: The patient with known liver mets and followed by hem/onc with apparent worsening disease on his CT. The patient was seen by his outpatient oncologist who recommended pain management with the current narcotics regimen. Addtionally, if the patient continued to have pain octerotide could be utilized for palliation. Otherwise, the treatment can be initiated as an outpatient when stable. The patient was also seen by pain and palliative care who recommended oxycontin 10mg Q12 with percocet for breakthough pain and was increased to 10mg TID. This should be titrated as needed. Additionally, he was started on gabapentin 100mg qhs. His pain regimen was changed and was increased to oxycontin 20mg [Hospital1 ], gabapentin 100mg qHS, standing tylenol, and dilaudid 2mg q4:prn for break through. The patient had continued back pain and additionally weakness. He underwent CT scan of his C,T,L spine that showed new sclerotic lesions concerning for malignancy. He was evaluated by Spine Surgery that did not feel the patient's exam or imaging were consistent with cord compression or need surgical treatment. He underwent octreotide scan that showed carcinoid in the right pubic bone, musculature poas[Name (NI) ] to the left greater trochanter, and liver. Additionally, the patient was started on octreotide 50mcg TID SQ which was discontinued prior to discharge. ESRD on PD: The patient was closely followed by nephrology. He was contined on PD during his admission. He was also continued on epo, calcitriol and renagel. These medications were discontinued on discharge. Shock liver ?????? LFTs peaked now trending down, patient had coagulopathy which improved during hospital course. Anemia: The patient had a baseline hct in low 30s that trended down to 23 during his admission. He was transfused 1U pRBC and improved. There was concern for GI bleed given his dark stools, but was guaiac negative. He was continued on a PPI. His Hct remained stable upon discharge. CAD s/p CABG/NSTEMI: The patient denied CP and EKGs was at baseline. The patient CK/MB were flat and troponin continues to trend down from max of 30 during prior admission. He was continued on Aspirin 325mg & Plavix 75mg daily. However, his plavix was discontinued after the intiation of coumadin. The patient's BB was held due to hypotension and was not restarted. He did continue on an aspirin on d/c. Ureteral stent ?????? Urology was consulted for hyperdense finding on CT scan. Urology reviewed the scan and did not think any intervention at this time was needed, especially in setting of this infection. FEN: The patient was intially on bowel rest and started on TPN. The patient's ileus resolved and was restarted on a regular diet. He had a speech and swallow evaluation for concern of aspiration, but was cleared for a regular diet. His nutrition has been poor and his meals have been supplemented with shakes. Prophylaxis: coumadin, PPI, bowel regimen - all d/c'd at discharge Access: RIJ was placed in the MICU and removed on [3-10]. The patient had a PICC line placed at IR, but was removed after thrombus. At discharge did not have any peripheral access. Code: DNR/DNI, but pressors/CVL okay Medications on Admission: Aspirin 325 mg daily Clopidogrel 75 mg daily Metoprolol Tartrate 50 mg [Hospital1 ] Simvastatin 40mg daily Lisinopril 5mg Imdur 30mg Terazosin 5mg Finasteride 5mg Amlodipine 10mg Protonix 40mg Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H Multivitamin daily Colace 100mg [Hospital1 ] 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q2H (every 2 hours). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H. 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Doctor Last Name ] Nursing & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: Primary: Colitis Peritonitis Secondary: Carcinoid tumor with mets to liver Hypertension Hyperlipidemia CAD s/p CABG x 4 ESRD on PD CAD AAA H/o ruptured disk Discharge Condition: Stable, normotensive, O2 sat >95% RA Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [Hospital1 18] because of low blood pressure, back pain and abdominal pain. You were treated with antibiotics for colitis and peritonitis. You had an ileus (slow movement of your bowels) that resolved. You were also seen by Pain and Palliative Care who recommended a pain regimen for you to control your pain. Please follow the medications prescribed below. Please call your PCP if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: Please call Dr. [Last Name (STitle) 17025] as needed. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2285]	[ "570", "567.9", "V17.3", "453.8", "790.92", "995.91", "305.1", "272.4", "560.9", "038.9", "V45.82", "721.0", "458.9", "996.74", "197.7", "558.9", "591", "276.8", "198.5", "008.45", "441.4", "V45.81", "209.20", "403.91", "562.11", "V17.49", "285.29", "198.89", "410.72", "293.0", "414.01", "560.1", "585.6", "721.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "99.04", "99.15", "99.21", "54.98" ]	icd9pcs	[ [ [] ] ]	19497, 19602	10021, 18132	323, 359	19804, 19843	3613, 9998	20499, 20682	3041, 3109		18475, 19474		19623, 19783		18158, 18452			19867, 20476										3124, 3594																								275, 285											387, 1679																1701, 2723	2739, 3025
2,582	132,783	46236	Discharge summary	report	Admission Date: [2195-2-18] Discharge Date: [2195-3-5] Date of Birth: [2137-3-21] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 14037] Chief Complaint: txf from [Hospital Unit Name 153] with shock liver, rhabdo, ARF Major Surgical or Invasive Procedure: Right IJ placement History of Present Illness: Briefly, 57M hx of Schizoaffective d/o, EtOH abuse admitted to ICU with acute hepatitis. Day PTA, patient had gone to [Hospital1 112] after falling down 5 days prior, found to have rib fx and d/c on pain meds. At [Hospital1 18] ED, reported rib pain had worsened. . Here, CTA was negative for PE, fx, or dissection. Found to have serum EtOH of 26 but reported no alcohol consumption in 3 days. Labs remarkable for AG of 33, lactate of 6.2, ALT 9900/AST 4049, and CK 6000+. Started on sepsis protocol and received 2L of NS, Vanco/Azithro/Ceftriaxone, and percocet for pain. Pt was never hypotensive and lactate decreased to 1.8. Pt denied med changes, no herbals. Denied recent tylenol use. . In the [Hospital Unit Name 153], liver was consulted. They recommended 17 doses Mucomyst. Liver enzymes trended down. CK peaked at 12k and also trended down. Went into ARF with peak Cr 3.3, improved to 3.1 on transfer. Received aggressive IV fluid hydration. Patient without fever or leukocytosis or focal complaints other than rib pain. Utox negative. . On transfer to the floor, patient was feeling well, only complaining of persistent left rib pain upon inspiration. Was making good urine. Denied HA, N/V, muscle pain, joint pains, abdominal pain, chest pain, shortness of breath, fevers, chills, or other concerning sign/symptoms. Past Medical History: Schizoaffective disorder. Hypertension. Bright red blood per rectum (occurred 6-7 years ago with previous sigmoidoscopy with hemorrhoids). Syphilis (treated). Alcohol abuse since age 8. NIDDM diagnosed [2187]. Dementia, likely alcohol related. Pancreatitis. Periodic homelessness. Thrombocytopenia. Status post removal of submandibular cyst. Denies history of withdrawal or DT's. Social History: Positive ETOH use since age 8. The patient goes through phases of dependence followed by non-use.Illicit drugs, used many in the past but no current IV drug abuse and no previous IV drug abuse. Tobacco, 5 cigs per day for the last 40 years. Lives in a group home in [Location (un) ] for people with mental illness. Family History: Parents both with diabetes Physical Exam: 98.6; BP 190/100 (170-190/86-120); 99-105; RR 20; 100%RA. I/Os 7.3/4.8 24h \| 4.5/4.2 12h today GEN: AA gentleman in NAD, pleasant, speech slow, deliberate HEENT: MM dry. PERRL. EOMI. sclera muddy. ? slight exopthalmos, no lid lag. LUNGS: CTA B/L ? slight gynecomastia CV: S1S2 RRR. No MRG ABDOMEN: soft, NT, +BS. + Distension. No rebound, no guarding, no fluid wave. No HSM. EXT: 2cm lipoma on R shoulder. No asterixis. 2+ pulses, radial and DP. Trace edema B/L. NEURO: CN II-XII intact. Moving all extremities on exam. No focal neuro deficits. Pertinent Results: EKG: 90 SR, nl axis, nl intervals, no st changes. . CT Head [2-18]: no intracranial hemorrhage, gross brain atrophy and a few lacunar infarcts. . CXR [2-18]: NO acute process. . RUQ U/S: 1. Diffusely echogenic liver compatible with fatty liver. Other forms of liver disease and more serious forms of liver disease cannot be excluded on the basis of this study. 2. Layering gallstones in gallbladder, without evidence of acute cholecystitis. 3. Subcapsular free fluid in the right kidney upper pole, of uncertain clinical significance. Renal cysts. . CTA chest [2-18]: 1. No evidence of pulmonary embolism or dissection. 2. Fatty liver. 3. Changes of CABG....?? (no hx of CABG) 4. Emphysematous changes of the lungs. 5. Right anterior inferior neck asymmetry . CXR [2-23]: 1. Right lower lobe posterior basilar segment consolidation concerning for pneumonia. Questionable subtle consolidation in the left lower lobe posteriorly, raising the possibility of an aspiration pneumonia. 2. Small bilateral pleural effusions. . Echo [2-25]: 1.The left atrium is normal in size. 2.There is mild symmetric left ventricular hypertrophy. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. . CXR [2-25]: Mild improvement has occurred in interstitial infiltration in the right lung. More radiodense perihilar consolidation on the left is unchanged. Heart size is normal, and there is no appreciable mediastinal venous engorgement, although there is a new small-to-moderate left pleural effusion. While the time course of changing in the lungs, onset over three days, severe worsening over 24 hours and then subsequent improvement, consistent with pulmonary edema, the asymmetry and severe perihilar consolidation on the left suggest other explanations such as asymmetric edema and pneumonia, pulmonary hemorrhage or aspiration. . CXR [2-28]: Improving asymmetrical alveolar and ground-glass opacities. Differential diagnoses include multifocal pneumonia and asymmetrical pulmonary edema. . Chest CT [3-2]: 1. Acute interstitial pulmonary abnormality, improving compared to the prior chest radiographs, differential diagnosis includes pulmonary hemorrhage, interstitial (viral) pneumonia and drug reaction. 2. Moderate left pleural effusion. 3. Gall stones without cholecystitis. . Hip X-ray [3-2]: No hardware identified. There are no radiopaque foreign bodies in the pelvis. . ADMIT LABS GLUCOSE-151* UREA N-18 CREAT-1.3* SODIUM-147* POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-14* ANION GAP-39* . ALT(SGPT)-4099* AST(SGOT)-9900* CK(CPK)-6851* ALK PHOS-107 AMYLASE-185* TOT BILI-0.5 DIR BILI-0.3 INDIR BIL-0.2 . LACTATE-6.2* . PT-16.6* PTT-30.2 INR(PT)-1.5* PLT COUNT-136* NEUTS-75.9* LYMPHS-19.0 MONOS-4.4 EOS-0.1 BASOS-0.5 WBC-7.0 HCT-39.6# MCV-87 . ASA-NEG ETHANOL-26 ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CRP-6.5* . CORTISOL-29.1* . DISCHARGE LABS NA 140 K 3.7 CL 105 BICARB 27 BUN 17 CR 1.3 GLU 194 INR 1.3 . CULTURES [2-18]: [1-10] BLD CX: COAG NEG STAPH all other bld cx from [Date range (1) 77744] NEG Urine cx negative C Diff neg CMV, EBV, Hepatitis neg HIV negative Brief Hospital Course: A/P: 57M Schizoaffective d/o, EtOH abuse admitted to ICU with acute hepatitis of unclear etiology, ARF, rhabdomyolysis . # Acute Hepatitis: AST and ALT were elevated to 4100 and 9900 respectively on admission. The liver team was consulted. The most likely etiology is shock liver though pt has no documented hypotension and would expect that if he was hypotensive, he would have been in renal failure on admission as well but his creatinine was normal. His lactate was also elevated to 6.2 indicating evidence of organ ischemia. RUQ ultrasound showed no evidence of budd chiari and changes consistent with fatty liver. Hepatitis panel was negative along with CMV, EBV, ceruloplasmin and anti-smooth muscle antibody. Tylenol toxicity is also a possibility due to the fact that pt was given percocet on d/c from [Hospital1 756] ED and could have taken too much but on arrival tylenol was negative. Pt was given 17 doses of mucomyst over several days and monitored closely in the ICU. His LFTs had peaked on admission, trended down and were normal within one week. . # Rhabdomyolysis: On admission, pt's CK was found to be 6800 with evidence of myoglobinuria. Troponin was negative. Again, the etiology of his rhabdo remains unclear. Pt presented with a rib fracture and could have been down for longer than he reported. His CK peaked at [Numeric Identifier 890] and trended down over the next several days. It was normal within one week. . # Renal Failure: Pt's baseline creatinine appears to be 1.0 and on admission, it was 1.3. Over the next several days, it rose and peaked at 3.3 likely secondary to his rhabdomyolysis. With aggressive fluid resuscitation, it slowly trended down and was 1.3 on day of discharge. . # Hypertension: Pt's blood pressure was very difficult to control. It remained in the 190s/100s for the first week of his hospital stay. Gradually, blood pressure meds were added. By the day of discharge, he was controlled on a clonidine patch, imdur, hydralazine and Toprol XL. ACE-I was not started [1-8] his renal failure. Echocardiogram done during this hospitalization showed a hyperdynamic EF consistent with his hx of long standing HTN. . # Bacteremia: In the ER, pt had blood cultures drawn after his lactate returned elevated. He then received vanc/ceftriaxone and azithro. Following this, he had a central line placed. Two days later, 2 of the 4 initial blood cultures returned positive for coag negative staph. He was started on Vancomycin for a total of 14 days. The line was pulled and the tip was sent for culture. This returned nebative. Multiple blood cultures over his hospital stay were all negative for growth. An echocardiogram was negative for vegetations. Pt reported a previous hip replacement on the right so it was thought he may have had infected hardware. However, a plain film of the right hip showed no hardware. The source of his bacteremia is still unknown. . # Fevers: Pt was admitted with a temp of 98.4. Over hospital day # 3, he spiked to 99.6. During the next 2 weeks, pt persistently had temperatures ranging between 99.5 and 102. He was initially on Vancomycin for coag negative staph (see above). His central line was pulled and the tip returned negative for growth. He was diganosed with a pneumonia on HD #5 and he was started on Levaquin. Two days later, his oxygen requirement dramatically increased (see below) and he was changed to vancomycin/aztreonam/flagyl to cover hospital acquired pneumonia given his penicillin allergy. ID was consulted and followed the patient. HIV returned negative. Blood cultures were repeatedly drawn every time pt spiked a temperature but all remain negative. Urine cultures also were negative. An echocardiogram showed no evidence of endocarditis. After one week of broad specturm antibiotics for his pneumonia, a non-contrast chest CT was done which showed no abscess or fluid collection. After two weeks, it was hypothesized that the pt was having drug fevers so his antibiotics were stopped. His temperature curve should be followed closely at his nursing home. . # Elevated ESR: To evaluated persistent fevers, ESR and CRP were sent. Both returned markedly elevated with ESR of 100 and CRP of 60. Ddx of ESR >100 included osteomyelities, endocarditis, CVD, TB or idiopathic. Pt had no complaints to indicate osetomyelitis. [Doctor First Name ] and PF returned negative. PPd was placed and was negative after 72 hours. A TTE had been done which showed no evidence of endocarditis and the suspicion was not high enough to perform a TEE. The ESR should be followed and further work-up should be pursued if it remains elevated. . # Hypoxia: During the pt's ICU stay, he did not require oxygen and his CXR was clear. CTA done in the ED showed no PE or dissection. On hospital day #5, pt had a new oxygen requirement and had a low grade fever. CXR was done which showed a RLL consolidation with maybe a small LLL consolidation. He was started on Levaquin. Two days later, his oxygen requirement increased and he was noted to be hypoxic to the 80s on 4L nasal cannula. ABG was done: 7.37/34/74 and he was placed on a 70% face mask. His antibiotics were broadened to vanc/aztreonam/flagyl to cover hospital acquired pathogens. A CXR showed bilateral opacities consistent with CHF so pt was given morphine, nitropatch and lasix. He had some improvement with this regimen but remained on the face mask. His hypoxia persisted over the next several days. CXR showed a largely unilateral opacity and there was concern for pulmonary hemorrhage vs unilateral effusion vs worsening pneumonia. ANCA and anti-GBM was sent but returned negative. Pulmonary was consulted and recommended agressive diuresis. Pt was diuresed over the next several days and his oxygen requirement decreased. A chest CT done to evaluate for persistent fevers showed an acute interstitial pulmonary abnormality consistent with either CHF, viral pneumonia or drug reaction. By discharge, pt was oxygenating well on 2L nasal cannula. . # Rib fracture: Pt presented to the ER with rib pain following a fall 5 days earlier. Given his description of his pain, a CTA was done to rule out dissection but this was negative except for a left-sided rib fracture. He was given oxycodone for pain. . # DM: Metformin was held due to his liver failure. And pt improved and his appetite increased, his insulin requirement increased as well. He was started on low dose Lantus and covered with a humalog sliding scale. . # ETOH abuse: Pt has a long history of alcohol abuse. He was placed on a CIWA scale with valium on admission. This was stopped after 5 days. He was given thiamine, folate and MVI. Social work and [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] spoke with the patient regarding his alcohol abuse and he understands that he should not drink anymore but does not qish to quit. He will go to an alcohol abuse program (CAB) following his stay at rehab. Please call them at [Telephone/Fax (1) 98302] once he is ready for D/C from rehab. . # Schizoaffective disorder: Psychiatry evaluated the patient and recommended restarting his prozac. He will have an expected 30 day or less convalescent stay. . # NSVT: During [Hospital ] hospital stay, he had short runs of NSVT and occasional PVCs. His electrolytes were repleted. He should have a stress test as an outpatient given his risk factors for heart disease. . # Access: Pt had a right-sided PICC placed due to poor IV access. This was pulled on the last hospital day. Medications on Admission: Metformin 850 mg PO DAILY Start: In am Thiamine HCl 100 mg PO DAILY Multivitamins 1 CAP PO DAILY Fluoxetine HCl 20 mg PO DAILY Pantoprazole 20 mg PO Q24H Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for fever or pain. 13. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 14. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: check blood sugars before meals and at bedtime and treat according to sliding scale. Discharge Disposition: Extended Care Facility: [Location (un) ] Manor Discharge Diagnosis: Primary Diagnosis: 1. Acute hepatitis, shock liver? 2. Rhabdomyolysis 3. Acute renal failure 4. Coag negative staph bacteremia 5. Fever of unknown origin 6. Hospital acquired pneumonia 7. diastolic heart failure 8. Diabetes 9. Schizoaffective disorder 10. Alcohol abuse 11. Rib fracture Discharge Condition: good, oxygenating well on ___ Discharge Instructions: Take all medications as instructed on medication sheet. Call Dr. [Last Name (STitle) 5762] or come to the ER if experience any fevers, chills, chest pain, abdominal pain, nausea/vomiting or diarrhea, shortness of breath or anything else that concerns you. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 5762] within one week of discharge.	[ "428.30", "291.81", "303.91", "584.5", "728.88", "807.09", "250.00", "790.7", "427.69", "507.0", "428.0", "E888.9", "570", "518.81" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	16047, 16100	6873, 14475	340, 361	16431, 16463	3104, 6850	16772, 16861	2493, 2522		14679, 16024		16121, 16121		14501, 14656			16487, 16749										2537, 3085																								233, 302											389, 1730							16140, 16410									1752, 2138	2154, 2477
24,134	108,301	4397	Discharge summary	report	Admission Date: [2124-12-30] Discharge Date: [2125-1-6] Date of Birth: [2050-11-25] Sex: F Service: Medicine CHIEF COMPLAINT: Shortness of breath/respiratory failure. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 18920] is a 74-year-old woman with a history of chronic obstructive pulmonary disease, end-state, on home oxygen with a FEV1 of 35%, and multiple previous admissions over the past several months for chronic obstructive pulmonary disease flares with pneumonia; initially admitted with a cough and increasing respiratory distress at home. She was initially treated with antibiotics and prednisone and found to be in increasing respiratory distress and transferred to the Medical Intensive Care Unit for trial support of BiPAP. However, the patient declined BiPAP in the unit stating that she no longer wished to prolong her life. She was lucid, alert, and rational per the Medical Intensive Care Unit at this point, and per her family. At this point the goals for the patient's care were changed to maximization of comfort. The decision was made to return the patient to the floor. PAST MEDICAL HISTORY: (Significant for) 1. Severe chronic obstructive pulmonary disease, oxygen dependent with multiple flares in the past several months. 2. Chronic pneumonias. 3. Osteoporosis. 4. Gastroesophageal reflux disease. 5. Anxiety. MEDICATIONS ON ADMISSION: Medications on arrival to the floor were Colace, Serevent, Flovent, levofloxacin, heparin, Protonix, Combivent, and morphine drip. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were satting at 90% to 97% on 6 liters nasal cannula with a temperature of 98.6, a heart rate of 90, a blood pressure of 130/70. In general, in no acute distress at this time, although thin and tired-appearing. Heart rate and rhythm were regular, with a normal first heart sound and second heart sound. Her lungs were significant for having slight wheezing, bilateral crackles at the bases, and very poor air movement. The abdomen was soft, nontender, and nondistended. She had trace edema in the lower extremities. Neurologically, she was alert and oriented and appropriate. HOSPITAL COURSE: After being transferred to the floor the patient's entire family arrived and a discussion regarding her prognosis and the appropriate course to be taken was made. The patient's wishes were explicit that she wished to be comfort measures only and did not wish to continue. The family agreed with this, and the decision was made at this time to withdraw all care with the exception of comfort medications including a morphine drip and oxygen by nasal cannula. After discontinuation of the albuterol and Atrovent nebulizers and her steroids, her pulmonary status rapidly declined. She was kept comfortable on a morphine drip with boluses as needed. Her family remained with her throughout the stay. After approximately 48 hours, the patient passed away comfortably. At this time the family declined a postmortem examination. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Pneumonia. [Name6 (MD) ] [Name8 (MD) 5647], M.D. [MD Number(1) 18922] Dictated By:[Name8 (MD) 4733] MEDQUIST36 D: [2125-1-7] 10:58 T: [2125-1-13] 09:11 JOB#: [Job Number 18923]	[ "300.00", "486", "276.8", "530.81", "518.81", "491.21", "285.9", "263.9", "459.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								3048, 3338					1414, 2178	2197, 3027																																				156, 198											227, 1137																1160, 1387
