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28,229	147,857	6933	Discharge summary	report	Admission Date: [2195-5-14] Discharge Date: [2195-5-15] Date of Birth: [2123-9-16] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Amoxicillin Attending:[First Name3 (LF) 2704] Chief Complaint: Elective Admision for Carotid PCI Major Surgical or Invasive Procedure: Carotid Stent Placement History of Present Illness: Patient is a 71 year old woman who has a history of hypertension, hyperlipidemia, a prior CVA in [2181] without residual, PVD, s/p left SFA and anterior tibial atherectomy in [2190] and bilateralbreast cancer. She also has known carotid artery disease, with a recent ultrasound revealing an increase in the velocities of the right carotid with 70-79% ICA stenosis in [Month (only) 116]. Pt was admitted for elective PCI and is now s/p PCI with stent placed to her R. ICA without complications. . In terms of symptoms, the patient denies any neurologic symptoms including no motor or sensory symptoms, no facial weakness, numbness or tingling. . Past Medical History: Hypertension Hyperlipidemia Elevated triglycerides [2181] CVA with no residual Carotid artery disease PVD, s/p left SFA and anterior tibial atherectomy in [Month (only) ] of [2190] [2191] left breast cancer, s/p lumpectomy, radiation and chemotherapy. [8-2]: right breast cancer, s/p mastectomy Neuropathy of her legs Resection of basal cell carcinomas Restless leg syndrome Partial hysterectomy Social History: Former smoker; quit in 30s. 10 pack years. Husband passed away from sudden cardiac death in [2194-12-26] at age 73. She has three daughters. Lives alone, retired social worker. Family History: Two daughters with MI??????s. One had an MI at age 38, another atage 45. Mother died of an MI at age 72. Father died from an MI atage 64. Sister died at age 55 after valve replacement. Physical Exam: VS: T , BP 123/64, HR 50 , RR 22, O2 96% on RA Gen: Elderly female in NAD, Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink Neck: Supple with JVP flat. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 SEM heard throughout. Chest: Resp were unlabored, no accessory muscle use. Lungs clear anteriorly. Abd: soft, NTND, +BS Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP Pertinent Results: [2195-5-14] 08:00AM GLUCOSE-98 UREA N-15 CREAT-0.9 SODIUM-141 POTASSIUM-6.1* CHLORIDE-105 TOTAL CO2-27 ANION GAP-15 [2195-5-14] 08:00AM estGFR-Using this [2195-5-14] 08:00AM WBC-6.1 RBC-4.20 HGB-12.4 HCT-37.0 MCV-88 MCH-29.6 MCHC-33.5 RDW-14.0 [2195-5-14] 08:00AM NEUTS-65.3 LYMPHS-26.6 MONOS-5.0 EOS-2.9 BASOS-0.3 [2195-5-14] 08:00AM PLT COUNT-218 [2195-5-14] 08:00AM PT-12.2 INR(PT)-1.0 C.CATH COMMENTS: 1. Access: retro RFA 2. Thoracic aorta. A pigtail catheter was placed in the ascending aorta and an aortogram was taken. This revealed a type 2 arch with all great vessels arising from separate ostia. 3. Left Carotid: A Berenstein catheter was advanced to the left CCA. The LCCA is normal. The ICA fills the ACA and MCA without cross filling of the contralateral carotid arteries. 4: Right Carotid. A catheter was advanced to the CCA. The RCCA was normal. The ICA fills the ipsilateral ACA and MCA with noted fetal orgin PCA. There is a 80% stenosis of the proxmial ICA. 5. Successful PTA/stent of right ICA with a [5-3] x30mm Protege RX stent posted with a 4.5mm balloon. Excellent result with normal flow down vessel and no residual stenosis. BP remained stable with no associated neurological symptoms. Patient left cathlab in stable condition. FINAL DIAGNOSIS: 1. Severe stenosis of right ICA. 2. Successful PTA/stent of right ICA with bare metal stent. Brief Hospital Course: Patient underwent PCI with stent to Right ICA without complications. Patient did not required any pressors to maintain her blood pressure at goal of systolic above >100. She was monitored in the cardiac intensive care unit overnight with frequent neurologic checks. She was continued on her home aspirin and plavix. Her home blood pressure medications were held, including HCTZ, atenolol, and valsartan due to systolic blood pressure in 100's at rest, and heart rate in 50's at rest. She will touch base with Dr. [First Name (STitle) ] over the weekend, based on frequent home blood pressure readings, and discuss restarting them at that time. She will follow up with Dr. [First Name (STitle) ] and neurology. Medications on Admission: Arimidex 1mg once a day Atenolol 50mg twice a day Plavix 75mg daily every morning Zetia 10mg at bedtime HCTZ 25mg one tablet every morning Mirapex 0.25mg one tablet mid day Mirapex 0.125mg one tablet at bedtime as needed Crestor 10mg one tablet every other day at bedtime Valsartan 160mg daily every morning Ambien 10mg as needed for sleep Aspirin 325mg daily every morning Fish oil one capsule twice a day Gabapentin 300mg daily every evening Calcium 500 + D twice a day Glucosamine/chondroitin two a day Vitamin B 12 1000mcg/Folic acid 400mcg SL daily MVI one daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet every other day. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily-2pm (). 10. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs () as needed. 11. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day: Take dose per home regimen. 12. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day: Take dose per home regimen. Discharge Disposition: Home Discharge Diagnosis: - Right Carotid Stenosis s/p PCI Discharge Condition: Stable, alert and oriented x3. Heart rate 62, Blood pressure 112/63. Discharge Instructions: You were admitted to the hospital for an elective carotid stent procedure. The procedure was successful and there were no complications. . There were changes made to your medications. Your blood pressure medications were held (Atenolol, Valsartan, HCTZ) and you should restart them only after speaking with Dr. [First Name (STitle) ] over the weekend. Please call Dr. [First Name (STitle) ] on his cell phone on either Saturday ([5-16]) or Sunday ([5-17]) to discuss your blood pressure readings and re-starting your blood pressure medications. His number is ([Telephone/Fax (1) 26085]. Please take your blood pressure regularly 4-5 times per day over the weekend. Otherwise you can continue your other medications. . If you have any lightheadedness, facial weakness, numbness or tingling, chest pain, shortness of breath, difficulty speaking, bleeding, fevers, or other concerning symptons please call Dr. [First Name (STitle) ] or return to the emergency room. . You will follow up with Dr. [First Name (STitle) ] as directed and arranged by his office within the next month. You will also follow up with Dr. [First Name (STitle) ] in neurology as directed. Followup Instructions: Please follow up with your usual primary care provider as scheduled. Provider: [Last Name (NamePattern5) 7224], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2195-7-28] 11:30 . If you have any questions please call Dr.[Name (NI) 3101] office.	[ "333.94", "443.9", "272.1", "272.4", "V10.3", "V45.89", "433.10", "401.9", "355.8" ]	icd9cm	[ [ [] ] ]	[ "00.63", "00.40", "00.45", "88.41", "00.61" ]	icd9pcs	[ [ [] ] ]	6140, 6146	3889, 4611	319, 345	6223, 6294	2457, 3754	7535, 7809	1688, 1874		5230, 6117		6167, 6202		4637, 5207		3771, 3866	6318, 7512											1889, 2438																				246, 281								373, 1033														1055, 1473	1489, 1672
61,590	130,431	35403	Discharge summary	report	Admission Date: [2201-4-7] Discharge Date: [2201-4-12] Date of Birth: [2162-11-20] Sex: F Service: MEDICINE Allergies: Percocet / Percodan / Banana Attending:[First Name3 (LF) 10435] Chief Complaint: Abdominal Pain, Fever Major Surgical or Invasive Procedure: paracentesis right IJ central venous line placement History of Present Illness: 38 y/o female with NASH and alcoholic cirrhosis c/b ascites, s/p Roux-en-Y surgery, s/p CCY, and h/o pancreatitis who presents with diffuse abdominal pain, rigors and chills for one day with a similar episode approximately 72 hours prior to admission. She denies any subjective fevers, nausea, vomiting, diarrhea, or constipation. In the ED, initial VS were 99.6, 109, 83/46, 16, 97%. CBC was notable for a white count of 23.7 with 76% PMNs and 14% bands. Serum chemistries were notable for a serum sodium of 128 and a bicarbonate of 20 with other chemistries within normal limits. Liver enzymes were notable for an albumin of 2.3, total bilirubin of 9.3, ALT of 16, AST of 45 and alk phos of 118, all approximately at their recent baseline. UA was notable for positive leukocyte esterase and nitrates 27 wbc, 9 rbcs 13 epis. A diagnostic paracentesis was performed with 3400 WBC and 525 RBC with 93% polys and an albumin less than 1.0. SAAG was > 1.3. Peritoneal fluid was sent for culture as well as two sets of blood cultures and urine. A CXR revealed bilateral pleural effusions, left larger than right, with left basilar atelectasis, though superimposed infection could not be excluded. She received 3L of normal saline boluses. She received Ceftriaxone 2 gm IV once. She subsequently received Zofran 4 mg IV once, Morphine 5 mg IV once and Ativan 2 mg IV once. Her blood pressure was stable with systolics in the 90s, no pressors were needed. A right IJ CVL was placed. On arrival to the MICU, patient's VS: 98.8 100 91/45 19 95% RA. Patient is jaundiced. Complaining of cramping abdominal pain diffusely. No N/V. No CP/SOB. No dysuria, has had urinary frequency since starting diuretics, no changes. Past Medical History: Past Medical History: - NASH, superimposed with alcoholic hepatitis (tbili ~20 in [12/2200]) - Status post gastric bypass in [2189]. She has lost 170 pounds since then. She also has iron deficiency and low normal B12 levels on account of this. - Hypothyroidism. - First episode of idiopathic pancreatitis in 02/[2197]. Social History: Works as a website designer at home Denies smoking or illicit drug use Drank two to three alcohol beverages on Fridays, Saturdays, and Sundays. The maximum amount of alcohol used in a day was five drinks, which she does maybe once a years. Quit drinking since [89]/[2200]. Family History: Positive for chrons disease in aunt, pancreatic cancer in the patient's paternal grandmother. Negative for acute pancreatitis in other family members. The family history is also negative for colon cancer, rectal cancer, and other HNPCC-related cancers. Physical Exam: Vitals: 98.8 Hr 70s BP 110s/70s RR 16 96% RA General: Alert, oriented x3, no acute distress HEENT: Jaundiced, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, crackles in Right lower lobe, no wheezes, ronchi Abdomen: well healed midline scar. soft, distended, not tympanitic, bowel sounds present, no organomegaly, tenderness to palpation diffusely, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing. 3+ pitting edema in biltaral lower extremities up to mid shin. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait normal. Pertinent Results: [2201-4-7] 9:12 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2201-4-9] MRSA SCREEN (Final [2201-4-9]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [2201-4-8] 9:48 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2201-4-9] C. difficile DNA amplification assay (Final [2201-4-9]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [2201-4-7] 9:39 pm URINE Source: Catheter. FINAL REPORT [2201-4-9] URINE CULTURE (Final [2201-4-9]): NO GROWTH. [2201-4-7] 6:35 pm URINE FINAL REPORT [2201-4-8] URINE CULTURE (Final [2201-4-8]): NO GROWTH. Imaging CHEST (PORTABLE AP) Study Date of [2201-4-7] 3:52 PM IMPRESSION: Bilateral pleural effusions, left larger than right, with left basilar atelectasis. Supervening infection cannot be excluded. CHEST (PORTABLE AP) Study Date of [2201-4-7] 8:02 PM IMPRESSION: Right IJ catheter ends in the mid SVC. CT ABD & PELVIS WITH CONTRAST Study Date of [2201-4-8] 2:17 AM 1. Moderate ascites. No evidence of loculated fluid collection. 2. Focal outpouching of oral contrast from the stomach to the excluded stomach just at the superior edge of the staple line. No evidence of contrast leak into the excluded stomach. Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.9 2.77* 8.9* 28.7* 103* 32.2* 31.1 17.3* 191 INR 2.1 Glucose UreaN Creat Na K Cl HCO3 AnGap 137 6 0.6 136 3.7 102 26 12 ALT AST AlkPhos TotBili 11 25 60 6.6* ASCITES ANALYSIS WBC RBC Polys Lymphs Monos 3400* 525* 93* 1 2* C. difficile DNA amplification assay (Final [2201-4-9]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. [2201-4-7] 5:20 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES FINAL REPORT [2201-4-13] Fluid Culture in Bottles (Final [2201-4-13]): NO GROWTH. [2201-4-7] 5:20 pm PERITONEAL FLUID FUNGAL CULTURE ADDED ON [2199-4-7] @ 0304. GRAM STAIN (Final [2201-4-7]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2201-4-10]): NO GROWTH. ANAEROBIC CULTURE (Final [2201-4-13]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2201-4-7] 4:15 pm BLOOD CULTURE FINAL REPORT [2201-4-13] Blood Culture, Routine (Final [2201-4-13]): NO GROWTH. No left lower extremity DVT to the popliteal veins. Calf veins not well seen due to overlying soft tissue edema. Brief Hospital Course: Assessment and Plan: NASH and alcoholic cirrhosis c/b ascites, s/p Roux-en-Y surgery, s/p CCY, and h/o pancreatitis who presents with diffuse abdominal pain, rigors and chills due to spontaneous bacterial peritonitis. # Intraperitoneal infection/sepsis. The patient presented with fever, rigors and abdominal pain. She had a temp of 100.4F recorded in ED, was tachy cardic with a leukocytosis thus she meets 3 SIRS criteria and has a source of infection, thus she has sepsis. The patient had a diagnostic paracentesis which showed WBC 3400, with a SAAG of > 1.3. This is consisttent with SBP. Of note, the patient did have a recent EGD on [2201-4-2], and it is possible that she could have seeded bacteria from this procedure. The patient was given Ceftriaxone in the ED for concerns for SBP. She may need broader Gram negative/anerobic coverage if this is seeded from the bowels. The patient's antibiotic coverage was broadened to Vancomycin, Zosyn. She also had an Abdominal CT performed for concern for perforation or abscess and it showed no leak or abscess. The patient was colloid resuscitated and required pressors initially. She was weaned off blood pressures on [2201-4-8]. Her pain was controlled with small doses of morphine, as well as tylenol and zofran for nausea. The patient had blood/peritoneal/urine cultures sent which did not grow out any organism. She completed a 5 day course of vancomycin and pip/tazo, and discharged on ciprofloxacin 250 mg daily for secondary prevention of spontaneous bacterial peritonitis. # NASH/alcoholic cirrhosis, MELD of 21 which indicates a 28% chance of mortality within the next 90 days. We contact[Name (NI) ] hepatology who recommended continuing our couirse. Initially we held Nadolol 20 mg PO daily, Spironolactone 100 mg PO daily Furosemide 40 mg PO daily, in the setting of hypotension. We continued continue Ursodiol 500 mg PO BID. Spironolactone and furosemide were restarted prior to discharge, as she was still volume overloaded upon discharge. She has follow up with Dr. [Name (NI) ] in the coming weeks. # Concern for DIC. Patient had a rising INR from 2.1 to 3.1 and a HCT which decreasing from 38 to 27, plt 266 to 184 though this is in the setting of fluid rescucsitation. Patient Had DIC labs sent with Hapto 25, (mildly low), FDP [10-11] (mildly high), Fibrinogen 172 (mildly low), LDH 161 (normal). These are difficult to assess in setting of cirrhosis, but we continued to trend CBCs and INRs and her labs were trended and were stable upon transfer to the floor #Hypothyroid. We continued her levothyroxine. # Diet: Regular, low sodium # FEN: No IVF, replete electrolytes # Prophylaxis: ambulating # Access: PIV # Communication: Patient # Code: Full Code Transitional issues: - follow up with PCP next week - follow up in the [Hospital1 18] Liver Center early next month Medications on Admission: 1. Acetaminophen 650 mg PO Q8H PRN pain 2. Ursodiol 500 mg PO BID 3. Levothyroxine 150 mcg PO daily 4. Vitamin E 800 PO daily 5. Multivitamin 1 PO daily 6. Nadolol 20 mg PO daily 7. Spironolactone 100 mg PO daily 8. Furosemide 40 mg PO daily Discharge Medications: 1. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for pruritis. Disp:1 unit Refills:2 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. vitamin E 400 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clotrimazole 1 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 6 days. Disp:1 tube Refills:0 9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:3 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary Diagnosis: Spontaneous bacterial peritonitis Secondary Diagnosis: Cirrhosis, likely due to NASH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a severe infection in your abdomen. You received care in the ICU, and your infection improved with IV fluids, antibiotics, and strong medications to help your heart (only for a short period of time). You made significant improvement, and your home medications were restarted to help remove fluid. You continued to improve, and you were able to go home on [2201-4-11]. You had some pain on your left arm at the site of a peripheral IV catheter. Please apply warm compresses to this area for 10 minutes 2-3 times per day until the discomfort resolves. The following medications changes have been made: START ciprofloxacin 250 mg daily START Sarna lotion for itchiness START clotrimazole cream for yeast infection STOP nadolol No other changes were made to your medications. Please see below for your follow up appointments. Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) 402] [Last Name (NamePattern1) ] When: Friday [2201-4-17] at 2:15 PM Address: [Hospital1 80695]., [University/College ],[Numeric Identifier 3471] Phone: [Telephone/Fax (1) 18377] Department: LIVER CENTER When: MONDAY [2201-5-4] at 11:30 AM With: [Name6 (MD) 1382] [Name8 (MD) 1383], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 10438]	[ "789.59", "785.52", "V02.54", "276.69", "599.0", "303.93", "038.9", "266.2", "511.9", "V45.86", "995.92", "286.7", "518.0", "276.1", "244.9", "571.2", "571.8", "571.1", "567.23", "280.9" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]	10737, 10808	6783, 9539	312, 366	10957, 10957	3825, 5326	11988, 12630	2777, 3034		9953, 10714		10829, 10829		9686, 9930			11108, 11965											3049, 3806								6455, 6760									9560, 9660			251, 274				5346, 6422				394, 2105			10904, 10936			10848, 10883			10972, 11084					2149, 2461	2477, 2761
6,534	125,584	8950	Discharge summary	report	Admission Date: [2125-4-23] Discharge Date: [2125-4-26] Date of Birth: [2055-11-6] Sex: F Service: [Hospital Unit Name 196] Allergies: Cortisone Attending:[First Name3 (LF) 9554] Chief Complaint: Status post motor vehicle accident Major Surgical or Invasive Procedure: none History of Present Illness: 69 year old female status motor vehicle accident as the restrained driver with loss of concoiousness and hitting a parked car at 40 miles per hour. Blood glucose at the scene was 28 per EMS. The patient was treated with a half amp of D50 with improvement. No nausea vomiting, chest pain, shortness of breath, palpitations, or extremity pain. patient takes coumadin. She had taken her normal breakfast and then went to the doctor for a blood draw. she did not have her usual mid morning snack, and blacked out while driving home Past Medical History: 1. Myocardial infarction [Numeric Identifier 13971] 2. Diabetes 3. Type III monoclonal ammopathy 4. Hypertension 5. Congestive heart failure (ejection fraction 20%) 6. ventricular tachycardia status post ICD Past surgical history: -4 vessel Coronary artery bypass graft, PTCA Social History: non contributory Family History: non contributory Physical Exam: General: No apparent distress head and neck: pupils equal round and reactive to light. Neck supple, trachea midline, no lymphadenopathy Cardiovascular: regular rate and rhythm Lungs: clear to ausultation bilaterally Abdomen: soft non tender non distended Extremities: good pulses throughout, no edema neuro: alert and oriented times three. motor and sensation grossly intact bilaterally Pertinent Results: CTA Chest/abdomen and pelvis [2125-4-23]: IMPRESSION: 1) Bilateral patchy diffuse ground-glass opacities consistent with failure. 2) Small right pleural effusions and trace left effusion. 3) No evidence of dissection. 4) No free fluid in the abdomen or solid organ injury. CT head [2125-4-23]: IMPRESSION: 1. No intracranial hemorrhage. 2. Findings consistent with old right parietal lobe infarction CT c-spine [2125-4-23]: There is no evidence of fracture or abnormal alignment of the component vertebrae. The vertebral bodies and intervertebral disc space height are preserved. There are atherosclerotic changes with calcifications within the region of the common carotid bifurcations. There is also note of biapical ground glass opacities within the lungs- apparently, the patient is in cardiac failure, as you indicated to us by telephone. ECHO: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed. Resting regional wall motion abnormalities include akinesis of the [Doctor Last Name ] [1-2]'s of th LV sparing the base and the lateral wall.. These remaining left ventricular segments are hypokinetic. Right ventricular chamber size is normal. Right ventricular systolic function is normal. Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There iis an echogenic density in the right ventricle consistent with a pacemaker lead. There is no pericardial effusion present. Ejection Fraction: 15% to 20% Brief Hospital Course: The patient was admitted to the surgical ICU on [2125-4-23] for neurologic and hemodynamic monitoring. He was kept NPO and was seen by cardiology. They recognized that the primary problem was hypoglycemia, and any shortness of breath that the patient had was related to IV fluid administration, and they suggested a gentle diuresis. He was ruled out for a myocardial infarction. the medical team felt that the CHF was attributed to the resuscitation at the trauma, but also that the patient needed diabetes teaching, especailly with respect to diet and nutrition. ON [4-25], the patients volume status had improved and his heartfailure had also imrovoved. He was on all of his home meds. There was a long session of counseling regarding diabetes management, was told to check her glucose before driving and the patients hemodynamic stauts was at its baseline by [2125-4-26]. she was able to be discharged at her baseline in stable condition Medications on Admission: actonel, aldactone, asprin, lipitor, iron, NPH (18/8), regular insulin ([7-2]), isosorbided SR, lisinopril, metformin, sublingual nitroglycerine, plavix, toprol XL, vitamin B12, coumadin (2 mg daily) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN PAIN Q5MIN. 9. Cyanocobalamin 100 mcg Tablet Sig: Ten (10) Tablet PO QD (once a day). Disp:300 Tablet(s) Refills:2 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 13. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Outpatient Lab Work Please have PT/INR drawn on Saturday [4-28] Discharge Disposition: Home Discharge Diagnosis: s/p motor vehicle crash congestive heart failure coronary artery disease s/p coronary artery bypass graft and stent diabetes mellitus iron deficiency anemia hypertension Type II monoclonal gammopathy osteoporosis history of arrythmia s/p ICD placement Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L -Please have INR drawn at [Hospital1 ] [Location (un) ] on Saturday [4-28] -Please snack regularly to avoid episodes of hypoglycemia, especially if you are going to be driving -Please decrease your standing morning regular dose to 6units instead of 8 until you have follow-up with [Last Name (un) ] -Your beta blocker will mask signs of hypoglycemia. It is better to be slightly high than to be as low as you were when you crashed. Followup Instructions: -Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2207] Date/Time:[2125-6-18] 3:00 -Provider: [Name10 (NameIs) ],[First Name3 (LF) ] [Location (un) 2788] CARDIOLOGY-PRIVATE Where: [Location (un) 2788] CARDIOLOGY-PRIVATE Date/Time:[2125-7-10] 1:00 -Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2125-5-4] 2:30 -Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Last Name (un) ] on [6-11] at 9:30am. Dr. [Last Name (STitle) ] can schedule further diabetic teaching to help you figure out how to prevent further hypoglycemic episodes when you cannot recognize the warning signs because of your betablocker [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ] MD [MD Number(2) 2139]	[ "250.80", "428.0", "280.9", "424.0", "273.1", "397.0", "V45.02", "V45.81", "E812.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "00.13" ]	icd9pcs	[ [ [] ] ]	5982, 5988	3458, 4419	325, 332	6284, 6292	1699, 3435	6914, 7890	1255, 1273		4673, 5959		6009, 6263		4445, 4650			6316, 6891									1159, 1205		1288, 1680																				251, 287								360, 895														917, 1136	1221, 1239