6,360	168,716	18352	Discharge summary	report	Admission Date: [2157-10-26] Discharge Date: [2157-10-31] Date of Birth: [2114-12-11] Sex: F Service: Vascular Surgery CHIEF COMPLAINT: Acutely ischemic right leg. HISTORY OF PRESENT ILLNESS: A 42-year-old nondiabetic white female with hypertension, hypercholesterolemia, peripheral vascular disease, status post left fem-[Doctor Last Name ] bypass graft, right fem-[Doctor Last Name ] bypass graft x2, had undergone a right popliteal to anterior tibial bypass graft with arm vein at an outside hospital in early [2157-9-19]. Patient presented to the Emergency Room at [Hospital1 346] on [2157-10-5] with drainage from her medial right leg incision around the knee. Patient had a palpable right graft pulse and an opening in the incision at the knee with exposed graft. Cultures grew coagulase-negative Staph, sparse probable enterococcus, and sparse gram-negative rods. Patient was treated with antibiotics, and her wound began to granulate. Patient was discharged home on levofloxacin and Flagyl with wet-to-wet normal saline dressings q.4h. Anticoagulation with Coumadin for patient's bypass graft was resumed. Patient was scheduled to followup in Dr.[Name (NI) 7257] office in one week after discharge. Patient presented to the Emergency Room at [Hospital1 346] on [2157-10-26] with a cool right foot and numbness and tingling since the previous evening. On the morning of admission, the patient found that she could no longer palpate a graft pulse at either her femoral or her anterior tibial site. Patient had not taken her Coumadin the previous three days because of a death in the family. Patient complains of severe rest pain in her right foot. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Peripheral vascular disease; status post angioplasty. PAST SURGICAL HISTORY: 1. Left femoral above the knee popliteal bypass graft in [2156-2-20] at an outside hospital. 2. Right femoral to above the knee popliteal bypass graft in [2155-9-20]. 3. Redo right femoral to above the knee popliteal bypass graft in [2156]. 4. Right popliteal to anterior tibial bypass graft with arm vein in early [2157-9-19] at an outside hospital. FAMILY HISTORY: CAD. SOCIAL HISTORY: Patient lives with her boyfriend. She ambulates with a cane. She smoked one cigarettes per day for the previous 30 years. She quit smoking one year ago. She occasionally drinks alcohol. ALLERGIES: Codeine causes severe nausea. MEDICATIONS ON ADMISSION: 1. Coumadin 5 mg p.o. q.d. 2. Toprol XL 10 mg p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. .......... 20 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. PHYSICAL EXAM: Vital signs: Temperature 97.0, pulse 117, respirations 16, blood pressure 127/87, O2 saturation 100% on room air. General: Alert, cooperative white female in no acute distress. Chest: Heart regular, rate, and rhythm. Lungs are clear bilaterally. Abdomen is soft. Nontender. Nondistended. Pulse examination: Carotid pulses, radial pulses, femoral pulses 2+ bilaterally. PT pulses have Doppler signals bilaterally. The left dorsalis pedis pulse has a Doppler signal, and the right dorsalis pedis pulse has no Doppler signal. The right graft pulse has a Doppler signal at the anterior tibial site, but is nonpalpable. Extremities: Right foot is cooler than the left, but not cold, [2-21] second capillary refill on the right. ADMISSION LABORATORIES: WBC 11.4, hematocrit 40.1, platelets 499,000. PT 12.7, PTT 26, INR 1.1. Sodium 137, potassium 4.1, chloride 102, CO2 21, BUN 9, creatinine 0.7, glucose 118. EKG showed sinus tachycardia at a rate of 101. T-wave inversions in I, aVL, and V4, V5, and V6. Chest x-ray from [2157-10-5] showed no acute pulmonary disease. HOSPITAL COURSE: Patient was admitted to the hospital on [2157-11-5]. She was started on IV Heparin after bolus. On the following day, the patient underwent an arteriogram which showed a patent right CFA and profunda. The SFA was occluded throughout its length. The popliteal artery had a short segment of reconstitution, but occluded after a short distance. The AT reconstituted just after its origin, but became 99% stenotic over 4 cm length in the distal calf. A large caliber DP is reconstituted. Patient's rest pain was initially managed with a Dilaudid PCA, and then was adequately managed with Percocet. Patient's hematocrit dropped to 26 during the course of lytic therapy. Patient was transfused 1 unit of packed red blood cells to a post-transfusion hematocrit of 29. Cardiology was consulted for preoperative clearance in preparation for possible bypass graft surgery. Patient had a normal EKG and was asymptomatic. She reported having a negative stress test by her PCP in recent months. No further cardiac studies were recommended by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], and patient was cleared for lower extremity bypass graft surgery. Patient continued on lytic therapy with TPA. Her right foot was warm, and she had a Doppler signal in her right graft. Anticoagulation with Coumadin was started on [2157-10-30]. On [2157-10-31], the patient abruptly decided to go home and had arranged a ride. Patient was advised that she should remain in the hospital until she was fully anticoagulated and her graft could be further monitored. However, patient insisted and agreed to sign out against medical advice. Patient was instructed on using Lovenox b.i.d. and taking her Coumadin. Her primary physician was to follow her INR and Coumadin dosing. Patient agreed to followup with Dr. [Last Name (STitle) ] in the office in one week. MEDICATIONS ON DISCHARGE: 1. Coumadin 5 mg p.o. q.d. 2. Lovenox 60 mg subQ q.12h. 3. Metoprolol XL 25 mg p.o. q.d. 4. Lisinopril 10 mg p.o. q.d. 5. Lipitor 20 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Protonix 40 mg p.o. q.d. 8. Lorazepam 1 mg p.o. b.i.d. 9. Percocet 1-2 tablets p.o. q.3-4h. prn pain. CONDITION AT DISCHARGE: Fair. DISPOSITION: Home with VNA services. PRIMARY DIAGNOSIS: 1. Acutely ischemic right leg with occluded right bypass graft. 2. Thrombolysis with TPA. SECONDARY DIAGNOSES: 1. Blood loss anemia, status post transfusion. 2. Tachycardia, medication adjusted. 3. Hypertension. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. 2914 Dictated By:[Last Name (NamePattern1) 3954] MEDQUIST36 D: [2157-11-2] 00:17 T: [2157-11-2] 04:02 JOB#: [Job Number 50555]	[ "V58.61", "E878.2", "285.1", "070.54", "272.0", "996.74", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.29", "88.42", "39.50", "88.48" ]	icd9pcs	[ [ [] ] ]							2263, 2269					5739, 6029	2546, 2691	3818, 5713											1878, 2246	2707, 3800		6221, 6576														6044, 6090								170, 199											228, 1733							6109, 6200									1755, 1855	2286, 2520
27,770	101,051	5765	Discharge summary	report	Admission Date: [2160-8-1] Discharge Date: [2160-9-8] Date of Birth: [2093-10-4] Sex: M Service: NEUROSURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2724] Chief Complaint: back pain Major Surgical or Invasive Procedure: Resection of T5 tumor, lateral extra cavitary T9 vertebrectomy, and posterior instrumented fusion from T2-T11. Left-sided thoracentesis tracheotomy Peg placement History of Present Illness: 66 year old male with known metastatic thyroid CA to spine, brain, ribs presented to Dr.[Name (NI) 6767] office for routine follow-up today. The patient has back pain but no numbness or tingling. The pain in his back is more of a dull ache and is not nearly as painful as the pain he had in his neck prior to the cyberknife treatment he had at C1 in [Month (only) 958] of this year. He has not had any urinary incontinence but did notice stool staining in his underwear twice this week when he woke up in the morning. He has had controlled bowel movements since then and reports no loss of sensation in the groin or buttock region. The patient noticed that his right leg felt slightly weaker recently, but he had a right hip replacement and attributed the weakness to that surgery. The patient had an MRI of the thoracic spine which showed a new large lesion almost completely occluding the canal. Dr. [Last Name (STitle) 724] sent him to the ER for neurosurgical evaluation. Past Medical History: Metastatic Thyroid Ca HTN Atrial Fibrillation Pulmonary Embolus [1-28] - Anticoagulated with coumadin; has two small lesions on MRI head c/w mets but not contraindications to anticoag. Hypothyroidism Social History: Lives with wife. [Name (NI) 1403] part time in real estate building and development and is still currently working. Retired from full time work in [2157-9-22]. Smoked approximately 30 years ago (quit in [2126]) EtOH: drinks 1 glass wine/day Family History: Mother with h/o emphysema. Physical Exam: PHYSICAL EXAM: T:98.2 BP:125/60 HR:54 RR:16 O2Sats:95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: In cervical collar. Surgical incision well-healed. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Spine: No point tenderness. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch bilaterally. No sensory loss in thoracic region or in legs. Reflexes: Pa Ac Right 2+ 1+ Left 3+ 1+ Toes downgoing bilaterally No clonus Pertinent Results: MRI of the thoracic and lumbar spine. [2160-8-1] IMPRESSION: Bony metastatic disease involving the T4, T5, T9, and T10 vertebrae. Spinous process metastasis at T5 indents the spinal cord and results in 50% narrowing of the spinal canal with slight indentation on the spinal cord. Epidural metastasis on the right side of the spinal canal at T9 level displaces the spinal cord to the left side and results in slightly more than 50% narrowing of the spinal canal with moderate cord compression. Other changes as described above. IMPRESSION: Bony metastasis to right pedicle and body of the L1 and superior portion of L2 vertebra as described above. No evidence of epidural mass or spinal cord compression. BONE SCAN. [8-4] IMPRESSION: 1. Osseous metastasis in multiple levels of the thoracic and lumbar spine as described above. Uptake in some vertebrae might be related to degenerative changes but a differentiation cannot be made on the base of this study. 2. Osseous metastasis involving multiple bilateral ribs. 3. Osseous metastasis involving bilateral distal femora. 4. Increased uptake surrounding the femoral component of the right hip prosthesis in the right acetabulum likely related to post-operative changes. However, residual underlying metastasis cannot be ruled out completely. [2160-9-8] 05:30AM BLOOD WBC-7.3 RBC-3.72* Hgb-10.8* Hct-32.0* MCV-86 MCH-29.0 MCHC-33.7 RDW-17.3* Plt Ct-74* [2160-9-2] 06:15AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL [2160-9-8] 05:30AM BLOOD Plt Ct-74* [2160-9-8] 05:30AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-131* K-4.5 Cl-97 HCO3-27 AnGap-12 [2160-9-4] 04:02AM BLOOD ALT-65* AST-22 AlkPhos-59 TotBili-0.5 [2160-9-3] 02:10AM BLOOD proBNP-1249* [2160-9-8] 05:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2 [2160-8-18] 03:18PM BLOOD Hapto-165 [2160-8-14] 04:02AM BLOOD Homocys-7.8 [2160-8-14] 02:49PM BLOOD Ammonia-<6 [2160-8-14] 02:49PM BLOOD T4-4.7 T3-24* [2160-8-15] 12:05PM BLOOD Cortsol-20.7* [2160-8-24] 02:44AM BLOOD Digoxin-1.0 Brief Hospital Course: The patient was admitted to the neurological surgery service on [8-1] for treatment. On admission, he was started on dexamethasone, maintained on levonox fo prior history of pulmonary embolism and maintained in a TLSO. In preparation for surgery on [8-4], a medicine consultation was obtained for surgical risk stratification. CT exam also showed a T9 destructive lesion. Also, bone scan showed evidience of mets at multiple levels of the thoracic and lumbar spine, ribs, and femurs. On [8-5] he had an embolization by Dr. [First Name (STitle) ] and on [8-7] he had T1-T12 Fusion. On [8-8] he had good strength but was not following commands. He received 2u PRBC and his repeat HCT was 28.9 On [8-10] Sputum Cx sent. SVT w/[Month/Year (2) 5509] so a dilt drip was started. One drain was removed. On [8-12] bilateral pleural effusions were tapped by IR and on the following day the 2nd drain out was removed and he was extubated. On [8-14] he was re-intubated. The next day his mental status improved, was following some commands and went to the OR for trach/peg. He tolerated the procedure well and was transitioned to a trach mask on [8-16]. On [8-18] he had A-fib with rapid rate and was on esmolol drip. Staples were removed that day. The esmolol was turned off on [8-19] and he was transferred to the step down unit. The patient had drainage from the JP site so a chest CT was obtained which did not show pleural or thoracic fistula. On [8-21] he was in a-fib again with [Month/Day (4) 5509] and was sent back to the ICU. Cardiology was consulted to help manage his heart rate/rhythm. He converted to sinus rhythm while in the ICU. The patient had drainage from his JP site on [8-24] that was purulent, tan, thick material. On [8-25] thoracics was consulted and they determined that there was no indication for surgery since the pleural effusions were improved. It appeared that the drainage was only from the JP site and not from the previous thoracentesis site. The JP site was still leaking but the drainage was thin and yellowish. Dr. [Last Name (STitle) 548] placed new sutures over the area and by the next day ([8-26]) the site was completely dry the sutures need to stay in place until [9-12] On [8-24] a sputum culture came bac positive for pseudomonas so Zosyn was started. ID was consulted and agreed that this should be continued for 7 days. The drainage from the JP site grew out proteus for which Zosyn was also appropriate. Mr. [Known lastname 20598] was treated for HSV 1 infection on his lips with acyclovir as well. He was transferred to step down unit again on [8-26] but then to the MICU on [8-28] for lower GI bleed and melena. Pt was transfused 1 U prbcs and underwent a colonoscopy which showed:Polyp in the ascending colon, Diverticulosis of the left > right, Ulcers in the distal rectum (biopsy. Recommendations from GI were: Follow-up pathology results. Hold anticoagulation for now and avoid rectal tubes. He was transferred to the MICU service on two different occassions due to a GI bleed and atrial fibrillation. Brief MICU course: # Afib with [Month/Day (4) 5509]. Has had intermittent Afib in past, on amio for rhythm control as well as metoprolol. Metoprolol just restarted today. Precipitant now unclear - hypovolemia, hypervolemia, infection/sepsis, PE, other pulmonary disease, hyperthyroidism. Appears slightly dry on exam (crackles asymmetric). Getting T4 replacement though not currently, appears to have been lost during transfer (last [8-21]). Has been on dilt gtt in past during admit. Did not respond to 10 IV dilt and 10 IV lopressor. BP holding >90. BP responsive to 500 cc bolus. Initially on esmolol gtt, now d/c??????d and getting Metoprolol PO. Echo showed no effusion, EF 55%, leaflets normal but limited study. On readmission to MICU, his TSH was found to be 15. There was concern for PE given the patient's history, but LENIs were negative. Pt had another episode of rapid rates to 180s on the morning of [9-3] which transiently decreased with lopressor and resolved after 750 mL NS bolus. Amiodarone was returned to former dosing of 200 mg [Hospital1 ]. . #Hypothyroidism. Current transfer meds did not include levothyroxine and apparently this med had been held since transfer on [8-21] (not reordered in transfer orders). Continued Synthroid at home dosing plus 200mcg daily. Will need close f/u of TSH in coming days and weeks to correctly dose levothyroxine. # Hypoxemia. After transfer to the MICU, was requiring more O2 than prior transfer (50% TM at the time, now 70-100%). Desat to 80s on [9-2], improved after Atrovent neb. Over remainder of stay requred 50-70% FiO2 on trach mask. There was intially concern for infiltrate on his CXR, so his Zosyn was continued until [2160-9-4]. An intial BNP 1727, which decreased to 1200s the next day. Given concern for PE, LENIs were performed and were negative. - Also tried to wean sedating meds including neuroleptics and pain meds. . #Metastatic papillary CA: S/p recent T1-T12 palliative decompression and fusion on [2160-8-7] with known brain, bone and soft tissue mets. -No active treatment for now, long-term plan of care per Neurosurgery . # LGIB: In the setting of anticoagulation with Lovenox (60mg [Hospital1 ]) for a history of PE in the past. 3 unit PRBC transfusion but now stable. Ulcers on colonoscopy, bx showed no evidence of malignancy, but acute and chronic inflammation consistent with ulcer. Pt has been continued on [Hospital1 ] PPI as per GI recs. Daily Hcts have been stable in MICU. . # Pseudomonas VAP: Pt with Pseudomonas in sputum from [8-25] and on Zosyn since [8-23]. 10 day course extended until [9-4] given hypoxemia and concern for infiltrate on CXR. Added vanc/cipro [2160-8-31], d/c'd cipro [2160-9-2]. Vancomycin was d/c'd on [9-3] when the sputum culture from [9-1] failed to show any growth. # Delirium: Pt with history of delirium that began this admission. Previously had been working. requires frequent reorientation. Has been getting zyprexa prn, however attempting to decrease amount of sedation. . # Leukocytosis: Stable in the 10K range. . # h/o PE: Pt with history of DVT/PE in [2159-1-22]. On anticoag at therapeutic dosing earlier during admit (when had GIB); also with history of hemoptysis presumably from lung mets; also known brain mets. Given his recent GI bleed and hemoptysis we decided to use heparin sq only #Thrombocytopenia: Plt count recovering from nadir of 38LK --> 89K, now 74K Unclear if thrombocytopenia was medication related. Stable. . #Prophy: Pneumoboots, PPI.# . #Code: FULL . Goals of care when speaking with Mrs [Known lastname 20598] is to get Mr [Known lastname 20598] home with services if possible. We discussed possible Hospice but she does not want to consider that option at this point. On discharge Mr [Known lastname 20598] was awake, alert, orientated x3 comfortable with full strenght in his lower extremities, his wound was healing no erthyema. He had low grade temps 99 range he had full work up given his complicated medical history. His UA and CXR were negative for infection, blood cultures are pending. He continues to receive tube feeds but has also passed a swallow test for ground food. His trach can be down sized. Medications on Admission: AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day ENOXAPARIN [LOVENOX]- 40 mg/0.4 mL Syringe GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth twice a day LEVOTHYROXINE - 200 mcg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE - 25 mcg Tablet - 0.5 (One half) Tablet(s) by mouth Mon, Wed, Fri OXYCODONE [OXYCONTIN] - 40 mg Tablet SustSR 12 hr - 1 Tablet(s) by mouth three times a day DOCUSATE SODIUM - 100 mg - 1 Capsule(s) by mouth twice a day Discharge Medications: 1. Acetaminophen 325 mg Tablet [Known lastname ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [Known lastname ]: One (1) Injection TID (3 times a day). 3. Senna 8.6 mg Tablet [Known lastname ]: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Known lastname ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Docusate Sodium 50 mg/5 mL Liquid [Known lastname ]: One (1) PO BID (2 times a day). 6. Gabapentin 250 mg/5 mL Solution [Known lastname ]: One (1) PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Olanzapine 5 mg Tablet, Rapid Dissolve [Last Name (STitle) ]: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 9. Mupirocin Calcium 2 % Cream [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation QID (4 times a day) as needed for wheeze or shortness of breath. 11. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 12. Levothyroxine 100 mcg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO TID (3 times a day). 14. Oxycodone 5 mg/5 mL Solution [Hospital1 ]: One (1) PO Q3H (every 3 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Metastatic thyroid cancer to spine HSV 1 infection on lips Pseudomonas infection in sputum Intermittent a-fib with rapid ventricular rate Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Wear cervical collar as instructed ?????? You may shower briefly without the collar unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 4 WEEKS. Have you drain sutures in the back removed on [9-12] you may do that at rehab Completed by:[2160-9-8]	[ "054.9", "518.5", "327.23", "198.5", "427.31", "244.1", "401.9", "V43.64", "998.32", "578.1", "709.8", "E879.8", "197.0", "293.0", "336.3", "511.9", "287.5", "198.3", "263.9", "V12.51", "482.1", "285.1", "569.41", "198.4", "V10.87", "V58.61", "458.29" ]	icd9cm	[ [ [] ] ]	[ "81.05", "84.51", "39.79", "77.81", "96.6", "81.04", "77.79", "80.99", "48.24", "31.1", "34.91", "33.22", "43.11", "86.59", "81.64", "86.11" ]	icd9pcs	[ [ [] ] ]	14664, 14743	5044, 12485	298, 465	14925, 14949	2907, 5021	16463, 16697	2002, 2030		13099, 14641		14764, 14904		12511, 13076			14973, 16440										2060, 2374																								249, 260											493, 1485									2389, 2888							1507, 1713	1729, 1986
22,520	139,893	43203	Discharge summary	report	Admission Date: [2132-12-28] Discharge Date: [2133-1-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: 1. Intubation and extubation History of Present Illness: [Age over 90 ] yo F with h/o CAD s/p CABG, diastolic CHF (EF 55%), HTN, and mild AS who presents with worsening SOB X 4-5 days. The patient was recently hospitalized earlier this month for similar complaints and was found to have a CHF exacerbation which was treated with diuresis. She was discharged on [12-7] and has since adhered to a low sodium diet and taken all of her pills as prescribed. The pt began to notice SOB approximately 4-5 days ago which was followed by increased fatigue and poor appetite since Friday. This was accompanied by subjective fevers, chills, and a productive cough of whitish sputum. The pt denies travel, sick contacts, and other localizing symptoms including dysuria, diarrhea, and abdominal pain. . In the ED, the pt was initially hypoxic to the 65% on RA and improved to 100% on NRB. CXR showed a mod to large sized loculated R pleural effusion that was unchanged from [12-7]. EKG was without new ischemic changes, cardiac enzymes negative, BNP 6244. She received levaquin 750 mg IV X 1, CTX 1 g IV X 1, tylenol 1 gm po (for temp to 101.8), lasix 40 IV then 80 IV with subsequent 130 ccs of urine output. She was taken off a NRB and placed on a ventimask sating 98%. She was then admitted to the [Hospital Unit Name 153] for further care. . On ROS, denies PND, LE edema, sleeps flat with one pillow at night but does feel less SOB sitting up. + back pain, which has since resolved. + CP without oxygen on. + occasional dysphagia with solids, no recent reported aspiration event. . Past Medical History: Coronary artery disease - s/p CABG [2128] (LIMA-D1, SVG-LAD, SVG-OM1, SVG-RPDA) - LVEF >55% Hypertension Dyslipidemia Mild aortic stenosis Diastolic CHF Post-op A.fib DJD Breast Ca s/p lumpectomy Social History: Russian speaking. No h/o tobacco, alcohol or IVDU. Grandson is HCP. Lives in senior apartments. Family History: No family h/o early cardiac death, arrhythmias Physical Exam: T 96.5 BP 117/75 HR 76 RR 20 O2 sat 95% on 6L NC Wt 65 kg Gen - NAD, speaking in full sentences without difficulty or SOB HEENT - slightly dry MM, OP clear Neck - JVP approximately 10 cm above sternal notch, neck supple, no LAD CV - RRR, nl s1/s2, II/VI systolic murmur over RUSB and II/VI holosystolic murmur radiating to apex Lungs - + expiratory wheezes throughout, + upper airway coase breath sounds, decreased BS over R base, no rales or rhonchi appreciated Abd - Soft, NT, ND, normoactive BS, Ext - minimal pitting edema over RLE, extremities cool to palpation but 1+ DP and PT pulses b/l Neuro - alert and oriented to situation, responds to questions from son appropriately, moves all 4 extremities purposefully Pertinent Results: [2132-12-28] 04:20PM GLUCOSE-202* UREA N-17 CREAT-1.0 SODIUM-137 POTASSIUM-7.1* CHLORIDE-99 TOTAL CO2-30 ANION GAP-15 [2132-12-28] 04:20PM CALCIUM-9.3 PHOSPHATE-4.7* MAGNESIUM-2.3 . [2132-12-28] 04:20PM CK(CPK)-481* [2132-12-28] 04:20PM cTropnT-<0.01 [2132-12-28] 04:20PM CK-MB-5 proBNP-6244* . [2132-12-28] 04:20PM WBC-11.6* RBC-4.12* HGB-11.8* HCT-35.9* MCV-87 MCH-28.7 MCHC-33.0 RDW-14.8 PLT COUNT-353 [2132-12-28] 04:20PM NEUTS-91.7* LYMPHS-5.6* MONOS-2.4 EOS-0.1 BASOS-0.1 [2132-12-28] 04:20PM PT-12.7 PTT-25.7 INR(PT)-1.1 . EKG: NSR @ 70 bpm, LAD, nl intervals, T wave flattening V6, I, aVL, II, III, aVF, poor R wave progression . IMAGING: Port CXR [12-28] - Lungs demonstrates moderate-to-large loculated right pleural effusion and adjacent atelectasis, not significantly changed in appearance from [2132-12-7]. The cardiomediastinal contour is stable. No pneumothorax is detected. Median sternotomy wires are redemonstrated. IMPRESSION: Moderate-to-large loculated right-sided effusion and adjacent atelectasis. Underlying consolidation not excluded. . TTE [6-8] - The left atrium is dilated. The right atrium is moderately dilated. The estimated right atrial pressure is [4-11] mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. At least moderate (2+) mitral regurgitation is present. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT CHEST W/O CONTRAST [2133-1-3] 1:47 PM CT CHEST W/O CONTRAST Reason: Evaluate pleural effusions [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with bilateral pleural effusions, possibly thought to be loculated on plain film, for the last month, diastolic CHF, CAD, HTN, and h/o breast cancer s/p lumpectomy REASON FOR THIS EXAMINATION: Evaluate pleural effusions CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL INDICATION: [Age over 90 ]-year-old woman with bilateral pleural effusions, possibly loculated on plain films, and history of breast cancer status post lumpectomy. Evaluate pleural effusions. COMPARISON: Multiple chest x-rays, the most recent one performed [2133-1-2], and CT Chest performed [11-5] and [6-7]. TECHNIQUE: CT of the chest was performed without IV contrast. CT CHEST WITH CONTRAST: A 1.7 cm right thyroid nodule is similar appearance to [2130-9-28]. Post-CABG changes are noted. There is a small right sided pleural effusion. Thickened pleura is seen anteriorly and posteriorly along the most inferior portions of the posterior right lower lobe effusion (5:55). This component of the effusion appears predominantly layering. There are small areas of loculation posterior and anterior (13:45) to the right right upper lobe. Debris is noted within the right bronchus intermedius upstream to a new 3.0 x 7.1 cm (5:49) area of consolidation in the right lower lobe. This may represent consolidation secondary to aspiration pneumonia, although neoplastic process cannot be excluded. A similar appearing region of consolidation is also seen in the right middle lobe, measuring 3.4 x 1.9 cm (5:42). 7 mm calcified nodule is also noted in the right middle lobe, similar to prior study of 7/[2130]. A 1.3-cm calcified left paratracheal lymph node is similar appearance to prior studies. There are no pathologically enlarged mediastinal, hilar, or axillary lymph nodes. The brachiocephalic artery is mildly dilated, unchanged since [2130-9-28]. Bone windows demonstrate no suspicious lytic or blastic lesions. Old right T11 rib fracture noted. The visualized portions of the upper abdomen again demonstrate calcified granuloma within the dome of the liver. A 2.1 x 1.6 cm right adrenal nodule measuring 35 Hounsfield units in attenuation, not scanned on prior imaging, does not meet CT criteria for adenoma. IMPRESSION: 1. A debris-filled right bronchus intermedius upstream to areas of consolidation may represent aspiration pneumonia, although a neoplastic process cannot be excluded in the right lower lobe. Followup to resolution recommended. 2. Right pleural effusion, with minimal loculated component, as noted above. There appears to be a thickened rind at the parietal pleura of the inferior right hemithorax. 3. Right adrenal nodule measuring 2.1 x 1.6 cm does not meet criteria for adenoma. Recommend MR [First Name (Titles) ] [Last Name (Titles) ] with adrenal protocol for further evaluation if clinically indicated. 4. Right thyroid nodule is grossly unchanged since [36]/[2128]. Brief Hospital Course: The patient was admitted to the ICU for flash pulmonary edema and noted to also have had a small NSTEMI in the setting of increased cardiac demand. She was intubated, and subsequently extubated without incident. She had some issues of delirium in the ICU requiring a sitter; however, by the time of her transfer to the floor these issues had resolved. She was aggressively diuresed and her blood pressure was aggressively controlled with good effect. She was covered with empric levofloxacin although no infectious sources were identified in the ICU. She was then transferred to the floor. The patient's loculated pleural effusions were re-evaluated with noncontrast chest CT which demonstrated interval improvement after aggressive diuresis. Pulmonary consult was obtained which recommended continued diuresis and conservative management. The patient developed mild acute renal failure and hypokalemia while being diuresed; her diuretic doses were adjusted and her kidney function returned to baseline. She was started on daily potassium supplement. On discharge, her blood pressure and heart failure were in good control. Her heart rate was well controlled in terms of her atrial fibrillation. Medications on Admission: Aspirin 81 mg daily Losartan 50 mg [Hospital1 ] Isosorbide Mononitrate 30 mg daily Paroxetine HCl 20 mg daily Buspirone 10 mg [Hospital1 ] Prilosec 40 mg daily Atorvastatin 40 mg daily Furosemide 60 mg [Hospital1 ] Metoprolol Tartrate 25 mg [Hospital1 ] Amlodipine 5 mg daily KCl 10 mEq daily . Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Paroxetine HCl 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Buspirone 10 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Atorvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) mL Injection TID (3 times a day). 8. Diltiazem HCl 120 mg Capsule, Sustained Release [Last Name (STitle) ]: One (1) Capsule, Sustained Release PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO BID (2 times a day). 10. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr [Last Name (STitle) ]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Furosemide 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 14. Hydrochlorothiazide 12.5 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal [Last Name (STitle) ]: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Acute on chronic diastolic heart failure with flash pulmonary edema and loculated pleural effusions 2. Non-ST elevation myocardial infarction 3. Coronary artery disease with history of 4-vessel CABG 4. Hypertension 5. Atrial fibrillation 6. Hyperlipidemia 7. Acute renal failure, resolved 8. Hypokalemia, resolved 9. Delirium, resolved Discharge Condition: Stable Discharge Instructions: You were admitted for congestive heart failure and also had a heart attack. Please contact your primary care physician if you develop worsening shortness of breath, chest pain, or swelling in your legs. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2133-4-20] 10:00	[ "511.9", "427.31", "410.71", "272.4", "428.0", "V45.81", "584.9", "428.33", "276.8", "414.00" ]	icd9cm	[ [ [] ] ]	[ "96.04" ]	icd9pcs	[ [ [] ] ]	11644, 11710	8363, 9563	270, 301	12092, 12100	3020, 5342	12453, 12603	2216, 2264		9925, 11621	5379, 5577	11731, 12071		9589, 9902			12124, 12430										2279, 3001																								223, 232	5606, 8340										329, 1863																1885, 2087	2103, 2200
4,787	112,600	2556	Discharge summary	report	Admission Date: [2127-7-28] Discharge Date: [2127-8-5] Date of Birth: [2044-1-3] Sex: M Service: MEDICINE Allergies: Meropenem / Penicillins Attending:[First Name3 (LF) 905] Chief Complaint: C2 fracture dislocation with progressive collapse Major Surgical or Invasive Procedure: 1. Open reduction internal fixation C2 fracture/dislocation. 2. Posterior instrumentation C1 to C2 and C2 to C5. 3. Posterior arthrodesis C1 to C5. 4. Left iliac crest bone graft. History of Present Illness: Mr. [Known lastname 12731] is a 83 yo man with MMP including ESRD on HD, CAD s/p MI, Afib not on anticoagulation, GIBs, COPD and restrictive lung disease, CVAs, nephrolithiasis with stent and nephrostomy tube, who was admitted in [4-28] for C2 dens fracture after falling off wheechair, failed conservative medical treatment, admitted on [2127-7-28] to ortho service for surgical management. Past Medical History: - ESRD on HD Tuesday/Thursday/Saturday - Atrial fibrillation, not on anticoagulation - h/o GI bleeds, diverticulitis - C. Diff colitis - h/o CVAs (two, with residual right-sided weakness) - h/o nephrolithiasis w/ stent and nephrostomy tube - CAD s/p MI - Sleep apnea (not on CPAP) - Depression - PFT's [2117] with mild restrictive ventilatory defect - Anemia with h/o iron deficiency - Recent fall with C2 dens fracture with anterior displacement ([4-/2127]) - Numerous line infections, most recently MRSA [4-/2127] which was treated with Vancomycin until [2127-5-10] (also with MRSA [8-/2125], ESBL E. Coli [9-/2125], [11/2125], [6-/2126], and [7-/2126]) - Delirium during hospital admissions - COPD and restrictive lung disease - Common bile duct stone s/p stenting [10/2126] - Urinary tract infections, including VRE and Klebsiella, with urosepsis Social History: Patient recently has been at rehabilitation since fall and C2 fracture. Lives with wife [Name (NI) ], daughter lives downstairs, h/o smoking [12-21] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. Family History: Non-contributory. Physical Exam: Physical exam on discharge: VS: T 97 HR 80 BP 98/62 RR 20 SaO2: 95% RA GA: Alert and oriented, lying in bed, NAD HEENT: MMM. no LAD. no JVD. Neck in brace. Cards: Soft heart sounds. RRR. S1/S2. no m/g/r. Pulm: Moving air appropriately, bibasilar crackles Abd: soft, NT, +BS. no g/rt. Extremities: wwp, no edema. DPs 2+ Skin: Sacral region with staples and dressing, c/d/i, Posterior neck with dressing. Neuro/Psych: A&O x 3. CN II-XII intact. 4/5 strength in U/L extremities. sensation intact to LT. Pertinent Results: [2127-7-29] 08:10AM BLOOD WBC-6.3 RBC-3.94* Hgb-12.0* Hct-37.6* MCV-96 MCH-30.5 MCHC-31.9 RDW-18.1* Plt Ct-120* [2127-8-4] 10:00AM BLOOD WBC-8.9 RBC-3.42* Hgb-9.9* Hct-31.3* MCV-92 MCH-29.1 MCHC-31.7 RDW-17.4* Plt Ct-158 [2127-7-28] 11:30PM BLOOD PT-14.0* PTT-25.8 INR(PT)-1.2* [2127-8-4] 10:00AM BLOOD PT-13.0 PTT-26.3 INR(PT)-1.1 [2127-7-31] 02:30PM BLOOD Fibrino-420* [2127-7-28] 11:30PM BLOOD Glucose-125* UreaN-46* Creat-5.5# Na-138 K-4.0 Cl-94 HCO3-27 AnGap-21* [2127-8-4] 10:00AM BLOOD Glucose-108* UreaN-28* Creat-3.6# Na-138 K-3.8 Cl-99 HCO3-28 AnGap-15 [2127-7-29] 08:10AM BLOOD Calcium-8.5 Phos-9.5# Mg-2.1 [2127-8-4] 10:00AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.0 [2127-8-1] 03:24PM BLOOD Type-ART pO2-187* pCO2-39 pH-7.45 calTCO2-28 Base XS-3 [2127-7-31] 07:59AM BLOOD freeCa-1.16 [2127-8-1] 02:33AM BLOOD freeCa-1.10* Imaging: 1. C-Spine (portable): In comparison with the study of [7-7], the area of the fracture of the dens is very poorly seen. There appears to be some posterior displacement of the body of C2, though it is difficult to determine whether there is any change from the previous study. Some soft tissue prominence is again seen at this level. CT may be necessary to properly evaluate the degree of displacement. 2. CXR: Questionable new rounded hazy opacities, could be artifactual from rib ends, but cannot exclude other processes such as septic emboli or traumatic etiology. Brief Hospital Course: # C2 dens fracture: Patient had originally been hospitalized in [4-28] after the fall from his wheelchair resulting in C2 dens fracture. At the time, the decision was made to manage him conservatively and patient was discharged to rehab. However, fracture did not heal well and patient developed progressive neurologic loss from spinal cord compression. After medical clearance, patient was admitted to the ortho spine service, where he underwent C1-C4 posterior fusion. Postoperatively he was transferred to the TSICU and kept intubated. He was successfully extubated and then underwent HD per normal regimen. He normally is slightly hypotensive during dialysis and required midodrine. He was transfused 2 units of pRBC at dialysis. Patient did well and then was transferred to the medical floor prior to discharge. . # ESRD: Patient is well known to the renal service. He was kept on his Tue/[Last Name (un) ]/Sat dialysis schedule while inpatient. He received midodrine to keep him normotensive during dialysis. Creatinine ranged from 2.1 to 5.5 during this hospitalization. He was kept on his home medications including nephrocaps and calcium acetate. His volume status and electrolytes were closely monitored. . # History of recurrent UTIs: UA on admission was concerning for UTI. Patient has a history of numerous resistent pathogens (VRE, ESNL, klebsiella). While on the ortho service received one dose of Vanco in OR and was started on bactrim, which was discontinued after urine culture came back negative. Foley was removed after transfer to the medicine floor. Patient remained afebrile with no leukocytosis, and thus did not require any antibiotics treatment. . # CAD: On admission did not show signs of ACS. Aspirin was held in the context of surgery. On discharge aspirin was continued per orthopedics service suggestion. . Medications on Admission: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY 4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO Tues-Thurs-Sat: Give one hour prior to dialysis. 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [12-21] Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: C2 dens fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 12731], you were admitted to the [Hospital1 ] Hospital because the fracture in your neck that you had was not healing on its own and so you decided to have surgery. Your orthopedic surgeon took bones from your hip and used it to make a bone graft for your neck. Your neck was also stabilized with instrumentation inside. After the surgery, you had a breathing tube, which was removed. You were placed in a soft neck collar which you have to continue wearing until you see the orthopedic surgeon for follow-up. Throughout the hospitalization you continued to get your normal dialysis treatments for end-stage renal disease. We gave you blood and medicine during dialysis to keep your blood pressure up. You never had a fever or had elevated white blood cell after the surgery. . We made the following changes to your medications: 1. Calcium Acetate 1334 mg by mouth three times a day WITH meals Followup Instructions: Department: NEUROLOGY When: FRIDAY [2127-8-8] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD [Telephone/Fax (1) 2574] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SPINE CENTER When: MONDAY [2127-8-18] at 9:40 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 Department: VASCULAR SURGERY When: WEDNESDAY [2127-9-10] at 8:00 AM [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2127-8-5]	[ "585.6", "E884.3", "280.9", "427.31", "438.89", "806.00", "V45.11", "780.79", "414.01", "412", "496" ]	icd9cm	[ [ [] ] ]	[ "81.63", "81.03", "03.53", "93.41", "39.95", "77.79" ]	icd9pcs	[ [ [] ] ]	6798, 6892	4177, 6025	331, 513	6953, 6953	2685, 4154	8081, 9102	2130, 2149				6913, 6932		6051, 6775			7129, 7962										2164, 2164															2192, 2666				7991, 8058					242, 293											541, 946									6968, 7105							968, 1860	1876, 2114
1,707	161,621	29677	Discharge summary	report	Admission Date: [2109-4-28] Discharge Date: [2109-5-3] Date of Birth: [2055-1-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10644] Chief Complaint: chest pain, right upper quadrant abdominal pain, mental status change Major Surgical or Invasive Procedure: none History of Present Illness: 54 M with Met RCC with brain mets, mid brain, s/p xrt 4 doses last on Monday [2108-3-25] w/ shunt placement, was placed at [Hospital1 ] then readmitted for a 5 week stay in [3-27] for multiple issues then discharged home. Patient now presenting with 1.5 days of diarrhea, decreased PO intake, confusion x3 days, generalized weakness, tachycardic with chest pain in the setting of steroid taper. He says that his gait has become more unsteady and his vision is "gone." Was brought to the ED by his son. . Son says that the pt had a clinic visit with Dr. [Last Name (STitle) 48151] on [4-15] (no note in OMR yet). Said at that time that the family wanted to shorten the rate of the steroid taper to get him off of it faster thinking it caused behavorial issues. The DC date was moved from [5-10] to [5-1]. . In the ED, vitals were 96.2, 102, 102/68, 18, 93% RA. ED was concerend for PE since had chest pain, was tachycardic, and had a clear CXR. Since had new ARF, no scan could be done in the ED and they arranged to have V/Q done on the [Hospital Ward Name ]. He was noted to have hyperkalemia and hyponatremia. He was given 1 L NS, morphine kayexelate, and dexamathasone 10 IV x1. Neuro was consulted in the ED and felt the patient had no significant changes on exam or on head CT. . On transfer to the [Hospital Unit Name 153], he was comfortable. Says has been having diarrhea the last few days. Has been eating less. Has had diploploa for the last 3 weeks, but says his near vision has gotten worse over the last few days. Can see far still, though double. Past Medical History: 1. RCC: The patient was initially found to have a renal cell abnormality in [2093] when he p/w flank pain. A CT scan identified a left adrenal nodule; this was biopsied and was negative. A bx revealed a renal cell carcinoma and underwent a L nephrectomy in [12-25]. with a left nephrectomy, that confirmed at 12.5 cm carcinoma. There was some concern also for pancreatic involvement. Followup CT scans done in [2-26] showed a new nodule in the lungs. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 437] at [Hospital1 112] resected 3 L lung nodules, but the patient states only one was positive, other two just showed necrosis. That [Month (only) 404], he began to notice difficulty with his L leg and in [Month (only) 116] had a lesion of the L femur. This was resected by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital1 112] and pathology was significant for metastatic clear cell renal carcinoma. The patient was then seen on [2109-2-6], by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] and based on the discussion decided to proceed with IL-2 therapy. He therefore had a head CT on [2109-2-20] that showed a 1.3 cm mid brain lesion and he was sent by Dr. [Last Name (STitle) 29267] for consult. This was biopsied during this [3-27] admission and showed renal cell. 2. DM dx after nephrectomy 3. Brain Mets s/p VP Shunt [3-1] Social History: Divorced. 50-pack-year history of smoking. He quit ~one year ago after his nephrectomy. He does not drink alcohol. Family has been providing him with total care at home. He is unable to go tot he bathroom, feed, or dress unassisted. Family History: His mother died at 73 of MI and his father died at 72 of an MI. He has three sisters, 67, 65, and 60 with high blood pressures. His brother is 60 with prostate cancer. He has twin sons who are 30 years old who are in good health. Physical Exam: VS: 95.7 90/57 92 23 98% 2L NC GEN: NAD in bed HEENT: sclerae anicteric, EOMI. L eye with disconjugate gaze. dry MM Neck: no JVD Lungs: CTA bilat, no w/r/r CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, nabs Extr: no c/c/e, DP 2+ bilat Neuro: CN II-XII grossly intact. 5/5 strength UE/LE, nl sensation throughout. Toes- downgoing. Reflexes- 2+ thoughout. Pertinent Results: [2109-4-28] 05:35PM BLOOD WBC-13.1* RBC-4.36* Hgb-12.1* Hct-34.1* MCV-78* MCH-27.8 MCHC-35.5* RDW-17.2* Plt Ct-289# [2109-4-29] 05:27AM BLOOD WBC-12.4* RBC-3.65* Hgb-9.9* Hct-28.8* MCV-79* MCH-27.1 MCHC-34.3 RDW-16.7* Plt Ct-256 [2109-5-1] 07:15AM BLOOD WBC-13.2* RBC-3.44* Hgb-9.2* Hct-26.6* MCV-77* MCH-26.7* MCHC-34.5 RDW-16.7* Plt Ct-295 [2109-5-2] 07:15AM BLOOD WBC-12.9* RBC-3.19* Hgb-8.8* Hct-25.5* MCV-80* MCH-27.6 MCHC-34.5 RDW-17.4* Plt Ct-253 [2109-5-2] 03:00PM BLOOD WBC-17.8* RBC-3.72* Hgb-10.1* Hct-29.4* MCV-79* MCH-27.1 MCHC-34.3 RDW-16.8* Plt Ct-333 [2109-4-28] 05:35PM BLOOD PT-13.8* PTT-24.8 INR(PT)-1.2* [2109-5-1] 07:15AM BLOOD PT-13.8* PTT-26.0 INR(PT)-1.2* [2109-5-2] 07:15AM BLOOD Ret Aut-3.1 [2109-4-28] 05:35PM BLOOD Glucose-178* UreaN-59* Creat-1.5* Na-122* K-6.2* Cl-93* HCO3-15* AnGap-20 [2109-4-28] 07:23PM BLOOD Glucose-170* UreaN-60* Creat-1.6* Na-122* K-6.1* Cl-93* HCO3-16* AnGap-19 [2109-4-29] 01:17AM BLOOD Glucose-225* UreaN-63* Creat-1.8* Na-122* K-6.1* Cl-92* HCO3-17* AnGap-19 [2109-4-29] 05:33PM BLOOD Na-125* K-5.4* [2109-4-30] 04:30PM BLOOD Glucose-127* UreaN-38* Creat-1.0 Na-126* K-5.2* Cl-96 HCO3-15* AnGap-20 [2109-5-1] 07:15AM BLOOD Glucose-105 UreaN-33* Creat-0.9 Na-130* K-4.3 Cl-95* HCO3-24 AnGap-15 [2109-5-2] 07:15AM BLOOD Glucose-76 UreaN-34* Creat-0.9 Na-130* K-3.9 Cl-97 HCO3-23 AnGap-14 [2109-4-28] 05:35PM BLOOD ALT-51* AST-23 CK(CPK)-20* AlkPhos-158* Amylase-43 TotBili-0.4 [2109-5-1] 07:15AM BLOOD ALT-23 AST-9 AlkPhos-97 TotBili-0.3 [2109-5-2] 07:15AM BLOOD Hapto-376* [2109-4-28] 07:23PM BLOOD Osmolal-280 [2109-4-30] 04:39AM BLOOD Osmolal-276 [2109-4-30] 04:30PM BLOOD Cortsol-1.3* [2109-4-30] 08:15PM BLOOD Cortsol-3.8 [2109-4-28] 05:42PM BLOOD Lactate-2.4* [2109-5-1] 08:32AM BLOOD Lactate-4.2* . . STUDIES: CT TORSO: 1. Marked increase in the size of the right adrenal lesion, multiple new pulmonary nodules, multiple new regions of nodularity within the omentum and peritoneum are all suggestive of marked disease progression. 2. New ascites in the abdomen likely relates to new ventriculoperitoneal shunt which is in place. 3. Normal appendix. 4. New small right pleural effusion. Brief Hospital Course: 54 M with metastatic RCC presenting with w/ CP/FTT/abdominal pain, found to have hypoNa, hyperK, low bicarb. Pt admitted initially to the ICU for close monitoring, then called out to medical service after 24hrs. . # hypoNa, hyperK, NG acidosis - originally concerned that this was [2-22] rapid withdrawal of prednisone resulting in adrenal insufficiency, pt not frankly hypotensive on admission, and was treated with dexamethasone in the ICU. After arriving on the medical service, pt noted to have SBPs 90s/60s, but responded well to 500cc fluid bolus. recurrent hypotension again [5-1] and [5-2], responds to 500cc fluid boluses. . a renal consult was obtained [5-1], and per recs, pt's labs were felt suggestive of SIADH [2-22] brain mets vs RTA. electrolytes improved with gentle fluid hydration, and bicarb replacement (PO NaHCO3 [Hospital1 ] + D5W + HCO3). did not feel that pt's mental status was related to electrolyte abnormalities, though plausbile. given goals of care in light of progression of malignancy, plan is to discharge pt on oral bicarb replacement (sodium bicarb tablets) and steroid replacement (both prednisone and florinef). . . # mental status - pt a&ox3, though frequently lethargic. originally felt mental status was related to brain mets rather than electrolyte imbalances, however his mental status has been stable despite correction of electrolytes. given goals care no further intervention needed at present. . . # abd pain/oncology - CT TORSO obtained in light of RUQ pain on admission to medical floor which revealed substantial disease progression as detailed in report above, including enlargement of adrenal mass. upon further discussion with pt and family, decision made to change goals of care to comfort measures only, and pt discharged to hospice, with possible plan for sutent treatment. pt made DNR/DNI. pain control initiated with oxycodone prn with bowel regimen prn. . . # Diarrhea- resolved upon arrival to medical service, culture data unremarkable. Pt trated with Immodium PRN. . . # Ronchi- ?bronchitis on initial presentation, though no evidence of pneumonia on CT scan, pt with stable O2 sats, started on MDI inhaler prn for SOB or wheezing. . . # DM- Stable. given goals of care, no need for insulin. . # ARF- improved w/IVF. pt treated with oral bicarb and D5W with 3amps BICARB per renal recs. plan to d/c pt home with bicarb repletion given ongoign acidosis (lactate 4.2, likely [2-22] renal cell ca). . . # FEN: diabetic diet, though could be switched to regular at hospice. . # DISPO: pt discharged home with hospice. will be followed by PCP. [Name10 (NameIs) ] consider sutent therapy. Medications on Admission: Levetiracetam 500 mg [Hospital1 ] Pantoprazole 40 mg daily Quetiapine 100 mg [Hospital1 ] Was DC on Dexamethasone 8 TID in [3-27] then has been on taper. Has taken: Monday - Tuesday 2,2,2; Wednesday - Saturday 2,2; Today took 2mg only per taper Bactrim daily Novolin 70/30 38 qAM, 26 qPM and Humalog in the afternoon Discharge Medications: 1. HOSPITAL BED please provide pt with HOSPITAL BED 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Florinef 0.1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 1 months. Disp:336 Tablet(s) Refills:0 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:30 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:60 Capsule(s) Refills:0 9. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:2 10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:30 Adhesive Patch, Medicated(s) Refills:2 12. 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 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [1-22] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:2 inhaler Refills:2 14. seroquel 100mg po bid Discharge Disposition: Home With Service Facility: [Hospital 71105] Hospice Discharge Diagnosis: metastatic renal cell carcinoma Discharge Condition: stable. Discharge Instructions: you were admitted to the hospital with multiple complaints including chest pain, abdominal pain, and mental status changes. a CT scan of your torso revealed significant progression of your previous malignancy. you are being discharged to home hospice. Followup Instructions: if you have any questions or concerns please contact your primary care physician.	[ "198.3", "197.0", "198.5", "786.59", "V10.52", "276.1", "783.7", "276.7", "787.91", "584.9", "250.00", "255.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11484, 11543	6735, 9429	385, 391	11619, 11629	4461, 6712	11931, 12016	3841, 4072		9809, 11461		11564, 11598		9455, 9786			11653, 11908										4087, 4442																								276, 347											419, 2017																2039, 3574	3591, 3825