8,177	140,259	14330	Discharge summary	report	Admission Date: [2103-3-19] Discharge Date: [2103-3-29] Date of Birth: [2041-3-3] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Progressive dyspnea on exertion. Major Surgical or Invasive Procedure: Coronary artery bypass graft x 1 and aortic valve replacement [2103-3-19]. Post-op complicated by apical pneumothorax with reinsertion of chest tube. [Last Name (NamePattern4) 15255] of Present Illness: This is a 61 yo male patinet with history od coronary artery disease and LAD stents x 2 with worsening SOB/DOE/Belching starting in [1-20]. He reports one episode of SOB and pain radiating to the left arm relieved with two sublingual nitroglycerine. He was then referred for cath showing LAD 70% (in-stent restenosis), [Location (un) 109] 1.1 cm2, EF 48%. He was at that time referred to Dr. [Last Name (Prefixes) ] for surgery. Past Medical History: Aortic stenosis. Diabetes-Insulin dependent. Hypertension. Hyperlipidimia. Coronary artery disease s/p LAD stenst [3-21]. Obesity. Benign Prostatic Hypertrophy. Social History: Lives with wife in [Name (NI) 42513]. Retired. Quit smoking 7 years ago with 76 pack year history. Reports ETOH consumption rarely. Family History: Mother deceased at age 84 with CAD. Pertinent Results: [2103-3-25] 10:30AM BLOOD WBC-11.8* RBC-2.77* Hgb-8.9* Hct-27.2* MCV-98 MCH-32.0 MCHC-32.7 RDW-14.1 Plt Ct-250# [2103-3-25] 10:30AM BLOOD Plt Ct-250# [2103-3-20] 04:03AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.3 [2103-3-25] 10:30AM BLOOD Glucose-239* UreaN-23* Creat-0.9 Na-138 K-5.2* Cl-100 HCO3-28 AnGap-15 [2103-3-25] 10:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 Brief Hospital Course: Mr. [Name13 (STitle) 22570] was admitted to the hospital on his operative day. He underwent a CABG x 1 and aortic valve replacement with Dr. [Last Name (Prefixes) 42514]. Please see OP note for full details. He was successfully weened and extubated on his operative day. On POD one he was transferred to the inpatient/telemetry floor for ongoing management and recovery. On POD two his medistinal chest tubes were discontinued with one left pleural chest tube left in place. On CXR he had a small left apical PXT. This PXT was persisent and an POD four, increased slightly in size with chest tube to water seal. On POD five a thoracic consult was obtained and a new left sided chest tube was placed. On POD six one of the two chest tubes was discontinued with the other continuing on suction with an ongoing small apical PTX. On POD seven, CXR on water seal showing marginal improvement in the PTX however on POD eight, there was slight worsening of the PTX and the CT was placed back on suction. On POD nine there was no change and on POD ten the remaining chest tube was discontinued with post-pull CXR showing significant improvement in the PTX. Throughut his hospital stay, Mr. [Known lastname 22571] was followed by the physical therapy team and was found to be safe for discharge home. On [3-29], POD ten, Mr. [Known lastname 22571] was discharged home with visiting nurses to follow. Medications on Admission: Glyburide 5/500, two tabs [Hospital1 ]. Zocor 40 daily. Lisinopril 40 daily. Toprol 50 daily. Plavix 75 daily. Aspirin 325 daily. Protonix 40 [Hospital1 ]. Multivitamin daily. Humalog 10-12 units at dinner. NPH 56 units q HS. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Glyburide-Metformin 5-500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Ovberlook VNA Discharge Diagnosis: Aortic stenosis. Coronary artery disease. Discharge Condition: Stable. Discharge Instructions: Shower daily and wash incisions with soap and water. Rinse well. Do not apply nay creams, lotions, powders, or ointments. You will be able to shower 24 hours after your chest tube has been removed. No lifting greater than 10 pounds. No driving. Please take all medications as prescribed. Schedule follow-up appointments as advised. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2103-6-19] 12:45 [Last Name (Prefixes) 413],[First Name3 (LF) 412] [Telephone/Fax (1) 170] Call to schedule appointment [Last Name (LF) ],[First Name3 (LF) 42515] [Telephone/Fax (1) 42516] Call to schedule appointment Completed by:[2103-3-29]	[ "V45.82", "278.00", "424.1", "715.94", "V58.67", "250.00", "996.72", "414.01", "401.9", "272.0", "512.1", "600.00" ]	icd9cm	[ [ [] ] ]	[ "97.41", "39.61", "35.22", "88.72", "34.04", "36.15" ]	icd9pcs	[ [ [] ] ]	4992, 5036	1827, 3243	353, 1010	5122, 5131	1426, 1804	5513, 5960	1370, 1407		3528, 4969		5057, 5101		3269, 3505			5155, 5490																															281, 315																						1032, 1198	1214, 1354
25,329	172,905	49966	Discharge summary	report	Admission Date: [2125-9-11] Discharge Date: [2125-9-11] Date of Birth: [2079-7-20] Sex: M Service: MEDICINE Allergies: Tomato Attending:[First Name3 (LF) 2297] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Hemodialysis [9-11] History of Present Illness: 46 year old gentleman comes in with cough without fever, body aches. N/V ~ 10 times yesterday with epigastric tenderness. Denies any [Month/Year (2) ] contacts, changes in meds, dyspnea, chest pain but complains of earlier weakness. He presented for evaluation of his weakness and body pain.. In the ED, initial vs were: 97.0 42 120/57 16 100. Patient was given Calcium, Insulin & Glucose, Bicarb and KX. He was also given Morphine and Zofran. Renal was consulted and recommended follow up postassium. Transfer VS: 60 110/70 . On the floor, the patient complains of generalized body pain but no nausea, chest pain or vomiting. Past Medical History: # DM type 1 complicated by gastroparesis # ESRD on HD TuThSa at [Location (un) ] [Last Name (LF) ], [First Name8 (NamePattern2) ] [Location (un) 805] # Recurrent HTN emergency/urgency # Chronic L flank pain since [2119] with multiple admissions and extensive work-up, possibly due to diabetic thoracic polyneuropathy # Chronic Diastolic CHF # Esophagitis/gastritis/duodenitis on EGD [10-21] with negative H. Pylori # Depression, prior suicide attempt # Fibromyaglia # Mod-severe cognitive deficits per neuropsych testing in [2121] # R foot ulcer s/p R foot operation - bone excision # Left cranial nerve 3 palsy # HBV surface ab and core ab pos Social History: Currently at [Hospital 4310] rehab and has been there for 8 months. Walks with a cane. Graduated from high school and worked as a janitor. Born in [Male First Name (un) 1056] and moved to United States in [2093]. Currently on disability. He is divorced. No tobacco or ETOH. Reports he has 4 children 2 girls, 2 boys. Daughter lives in [Name (NI) ], sons in [Name (NI) 108]. He is well supported by his siblings who live in the Greater [Location (un) 86] area. Family History: Mother is 65 with diabetes (now deceased); two brothers with diabetes; three sisters, one with hypertension and one with gestational diabetes. Mother with ovarian cancer. No history of CAD Physical Exam: Physical Exam: Vitals: T: 96.5 BP: 170/79 P: 90 R: 21 O2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, LUE w/ fistula and L hand w/ thenar-hypothenar wasting Pertinent Results: [2125-9-11] 01:21a K:6.7 Glu:86 [2125-9-11] 01:20a [Year (4 digits) ] HEMOLYZED SPECIMEN REPEAT K: 5.7 135 97 80 --------------<93 8.7 20 9.6 Ca: 9.8 Mg: 2.2 P: 6.7 . [2125-9-10] 9:40p K:7.1 TCO2:20 Glu:216 Lactate:1.5 pH:7.43 [2125-9-10] 9:35p 133 97 79 --------------<233 6.9 20 9.5 Ca: 9.3 Mg: 2.0 P: 6.3 ALT: 26 AP: 114 Tbili: 0.4 Alb: 4.1 AST: 24 Lip: 19 . 12.7 8.7>---<165 12.7 165 39.3 N:68.9 L:22.1 M:4.4 E:4.0 Bas:0.6 . PT: 14.1 PTT: 28.6 INR: 1.2 . Micro: None . Images: CT Ab/Pelvis (wetread) small volume ascites and mild stranding around the pancreas. Please correlate to amylase/lipase levels. interlobular septal thickening in the lungs, mild ground glass opacity and right pleural effusion, all of which may be related to volume overload. . CXR: elevated R hemidiaphragm, no consolidation . EKG: Sinus @ 82, PR 212, QRS 94, no st elevations or depressions Brief Hospital Course: 1) Hyperkalemia: Not acute when seen on the floor (K = 5.7, no ECG changes). Received hemodialysis morning of [9-11]. . 2) Nausea/Vomiting: Unclear etiology, no hyperglycemia to suggest DKA. Known gastroparesis, possible viral gastroenteritis, uremia all possible. No complaints when arrived to the floor. Written for reglan/zofran prn but did not require any. . 3) ESRD: Hemodialysis morning of [9-11] . 4) DM1: Continued Home insulin plus sliding scale . 5) Hypertension: continued home doses of carvedilol and verapamil. . 6) Generalized pain: written for one dose of morphine IR prn. . 7) CHF: Continued home carvedilol, [Date Range ], held lisinopril for poor renal function and hyperkalemia. 8) Generalized itching: Patient required po benadryl on arrival to the floor and iv benadryl with his hemodialysis in the am. Per patient, the itching is typical for him during [Date Range 2286]. Medications on Admission: Aspirin 81 mg PO Daily B Complex-Vitamin C-Folic Acid 1 Cap Daily Carvedilol 25mg PO BID Citalopram 20mg PO daily Docusate Sodium 100mg PO BID Insulin Lispro Protam & Lispro [Humalog Mix 75-25] 6 units QAM, 6 units QPM Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Lisinopril 20mg PO Daily Metoclopramide [Reglan] 5mg PO QID Minoxidil 5mg PO Daily Omeprazole 20mg PO daily Sevelamer HCl 800mg PO TIDAC Verapamil 240mg PO Q12 Discharge Disposition: Home Discharge Diagnosis: Hyperkalemia Discharge Condition: Stable Completed by:[2125-9-11]	[ "250.61", "070.30", "729.1", "428.32", "276.7", "536.3", "403.91", "428.0", "585.6", "311" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	5329, 5335	3930, 4846	276, 301	5391, 5428	2991, 3907		2179, 2369				5356, 5370		4872, 5306														2399, 2972																				228, 238								329, 964														986, 1661	1677, 2163
19,677	119,540	16185+16186	Discharge summary	report+report	Admission Date: [2191-2-7] Discharge Date: [2164-3-12] Date of Birth: [2161-11-13] Sex: M NOTE: ANTICIPATED DATE OF DISCHARGE IS [2-28] OR [2191-3-1]. HISTORY OF PRESENT ILLNESS: The patient is a 29 year old male with a history of hypertension, hypercholesterolemia, originally admitted to the [Hospital 1474] Hospital on [2191-1-18], after change in mental status and shortness of breath. The patient had been living in a mental health facility and reportedly had shortness of breath and diarrhea. The patient was admitted to the outside hospital with temperature of 99.2 F., blood pressure 112/64; pulse 110; respirations 24; saturating 90% on room air which increased to 94% on two The patient was treated with Ceftriaxone, however, developed worsening mental status change and respiratory failure requiring intubation. The patient was also found to be in acute renal failure. His initial serum toxicology screen at the outside hospital revealed negative alcohol, acetaminophen, salicylate, tricyclics, ethylene glycol and Doxepin. His valproic acid level was 48.3 which was subtherapeutic. Clonazepam was elevated at 1193 (normal reference range being 100 to 700), and his normal clonazepam level was 370. The etiology of his renal failure was never clarified. The patient was extubated and reintubated several times during his hospital course at the outside hospital. New arterial blood gases were done and the etiology of his hypoxia and respiratory distress was also unclear. The patient had episodes of hypotension requiring pressors. The patient also had an Methicillin resistant Staphylococcus aureus bacteremia that was treated with Vancomycin, nadifloxacin, ceftazidine and Flagyl by report. The patient also had thrombocytopenia and a question of a neuroleptic-malignant syndrome secondary to Haldol (unclear diagnosis). The patient was then transferred to the Medical Intensive Care Unit at the [Hospital1 69]. All of his intravenous and central lines were discontinued and changed over. The patient was extubated on [2-11] with an arterial blood gas of 7.4, 39, 77, and pulse oximetry of 90%. The patient was noted to desaturate that night secondary to obstructive sleep apnea. The patient was treated for a pneumonia acquired while intubated with Ceptaz and his Methicillin resistant Staphylococcus aureus was treated with Vancomycin. The patient was noted to have questionable positive ACTH stimulation test and was placed on stress dose steroids for that. Subsequent blood cultures were found to be negative. The patient was followed by the Psychiatric Service during his hospital course in the Intensive Care Unit. The patient was then transferred to the [Hospital1 ] Medicine Service on [2191-2-13], the hospital course of which will be dictated below. PAST MEDICAL HISTORY: 1. Paranoid schizophrenia, bipolar disorder. The patient has been admitted multiple times for episodes of psychosis and agitation, the last one being [2190-4-12]. Also has a history of suicide attempts in the past, including jumping out of a car. 2. History of polysubstance abuse, including cocaine, ecstasy, THC and alcohol. 3. Obstructive sleep apnea. 4. Hypertension. MEDICATIONS AT TIME OF TRANSFER FROM OUTSIDE HOSPITAL ON [2191-2-7]: 1. Lipitor 40. 2. Seroquel 150 mg p.o. twice a day. 3. Lansoprazole 30 mg q. day. 4. Ceptaz one gram q. day started on [2191-2-1]. 5. Vancomycin one gram intravenous. 6. Flagyl 500 mg p.o. q. eight hours. 7. Valproic acid 750 mg p.o. twice a day. 8. Paxil 60 mg p.o. twice a day. 9. Nephrocaps. 10. Folate. 11. Fluticasone twice a day. 12. Versed drip. 13. Neo-synephrine. 14. Xopanex 1.25 mg q. four hours. LABORATORY: At the time of admission to the Medical Intensive Care Unit at [Hospital1 69], white blood cell count 9.9, hematocrit 25.7, platelets 61, 77% neutrophils, 17% lymphocytes, INR 1.4, PTT 37.5, fibrinogen 701. Arterial blood gases 7.39/47/149. Sodium 143, potassium 3.4, chloride 103, bicarbonate 26, BUN 45, creatinine 8.5, glucose 131. ALT 26, AST 42, alkaline phosphatase 169, total bilirubin 0.2, albumin 2.5, calcium 8.4, magnesium 2.0, phosphorus 5.2. Chest x-ray revealed OG tube in appropriate position. Question of retrocardiac, left lower lobe opacity. STUDIES: The patient reportedly had an echocardiogram with normal valves and normal ejection fraction on [2191-2-4], at the outside hospital. Head CT scan on [2191-2-3], at the outside hospital was negative. Echocardiogram on [2191-2-9], at [Hospital1 190] revealed no atrial thrombus, no arteriosclerotic disease, ejection fraction greater than 55%, no vegetations on any of the valves, no effusion, no endocarditis. Normal echocardiogram. Chest x-ray on [2191-2-10], at [Hospital1 190] revealed left pleural effusion and mild congestive heart failure. PHYSICAL EXAMINATION: At the time of admission to the Medical Intensive Care Unit: Vital signs 99.6 F.; pulse 81; blood pressure 95/38; saturation at 100%. In general, intubated and sedated. HEENT: Pupils are equal, round and reactive to light. Mucous membranes were dry. Cardiovascular: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. Pulmonary: Decreased breath sounds bilaterally left worse greater than right. No wheezes. Abdomen: Soft, nontender, nondistended, hypoactive bowel sounds. Extremities with no edema, warm, no rashes. Neurological: Intubated, sedated, moves all extremities. HOSPITAL COURSE: Medical Intensive Care Unit course briefly described in HISTORY OF PRESENT ILLNESS. The remainder of hospital course from dates of [2191-2-13], until the time of discharge will be dictated below: 1. PULMONARY: Most recent chest x-ray while in the Intensive Care Unit did not have any commented infiltrate. The patient had sputum culture which had revealed rare Methicillin resistant Staphylococcus aureus and the patient was treated with Ceptaz and Vancomycin for hospital acquired Intensive Care Unit pneumonia with broad spectrum coverage for Pseudomonas as well as Methicillin resistant Staphylococcus aureus. The patient did have a productive cough and low grade temperature with gram positive cocci in his sputum and was started on Vancomycin subsequently on [2191-2-21]. His sputum culture then grew out a moderate amount of Methicillin resistant Staphylococcus aureus, however, the patient then refused further Vancomycin. He clinically improved with decreased cough and remained afebrile and further antibiotics were withheld until moderate Methicillin resistant Staphylococcus aureus in sputum was deemed to be the possible etiology of prior fevers. The patient had no further oxygen requirement and was saturating greater than 90% on room air. Pulmonary examination continued to reveal occasional coarse breath sounds but no crackles or wheezes. The patient was started on Levaquin p.o. for additional coverage of potential community acquired pneumonia. In the end he defevervesced and we felt either we had adequately treated staph or atypical bronchitis, or he had a viral URI that resolved. 2. HYPERTENSION: The patient had blood pressures between 130s and 160s systolic, however, no additional blood pressure medication was added as patient was initially maintained on steroids for the question of adrenal insufficiency and subsequently blood pressures were not treated as the patient is a dialysis patient and did not want to further decrease his blood pressures during treatment. 3. ACUTE RENAL FAILURE: The patient continued to have some improvement in his urine output, however, his BUN and creatinine continued to remain persistently elevated when the patient was not dialyzed. Given that initial etiology of acute renal failure has never been identified, prognosis still remains unclear although urine output is encouraging. The patient continued to require hemodialysis throughout hospital course. Repeat assessment of urine sediment showed muddy brown casts consistent with potential ATN, however, prognosis again was unclear. The patient was followed by the Renal Service while in-house. The patient initially had a right Quinton catheter which was discontinued and had a Perma-Cath placed for access on [2191-2-14]. The patient was maintained on Nephrocaps and calcium acetate and was given Epogen at his dialysis for his persistent anemia. 4. FEVERS: The patient remained clinically well after his Ceptaz and Vancomycin course were completed, after transfer from Intensive Care Unit to Medical Service, however, the patient redeveloped fevers on [2-20] and 10. The patient had episode of loose stool with C. difficile toxin assay negative. The patient had blood cultures drawn from his right IJ catheter which were negative to date. These cultures were drawn on [2-20]. The patient also had blood cultures drawn on [2-22] from his Perma-Cath and these cultures were also no growth to date. The patient had no other localizing signs or symptoms of infection aside from an intermittent cough. Again, sputum revealed a moderate amount of Methicillin resistant Staphylococcus aureus for which the patient was treated with a dose of Vancomycin. The patient's right IJ catheter was discontinued given the fevers and catheter tip also revealed no growth. 5. QUESTION OF ADRENAL INSUFFICIENCY: The patient had a repeat cosyntropin stimulation test which was normal. The patient at that point was on low dose Prednisone which was then discontinued. His Florinef was also discontinued at that time and his BP was well maintained off Rx. 6. ACCESS: The patient had a right IJ catheter that was maintained for part of his hospital course while he was on the [Hospital1 ] Medicine Service, however, after the patient had two days of fevers, the catheter was removed. The patient then refused any peripheral intravenous access as he was a difficult stick and remained only with his Perma-Cath in place for access. This catheter was only used for dialysis. Renal was having some diff accessing the permacath due to his diff with heparin, and they had been using some thrombolytics with some success. 7. THROMBOCYTOPENIA: The patient was noted to have a positive HIT antibody. The patient had no further heparin flushes and the patient's platelet count increased back to the normal range subsequent to this. 8. ANEMIA: Likely secondary to low EPO from his acute renal failure, however, his MCV was 88, RDW 16.8. His iron level was 19. His ferritin was 915. 9. PSYCHIATRY: Bipolar disorder / paranoid schizophrenia. The patient had a one-to-one sitter given his past history of violence, past suicide attempt and unpredictable nature of his agitation/psychosis. Initially, one-to-one sitter was inside the room, however that upset him and the patient agreed to have one-to-one sitter if the sitter was just outside of the room. The patient did quite well throughout the remainder of the hospital course where he did not need any further p.r.n. medication such as Trilafon for episodes of agitation. However, on [2191-2-25], the patient was becoming increasingly agitated and required Ativan and Trilafon p.o. for agitation and his sitter was changed to a security sitter. The patient was maintained on his medications including Piroxatine 10 mg p.o. q. day; Ativan which was titrated from intravenous to p.o. and maintained at 0.5 mg p.o. three times a day, Valproic acid 750 mg p.o. q. day and Seroquel which was gradually titrated upward from Seroquel and his dose at the time of dictation was 175 mg p.o. in the morning and 200 mg p.o. q. h.s. It was deemed that Clozaril may be a better medication for this patient given that it has worked well with him in the past, however, Psychiatry Service deemed that they would not start the medication at this time as it also may complicate potential fever work-up because potential side effects include fevers and low white blood cell count. However, once medically stabilized, the patient will be transferred to a locked psychiatry unit to restart his Clozaril; so at this time the patient was started on Trilafon 8 mg p.o. twice a day. The patient was continuously followed by the Psychiatry Service during his hospital course. 10. NUTRITION: Initially, the patient complained of decreased appetite and had fairly poor p.o. intake. The patient was given Boost to drink between meals. The patient had calorie counts, however, the patient also occasionally refused hospital trays and hospital staff was unaware of whether patient was receiving food from outside the hospital. Therefore, calorie counts were inadequate. However, the patient gradually stated that he was able to eat more as he regained his appetite and had decreased nausea. His PO intake seemed to improve as his agitation reduced, so I expect that his PO intake will mirror control of his psychiatric illness. 11. REHABILITATION: The patient was seen by the Physical Therapy Service. He was followed during his hospital course and did quite well. Eventually he was deemed to not need Physical Therapy services. 12. DISPOSITION: The patient is being evaluated for placement to a psychiatric/medical facility where he will require in-patient psychiatric care as well as medical services that are able to connect him to dialysis. Medical condition was discussed with patient's guardian, [Name (NI) ] [Name (NI) 46207], phone number [Telephone/Fax (1) 46208], who is the guardian and medical decision maker for this patient. His help was required when the patient began to refuse antibiotics such as Vancomycin and the guardian stated that if the antibiotics became absolutely medically necessary, the patient would have to be potentially restrained in order to receive these medications or medications could be given at dialysis without complete awareness of patient as long as the guardian was fully aware that the patient would be getting these medications for medical necessity. If clinical status or psychiatric status changes after this dictation, a Discharge Summary Addendum will be dictated. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10545], M.D. [MD Number(1) 46209] Dictated By:[Name8 (MD) 231] MEDQUIST36 D: [2191-2-25] 16:19 T: [2191-2-25] 17:48 JOB#: [Job Number 43071] cc:[Name (STitle) 46210] Admission Date: [2191-2-7] Discharge Date: [2191-3-3] Date of Birth: [2161-11-13] Sex: M Service: Addendum to previously dictated discharge summary. Detailed hospital course from [2191-2-26], until [2191-3-3]. HOSPITAL COURSE: The patient remained relatively stable from a medical standpoint during this portion of the hospital 1. Psychiatric - History of bipolar disorder/paranoid schizophrenia. On [2191-2-25], the patient had an episode of agitation. At this time, his regular one to one sitter was changed to a security sitter. He was started on Trilafon 8 mg p.o. twice a day for increasing agitation. However, after the onset of this medication, the patient was also noted to his mood did stabilize quite well. The patient was also noted to have mild cogwheeling by psychiatric resident and was started on Cogentin 0.5 mg p.o. twice a day which he tolerated well. However, Trilafon was discontinued on [2191-3-2], secondary to potential side effects of orthostatic hypotension. See details below. 2. Orthostatic hypotension - The patient was doing well, however, on [2191-3-1], the patient had an episode of orthostatic hypotension posthemodialysis. The patient had 2 kilograms of fluid removed at this hemodialysis as he was noted to have a significant weight gain between hemodialysis treatments. This weight gain was slightly questionable as the patient had clearly been having decreased p.o. intake secondary to his fatigue and perhaps weight gain was associated with a scale error. Posthemodialysis, the patient was noted to have a blood pressure systolic of 60. The patient was given back some fluid, rested and subsequently had no further symptoms of orthostasis. The patient had a repeat blood pressure in the one teens and was sent back to the floor. However, the patient attempted to get out of bed to chair and had some light-headedness. In addition, he also went to the bathroom and on his way back, felt quite light-headed and fell to the floor on his knees and subsequently hit his head and had a potential vasovagal/orthostatic hypotensive event. The patient had a blood pressure of 50 at this time. A code was called. The patient was placed in Trendelenburg position. The patient was given two liters of intravenous fluid hydration immediately at which time his blood pressure gradually increased back to final blood pressure of 118 systolic over doppler. After the patient was stabilized, he had a head CT to rule out any evidence of acute bleed or fracture. The patient's head CT was negative. Enzymes and EKG were not suggestive of myocardial injury. This event was thought to be a combination of potential orthostatic hypotension in association with medication Trilafon, in addition with fluid shift during hemodialysis, which responded well to intravenous fluids. The patient had orthostatic vital signs checked on [2191-3-2], and in the morning, he still had evidence of orthostasis. However, the patient was unable to ambulate with walker and assistance to the bathroom and had no light-headedness or dizziness. Subsequently, the patient had medical workup which included complete blood count, CK, troponin, electrocardiogram and blood cultures, all of which were stable and showed no evidence of acute bleed, infection or cardiac event of potential related etiology of this episode of hypotension. It is recommended that the patient have orthostatic vital signs checked daily. The patient was stable post hemodialysis on [2191-3-3], and was discharged to [Hospital3 ] for management of his acute psychiatric needs as well as medical management of his acute renal failure. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10545], M.D. [MD Number(1) 46209] Dictated By:[Name8 (MD) 231] MEDQUIST36 D: [2191-3-3] 19:41 T: [2191-3-3] 20:12 JOB#: [Job Number 46211] cc:[Location (un) 46212]	[ "996.72", "285.9", "428.0", "295.30", "518.81", "287.5", "584.5", "038.11", "482.41" ]	icd9cm	[ [ [] ] ]	[ "38.95", "88.72", "39.95", "96.71", "96.04", "38.91", "38.93" ]	icd9pcs	[ [ [] ] ]														14782, 18506																										4953, 5558															223, 2863														2885, 4929