43,450	177,207	566	Discharge summary	report	Admission Date: [2156-9-14] Discharge Date: [2156-10-4] Date of Birth: [2116-3-20] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2090] Chief Complaint: confusion Major Surgical or Invasive Procedure: Dialysis on [2156-9-14] for acidosis and hypokalemia Intubation PICC line placement History of Present Illness: 40-year-old female DM2 transferred from [Hospital 1562] Hospital for severe acidosis from ? DKA, altered mental status, and respiratory failure. Patient presented to the outside hospital with altered mental status and agitation. She was noted to be hypotensive. Initial labs revealed elevated lipase. As the patient became more agitated, she was intubated for airway protection. She was given 6 L of NS with levophed at 3 mcg/min started and increased to 25 mcg/min. Vent settings on transfer were SIMV 12/500/1/5. She was given KCl 10 mEq x 2. She was transferred to [Hospital1 18] for further management. Labs prior to transfer were lactate 0.8, alcohol < 10, lipase 1027, CK 86, cTropnT < 0.010, amylase 553, ALP 173, GGT 107, AST 50 ALT 58, Na 123, K 4, Cl 93, HCO3 3, BUN 42, Cr 1.05, Glc 685, Mg 2.7, Ph 4.4, Gap 30. CBC WBC 35.9, Hgb 13.2, Plt 97, 8 % bands. In the ED, initial VS were: 82 95/51 22 100% Patient received intubated from OSH. 7.5 ETT secured @ 22cm @lips. Initial vent settings were FiO2: 100% PEEP: 5 RR: 14 Vt: 500 Initial ABG was pH 6.74 pCO2 33 pO2 385 HCO3 5. Based on ABG results RR increased to 22 and FiO2 decreased to 40%. A RIJ and left femoral a-line was placed in the ER. Past Medical History: Insulin dependent diabetes mellitus Social History: Patient lives in [Location ]. Her father is an internist and is currently here visiting while she is in the hospital. Tobacco: [8-1] pack year smoking history in the [2134]. Quit for 10 years, recent relapse, but now without smoking for 6 months. EtOH: Socially; 2 drinks/month. IVDU: Denies. Family History: Diabetes in multiple family members. Denies family history of seizures and strokes. Physical Exam: Admission Physical Exam: General Appearance: Intubated, sedated Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, atraumatic, IJ line in place Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), no murmurs Peripheral Vascular: pulses present throughout Respiratory / Chest: clear bilaterally Abdominal: Soft, Non-tender, Bowel sounds present Extremities: no peripheral edema Skin: Warm Neurologic: intubated, sedated Physical Exam on Discharge: Vitals: afebrile, hemodynamically stable General: Awake, cooperative, NAD. Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 5 5 4+ 5 3 3 5 5 5 5 2 5 3 R 5 5 5 5 5 5 5 5 5 4 2 5 3 -Sensory:decreased in L 5 to midshin b/l, decreased at L ulnar n distribution from 5th digit to wrist -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Pertinent Results: ADMISSION LABS: [2156-9-14] 12:52AM BLOOD WBC-37.36* RBC-4.25 Hgb-12.4 Hct-38.5 MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-67* [2156-9-14] 04:00AM BLOOD Neuts-59 Bands-8* Lymphs-16* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-11* [2156-9-14] 12:52AM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1 [2156-9-14] 04:00AM BLOOD Glucose-568* UreaN-33* Creat-1.1 Na-134 K-2.1* Cl-109* HCO3-LESS THAN [2156-9-14] 12:52AM BLOOD ALT-92* AST-129* AlkPhos-149* TotBili-0.4 [2156-9-14] 12:52AM BLOOD Lipase-612* [2156-9-14] 04:00AM BLOOD cTropnT-<0.01 [2156-9-14] 12:52AM BLOOD Calcium-6.3* Phos-2.3* Mg-2.1 [2156-9-19] 09:00PM BLOOD calTIBC-221* Ferritn-293* TRF-170* [2156-9-14] 04:00AM BLOOD %HbA1c-13.1* eAG-329* [2156-9-14] 12:52AM BLOOD Triglyc-488* [2156-9-14] 04:00AM BLOOD Acetone-SMALL Osmolal-336* [2156-9-14] 04:00AM BLOOD TSH-1.2 [2156-9-14] 04:00AM BLOOD Cortsol-91.5* [2156-9-14] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2156-9-14] 04:00AM BLOOD HCG-<5 [2156-9-20] 04:00PM BLOOD [Doctor First Name ]-NEGATIVE [2156-9-20] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76 IFE-MONOCLONAL [2156-9-14] 12:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2156-9-14] 01:57PM BLOOD HCV Ab-NEGATIVE [2156-9-14] 01:12AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5 FiO2-100 pO2-385* pCO2-33* pH-6.74* calTCO2-5* Base XS--33 AADO2-294 REQ O2-55 -ASSIST/CON Intubat-INTUBATED [2156-9-14] 12:53AM BLOOD Glucose-500* Na-137 K-2.7* Cl-118* calHCO3-3* [2156-9-14] 12:52AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 [2156-9-14] 12:52AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2156-9-14] 12:52AM URINE RBC-<1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1 [2156-9-14] 12:52AM URINE Mucous-RARE [2156-9-14] 12:52AM URINE UCG-NEGATIVE [2156-9-14] 12:52AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Relevant Labs: [2156-9-29] 05:10AM BLOOD ESR-99* [2156-9-26] 12:05PM BLOOD ESR-103* [2156-9-29] 05:10AM BLOOD Ret Aut-8.5* [2156-9-20] 07:24AM BLOOD Ret Aut-0.6* [2156-9-20] 07:24AM BLOOD calTIBC-211* Hapto-286* Ferritn-256* TRF-162* [2156-9-20] 04:00PM BLOOD VitB12-1251* [2156-9-14] 04:00AM BLOOD %HbA1c-13.1* eAG-329* [2156-9-15] 07:55AM BLOOD Triglyc-276* [2156-9-14] 04:00AM BLOOD TSH-1.2 [2156-9-14] 04:00AM BLOOD Cortsol-91.5* [2156-10-1] 03:18AM BLOOD HIV Ab-PND [2156-9-14] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2156-9-24] 05:21AM BLOOD ANCA-NEGATIVE B [2156-9-29] 05:10AM BLOOD b2micro-1.5 [2156-9-20] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76 IFE-MONOCLONAL [2156-10-1] 03:18AM BLOOD HIV Ab-PND RPR [2156-9-20]: negative Lyme [2156-9-20]: negative [2156-9-18] 8:22 pm BLOOD CULTURE Source: Venipuncture. MICRO: [2-1] blood cultures: Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . 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 TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S STUDIES: ECHO ([2156-9-14]) IMPRESSION: Normal biventricular cavity sizes with preserved regional and hyperdynamic global biventricular systolic function. No valvular pathology or pathologic flow identified. CT Head Non-con ([2156-9-14]): IMPRESSION: No evidence of acute intracranial pathology. CT Abd/Pelvis ([2156-9-14]): 1. Visualized lung bases show bilateral trace pleural effusions with adjacent opacification which likely represents atelectasis; however, a component of aspiration versus infectious process such as pneumonia cannot be completely excluded. 2. Minimal edema within the fat in the groove between the pancreas and duodenum which may represent focal acute pancreatitis with extension of edema to the pericholecystic region. 3. Multiple transient intussceptions are noted along the jejunum (uncertain significance). 4. Significantly fatty liver. ECHO ([9-21]): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [2156-9-14], findings are similar. The heart rate is now slower. EMG [2156-9-23] Abnormal study. There is electrophysiologic evidence for an acute, severe, sensorimotor polyneuropathy affecting the bilateral lower extremities. Although this neuropathy appears to have axonal features, a demyelinating pathology cannot be entirely excluded due to the absence of distal sensorimotor responses. In addition, there is evidence for a severe, acute ulnar neuropathy at the left elbow. A right lumbosacral polyradiculopathy cannot be entirely excluded. EMG [2156-9-30] Taken together with the results of [9-23], the findings are most consistent with severe, acute bilateral sciatic neuropathies. Given the clinical history and evidence for left ulnar neuropathy, a compressive etiology for these neuropathies is most likely. MRI L spine w/o contrast FINDINGS: Intervertebral disc heights and signals are maintained. There is no signal abnormality in the cord. Vertebral body heights are maintained and show normal signal. Imaged portions of the soft tissues are unremarkable. A small disc buldge is present at L5-S1 with very minimal compression of the thecal sac, but no contact with traversing nerve roots. IMPRESSION: Very minimal disc buldge of L5-S1. If there is concern for polyneuritis, post gadolineum imaging can be obtained. Skeletal Survey LATERAL SKULL: No focal lytic or blastic lesions are seen. BILATERAL HUMERI: There is a portion of a central venous catheter seen in the right arm. There are no focal lytic or blastic lesions or significant degenerative changes. THORACIC SPINE: No compression deformities are seen. There is minimal spurring at the anterior aspect of several lower thoracic vertebral bodies. Visualized lung fields are clear. There is a central venous catheter with distal lead tip at the cavoatrial junction. LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies. There is no compression deformity. Minimal spurring at the L4 and L5 vertebral bodies are seen anteriorly. AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen. The sacroiliac joints are grossly within normal limits. Bilateral hip joint spaces demonstrate mild spurring in the superolateral aspect, consistent with early degenerative changes. IMPRESSION: No focal lytic or blastic lesions in the skeleton to indicate definite myelomatous deposits. Sural biopsy: final report pending at time of discharge. Prelim read was normal. Labs on Discharge: (most recent) [2156-10-1] 03:18AM BLOOD WBC-3.7* RBC-3.08* Hgb-8.9* Hct-27.4* MCV-89 MCH-29.0 MCHC-32.7 RDW-15.8* Plt Ct-327 [2156-9-29] 05:10AM BLOOD PT-11.5 PTT-25.9 INR(PT)-1.1 [2156-10-1] 03:18AM BLOOD Glucose-121* UreaN-14 Creat-0.5 Na-137 K-4.7 Cl-103 HCO3-27 AnGap-12 [2156-9-29] 05:10AM BLOOD ALT-45* AST-35 LD(LDH)-200 AlkPhos-81 TotBili-0.3 [2156-9-29] 05:10AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.7 Mg-1.9 Brief Hospital Course: 40F unknown past medical history with Insulin dependant DM2 transferred to [Hospital1 18] for severe acidosis and hypokalemia in setting of DKA. Patient managed in the MICU for 6 days with resolution of her acidosis noted. Patient was called out to the floor on hospital day 6 after being stable on SubQ insulin. Course complicated by new sensory-motor polyneuropathy of left upper extremity and bilateral lower extremities. Transfered to neurology service after EMG concerning for axonal neuropathy on hospital day 11, ultimately determined to be a compressive neuropathy vs. multiple root radiculopathy. # Severe acidosis likely DKA Patient has severe acidosis on ABG with both primary metabolic non-gap and gap acidoses with superimposed respiratory acidosis. Etiology of primary metabolic non-gap acidosis may be from NS volume resuscitation, diarrhea, or other etiologies. The likely cause of the anion gap acidosis is DKA with no other apparent MUDPILES etiologies based on urine/serum toxicology. Osmolar gap initially 51, so methanol, polyethylene glycol or other exogenous substance may explain extra osmoles that would not be accounted for by DKA alone. Patient started on Insulin drip and Bicarb which were rate limited so as not to drop K+ faster than it could be repleted. Over the course of hospital day 1 patient was noted to have progressive improvement of her acidosis. In setting of severe acidosis and osmolar gap, patient received a single episode of hemodialysis. In the evening of hospital day 1 the patient's anion gap was noted to re-open to 24, patient was given additional IV fluids and insulin drip was continued with resolution of anion gap noted on repeat Chem7. Patient tolerated a PO diet on hospital day 4 and was started on SubQ insulin. Following initiation of SubQ insulin the insulin drip was discontinued. The patient was observed in the MICU following discontinuation of the insulin drip and her anion gap was noted to remain closed. Once the patient was fully awake she endorsed poor medication compliance with regards to her insulin. She states that she was on vacation prior to onset of DKA and that she did not utilize her insulin at all during a period of time during her vacation making medication non-compliance the most likely etiology of her DKA. After transfer to the general medicine, her blood sugars remained in the 120-250 range and she was kept on Lantus 50 units in the am and humalog sliding scale. She was followed closely by the [Last Name (un) ] service. Insulin dose on discharge was Lantus 40qam and 16qhs along with sliding scale. Instructed patient about importance of insulin compliance and establishing care with a primary care doctor upon return to [State 4565]. # Leukocytosis/hypothermia/MRSA bacteremia Initial concern for hypothermic sepsis given marked leukocytosis. Careful skin exam did not reveal any skin/soft tissue infection. CXR showing ? atelectasis vs. developing LL infiltrate after fluid resuscitation. CT Abdomen could suggest colitis although indefinite. Host factors include DM2 - no recent healthcare exposure- vancomycin/cefepime/flagyl given empirically as patient critically ill pending culture results. Patient's antibiotics discontinued on hospital day 3 as all cultures acquired were negative. On hospital day 5, repeat CXR concerning for new pneumonia and UA concerning for UTI. Repeat cultures sent and patient re-started on vanc and cefepime. Cultures sendt [9-18] noted to grow out gram positive cocci in clusters, central line discontinued and patient continued on vanc and cefepime. She remained on Vancomycin after confirmed MRSA bacteremia to complete a 2 week course ending [2156-10-2]. A PICC was placed [2155-9-22] via IR guidance after an initial failed attempt. She also had a TTE which did not show evidence of vegetation, thus low suspicion of endocarditis. She completed a course of Vancomycin per recommendations of the infectious disease team on [2156-10-3]. # ? Pancreatitis The patient had elevated pancreatic enzymes, which may reflect either pancreatitis or increased pancreatic enzyme activities in the setting of DKA. Her abdominal exam appears to be bengin. A CT Abd/pelvis showed bowel wall thickening mainly involving the proximal small bowel (duodenum and jejunum) which could represent peristalsis, enteritis (such as infectious, inflammatory or ischemic) with mild blurring of pancreatic margins with minimal mesenteric stranding. It also shows multiple transient intussusception of jejenum, little bit of fluid in mesenetery and pancreas consistent with ? focal pancreatitis. Patient was evaluated by surgery for questionable CT abdomen findings, no surgical intervention indicated per surgery. TG mildly elevated, but unclear if high enough to have precipitated pancreatitis. Ca within normal limits; no evidence of CBG/gallstone pancreatitis on CT Abd. As patient's mental status improved appeared to be in pain with apparent tenderness to palpation of epigastrum, in setting of elevated lipase we have increased suspiscion of pancreatitis as cause of pain and possibly as etiology of DKA. Treated with IV Dilaudid PRN pain. Patient subsequently noted to have improvement of pain and tenderness likely representing resolution of acute pancreatitis episode. There was no further abdominal pain/tenderness while on the floor. # Respiratory failure Patient was intubated secondary to depressed mental status for airway protection. Patient passed spontaneous breathing test on hospital day two and was extubated. No further respiratory distress. # Shock Patient likely had septic shock from underlying infection, hypovolemic shock from osmotic diuresis in setting of DKA. Doubt cardiogenic or distributive shock. Her opening CVP was 11 with good urine output, normal lactate, and exam consistent with good perfusion. ScVO2 is ~ 90 suggestive of likely tissue mitochondrial dysfunction in setting of severe acidosis. She has been responsive to IVF resuscitation. By hospital day 2 patient was noted to have improvement in hemodynamics and was weaned off of phenylephrine. # Elevated LFTs Patient had mild elevated LFTs at OSH and on admission at [Hospital1 18]. Uncertain etiology - abdominal CT not showed elevated Tbili or other overt abnormalities. Could be from toxidrome vs. early shock liver given hypotension or other causes. Patient's LFTs were trended and returned to baseline. # Thrombocytopenia Admission platelets with thrombocytopenia. Etiology is likely marrow suppresion from acute sepsis/illness. No evidence of sequestration or destruction - firinogen and coagulation is within normal limits speaking against DIC. Was noted to have improvement of platelet count during ICU stay. Normal platelet counts while on the floor. She was seen by heme/onc who recommended a skeletal survey which was normal. Also recommended HIV, which is pending at time of discharge. Considered bone marrow biopsy, but deferred given abnormalities likely in setting of acute illness. Asked patient to seen a hematologist/oncologist in 3 months and have them re-check SPEP, free kappa/lambda chains. Also, re-consider a bone marrow biopsy if values have not normalized. #Anemia: She developed normocytic anemia during this hospitalization (Hgb 12.5 -> 8.4). This was likely secondary to volume repletion. B12, folate, and Iron studies within normal limits. No evidence of active bleeding. Would continue to follow H/H, although it has remained stable. # Severe acute axonal sensory-motor polyneuropathy Patient was in ICU for 6 days. Intubated and sedated. Then extubated and off sedation and noted tingling in her hands and feet. She couldn't "wiggle her ankles". Her exam was most notable for an Left Ulnar neuropathy and difficulty with TA [2-29] bilateralas well as weakness of the toe flexors. Did not fit distribution. Differential was initially critical illness neuropathy, mononeurotis multiplex. EMG looked like a severe acute axonal sensorimotor polyneuropathy intially. Confirmed that the left wrist was an ulnar neuropathy. Had repeat EMG which showed bilateral sciatic nerve neuropathies, probably compression from position. Also possible that she has a multiple root lumbosacral radiculopathy. Currently, strength and sensation improving as per discharge exam. Does have painful tingling in her lower extremities, likely nerve pain with regeneration, which responds well to Gabapenin and tylenol with codeine. Since patient has bilateral foot drop, had orthotics made for her. She will follow up with neurology as an outpatient once she returns to [State 4565]. TRANSITIONAL ISSUES: - follow up with PCP regarding fatty liver on ultrasound, high triglycerides, hepatitis serology - 3 months from now (early [Month (only) 1096]) you should see a hematologist/oncologist and ask them to check these labs: SPEP, free kappa/lambda chains. Also, re-consider a bone marrow biopsy if values have not normalized. - HIV and final report of sural nerve biopsy pending at time of discharge - patient will follow up with a new PCP and neurologist upon return to [State 4565]. Medications on Admission: Lantus 40 units SC daily Discharge Medications: 1. Gabapentin 200 mg PO TID RX gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #180 Capsule Refills:2 2. Glargine 40 Units Breakfast Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX blood sugar diagnostic [Accu-Chek Active Test] QAHS Disp #1 Not Specified Refills:2 RX insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 40 Units before BKFT; 16 Units before BED; Disp #2 Not Specified Refills:2 RX blood-glucose meter [Accu-Chek Active Care] Before every meal and at bedtime QAHS Disp #1 Kit Refills:1 RX insulin lispro [Humalog KwikPen] 100 unit/mL Up to 25 Units per sliding scale four times a day Disp #2 Not Specified Refills:2 RX lancets [Accu-Chek Multiclix Lancet] QAHS Disp #1 Not Specified Refills:1 3. Miconazole Powder 2% 1 Appl TP TID:PRN groin rah RX miconazole nitrate [Anti-Fungal] 2 % apply to affected area three times a day Disp #1 Tube Refills:0 RX miconazole nitrate [Anti-Fungal] 2 % three times a day Disp #1 Tube Refills:1 4. Acetaminophen w/Codeine [1-26] TAB PO Q4H:PRN pain please hold for rr <12, sedation RX acetaminophen-codeine 300 mg-30 mg 1 tablet(s) by mouth every four (4) hours Disp #24 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: diabetic ketoacidosis bilateral sciatic neuropathies vs. multiple root lumbosacral radiculopathy secondary diagnosis: diabetes mellitus type I Critical illness polyneuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 4566], It was a pleasure taking care of you. You were admitted to the [Hospital1 69] for a severe case of diabetic ketoacidosis. You were initially stabilized in the intensive care unit (ICU). We found that you had a blood stream infection and treated you with intravenous antibiotics. You had a weakness of your ankles and left arm that we investigated. We biopsied several of your nerves and did EMGs. We determined that the cause of your weakness was due to compression of the scitic and ulnar nerves as you are at risk for this with your diabetes. During the hospital stay, your strength and sensation gradually began to improve. We think this will continue to improve over the next year. We started you on Gabapentin (Neurontin) for the pain. When you return to [State 4565] it is important that you schedule an appointment with a neurologist. Also it is CRITICAL that you follow up with your primary care doctor for STRICT management of your diabetes as we do not want you to become ill from the high sugars as you did this time. You MUST check your blood sugars regularly and [Last Name (un) ] your insulin. You had some abnormal blood counts so we asked the hematology/oncology team to evaluate you. They recommended an x-ray of your body which was quite normal. Most likely, these abnormalities were in the setting of acute illness. 3 months from now (early [Month (only) 1096]) you should see a hematologist/oncologist and ask them to check these labs: SPEP, free kappa/lambda chains. Also, re-consider a bone marrow biopsy if values have not normalized. We have made the following changes to your medications: START Gabapentin 200mg three times per day for nerve pain Tylenol with codeine up to every 4 hours as needed for pain Miconazole powder as needed for rash Insulin sliding scale INCREASE Lantus to 40 units in the morning and 16 units at bedtime On discharge, please schedule appointments with a neurologist, a primary care doctor as soon as possible. Also, schedule an appointment with a hematologist/oncologist in early [Month (only) 1096]. It was a pleasure taking care of you, we wish you all the best! Followup Instructions: On discharge, please schedule appointments with a neurologist and primary care doctor as soon as possible. Also, schedule an appointment with a hematologist/oncologist in early [Month (only) 1096]. Please ask them to check the tests mentioned above. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43] MD [MD Number(1) 2107] Completed by:[2156-10-4*]	[ "E879.8", "272.1", "288.60", "401.9", "780.65", "250.62", "V15.81", "571.8", "112.2", "354.2", "276.8", "293.0", "785.59", "276.0", "995.93", "355.0", "999.32", "V15.82", "250.12", "V58.67", "790.7", "354.5", "273.1", "728.88", "724.4", "736.79", "577.0", "287.5", "041.12" ]	icd9cm	[ [ [] ] ]	[ "04.12", "39.95", "96.71" ]	icd9pcs	[ [ [] ] ]	23430, 23436	12928, 21597	315, 404	23675, 23675	4267, 4267	26079, 26490	2051, 2136		22184, 23407		23457, 23457		22134, 22161			23858, 25513							3260, 4248			2176, 2603						7321, 12447									2632, 2875			21618, 22108	25542, 26056					266, 277						12466, 12905					432, 1652			23595, 23654		4283, 7277		23476, 23574		23690, 23834							1674, 1711	1727, 2035