53,577	151,930	41051	Discharge summary	report	Admission Date: [2178-2-15] Discharge Date: [2178-2-20] Date of Birth: [2105-8-23] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: CT-guided embolization of hepatic artery branches Packed red blood cell transfusion History of Present Illness: Pt is a 72 yo male with a history of multifocal hepatocellular carcinoma [12-25] alcoholic cirrhosis s/p Cyberknife therapy and sorafenib (discontinued two weeks ago [12-25] nausea and vomiting) who presented to OSH with sharp, right-sided abdominal pain and worsening abdominal distention since last night, found to have hemoperitoneum on CT scan and a Hct of 17. He was given 2 units of PRBCs and transferred to [Hospital1 18]. Also desscribed nonbloody emesis. He denies any BRBPR or melanotic bowel movements. He denies fever, chills, shortness of breath or chest pain. He also denies hx SBP, varices or hepatic encephalopathy. . Initial ED VS were 165/68 97.5 100% 2L, 80, 113. In the ED labs were significant for a BUN/Cr of 83/4.0 (apparently at baseline), Hct of 22.7 (taken during blood transfusion) with guaiac positive brown stool. . On arrival to the MICU, pt is still having nausea and emesis, but says that his abdominal pain has improved since receiving pain medications in the ED. Past Medical History: - Alcoholic Cirrhosis - Multifocal HCC s/p treatment with cyberknife and sorafenib - CAD - HTN - CHF - HLD - chronic kidney disease (baseline Cr of 4.0) - anemia of chronic disease - MGUS - Diabetes Social History: He is a retired government employee. He has been a custodian in the past. Lived by himself since divorce in [2159]; reunited with wife approximately 2 years ago but maintains his own apartment. Two daughters ([Name (NI) ] and [Name (NI) 1258]) also involved in care. . He has not smoked for 30 years Regarding alcohol use - reports he used to drink heavily (approx a six-pack/day for many years but he said he has not been drinking anything for the past two years). Family describes ongoing daily alcohol consumption. Family History: His mother died of smoking-related lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T: 36.6 ??????C (97.8 ??????F), HR: 79 (79 - 87) bpm, BP: 115/57(71) {115/54(71) - 157/74(93)} mmHg, RR: 10 (10 - 25) insp/min, SpO2: 100% General: Alert, oriented, no acute distress HEENT: 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: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: distended, mild diffuse tenderness to palpation, worse in the bilateral lower abdominal region GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength upper/lower extremities, grossly normal sensation . DISCHARGE PHYSICAL EXAM: VS 98.5 132/50 (130-140s) 69 16 98/RA FS 180 GEN elderly man lying in bed, mildly uncomfortable-appearing but NAD, no jaundice HEENT NCAT MMM EOMI sclera anicteric OP clear +facial spider angiomas NECK supple JVP +5 no LAD PULM CTAB no rales/rhonchi/wheeze CV RRR normal S1/S2, III/VI late-systolic murmur ABD very prominently distended but nontender, w/shifting dullness, normoactive BS, no rebound/guarding, no caput medusa EXT WWP 2+ pulses, no edema NEURO AOX3 CNs2-12 intact, strength 5/5 throughout, no asterixis, gait not assesed Pertinent Results: ADMISSION LABS [2178-2-15] 01:30PM BLOOD WBC-17.6# RBC-2.34# Hgb-7.3# Hct-22.7# MCV-97 MCH-31.4 MCHC-32.3 RDW-16.4* Plt Ct-262# [2178-2-15] 01:30PM BLOOD Neuts-92.0* Lymphs-3.3* Monos-4.3 Eos-0 Baso-0.3 [2178-2-15] 01:30PM BLOOD PT-13.3* PTT-24.5* INR(PT)-1.2* [2178-2-15] 01:30PM BLOOD Glucose-225* UreaN-83* Creat-4.0* Na-139 K-4.8 Cl-105 HCO3-21* AnGap-18 [2178-2-15] 01:30PM BLOOD ALT-59* AST-38 AlkPhos-134* TotBili-0.7 [2178-2-15] 01:30PM BLOOD Albumin-2.9* Calcium-7.4* Phos-5.8* Mg-2.3 [2178-2-15] 01:35PM BLOOD Type-[Last Name (un) ] pO2-47* pCO2-47* pH-7.27* calTCO2-23 Base XS--5 Comment-GREEN TOP [2178-2-15] 01:35PM BLOOD Lactate-2.7* [2178-2-15] 09:36PM BLOOD freeCa-1.02* . PERTINENT LABS (SERIAL HCTs) [2178-2-15] 01:30PM BLOOD Hgb-7.3* Hct-22.7* Plt Ct-262 [2178-2-15] 05:00PM BLOOD Hgb-9.1* Hct-28.2* Plt Ct-169 [2178-2-15] 09:00PM BLOOD Hct-26.0* [2178-2-16] 02:35AM BLOOD Hgb-8.6* Hct-27.0* Plt Ct-130* [2178-2-16] 11:03AM BLOOD Hct-29.8* [2178-2-16] 05:40PM BLOOD Hct-28.5* [2178-2-16] 11:48PM BLOOD Hct-30.0* [2178-2-17] 05:26AM BLOOD Hgb-8.9* Hct-27.8* Plt Ct-100* [2178-2-17] 11:40AM BLOOD Hct-28.2* [2178-2-18] 06:33AM BLOOD Hgb-8.2* Hct-25.3* Plt Ct-86* [2178-2-18] 09:15PM BLOOD Hct-31.3* [2178-2-19] 04:07AM BLOOD Hgb-11.2# Hct-34.0 Plt Ct-111* . DISCHARGE LABS [2178-2-20] 06:04AM BLOOD Hct-32.3* [2178-2-20] 06:04AM BLOOD Glucose-166* UreaN-99* Creat-4.9* Na-130* K-4.1 Cl-100 HCO3-18* AnGap-16 [2178-2-19] 04:07AM BLOOD ALT-57* AST-38 LD(LDH)-203 AlkPhos-118 TotBili-2.4* DirBili-1.8* IndBili-0.6 [2178-2-20] 06:04AM BLOOD Calcium-7.6* Phos-6.3* Mg-2.3 . MICRO [2178-2-15] MRSA SCREEN - NEGATIVE . IMAGING . CXR (AP) [2178-2-15] FINDINGS: There is a moderate-sized right pleural effusion. Lung volumes are low. No pneumothorax is detected. Heart size may be enlarged but may be exaggerated by low lung volumes. Aortic calcification is noted. IMPRESSION: Moderate-sized right pleural effusion. . CT ABD/PELVIS, NONCONTRAST [2178-2-15] IMPRESSION: 1. Cirrhotic liver with a large mass residing along the inferior right hepatic lobe, most likely representing hepatoma, although not fully characterized on non-contrast imaging. Complex free fluid within the abdomen with the highest density noted in the region of the suspected liver mass is consistent with extensive peritoneal hemorrhage suspected to reflect bleeding from a large hepatoma. 2. Small hiatal hernia. . [2178-2-20] KUB FINDINGS: Supine and left lateral decubitus frontal views of the abdomen demonstrate gas in multiple non-dilated loops of small and large bowel. No free air is detected. A surgical clip is noted in the mid upper abdomen. Vas deferens calcifications suggest underlying diabetes. Degenerative changes are noted in the lumbar spine with bridging osteophytes. Degenerative changes also noted in the bilateral femoroacetabular joints. IMPRESSION: Nonspecific bowel gas pattern with no evidence of obstruction or free air. . OTHER STUDIES . ECG [2178-2-15] Sinus rhythm with ventricular premature beats. Atrio-ventricular conduction delay and diffuse non-specific ST-T wave abnormalities. No previous tracing available for comparison. . PROCEDURE NOTES [2178-2-18] ABDOMINAL ARTERIOGRAM W/EMBOLIZATION FINDINGS: 1. SMA angiogram did not demonstrate any supply to the liver. Grossly patent main portal vein. 2. Common hepatic arteriogram demonstrated right and left hepatic arterial branches, GDA and cystic arteries. In addition, multiple abnormal vessels are noted in the region of multiple foci of tumor blush in the right hepatic lobe. No active extravasation or pseudoaneurysm seen. 3. Selective third/fourth order branches arising from the right hepatic lobe confirmed the anatomy and presence of tumor blush in their territories. Gelfoam embolization was performed in these territories to near stasis. 4. Celiac arteriogram demonstrated significantly diminished flow to the right hepatic artery, with normal flow into the splenic, left gastric, left hepatic and gastroduodenal arteries. 5. Right femoral arteriogram demonstrated access of a normal caliber right common femoral artery with bifurcation well below the access site. IMPRESSION: Uncomplicated hepatic angiogram and Gelfoam embolization. Brief Hospital Course: 72M w/hx alcoholic cirrhosis & multifocal hepatocellular carcinoma who initially presented to OSH with sharp, sudden-onset right-sided abdominal pain and distention, found to have hemoperitoneum and Hct 17. Hospital course was notable for transfer to [Hospital1 18] MICU and eventual stabilization of bleeding after transfusion of 6 units of packed red cells and CT-guided gel foam embolization of hepatic artery branches. After a meeting with the patient, family, and palliative care, the patient was ultimately discharged home w/hospice services. # MULTIFOCAL HCC [12-25] ALCOHOLIC CIRRHOSIS complicated by hemoperitoneum: Patient is followed by outpatient oncologist Dr. [First Name4 (NamePattern1) 402] [Last Name (NamePattern1) ] at [Hospital3 ]. Two known lesions located in R and L lobes. Patient underwent cyberknife treatment here at [Hospital1 18] approximately 1 year ago & had been receiving sorafenib until recently when it was discontinued because of intractable nausea and vomiting. Outpatient oncologist and radiation oncologist both visited the patient in-house. In the setting of his acute HCC bleed (see below) and lack of remaining therapeutic options, palliative care discussions were held w/patient and family. Patient discharged home with hospice and 24h family support. Outpatient providers were made aware. #HEMOPERITONEUM FROM BLEEDING RIGHT LOBE HEPATOCELLULAR CARCINOMA LESION: Pt was admitted to [Hospital3 7571]ICU with sudden-onset severe abdominal pain, distension, and blood loss anemia with Hct 17 and CT-demonstrated hemoperitoneum from bleeding R lobe hepatoma. Transferred to [Hospital1 18] via ED after 2U PRBC transfusion. At [Hospital1 18] he was again admitted to the ICU with concern for ongoing liver bleed. He was hemodynamically stable on arrival but required w 2 units of additional PRBCs for initial Hct 22.7. IR and transplant surgery were both consulted to consider interventional options for hemostasis. Pain acutely worsened on [2-18], prompting additional 2 unit PRBC transfusion (for 6U total) and CT-guided embolization of 3 branches of his hepatic artery feeding his R hepatic lobe (where the offending HCC lesion was located). Hct was stable thereafter at ~33 at time of discharge. . #HYPERTENSIVE URGENCY Pt has hx hypertension but outpatient antihypertensive regimen unclear - had been previously prescribed labetolol, hydralazine and amlodipine but only script filled within past 5 months was amlodipine. When admitted he was found to have severe (asymptomatic) hypertension to SBP 190s-200s. Stabilized w/SBPs ranging 140-160 with PO labetolol and hydralazine (thought to be home meds at the time). There was some difficulty controlling BPs again when pt could not tolerate POs due to nausea/vomiting, was also likely exacerbated by underlying nausea and abdominal discomfort. Blood pressures were ultimately better controlled after achieving better control of pain and nausea and hydralazine was successfully weaned and labetolol dose decreased after pt started on home amlodipine 10 mg QD plus PRN ativan. # NAUSEA/VOMITING This was felt to be related to his known cancer, acutely exacerbated by hemoperitoneum and abdominal distension. Required IV zofran, phenergan and ativan (plus aggressive bowel regimen). Transitioned to SL/PO antiemetics prior to discharge, as pt will continue to require these meds on hospice at home. # CONSTIPATION Pt had constipation on admission. Had regular bowel movements here with standard bowel regimen. KUB prior to discharge showed gas throughout bowel, no evidence of obstruction or stool load. Discharged with bowel medications to prevent further constipation while taking opiates for pain. # THROMBOCYTOPENIA Plts 260 on admission, dropped to a nadir of 88 then rose to within historical baseline ~150. Chronically low baseline Plts expected in liver failure; further acute thrombocytopenia could be explained by bleeding/clotting (consumption) and/or DIC. HIT not likely given lack of exposure. Labs and blood smear showed no evidence for hemolysis. # GOUT Pt has history of gout previously treated with short-course PO prednisone. On HD3 he developed a tender swollen L knee. Rheumatology consulted but did not perform joint aspiration or intra-articular steroid injection because patient refused given severity of other medical problems. [Name (NI) 35632] pain controlled w/tylenol + PRN oxycodone. # HX CONGESTIVE HEART FAILURE During his MICU stay he was without evidence of fluid overload of CHF exacerbation. Lasix, aspirin, and valsartan were held in the setting of his bleed. Later determined that pt was only taking ASA at home so lasix and valsartan were not restarted. # HX DIABETES [Name (NI) ] Pt prescribed glyburide as an outpt but script not filled in several months. This was held on admission and started on a HISS in-house, with minimal insulin requirements. Discharged on glyburide 5 mg QD. TRANSITIONAL ISSUES 1. Patient discharged with home hospice 2. Control nausea/vomiting symptoms. 3. Control pain. 4. Ensure regular bowel movements. 5. NOTE: PCP and outpatient oncology appointments scheduled for ongoing patient/family support as-needed. [Month (only) 116] need blood pressure check and antihypertensive med adjustment at these follow-up appointments. Medications on Admission: metaclopramide QAC (dose unknown) ondansetron 3 mg PO q8h prn folate 1 mg QD amlodipine 10 mg QD ranitidine 150 [Hospital1 ] ASA 81 mg QD Note: Patient's home medication list also includes glyburide, lasix, labetolol, hydralazine, clonidine and omeprazole but either didn't fill these prescriptions or hadn't taken them in several months.) Discharge Medications: 1. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. Disp:180 Tablet(s) Refills:2 4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:120 Tablet(s) Refills:2 5. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:120 Tablet(s) Refills:2 6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO every four (4) hours: Give 5 mg by mouth or under tongue every 4 hours as needed for pain or for breathlessness. [Month (only) 116] cause sedation. Disp:30 ml Refills:2 7. atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for secretions. Disp:15 ml Refills:0 8. lorazepam 1 mg Tablet Sig: 0.5-1 Tablet PO every six (6) hours as needed for nausea: note: may cause sedation. Disp:180 Tablet(s) Refills:0 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. 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 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:30 Suppository(s) Refills:0 12. glycerin (adult) Suppository Sig: One (1) Suppository Rectal twice a day as needed for constipation. Disp:60 Suppository(s) Refills:0 13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:1 Powder in Packet(s) Refills:0 Discharge Disposition: Home With Service Facility: Care network Discharge Diagnosis: PRIMARY DIAGNOSES Hemoperitoneum Spontaneous Hepatocellular Carcinoma Bleed Hepatocellular Carcinoma Hypertensive Urgency Gout . SECONDARY DIAGNOSES Alcoholic Cirrhosis Diabetes [Month (only) ] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 89518], It was a pleasure to care for you at [Hospital1 18]. You were admitted to the hospital via [Hospital6 20592], where you were found to have extensive bleeding into your belly from your liver cancer. You required 6 blood transfusions, 2 at [Hospital3 7571]and 4 here. You also had a procedure by interventional radiology to attempt to stop the bleed. We discussed with you and your family that our medical care here was supportive but not curative. Your outpatient oncologist confirmed that there are no further treatment options. You and your family elected to go home to be with family, with support from hospice and your doctors. We made several changes to your medications to help control your symptoms at home & minimize other medications. Current medication list: GLYBURIDE 5 MG DAILY AMLODIPINE 10 MG DAILY (two 5mg tablets) LABETOLOL 200 MG THREE TIMES DAILY (8 HOUR INTERVALS) The following medications were started to control your symptoms and should be used as needed according to your symptoms: ONDANSETRON 8 mg (two 4mg tablets) every 8 hours as needed for nausea COMPAZINE, one 10 mg Tablet every 6 hours as needed for nausea LORAZEPAM, [11-24]-to-one 1 mg tablet every 6 hours as needed for nausea MORPHINE SULFATE SOLUTION, 5 mg every 4 hours as needed for pain TYLENOL, one 500 mg Tablet every 6 hours as needed for pain ATROPINE 1 % Drops, 2 drops every 4 hours as needed for secretions LAXATIVES (COLACE, SENNA, MIRALAX AND SUPPOSITORIES), use as-needed for constipation. At minimum, recommend using colace and senna daily to prevent constipation. Please review these medications with the hospice nurses and with your physicians at your follow-up appointments. Followup Instructions: We made follow-up appointments for you with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] because we thought you and your family might benefit from ongoing relationships with them. If you are feeling too unwell to attend these appointments, please call to cancel. Name: [Last Name (LF) 16826],[First Name3 (LF) ] W. Location: [Hospital ] MEDICAL ASSOCIATES Address: [Location (un) 77760], [Location (un) ],[Numeric Identifier 29816] Phone: [Telephone/Fax (1) 33980] When: [Last Name (LF) 766], [2177-3-1]:15 AM Name: Stone, [First Name7 (NamePattern1) 402] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital6 ] CTR/ONCOLOGY DEPT Address: [Location (un) 89519], [Location (un) ],[Numeric Identifier 28704] Phone: [Telephone/Fax (1) 89520] When: [Last Name (LF) 2974], [3-6], 9:30 AM	[ "362.01", "428.0", "155.0", "285.1", "272.4", "585.4", "573.8", "V49.86", "303.93", "287.5", "414.01", "250.50", "274.01", "584.9", "787.01", "571.2", "568.81", "403.10", "564.00", "273.1", "285.21" ]	icd9cm	[ [ [] ] ]	[ "88.47", "99.29" ]	icd9pcs	[ [ [] ] ]	15538, 15581	7970, 13314	318, 404	15823, 15823	3600, 7947	17762, 18666	2232, 2281		13708, 15515		15602, 15802		13340, 13685			16000, 17739											2321, 3014																				264, 280								432, 1445									15838, 15976					1467, 1667	1683, 2216				3039, 3581
1,829	108,935	20584	Discharge summary	report	Admission Date: [2187-4-17] Discharge Date: [2187-5-1] Date of Birth: [2143-6-24] Sex: M Service: Surgery, Blue Team HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 53-year-old Caucasian male with no significant past medical history who was transferred to this institution from the [Hospital3 3583] for treatment of necrotizing fasciitis of the right thigh. The patient presented to his primary care physician approximately three weeks ago for right thigh swelling. He was treated with a 10-day course of antibiotics without relief. The patient returned to his primary care physician following this course and was admitted for an enlarged/fluctuant right thigh mass along with new onset diabetes with a fasting blood sugar of 500. A computed tomography scan was done at the outside hospital which showed a large amount of fluid in the posterior thigh. The General Surgery Service was consulted, and the patient went to the operating room where 4 liters of purulent material was found along with a suspicion for necrotizing fasciitis. There was no suspected source as the patient had not had any injuries or lines placed. The wound was packed with a wet dressing, and the patient was subsequently transferred to the [Hospital1 69] for treatment. When the patient first presented, an ultrasound was done at the outside hospital which did not show evidence of clot in the deep veins. Cultures were obtained during the time of his debridement which grew oxacillin-sensitive Staphylococcus aureus. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: The patient had open reduction/internal fixation of the left ankle approximately 10 years ago. MEDICATIONS ON ADMISSION: The patient takes no medications at home. MEDICATIONS ON TRANSFER: 1. Ativan 0.5 mg to 1 mg by mouth q.6h. as needed. 2. Timentin 3 grams intravenously q.4h. 3. Regular insulin sliding-scale. 4. Morphine 2 mg to 4 mg intravenously q.2h. as needed. 5. Percocet 5/325-mg tablets one to two tablets by mouth q.4-6h. as needed. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed his temperature was 98.9 degrees Fahrenheit, his pulse was 85, his blood pressure was 135/75, his respiratory rate was 18, and his oxygen saturation was 99% on room air. In general, the patient was a pleasant Caucasian male who appeared his stated age and was in no apparent distress. The oropharynx was clear with moist mucous membranes. The neck was supple and without lymphadenopathy or jugular venous distention. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds, and no palpable masses. The heart was regular in rate and rhythm. The rectal tone was normal and without masses or fecal occult blood. The right lower extremity demonstrated an approximate 10-cm X 4-cm incision on the posterior aspect of the thigh. It was packed with a moist gauze dressing and had good granulation tissue. A Penrose drain exited the skin approximately 4 cm proximal to the wound. The sural, saphenous, deep peroneal, and superficial peroneal nerves were intact to light touch. The popliteal, dorsalis pedis, and posterior tibialis pulses were 2+. The knee extensors, knee flexors, gastroc-soleus, anterior tibial, and extensor hallucis longus muscles were [5-16]. PERTINENT LABORATORY VALUES ON PRESENTATION: At the time of admission, the patient's white blood cell count was 14.3, his hematocrit was 31.4, and his platelet count was 328. His INR was 1.1. The creatinine was 0.6, with a potassium of 4.6, and blood sugar of 388. PERTINENT RADIOLOGY/IMAGING: None. BRIEF SUMMARY OF HOSPITAL COURSE: After being transferred to the [Hospital1 69], the patient was evaluated by the Surgical Service and was admitted to the Intensive Care Unit for blood sugar control. The [Last Name (un) ] Diabetes Service was consulted, and an insulin drip was initiated. The patient's initial antibiotic cover included Zosyn and Flagyl. His pain was controlled with a morphine patient-controlled analgesia pump. The wound was initially cared for via wet-to-dry dressing changes twice per day. He remained on an insulin drip and was initiated on long-acting antidiabetic medication along with a Humalog sliding-scale on hospital day two. At this time, the patient was deemed stable without acidosis and was transferred to the regular hospital floor. On hospital day three, the patient underwent irrigation and debridement of the right thigh wound. The estimated blood loss for this procedure was approximately 25 cc. A Hemovac dressing was placed intraoperatively. At this time, it was noted that there was no further spread of infection, and the wound appeared clean and to be healing well with good granulation tissue. The patient's blood sugars remained stable throughout his stay. He received diabetic teaching by the [Last Name (un) ] Service and was treated with Glargine and Humalog with excellent results. On hospital day eight, after the culture results were received from the patient's primary care physician indicating the presence of methicillin-sensitive Staphylococcus aureus from the initial operative wound culture, the patient was started on oral dicloxacillin. He remained afebrile throughout the duration of his stay. On hospital day nine, the patient returned to the operating room under the care of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from Plastic Surgery where the Hemovac dressing was removed and a split-thickness skin graft was applied. The donor tissue was taken from the proximal anterior right thigh. Following the application of the skin graft, a Hemovac dressing was reapplied. Postoperatively, the patient remained nonweightbearing with elevation of the right lower extremity to [Last Name (NamePattern1) ] with graft take. The donor site was cared for using Xeroform and dry gauze as needed. The recipient site remained with a Hemovac in place for five days. This device was removed on [2187-4-30]. The recipient site was then treated with Xeroform, dry gauze, and a circumferential Kerlix dressing. He was discharged to home with a visiting nurse [First Name (Titles) ] [Last Name (Titles) ] with wound care and blood sugar management on [2187-5-1]. The patient was to finish three additional days of oral dicloxacillin to complete a total of a 10-day course. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to home with a visiting nurse [First Name (Titles) ] [Last Name (Titles) ] with wound care. DISCHARGE DISPOSITION: 1. The patient was to have his split-thickness skin graft site change daily. 2. The patient was instructed to keep his right lower extremity elevated while in bed. DISCHARGE DIAGNOSES: 1. New onset diabetes mellitus. 2. Fasciitis of the right lower extremity. 3. Status post irrigation and debridement of a right lower extremity wound. 4. Status post Hemovac placement. 5. Status post split-thickness skin graft. MEDICATIONS ON DISCHARGE: 1. Dicloxacillin 500 mg by mouth q.6h. (times three days). 2. Percocet 5/325-mg tablets one to two tablets by mouth q.4-6h. as needed (for pain). 3. Colace 100 mg by mouth twice per day. 4. Humalog insulin sliding-scale (as directed). 5. Glargine insulin 48 units subcutaneously at hour of sleep. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from the Department of General Surgery in approximately 7 to 10 days for staple removal. 2. The patient was also instructed to follow up with his primary care physician in [Name9 (PRE) 3320] as soon as possible following discharge. 3. The patient was to be following up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from the Department of Plastic Surgery in approximately one week to assess his right lower extremity wound. 4. The patient was also to follow up with the [Last Name (un) ] Diabetes Center as needed for blood sugar management. 5. The patient was instructed to follow up sooner if he developed fevers of greater than 101.5 degrees Fahrenheit, numbness, weakness, or swelling in his right lower extremity. 6. The patient was instructed to follow up sooner if he had any questions or concerns. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 26023] MEDQUIST36 D: [2187-5-1] 18:04 T: [2187-5-1] 18:17 JOB#: [Job Number 55045]	[ "250.02", "728.86", "285.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.59", "86.59", "86.69" ]	icd9pcs	[ [ [] ] ]	6739, 6906							6927, 7161				7187, 7490	1728, 1771					7523, 8769							1605, 1701											3771, 6547						6562, 6716													175, 1551													1796, 3742	1574, 1581
3,078	183,784	21242	Discharge summary	report	Admission Date: [2175-8-24] Discharge Date: [2175-8-29] Date of Birth: [2128-2-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: Mental Status Changes Major Surgical or Invasive Procedure: Abscess I & D History of Present Illness: 47M with h/o ESRD on HD, ESLD [2-17] hepatitis C,alcoholic cirrhosis, encephalopathy who presents with altered mental status. He was found by his wife today to be lethargic and confused. Also noted to be vomiting, nonbilious and nonbloody per report. Of note, patient has a history of muliple admissions for altered mental status. He was most recently discharged yesterday after admission from [Date range (1) 56225]/07 for altered mental status and replacement of his HD catheter. His HD catheter was replaced. He also received a diagnostic and therapeutic paracentesis which was negative for SBP but was also found to have a UTI and was discharged to receive an empiric course of Cipro x 14 days. Urine cultures eventually came back positive for yeast for which the patient was not treated. . In the ED, T 100.6, BP 112/63, HR 79, RR 18, O2 100% RA, FSBG 145. On initial lab work he was found to have elevated ammonia (408), possible UTI by U/A, elevated lactate(2.7), and leukocytosis (13,000), unchanged from leukocytosis on recent discharge. Liver was consulted and recommended diagnostic tap. However, while attempting paracentesis in the ED, patient began to exhibit extensor posturing, rigidity of extremities, and upward eye deviations in pattern with his respiratory cycle concerning for seizure. Neurology was consulted who were unsure if these movements represented seizure activity but did feel that they wre likely secondaary to toxic metabolic abnormalities. He received 1000 mg of Dilantin as well as 2 mg of Ativan x 2 and a lactulose enema. Blood cultures were drawn and he received 1000 mg of ceftriaxone for potential UTI. CXR showed no evidence of infection. CT was negative for ICH. . Upon arrival to the ICU, patient continues to show extensor posturing. He withdraws to noxious stimuli but is otherwise unresponsive. Further history or review of systems cannot be obtained at this time. . Past Medical History: # Cirrhosis - hep C + EtOH abuse - c/b esophageal varices s/p banding in [12-26] - EGD [2175-4-28]: 4 cords of grade II varices, nonbleeding GE jctn ulcer - has not been treated for hepatitis C - has nodular lesions on US -> no MRI to eval for HCC, AFP 4.3 - h/o SBP in [9-21], ? SBP during last hospitalization (empiric) # ESRD on HD T/Th/Sat # Anemia of chronic disease # Left Lower extremity wound # h/o major depression # schizotypal personality disorder Social History: Lives with wife. Denies tobacco, ETOH, or drug use currently. Heavy ETOH use in the past, prior IV drug use in early 80s (last [4-21]). Family History: Maternal aunt with DM Physical Exam: T: 96.0 BP: 132/68 HR: 67 RR: 14 O2 100% RA Gen: somnolent. unarousable. Intermittently posturing. HEENT: Icteric sclera. MMM. OP clear. NECK: Supple, JVP ~ 10 cm H2O. CV: RRR. nl S1, S2. No MRG LUNGS: CTAB. No rales or rhonchi. ABD: Distended. Large umbilical hernia. Dullness to percussion on dependent flanks. Hypoactive BS. Significant abdominal muscle contraction with expiration. Otherwise soft. No rigidity. EXT: Warm. 1+ LE edema. ~9 cm soft tissue mass vs. fluid collection below L knee on the anterolateral surface of leg, increased warmth on palpation SKIN: mild jaundice. No spider angiomas. Small UE ecchymoses. NEURO: Somnolent. Unarousable. Extensor posturing correlating with expiration. Withdraws to pain in all extremities. PERRL. Face symmetric. Brisk [2-18]+ reflexes, biceps, patella. Upgoing toes bilaterally. Pertinent Results: [Date range (1) 56226] - ADMISSION LABS . CBC: WBC-13.3* RBC-2.45* HGB-9.2* HCT-27.6* MCV-113* MCH-37.6* MCHC-33.4 RDW-19.1* . CHEMISTRY: GLUCOSE-114* UREA N-68* CREAT-6.1* SODIUM-135 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 CALCIUM-9.0 PHOSPHATE-4.6* MAGNESIUM-2.9* . ABG: PO2-102 PCO2-31* PH-7.50* TOTAL CO2-25 BASE XS-2 LACTATE-3.5* . LFTs: ALT(SGPT)-30 AST(SGOT)-58* LD(LDH)-430* ALK PHOS-123* AMYLASE-79 TOT BILI-6.7* LIPASE-115* ALBUMIN-3.1* AMMONIA-308* . COAGS: PT-18.9* PTT-34.6 INR(PT)-1.8* . SERUM TOX: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . URINE TOX: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . U/A: COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.014 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-0-2 WBC-[12-5]* BACTERIA-RARE YEAST-FEW EPI-0 . CT head [2175-8-24]: No intracranial hemorrhage, mass effect, or short interval change. . CXR [2175-8-23]: IMPRESSION: No acute cardiopulmonary disease detected. EEG [2175-8-24]: IMPRESSION: This is an abnormal portable EEG due to the low voltage, poorly modulated, and slow background rhythm. The majority of the tracing was spent in the excessively drowsy state. The findings together are consistent with a moderate encephalopathy. Medications, metabolic disturbances, infections, and anoxia are among the most common causes. There are no triphasic wave forms seen and no epileptiform discharges were noted. There were no electrographic seizures. . [2175-8-25] Ammonia-109* . BONE SCAN [2175-8-28] IMPRESSION: 1. Findings suggestive of possible infection or hematoma involving soft tissue anterior to left tibia. No findings to suggest osteomyelitis. 2. Horizontal linear area of increased uptake seen in region of L2 vertebral body, possibly representing collapse. Clinical correlation recommended. 3. Ascites. 4. Probable fracture lower posterior left rib . [8-29] DISCHARGE LABS . CBC: WBC-7.4 RBC-2.25* Hgb-8.2* Hct-24.1* MCV-107* MCH-36.4* MCHC-34.1 RDW-22.9* Plt Ct-95* . COAGS: PT-18.5* PTT-39.0* INR(PT)-1.7* . CHEMISTRY:Glucose-115* UreaN-57* Creat-5.4* Na-133 K-4.4 Cl-106 HCO3-17* AnGap-14 Calcium-8.2* Phos-5.5* Mg-2.9* . LFTs: ALT-26 AST-45* LD(LDH)-281* AlkPhos-111 TotBili-3.4* Albumin-2.6* Brief Hospital Course: 47 yoM with h/o ESRD on HD, ESLD ([2-17] hepatitis C,alcoholic cirrhosis) now presenting stage 4 hepatic encephalopathic coma. He presented nonresponsive and with altered mental status and found to have elevated ammonia, lactate, and leukocytosis. He had questionable extensor posturing on admission, c/w seizure. Pt was initially admitted to MICU, treated with aggressive lactulose and rifaximin with good response, quickly regained mental status. Also s/p I&D of left anterior tibial abscess on [8-24], with wound culture that grew E. Coli resistant to cipro. Had bone scan showing no osteo. Begun on ceftriaxone for this infection on [8-24]. Transferred to floor on [8-27], where he remained A+Ox3 and stable throughout. Hospital course by problem: . # AMS: Initial DDx included encephalopathy vs. intoxication vs. seizures vs. infection (SBP). All of these were been progressively ruled out, leaving the most likely etiology as hepatic encephalopathy. A urine and serum tox screen were negative. Initial WBC count was elevated, but not significantly changed from prior recent discharge. CXR was unremarkable. U/A had evidence of possible UTI, but had been treated for UTI at the time of last discharge with cipro, UCx: no bacteria only yeast. EEG unrevealing for seizures, neuro signed off. We continued lactulose and rifaximin with excellent resolution of encephalopathy and regaining of mental status. . # LLE abscess: In the MICU he was initially put on vancomycin and ceftriaxone, and gentamycin was added shortly thereafter. When culture results of I+D returned with E. Coli resistent to cipro, bactrim, but sensitive to Ceftriaxone, we discontinued vanc and gent, continuing ceftriaxone ([8-24] - discharge). This was considered to be the best inpatient antibiotic option given that he was never tapped to rule out SBP, and ceftriaxone would potentially cover SBP as well as his LLE abscess. ID was curbsided to see if cefpodoxime was an acceptable po alternative to ceftriaxone, and they felt that it was given the E. Coli sensitivity profile. We performed a bone scan which was negative for osteo, and orthopedics then signed off. VNA was arranged for dressing changes at home. . # ESLD: stable cirrhosis secondary to HepC and EtOH abuse. INR, LFTs stable at baseline. Ammonia was significantly elevated at 408 on admission, lowered to 108 after lactulose and rifaximin. We suspect that the patient continue to be noncomplient with his medicatinons at home. We continued Nadolol, lactulose, and rifaximin. . # ESRD: Initially put on CVVH in MICU. Renal followed. Had HD on schedule on [8-29]. Lytes and volume were stable. Pt has RSC tunneled catheter for access. Continued sevelamer tid with meals, epo at HD. . # Anemia/coagulopathy: Known ACD to explain anemia. Elevated INR, low platelets likely due to ESLD, splenic sequestration with likely malnutrition component. Was initially transfused 2 units PRBCs in MICU with appropriate bump. No bleeding episodes on floor. . # FEN: Advanced PO diet as tolerated. . # PPx: wore Pneumoboots, got PPI, on bowel regimen (lactulose). . # ACCESS: Tunneled RSC HD line, PIVs . # CODE: FULL throughout . # COMM: wife [Name (NI) 553] [Name (NI) 19419], Phone: [Telephone/Fax (1) 56227] . # F/U: pt instructed to arrange f/u with PCP and with liver clinic (has been seen by Dr. [Last Name (STitle) ] Medications on Admission: MEDS: (per d/c summary [2175-8-22]) lactulose 30 mg TID Rifaximin 400 mg TID folic acid 1 mg Qday thiamine 100 mg Qday Nadolol 20 mg Qday Protonix 40 mg Qday Sevelamer 1600 mg TID Cipro 500 mg Qday for total of 14 days to be taken post-HD Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO QID (4 times a day). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): take with meals. 8. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO qTuesThursSat for 9 days: Take pill AFTER HEMODIALYSIS on Tuesdays, Thursdays, and Saturdays. First dose after HD on [8-31], last dose on Thursday, [9-7], after dialysis. Disp:8 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Care Group Home Care Discharge Diagnosis: primary: hepatic encephalopathy . secondary: alcoholic and HCV cirrhosis Left Lower extremity wound ESRD on HD (Tu/Th/Sat) Anemia Discharge Condition: improved, A+O x 3 Discharge Instructions: You were admitted to the hospital with confusion and non-responsiveness. This was due to a complication of uncontrolled liver disease called hepatic encephalopathy. You were briefly treated in the intensive care unit, where you regained a normal mental status, which you maintained after you were transfer to the regular wards. . You also were noted to have an infection of your left leg. The surgeons came by and drained the infection. You will need to take an antibiotic called Vantin (cefpodoxime). This antibiotic is a pill that you must take 3 times per week AFTER your hemodialysis (every Tuesday, Thursday, and Saturday). This will continue to treat your infection. We have arranged for the Visiting Nurses Association to come to your home to help you with dressing changes for the wound. . It is quite important to take your all your medicines when you return home, including your lactulose and rifaximin. These will help prevent the confusion and unresponsiveness from happening again. . If you experience any confusion, nausea or vomiting, fevers or chills, or abdominal pain, please call your doctor or go to the nearest ER. Followup Instructions: Please make an appointment to follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Telephone/Fax (1) 56152] in [1-17] weeks. . Please call the liver center at [Telephone/Fax (1) 2422], to make an appointment for follow up.	[ "041.4", "276.52", "301.22", "287.5", "585.6", "682.6", "285.21", "571.2", "070.44", "276.1", "780.39" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.04", "86.04" ]	icd9pcs	[ [ [] ] ]	10756, 10807	6241, 9636	336, 351	10981, 11001	3870, 6218	12185, 12456	2976, 2999		9929, 10733		10828, 10960		9662, 9906			11025, 12162											3014, 3851																				275, 298								379, 2308														2330, 2802	2818, 2960
52,837	188,363	53893	Discharge summary	report	Admission Date: [2152-8-23] Discharge Date: [2152-8-26] Date of Birth: [2107-4-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 2080] Chief Complaint: intoxication w isopropyl alcohol Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] presents to the ICU [2152-8-23] after being diagnosed in the ED with acute isopropyl alcohol intoxication. She is unable to give much of a history on initial evaluation, simply shrieking the word "Thirsty!" again and again while rocking back and forth; and affirming when asked, that she is indeed thirsty. Later, when re-evaluated, she is somewhat more calm, and says "Hungry!" in a somewhat less urgent tone. Per report of ED, Ms. [Known lastname ] is well-known to our hospital with several past admissions related to isopropyl alcohol intoxication. Apparently earlier today, per ED report and documentation her family tried to get a hold of her and when they could not do that, located her at her home where she was found down with crack pipe and empty isopropyl alcohol bottle. (On further questioning in wrapping up assessment, as she became more interactive and moved to saying ??????I??????m hungry and thirsty,?????? she said she had been drinking rubbing alcohol; and that she last used cocaine yesterday.) In the ED, initial vs were: T 97.1 P 116 BP 127/92 R 14 O2 sat. 100% 3L NC. Patient was given 2L NS and 1L banana bag (folate 1 mg, MVI IV, thiamine 100 mg, in 1L NS). Haldol 5mg IV was given in preparation for CT head given pt's agitation. Tox + for cocaine. In the ICU she was given IVF and her osmolar gap closed (osm 379->319). Her mental status improved. Toxicology wanted ppi started. SW was consulted, will need ppd for rehab, so one was placed [2152-8-24] on her left arm. Also of note has hepatitis C, just told that she has it, will need hepatology consult. [Month (only) 116] need pt consult as has had gait instability in the past. On CIWA but no signs of this so far, may be having narcotic withdrawl. Currently she feels well, no complaints except nasal congestion and right shoulder pain. She does not recall the events leading to her admission but does remember drinking rubbing alcohol to get intoxicated and using crack cocaine. She again asserts that she would like inpatient substance abuse treatment. With her shoulder pain, it is on the outer aspect of her right shoulder, no radiation, no associated tingling or numbness, or weakness. She denies fevers, chills, nausea, vomitting, diarrhea, constipation, melena, brbpr, dysuria, hematuria, other arthralgias or myalgias, cough, sob, cp, palpitations, rash. ROS: 10 point review of systems otherwise negative except as noted above. Past Medical History: #. Hepatitis C positive - was unaware of diagnosis on admission, not followed by anyone currently #. Ongoing Dental Health - tooth pulled recently - received course of Amoxicillin #. Alcohol Abuse #. Cocaine/Crack abuse #. History of burn to back, arms, chest - s/p skin graft - patient reports she fell on to a radiator #. stable carotid aneurysm seen on CTA [8-17] Social History: Occupation: unemployed Drugs: regular crack abuse, unable to quantify currently. Does have history of IV drug use in [2122] for 3-4 years-- denies any recent IVDU. Tobacco: past OMR: 1 cigarette daily Alcohol: past and current hx of EtOH abuse; unable to quantify currently Other: The patient is originally from Lousiana currently lives in [Location (un) 686]. She lives in an apartment, Section 8 housing, alone although her father lives nearby. She is not currently working and receives food stamps and financial support from her father. She has 4 children ages 16-30 who currently all live in Lousiana. Family History: Denies any significant family history. Physical Exam: VS: T 98.9 BP 132/84 HR 84 RR 18 Sat 99% RA Gen: Well appearing woman in NAD Eye: extra-occular movements intact, pupils equal round, reactive to light, sclera anicteric, not injected, no exudates ENT: mucus membranes moist, no ulcerations or exudates Neck: no thyromegally, JVD: flat Cardiovascular: regular rate and rhythm, normal s1, s2, no murmurs, rubs or gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: Soft, non tender, non distended, no heptosplenomegally, bowel sounds present Extremities: No cyanosis, clubbing, edema, joint swelling Neurological: Alert and oriented x3, CN II-XII intact, normal attention, sensation normal, asterixis absent, speech fluent, motor [3-28] UE, LE bilaterally Integument: Warm, moist, no rash or ulceration Psychiatric: appropriate, pleasant, not anxious Hematologic: no cervical or supraclavicular LAD Pertinent Results: Admit labs: WBC-7.2 Hgb-15.5 Hct-45.2 Plt Ct-329 Glucose-118* UreaN-6 Creat-1.2* Na-144 K-3.4 Cl-105 HCO3-26 . ALT-24 AST-31 CK(CPK)-251* AlkPhos-51 TotBili-0.2 . Osmolal-379, BLOOD Osmolal-348, BLOOD Osmolal-326, BLOOD Osmolal-319, 306, 290 . Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . ECG [8-23]: ST (117), nl axis, intervals, no acute st-t changes. . CXR [8-23]: portable: No acute intrathoracic process. . CT head [8-23]: prelim: no intracranial hemorrhage or edema Brief Hospital Course: 47 year old woman with isopropyl alcohol intoxication. 1. Isopropyl alcohol intoxication: She was placed on both a CIWA scale and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] scale. She did admit to drinking rubbing alcohol, and her urine toxin screen was positive for cocaine, which she also admits to. Serum osmolarity trended down to 290 with ivf. She remained on IVF until her osmolar gap resolved. She was maintained on CIWA monitoring. She agreed to inpatient substance abuse treatment initially, then decided that she did not want treatment. She was urged by social work and the physician to consider voluntary detox, but still she refused. The risks of drinking rubbing alcohol and cocaine were explained in detail, which she understood. . 2. Cocaine use: as above, she admitted to smoking cocaine and ultimately refused detox. . 3. Cerebral aneurysm: Pt has already seen outpatient neurosurgery who felt that she would benefit from a cerebral angiogram. She will need to follow up with them in order to schedule this. . 4. Hepatitis C: This is a new diagnosis for the patient and she will need outpatient hepatology follow up for further evaluation and treatment. . 5. Shoulder pain: This is likely an injury suffered during intoxication. She had no deficits and did not require further therapy. . 6. Gait instability: Pt had initially noted gait instability, but she was able to ambulate in the morning without any evidence of gait instability. . Full code for this admission. Medications on Admission: medications on admission: MVI thiamine folate Medications on transfer: Multivitamins 1 TAB PO DAILY Omeprazole 20 mg PO DAILY Diazepam 5-10 mg IV Q2H:PRN CIWA>10 FoLIC Acid 1 mg PO DAILY Heparin 5000 UNIT SC TID Thiamine 100 mg PO DAILY Discharge Medications: MVI 1 tab daily thiamine 100mg daily folic acid 1mg daily Discharge Disposition: Home Discharge Diagnosis: Isopropyl alcohol ingestion Cerebral aneurysm Polysubstance abuse Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you were intoxicated with isopropyl alcohol. You were sent to the intensive care unit where you were given intravenous fluids and were carefully monitored. Once you were safe, you were transferred to the floor. You also expressed interest in inpatient substance abuse rehabilitation but later refused. You understand the risks of further alcohol and cocaine consumption. Please resume all medications as before. Follow up with your PCP as soon as possible. You have a neurosurgery appointment scheduled. Return to the hospital with fevers/chills, abdominal pain, or any other concerning symptoms Followup Instructions: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7746], MD Phone:[Telephone/Fax (1) 3666] Date/Time:[2152-8-31] 1:45 Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) 540] & [Doctor Last Name 6596] Phone:[Telephone/Fax (1) 44] Date/Time:[2152-9-5] 4:00 Follow up with Dr. [Last Name (STitle) 8499] as soon as possible [Telephone/Fax (1) 7976*]	[ "E860.3", "305.61", "070.70", "781.2", "305.01", "437.3", "719.41", "980.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7287, 7293	5402, 6915	349, 355	7403, 7412	4861, 5379	8106, 8510	3897, 3937		7204, 7264		7314, 7382		6967, 6988			7436, 8083											3952, 4842																				277, 311								383, 2853													7013, 7181	2875, 3247	3263, 3881
15,945	106,687	5791	Discharge summary	report	Admission Date: [2166-12-5] Discharge Date: [2167-1-1] Date of Birth: [2099-9-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Metastatic cervical cancer with abdominal carcinomatosis and obstructive symptoms Major Surgical or Invasive Procedure: Exploratory laprotomy Placement of G-tube History of Present Illness: Ms. [Known lastname 9006] is a 67-year-old woman diagnosed with metastatic cervical cancer approximately six years ago, was treated with radiation and chemotherapy. She had done well until recently when she developed obstruction of the third portion of her duodenum. The patient was referred to Dr. [Last Name (STitle) 816] because of concern for a biliary problem. [Name (NI) ] biliary tree proved subsequently to be intact; however, she had continued problems with emptying her gastrojejunostomy. As the reasons for this were unclear, as well as a reason to make a definitive diagnosis of a periaortic mass and intestinal studding, which had previously come back only as fibrotic tissue, as well as the possibility of tuberculosis, she underwent exploration for 1) establish a diagnosis of peritoneal fibrosis versus tuberculosis versus metastatic cancer, 2) for palliation of her inability to tolerate p.o. Past Medical History: cervical cancer s/p chemo and radiation in [2159] hypertension acute renal failure intermittent small bowel obstruction Social History: no tobaccono EtOHmarriedmoved to US in [2158] Family History: non-contributory Brief Hospital Course: Admitted [2166-12-5] with symptoms of carcinomatosis of the abdomen and biliary obstruction. She spiked a temperature on [2166-12-13] and was cultured: Klebsiella was isolated from sputum. Over the next week and a half, her nutrition was optimized for the OR with TFs and IVF and later TPN, Doboff was removed on [2166-12-21]. Pt was taken to the OR on [2166-12-23] for an ex-lap, gastrostomy and staging biopsies for known intestinal and periaortic masses. The path result return poorly differential carcinoma. She was transferred to the SICU post-operatively and based on the intraoperative findings, it was thought that her condition was not amenable to resection or future radiation and was moreover, incompatible with life. After a long discussion with the patient and family, she was transferred to the floor on POD#3 and made DNR. She was placed on a PO regimen of pain medication, and antibiotics were stopped; she was restarted on TPN and a Nutrition consult was obtained to aid in her manangement. TPN was transitioned to TF, and placement in a Hospice facility was sought. She was discharged to a hospice facility in Brookeline on POD#9 in stable, but terminal condition. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO q2 hour:PRN: For pain relief. Disp:qs qs Refills:2 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<100 and HR<60. Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: 1) Metastatic cervical cancer 2) Carcinomatosis of the abdomen 3) Obstruction of gastrojejunostomy Discharge Condition: DNR, DNI. Vital signs stable, palliative measures only. Pain controlled with PO regimen. Discharge Instructions: Discharge to [Hospital 7578] Health Care-Hospice. Medications as written, continue O2 and IVF as needed. Continue TF as written 10cc/hr. PO as tolerated. Followup Instructions: None indicated	[ "V44.6", "783.7", "197.6", "614.6", "537.3", "401.9", "584.5", "276.2", "276.5", "112.2", "038.9", "789.5", "263.9", "518.5", "995.93", "V10.41" ]	icd9cm	[ [ [] ] ]	[ "43.19", "46.39", "54.23", "96.71", "99.04", "54.91", "96.6", "96.08", "51.10", "38.91", "45.91", "54.59", "38.93" ]	icd9pcs	[ [ [] ] ]	3414, 3484	1662, 2870	395, 439	3627, 3719		3928, 3946	1621, 1639		2893, 3391		3505, 3606					3743, 3905																															274, 357								467, 1391														1413, 1538	1554, 1605
30,570	148,381	33355	Discharge summary	report	Admission Date: [2115-4-2] Discharge Date: [2115-4-6] Date of Birth: [2061-3-22] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2115-4-2] - CABGx4 (Left internal mammary artery-Left anterior descending artery, Vein-Diagonal, Vein-Obtuse Marginal, Vein-Right Coronary Artery) History of Present Illness: 54 y/o gentleman who presented to [Hospital3 3583] with left arm pain. He ruled out for an MI however had a positive stress test. He was subsequently referred for a cardiac catheterization which revealed three vessel disease. Past Medical History: HTN Hyperlipidemia Social History: Maintenance worker at [Company 77419]. Lives with wife who is schizophrenic. Quit smoking 18 years ago. Drinks 3-4 shots daily. Family History: Brother with MI at age 57. Father died at age 59 after CABG. Physical Exam: 85 20 146/82 70" 210lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. Multiple solar/actinic kertosis and nevi. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally HEART: RRR, Nl S1-S2, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities. NEURO: No focal deficits. Pertinent Results: [2115-4-2] - ECHO Prebypass 1.No atrial septal defect is seen by 2D or color Doppler. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. Dr. [Last Name (STitle) ] was notified in person of the results on [2115-4-2] at 830 am. Post Bypass 1. Patient is in sinus rhythm on an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Aorta intact post decannulation. [2115-4-4] CXR 1) Stable appearance of the heart with no cardiomegaly. 2) Bibasilar atelectasis, slightly progressed . 3) Unchanged small left apical pneumothorax. 4) New finding -dilated small bowel loops. Brief Hospital Course: Mr. [Known lastname 39049] was admitted to the [Hospital1 18] on [2115-4-2] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He later awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day two he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [Known lastname 39049] continued to make steady progress and was discharged home on postoperative day three. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist Dr. [Last Name (STitle) 3321] and his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 41415] as an outpatient. Medications on Admission: Pt was not on any medications at home until 1 week prior to admission. Aspirin 325mg QD Lipitor 80mg QD Lisinopril 10mg QD Torpol 25mg QD Plavix 75mg QD Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 6. Multivital Platinum Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: CAD s/p CABGx4 Hyperlipidemia HTN Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 1112] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month. Please call for appointment. Follow-up with cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 31648] in 2 weeks. Please call for appointment. ([Telephone/Fax (1) 8937] Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 61767] Follow-up appointment should be in 2 weeks. Please call for appointment. Completed by:[2115-4-5]	[ "410.71", "272.4", "414.01", "401.9", "458.29" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.13", "39.61" ]	icd9pcs	[ [ [] ] ]	4489, 4495	2514, 3540	330, 484	4573, 4582	1402, 2491	5324, 5882	950, 1012		3744, 4466		4516, 4552		3566, 3721			4606, 5301											1027, 1383																				280, 292								512, 743														765, 785	801, 934