23,779	187,571	16125	Discharge summary	report	Admission Date: [2199-7-7] Discharge Date: [2199-7-10] Date of Birth: [2150-8-5] Sex: M Service: MEDICINE Allergies: Vancomycin / Percocet Attending:[First Name3 (LF) 106] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: tandemheart mechanical ventilation central line arterial line History of Present Illness: 48M with sick social contacts, [1-20] day history of n/v/d, fever/chills, mylagias, had one episode of BRBPR this morning (bright red and mixed with stool) and since that time more lightheaded, fatigued, here for further evaluation. Reports chest pain, "non-pleuritic" otherwise denies shortness of breath. . In the ED, initial vs were: 98.3 89 92/52 16 98% RA. Exam notable for clear chest, guaiac positive brown stool. CXR, UA unremarkable. SBP's in 70's. NG lavage showed coffee grounds that cleared. Given 5mg of VitK for INR of 3.9 given the concern for GI bleed. Linezolid, zosyn. Serial EKGs taken with the third looking wellinoid. Trop came back at 0.44. ED thought it was "demand ischemia". GI and Cards were consulted and then the patient bradied down and lost pulse. Coded in the ED for 30 minutes. Two returns of spont circ. Shocked 5 times for "vfib/vtach". Received epi, lido, ca, amio, bicarb. Given norepi and dobutamine, 5L of NS. Bedside US - no effusion. Sent to cath lab. . In Cath lab patient was in PEA arrest. 60 additional minutes of ACLS ensued with high pressure chest compressions. Received several rounds of epi, atropine, 4 u of pRBC; also norepi and vasopressin. A balloon pump trialed and replaced with tandem heart. . In the CCU, phone numbers called, no answer. His cellular phone is dead. His PCP was emailed. Ultimately, family contact[Name (NI) ] and will come in. Family meeting had with partner. . Patient was medically unstable on levophed and epi drip. Began in sinus brady, received 2mg of atropine, 1 of epi, 7 amp of bicarb. Bicarb drip started, dopa added briefly. Patient went into VF 3 times and [Name (NI) 3941] shocked and came out into sinus tach. Lidocaine 50 bolus followed by drip. Very difficult to ventillate (non-compliant), bag masked throughout this medical-code, and then switched to ECMO. Past Medical History: - Diabetes - Dyslipidemia, -CAD: Early onset CAD, s/p CABG [2191], angio in [2192] demonstrated vein stump occluded SVG to D1, OM1, RPDA but with patent LIMA-LAD graft. MIBI in [2194] demonstrated multiple fixed defects and akinesis, no reversible defects. Patient has history of silent MI prior to CABG. Reported as anterior apical myocardial infarct. -CHF: MIBI in [2194] demonstrated a LVEF of 25%. [Year (4 digits) 3941] placed for episode of V-tach on day of CABG. h/o chronic systolic HF (EF 30%) -PA hypertension: Cardiac cath in [2192] demonstrated moderate pulmonary hypertension (45mm Hg) and severely elevated left-sided filling pressures. Heart Failure Diagnosis [2192-7-16] -PVD: s/p recent L toe amputation for gangrene; [12-26]- Left fem-[Doctor Last Name ] bypass; [9-/2197] Thrombectomy of femoral-popliteal bypass graft left side and revision with bovine pericardial patch of the distal anastomosis. -DM type II: on metformin, glipizide, insulin, last A1c 6.9. Diagnosed at age 14. -Hepatitis: Patient reports possible Hep A and Hep B infections in past, reports that follow-up testing showed no chronic infection -Renal insufficiency- began recently. DM-related. Followed at [Last Name (un) ]. -Angiography in [2192] showing only patent LIMA-LAD PSH: -CABG [2191] -L 3rd toe amp [2193] -L SFA angioplasty [2195] -L 4th toe amp [2195] -L SFA angioplasty and stent [2196] -L CFA-AK [Doctor Last Name ] with vein then PTFE -R 4th toe partial amp [2197] -Thrombectomy of L BPG revision with bovine pericardial patch of the distal anastomosis [9-27] -Angioplasty of common femoral artery and proximal anastomosis. Angioplasty of above-knee popliteal artery and distal anastomosis. Stenting of above-knee popliteal artery for residual stenosis.[1-/2198] -AngioJet thrombectomy and rheolytic thrombolysis of the left common femoral artery to above-knee popliteal artery PTFE bypass graft with Balloon angioplasty of the left popliteal artery stent [6-/2198] -Incision and drainage of left leg abscess [7-/2198] Social History: The patient is a make-up artist in a department store. Tob: Neg EtOH: Occasional EtOH use Drugs: Denies IVDU (history when he was in his 20's) Family History: CAD with MI in father in his 50s and mother in her 60s DM in both parents HTN in both parents. Sister also has diabetesCAD with MI in father in his 50s and mother in her 60s DM in both parents HTN in both parents. Sister also has diabetes. Physical Exam: ED exam: Temp: 98.3 HR: 89 BP: 92/52 Resp: 16 O(2)Sat: 98 Normal Constitutional: The patient is awake, alert and oriented. At the time of my examination he is nontoxic in appearance. HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact His neck is supple, no JVD Chest: Lungs are clear bilaterally Cardiovascular: Normal S1-S2 Abdominal: His belly is soft, nontender, nondistended. He does not have any guarding or rebound. No peritoneal signs Rectal: Brown stool that is heme positive GU/Flank: No CVA tenderness Extr/Back: No lower extremity edema and his legs are warm Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[Last Name (un) ]/[Last Name (un) ]: No petechiae . On discharge, the patient was deceased Pertinent Results: [2199-7-7] 11:47PM TYPE-ART TEMP-33.6 PO2-377* PCO2-38 PH-7.30* TOTAL CO2-19* BASE XS--6 INTUBATED-INTUBATED COMMENTS-TANDEM HEA [2199-7-7] 11:47PM LACTATE-11.5* [2199-7-7] 11:47PM O2 SAT-98 [2199-7-7] 11:47PM freeCa-1.37* [2199-7-7] 10:35PM TYPE-ART PO2-159* PCO2-49* PH-7.24* TOTAL CO2-22 BASE XS--6 [2199-7-7] 10:35PM LACTATE-11.1* K+-3.2* [2199-7-7] 10:35PM HGB-11.6* calcHCT-35 [2199-7-7] 10:35PM freeCa-1.38* [2199-7-7] 09:57PM TYPE-ART PO2-164* PCO2-45 PH-7.09* TOTAL CO2-14* BASE XS--16 [2199-7-7] 09:57PM GLUCOSE-268* LACTATE-10.2* NA+-137 K+-5.6* CL--109 TCO2-13* [2199-7-7] 09:57PM HGB-12.1* calcHCT-36 O2 SAT-97 [2199-7-7] 09:57PM freeCa-0.80* [2199-7-7] 09:23PM TYPE-ART PO2-264* PCO2-33* PH-7.17* TOTAL CO2-13* BASE XS--15 [2199-7-7] 09:23PM LACTATE-8.5* [2199-7-7] 09:23PM freeCa-1.05* [2199-7-7] 09:15PM GLUCOSE-239* UREA N-46* CREAT-2.3* SODIUM-143 POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-12* ANION GAP-25* [2199-7-7] 09:15PM ALT(SGPT)-1163* AST(SGOT)-1439* CK(CPK)-743* ALK PHOS-117 TOT BILI-2.5* [2199-7-7] 09:15PM CK-MB-63* MB INDX-8.5* cTropnT-2.49* [2199-7-7] 09:15PM CALCIUM-7.9* PHOSPHATE-7.1# MAGNESIUM-1.9 [2199-7-7] 09:15PM WBC-19.1# RBC-3.54* HGB-10.8* HCT-32.5* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.9* [2199-7-7] 09:15PM NEUTS-87.8* LYMPHS-7.7* MONOS-4.2 EOS-0.2 BASOS-0.2 [2199-7-7] 09:15PM PLT COUNT-175 [2199-7-7] 09:15PM PT-52.7* PTT-78.3* INR(PT)-5.6* [2199-7-7] 08:30PM GLUCOSE-239* UREA N-44* CREAT-2.1* SODIUM-143 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-13* ANION GAP-25* [2199-7-7] 08:30PM CK(CPK)-373* [2199-7-7] 08:30PM CALCIUM-6.4* [2199-7-7] 08:30PM WBC-11.1* RBC-2.84* HGB-8.8* HCT-26.8* MCV-95 MCH-31.2 MCHC-32.9 RDW-15.6* [2199-7-7] 08:30PM PLT COUNT-132* [2199-7-7] 08:30PM [Name (NI) 8255] TO PTT-UNABLE TO INR(PT)-UNABLE TO [2199-7-7] 07:50PM PO2-178* PCO2-41 PH-7.18* TOTAL CO2-16* BASE XS--12 [2199-7-7] 07:50PM LACTATE-9.7* [2199-7-7] 07:50PM HGB-9.1* calcHCT-27 O2 SAT-97 [2199-7-7] 07:10PM TYPE-ART PO2-127* PCO2-46* PH-6.95* TOTAL CO2-11* BASE XS--23 INTUBATED-INTUBATED [2199-7-7] 07:10PM LACTATE-10.8* [2199-7-7] 07:10PM HGB-8.0* calcHCT-24 [2199-7-7] 06:41PM TYPE-ART PO2-165* PCO2-37 PH-7.10* TOTAL CO2-12* BASE XS--17 INTUBATED-INTUBATED [2199-7-7] 06:41PM GLUCOSE-159* LACTATE-9.2* NA+-137 K+-4.1 CL--115* [2199-7-7] 06:41PM HGB-8.6* calcHCT-26 O2 SAT-96 CARBOXYHB-1 MET HGB-0 [2199-7-7] 06:41PM freeCa-0.88* [2199-7-7] 05:36PM HGB-10.9* calcHCT-33 [2199-7-7] 03:50PM URINE HOURS-RANDOM [2199-7-7] 03:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2199-7-7] 03:50PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2199-7-7] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2199-7-7] 03:50PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2199-7-7] 03:50PM URINE GRANULAR-4* HYALINE-18* [2199-7-7] 03:50PM URINE MUCOUS-RARE [2199-7-7] 01:23PM LACTATE-1.9 K+-4.0 [2199-7-7] 01:05PM GLUCOSE-192* UREA N-45* CREAT-1.9* SODIUM-131* POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-20* ANION GAP-18 [2199-7-7] 01:05PM estGFR-Using this [2199-7-7] 01:05PM ALT(SGPT)-37 AST(SGOT)-35 LD(LDH)-278* CK(CPK)-253 ALK PHOS-84 TOT BILI-1.0 [2199-7-7] 01:05PM LIPASE-21 [2199-7-7] 01:05PM cTropnT-0.44* [2199-7-7] 01:05PM CK-MB-7 [2199-7-7] 01:05PM WBC-11.8# RBC-3.39 HGB-10.2# HCT-30.0 MCV-89 MCH-30.1 MCHC-34.0 RDW-15.6* [2199-7-7] 01:05PM NEUTS-90.7* LYMPHS-6.2* MONOS-2.8 EOS-0.1 BASOS-0.2 [2199-7-7] 01:05PM PLT COUNT-135* [2199-7-7] 01:05PM PT-38.4* PTT-42.5* INR(PT)-3.9* . ECHO [7-9]: Dilated left ventricle with severe global systolic dysfunction. Moderate right ventricular systolic dysfunction in a rather small RV cavity. Mild mitral regurgitation. At least mild pulmonary hypertension. Compared with the prior study (images reviewed) of [2199-7-7], RV size is smaller. The TandemHeart catheter now terminates in the right atrium and a small residual ASD is seen. If clinically-indicated, would consider reducing the apparent [Last Name (un) ]-arterial ECMO flow rate or volume-loading the patient. . [7-9] CXR: FINDINGS: In comparison with the study of [7-7] and [7-8], the monitoring and support devices are all in good position. Diffuse bilateral pulmonary opacifications with enlargement of the cardiac silhouette is consistent with pulmonary edema. However, superimposed aspiration, especially in the right upper zone, could certainly reflect aspiration. Retrocardiac opacification with silhouetting the hemidiaphragm is consistent with some combination of volume loss in the left lower lobe, pleural effusion, and possible superimposed pneumonia. . [2199-7-7] 1:05 pm BLOOD CULTURE #1. FINAL REPORT [2199-7-11] Blood Culture, Routine (Final [2199-7-10]): BETA STREPTOCOCCUS GROUP C. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN = <= 0.12 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP C \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [2199-7-8]): Reported to and read back by DR. [Last Name (STitle) ] [Doctor Last Name ] PAGER# [Serial Number 23365] @ 0500 ON [2199-7-8]. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Final [2199-7-8]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. . [2199-7-10] 9:04 am SWAB Source: L thigh abscess. FINAL REPORT [2199-7-12] WOUND CULTURE (Final [2199-7-12]): BETA STREPTOCOCCUS GROUP C. SPARSE GROWTH. Brief Hospital Course: Mr [Known lastname ] was a 48 yo M with CAD, DMII, ischemic cardiomyopathy s/p CABG [2191] (EF25%), [Year (4 digits) 1106] disease + mild CRI. The pt presented to the ED complaining of [1-20] day history of n/v/d, fever/chills, mylagias, had one episode of BRBPR. He also reported chest pain that was non-pleuritic. In the ED the pt's SBPs declined from the 90s to the 70s, and serial ekgs demonstrated [Last Name (un) 46104] sign with a trop of 0.44. The pt became bradycardic and lost his pulse, and was subsequently coded for 30minutes in the ED with two returns of spontaneous circulation receiving 5 shocks for vfib/vtach, as well as epi, lido, ca, amio, bicarb, then norepi, dobutamine, 5L NS. He was sent to the cardiac catheterization lab where he was found to be in PEA arrest. 60 additional minutes of ACLS ensued with high pressure chest compressions. He received several rounds of epi, atropine, 4 u of pRBC; also norepi and vasopressin. During chest compressions, a balloon pump was trialed and replaced with tandem heart. . The patient was then transferred to the the CCU, where he was medically unstable on levophed and epi drip. He went into sinus brady, received 2mg of atropine, 1 of epi, 7 amp of bicarb. A bicarb drip was started, and dopamine added briefly. The patient went into VF 3 times resulting in [Last Name (un) 3941] shocks and came out into sinus tach. The pt was then bolused with lidocaine 50mg followed by drip. The pt was very difficult to ventilate (non-compliant lungs), had been bag masked throughout this medical-code, and then switched to ECMO. During this time he was started on cardiac arrest cooling protocol and treated with broad spectrum antibiotics. . Over the course of the pt's admission he developed signs of severe multi-organ system failure (DIC / coagulopathy, shock liver, ARF, cardiogenic and likely distributive shock with Group C Strep) and had a CXR with evidence of massive acute alveolar filling and ? pleural effusions and ventilator mechanics c/w severely reduced resp system compliance. Given the pt's poor prognosis, taking into account his poor chronic baseline, multiorgan system failure, in addition to his minimal cardiac function (EF <10% without being a candidate for heart transplant), the family decided to withdraw care and the pt passed shortly thereafter. Medications on Admission: 1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please alternate between 6 mg of Coumadin on even days and 7 mg of coumadin on odd days as per your physician. 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day. 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 6. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a	[ "427.1", "E878.2", "V45.02", "570", "427.41", "V58.67", "428.0", "038.9", "518.81", "785.51", "414.00", "578.9", "276.2", "496", "443.9", "427.5", "995.92", "996.72", "250.00", "410.71", "428.23", "584.9" ]	icd9cm	[ [ [] ] ]	[ "37.68", "37.78", "37.22", "96.71", "37.61", "00.14", "88.56", "38.93", "96.04", "88.53" ]	icd9pcs	[ [ [] ] ]	15199, 15208	11874, 14230	285, 348	15255, 15265	5625, 11851	15317, 15323	4563, 4804		15171, 15176		15229, 15234		14256, 15148			15289, 15294										4819, 5606																								240, 247											376, 2237																2259, 4386	4402, 4547
75,395	126,239	4622	Discharge summary	report	Admission Date: [2181-4-23] Discharge Date: [2181-5-3] Date of Birth: [2126-7-20] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Oxycontin / Oxycodone Attending:[First Name3 (LF) 3948] Chief Complaint: large right-sided pleural Major Surgical or Invasive Procedure: [2181-4-26] 1. Medical thoracoscopy on the right side. 2. Transthoracic ultrasound. 3. Pleural biopsy. 4. Pleurx catheter placement. History of Present Illness: 54 yo male with h/o Renal cell carcinoma, metastatic to the right neck, testicle, right scapula; now with a right-sided pleural effusion. Admitted for drainage, pleurodesis and Pleurx catheter placment. Past Medical History: COPD h/o renal cell carcinoma - as above degenerative joint disease, osteoarthritis of neck, h/o cervical disc herniation s/p splenic rupture and splenectomy fibromyalgia Social History: Married, lives with his wife, daughter, and a friend Previously worked as an air conditioner repairman, currently disabled Tob: 1/2-1ppd x 30 yrs; quit [2165] EtOH: none Illicits: none Family History: Mother d. cardiovascular disease Father d. cardiovascular disease Sister - lung cancer in 60s Brother d. 27yrs of EtOH cirrhosis Brother with RCC at 56yrs, also h/o EtOH abuse Physical Exam: VS: General: [Last Name (un) 4969] appearing 54 year-old male HEENT: normocephalic, mucus membranes moist Neck: palpable 8cm right mass Lymph: no palpable lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: absent breath sounds on right, decreased on left GI: bowel sounds positive, abdomen soft NT/ND Extr: warm no edema Neuro: non-focal Pertinent Results: [2181-5-2] WBC-20.7* RBC-3.32* Hgb-9.1* Hct-28.1* Plt Ct-426 [2181-5-1] WBC-19.4* RBC-3.34* Hgb-9.0* Hct-29.1* Plt Ct-439 [2181-4-23] WBC-18.5* RBC-4.02* Hgb-10.5* Hct-32.0* Plt Ct-745* [2181-4-23] WBC-18.3# RBC-3.93 Hgb-10.6* Hct-32.1* Plt Ct-751* [2181-4-23] Neuts-94* Bands-0 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2181-5-2] Glucose-100 UreaN-30* Creat-0.6 Na-129* K-4.3 Cl-91* HCO3-29 [2181-5-1] Glucose-145* UreaN-26* Creat-0.5 Na-130* K-4.1 Cl-92* HCO3-29 [2181-4-23] Glucose-132* UreaN-37* Creat-0.7 Na-129* K-5.5* Cl-93* HCO3-28 [2181-4-23] Glucose-146* UreaN-38* Creat-0.7 Na-131* K-5.3* Cl-93* HCO3-26 [2181-4-25] ALT-11 AST-15 LD(LDH)-173 AlkPhos-129* TotBili-0.7 CXR: [2181-5-1] In comparison with the study of [4-30], there is little change in the opacification filling much of the right hemithorax consistent with a partially loculated effusion. Subcutaneous gas is decreasing. Opacification at the left base in the retrocardiac region persists. [2181-4-29] Both right chest tubes are in unchanged position. There is no interval change of mild interval increase in the large partially loculated right pleural effusion. The small apical pneumothorax is unchanged. The adjacent consolidation at the right lung base is unchanged as well, most likely represented atelectasis. Subcutaneous air collection is unchanged. There is no change in the lucency around the right heart border that might represent as mentioned previously either improved aeration of the right lung or basal component of pneumothorax [2181-4-27] Since [2181-4-26], loculated right pleural effusion significantly reaccumulated. Two chest tubes are still in unchanged position. Diffuse lung opacities on the right significantly increased, could be hemorrhage, re-expansion edema, or pulmonary edema superimposed on atelectasis. Right pneumothorax slightly increased, still small. Left nodules are unchanged. Pathology: [2181-4-26] Pleura, parietal, right: Metastatic carcinoma, large cell undifferentiated type. The morphology is consistent with a metastasis from the patient's known renal cell carcinoma, clear cell type. Brief Hospital Course: Mr. [Known lastname 4469] was admitted on [2181-4-23] for recurrent right pleural effusion which was drained for 1600 mL of serosanguineous fluid. He tolerated the procedure. On [2181-4-26] his right pleural effusion had reaccumalated and was drained for 5.2L of serosanguineous fluid. A Pleurx catheter was placed. He was repleted with 2.5 Liters of normal saline but remained hypotensive and was transferred to the SICU for close monitoring. Once his volume status improved he was transferred to the floor. Right Pleural effusion: Pleurx catheter drained on [2181-5-2] for 400 mL, [2181-5-3] 500 mL serosanguineious fluid. He requires daily drainage. Pain: he was followed by the Palliative Care team. He did not tolerate narcotics well. His methodone was increased to 10 mg tid with good control. Hyponatremia improved with fluid restriction. Leukocytosis: unclear etiology. All cultures with no growth. Heme: Anemia of chronic inflammation. baseline HCT high 20's low 30's. Hct stable. Upon admission his INR was slightly elevated in the setting of poor nutrition. He was given Vit K with a good result. Disposition: he was followed by physical therapy. He requires a walker for ambulation. Medications on Admission: PAIN MEDICATIONS (At home): Dilaudid 8mg [12-15] po q 4hrs prn ([3-19]/day) Lorazepam 1mg po q 6hrs prn. MEDICATIONS (in-house): Lorazepam 1 mg PO Q6H:PRN anxiety or nausea Acetaminophen 325-650 mg PO Q6H:PRN pain, fever Methadone 5 mg PO TID Docusate Sodium 100 mg PO BID:PRN constipation Ondansetron 4 mg IV Q8H:PRN nausea Ondansetron ODT 4 mg PO Q8H:PRN nausea HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain Pantoprazole 40 mg PO Q24H HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN breakthrough pain Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety or nausea. 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop PO DAILY (Daily). 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ML Injection Q8H (every 8 hours) as needed for nausea. 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Metastic renal carcinoma Discharge Condition: stable Discharge Instructions: Call Dr. [Last Name (STitle) 19610] office [Telephone/Fax (1) 7769] if experience fever > 101 or chills: Pleurex Catheter; -Call immediately if drain comes out. Cover site immediately with a clean dressing -[Month (only) 116] shower with water-proof occlusive dressing. -No bathing or swimming Pleurax site keep covered with a clean dressing. Drain day: keep log of drainage Do not drain more than 1 liter at a single drainage. Call IP if have questions or concerns, drainage around tube or if drainage less than 50 cc for 3 consecutive drains. [Telephone/Fax (1) 10651] Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [Name (STitle) ] with Dr. [Last Name (STitle) ] interventional pulmonology [Telephone/Fax (1) 7769] Completed by:[2181-5-10]	[ "198.5", "E879.8", "V45.73", "729.1", "263.9", "288.60", "198.89", "197.2", "198.82", "197.7", "496", "311", "285.29", "458.29", "721.0", "276.1", "276.7", "V45.79", "189.0" ]	icd9cm	[ [ [] ] ]	[ "34.91", "34.20", "34.04" ]	icd9pcs	[ [ [] ] ]	6910, 6982	3907, 5142	325, 464	7051, 7060	1690, 3884	7696, 7884	1118, 1295		5700, 6887		7003, 7030		5168, 5677			7084, 7673										1310, 1671																								259, 287											492, 698																720, 892	908, 1102