5,724	162,422	50271+50272+59242	Discharge summary	report+report+addendum	Admission Date: [2150-2-24] Discharge Date: [2150-2-26] Service: HISTORY OF PRESENT ILLNESS: The patient is a 79 year old male with a past medical history of hypertension, multiple myocardial infarctions, malignant melanoma, who had the onset of left sided weakness yesterday. By report, the patient awoke about 3:00 a.m. and was unable to move his left upper or lower extremity. He fell out of bed towards his left because he could not support his weight. His family called an ambulance at that time and he was brought into the Emergency Department for further evaluation. Overnight, he had some improvement of his strength. The patient recognizes that over the past several days he has had an upset stomach, right lower quadrant pain and may have been dehydrated. He does not recognize that he may have had a stroke and does not notice that his left side is weak. PAST MEDICAL HISTORY: 1. Multiple myocardial infarctions. 2. Hypertension. 3. Bladder cancer. 4. Malignant melanoma. 5. Alcohol abuse. 6. Appendectomy. 7. Cholecystectomy. MEDICATIONS ON ADMISSION: 1. Inderal 20 mg p.o. twice a day. 2. Cardura 4 mg p.o. once daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives in [Location 86]. He is a retired bus driver. He smoked tobacco in the past and he had a history of alcohol abuse. PHYSICAL EXAMINATION: On admission, vital signs revealed temperature of 97.9, blood pressure 142/70, pulse 72 and regular, respiratory rate 18. In general, he is a well nourished, well developed elderly man lying in bed looking to the right. Head, eyes, ears, nose and throat shows no evidence of trauma. Pulmonary is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm, no murmurs. The abdomen is soft, nontender, nondistended, positive bowel sounds times four. Extremities - 2+ pulses, no edema. Neurologically, mental status - He is awake, alert and oriented to place, but not time. Language is fluent with good comprehension and repetition. He can read but not able to write with left hand. He can do months of the year backwards slowly. Digit span six. Difficulty with calculations in head. Neglect left [Location (un) ] space, distinguishes to double simultaneous stimuli. He can recognize picture of President [Last Name (un) 2450] by telling his function, but cannot comment his name. He has a mild agnosia. He has difficulty initiating and imitating hand gestures. He recalls two out of three objects with cueing. Cranial nerves reveal visual loss, 2400 O.U., left homonymous hemianopsia, does not blink to threat on the left. Funduscopic examination is impaired by cataract. He has extraocular muscles which do not move to the midline. Eyes are deviated to the right. No diplopia or nystagmus. Facial sensation is normal. He has a left facial droop. Did not appreciate auditory stimuli on the left. Palate and tongue symmetric. Head deviated to the right. Motor examination - The right side was with full strength. The left side weakness in deltoid 4+/5, triceps 4+/5. Intrinsic muscles in left hand much weaker. Sensory examination - gross touch is decreased on the left, hemibody proprioception, he detects movement ankle joint but not toe. Pin prick - he feels pin prick and temperature but does not appreciate how painful these sensations are. Reflexes - deep tendon reflexes are 2+ in the upper extremities and 1+ in the lower extremities, toes are downgoing bilaterally. Gait was not tested. LABORATORY DATA: White blood cell count 13.9, hematocrit 38.8, platelet count 171,000. Prothrombin time 13.9, INR 1.3, partial thromboplastin time 29.1. Sodium 138, potassium 3.6, chloride 99, bicarbonate 27, blood urea nitrogen 21, creatinine 1.4, glucose 106, magnesium 2.0. Urinalysis was amber with a specific gravity of 1.020, nitrites positive, glucose negative, urobilinogen 2, pH 6.0. Blood cultures and urine cultures were sent and were negative. Magnetic resonance scan showed a right middle cerebral artery infarction affecting both frontal and parietal as well as occipital territories. HOSPITAL COURSE: The patient was admitted to the neurology service. He was restarted on his outpatient medications. His blood pressure was rather hard to regulate. He was also started on Aspirin and stroke prophylaxis. He will have an echocardiogram and carotid study prior to discharge. His lipid panel disclosed hypercholesterolemia. He was therefore started on a statin. The patient's clinical condition did not improve. He still has a right gaze preference and is neglecting the left side. His sensation is impaired on the left side. DISCHARGE DIAGNOSIS: Stroke resulting in a left hemiparesis, right eye deviation and neglect to the left side. MEDICATIONS ON DISCHARGE: 1. Propranolol 20 mg twice a day. 2. Protonix 40 mg once daily. 3. Aspirin 325 mg once daily. 4. Levofloxacin 500 mg p.o. once daily which was started for urinary tract infection. 5. Ativan 0.5 mg p.o. three times a day. 6. Thiamine 100 mg p.o. once daily. 7. Folic Acid 1 mg p.o. once daily. 8. Multivitamin one tablet p.o. once daily. The patient will follow-up with his primary care physician as an outpatient as well as myself, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1206]. [Name6 (MD) 11982] [Last Name (NamePattern4) 11983], M.D. [MD Number(1) 11984] Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2150-2-25] 18:48 T: [2150-2-25] 19:34 JOB#: [Job Number ] Admission Date: [2150-2-24] Discharge Date: [2150-3-9] Service: GENERAL SURGERY CHIEF COMPLAINT: STATUS POST EXPLORATORY LAPAROTOMY WITH SIGNIFICANT BOWEL RESECTION, STATUS POST RIGHT MCS STROKE, CT SHOWING 7 X 7 ABDOMINAL AORTIC ANEURYSM. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old male with a past medical history of hypertension, multiple myocardial infarctions, and malignant melanoma who had the onset of left-sided weakness the day before presentation. By report, the patient was awake at about 3 a.m. and was able to move his left upper extremity and lower extremities, but then he fell out of bed towards his left because he could not support his weight. His family called an ambulance at that time. He was brought to the Emergency Room for further evaluation. Over night he had some improvement in his strength. The patient recognizes that the past several days prior to admission, he had an upset stomach, right lower quadrant pain, and may had been dehydrated. He did not recognize that he may have had a stroke. He did not notice that his left side was weak. On the NIH stroke scale in the Emergency Room, he scored a 13. PAST MEDICAL HISTORY: 1. Multiple myocardial infarctions. 2. Hypertension. 3. Bladder cancer. 4. Malignant melanoma. 5. Ethanol abuse. 6. Appendectomy. 7. Cholecystectomy. MEDICATIONS: Inderal 20 mg p.o. b.i.d., Cardura 4 mg p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He lives in [Location 86]. He is married. He has smoked cigarettes in the past. He is a retired bus driver. He has a history of alcohol abuse. PHYSICAL EXAMINATION: Vital signs: He was afebrile. Vitals signs were stable. General: He was a well-developed, well-nourished, elderly man, lying in bed. He was looking to the right. HEENT: No evidence of trauma. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. No murmurs. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: There were 2+ pulses. No edema. Neurological: He was awake, alert and oriented to place but not to language. He showed good comprehension. He was able to read but not able to write. He neglects the left half of his face. He has severe visual loss. His left extraocular muscles do not move past the middle. His eyes were deviated to the right. He did not appreciate auditory stimulus on the left. His head was deviated to the right. His right side showed full strength. His left side showed weakness in the deltoid and the triceps. IMAGING: MRI showed a right-sided MCA infarct. HOSPITAL COURSE: The patient was admitted to the Neurology Service. He was kept NPO. He was started on Aspirin 325 mg. An echocardiogram, carotid ultrasound and lipid panels were performed. The patient was being monitored when on hospital day #2, the patient had some maroon colored stool and lower GI pain. At this point, a GI consult was obtained for his GI bleed; however, over the next day, the patient continued to become distended with increased abdominal pain. The thought at this point was question of partial small bowel obstruction, and a Surgery consult was obtained. He also received a CT scan at that point. CT scan showed small bowel obstruction with transition point likely within the right lower quadrant involving the ileum. There was also a thickened segment of right lower quadrant small bowel showing the possibility of ischemia. Also seen on the CT scan was a 7 cm infrarenal abdominal aortic aneurysm and infarcts within the spleen. The recommendation at that point was to get a follow-up CT scan to look for progression; however, on follow-up CT scan, there was continued small bowel with thickened wall and adjacent mesenteric stranding which was likely ischemic bowel. A Vascular Surgery consult was also obtained at that point due to the large abdominal aortic aneurysm within the patient's abdomen. The thought at this point was that this abdominal aortic aneurysm would not be dealt with until the immediate issues had been resolved. As a CT scan showed complete small bowel obstruction with a loop under an old appendix scar, the patient and family were advised that the patient needed to go to the operating room for an exploratory laparotomy, lysis of adhesions and possible resection. They agreed with this plan. On [2150-2-28], the patient went to the Operating Room and underwent exploratory laparotomy, lysis of adhesions and a ischemic small bowel excision. Please refer to the official operative report for all details. The patient tolerated the procedure well. He was admitted to the Intensive Care Unit immediately postoperatively for monitoring. The estimated blood loss was 100 cc, and the patient received 1800 cc crystalloid and made 350 cc of urine intraoperatively. The patient received some perioperative Kefzol and Flagyl; however, these were soon discontinued. The patient remained in the Intensive Care Unit. On postoperative day #2, he was stable enough to be transferred to the floor. On the floor, the patient was kept under strict blood control with intravenous Metoprolol. Neurology was also following the patient. TPN was started for nutrition, as secondary to the patient's stroke he was still unable tolerate p.o. intake. Neurology recommended to perform another MRI of the brain. MRI of the brain showed continued evolution of a right MCA infarct without evidence of acute infarction or hemorrhage. MRA of the circle of [Location (un) 431] showed normal anterior and posterior circulation. Also of note, the patient received carotid ultrasound while in the hospital which showed left-sided stenosis of approximately 40% and right side having insignificant stenosis. Aortic angiogram with bilateral femoral runoff was performed to assess his abdominal aortic aneurysm. The findings included a patent celiac trunk, although mild stenosis of the proximal celiac trunk, patent single bilateral renal arteries, bilateral common internal and external iliac arteries patent, femoral arteries also widely patent, as are the superficial femoral and profunda femoris arteries, bilateral superficial arteries have diffuse mild disease. Of note, the vascular surgeon following the patient was Dr. [Last Name (STitle) 1391] from Vascular Surgery. The patient also received a TEE which revealed no cardiac source of emboli but did show a mobile, friable plaque in the ascending and descending thoracic aorta. On the floor, the patient did well, and some of his symptoms from his stroke slowly improved. The patient received a speech and swallow evaluation which showed some mild oral and moderate pharyngeal dysphagia, but the patient demonstrated some improvement from the initial study. He was still a significant risk for aspiration. The recommendation by Speech and Swallow was to initiate a p.o. diet, give nectar-thick liquids with pureed solids and to have the patient sit upright for all meals. By postoperative day #8, the patient was tolerating an oral diet and was switched over to oral p.o. medications. The TPN was continued however due to the low p.o. intake, and by postoperative day #9, the patient was ready for discharge. He will follow-up with Vascular Surgery as an outpatient for treatment of his abdominal aortic aneurysm. CONDITION ON DISCHARGE: The patient is stable, tolerating a p.o. diet including nectar-thick liquids and oral medications which were mostly crushed. The patient is still on TPN and from out of bed to sit in chair, however, not ambulating secondary to his stroke. DISCHARGE STATUS: To rehabilitation center, most likely [Location (un) 38]. DISCHARGE DIAGNOSIS: 1. Status post exploratory laparotomy secondary to small bowel obstruction with ischemic bowel resection on [2-28]. 2. Status post right MCA stroke on [2-23]. 3. Abdominal aortic aneurysm, 7 x 7 cm. 4. Splenic infarct. DISCHARGE MEDICATIONS: Metoprolol 25 mg p.o. b.i.d., Heparin subcue 5000 U b.i.d., Pepcid 40 mg in the TPN, Hydralazine p.r.n., Morphine p.r.n., regular Insulin sliding scale, TPN. FOLLOW-UP: 1. The patient will be following up with Dr. [Last Name (STitle) ]. 2. The patient will follow-up with Vascular Surgery. 3. The patient will also follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 104841] from Neurology, [Telephone/Fax (1) 541]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 28129], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 1750] MEDQUIST36 D: [2150-3-9] 11:13 T: [2150-3-9] 11:21 JOB#: [Job Number 104842] Name: [Known lastname 10645], [Known firstname 63] Unit No: [Numeric Identifier 17032] Admission Date: [2150-2-24] Discharge Date: [2150-3-11] Date of Birth: [2070-4-18] Sex: M Service: General Surgery ADDENDUM: [Hospital ] HOSPITAL COURSE: The patient was to be discharged to rehab, however, the night before he was to go he spiked a temperature up to 103 and had some mental status changes. At that time a chest x-ray was done, urine culture, blood culture sent, however, after talking with the family and the situation being a possible new stroke versus sepsis in depth discussions were done with the family. Dr. [Last Name (STitle) ], the attending surgeon had in depth discussions with the patient both preoperative and postoperative concerning his wishes and although he did not want surgical intervention at that time he did not wish to have a prolonged dependence on medical care. Due to his deteriorating status he and the family communicated their wish to not receive any additional intervention at this point and they requested supportive care only. We established a DNR and DNI status and also moved to comfort measures only. On postoperative day eleven the patient was to be discharged home with hospice care. CONDITION ON DISCHARGE: The patient stable, currently afebrile, however, mental status still decreased, no IV fluids, no Foley catheter, some diffuse tenderness in the abdomen, central line out. DISCHARGE STATUS: To home with hospice care. DISCHARGE DIAGNOSIS: Status post exploratory laparotomy secondary to small bowel obstruction, small bowel resection, right MCA stroke, coronary artery disease, melanoma, ethanol abuse, hypertension. FOLLOW UP PLANS: 1. The patient will be followed at home with palliative care. 2. The patient and the family is to follow up with [Doctor Last Name ] as necessary. DISCHARGE MEDICATIONS: 1. Ativan 1 mg sublingual q3 hours p.r.n. 2. Artificial tears p.r.n. 3. Lopressor 25 mg p.o. b.i.d. 4. Scopoline patch q3 days. 5. Morphine sulfate elixir sublingual 5 to 20 mg p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 17033], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 4851] MEDQUIST36 D: [2150-3-11] 20:04 T: [2150-3-13] 15:13 JOB#: [Job Number 17034]	[ "444.89", "557.0", "412", "560.9", "401.9", "V10.82", "V10.51", "441.4", "434.91" ]	icd9cm	[ [ [] ] ]	[ "45.62", "88.42", "88.72", "99.15" ]	icd9pcs	[ [ [] ] ]							7133, 7151		16347, 16801		15966, 16324	4867, 5748	1099, 1208	14708, 15700																										7342, 8304							5766, 5910								5939, 6828														6851, 7116	7168, 7319	15725, 15944
53,731	125,042	38548	Discharge summary	report	Admission Date: [2162-6-1] Discharge Date: [2162-7-2] Date of Birth: [2110-8-18] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Levaquin Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Right Heart Catheterization History of Present Illness: Mr [Known lastname 69602] is a 52 year old man with pulmonary hypertension detected approximately six months ago by echo, afib, PAD, COPD (2L of home O2), chronic edema and anasarca and DM2 who presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] after a fall. He reports that he had difficulty getting up after his fall. During his admission at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] his weight was found to be over 400 pounds. He was found to be volume overloaded and they began diuresis. He was noted to be dropping his O2 sats to the mid 70??????s with exertion on oxygen. He is usually on 3L home oxygen. On review of systems, he denies history deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: Pulmonary Hypertension COPD Atrial Fibrillation Peripheral Artery Disease Type 2 Diabetes A1c: 5.3 Chronic Leg Edema and Anasarca Social History: history of smoking but no current tobacco use, alcohol or IVDU Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T: 98 HR: 76 (76-84) BP: 114/79 (91-114/52-79) RR: 20 O2: 94% on RA Ins: 1241/1700 = Net neg 450ml Wgt: 116.5 from 117.6 kg yest Gen: NAD, soft spoken, sitting in chair Cardiac: no JVD, IRIR, [1-9] mid systolic murmur Lungs: CTAB, decreased airmovement diffusely Abd: grossly distended and anasarcic, BS normoactive, NT, UE: radial 2+, PICC line in L arm no erythema or induration LE: brawny lower extermities with bluish discoroloration, only trace edmea to mid-shins now, DP 2+ Pertinent Results: Admission Labs ([0-0-0]): #)CBC: WBC-5.6 RBC-3.33* Hgb-10.3* Hct-32.0* MCV-96 MCH-31.1 MCHC-32.3 RDW-14.8 Plt Ct-177 #)Coags: PT-24.3* PTT-39.6* INR(PT)-2.3* Fibrino-312 #)Chem: Glucose-94 UreaN-15 Creat-0.9 Na-140 K-3.8 Cl-90* HCO3-47* AnGap-7* ALT-7 AST-17 AlkPhos-94 TotBili-1.2 Calcium-8.9 Phos-3.3 Mg-2.2 #)ABG: Type-ART pO2-66* pCO2-74* pH-7.41 calTCO2-49* Base XS-17 . Other Labs: #) UA ([2162-6-4]): Color-LtAmb Appear-Hazy Sp [Last Name (un) ]-1.012 Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-LG RBC-276* WBC-68* Bacteri-FEW Yeast-NONE Epi-0 #) Urine Cx ([6-/2162]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . Other Studies: #) CXR ([2162-6-1]): IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lower aspect of the chest is excluded from the examination. Cardiac enlargement is severe and pulmonary vasculature both peripherally and in the hila is engorged. Opacification blanketing the right lower chest is probably effusion. Borderline pulmonary edema is present. Consolidation particularly in the lower chest and right apex medially is suspected. . #) CXR ([2162-6-24]): IMPRESSION: Left-sided PICC line terminating in similar position as before. Marked regression of pulmonary vascular distention related to successful dehydration. No new infiltrates or pneumothorax. . #) Abd U/S ([2162-6-20]): Limited ultrasound of the abdomen demonstrates a moderate amount of ascites, predominantly within the lower quadrants. A right pleural effusion is seen. . #) CT Neck/Lungs with and without Contrast ([2162-6-27]) FINDINGS: There is a tunneled left-sided central venous line with the tip terminating at the proximal SVC. The arch vessel origin is normal. There are no abnormally enlarged superior mediastinal nodes. A tiny wall calcification is in the aortic arch and both cervical carotid bifurcations and cavernous carotid segments. HEAD: There is no significant cervical or intracranial stenosis, aneurysm, or occlusion. NECK: There is no significant cervical or intracranial stenosis, aneurysm, or occlusion. Note is made of a left maxillary sinus mucous retention cyst. There are no abnormally enlarged cervical nodes. The left aryepiglottic fold is mildly thickened compared to the right and the left piriform fossa is partially effaced. There is enlargement of the left laryngeal ventricle, and mild thickening of the left aryepiglotic fold, consistent with left vocal cord paralysis. IMPRESSION: Partially effaced left piriform sinus and mild asymmetric thickening of left aryepiglottic fold. No compressive lesion of the recurrent laryngeal nerve is demonstrated on the current study. . #) MRI Brain ([2162-6-28]): IMPRESSION: Normal intracranial appearances. . #) ECHO ([2162-6-30]): Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 6.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 8.3 cm <= 5.2 cm Right Atrium - Four Chamber Length: 6.9 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Right Ventricle - Diastolic Diameter: 3.7 cm <= 2.1 cm Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.2 cm Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - E Wave deceleration time: 175 ms 140-250 ms TR Gradient (+ RA = PASP): 45 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.0 cm Conclusions The left atrium is markedly dilated. A color Doppler jet of left-to-right shunt across the interatrial septum is seen at rest c/w a small secundum atrial septal defect. Premature appearance of echo contrast is seen in the left atrium post-cough and Valsalva release. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The 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 regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, inferolaterally directed jet of mild to moderate ([12-5]+) mitral regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is a atrivial/physiologic pericardial effusion. IMPRESSION: Pulmonary artery systolic hypertension. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Small secundum atrial septal defect. Mild-moderate mitral regurgitation. . #) Cardiac Cath ([2162-6-30]) - Preliminary Report: COMMENTS: 1. Resting hemodynamics revealed elevated right and left heart filling pressures with RVEDP 15 mmHg and PCWP 19 mmHg. There was moderate pulmonary arterial hypertension with PASP 55 mmHg. The cardiac index was preserved at 3.1 L/min/m2. The pulmonary vascular resistance was elevated at 200 dyn-sec/cm5. FINAL DIAGNOSIS: 1. Mildly elevated biventricular filling pressures. 2. Moderate pulmonary arterial hypertension. 3. Mildly elevated pulmonary vascular resistance. . Discharge Labs ([2162-7-2]): Chest [Known firstname ] [6-1]: Left PIC line can be traced as far as the left brachiocephalic vein, but the tip is indistinct. There are severe cardiomegaly and moderate right pleural effusions are unchanged. Pulmonary edema is mild if any. Consolidation in the lower lungs is difficult to exclude because of relative [Name (NI) 76419] and there may be a region of consolidation or other poorly defined lesion in the right suprahilar lung medially. Conventional radiographs are essential for better characterization. Brief Hospital Course: ID: Mr. [Known lastname 69602] is a 51 year old man with pulmonary hypertension detected approximately six months ago by echo, afib, PAD, COPD (2L of home O2), chronic edema and anasarca and DM2 who presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] s/p fall and found to be in congestive heart failure with subsequent transfer to [Hospital1 ]. . #. Right Sided Heart Failure: On admit, Pt volume overloaded with generalized edema and anasarca. Thought due to right heart failure [1-5] to obstructive sleep apnea/COPD. Outside ECHO showed EF 55-60% with increased right-sided pressures. Exertional desaturation, lung crackles, and boarderline pulmonary edema on presentation argued for some degree of left heart involvement. Diuresis was started with a lasix drip and continued for 4 weeks until [6-29]. Good response with daily goal 2-3L neg. Creatinine never rose. Eventually transitioned IV pushes before home dose of PO lasix started on [6-30]. Final net fluid output for hospitalization was roughly 85L negative with patient's weight falling from 410lbs pre admission to 255lbs at time of discharge. ECHO and Right Heart Cath on [6-29] are mentioned in results. Pt was changed back to his home regimen of lasix 80mg PO BID with the new addition of spironolactone two days before discharge. He was achieving a net negative output for two days on this regimen before discharge. . #. Hemoptysis: Pt had intermittent cough which started to be productive of small amounts of blood. Pt was on either warfarin or heparin gtt while experiencing this trace hemoptysis. Pulmonary saw pt in consult and lung imaging was obtained which did not show evidence of pulmonary process. All anticoagulation was stopped for the period of 1 week and hemoptysis resolved, but reocurred within 24hrs of reinitiation of heparin gtt. When ENT saw pt regarding vocal cord paralysis they described traumatic changes to both nares likely caused by prolonged use of a nasal cannula. Because of this and the patient's report that he often felt bloody tasting drainage at the back of his [Month/Year (2) ], he small amount of hemoptysis was believed due to dry upper airway mucosa, worsened when pt was on anticoagulation. Pt was restarted on warfarin 2 days before discharge had not experienced any degree of hemoptysis for 48 hours prior to his discharge although his INR was not yet therapeutic. . #. Persistent Atrial Fibrillation: Pt in persistent atrial fibrillation during his admission. After admission his coumadin was held in anticipation of a proceedure and pt was started on a heparin drip for anticoagulation. Heparin was also stopped for 1 week later in proceedure and pt was put on full strength ASA in attempt to decrease hemoptysis, which was successful. Home warfarin dose restarted before discharge in light of atrial fib. . # Pulmonary Hypertension: Elevated pulmonary pressures thought [1-5] to OSA and COPD. Pulmonary was consulted which recommeneded aggressive diuresis. Sleep medicine who thought that he needed BIPAP and he was was sent to the CCU on [6-3] for BIPAP trial which he did not tolerate. Sleep recommended outpt sleep study once closer to dry weight. . #. COPD: PFT's from outside hospital revealed severe obstructive disease. Initial ABG showed hypercarbia (pCO2 of 73) with a bicarb of 48 suggestive of a chronic process. Pt was placed on tiotropium and fluticasone/salmeterol inhalers with PRN short-acting coverage while inpt. Initially required supplementary O2 both at rest and with exertion, but after large volume diuresis was satting between 90-96% on RA at rest and rarely used O2 throughout day. The day before discharge patient was able to tolerate 5 minutes of ambulation which brought his heart rate up to 130s without dropping his room air sat below 94%. As a result it appears unlikely that pt needs daytime supplementary oxygen s/p the large volume diuresis from this hospitalization. . # Lower Extremity Edema/Wounds: Most likely [1-5] to heart failure. Dermotology thought that his findings are consistent with stasis dermatitis. They recommended current leg elevation, compression by ace bandages, aggressive diuresis, clobetosol propionate 0.05% cream [Hospital1 ] for stasis dermatitis followed by wrapping with kerlix then ace bandaging, and cleansing with mild cleanser, moisture barrier ointment. He was noted to have tinea pedisand started on ketaconazole 2% topical ointment [Hospital1 ] for four weeks. Wound care service also saw patient in hospital and skin changes and chronic wounds improved with their management and above treatment. . #. UTI: He was found to have a urine culture pos. for coag + staph - MSSA. He was started on dicoxacillin 12.5mg on [6-6] and completed a 7 day course. . #. Acid Reflux: He had been complaing of indigestion consistent with acid reflux. He was started on Pantoprazole 40 mg PO Q24H and Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID while in hospital. Because pt did not have symptoms the last 10 days in the hospital his acid reflux medications were stopped before discharge. . Medications on Admission: Atenolol 100mg [Hospital1 ] Lasix 80mg [Hospital1 ] Warfarin 5mg daily Finasteride 5mg daily Lasix 80mg [Hospital1 ] Combivent 2 puffs qid Ventolin 2 puffs q2hrs Aspirin 81mg daily K-Dur 20mg [Hospital1 ] Flomax 0.4mg daily Oxycodone 15mg q12 PRN Sertraline 100mg daily Lorazepam 0.5mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s)* Refills:3 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. Disp:60 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 8. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation [Hospital1 ] PRN as needed for shortness of breath or wheezing. 9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:60 1 Refills:0 10. Oxycodone 15 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID: PRN as needed for pain. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for rash: Apply to rash under stomach folds as needed [Hospital1 ]. Disp:1 bottle Refills:0 12. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days. Disp:1 tube Refills:0 13. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days. Disp:1 tube Refills:0 14. Outpatient Lab Work INR, Potassium, BUN, Creatinine to be check by VNA on [Hospital1 766], [7-5]. . Results should be communicated to Dr. [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) ] with [Location (un) ] Internal Medicine: phone [Telephone/Fax (1) 84643] 15. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 16. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: Homehealth VNA Discharge Diagnosis: Primary Diagnosis: Right Sided Heart Failure Left vocal cord paralysis Urinary Tract infection Secondary Diagnosis: Atrial Fibrillation Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 69602], You were admitted because of heart failure. You were having difficulty breathing because you had fluid in your lungs and had fluid backed up into your stomach and lower extremities. You were put on a lasix drip for diuresis and urinated over 80 liters of fluid over the course of 4 weeks. . You were coughing up small amounts of blood during your hospital stay. We believe this was coming from dry upper airway mucosa in your nose. . You came to the hospital with a horse voice. The Ear,Nose and [Known lastname 6212] doctors examined your [Name5 (PTitle) ] and observed that your left vocal cord was paralyzed. A CAT Scan of your neck and lungs and an MRI of your head showed no masses that would explain your hoarseness. You will need to follow up with an Ears, Nose and [Name5 (PTitle) 6212] doctor when you leave the hospital. . You also developed a urinary tract infection while in the hospital which was treated successfully with antibiotics. . Medications changed during your admission: STOP: Atenolol STOP: Lorazepam New Med: START metoprolol succinate 100mg daily New Med: Spironolactone 25mg by mouth twice each day New Med: Advair Diskus Inhaler, 1 puff in morning and 1 puff in evening New Med: Potassium Chloride 20mEq tabs, 2 tabs by mouth twice a day New Med: Clobetasol cream for both lower legs to be applied twice each day for 1 week New Med: Ketoconazole Cream to be applied to feet tonails twice each day for 1 week New Med: Miconazole Powder to be applied beneath stomach skin fold daily for 1 week . Scheduled Follow-up: Primary care doctor: Dr. [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) ]. See below Pulmonologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. See below Cardiologist: Dr. [First Name (STitle) ], [First Name (STitle) 766] [7-12] at 2pm. See below. . Home with services: VNA for lab draws and skin care. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) ] . Pulmonologist Dr. [Last Name (STitle) 85731] [Name (STitle) ] . Cardiologist: Dr. [Doctor Last Name 85732] [Name (STitle) ] [Last Name (LF) 766], [7-12] at 2pm Clipper Cardiovascular Associates [Last Name (NamePattern1) 85733]. [Location (un) 5028], [Numeric Identifier 12023] Phone: [Telephone/Fax (1) 65733] Fax: [Telephone/Fax (1) 85734] Before the visit you will need to fax/bring your medical records to the office 24hrs before your appointment. You will need to bring a copy of your medication list to the appointment and you will need to bring your insurance card. . ENT to be referred by Dr. [Last Name (STitle) ] If Persisting hoarseness could consider outpt voice therapy referral -ask Dr. [Last Name (STitle) ].	[ "784.7", "428.0", "707.25", "041.11", "428.31", "327.23", "V15.88", "786.3", "478.31", "V85.4", "427.1", "530.81", "599.0", "496", "459.81", "250.00", "427.31", "416.8", "112.3", "707.07", "E934.2", "518.83", "414.01" ]	icd9cm	[ [ [] ] ]	[ "31.42", "37.21" ]	icd9pcs	[ [ [] ] ]	16411, 16456	8855, 14006	317, 346	16661, 16661	2270, 2650	18878, 19765	1664, 1746		14364, 16388		16477, 16477		14032, 14341		8115, 8832	16812, 18855											1761, 2251																				258, 279								374, 1415			16594, 16640			16496, 16573			16676, 16788					1437, 1568	1584, 1648			2662, 8098
16,453	117,450	16693	Discharge summary	report	Admission Date: [2116-2-11] Discharge Date: [2116-2-13] Date of Birth: [2048-2-14] Sex: M Service: Urology HISTORY OF PRESENT ILLNESS: Benign prostatic hypertrophy. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient was a well-developed and well-nourished male in no apparent distress. Head, eyes, ears, nose, and throat examination revealed no evidence of cervical lymphadenopathy. The mucous membranes were moist. No oral ulcers. Cranial nerves II through XII were intact. No evidence of scleral icterus. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rhythm and rate. No murmurs. The abdomen was soft, nontender, and nondistended. No evidence of abdominal incisional scars. Pelvic/rectal examination performed prior to the surgery indicated report of benign prostatic hypertrophy. No inguinal lymphadenopathy was noted, and Foley was intact with no evidence of gross blood from the meatus of urethra, and urine was clear. PERTINENT LABORATORY VALUES ON DISCHARGE: On the day of discharge, the patient's sodium was 140 and hematocrit was stable at 26.7. SUMMARY OF HOSPITAL COURSE: Mr. [Known firstname ] [Known lastname 47233] is a 67-year-old male who presented with increasing difficulty with urination secondary to benign prostatic hypertrophy. The patient underwent transurethral resection of prostate with intraoperative complication of hyponatremia to 117 with corresponding confusion. The procedure was completed, and the patient was transferred to the Postanesthesia Care Unit where hyponatremia was corrected with normal saline fluids and Lasix. To preserve cardiac and neurologic stability, magnesium and calcium were administered. Status post diuresis, hypocalcemia was counteracted with oral potassium and intravenous potassium administration. The patient's cardiac enzymes were not elevated during the postoperative period, and no electrocardiogram changes were noted. After monitoring, the patient with every one hour vital signs and every four hour electrolyte checks, the patient achieved normonatremia by postoperative day one. The decision was made to transfer the patient to the floor where continuous bladder irrigation was weaned secondary to association of postoperative gross hematuria. No blood transfusion was required since the patient's hematocrit remained stable throughout the postoperative course. The patient was discharged on postoperative day two with a Foley in place. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: Status post transurethral resection of prostate, transurethral resection of prostate syndrome. MEDICATIONS ON DISCHARGE: The patient was discharged with five days of Levaquin and a Foley catheter in place. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with Dr. [Last Name (STitle) 4229] the following week. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 13920] Dictated By:[Name8 (MD) 11079] MEDQUIST36 D: [2116-2-14] 09:53 T: [2116-2-17] 09:39 JOB#: [Job Number 40733]	[ "276.1", "276.8", "602.3", "458.2", "600.0", "601.0", "788.20" ]	icd9cm	[ [ [] ] ]	[ "60.29" ]	icd9pcs	[ [ [] ] ]								2683, 2779				2806, 2892						2926, 3271																		1209, 2559						2575, 2661	1090, 1180												165, 1075
31,070	127,927	49038	Discharge summary	report	Admission Date: [2168-4-26] Discharge Date: [2168-5-6] Date of Birth: [2094-1-3] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Sudden onset severe headache Major Surgical or Invasive Procedure: [4-26]: Cerebral Angiogram [5-4]: Placement of VP shunt History of Present Illness: 74F spanish speaking, with HTN, experienced sudden onset severe HA on [2168-4-26] in R temporal region, but also with some neck discomfort. No trauma. Pt apparently had not taken any BP meds that day. EMS called and initial SBP 220-248. Pt brought to [Hospital1 18] where Pt alert and neurologically intact by report. Placed on Nitroprusside and labetalol gtt. CT revealed SAH in basal cisterns B/L. CTA performed revealed no obvious aneurysm. Past Medical History: 1. DM 2. HTN Social History: resides at home with daughters, denies tobacco use Family History: non-contribuitory Physical Exam: VS: afeb bp130/70 (on admission 220-248/90-119) hr60-80 rr20-22 General: WNWD HEENT: Anicteric, MMM without lesions, OP clear Neck: Supple, no carotid bruits CV: RRR s1s2 no m/r/g Resp: CTAB no r/w/r Abd: +BS Soft/NT/ND no HSM/masses Ext: No c/c/e, distal pulses intact Skin: No rashes, petechiae MS: A&O x 3, interactive, appropriate, following all commands CN: I ?????? not tested, II,III ?????? PERRL (3-2mm OU), VFF by threat; III,IV,VI ?????? EOMI, no ptosis, no nystagmus; V- sensation intact to LT; VII ?????? R facial weakness/asymmetry; VIII ?????? hears finger rub B; IX,X ?????? palate elevates symmetrically; [Doctor First Name 81] ?????? SCM/Trapezii [4-25] B; XII ?????? tongue protrudes midline, no atrophy or fasciculations Motor: nl bulk and tone, no tremor, rigidity or bradykinesia. No pronator drift. Full power throughout UE and LE. DTRs: [Name2 (NI) ] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar L 2 2 1 1 1 mute R 2 2 1 1 1 mute Sensory: w/d to pinch throughout. Coord: finger tap rapid & symm, F??????N & FNF intact B. Gait: deferred Pertinent Results: [2168-5-5] 06:38AM BLOOD WBC-15.9* RBC-3.22* Hgb-9.8* Hct-29.7* MCV-92 MCH-30.3 MCHC-32.8 RDW-13.4 Plt Ct-454* [2168-5-2] 02:47AM BLOOD Neuts-69.3 Lymphs-23.4 Monos-6.4 Eos-0.7 Baso-0.2 [2168-5-5] 06:38AM BLOOD Glucose-171* UreaN-13 Creat-0.6 Na-133 K-3.5 Cl-99 HCO3-21* AnGap-17 [2168-5-5] 06:38AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 [2168-5-1] 03:14AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2168-5-1] 03:14AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE CULTURE (Final [2168-5-2]): NO GROWTH. Blood Culture, Routine (Final [2168-5-6]): NO GROWTH. GRAM STAIN (Final [2168-5-1]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. [2168-5-1] 12:55 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): GRAM STAIN (Final [2168-5-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. CTA HEAD W&W/O C & RECONS [2168-4-25] 9:52 PM 1. 2-mm outpouching, from the posterolateral aspect of paraclinoid portion of the cavernous segment of the left internal carotid artery, seen on the thick section MIP reformations can represent a tiny aneurysm. 2. Focal prominence at the termination of the left supraclinoid internal carotid artery likely represents tortuosity, as this is not confirmed on multiple planes. 3. Atherosclerotic disease involving the cavernous internal carotid arteries on both sides. 4. Extensive subarachnoid hemorrhage with small amount of intraventricular component, as described above, without shift of the midline structures or intraparenchymal hemorrhage. CT HEAD W/O CONTRAST [2168-4-26] 3:21 AM Similar appearance of subarachnoid hemorrhage, now with a small amount of intraventricular blood in the occipital [Doctor Last Name 534] of the left lateral ventricle. CT HEAD W/O CONTRAST [2168-4-26] 9:56 AM There is interval placement of the intraventricular drain, with tip in the region of the right foramen of [Last Name (un) 2044]. Interval development of small amount of blood in the body of the right lateral ventricle without significant change in the extent of subarachnoid hemorrhage as well as small amount of blood in the left lateral ventricle. CTA HEAD W&W/O C & RECONS [2168-4-28] 2:16 PM 1. Improvement in ventricular size following change in position of the ventricular drain. 2. Subarachnoid hemorrhage. 3. No evidence of vasospasm or aneurysm identified on CT angiography. CT HEAD W/O CONTRAST [2168-4-30] 11:27 AM 1. No significant change in the subarachnoid hemorrhage and dependent layering blood within the lateral ventricles. 2. Slight increase in size of the ventricular system from [2168-4-28]. CAROT/CEREB [Hospital1 ] [2168-5-3] 10:53 AM 1. Severe vasospasm of the right A1 segment of the anterior cerebral artery. 2. Moderate vasospasm of the left P1 segment of the posterior cerebral artery. 3. No aneurysms or arteriovenous malformations. 4. Treatment of vasospasm with Verapamil. CT HEAD W/O CONTRAST [2168-5-4] 12:00 PM 1. Interval decrease in subarachnoid hemorrhage and hemorrhage within the basal cisterns. 2. No change in the ventricular system compared to [2168-4-30]. CT HEAD W/O CONTRAST [2168-5-4] 4:52 PM 1. Unchanged appearance of subarachnoid hemorrhage in the sulci and basal cisterns since the prior study five hours ago. 2. Unchanged ventricular system compared to the [2168-4-30]. Brief Hospital Course: Patient admitted to [Hospital1 18] from OSH for definitive treatment of a SAH. On transfer her BP was quite elevated and initial management began in the ED with labetalol and Nipride. She was admitted to the ICU for close mental status monitoring and blood pressure management. She was also started on Nimodipine. She was taken for angiogram on [4-26] which was negative for aneurysm or vascular malformation. On [4-26], she also became more lethargic than her initial presentation. An EVD was placed by Dr. [First Name (STitle) ] in the ICU, and mental status significantly improved. On [4-27] erythromycin was started for conjunctivitis. CTA on [4-28] revealed no evidence of vasospasm or aneurysm. The patient failed an EVD clamping trial on [4-29]. On [4-30] the patient was found to be more lethargic and was febrile to 102.8, blood culture at this time was negative; repeat CT scan demonstrated slightly increased ventricular size. On [5-1] the patient was started on a dilantin to Keppra transition. CSF analysis revealed 4+ PMNs without microorganisms, culture revealed no growth. On [5-2] the patient failed a second EVD clamping trial, and again failed a third EVD clamping trial on [5-3]. On [5-3] the patient again underwent angiogram which demonstrated severe vasospasm of the right ACA, moderate vasospasm of the left PCA, and no aneurysms or AVMs. Verapamil was administered for treatment of the vasospasm. Due to multiple failed EVD clamping trials, the patient was taken to the OR for VP shunt placement on [5-4]. CSF analysis from [5-4] revealed 1+ PMNs and was negative for microorganisms, culture at time of discharge is pending but has had no growth to date. The patient's Foley catheter was reinserted on [5-5] secondary to inability to void. The patient was evaluated by physical therapy and determined to be appropriate for rehabilitation. The patient was discharged to rehabilitation on [5-6] in stable condition. Medications on Admission: Synthroid 200mcg daily Lipitor 80mg daily Zetia 10mg daily Labetolol 200mg daily Citalopram 20mg daily Meclizine 25mg daily Enalapril 20mg daily Tizanidine 2mg Insulin Lente 35-40units twice daily ASA 81mg daily Folic Acid 800mg daily MVI daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 3. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): discontinue on [5-16](completion of 21 day course). 4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H (every 6 hours) as needed. 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [12-23] Tablets PO Q6H (every 6 hours) as needed for headache. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H () as needed. 12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Subarachnoid hemorrhage Discharge Condition: stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast.	[ "401.9", "372.00", "331.3", "276.8", "788.20", "430", "435.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "02.34", "99.29", "88.41", "02.39" ]	icd9pcs	[ [ [] ] ]	9800, 9870	5840, 7844	344, 410	9938, 9947	2149, 2959	11462, 11780	1017, 1036		8139, 9777		9891, 9917		7870, 8116			9971, 11439											1051, 2130												3106, 3240								276, 306								438, 896														918, 933	949, 1001		3272, 5817
21,401	189,819	11922	Discharge summary	report	Admission Date: [2176-3-30] Discharge Date: [2176-4-10] Date of Birth: [2104-3-31] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 668] Chief Complaint: urethral disruption and a rectourethral fistula Major Surgical or Invasive Procedure: Transverse loop colostomy History of Present Illness: Mr. [Known lastname 37557] is 72-year-old male who underwent a prostatectomy for BPH, and during that procedure developed a urethral disruption and a rectourethral fistula. During the workup, he was found to have an incidental thoracoabdominal dissection, and now presents for a temporizing procedure prior to planned thoracoabdominal repair. Past Medical History: HTN, hyperlipidemia, Diverticulitis ([10-13]), h/o MI ('[69]) h/o colon cancer, prostate ca Social History: 4 beers/week, no etoh, no smoking Physical Exam: NAD CTAB RRR soft, NT, obese [Last Name (un) ] pink +drainage/gas midline perineal incision with urine draining foley in place Pertinent Results: [2176-4-10] 05:17AM BLOOD WBC-8.7 RBC-4.09* Hgb-12.2* Hct-35.4* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.6 Plt Ct-438 [2176-4-10] 05:17AM BLOOD Plt Ct-438 [2176-4-5] 04:15AM BLOOD PT-15.1* PTT-37.0* INR(PT)-1.4* [2176-4-10] 05:17AM BLOOD Glucose-98 UreaN-9 Creat-0.8 Na-132* K-5.2* Cl-101 HCO3-22 AnGap-14 [2176-3-30] 07:47PM BLOOD ALT-20 AST-18 LD(LDH)-170 AlkPhos-74 TotBili-0.8 [2176-4-9] 05:17AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8 [2176-3-30] 07:47PM BLOOD Albumin-3.1* [2176-3-30] CT: 1. Large aortic dissection involving the ascending aorta to the right common iliac artery. The true lumen feeds the great vessels and major abdominal arteries. 2. Right renal cysts. 3. Sacroiliac joint fusion and degenerative changes of the spine. 4. Thick walled bladder. [2176-4-1] ECHO: 1. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4.The ascending aorta is markedly dilated There are simple atheroma in the ascending aorta. The descending aorta was not seen on the present study. No dissection was seen in the limited views of the ascending aorta. 5.The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.The estimated pulmonary artery systolic pressure is normal. 8.There is no pericardial effusion. [2176-4-2] CT: 1) Stable aortic dissection where imaged; the most inferior aspect of the dissection was not imaged on this study. All major abdominal vascular branches originate from the true lumen. 2) Stable dilatation of the ascending aorta/aortic root. 3) Coronary artery calcification. 4) Multiple simple right renal cysts. 5) Cholelithiasis without evidence of cholecystitis. 6) Small bilateral pleural effusions. Brief Hospital Course: 72M s/p urethral disruption and a rectourethral fistula after radical prostatectomy for BPH. A type A thoracoabdominal dissection was found incidentally on work-up and pt was transferred to [Hospital1 18] cardiac surgery service for monitoring and evaluation. Pt denied symptoms and was hemodynamically stable during his entire hospital course. Serial chest CT's showed no progression of the dissection, and cardiac surgery felt that the dissection was chronic in nature. Urology was consulted to evaluate perineal injury. Pt had stool draining from both his perineal wound and foley catheter at this time. He was started on levo/flagyl for empiric coverage. Urology recommended a diverting colostomy to allow the perineum to heal and later repair. Transplant surgery was consulted for the diverting colostomy and pt underwent the procedure on [2176-4-3]. Urology also performed cystoscopy, exam under anesthesia, as well as perineal washout at this time. Pt tolerated the procedure well and was extubated to the CRSU in stable condition. His post-operative course was uncomplicated, and his colostomy began putting out stool by POD3. He was tolerating a PO diet and pain was well-controlled with PO analgesia. Ostomy care was taught at bedside and patient was instructed to keep the foley catheter in at all times indefinitely, per urology. Pt remained in house until cleared by Dr. [Last Name (STitle) ] of cardiac surgery for discharge home on [2176-4-10]. He was instructed to return to the hospital the following week for repair of his aortic dissection. His discharge medications included abx levo/flagyl (for a total of 2 weeks) as well as anti-hypertensive medications (goal SBP<120). Medications on Admission: lipitor 20' atenolol 25' norvasc 10' lasix 20' ASA 81' Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Disp:24 Tablet(s) Refills:0 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: North County Home and Health Care Discharge Diagnosis: Urethrorectal fistula thoracoabdominal aneurysm Discharge Condition: Stable Discharge Instructions: Start your medications as instructed. Please fill new medications (antibiotics levofloxacin and metronidazole, as well as multiple cardiac medications) and take as instructed. Call your physician or go to the emergency room if you experience fever >101.4F, pain unrelieved by medication, intractable nausea or vomiting, or foul-smelling drainage from your abdominal incision. Followup Instructions: Call Dr.[Name (NI) 3502] clinic for instructions regarding your return to the hospital next Wednesday morning for your cardiac evaluation prior to surgery. Dr. [First Name (STitle) ] will see you when you return to the hospital next Wednesday for your cardiac surgery. For any questions, he can be reached at his clinic [Telephone/Fax (1) 673]. Follow-up with your urologist on discharge regarding management of your urethrorectal fistula. Completed by:[2176-4-10]	[ "998.6", "441.03", "V10.05", "998.83", "401.9", "V10.46", "272.4", "608.4" ]	icd9cm	[ [ [] ] ]	[ "96.59", "46.03", "57.94", "87.77" ]	icd9pcs	[ [ [] ] ]	6061, 6125	3193, 4919	318, 345	6217, 6225	1061, 3170	6651, 7136			5025, 6038		6146, 6196		4945, 5002			6249, 6628											910, 1042																				231, 280								373, 721														743, 844	860, 895