43,439	128,326	4433	Discharge summary	report	Admission Date: [2188-8-25] Discharge Date: [2188-9-18] Date of Birth: [2123-6-24] Sex: M Service: MEDICINE Allergies: Clotrimazole / Augmentin Attending:[First Name3 (LF) 4095] Chief Complaint: Fevers, low blood pressure, abdominal pain Major Surgical or Invasive Procedure: CT guided drainage of peri-hepatic abscess with placement of a pig-tail drain. ERCP with placement of CBD stent Ultrasound guided PICC placement History of Present Illness: 65M with chronic pancreatitis, several intra-abdominal abscesses p/w with 3 d of severe low back pain. Patient has been to ED 3 times in the past 3 days with no resolution of symptoms. He reports that he can not move or walk due to the pain, worst with standing up, no radiation. He spoke with his PCP today, who was concerned about osteomyelitis given low back pain with history of intraabdominal abscesses and elevated white count. He recommended he come to the ED for evaluation. . In the ED, initial VS were: 98.1 79 100/64 20. Physical exam showed tenderness to palpation adjacent to spine. Labs were remarkable for elevated alk phos and WBC 14.2. He was given hydromorphone 2mg po q8h for pain control and started on IV vancomycin and ceftriaxone, no blood cultures were drawn prior. No imaging obtained in the ED. Admitted to medicine for evaluation of osteomyelitis. Vitals prior to transfer were 98.4 87 116/83 16 95% room air. . On arrival to the floor, the patient was found to be hypotensive to the 70s sytolic, tachycardic to the 130s, febrile to 102. He was given 3L NS, blood cultures were drawn. Labs were redrawn and WBC had risen to 25.5 (from 14.2 6h earlier), lactate 4.0. Given daptomycin to cover VRE, given his hx of VRE bacteremia in the past. He was transfered to the MICU for sepsis. . On arrival to the MICU, he is lying in bed complaining of pain in his back but otherwise doing well. Awake and interactive, able to give the HPI. Past Medical History: 1. Multiple polymicrobial fluid collections, status post multiple drain procedures over the past several years. Most recently MRSA in new L flank abscess in [2188-6-6], past h/o psoas abscess, retroperitoneal abscess, enterocutaneous fistula. 2. Ventral hernia repair complicated by severe pancreatitis, leading to a nearly yearlong hospitalization starting [2185-4-7] at [Hospital6 10353] and at the [Hospital1 2177] to rehabilitation ending [2186-1-8]. 3. Pancreatic mass per GI notes. Endoscopic ultrasound performed twice, most recently [2187-1-8] showing 2 x 3 cm ill-defined mass to the pancreas. FNA was performed. No malignancy was found. 4. CAD status post MI [2185] 5. Diverticulosis. 6. Anxiety. 7. Hypothyroidism. 8. Hypertension. 9. Lower extremity DVT status post IVC filter ([2185] or [2186]) 10. Portal vein thrombosis. 11. Status post fundoplication 16 plus years ago complicated by splenic injury requiring splenectomy. 12. BPH. 13. Vitamin D deficiency. 14. Abnormal LFTs intermittently, most recently thought due to Augmentin. 15. Gynecomastia. 16. Cirrhosis - dx in [2186] Social History: Lives in [Location (un) 7913] with [Doctor First Name 1258] his wife. [Name (NI) ] is unemployed. - Tobacco: smoked <1 PPD for 1 year in the past - Alcohol: denies - Illicits: denies Family History: Non-contributory. Physical Exam: On Admission: Vitals: T: 96.7 BP: 97/66 P: 99 R: 18 O2: 98% on 3L General: Alert, oriented to place and situation but not time. In no acute distress unless being turned/moved (severe pain) HEENT: PERRL, sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished breath sounds in bases bilaterally, no wheezes, rales, ronchi Abdomen: BS+, distended, caput medusa seen, soft, moderately tender to palpation of RUQ and left flank. Protrusion seen below ribs on right side. Some voluntary guarding, but no rebound GU: foley draining clear yellow urine Back: pain to palpation of spine at L3-L5 levels, no paraspinous tenderness Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs II-[Doctor First Name 81] intact, strength 4+/5 and symmetric in UE, stength [2-9] in hip flexors and [3-11] knee extensors, [4-10] in other LE muscle groups. Discharge: VS: 98.7, 116/80, 85, 16, 97% RA. Gen: Resting comfortably in bed; appropriate conversation HEENT: PERRLA, EOMI Lungs: CTA bilat, no r/rh/wh CVS: RRR, no MRG, nl S1/S2 Abd: nontender to palpation in all four quadrants and flank. Mildly distended, bs x 4, no masses, dilated superficial epigastric veins; RUQ drain w/ scant green bilious fluid Ext: warm, perfused, 2+ edema b/l; PICC in place Skin: no rashes Neuro: CNIII-XII intact, strength 5/5 throughout, sensation grossly intact b/l UE/LE, gait not tested. . Pertinent Results: [2188-8-24] 07:00PM BLOOD WBC-16.1* RBC-4.23* Hgb-12.0* Hct-36.6* MCV-87 MCH-28.5 MCHC-32.9 RDW-15.2 Plt Ct-765* [2188-8-24] 07:00PM BLOOD Neuts-85.6* Lymphs-6.5* Monos-5.8 Eos-1.1 Baso-0.8 [2188-8-24] 07:00PM BLOOD PT-14.2* PTT-27.2 INR(PT)-1.2* [2188-8-25] 06:45PM BLOOD ESR-56* [2188-8-24] 07:00PM BLOOD Glucose-74 UreaN-12 Creat-0.6 Na-138 K-4.9 Cl-105 HCO3-25 AnGap-13 [2188-8-25] 06:45PM BLOOD ALT-19 AST-38 AlkPhos-304* TotBili-0.3 [2188-8-25] 06:45PM BLOOD Lipase-31 [2188-8-25] 06:45PM BLOOD Albumin-2.1* [2188-8-25] 06:45PM BLOOD CRP-188.3* [2188-8-26] 02:26AM BLOOD Lactate-4.0* calHCO3-19* . [2188-9-18] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.2* Hct-31.0* MCV-92 MCH-30.4 MCHC-33.0 RDW-18.1* Plt Ct-596* [2188-9-13] 10:00AM BLOOD Neuts-73* Bands-0 Lymphs-16* Monos-7 Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-0 [2188-9-18] 07:25AM BLOOD Glucose-78 UreaN-37* Creat-3.4* Na-141 K-4.4 Cl-110* HCO3-22 AnGap-13 [2188-9-16] 09:30AM BLOOD ALT-11 AST-37 LD(LDH)-165 AlkPhos-219* TotBili-0.4 [2188-9-16] 09:00AM BLOOD CK(CPK)-18* [2188-9-15] 04:05AM BLOOD Lipase-20 [2188-9-16] 09:00AM BLOOD CK-MB-2 cTropnT-0.03* [2188-9-18] 07:25AM BLOOD Calcium-8.3* Phos-4.6* Mg-1.9 [2188-9-9] 06:10AM BLOOD CEA-1.4 AFP-2.7 . [8-23] CT Abdomen: 1. A longstanding fluid collection adjacent to the right hepatic lobe and the gallbladder persists, and shows mild increase in size since [Month (only) 205]. This most likely represents a pseudocyst, though abscess or superinfection cannot be excluded. Note is made of an equivocal communication to the gallbladder/cystic duct. This could be further assessed with HIDA on a nonurgent basis. 2. No additional sites of new or worsening fluid collections. 3. Unchanged appearance to intra- and extra-hepatic biliary ductal dilatation, foci of free air adjacent to the liver and pancreatic head, extensive inflammatory and fibrotic change in the region of pancreatic head along with cavernous circulation transformation of the portal vein, all consistent with changes of prior/chronic pancreatitis. . [8-27] MR [Name13 (STitle) ]: TECHNIQUE: Sagittal T1, T2 STIR and axial T1- and T2-weighted images were obtained through the lumbar spine. Following administration of intravenous contrast, sagittal and axial T1-weighted images were obtained. . FINDINGS: Lumbar vertebrae reveal normal height and signal intensities. There is grade 1 retrolisthesis at L5-S1. The spinal cord terminates at the upper border of L1. Conus medullaris and cauda equina has normal morphology and signal intensities. . At T12-L1, L1-L2, there is no significant disc herniation, spinal canal or neural foraminal narrowing. . At L2-L3, there is mild disc bulge with no significant canal or neural foraminal narrowing. . At L3-L4, there is disc desiccation with diffuse disc bulge, but no significant canal or neural foraminal narrowing. . At L4-L5 there is disc desiccation with diffuse disc bulge and posterior annular tear causing mild narrowing of bilateral neural foramina but no significant nerve root impingement is seen. . At L5-S1 there is grade 1 retrolisthesis with type 2 endplate changes. There is a posterior disc protrusion predominantly to the left of the midline touching the traversing left S1 nerve root. . Post-contrast scans reveal no abnormal enhancement. Subtle signal alteration in bilateral psoas muscles, likely secondary to inflammatory changes in the retroperitoneum. There is no evidence of epidural abscess. . IMPRESSION: 1. Degenerative changes in the lumbar spine, most prominent at L5-S1 where there is grade 1 retrolisthesis with discogenic endplate marrow changes. No evidence of epidural abscess. . 2. Subtle signal alteration in bilateral psoas muscles, likely secondary to inflammatory changes in the retroperitoneum. No drainable collection is seen. . [2188-8-31] MRCP: MR ABDOMEN WITH MRCP . CLINICAL HISTORY: A 65-year-old man with history of chronic pancreatitis and several intraabdominal masses, presents with sepsis. Evaluation prior to ERCP. . TECHNIQUE: Multiplanar T1 and T2-weighted images of the abdomen were obtained both pre- and post-administration of 15 cc of gadolinium DTPA. The patient was also given 75 cc of distilled water mixed with 5 cc of gadolinium orally. . A prior CT study of the abdomen and pelvis dated [2188-8-23] was available for comparison. . FINDINGS: . LUNG BASES: Lung bases are included and show a small left-sided pleural effusion which is new in comparison with the prior study. . ABDOMEN: The patient is status post splenectomy. Few splenosis nodules are identified in the splenic bed. The liver is normal in size. No focal hepatic lesions are identified. There is persistent moderate dilation of the intra- and extrahepatic biliary system with tapering of the common bile duct at the level of the head of the pancreas. There is also stable persistent dilation of the main pancreatic ducts also tapering within the head of the pancreas. There is stable-appearing inflammation in the head of the pancreas and the duodenal sweep consistent with the patient's known diagnosis of chronic pancreatitis. An air-fluid level is identified in the cystic duct stump. There is also stable mild right-sided hydronephrosis, most likely due to the presence of inflammation adjacent to the right renal pelvis. There is an extensive anasarca in the subcutaneous tissues. Few small renal cysts that are stable are identified in the right kidney measuring up to 10 mm. A small amount of fluid is identified surrounding the pancreatic glands, unchanged in comparison to the prior study. Following administration of contrast material, there is marked cavernous transformation of the portal vein with presence of numerous venous collaterals in the hepatico-duodenal ligament encircling the biliary system. This is not significantly changed from the prior study. . IMPRESSION: . 1. Small new left pleural effusion. . 2. Persistent moderate dilation of the intra- and extrahepatic bile ducts with tapering of the CBD at the level of the pancreatic head, most likely due to combination of the patient's known chronic pancreatitis and peri-biliary varices formation following cavernous transformation of the portal vein. . 3. Status post splenectomy with splenosis nodule in the left upper quadrant. . 4. Moderate dilation of the pancreatic duct which is also tapering in the pancreatic head region due to the patient's known chronic pancreatitis with associated inflammation. . 5. Stable mild right hydronephrosis, also induced by the inflammatory process in the retroperitoneum. . 6. Significant subcutaneous edema. . [2188-9-6] RENAL ULTRASOUND: . The right kidney measures 11.5, the left kidney measures 11.2 cm. There is mild right-sided hydronephrosis without evidence of obstructing stones in the kidney or the right ureter; however, CT is more sensitive for assessment of the renal or ureteral stones. . There is no evidence of hydronephrosis or masses of the left kidney. . A Foley catheter is seen in empty urinary bladder. . IMPRESSION: Mild right hydronephrosis, unchanged since [8-23], [2187]. No evidence of obstructing stones. . [2188-9-8] LIVER/BILLIARY HIDA SCAN: . RADIOPHARMACEUTICAL DATA: 4.4 mCi Tc-[Age over 90 ]m DISIDA ([2188-9-8]); HISTORY: perihepatic infected fluid collection . DECISION: gallbladder scan followed by 18 hour delayed scan . INTERPRETATION: Serial images over the abdomen show delay in uptake and excretion of the tracer into the hepatic parenchyma. Activity was seen within the small bowel at 55 minutes and then within the gallbladder at 90 minutes. which is delayed in comparison to normal. . The patient returned the morning following tracer administration and there was intense tracer activity within the large bowel. There was no evidence of a leak. . IMPRESSION: 1. No evidence of biliary leak. 2. Delayed hepatic and gallbladder uptake. . [2188-9-15] Abdominal Xray: . A pigtail catheter is seen projected over the right upper quadrant. Biliary stent is present. Gas pattern is normal. I see no evidence of free air. Gas is noted in the biliary tree which is not unexpected given the biliary stent. . IMPRESSION: No evidence of obstruction. . [2188-9-16] Abdominal Ultrasound: . FINDINGS: Note is made that this is a very limited ultrasound due to the limited acoustic window. Pneumobilia is seen within the intrahepatic bile ducts. No biliary dilatation is identified. Linear echogenic structures in the right upper quadrant are consistent with the patient's known drainage catheter. The visualization of the prior right upper quadrant collection is very limited, but appears to be partially resolved. . No hydronephrosis is seen on limited views of the kidneys. No fluid collections are seen within the intra-abdominal space. There are edematous soft tissues seen in the subcutaneous space along the left flank. These edematous structures correspond to the patient's area of discomfort. No discrete collection is identified. The portal vein is patent with hepatopetal flow. . IMPRESSION: Edematous soft tissues consistent with cellulitis seen along the left flank in a location that corresponds with the patient's discomfort. No discrete collection identified. . Brief Hospital Course: 65M with chronic pancreatitis, complicated history w/ multiple past intra-abdominal abscesses presented w/ 3 days of severe low back pain, was septic on admission, transferred to the ICU, had IR drainage of perihepatic fluid collection, transferred to the floor on [8-29] from the MICU. Had ERCP/biliary stent placed for biliary leak - perihepatic drain still draining bilious fluid, but at decreasing cc/day rate. Now in acute renal failure, but slowly trending downward (Cre 3.4 on discharge). New development of heme+ emesis [2187-9-15] w/o corresponding HCT drop, but no other episodes. New left abdominal wall pain/tenderness w/ u/s showing abominal wall soft tissue swelling, but pain/tenderness has since resolved. [Last Name (un) ] [1-9] vancomycin and perhaps due to zosyn as well is now resolving with downtrending Cre. Patient broadly covered on multiple antibiotic regimens and will be discharged on daptomycin, moxifloxacin, and fluconazole. # Sepsis: Patient was hypotensive but responsive to fluid boluses and did not need pressors. Blood culture postive for MRSA. IR guided drainage of perihepatic fluid collection showed polymicrobial infection (+ MRSA and vanc-sensitive enterococcus). TTE showed no vegetations. Lactate originally 4.0, but returned to [Location 213] with fluids. Patient originally on zosyn, fluconazole, and daptomycin. Zosyn discharged due to suspicion of causing [Last Name (un) ] and cipro/flagyl started. Daptomycin stopped and vancomycin started, but then vancomycin stopped as well do to [First Name9 (NamePattern2) 19040] [Last Name (un) ] and suspicion that vancomycin may be contributing factor. At time of discharge, all BCx negative. Will discharge on daptomycin, moxifloxacin, and fluconazole. PICC successfully placed on [9-18]. . #Biliary Leak: At time of discharge, continues to drain small amounts bilious fluid from perihepatic drain. ERCP showed no biliary leak or strictures but stent was placed and will need to be removed AFTER surgery evals as outpatient. HIDA scan ([9-9]) was noncontributory and did not show an active leak. Fluid cc/day has recently decreased markedly since original placement and only ~ 5 - 10 cc/day at time of discharge. . # Back pain: Likely musculoskeletal, no abcess on MRI but a lot of DJD and retrolisthesis at L5-S1. Pain controlled on prn oxyxcodone and daily lidocaine patch. . # Chronic pancreatitis: no signs of acute flare at this time. Home pancrease replacement meds as per outpatient regimen. . # CAD s/p MI: last echo in [1-/2188] shows normal EF (>55%), no suggestion that there is a cardiogenic component to his hypotension. TTE ECHO here showed EF >55%, normal valves except "trivial" MR. [Name13 (STitle) ] signs of vegetations or abscesses, home ASA regimen continued. . # Cirrhosis vs. Fatty Liver Disease: RUQ US and CT in [2186] shows echogenicity c/w cirrhosis vs. fatty liver disease. Very low concern for HRS given this picture. . #Left abdominal wall tenderness: patient has tenderness to minimal palpation of left lower quadrant onto left flank on [9-16]. Pain has since resolved. Abdominal u/s shows soft tissue edema of left abdominal wall that was concerning for cellulitis, but there are no clinically correlated signs or symptoms. Patient is being covered for gram (+) with daptomycin. . #Acute renal failure: Unclear etiology of this acute kidney injury but our suspicion is secondary to zosyn. Then, patient was found to have supratherapeutic levels of vancomycin which may represent a second insult to this patient's kidneys. Cre peaked at 4.8 and now downtrending. 3.4 at time of discharge. During the admission, patient's potassium was intermittently elevated in the setting of [Last Name (un) ]. K+ peaked at 6.3. Kayexalate brought potassium into normal limits. Since Cre has been downtrending, patient has not required the use of kayexalate. He has been maintained on a low potassium diet of less than 1 mEq of potassium daily. . # Heme+ coffee ground emesis. On [9-13], patient had heme positive emesis with no other symptoms except for some nausea. This episode resolved spontaneously and there have been no repeat episodes or concerning signs/symptoms since. . Medications on Admission: FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth Monday/Wednesday/Friday HYDROMORPHONE - 2 mg Tablet - 1 Tablet(s) by mouth every 8 hours Do not drive while taking this medication. LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth qday LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[Unit Number ],000 unit-[Unit Number ],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth with meals 1 capsule with snac - No Substitution METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea MOXIFLOXACIN [AVELOX] - 400 mg Tablet - 1 Tablet(s) by mouth qdaily OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily SODIUM POLYSTYRENE SULFONATE [KAYEXALATE] - Powder - 30Gm dose by mouth once as directed as needed for then call for instructions CVS will dispense the suspension; 15Gm/60mL TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily TRAZODONE - 50 mg Tablet - 1.5 Tablet(s) by mouth at bedtime as needed for insomnia ASPIRIN [ASPERDRINK] - 81 mg Tablet, Effervescent - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MICONAZOLE NITRATE [MICRO-GUARD] - 2 % Powder - please place along wound area three times a day as needed for moisture accumulation MULTIVITAMIN WITH MINERALS - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Cap(s) Refills:2 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for moisture accumulation. Disp:90 applications Refills:0 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on; 12 hours off. Disp:30 Adhesive Patch, Medicated(s) Refills:2 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain: Do not give more than 2 grams within any 24 hour window. Disp:120 Tablet(s) Refills:0 7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Tablet(s) Refills:2 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 9. 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 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) 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 11. daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg Intravenous Q48H (every 48 hours). Disp:6000 mg Refills:2 12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 13. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Sepsis due to MRSA bacteremia Perihepatic fluid collection Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], . We appreciated the opportunity to participate in your care at [Hospital1 18]. . You were admitted for an infection of your bloodstream with a bacteria called MRSA. We also found that you had a large collection of fluid near your liver which was also infected with MRSA and another bacteria called enterococcus. Antibiotics were started to treat the infection, and a drain was placed in the fluid collection. Because the fluid collection contained bile, you underwent a procedure called an ERCP to place a stent in your bile ducts to help relieve possible pressure in the ducts that might have contributed to the leaking bile. While you still a very small amount of bile leaking from the drain, this has slowed considerably since your admission. You have an upcoming appointment with your surgeon, Dr. [Last Name (STitle) 468]. At this appointment, it will be determined if the drain can be removed or not. In the meantime, we would like you to keep a record of how much fluid collects in the drain each day. Also make a daily note of what that fluid looks like. . During your admission, you also suffered an injury to your kidneys. This may have been due to an antibiotic you were getting called vancomycin. You are no longer on vancomycin and you should avoid taking vancomycin in the future. Your kidneys have not completely returned to their previous level of functioning, but we are hopeful that they will heal on their own with some time. Your doctors [Name5 (PTitle) ] [Name5 (PTitle) 4169] a blood test called Creatinine to see how they are functioning. Until they have returned to [Location 213], you should maintain a low potassium diet and try not to become dehydrated by drinking plenty of fluids. . You are being sent home on daptomycin, fluconazole, and moxifloxacin which you will need to take indefinitely until your infectious disease doctor thinks it is safe for you to come off these medications. We have made arrangements for your rehab facillity to help manage and administer these antibiotics until your course is complete. . START taking the following medications: - Daptomycin 400mg IV every 48 hours. This dose will be adjusted as your renal function gets better. - Sevelemer three times a day with meals - You may place a lidocaine patch once daily on any area where you are having pain . STOP taking the following medications: - Vancomycin - Lasix (furosamide), the doctors at rehab [Name5 (PTitle) ] restart this when your kidney function is better. - hydromorphone (Dilaudid), ask the rehab doctors if [Name5 (PTitle) ] need additional pain medicine - metrochlopramide (Reglan), please alert the doctors if [Name5 (PTitle) ] are having nausea . Followup Instructions: Department: RADIOLOGY When: MONDAY [2188-9-29] at 9:00 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: SURGICAL SPECIALTIES When: MONDAY [2188-9-29] at 10:30 AM With: [First Name8 (NamePattern2) 251] [Name8 (MD) ], MD [Telephone/Fax (1) 2835] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: INFECTIOUS DISEASE When: WEDNESDAY [2188-10-8] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13896], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2188-9-21]	[ "276.7", "518.81", "285.9", "577.1", "560.1", "V12.51", "576.8", "591", "584.5", "562.10", "E930.8", "401.9", "041.04", "414.01", "611.1", "578.0", "567.22", "E930.0", "268.9", "571.5", "V49.86", "600.00", "995.92", "300.00", "348.30", "038.12", "721.3", "244.9", "412" ]	icd9cm	[ [ [] ] ]	[ "51.87", "52.93", "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]	22234, 22306	14290, 18571	328, 474	22429, 22429	4963, 14267	25348, 26238	3377, 3396		20190, 22211		22327, 22408		18597, 20167			22580, 25325										3411, 3411																								246, 290											502, 1971								3425, 4944	22444, 22556							1993, 3145	3161, 3361
80,778	185,603	39095	Discharge summary	report	Admission Date: [2140-7-23] Discharge Date: [2140-7-28] Date of Birth: [2080-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Bronchoscopy ([7-27]) Tracheostomy tube exchange ([7-27]) History of Present Illness: 60 yo with h/o of an elective endoscopy complicated by ARDS, [Month/Day (4) 16630] (Klebsiella and E.Coli - pansensitive), Sepsis, DIC, tracheostomy, ARF requiring CVVH/HD (now resolved), ventilator dependence, anemia, H. pylori gastritis/PUD, remote pancreatitis s/p partial pancreatectomy who was transferred from [Hospital 100] rehab to [Hospital1 18] for increasing respiratory support requirements and fever suspicious for HAP to the rehab physician. [Name10 (NameIs) 357] refer to a detailed D/C summary of [6-2] for details of the complicated course. He was discharged from [Hospital1 18] with treatment for HAP, recurrent fevers, persistent anemia, ventilator dependence, RIJ thrombus on coumadin, resolving thrombocytopenia and severe steroid/ICU myopathy. He had developed marked cystic changes on interval CT chest [7-6] but was noted to have improvement in consolidations/ground glass opacities. Since discharge, he had had moderate success of weaning from the ventilator (end of [Month (only) 116] was on [5-25] CPAP overnight and on trache mask during the day), however, had developed significant anxiety and felt he could not tolerate staying off ventilator resulting in tachypnea, low TV requiring reinitiation of PSV. He was started on Klonopin that was eventually advanced to 1mg TID (last week) with mild improvement. Of note, he developed low grade fevers and tachypnea, requiring increasing PS and was treated with Vanco/Zosyn x 4 days (started [7-4]) and eventually changed to Levofloxacin for a total of 14d of ABx completed [7-18]. At the same time, underwent further investigation for low grade fevers with CT abdomen that showed no signs of infection and had a negative C.Diff x1. As respiratory status improved, another weaning trial was attempted, during one of which he developed emesis and likely aspirated at that time. On [7-22] he was found to be tachypneic to mid 30s, had a repeat CXR that was unchanged and required increase in PSV to 15/5 from [6-25] during that time to maintain ventilation. On [7-23] at ~ 3am, was noted to have a fever to 102.6F and developed tachypnea. CXR at [Hospital1 100] was unchanged but poor quality. BCx and CBC were obtained and he was sent to [Hospital1 18] for further evaluation given concern for recurrent infections and physiatrists suspicion for bronchiolitis/BOOP. There has been no productive cough, no sputum production, infrequent suctioning that remained clear. Over the past week, was treated with "cough medicine" and chloraseptic to provide relief. In the ED, initial vs were: T100.4F P132 BP103/66 RR 30s O2 sat 100% bagged w/ 100%. Patient was given 4L IVF for SBP nadir of 86 and suspected hypovolemia, he was empirically started on Vancomycin and Meropenem, Tylenol for temperature of 101F and WBC of 18K with 7 bands. S/p R femoral placement. VBG showed 7.35/54/118. He received ativan 1mg and APAP 1300mg total while in ED. He underwent a CT chest which showed "small mixed changes in a post-ARDS fibrotic phase. some new tree-in-buds, some decrease of prior consolidation" Of note, had a L midline placed on [6-26]. Had a R arm hematoma (early [Month (only) ], not in records) thus discontinued his coumadin. Required 1U PRBCs. Over the past 10 days has lost 7 pounds, despite increase in caloric intake via TFs. He had improved in terms of deconditioning and is now able to stand and take a few steps with PT. On the floor, VS were 99F 113 144/86 RR29 and 100% on 70% FiO2. He appeared ill and diaphoretic, however had no complaints, including no dyspnea/cp/pressure. He noted feeling air hunger intemittently over the past 4 days. . Review of systems: (+) Per HPI. Past Medical History: Past Medical History: . - Septic shock (no bacteremia, but had Klebsiella and Ecoli in sputum, s/p Meropenem) - [Month (only) 16630] - DIC - Difficulty with mechanical ventilation (see above) - ARDS - Gastritis h/o H. pylori (treated with triple therapy). Patient with admission in [2-/2140] with acute UGIB, found to have chronic active H. pylori s/p tx with Prevpac. Plan for PPI x 3 months (normal colonoscopy [2138]) - severe iron deficiency anemia - remote pancreatitis s/p partial pancreatectomy (in 20s, unclear etiology) - Hypothyroidism - Hyperlipidemia - Lyme disease treated in [2138] - Anxiety - R pneumothorax s/p CT, now resolved. - RIJ clot on coumadin - Thrombocytopenia (? [2-23] vancomycin and/or DIC) Social History: Social History: Has lived in [Hospital ] rehab since discharge from [Hospital1 18]. Has since discharge began to walk with PT, but continued to loose weight despite increasing caloric intake. Family is devastated by lack of progress. - Tobacco: never - Alcohol: wine [2-24] glasses/night (prior to the event) - Illicits: no drug use. Family History: NC Physical Exam: Vitals: 99F 113 144/86 RR29 and 100% on 70% FiO2 General: Alert, awake, oriented, diaphoretic, ill appearing man. HEENT: Sclera anicteric, dMM, oropharynx clear. Dobhoff in place. Neck: supple, JVP not elevated, no crepitus. Lungs: Diffuse rhonchi b/l with end inspiratory crackles throughout, mild wheezing bilaterally, mostly posteriorly. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley Ext: warm, dry, well perfused, 1+ pulses, atrophic. NEURO: see general, attn intact to DOWb, follows axial and appendicular commands. 4/5 strength in UEs and LEs, weaker proximally, there is significant wasting in all muscle groups. Toes down. Pertinent Results: [2140-7-23] 07:00AM BLOOD WBC-18.3# RBC-2.89 Hgb-8.9* Hct-27.2* MCV-94 MCH-30.8 MCHC-32.8 RDW-17.3* Plt Ct-258 [2140-7-25] 04:09AM BLOOD WBC-13.0* RBC-2.85# Hgb-9.0 Hct-26.9* MCV-94 MCH-31.6 MCHC-33.5 RDW-17.7* Plt Ct-217 [2140-7-28] 03:58AM BLOOD WBC-12.2* RBC-2.78* Hgb-8.8* Hct-26.0* MCV-93 MCH-31.7 MCHC-33.9 RDW-17.0* Plt Ct-233 [2140-7-23] 07:00AM BLOOD PT-15.6* PTT-30.2 INR(PT)-1.4* [2140-7-25] 04:09AM BLOOD PT-12.9 INR(PT)-1.1 [2140-7-23] 07:00AM BLOOD Glucose-115* UreaN-24* Creat-0.8# Na-135 K-4.2 Cl-98 HCO3-31 AnGap-10 [2140-7-26] 03:56AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-105 HCO3-34* AnGap-8 [2140-7-28] 03:58AM BLOOD Glucose-111* UreaN-19 Creat-0.8 Na-144 K-3.8 Cl-101 HCO3-39* AnGap-8 [2140-7-23] 07:00AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.8# Mg-1.5* [2140-7-26] 03:56AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8 [2140-7-28] 03:58AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.8 [2140-7-23] 07:00AM BLOOD Ferritn-596* [2140-7-23] 07:00AM BLOOD TSH-56* [2140-7-23] 07:00AM BLOOD Free T4-0.58* [2140-7-24] 04:57PM BLOOD Vanco-18.1 [2140-7-26] 03:48PM BLOOD Vanco-34.3* [2140-7-26] 07:07PM BLOOD Vanco-30.1* [2140-7-27] 09:07PM BLOOD Vanco-23.4* [2140-7-23] 11:46AM BLOOD pO2-118* pCO2-54* pH-7.35 calTCO2-31* Base XS-3 Comment-GREEN TOP [2140-7-26] 04:28AM BLOOD Type-ART Temp-37.0 Rates-/31 PEEP-10 FiO2-50 pO2-166* pCO2-67* pH-7.31* calTCO2-35* Base XS-5 Intubat-INTUBATED . [7-23] CT Chest: IMPRESSION: 1. Many focal areas of unchanged scarring in the lungs. Previously seen LLL focal consolidation has mostly resolved, and some other areas of opacity have also improved. However, there are a few new focal tree-in-[Male First Name (un) 239] opacities, particularly in the RLL and lingula, which may represent an acute on chronic infectious process, or perhaps a shifting pattern of chronic airway inflammation. Tree-in-[Male First Name (un) 239] opacities can be seen with bronchiolitis. 2. Interval decrease of now small right-sided pleural effusion. . [7-27] CXR: FINDINGS: The tracheostomy tip is 6.5 cm above the carina. Endogastric tube is noted to coil over the upper portion of the esophagus - this is presumably external to the patient. The heart and mediastinal contours appear unchanged from prior study. The hila appear unremarkable bilaterally. There persist patchy opacities bilaterally, particularly in the retrocardiac region and in the left upper lung, all concerning for pneumonia. There may be a trace pleural effusion on the left. There is no pneumothorax. The osseous structures appear intact. IMPRESSION: Unchanged-to-worsening bilateral opacities consistent with pneumonia. Brief Hospital Course: 60 yo with h/o H. pylori PUD and chronic anemia s/p elective endoscopy that was complicated by ARDS, [Month/Day (4) 16630], Sepsis, DIC, tacheostomy and vent dependence, ARF requiring CVVH/HD (now resolved), ventilator dependence, and severe ICU/steroid myopathy who was transferred from [Hospital 100] rehab to [Hospital1 18] for increasing respiratory support requirements and fever suspicious for HAP to the rehab physician. # Fever/WBC 18K w/ 7 bands: Multiple etiologies possible. CT chest not overwhelmingly supportive of a new infiltrate, mostly notable for bronchiolitis and cystic changes from prior aspiraton. Pt has a hx of PUD; it's possible that this may serve as a source/nidus. Another possible source is his L midline placed on [6-26], but no abnormalities on exam. Recent course of ABx puts him at risk of C.Diff. No evidence for sinusitis or cellulitis. Lactate had decreased to 1.1 at admission and continued to decrease to 0.5. Given pre-admission history of fever and diaphoresis, patient was started on empiric course for HAP with Vancomycin and Cefepime to cover both respiratory and GI sources. Blood and urine cultures have been negative to date, and sputum cultures grew rare GNR. Sputum and blood cultures from Rehab prior to transfer have been negative to date. The femoral line that was placed in the ED on [7-23] was removed the following day on [7-24], and the midline placed previously on [6-26] was replaced by a PICC on [7-25] to facilitate administration of the antibiotics. Stool was neg for C diff. MRSA screen still pending at discharge. Is completing 8 day course of vanco/cefepime until [7-31]. . # Tachypnea: Unclear whether this is from worsening lung compliance, anxiety or both. He was oxygenating well at admission and in the unit. Given the past insults of ARDS, [Month/Year (2) 16630], and ventilator dependence, the pt's new baseline is rapid, shallow breathing with a high autoPEEP. His lung volumes were 300-400 most of the time with a RR in the 20s. ABGs showed mild respiratory acidosis. Initially, the patient was sedated on Klonopin 1.5 mg TID with PRN IV ativan; this was titrated down to Klonopin 1.0 mg TID and PO Ativan on [7-25]. On [7-24], he was changed from pressure control 25/5 to pressure support 20/5, which was more comfortable for the pt. From [7-25] to the time of discharge, we attempted to wean him from the ventilator, but the patient developed recurrent (once-twice daily) episodes of increased tachypnea, diaphoresis, and anxiety. He was bronched by Interventional Pulmonology and switched to a bigger trach size (6->8mm) on [7-27]. BAL Gram stain showed 1+ PMNs, and culture is still pending. The optimal settings at the time of discharge seemed to be a pressure support of 15-20, PEEP of 10, and FiO2 of 40% (oxygenating 97-100%). Since these episodes of respiratory difficulty seemed to be perpetuated by anxiety, we tried to optimize his anxiolytic regimen. On [7-25] we switched from prn Ativan to morphine prn at pt's request because this was his pre-admission med. On [7-27], per Psych recs, we changed the prn morphine to prn Seroquel, and prn QHS trazodone to standing QHS mirtazapine. We added standing oxycodone to his regimen on [7-28] to help treat tachypnea and minimize withdrawal symptoms s/p morphine dependence. At time of discharge he is also still on standing Klonopin 1.5 mg TID. . # Tachycardia: patient with tachycardia, usually related to anxiety and attempted vent wean. He did have intermittent periods when his HR would fall to the 50s. He would remain asymptomatic during these times. Likely tachy-brady syndrome. We started his metoprolol and he tolerated well. We were getting an echo today to evaluate for structual heart disease in any relation to these heart rates. It is a low suspicion. The echo final report was still pending. We will fax it to [Hospital 100] Rehab tonight. # Hypotension: Resolved on [7-24]. Likely due to either SIRS or insufficient TFs. No cardiac sx, EKG SR. Lopressor was discontinued on [7-24] because he was normotensive. He was bolused with NS for sbp's < 90. We restarted his metoprolol at his home dose during his admission. # Anemia: Normocytic. Pt has hx of chronic anemia and PUD, last HCT at rehab 29.7 last week. Underlying anemia likely multifactorial: ACD and Fe deficiency. On [7-24], pt developed acute drop in hct to 21.5 and was transfused 1 unit and started on IV Protonix. He responded well with a subsequent hct of 26. The acute anemia was likely hemodilutional from the fluid resuscitation. Since he didn't seem to be bleeding, the IV PPI was switched to PO omeprazole on [7-25]. His hct has been stable since then, between 24 and 27. # Steroid/ICU myopathy: Improved from last discharge, however progress over the past week has halted. Has also lost further weight. PT was consulted and recommended 2+ hrs OOB everyday. They also endorsed weaning pt off ventilator as he didn't desat during the eval. . # Anxiety: Likely contributing to difficulty weaning from ventilator. Currently euthymic. Pt was kept on Citalopram. Psych consulted for acute anxiety. They recommended discontinuing prn morphine completely, continuing standing Klonopin, starting QHS mirtazapine, and starting prn Seroquel. They also recommended behavioral therapy, which is most likely to help the pt during his episodes of acute respiratory difficulty. We d/c'ed prn trazodone on [7-28] to minimize polypharmacy. . # Nutritional status/Weight loss 7lbs in 10 days. Pt. appears cachectic and malnourished. Losing wt despite increased calories in TFs at Rehab. Possibly increased demand in setting of infection. Patient was titrated over 2 days from 10 cc/hr feeds to goal of Nutren 45cc/hr as determined by Nutrition, put on Full-Strength on [7-26]. Prealbumin is still pending. Nutrition rec'd daily weights. Medications on Admission: Chlohexidine - Citalopram 40mg daily - Clonopin 1.5mg TID - Iron 325mg daily - Flovent - 2 puffs [Hospital1 ] - Heparin SC - Levothyroxine 88mcg - Metoprolol 12.5mg daily - APAP 325mg prn Q6H - artificial tears - bisacodyl 10mg pr - colace - guaifenesin - ativan 0.5mg prn - morphine 2mg Q4H prn pain/anxiety - zofran 8mg NG prn - Trazodone 37.5mg HS prn - Clotrimazol. Discharge Medications: 1. Citalopram 20 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Chlorhexidine Gluconate 0.12 % Mouthwash [Hospital1 ]: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-23] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. Levothyroxine 112 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily) as needed for hypothyroid. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Ondansetron 4 mg Tablet, Rapid Dissolve [Month/Day (2) ]: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 8. Clotrimazole 1 % Cream [Month/Day (2) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection [Hospital1 ] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: Two (2) Puff Inhalation QID (4 times a day). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: Four (4) Puff Inhalation Q2H (every 2 hours) as needed for sob/wheeze. 12. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Oxycodone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours). 15. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [Last Name (STitle) ]: One (1) Puff Inhalation [Hospital1 ] (2 times a day) as needed for copd. 16. Nystatin 100,000 unit/mL Suspension [Hospital1 ]: Five (5) ML PO QID (4 times a day). 17. Clonazepam 1 mg Tablet [Hospital1 ]: 1.5 Tablets PO TID (3 times a day). 18. Mirtazapine 15 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 19. Quetiapine 25 mg Tablet [Hospital1 ]: One (1) Tablet PO QID (4 times a day) as needed for anxiety, agitation. 20. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 21. Heparin, Porcine (PF) 10 unit/mL Syringe [Hospital1 ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 22. Furosemide 10 mg/mL Solution [Hospital1 ]: [1-23] Injection once a day for 3 days: Ongoing diuresis for pulmonary edema. Please hold for SBP < 100. Please discontinue if patient seems dry. Please continue if still has signs of volume overload. 23. Cefepime 1 gram Recon Soln [Month/Day (2) ]: Two (2) gm Injection once a day for 3 days: last day [7-31]. 24. Vancomycin 500 mg Recon Soln [Month/Year (2) ]: 2.5 recon solutions Intravenous once a day for 3 days: please give 1250 mg daily; last day [7-31]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Respiratory Failure Anxiety Discharge Condition: Stable. Mental status back to baseline. No pain control needed, but agitation/anxiety addressed with medication. Discharge Instructions: Mr. [Known lastname 86645] was treated for acute respiratory failure thought to be secondary to a possible hospital-acquired pneumonia with sepsis. He has been stabilized on treatment with ventilatory support and antibiotics and is ready for discharge back to rehabilitation. We changed several of his medications. Mostly it was his anxiety medications. He was getting clonapin and morphine for air hunger PRN. We placed him on standing oxycodone and clonapin. We added seroquel PRN for further anxiety. He is on remeron at night to help him sleep. Psychiatry saw him for this reason. Otherwise, he needs to complete his course of antibiotics for hospital acquired pneumonia. Followup Instructions: Patient is being returned to [Hospital 100] Rehab for continuation of his treatment [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2140-7-28]	[ "531.90", "427.81", "486", "E932.0", "263.9", "518.83", "244.9", "783.21", "359.4", "276.52", "285.29", "V46.11", "276.2", "300.00" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.72", "38.93", "31.74" ]	icd9pcs	[ [ [] ] ]	18183, 18249	8827, 14772	342, 410	18321, 18436	6082, 8804	19173, 19428	5311, 5315		15198, 18160		18270, 18300		14799, 15175			18460, 19150										5330, 6063																				4152, 4167				282, 304											438, 4133																4211, 4931	4963, 5295
30,170	120,612	33502	Discharge summary	report	Admission Date: [2145-3-31] Discharge Date: [2145-4-12] Date of Birth: [2079-2-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: syncope Major Surgical or Invasive Procedure: Pacemaker placement [4-7] History of Present Illness: 66 year old man with CAD s/p CABG and mechanical AVR in [2142], with multiple medical problems who has been hospitalized frequently in the past year, presented to OSH with chest pain and SOB on [3-19]. He was diagnosed with PNA and ruled out for MI. He completed a course of azithro and CTX and was ready for rehab. . On [3-27], reports say that he was walking in the hallway when he had a vfib arrest. He was defibrillated and subsequently developed PEA arrest and bradycardia. Epi was given and he was intubated and sent to the CCU at OSH. Temporary pacing wires were placed. His vfib arrest may have been due to hyperkalemia (K=6.1) although he did not have any EKG changes prior to arrest. He was also on dopamine. . Neurology consult was called and they did not note any focal neurological deficits while he was intubated. Cardiology consult was called and they believed he may need an ICD for his vfib arrest. On [3-31], he was extubated and dopamine was stopped. He was transferred to [Hospital1 18] for cath and ICD placement. Past Medical History: ) CAD, s/p CABG (in [2142]) 2) Status post AVRx2, (St. [Male First Name (un) 1525] Mechanical valve in [2142] revision) 3) CVA (complication of [2142] CABG/AVR) 4) Congestive heart failure, EF 45% 5) Paroxysmal atrial fibrillation 6) COPD 7) Multiple pneumonias, twice requiring intubation. 8) Diabetes type II 9) Bladder cancer 10) History of alcohol abuse 11) History of drug abuse 12) Gastroesophageal reflux disease 13) Depression/Anxiety . Cardiac History: CABG, in [2142] anatomy as follows: LIMA to LAD SVG to PDA Social History: Continues to smokes half a pack of cigarretts daily. No alcohol use. . Family History: non contributory Physical Exam: VS: T 98.9, BP 105/48, HR 63, RR 18, O2 98% on 5LNC Gen: A+ox2, somnelent, follows simple commands and answers simple queastions HEENT: PERRL, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 10 cm. CV: Regular rate. S1 and mechanical S2. No M/G/R. Chest: Resp were unlabored, no accessory muscle use. Bibasilar crackles, left > right half way up. No wheezes or rhonchi. Abd: Soft, NTND, No HSM or tenderness. Ext: No c/c/e. Pulses: Right: 1+ DP, 2+ TP Left: 1+ DP, 2+ TP Pertinent Results: CHEST (PORTABLE AP) [2145-3-31] 11:01 AM CHEST (PORTABLE AP) Reason: assess for CHF and line placement [Hospital 93] MEDICAL CONDITION: 66 year old man with vfib arrest xfer from OSH with central lines REASON FOR THIS EXAMINATION: assess for CHF and line placement HISTORY: Ventricular fibrillation and arrest, transferred from outside hospital. To assess for congestive failure and line placement. FINDINGS: No previous images. There are intact sternal sutures in a patient with previous CABG and a prosthetic valve. There is substantial enlargement of the cardiac silhouette with a plethora of ill-defined pulmonary vessels consistent with vascular congestion. Some areas of increased opacification at the bases could reflect atelectasis, though the possibility of supervening infection cannot be excluded. Right IJ catheter which could be a lead with a metallic tip extends to the region of the apex of the right ventricle. A left subclavian catheter does not appear to cross the midline. Of incidental note are surgical clips overlying the right axillary region. . COMMENTS: 1. Coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had a 20% stenosis. The LAD had a 50% mid-vessel stenosis and an 80% origin stenosis of a moderate-sized Diagonal-1 branch. The LCx had a 50% origin stenosis after a large patent ramus intermedius. The RCA had mild diffuse disease in the proximal segment and moderate diffuse disease in the stented segment distally, up to 50% stenosis. The PDA was occluded. 2. Arterial conduit angiography demonstrated a patent LIMA-LAD. 3. Graft angiography demonstrated a patent SVG-PDA. The PDA was small. 4. Limited resting hemodynamics revealed normal systemic arterial pressure with a central aortic BP of 125/63 mmHg. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA-LAD and SVG-rPDA. . ECG Underlying rhythm is sinus rhythm with prolonged A-V conduction. P-R interval measures approximately 270 milliseconds and is further prolonged following premature complexes. Two atrial premature beats, one aberrantly conducted, are noted. Underlying QRS pattern is right bundle-branch block with left anterior hemi-block. Diffuse, but especially lateral, ST-T wave changes are seen and may represent myocardial hypertrophy and/or ischemia. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 90 0 152 410/462 0 -71 102 . Echo: The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral severe hypokinesis/akinesis. The remaining segments contract normally (LVEF = 50%). The right ventricular cavity is moderately dilated with focal basal free wall hypokinesis. The aortic root is moderately dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. Mild to moderate ([12-16]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Dilated right ventricle with mild systolic dysfunction. Normally-functioning aortic valve bioprosthesis. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: 66 year old male with CAD s/p CABG and mechanical AVR p/w syncope, found to have 1st degree heart block, in addition to left anterior fascicular block and RBBB. . # Heart Block: The diagnosis of ventricular fibrillation from the outside hospital was in doubt, given that no tele strips or ekg's were produced which detected ventricular tachycardia or ventricular fibrillation. Given this information, and the fact that his ekg continued to show first degree heart block, left anterior fascicular block, and right bundle branch block, it was thought that the patient's episode at the outside hospital was secondary to syncope from bradycardia. In addition, cardiac catheterization showed diffuse three vessel disease but [Last Name (un) ] active lesions which may have precipitated an ischemic event. Therefore, it was decided not to implant an ICD. The patient was kept on a temporary pacer for the first several days of admission. The patient's native heart rate eventually outpaced the pacer, at a rate ranging in the 50's, and his temporary pacer was removed. He remained with a heart rate in the 50's over the next several days. He was asymptomatic at rest. However, he continued to have heart rates as low as the 20's and 30's, and was developing frequent [1-17] second pauses while being monitored on telemetry. Therefore, a dual chamber pacemaker at setting DDD was placed on [4-8]. On [4-9], he began having runs of atrial tachycardia in the 120-130's, secondary to atrial sensed ventricular pacing. His pacemaker setting was therefore changed to DDI, and he did not experience further tachycardia. The pacemaker implantation was without complications. He was continued on IV heparin and transitioned to PO coumadin. His goal INR is 2.5 to 3.5. He has follow-up with device clinic and Dr. [Last Name (STitle) ] as per discharge information. . # COPD: Continued albuterol, ipratropium nebs. Given inhalers upon d/c. . # CAD/Ischemia: s/p CABG [2143], LIMA to LAD, SVG to PDA. Cardiac cath showed patent grafts, Lcx 50% stenossi, DI w/ 80% stenosis, RCA with diffuse disease, distal 50% stenosis. The patient was continued on aspirin, lisinopril, and atorvastatin. His metoprolol was held until his pacemaker was placed and then was restarted. . # Pump: Echo with LVEF 50%, mild symmetric LVH, mild regional LV systolic dysfunction with basal inferior and inferolateral severe hypokinesis/akinesis. Rv is moderately dilated with focal basal free wall hypokinesis. he was continued on lasix and lisinopril. His metoprolol was initially held and restarted after pacemaker placement. . # Rhythm: History of paroxysmal afib. The patient was continued on IV heparin. His coumadin was restarted after pacemaker placement. His metoprolol was restarted after pacemaker placement. . # Valves: s/p AVR x 2. St. [Male First Name (un) 1525] mechanical valve in [2143]. The patient remained on heparin IV. He was transitioned to coumadin after his pacemaker was placed. Goal INR 2.5 to 3.5. . # History Of CVA: continued depakote. . # DM: Insulin sliding scale . # Code: full . # Communication: wife, [Name (NI) 2048] [Name (NI) 77679] [Telephone/Fax (1) 77680]. Medications on Admission: HOME MEDICATIONS: Albuterol nebs q6H Oxycodone 10 q4H Lisinopril 10 Aldactone 25 Coreg 6.25 [Hospital1 ] Lipitor 20 Lasix 40 Protonix 40 Fentanyl patch 50 q72 Trazadone 50 QHS Depakote 500 Ativan q4 PRN Olanzapine 10 QHS Folic acid 1 coumadin 7.5 mg qhs . TRANSFER MEDICATIONS: Ceftriaxone 1 Vanc 1 q 12 Lasix 40 IV daily Protonix 40 albuterol Atropine 0.5 mg four times daily-- ???? Valproic acid 750 QHS Lipitor 20 Folic acid 1 Olanzipine 5 Regular insulin sliding scale Haldol PRN Ativan PRN Metoprolol IV PRN Morphine PRN Albuterol/atrovent nebs PRN Trazadone 50 PRN Riopan 10 four times daily PRN . ALLERGIES: NKDA 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: [12-16] Tablet, Rapid Dissolves PO QHS (once a day (at bedtime)) as needed. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. Disp:1 inhaler Refills:2 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 15. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 16. Outpatient Lab Work Please draw INR on Wed. [2145-4-7]. Please have results faxed to PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5936] at [Telephone/Fax (1) 77681]. His office number is [Telephone/Fax (1) 42923]. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Discharge Diagnosis: Syncope Bradycardia First Degree Heart Block Left Anterior Fascicular Block Right bundle branch block Atrial Fibrillation Coronary Artery Disease COPD Discharge Condition: good. Discharge Instructions: You were admitted to the hospital after being found down. It is thought that you passed out because your heart was beating too slow. You received a pacemaker to ensure that your heart beats at an adequate rate. . Please take your medications as prescribed. Changes have been made to your regimen. . Your INR was 2.6 upon discharge. The goal INR is 2.5 to 3.5. Your INR will need to be followed by Dr. [First Name (STitle) 5936]. . Please follow up as described below. . Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, fever, or any other concerning symptoms. Followup Instructions: Follow up with Device Clinic: [Telephone/Fax (1) 59]. Wednesday, [4-14] at 11:30, [Hospital Ward Name 23] Building, [Location (un) 436] Follow up with Dr. [Last Name (STitle) ] from Electrophysiology. [Telephone/Fax (1) 9530] Friday [5-14] at 10:00am, located at [Hospital Ward Name 23] Building [Location (un) 3971]. . Follow up with your PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5936] [Telephone/Fax (1) 42923] in two weeks. Please call to make this appointment as soon as possible. . Please call if you need to reschedule any of the above appointments. Completed by:[2145-4-15]	[ "426.52", "428.0", "426.11", "427.31", "482.41", "V43.3", "496", "428.22", "250.00", "V10.51", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "88.52", "37.22", "37.72", "37.83", "88.55" ]	icd9pcs	[ [ [] ] ]	12126, 12179	6415, 9629	321, 352	12374, 12382	2674, 2785	13049, 13705	2107, 2125		10304, 12103	2822, 2888	12200, 12353		9655, 9655		4511, 6392	12406, 13026										2140, 2655				9673, 9915																				274, 283	2917, 4494								9937, 10281		380, 1437																1459, 2002	2018, 2091
11,444	139,872	8338	Discharge summary	report	Admission Date: [2185-4-15] Discharge Date: [2185-4-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2074] Chief Complaint: Emergent Cardiac Catheterization Major Surgical or Invasive Procedure: Left and Right Heart Cath History of Present Illness: 84 year old male with dyslipidemia, GERD, s/p recent R shoulder surgery and history of "equivocal" exercise ECHO [10-27] who presents from [Hospital ] hospital for emergent cath. He had been experiencing crescendo chest pain X ~48 hours prior to presentation, on & off. [1-6] right sided, +nausea, + dizziness, no SOB. EKG with STE's V2, V4-V6. CK 1732, MB 138 with TnI 47.1. Received sl ntg's X 3, 325mg asa, [11-28] inch ntg paste, hep 4000U bolus and integrillin boluls + drip and sent to [Hospital1 18] for urgent cath. CP free. Stable vitals at OSH, and no 02 req. At [Hospital1 18], underwent emergent cath which TO prox LAD, 50% LMCA, 70% large OM1, 80% lower pole OM2. In process of shooting RCA, pt had dissection of prox RCA, which was then ballooned and stented and had 0% residual and TIMI III flow at end of case. LAD ostium and prox LAD stented with cyphers. RA 8, PA 39/16 (26), PCWP 17, CO 4.96, CI 2.48. 330 mL Optiray. Past Medical History: GERD Dyslipidemia--> TC 138 TG 135 HDL 51 LDL 50 ([12-1]) Equivocal Stress--> 8 minutes on modified [Doctor First Name ], stopped [12-29] fatigue, blunted exercise response to exercise. Normal rest and exercise TTE images. 1+MR and 1+AR. Actinic Keratosis Basal Cell Keratoses --> numerous biopsies over the years pyloric stenoses diverticulosis history of HAV Social History: Lives with wife, with 2 butlers. No tob/etoh/drugs. No tatoos. Family History: Non-contrib Physical Exam: AF 99/65 67 18 98%RA Gen: NAD, lying flat Heent: EOMI, PERRL, MMM Neck: No JVD Heart: RRR no mrg. Normal PMI Lungs: Clear Abd: Benign Ext: No c/c/e. R groin without bruit or hematoma. Skin: Erythematous papular rash on back. Solar-palmar sparin. Pertinent Results: [2185-4-18] 08:05AM BLOOD WBC-9.1 RBC-4.25* Hgb-13.1* Hct-39.0* MCV-92 MCH-30.8 MCHC-33.5 RDW-13.2 Plt Ct-136* [2185-4-18] 08:05AM BLOOD Plt Ct-136* [2185-4-18] 08:05AM BLOOD PT-13.3 PTT-44.1* INR(PT)-1.2 [2185-4-18] 08:05AM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-139 K-4.1 Cl-106 HCO3-24 AnGap-13 [2185-4-16] 04:07AM BLOOD CK(CPK)-1379* [2185-4-15] 09:00PM BLOOD CK(CPK)-1463* [2185-4-16] 04:07AM BLOOD CK-MB-101* MB Indx-7.3* [2185-4-15] 09:00PM BLOOD CK-MB-144* MB Indx-9.8* cTropnT-11.15* [2185-4-18] 08:05AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 [2185-4-16] 04:07AM BLOOD Triglyc-69 HDL-50 CHOL/HD-2.1 LDLcalc-41 LDLmeas-<50 Cardiac Cath ([4-15]): 1. Coronary angiography of this right dominant circulation demonstrated two vessel and branch vessel coronary artery disease. The LMCA had a 50% mid lesion. The LAD was proximally 100% occluded with significant thrombus. D1 was filled via left to left collaterals. Distal LAD was filled via right to left collaterals. The LCX had 70% lesion in the large OM1. There was also a 80% lesion in the lower pole of OM2. RCA had 70% proximial stenosis in this large dominant vessel. During diagnostic angiography, the catheter dove deeply into RCA causing proximal RCA dissection with associated 95% stenosis and TIMI2 flow. 2. Resting hemodynamics demonstrated mildly elevated left sided filling pressures with mPCWP of 17 mmHg. There was mild pulmonary hypertension with PASP of 39 mmHg and mean PA pressure of 26 mmHg. The cardiac output and cardiac index were preserved at 5 L/min and 2.5 L/min/M2, respectively. 3. Left ventriculography was not performed. 4. Successful PCI of the proximal RCA with a 3.0 x 18 mm Cypher DES. 5. Successful PCI of the occluded ostial/proximal LAD with a 3.0 x 33 mm Cypher DES, post-dilated with a 3.5 mm balloon. ECHO ([4-18]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal half of the anterior wall and apex. There is no apical aneurysm or evidence for left ventricular thrombus. The remaining walls contract well. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is present. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 84 y/o male with acute anterior STEMI. 1. CAD: Found to have 50%LMCA, acute TO prox LAD, 70% OM1 and 80% OM2. Treated successfully with PCI and DES during cath. He remained chest pain free during the remainder of the hospital course. He was given 18 hours of integrillin and loaded with plavix. He was also started on beta-blockade and ACE-inhibition. His crestor was continued given his low LDL and CRP. He was transitioned to once a day lisinopril and toprol XL at discharge. 2. Rhythm: No dysrrhythmias during this hospitalization. Given EF > 35%, does not need repeat ECHO in 30 days. 3. Pump: EF 45% by ECHO. His anterior wall is pumping remarkably well given the degree of infarction (CK peak ~1700). No need for further ECHO. Continue ACE for remodelling. 4. Rash: Developed erythematous papular rash on back on [4-16]. Palmar-solar sparing. Not pruritic. Thought to be [12-29] contact dermatitis. Does not appear vasculitic or hyepersensitiviy reaction. Medications on Admission: pepcid crestor 10 Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Rosuvastatin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home with Service Discharge Diagnosis: Anterior STEMI Discharge Condition: Good Discharge Instructions: If you have these symptoms, call your doc or go to the ED: -chest pain -shortness of breath -paplitations -nausea/vomiting -fainting Followup Instructions: Dr.[First Name4 (NamePattern1) 679] [Last Name (NamePattern1) 2974] [4-22] at 12:30, 110 [Doctor First Name ] [Hospital Unit Name 29516]. Dr[Doctor Last Name ] office will call you and schedule an appointment within 2-4 weeks. You can reach his office at ([Telephone/Fax (1) 29517]. Completed by:[2185-4-18]	[ "E870.6", "414.12", "272.0", "414.01", "692.9", "998.2", "410.11" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23", "99.20", "36.07", "36.05" ]	icd9pcs	[ [ [] ] ]	6401, 6420	4817, 5810	295, 323	6479, 6485	2146, 4794	6667, 7010	1827, 1840		5878, 6378		6441, 6458		5836, 5855			6509, 6644										1855, 2127																								223, 257											351, 1323																1345, 1728	1744, 1811
45,914	113,237	38727	Discharge summary	report	Admission Date: [2144-1-5] Discharge Date: [2144-1-21] Date of Birth: [2059-8-25] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Sulfa (Sulfonamide Antibiotics) / Tetracycline / Novocain / Levaquin / Zoloft / Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2144-1-7] 1. Left video-assisted thoracoscopic surgery converted to left anterior thoracotomy. 2. Drainage of pleural and pericardial effusion. 3. Pericardial window. History of Present Illness: 84 year old female with history of mitral regurgitation and a chronic pericardial effusion who was admitted for mitral valve replacement with Dr [Last Name (STitle) 914] on [12-13], post op course c/b likely thromboembolic ischemic event involving the frontal lobes and parietal regions, she recovered significantly, was started on Dilantin and Keppra and discharged to rehabilitation at [Hospital1 ]-[Location (un) 86] on [12-21]. She now returns w/chest pain and hypotension. Echo done in ED c/w loculated pericardial effusion-no evidence of tamponade. Past Medical History: 1. Mitral regurgitation s/p mitral valve replacement [2143-12-13] 2. Atrial fibrillation s/p MAZE procedure [2143-12-13] 3. Complex partial seizures secondary to ischemic stroke after surgery 4. Hypertension 5. Hyperlipidemia 6. Non-insulin dependent diabetes mellitus, type 2 7. Obesity 8. Fibromyalgia 9. Osteopenia 10. Irritable bowel syndrome 11. Obstructive sleep apnea 12. h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear ([3-/2142]) - Transfused with 4 Units of RBC 13. Cystic pancreatic mass ([9-/2142]) - Bx negative 14. Mild coronary artery disease (no prior cath reports available) 15. Congestive heart failure 16. Esophageal ulcers/GERD 17. Brain Schwannoma's (4 which are stable by MRI) 18. Left metatarsal fracture 19. Type 2 Diabetes 20. Anemia Social History: Race: Caucasian Last Dental Exam: > 2 years ago Lives with: Alone in [Location (un) 5110], MA Contact: Daughter Phone # Occupation: Alone Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [X] [12-31] drinks/week [] >8 drinks/week [] Illicit drug use Family History: No noted Premature coronary artery disease Physical Exam: Pulse: 96 AF Resp: 18 O2 sat: 96% 1L B/P Right: 96/62 Left: General: Lying in bed talking in full sentances Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: BS diminished bilat half way up Heart: RRR [] Irregular [x] Murmur-no Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [] Edema [x]2+ bilat Neuro: A&O x3. MAE, left sided weakness upper greater than lower Pulses: DP Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Pertinent Results: [2144-1-5] Echo: Normal left ventricular wall thickness and cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic regurgitation. A well-seated bioprosthetic mitral valve prosthesis is present. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a large, partically echofilled pericardial effusion most prominent inferlateral to the left ventricle (2-2.6cm). The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Large loculated ?bloody pericardial effusion most prominent along the inferolateral wall of the left ventricle and anterior to the right ventricle but without echocardiographic signs of tamponade. Mildly depressed global left ventricular systolic function. Well seated bioprosthetic mitral valve replacement with no mitral regurgitation. Compared with the findings of the prior study (images reviewed) of [2143-9-8], the pericardial effusion is slightly smaller and appears more loculated. Global left ventricular systolic function is now lower, and the patient is now in atrial fibrillation. The mitral valve has been replaced. . [2144-1-6] Chest CT: 1. Status post mitral valve replacement and Maze procedure with expected appearance of the mitral valve and left atrium. 2. Small left and small-to-moderate right pleural effusion. Substantial atelectasis of the left lower lobe, with no evidence of central compression with not re-expanding left lung and substantial left mediastinal shift. 3. Evidence of substantial pulmonary hypertension. . [2144-1-6] Lower Ext. U/S: Left and right subclavian veins are patent with normal flow and compressibility. Left internal jugular vein is patent with normal flow and normal compressibility. There is normal compression and augmentation of the left axillary, left brachial, left basilic, and left cephalic veins. . [2144-1-7] Echo: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. 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. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is a large pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. Dr. [First Name (STitle) ] was notified in person of the results at time of surgery. Post evacuation\window: no effusion, otherwise no change. . [2144-1-21] 06:10AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.1* Hct-30.7* MCV-87 MCH-28.7 MCHC-32.8 RDW-15.4 Plt Ct-145* [2144-1-21] 06:10AM BLOOD Plt Ct-145* [2144-1-21] 06:10AM BLOOD Glucose-106* UreaN-31* Creat-0.6 Na-147* K-3.7 Cl-105 HCO3-39* AnGap-7* Brief Hospital Course: 84 yr old s/p MVR/MAZE on [12-13] discharged to rehab on [12-21]. She returned from rehab to [Hospital1 18] on [2144-1-4] with complaints of chest pain associated with hypotension. TEE showed loculated pericardial effusion. On [1-7] she underwent pericardial window via left anterior thoracotomy. In [Name (NI) 13042] PT was not able to be extubated due to low o2 and high CO2. She was therefore transferred to CVICU vented on Neo gtt and bilateral [Doctor Last Name ] drains. She eventually extubated and was transferred to floor the following day, CTs' were removed prior to transfer. The following day while on the floor she became hypoxic and CXR revealed large left effusion with collapse. She was therfore transferred back to the CVICU for care. Left pigtail placed by IP for drainage of effusion and she required reintubation for left lower lobe collapse. She was bronched and mucus plug was extracted. She was rebronched the following day with improvement in lung findings. However she remained intubated for several days longer due to continued tachypnea and SOB. She eventually self extubated on [1-13] and continued an 8 day course of antibiotics for VAP coverage. She also received a short course of steroids for possible reactive airway disease. She remained hemodynaically stable. TTE revaled that she was underfilled and was transfused to optimize her BP. During her ICU stay she was in rapid afib and was started on amiodarone for rate contol. At times she bacame bradycardic into the 30's therefore her lopressor was adjusted. She was seen by speach and swallow and was placed on modified diet for mild swallowing difficulties regular with nectar thick. She was restarted on anticoagulation for her a-fib with goal INR 20-2.5. Once her respiratory status improved she transferred to floor on [1-17] where she continued to progress slowly. Patient became resistent to care and very depressed stating that she wanted to die. She was restarted on her preopertaie doses of ativan, Zoloft and Keppra for her seizure history. She was also seen by the social service department for her depression which at the time of discharge was improved. She required a lot of encourgement and support. Patient has a history of IBS and has had persistent loose stool but was c-diff negative and required immodium with good effect. Her PA &lat CXR on [1-20] showed moderate right effusion the plan is to continue with diuresis and CXR to be obtained at f/u with Dr. [Last Name (STitle) 914]. She continues to have a metabolic alkalosis and is being discharged short course of diamox. She will need to have her renal function followed closely at rehab. On POD#13 she was seen by ENT for worsening hoarseness. She was determined to have a left cord hypomobility, bowing and bilateral TVC nodules. She was compensating well and was cleared for cleared for a modified diet. Her injury was likely related to her recent intubations and observation was favored for now with close oral f/u: - Voice rest - Maximize PPI therapy - Diet per speech and swallow - Humidification - Avoid use of nasal cannula oxygen if possible; trial oxygen delivery via humified face mask. - Nasal saline spray to both nostrils at least TID. -F/U with Dr.[First Name (STitle) ] She was seen by the physical therapy department for strengtening and conditioning and it was determined that due her continued needs she would require rehab placement. She was discharged to [Hospital 100] Rehab MACU all questions and concerns addressed. Follow-up appts arranged Medications on Admission: 1. potassium chloride 20 mEq Q12H for 10 days. 2. metoprolol tartrate 50 mg [Hospital1 ] 3. aspirin 81 mg DAILY 4. acetaminophen 325-650 mg Q4H as needed for pain. 5. amiodarone 400 mg [Hospital1 ] for 5 days: After 5 days decrease the dose to 400 mg daily for 1 week, then after 1 week, decrease dose to 200 mg daily. 6. levetiracetam 1500 mg [Hospital1 ] 7. rosuvastatin 20 mg DAILY 8. fexofenadine 180 mg [Hospital1 ] 9. Protonix 40 mg once a day. 10. furosemide 40 mg once a day for 10 days. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 12. alprazolam 0.25 mg TID as needed for anxiety. 13. Coumadin once a day: titrate to an INR of [12-26].5. 14. diphenoxylate-atropine 2.5-0.025 mg [Date Range 8426] Sig: One (1) [Date Range 8426] PO Q6H (every 6 hours) as needed for loose stool. Discharge Medications: 1. bisacodyl 5 mg [Date Range 8426], Delayed Release (E.C.) Sig: Two (2) [Date Range 8426], Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg [Date Range 8426] Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. rosuvastatin 20 mg [Date Range 8426] Sig: One (1) [Date Range 8426] PO DAILY (Daily). 5. amiodarone 200 mg [Date Range 8426] Sig: Two (2) [Date Range 8426] PO DAILY (Daily) for 1 weeks: then decrease to 200mg daily until seen by cardiology. 6. aspirin 81 mg [Date Range 8426], Delayed Release (E.C.) Sig: One (1) [Date Range 8426], Delayed Release (E.C.) PO DAILY (Daily). 7. levetiracetam 500 mg [Date Range 8426] Sig: Three (3) [Date Range 8426] PO twice a day. 8. acetaminophen 325 mg [Date Range 8426] Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. warfarin 1 mg [Date Range 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] DAILY (Daily): take as directed for INR goal 2.0-2.5. 10. fexofenadine 60 mg [Last Name (Titles) 8426] Sig: Three (3) [Last Name (Titles) 8426] PO BID (2 times a day). 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 12. metoprolol tartrate 50 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO TID (3 times a day). 13. sertraline 25 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO DAILY (Daily). 14. ipratropium bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 15. guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours). 16. alprazolam 0.25 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO BID (2 times a day). 17. alprazolam 0.25 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO QHS (once a day (at bedtime)). 18. sodium chloride 0.65 % Aerosol, Spray Sig: [11-25] Sprays Nasal TID (3 times a day). 19. Protonix 40 mg [Month/Day (2) 8426], Delayed Release (E.C.) Sig: One (1) [Month/Day (2) 8426], Delayed Release (E.C.) PO twice a day. 20. Lasix 40 mg [Month/Day (2) 8426] Sig: One (1) [Month/Day (2) 8426] PO twice a day: for 1 week then decrease to daily and evaluate. 21. potassium chloride 25 mEq Packet Sig: One (1) PO twice a day for 1 weeks: then decrease to daily while on lasix. 22. Diamox Sequels 500 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 1 weeks: while on [Hospital1 ] lasix. 23. immodium Sig: One (1) four times a day as needed for diarrhea. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Mitral regurgitation s/p mitral valve replacement [2143-12-13] 2. Atrial fibrillation s/p MAZE procedure [2143-12-13] 3. Complex partial seizures secondary to ischemic stroke after surgery 4. Hypertension 5. Hyperlipidemia 6. Non-insulin dependent diabetes mellitus, type 2 7. Obesity 8. Fibromyalgia 9. Osteopenia 10. Irritable bowel syndrome 11. Obstructive sleep apnea 12. h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear ([3-/2142]) - Transfused with 4 Units of RBC 13. Cystic pancreatic mass ([9-/2142]) - Bx negative 14. Mild coronary artery disease (no prior cath reports available) 15. Congestive heart failure 16. Esophageal ulcers/GERD 17. Brain Schwannoma's (4 which are stable by MRI) 18. Left metatarsal fracture 19. Type 2 Diabetes 20. Anemia Discharge Condition: Alert and oriented x3 nonfocal Out with bed with assistance Incisional pain managed with Tylenol Lungs: diminished Right greater than left Incisions: Sternal - healing well, thoracotomy incision clean, dry and intact Edema +1 lower extremity bilaterally Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. 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: Cardiac Surgeon: Dr. [Last Name (STitle) 914] on [2144-2-17] 1pm Cardiologist: Dr. [Last Name (STitle) ] on [2144-2-3] 1:30 Thoracic surgeon: Dr. [First Name (STitle) ] on [2144-1-28]/12 @9AM ENT: Dr. [First Name (STitle) ] on [2-21] at 9:00 [Telephone/Fax (1) 2349] Please call to schedule appointments with your Primary Care: Dr. [Last Name (STitle) ] in [11-25] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: Atrial fibrillation Goal INR 2-2.5 First draw [2144-1-22] Results to phone fax to PCP's office [Hospital1 ] after discharge from rehab Completed by:[2144-1-21]	[ "272.4", "933.1", "V64.41", "276.3", "511.9", "250.00", "E912", "997.31", "780.79", "599.0", "423.9", "327.23", "401.9", "518.51", "518.0", "V58.61", "345.80", "784.42", "438.89", "V42.2", "427.31", "733.90", "416.8", "493.90" ]	icd9cm	[ [ [] ] ]	[ "29.11", "34.04", "96.71", "96.6", "37.0", "34.09", "33.24", "93.90", "37.12", "96.04" ]	icd9pcs	[ [ [] ] ]	13782, 13848	6407, 9990	377, 550	14712, 14968	2968, 6384	15980, 16779	2358, 2402		10950, 13759		13869, 14691		10016, 10927			14992, 15957										2417, 2949																								327, 339											578, 1154																1176, 1998	2014, 2342

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