29,632	128,856	46442	Discharge summary	report	Admission Date: [2144-9-21] Discharge Date: [2144-9-28] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 552] Chief Complaint: GI bleeding, hypotension Major Surgical or Invasive Procedure: [2145-9-23] DART Chest tube insertion [2144-9-25] Colonoscopy History of Present Illness: 89 year old female with a history of hemorrhagic stroke, seizure disorder, and recent fall with resultant pelvic fracture, hypertension, history of rectal prolapse and constipation who initially presented with acute blood loss anemia from lower GI bleeding. The patient prior to hospitalization was at [Hospital 100] Rehab after her recent Pelvic fracture. The patient at rehab experienced 1 episode of black stool followed by frank hematochezia which continued over next 24 hours including red clots. The patient has never previously experienced GI bleeding and per PCP notes the patient underwent colonoscopy in [2140] which was normal. On initial arrival the patient was with BP 102/57 which dropped to 77/43 on admission, improved to 100/50 with 1L NS and 2Units PRBCs. The patient received 1 additional unit of blood [2144-9-22] at 9am with Hct bump from 28.1 to 31.7, stable to 33.1 over 24 hours without additional transfusion (3Units PRBC total). The patient was seen by GI with initial plan to perform colonoscopy. However, the patient has been noted to have no additional bleeding and was additionally noted to have pneumothorax from CVL placement and tachycardia for which endoscopy was delayed. Given relative stability since initial presentation and cessation of bleeding, decision was made to forego endoscopy at that time. With regards to the murmur this was subsquently confirmed to have been present previously after discussion with the patient's daughter. [Name (NI) 6] Echocardiogram was obtained which was revealing for a hyperdynamic LVEF >75% and severe resting LVOT gradient and moderate to severe Mitral regurgitation. The patient was seen by cardiology with impression LVOT was likely secondary to longstanding hypertension and now hypovolemia with recommendation to continue beta blockade, maintain normovolemia, and avoid medications that might dramatically lower preload or afterload. Of additional note the patient experienced a complication of a right apical pneumothorax in setting of attempted IJ line placement in the ED. The patient has subsequently had a DART chest tube placed by IR with subsequent near resolution of pneumothorax. On arrival to the floor the patient reported only some mild discomfort over her right lower back and hip. After patient transfer, [Name (NI) 653] by lab that 2 bottles from single set of blood cultures from the CVL placement had grown out gram positive cocci, which initially were treated with vancomycin, but ultimately were judged to be contaminant, given no fever and negative peripheral cultures. On [9-24] she again experienced frank hematochezia, and so underwent repeat colonscopy on [9-25], during which they were unable to pass the scope beyond 35cm due to a stricture. A CT Abdomen revealed a stricture, but no mass, so surgery was consulted, who felt no immediate need for surgery given lack of obstruction. The patient and daughter repeatedly expressed no desire for major surgery. Past Medical History: Hemorrhagic stroke in [2140]. Per daughter, patient was unconscious for two days. Once she became conscious, she had significant difficulty producing language. Hemorrhagic stroke in [2142] Seizure disorder Her daughter was not sure about the manifestations of the seizures. The patient was previously on Topamax 100mg [Hospital1 ], but this was decreased to 50mg [Hospital1 ] due to concerns about drowsiness due to the Topamax Hypertension rectal prolapse hearing loss hip fracture hyponatremia This was thought to be due to HCTZ which was discontinued. PSH: Rectal prolapse repair Hip fracture repair Social History: Patient has a high school education and was a professional modern dancer. She lives [Hospital 98657] nursing home. She did not smoke but she was exposed to secondhand smoke. She was widowed twenty years ago. Family History: Non-Contributory Physical Exam: At Discharge: ROS: c/o difficulty taking a deep breath, no SOB, DOE, CP, no cough, nausea, vomiting, abdominal distention or pain, + loose BM today, no hematochezia PHYSICAL EXAM: VSS: Afebrile GEN: NAD, pelvic pain with movement HEENT: EOMI, MMM PUL: CTA B/L, decreased BS bilat COR: reg, no murmur ABD: ND,+BS,NT EXT: [1-22]+ bilat ankle edema NEURO: AOx3, Non-Focal, generalized weakness Pertinent Results: [2144-9-27] 05:45AM BLOOD WBC-4.6 RBC-3.63* Hgb-11.2* Hct-33.3* MCV-92 MCH-30.8 MCHC-33.6 RDW-14.9 Plt Ct-241 [2144-9-22] 04:13AM BLOOD WBC-11.7# RBC-3.21 Hgb-10.1* Hct-28.1* MCV-87 MCH-31.5 MCHC-36.0* RDW-15.2 Plt Ct-290 [2144-9-24] 03:34AM BLOOD Neuts-82.8* Lymphs-9.0* Monos-4.2 Eos-4.0 Baso-0 [2144-9-26] 05:32AM BLOOD PT-12.5 PTT-24.7 INR(PT)-1.0 [2144-9-27] 05:45AM BLOOD Glucose-84 UreaN-9 Creat-0.5 Na-132* K-4.4 Cl-100 HCO3-25 AnGap-11 [2144-9-26] 05:32AM BLOOD Glucose-80 UreaN-8 Creat-0.4 Na-134 K-3.6 Cl-98 HCO3-28 AnGap-12 [2144-9-21] 10:50AM BLOOD Glucose-156* UreaN-16 Creat-0.5 Na-127* K-4.5 Cl-93* HCO3-27 AnGap-12 [2144-9-27] 05:45AM BLOOD CK(CPK)-22* [2144-9-26] 09:20PM BLOOD CK(CPK)-25* [2144-9-23] 04:47AM BLOOD CK(CPK)-32 [2144-9-22] 12:51PM BLOOD CK(CPK)-33 [2144-9-22] 04:13AM BLOOD CK(CPK)-28 [2144-9-27] 05:45AM BLOOD CK-MB-3 cTropnT-<0.01 [2144-9-26] 09:20PM BLOOD CK-MB-3 cTropnT-<0.01 [2144-9-23] 04:47AM BLOOD CK-MB-3 cTropnT-0.01 [2144-9-22] 12:51PM BLOOD CK-MB-3 cTropnT-0.01 [2144-9-22] 12:44PM BLOOD CK-MB-3 cTropnT-0.01 [2144-9-22] 04:13AM BLOOD CK-MB-3 cTropnT-<0.01 [2144-9-26] 05:32AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.6 [2144-9-22] 01:03AM BLOOD Albumin-3.0* Calcium-7.6* Phos-3.3 Mg-1.8 [2144-9-25] 07:15AM BLOOD VitB12-850 [2144-9-21] 10:50AM BLOOD Osmolal-264* [2144-9-22] 04:13AM BLOOD Phenyto-2.5* [2144-9-26] 06:33AM BLOOD Lactate-0.9 [2144-9-22] 07:16PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.011 [2144-9-22] 07:16PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2144-9-22] 07:16PM URINE RBC-33* WBC-41* Bacteri-MOD Yeast-NONE Epi-<1 [2144-9-22] 07:16PM URINE CastHy-1* [2144-9-22] 1:50 pm BLOOD CULTURE Source: Line-tlc. Blood Culture, Routine (Pending): [2144-9-22] 7:16 pm URINE Source: Catheter. FINAL REPORT [2144-9-24] URINE CULTURE (Final [2144-9-24]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2144-9-22] 7:16 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [2144-9-23] 4:47 am BLOOD CULTURE Source: Line-central line. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2144-9-24]): REPORTED BY PHONE TO [Initials (NamePattern4) ] [Last Name (NamePattern4) ], R.N. ON [2144-9-24] AT 0540. GRAM POSITIVE COCCI IN CLUSTERS. [2144-9-24] 3:34 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [2144-9-24] 6:40 am BLOOD CULTURE Blood Culture, Routine (Pending): [2144-9-24] 4:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): ECG Study Date of [2144-9-21] 10:49:56 AM Sinus rhythm. Compared to the previous tracing of [2144-6-28] the rate has slowed. Atrial ectopy is no longer recorded and there is improved voltage. The ST segments are similar to those recorded on [2144-6-26]. No diagnostic interim change. CHEST (PORTABLE AP) Study Date of [2144-9-22] 5:21 AM Right internal jugular vascular catheter terminates at junction of superior vena cava and right atrium. Small-to-moderate right apical pneumothorax has apparently slightly decreased, but it is difficult to quantify due to overlying subcutaneous emphysema and external artifact. Minimal vascular engorgement and interstitial edema have developed. Small right pleural effusion has slightly increased but small left effusion is unchanged. Patchy right basilar opacity has developed and is probably due to atelectasis, but aspiration or early infection are also possible. Subcutaneous emphysema has slightly worsened, and pneumomediastinum has also progressed. CHEST (PORTABLE AP) Study Date of [2144-9-23] 6:03 PM As compared to the previous examination, a right-sided chest tube has been inserted. The tip of the tube projects over the apex of the right hemithorax. The apical pleural gap has decreased in extent and it now measures 1 cm. There is no evidence of tension. Otherwise, no relevant change. CHEST (PA & LAT) Study Date of [2144-9-26] 10:38 AM FINDINGS: There has been interval removal of the right catheter. There is a tiny right apical pneumothorax. There is a small right effusion and small left effusion that are similar in size compared to prior. There is no new infiltrate. Subcutaneous emphysema is seen on the right similar in appearance compared to prior. CT ABDOMEN W/CONTRAST Study Date of [2144-9-26] 1:35 PM IMPRESSION: 1. Two apparent foci of narrowing involving the sigmoid colon, one of which is located at the rectosigmoid anastomsis and the other in the more proximal sigmoid colon. While these findings could represent transient narrowing, a fixed stricture is not excluded. No evidence of discrete mass or bowel obstruction. 2. Non- healed fracture involving the anterior and posterior columns of the right acetabulum. Mild callus formation about the right inferior pubic ramus fracture. 3. Increased trabeculation of the left iliac bone which may represent Paget's. 4. Bilateral pleural effusions and adjacent atelectasis. Ascites and body wall anasarca. 5. 8-mm hypodensity in the pancreas for which further evaluation with MRI is recommended. Portable TTE (Complete) Done [2144-9-22] at 4:19:47 PMAge (years): 89 F Hgt (in): 64 BP (mm Hg): 111/49 Wgt (lb): 89 HR (bpm): 100 BSA (m2): 1.39 m2 Indication: Murmur. Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 3.9 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.5 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: >= 75% >= 55% Left Ventricle - Lateral Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 3.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.3 m/sec Mitral Valve - E/A ratio: 0.77 Mitral Valve - E Wave deceleration time: 157 ms 140-250 ms TR Gradient (+ RA = PASP): 40 to 50 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA and RA cavity sizes. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV systolic function. Hyperdynamic LVEF >75%. Severe resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Midsystolic closure of aortic leaflets. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. [Male First Name (un) ] of mitral valve leaflets. Eccentric MR jet. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed with the houseofficer caring for the patient. Ascites. Conclusions: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is prominent valvular [Male First Name (un) ] with severe resting left ventricular outflow tract obstruction (difficult to quantify due to contamination from the mitral regurgitation jet). 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. Midsystolic closure of the aortic leaflets is seen. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is systolic anterior motion of the mitral valve leaflets. An eccentric jet of at least moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion most prominent around the right atrium. IMPRESSION: Mild symmetric left ventricular hypertrophy with valvular [Male First Name (un) ]/severe resting LVOT gradient and hyperdynamic systolic function. At least moderate to severe mitral regurgitation. Moderate pulmonary artery systolic hypertension. COLONSCOPY [2144-9-25]: Findings: Lumen: A stricture was noted at the sigmoid colon with friable surrounding mucosa. The scope did not traverse the lesion. Differential diagnosis includes the ischemic colitis and possible underlying malignancy. Cold forceps biopsies were performed for histology at the sigmoid colon from the abnormal appearing mucosa. Impression: Stricture at the sigmoid colon with friable mucosa localized 35 cm from anus . Differential diagnosis includes ischemic colitis or malignancy. Brief Hospital Course: 1. Acute Blood Loss Anemia due to GI Bleeding - GI Consultation was obtained. Colonscopy performed as above. Given worry about mass, a CT Abdomen was performed as above. No source was identified as the scope could not be passed beyond a stricture. The stricture was confirmed on CT but no obvious mass seen - Patient had not had further bleeding x72 hours at time of discharge - Hematocrit has been stable at time of discharge - Given stricture in the sigmoid, we obtained a surgical consult, who concurred that watchful waiting is best given her high risk for surgery, and the lack of obstruction or other surgical lesions. She does not have nausea, vomiting, abdominal distention, or pain and her vital signs are stable. This was discussed with the patient and her daughter, [Name (NI) ], who do no not want further work up. A biopsy is pending and the results will be sent to her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. - She is being treated for colitis with Cipro and Flagyl to finish on [2144-9-30]. 2. Post Procedure Pneumothorax - Upon placement of RIJ in the ED, patient was found to have a pneumothorax on CXR, with subcutaneous emphysema. - She was placed on oxygen and monitored by serial CXR - After 24 hours with lack of improvement a DART chest tube was placed by interventional radiology. Which was removed 48 hours prior to discharge, with follow up xray as above. 3. Bacterial UTI - treated with Cipro for pan sensitive Klebsiella 4. Pelvic Fracture - Note non-healing acetabulum - Pain control with Tylenol 1 gm QID and Lidoderm Patch. Only c/o pain with movement and declines stronger pain medicine. - Patient's daughter will set up FU with [Hospital3 2568] orthopedics - Physical Therapy 5. Tachycardia - In the MICU, most likely MAT in setting of a pneumothorax and anemia - Resolved with variation in heart rate of 80 to 100 - continus metoprolol for rate control 6. Bactremia - only 1 set of cultures were positive, which was presumed to be contamination 7. Hypertrophic Obstructive Cardiomyopathy, MR - Preload Dependent - Cardiology was consulted who recommended continuing Metoprolol - Avoid reducing preload or afterload, maintain euvolemia, try to avoid diuretics, dehydration 8. Hyponatremia - Pt has hx of hyponatremia, transiently improved w IVFs, Na at discharge 130, asymptomatic, monitor 9. Benign Hypertension - metoprolol 10. Epilepsy, last seizure in [Month (only) ]. has been stable on current regimen of keppra and dilantin. She will be followed by her neurologist at [Hospital6 1597]. 11. Pancreatic Mass - Incidentally found 8mm pancreatic mass. Letter sent to PCP. [Name10 (NameIs) 227] the patient's views unlikely she would want to do anything. 12. Malnutrition and edema due to hypoalbuminemia - Diet and protein supplements - avoid diuretics if possible CODE STATUS: DNR/DNI, confirmed w/daughter (HCP) ??????no heroic measures?????? HEALTH CARE PROXY: Daughter [Telephone/Fax (1) 98658] Medications on Admission: Lisinopril 40 mg daily Toprol XL 50 mg daily Dilantin ER 200 mg [Hospital1 ] Lidoderm Patch heparin 5000units [Hospital1 ] Tylenol 640 QID Calcium Carbonate 650mg [Hospital1 ] Cholecalciferol 1000 units Daily Ducosate 100mg [Hospital1 ] Keppra 250mg [Hospital1 ] Senna 2 tabs [Hospital1 ] Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): last dose on [9-30]. 3. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): last dose 9/10. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Acute Blood Loss Anemia Gastrointestinal bleed Pneumothorax Urinary tract infection fracture of pubis and acetabulum Hypertrophic Obstructive Cardiomyopathy Epilepsy Bactremia Benign Hypertension Hypotension Discharge Condition: Stable Discharge Instructions: Return to the hospital with further bleeding, low blood pressure, nausea/vomiting, fever/chills or severe abdominal pain. You were admitted to the hospital with gastrointestinal bleeding, treated with blood transfusions. Colonoscopy showed that there was a stricture in the sigmoid colon. You also sustatined a pneumothorax, or collapsed lung, from central line placement. This was treated with a chest tube and improved during your hospital stay. You were also found to have a urinary tract infection and completed a course of antibiotics for this. You are currently on antibiotics for colitis. You have a small nodule on your pancreas, which can be further examined by your primary care physician with an MRI. Followup Instructions: Please follow up with Dr. [First Name (STitle) 3441] from oprhopedics at [Hospital3 60734] as previously scheduled for your fractures. [Telephone/Fax (1) 98659] Please follow up with Dr. [First Name (STitle) 4223] from [Hospital6 2561] Geriatrics [Telephone/Fax (1) 59410]. and Dr. [First Name (STitle) ] from [Hospital3 ] Neurology to follow up on your seizure disorder as was previously scheduled. [Telephone/Fax (1) 98660] Completed by:[2144-9-28]	[ "578.1", "425.1", "599.0", "733.82", "285.1", "V12.54", "512.1", "785.0", "E879.8", "345.90", "458.9", "276.1", "263.9", "401.1", "276.52", "560.9", "577.9", "273.8", "041.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "34.04", "38.93", "45.25" ]	icd9pcs	[ [ [] ] ]	19085, 19170	14935, 17942	286, 358	19422, 19431	4726, 6600	20198, 20694	4276, 4294		18306, 19062		19191, 19401		17968, 18283			19455, 20175											4491, 4707						7686, 8085						8274, 14912			4324, 4476					222, 248								386, 3383														3405, 4031	4047, 4260
24,986	189,658	8241	Discharge summary	report	Admission Date: [2161-12-7] Discharge Date: [2161-12-21] Date of Birth: [2117-10-29] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 6021] Chief Complaint: Pericardial effusion Major Surgical or Invasive Procedure: Pericardiocentesis Pericardial window placement bone marrow biopsy History of Present Illness: Pt is a 44 yo man with PMH HIV (CD4 390 in [10-12]) who initially presented to [Hospital1 18] [Location (un) 620] with abd distension. Pt states that he was in his USOH until 1 week PTA when noted increased constipation and increased abd distension. He self treated constipation w/ laxatives and enemas, without relief in abd distension. Pt also noted some SOB over the past week which he attributed to his abd distension pushing on his diaphragm. Of note, pt also noted some chest pressure, which he described as musculoskeletal, associated w/ b/l rib pain approximately 1 week ago, which he attributed to muscle strain from moving x-mas trees (he owns a nursery). He also experienced fatigue at this time, and both resolved w/ rest. He otherwise denies any L sided CP, radiation to L arm or jaw, orthopnea, PND, LE edema. Due to his abdominal distension, his covering outpt provider told him to go to the ED. Pt presented to [Hospital1 18]-[Location (un) 620] ED where CT scan demonstrated ascites and pericardial effusion and pt was transferred to [Hospital1 18]. In our [Name (NI) ], pt had HR 100, SBP 120-130, Pulses 30, distended neck veins. Was noted to have decreased voltage on EKG. Emergent ECHO in ED demonstrated RV diastolic collapse and pt was taken to cath lab for emergent pericardiocentesis. Of note, ED course also notable for 1 episode of apnea, cyanosis, and hypotension shortly after morphine administration, resolved within seconds and back to baseline. Pericardiocentesis demonstrated equalization of pressures, w/ RA, RV, PCWP equal to 25, opening pressure 20. 1.1L of hemorrhagic fluid was drained and sent for studies, pericardial drain was left in place. Post-procedure, RA pressure was 14, and pt had symptomatic relief. Pt transferred to CCU for further care. Currently pt c/o only mild SOB, mild pain at pericardial drain site. Past Medical History: -HIV, last CD4 390, VL 12K in [10-12], no h/o opportunistic infections, but has poor genotype on 6 Antiretroviral medications. -Kaposi's sarcoma -anxiety Social History: Pt lives in [Location 620], MA with his partner, owns a nursery (plants). Travels to [Location (un) 29255] every winter, no recent travel outside the country. Past travel includes islands in the Indian Ocean, carribean, French Polynesian Islands. No h/o travel to [Country 11150], S. America, [Country 480], [Female First Name (un) 8489]. Has 3 dogs and 1 cat. Family History: Mother w/ h/o Breast Ca (doing well), maternal grandmother w/ CAD at late age. Physical Exam: Vitals: T 100.8, HR 92, BP 122/68, RR 19, O2 95-97% RA Gen: Awake, alert, somewhat shallow breathing, NAD HEENT: PERRL, EOMI, MMM Neck: JVD approx 8cm, + hepatojugular reflex CV: RRR, nl S1, S2, + pericardial rub Pulm: CTA b/l Abd: distended, soft, non-tender, no noted HSM Skin: warm, dry, + erythema on abdomen, + hard masses in SC on abdomen (per pt, where fusion shots go) Extremities: No LE edema, 1+ DP pulses b/l . Pertinent Results: Admission Labs: [2161-12-7] 03:45AM GLUCOSE-96 UREA N-9 CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-2.3 . WBC-4.1 RBC-2.31# HGB-9.3# HCT-26.8# MCV-116 MCH-40.2* MCHC-34.6 RDW-13.1 PLT COUNT-312# PT-14.6* PTT-23.1 INR(PT)-1.3* . [2161-12-7] 01:15AM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-9 LD(LDH)-7770 AMYLASE-31 ALBUMIN-3.4 WBC-[Numeric Identifier 29256]* HCT-12* POLYS-18* LYMPHS-66* MONOS-0 MESOTHELI-2* MACROPHAG-14* . [2161-12-7] 11:53AM OTHER BODY FLUID CD23-DONE CD38-DONE CD45-DONE HLA-DR[Last Name (STitle) 7735] [Name (STitle) 7736]7-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD19-DONE CD20-DONE LAMBDA-DONE CD5-DONE . [2161-12-7] Cardiac Cath: COMMENTS: 1. Resting hemodynamics revealed equalization of mean RA, RV end-diastolic and mean PCW pressures at 25mmHg. The arterial pressure tracings confirmed a 30mmHg difference in SBP with respiration. 2. 1120cc of hemorrhagic fluid was removed from the pericardial space. 3. Post intervention, the mean RA decreased to 14mmHg and the pericardial pressure to -10mmHg with inspiration. FINAL DIAGNOSIS: 1. Large pericardial effusion resulting in cardiac tamponade. . [2161-12-7] Echo: Conclusions: The estimated right atrial pressure is >20 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is a large pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . [2161-12-11] Echo: Conclusions: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a moderate sized pericardial effusion. The effusion appears circumferential. Stranding is visualized within the pericardial space c/w organization. Impression: Moderate sized circumferential pericardial effusion with stranding and preserved biventricular systolic function. Post pericardial window the effusion has decreased to trivial to small. . PATHOLGOY: . Cell marker analysis demonstrates an abnormal lymphoid population expressing the B-cell marker CD19 along with CD38 (bright). These cells do not express CD20, nor CD10 or CD5. Review of corresponding cytospin shows highly atypical mononuclear cells with are medium-sized, with a basophilic cytoplasm, occasional cytoplasmic vacuolation, large round nuclei and prominent abnormally-shaped nucleoli. Together these findings are highly suspicious for involvement by a Malignant Lymphoma. In the setting of HIV infection, these morphologic and immunophenotypic findings are highly suspicious for a primary effusion lymphoma. An alternative morphologic consideration includes Burkitt lymphoma, however the CD20 and CD10 negativity would argue against that. Additional studies, particularly HHV8 staining will be attempted on cell block and/or cytospin preparations for confirmation of the former differential consideration and reported as an addendum. Findings discussed with Dr. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] via telephone on [2161-12-14]. . LABS ON DISCHARGE: CBC: 4.2 / 26.9* / 325 Chem 10: GLU:132* BUN:14 CR:0.5 Na:136 K:3.8 Cl:99 HCO3:30 Brief Hospital Course: Pt is a 44 yo man w/ PMH HIV (last CD4 390 in [10-12]) who p/w ascites, pericardial effusion, tamponade physiology. Transfered from surgery following pericardial window for tamponade. After definative surgical treatment, his tamponade physiology did not return. . the patient was transfered to oncology for a diagnosed of HIV associated lymphoma. Path results of pericaridal fluid and tissue samples obtained at time of operation were diagnostic for primary effusion lymphoma, an HIV associated lymphoma. . His HIV medications were changed to the combination listed in the discharge summary in an attempt to decrease his viral load. The patient's HIV is known to be multi-drug resistant with a detectable viral load when last measured. . He was taken to surgery for the placement of a double lumen central venous port for the initiation of chemotherapy. He was started on [Hospital1 ]-R for a continuous 5 day infusion on [2161-12-16]. He tolerated the chemotherapy well with no significant complications and good control of adverse symptoms. . After the 5-day infussion, he was discharged on monday, [2161-12-21], to follow up with Dr. [Last Name (STitle) ] on [2161-12-22] for the initiation of neulasta. Medications on Admission: Fusion SC BID Combivir [Hospital1 ] Aptivis [Hospital1 ] Norvir [Hospital1 ] Viriad daily Paxil 40mg daily Lipitor 40mg daily MultiVit daily Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [Hospital1 ] (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 5. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Darunavir 300 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: HIV Primary Effusion Lymphoma Pericardial Effusion Cardiac Tamponade Discharge Condition: ambulating, tolerating POs Discharge Instructions: Please take all medications as prescribed. Please attend all follow up appointments. If you develop chest pressure, shortness of breath, increasing abdominal Followup Instructions: Provider: [Name Initial (NameIs) 455] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2161-12-22] 3:00	[ "423.9", "997.1", "789.5", "682.3", "512.1", "042", "202.80" ]	icd9cm	[ [ [] ] ]	[ "99.25", "41.31", "37.0", "37.12", "86.07" ]	icd9pcs	[ [ [] ] ]	9687, 9693	7563, 8797	292, 360	9806, 9835	3411, 3411	10041, 10154	2873, 2953		9001, 9664		9714, 9785		8823, 8978		4573, 7433	9859, 10018											2968, 3392																				232, 254		7453, 7539						388, 2277					3427, 4556									2299, 2459	2475, 2857
23,903	179,184	27788	Discharge summary	report	Admission Date: [2128-7-9] Discharge Date: [2128-7-24] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1436] Chief Complaint: Presented to [Hospital3 3583] with Chest Pain. Transfered to [Hospital1 18] from [Hospital3 3583] with respiratory arrest, CHF, & NSTEMI. Major Surgical or Invasive Procedure: Intubation Cardiac cath with stent placmenent & Valvulopasty Chest tube placement History of Present Illness: [Age over 90 ]yo F with PMH significant for HTN, colon CA, hyperlipidemia, and CAD who presented to [Hospital3 ] on the evening of [7-8] with sudden onset CP. On arrival to [Hospital3 3583], her SaO2 was found to 79% on room air, and she was intubated. A chest CT-angiogram was done, which was reportedly negative for pulmonary embolus. Initial ECG demonstrated a junctional rhythm with new 2-3mm inferior and anterolateral ST depressions and ST elevations in AVR and V1. She was given ASA, loaded with plavix, and started on heparin and integrillin gtt prior to transfer. In the [Hospital1 ] ED, her VS were T 95.8F (rectal) to 99.8F, HR 63-80, BP 100-127/40-50. ECG demonstrated junctional rhythm with HR 60 with persistent lateral ST depressions, but resolving ST depressions in inferior leads and resolving ST elevations in AVR and V1. Initial CEs were CK 185(17), tropT 0.63, drawn 6 hours after onset of symptoms. Other initial labs were significant for BUN/Cr of 28/1.9, K 2.8, and BNP of [Numeric Identifier 961]. CXR demonstrated hyperinflation with hilar congestion and possible R-sided consolidation--question of PNA. She received levofloxacin 500mg IV and blood cultures were sent. She was admitted to CCU for further management of NSTEMI, CHF and respiratory distress. Past Medical History: HTN Hyperlipidemia ?CAD - note made of h/o angina h/o Colon CA s/p resection s/p hip fracture with THR Vit B12 deficiency Social History: Lives in senior housing where meals are prepared for her. Walks with a cane. Daughter comes to visit daily. Family states she has never smoked and does not drink. No h/o lung problems or use of home O2. Family History: non-contributory. Physical Exam: T: 98.8F (rectal), BP: 108/46, HR 62 (junctional), RR: 11 Current settings: AC 450x12/5/60%. Gen: Intubated and sedated. NAD HEENT: PERRL, MMM CV: RRR, II/VI harsh SEM radiating to carotids, II/IV diastolic murmur Chest: Coarse BS diffusely, no rales. BS equal. Abd: Soft, NT/ND, +BS, no HSM Extr: 1+ LE edema bilaterally, 2+ DPs bilaterally Neuro: Intubated, sedated. No focal deficits. Pertinent Results: [2128-7-24] INR = 4.4 (off coumadin for 2days) [2128-7-8] 11:45PM GLUCOSE-180* UREA N-28* CREAT-1.9* SODIUM-133 POTASSIUM-2.8* CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [2128-7-8] 11:45PM WBC-22.5* RBC-4.21 HGB-12.0 HCT-34.0* MCV-81* MCH-28.5 [2128-7-8] 11:45PM calTIBC-222* FERRITIN-226* TRF-171, RET AUT-1.8 [2128-7-8] 11:45PM cTropnT-0.63, CK(CPK)-185* [2128-7-9] 10:59AM TYPE-ART PO2-76* PCO2-33* PH-7.41 TOTAL CO2-22 BASE XS-2 Echo [2128-7-9]: Ejection Fraction: 45% to 50% 1. The left atrium is moderately dilated. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include anterior hypokinesis with distal septal akinesis. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis. Trace aortic regurgitation is seen. 5.The mitral valve leaflets are moderately thickened. There is minimal to mild mitral stenosis. Mild (1+) mitral regurgitation is seen. 6.There is no pericardial effusion. Brief Hospital Course: #Cardiovascular- STEMI: Pt found to have NSTEMI with troponin peaking 1.232. Trigger for MI may have been plaque rupture or, also, demand-supply mismatch in the setting of possible PNA & respiratory failure. Cardiac catheterization on [2128-7-12] revealed normal LMCA, 70-80% calcified stenosis of LAD, small LCx, and RCA with 90% mid-occlusion. The RCA was stented with Sirolimus-eluting stents. Pt recovered uneventfully from the cath. NSTEMI & post-cath therapy included ASA, Plavix, and heparin gtt. . CHF: Pulmonary edema on admission thought to be due to CHF. Echo on [7-9] revealed moderate to severe AS (tx'd at cath) and an EF of 45 to 55%. It appears that pt may have mild CHF. After admission, she showed few if any signs of heart failure. . A-fib: Pt monitored on telemetry. Went into rapid a. fib during admission. Underwent D/C cardioversion, which failed to convert her to NSR. Multiple meds were equired to slow rate (amiodarone, metoprolol, and diltiazem). Her rapid afib seemed to respond best to the diltiazem & amiodarone. On these three medications, she eventually converted into sinus rhythm, which she has been in for 3 days now. Since converting into sinus rhythm, her HR has dropped into the 50's. Because of this slow rate, her beta-blocker was d/c'd and her calcium-channel blocker was continued at lower dose--short acting diltiazem 30mg, three times a day. The patient was also started on coumadin for the afib. However, there was debate over whether the patient should be on coumadin (given her age, risk factors for a fall, and the fact that she is already on aspirin & plavix for her cardiac issues). After extensive discussion, it was determined to proceed with coumadin therapy during hospitalizaiton and to discuss the issue with the patients PCP before discharge; however, we were unable to contact PCP prior to this discharge. While on coumadin, the pt had two bouts of uncomplicated, supratherapeutic INRs. Becuase of this we eventually, decided that it would be safer for her to be off coumadin, and tx'd only with aspirin & plavix. . # Aortic Stenosis: Found to have moderate to sever AS on echo. During cath, the pt underwent balloon valvuloplasty for AS (valve area 0.7cm2-->0.9cm2), reducing the gradient by 50%. . #Respiratory failure: Hypoxic respiratory failure. Intubated on [7-9]. Failed extubation on [7-12], after developing worsening pulmonary edema. Successful extubation on [7-13], post-cath. . #? RLL PNA/infx: afebrile on admission, though CXR suspicious for PNA. Pt tx'd with azithromycin, ceftriaxone & levofloxacin, which were d/c'd after concern of pt developing ATN w/ azithro & CTX and of further prolonging QTc interval. Pan-cultured, yielding no evidence of infection. . #Pneumothorax: caused during placement of central line. Resolved with chest tube. . #Elevated WBC w/ monocytosis: Noted upon arrival at [Hospital1 18]. Unclear what baseline white count or differential is. While WBC has declined somewhat, it is still elevated, The differential has shown persistent monocytosis (>4,000 u/L) along with promyelocytes and metamyelocytes on peripheral smear. (No blasts seen on smear.) Pt seen & elavuated by Hematology/Oncology, who believes pt likely has a myeloproliferative disorder. They have recommended a number of blood tests (including a complete anemia evaluation and cytogenetic testing). They will help develop plan for follow-up care, and are in the process of contacting the pt's PCP. . #Anemia: Pt required multiple transfusions during hospitalization. She reportedly has h/o B12 defic, requiring B12 injections. Iron studies revealed a nml iron level (88) and an elevated ferritin (226). If the pt does have a myeloproliferative d/o, her anemia may be related to that. . #Renal Failure: baseline Creatinine is unknown, though her crt has settled at 0.9. It peaked at 2.4, and improved since then. Exact cause of her ARF is unclear. It may have been due in part to a pre-renal state given that she was showing some signs of CHF. Medications renally dosed. . #Coagulation issues: after pt was started on coumadin for afib, she developed a supratherapeutic INR. Coumadin d/c'd because of pt's risk for fall. . #FEN: pt started on tube feeds via NGT while intubated. She continued on tube feeds s/p extubation after failing two swallowing evaluations. Her NGT was removed. She underwent a third swallowing evaluation with video imaging, which revealed that she could safely take ground solids and nectar thick liquids. She needs assistance with feeding herself. . #Psych/Neuro: Some confusion during hospitalization. Required wrist restraints & a sitter for short period. Oriented to place (hospital) and people. . #[Name (NI) ] pt seen and evaluated by PT, who recommends therapy * assist for poor balance. Medications on Admission: Diltiazem 360mg PO qD Imdur 60mg PO qD Norvasc 5mg PO qHS Lipitor 10mg PO qD Aciphex 20mg PO qD B12 inj qmonth MV Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Ipratropium Bromide 0.02 % Solution Sig: [1-19] Inhalation Q6H (every 6 hours) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 3320] Discharge Diagnosis: 1.Hypoxic respiratory failure 2.Non-ST elevation MI s/p percutaneous transluminal coronary angiography with Sirolimus-eluting stents 3.CHF (diastolic) 4.Atrial fibrillation (rate & rhythm controlled) 5.Anemia 6.?Myeloproliferative disorder 7.Dysphagia requiring ground & nectar thick liquids 8.Hard of hearing Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Please continue to take all your medications as prescribed and follow up with your appointments as below. . Please do not stop your aspirin and plavix until you speak with your cardiologist. . If you have chestpain, shortness of breath or fevers or chills please contact your PCP or return to the emergency room. Followup Instructions: 1. An appointment with Mrs.[Doctor Last Name 29172] PCP [Name9 (PRE) ] [Name9 (PRE) 67752] (phone #[Telephone/Fax (1) 60784]) should be scheduled within 1 week of discharge from [Hospital1 18]. 2. Pt's PCP should review whether or not pt a candidate for coumadin tx for afib. 3. Heme-onc follow-up to be arrange with PCP via [Hospital1 18] [Name9 (PRE) ] team.	[ "293.0", "410.71", "V10.00", "428.31", "427.31", "414.01", "518.81", "486", "584.9", "512.1", "401.9", "272.4", "424.1", "238.7", "266.2", "V43.64", "585.9" ]	icd9cm	[ [ [] ] ]	[ "36.07", "36.06", "00.40", "99.62", "00.48", "96.72", "96.6", "99.04", "88.56", "34.04", "96.04", "37.23", "00.66", "39.64", "38.93", "35.96" ]	icd9pcs	[ [ [] ] ]	9809, 9879	3893, 8747	412, 496	10233, 10240	2657, 3870	10703, 11095	2214, 2233		8912, 9786		9900, 10212		8773, 8889			10264, 10680											2248, 2638																				222, 374								524, 1832														1854, 1978	1994, 2198
28,578	193,880	1385	Discharge summary	report	Admission Date: [2189-1-30] Discharge Date: [2189-2-3] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1990] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: (pt unable to report hx, info is from daughter and [Name (NI) ] record) [Age over 90 ] F from cooliage house who presents with somnolence, reported respiratory distress with sat 88% on unclear amount of oxygen. Per daughter pt has had cough for several days, slightly worsened MS [First Name (Titles) 767] [Last Name (Titles) 5348] dementia. Pt often becomes more paranoid with illness. Pt is on 2 liters NC at [Last Name (Titles) 5348], with RA sats 83-90%. Pt has no recorded fevers. Has a hx of at least a dozen UTIs per daughter in last year. . In ER VS were 98.4 90 123/66 22 93% 4l NC. Pt was crackly on exam. CXR was a poor film, unable to assess for consolidation, but appeared to have bilateral effusions and edema. FS was 187. Pt had a congested cough. UA + for UTI. Pt was given vanco/levo for UTI and possible PNA. BP briefly was 93/40 and returned to 120s with out intervention. Lactate was 3.1. PIV x [Street Address(2) 8375]. CE with trop of 0.08. EKG similar to prior. BNP>9000. Pt was transferred to ICU due to concern for sepsis. Past Medical History: . Past Medical History: - CAD, s/p MI [5-23] (no intervention); Stress MIBI in [2182] nml; possible NSTEMI in [7-26] - Diastolic CHF, EF 65% (TTE 09) - HTN - Mild AS 09 - moderate TR - Afib (dx '[84], not on coumadin b/c of GIB history) - Type II DM - Colon Ca, s/p resection [9-22] - Partial small bowel obstruction in [7-26] - GIB w/ coffee ground emesis (no scope) in [7-26] - Cellulitis - Osteoporosis - Urinary incontinence, multiple UTIs in last year - moderate pulmonary hypertension - cataracts - hearing loss - Dementia . Social History: She is living at [Hospital3 2558]. She is widowed and has two adopted children. No history of smoking, alcohol or drug use. Previously worked at [Doctor Last Name ] Rubber making shoes. Has not ambulated since appx [2185]. Family History: Sister died at age 70 of colon cancer. Brother died at age 84 of Alzheimer's disease. Brother died at 75 secondary to multiple medical problems including renal failure. Third brother died at age 1 secondary to pneumonia. Physical Exam: Physical Exam on ICU admission VS: 98.5 135/109 100 23 97% 2L GEN: pleasant, comfortable, NAD HEENT: hard of hearing, PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, unable to assess jvd RESP: crackles [12-21] way up bilatearlly, CV: RR, no m; but pt was making noise so difficult to assess ABD: nd, +b/s, soft, nt,, prominent umbilical hernia that reduces easily EXT: 2+ pitting edema, warm, difficulty to feel pulses SKIN: no rashes/no jaundice NEURO: AAOx1 (to person and birthdate). Cn II-XII grossly intact. tremor in hands, moving all limbs, does not follow most commands. . Pertinent Results: Labs: see below Lactate:1.5 CK: 25 MB: 2 Trop-T: 0.08 . 143 96 31 AGap=16 ------------<167 3.8 35 0.8 . CK: 20 MB: 2 Trop-T: 0.08 proBNP: 9302 PT: 12.0 PTT: 19.3 INR: 1.0 MCV 104 WBC 7.3 Hct 27.4 plts 161 . EKG: afib, RBBB, stable from prior . Imaging: CXR IMPRESSION: Mild congestion, possible bilateral small effusions. Retrocardiac left lower lobe difficult to assess. Limited evaluation given technique Brief Hospital Course: [Age over 90 ] yo f with hx of AMS and reported worsening respiratory status admitted for now SOB, hypoxia and found to have UTI and CXR changes concerning for CHF with possible PNA. . # Hypoxia/Dyspnea: Likely with acute CHF causing pulmonary edema. CXR and BNP are consistent with this dx. [Month (only) 116] also have underlying PNA, but it is unclear due to difficult to assess hx and CXR. Pt seems at risk for aspiration. [Month (only) 116] have acute CHF due to UTI or could have had a change in cardiac status. Last echo is from [2186] with normal EF. Troponin was flat at 0.08 X3. EKG was non dynamic. We continue [Year (4 digits) ] and statin, Pnt was given lasix 80mg IV followed by 40mg IV with ICU LOS fluid balance of - 1.4L. Echo and later ACE-I and BB should be considered. Patient was also covered for pneumonia with a dose of Vanco + Levo in the ED. In the ICU coverage with Vanco + Zocyn was continued to cover health-care assoiated pneumonia and possibly aspiration. Cultures negative except urine revealed pan sensitive e coli. Antibiotics tapered to [Year (4 digits) 1378] alone with clinical improvement . # UTI: Has hx of many recent UTIs per daughter. [Name (NI) ] as above. . # Altered mental status: delerium in addition to dementia, likely from infection and hospital stay. Home seroquel continued. Improved dramatically through hospitalization . # Comm: daughter is HCP (# is on ICU consent) . # Code: DNR/DNI discussed with dtr and hcp [Name (NI) ] Medications on Admission: Medications at home: (from NH list) Seroquel 25mg HS, 12.5mg AM Pradin 0.5mg 30mg prior to breakfast Lasix 80mg PO qday Prilosec 20mg qday [Name (NI) ] 81mg Citalopram 10mg qday Lactulose 15g qday Isosorbide Mono 40mg QAM MV qday Aranesp 40mcg IM Qfriday Bisacodyl M/W/F Maalox prn Milk of Mag prn SLN 0.3mg prn Robatussin prn Trazdone 12.5mg Q8H prn Tylenol 650mg prn Vit D 800 units qday Levothyroxine 88mcg qday Ca Carbonate 500mg [Hospital1 ] Docusate 100mg [Hospital1 ] Ferrous Sulfate 325mg [Hospital1 ] Senna 17mg HS Simvastatin 20mg HS . Allergies: NKDA . Discharge Medications: 1. quetiapine 25 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 2. aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. citalopram 20 mg Tablet [Hospital1 ]: 0.5 Tablet PO DAILY (Daily). 4. lactulose 10 gram/15 mL Syrup [Hospital1 ]: Fifteen (15) ML PO DAILY (Daily). 5. isosorbide mononitrate 20 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. multivitamin Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. magnesium hydroxide 400 mg/5 mL Suspension [Hospital1 ]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. nitroglycerin 0.3 mg Tablet, Sublingual [Hospital1 ]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 10. acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 11. cholecalciferol (vitamin D3) 400 unit Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 12. levothyroxine 88 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 13. calcium carbonate 200 mg (500 mg) Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO BID (2 times a day). 14. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 15. ferrous sulfate 300 mg (60 mg Iron) Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 16. simvastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 17. levofloxacin 750 mg Tablet [Hospital1 ]: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. 18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 19. furosemide 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 20. Prandin 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: cooledge house Discharge Diagnosis: Heart failure, acute diastolic. Urinary tract infection, bacterial, possible pneumonia, bacterial Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: see below Followup Instructions: With primary MD per routine lisinopril and atenolol are still not being given. Consider re-initiation of these medications if stable for same, (25 mg [Last Name (STitle) 8371] QD, and 5 mg lisinopril QD)	[ "733.00", "428.33", "311", "427.31", "366.9", "V10.05", "428.0", "788.30", "482.9", "276.50", "414.01", "V49.86", "780.09", "294.8", "412", "599.0", "401.9", "250.00", "416.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7771, 7812	3561, 4800	255, 261	7955, 8002	3112, 3538	8167, 8379	2218, 2443		5706, 7748		7833, 7934		5101, 5101			8133, 8144					5123, 5683						2458, 3093																				211, 217								289, 1363									8017, 8109					1409, 1945	1962, 2202
21,149	154,574	9503+9504	Discharge summary	report+report	Admission Date: [2107-10-1] Discharge Date: [2107-10-4] Service: ADMISSION DIAGNOSIS: Subarachnoid hemorrhage, posttraumatic. HISTORY OF PRESENT ILLNESS: The patient was a 79-year-old gentleman found down at home unresponsive by his wife after lunch. He had an unwitnessed fall. He had no history of headaches or recent illness. He remained unresponsive when the ambulance arrived. Systolic blood pressure was reported 250 on arrival to the [Hospital6 256] Emergency Department. He was intubated and given Versed and Fentanyl. His GCS was reported as 3 on arrival to the Emergency Department. PAST MEDICAL HISTORY: Hypertension. Status post coronary artery bypass grafting. Pacemaker implantation. Atrial fibrillation. Cerebrovascular accident. Previous intracranial hemorrhage. MEDICATIONS: Aspirin, Folate, Multivitamin, Amiodarone, Lasix, Imdur, Celexa, Lipitor, Potassium. PHYSICAL EXAMINATION: Vital signs: He was afebrile, blood pressure 154/75, on Nipride drip, heart rate 81, oxygen saturation 97%. General: He was intubated and sedated at the time. Neurological: Pinpoint pupils, intact corneal reflexes bilaterally. Doll's eyes. He withdrew both lower extremities to peripheral stimulation, as well as his upper extremities to peripheral stimulation. He also withdrew his left upper extremity to peripheral stimulation but not his right upper extremity. His reflexes were brisk in his patellas bilaterally, and he had upgoing toes bilaterally. IMAGING: Head CT showed diffuse subarachnoid hemorrhage. HOSPITAL COURSE: He was admitted to the Neuro Surgical Intensive Care Unit for close monitoring and Neuro-checks. A Vent drain was placed to monitor and CP and relieved fluid. He received 12 U of platelets. His Intensive Care Unit stay was unremarkable. His neurologic exam did not change significantly. His ICPs were in the range of [12-3], and he was weaned off the Nipride drip. He developed extensive posturing. A CTA showed diffuse subarachnoid hemorrhage and intraventricular blood but no evidence of an aneurysm. A repeat CT on [10-3] showed worsening of the diffuse subarachnoid hemorrhage and a new cerebellar hemorrhage. The family was informed of the patient's condition and repeat scan. A family discussion resulted in the decision to make the patient comfort measures only. The patient was placed on a Morphine drip and extubated and passed away at 10:55 a.m. on [2107-10-4]. The family was notified of the patient's passing. The medical examiner has also been notified of the passing of the patient. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 32321] MEDQUIST36 D: [2107-10-4] 11:53 T: [2107-10-4] 12:41 JOB#: [Job Number 32322] Admission Date: [2107-10-1] Discharge Date: [2107-10-4] Service: NEUROSURGE ADMISSION DIAGNOSIS: Post traumatic subarachnoid hemorrhage. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 7086] is a 79 year-old gentleman who presented on [10-1]. He was found unresponsive at home presumably secondary to a fall. He had no history of a headache or any other illness. His wife found him after lunch unconscious and unresponsive. He remained that way until he arrived in the Emergency Department and he reportedly had a GCS of 3. He was then intubated and sedated. He has a past medical history significant for status post coronary artery bypass graft, hypertension, pacemaker implantation, atrial fibrillation, history of old stroke, prior intracranial hemorrhage. MEDICATIONS: 1. Aspirin. 2. Folate. 3. Multivitamin. 4. Amiodarone. 5. Lasix. 6. Imdur. 7. Celexa. 8. Lipitor and potassium. PHYSICAL EXAMINATION: His examination in the Emergency Department was limited due to his intubation and sedation. He is afebrile with a blood pressure of 154/75 on Nipride, heart rate of 81 and sating 97%. His neurological examination showed pin point pupils, intact corneas bilaterally and positive dolls eyes. He withdrew both lower extremities briskly to peripheral stimulation as well as his left upper extremity. He was moving his right upper extremity. He had brisk patella reflexes bilaterally and upgoing toes. Head CT displayed diffuse subarachnoid hemorrhage. HOSPITAL COURSE: He was admitted to the Neurologic CICU for q one hour neurological checks. He was given 12 units of platelets. He received extraventricular drain placement for monitoring of his intracranial pressure and to drain cerebral spinal fluid. His blood pressure was kept below 150 on a Nipride drip. His neurological examination did not change significantly over the next couple of days. A repeat CT on [10-3] displayed worsening of the diffuse subarachnoid hemorrhage and a new cerebellar hemorrhage. His neurological examination was then limited to posturing of his upper extremities to central stimulation. A family discussion was initiated on [10-4] to discuss his further care. The family agreed to limit medical care to comfort measures only. The patient was then extubated and placed on a morphine drip for comfort. The patient was pronounced at 10:55 a.m. [2107-10-4]. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 32323] MEDQUIST36 D: [2107-10-3] 11:59 T: [2107-10-4] 13:49 JOB#: [Job Number 32324]	[ "427.31", "414.01", "401.9", "V45.81", "852.00", "E880.9", "518.81", "V45.01" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.71", "96.04", "02.2" ]	icd9pcs	[ [ [] ] ]														4413, 5589																										3841, 4395	3004, 3045														3074, 3818														648, 918
78,234	161,481	12673	Discharge summary	report	Admission Date: [2107-3-28] Discharge Date: [2107-3-31] Date of Birth: [2045-9-8] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2107-3-28]: Ultrasound guided percutaneous cholecystostomy drain placement History of Present Illness: Mr. [Known lastname ] is a 61 year old obese man, with DM Type 2 who began having abdominal pain in his RUQ on Friday [2107-3-25] while at work. The pain worsened over the next two days and was not alleviated by Percocet, which patient had PRN for leg pain. The patient rated the pain as [8-24] through Friday and Saturday and began experiencing nausea. He denies diarrhea, vomiting, fever and chills. He presented to OSH on Sunday [2107-3-27], and had CT scan and ultrasound. He was transfered to [Hospital1 18] Sunday night and was hypotensive on arrival to 70s requiring 3L of IVF. On arrival his pain is [6-24] and still has nausea. Of note, patient has an incarcerated umbilical hernia which he states has been present for many years and is unchanged. Past Medical History: Past Medical History: - Two cardiac stents placed 10-15 years ago - Type 2 Diabetes Mellitus dx [2104] - Peripheral neuropathy - Hypertension - Hyperlipidemia Past Surgical History: - Gastric bypass [2085] - Umbilical hernia repair 10 years ago complicated by mesh infection requiring removal resulting in subsequent recurrence - Left eye cataract surgery Social History: Social History: Does not drink, smoke or use recreational drugs Family History: Family History: non-contributory Physical Exam: On admission: Vitals: Temp 97.6, HR 82, BP 85/47, RR 25, SpO2 96% on 2 L NC General: Aptient appears is alert and cooperative. He appears mildly uncomfortable but is in no acute distress. HEENT: Right pupil round, reactive to light. Left pupil fixed and elliptical shaped. Had previous surgery on left eye. CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, obese, non-distended. TTP in RUQ without rebound/gaurding. [Doctor Last Name 515] sign negative, though exam limited by body habitus. Incarcerated umbilical hernia present, non-tender, with no overlying skin changes. Extremities: No edema or cyanosis. Peripheral pulses present. Bruising on ankles bilaterally. Pertinent Results: [2107-3-27] 10:45PM BLOOD WBC-21.1* RBC-4.34* Hgb-12.7* Hct-40.3 MCV-93 MCH-29.2 MCHC-31.5 RDW-13.5 Plt Ct-225 Neuts-86* Bands-4 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 ALT-15 AST-31 AlkPhos-127 TotBili-1.2 Lipase-11 Lactate-1.5 [2107-3-28] 02:30AM BLOOD CK-MB-5 cTropnT-<0.01 [2107-3-29] 03:55AM BLOOD PT-13.7* PTT-28.4 INR(PT)-1.3* Lipase-13 [2107-3-30] 05:17AM BLOOD WBC-11.0 RBC-3.95* Hgb-11.7* Hct-37.6* MCV-95 MCH-29.7 MCHC-31.2 RDW-13.6 Plt Ct-195 Glucose-94 UreaN-25* Creat-1.1 Na-140 K-4.1 Cl-102 HCO3-25 AnGap-17 ALT-20 AST-33 AlkPhos-111 TotBili-0.7 Calcium-8.9 Phos-3.8 Mg-2.2 IMAGING: [2107-3-27]: CHEST (PORTABLE AP): IMPRESSION: Bibasilar atelectasis without acute intrathoracic process. [2107-3-28] ECG: Normal sinus rhythm. Precordial leads [Location (un) 381] voltage and non-specific T wave abnormalities. No previous tracing available for comparison [2107-3-28]: LIVER OR GALLBLADDER US (SINGLE ORGAN): IMPRESSION: Findings suggestive of acute cholecystitis. The patient was scheduled for percutaneous cholecystostomy drain placement. [2107-3-28] GB DRAINAGE,INTRO PERC TRANHEP BIL US: IMPRESSION: Successful ultrasound-guided percutaneous cholecystostomy tube placement. A sample of the drained bile sent for microbiological analysis [2107-3-29]: CHEST (PORTABLE AP): IMPRESSION: AP chest compared to [3-27]: Previous mild pulmonary edema and vascular congestion have resolved and lung volumes have improved. There are no findings to suggest pneumonia. Heart size, currently normal. No pleural abnormality. Brief Hospital Course: He was admitted to the Acute Care Surgery team and underwent gallbladder ultrasound revealing findings suggestive of acute cholecystitis. He was given intravenous antibiotics and placed NPO. He was then referred to Radiology for placement of percutaneous gallbladder drainage. There were no procedural complications. Post procedure he progressed without any issues and was provided with drain teaching. His antibiotics were changed to Augmentin for which he will continue with for another 3 days after discharge. His diet was advanced and his home medications were restarted. He is being discharged to home with instructions to follow up with his PCP and in Acute Care Surgery clinic in the next few weeks. Medications on Admission: Allopurinol 100mg 2x Daily Percocet PRN Citalopram 20 mg 1 tab QD Lisinopril 10 mg Daily Pantoprazole 40 mg Daily Clonazepam 1 mg 1 tab daily Folic acid 1 mg QD Simvastatin 40 mg Evening Lorazepam 0.5 mg 1-2 tabs at bedtime Bupropion 150 mg 1 tab 2x day Nitro PRN Vitamin D, Mag, ASA Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:25 Tablet(s) Refills:0 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 4000 mg per 24 hours. 4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. multivitamin with minerals Capsule Sig: One (1) Capsule PO once a day. 14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 15. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Acute cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain due to acute cholecytisis. You were placed on bowel rest, intravenous fluids/ antibiotics and a percutaneous catheter was placed into your gallbladder to drain the infected fluid. You should measure the output from this drain everyday and record it on a log/jounral and bring this inforamtion with you to your follow up appointment with the Acute Care Surgery clinic. Be sure to finish all of your antibiotics as prescribed. As you recovered in the hospital, your diet was advanced, which was well tolerated. You are now preparing for discharge to home with your drain in place. Additionally, please note the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [3-24] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. General Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Additionally, please avoid all NSAIDs including Aleve, Motrin, ibuprofen, naproxen, etc. Followup Instructions: Name:[First Name11 (Name Pattern1) 21939] [Initials (NamePattern4) ] [Last Name (NamePattern4) ],MD Specialty: Primary Care Location: THE MEDICAL GROUP Address: [Last Name (un) 15488] [Apartment Address(1) 31103], [Hospital1 420],[Numeric Identifier 15489] Phone: [Telephone/Fax (1) 10508] When: The offie is working on an appointment in the next two weeks. You will be called at home with an appointment. If you have not heard, please call above number for status. Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2107-4-19] at 2:00 PM With: ACUTE CARE CLINIC with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2107-4-1]	[ "401.9", "356.9", "250.00", "414.01", "V45.86", "278.00", "272.4", "V45.82", "575.0" ]	icd9cm	[ [ [] ] ]	[ "51.01", "38.91" ]	icd9pcs	[ [ [] ] ]	6533, 6608	4076, 4786	316, 398	6672, 6672	2446, 4053	10323, 11355	1710, 1729		5150, 6510		6629, 6651		4812, 5127			6823, 8958								8973, 10300	1417, 1597		1744, 1744																				262, 278								426, 1208							1758, 2427		6687, 6799					1252, 1394	1629, 1678
2,944	165,971	49839	Discharge summary	report	Admission Date: [2171-1-10] Discharge Date: [2171-1-12] Date of Birth: [2095-4-19] Sex: M Service: MEDICINE Allergies: Halcion Attending:[Last Name (NamePattern1) 7539] Chief Complaint: chest pain Major Surgical or Invasive Procedure: ICU stay History of Present Illness: 75M with h/o CAD s/p CABG (last cath [6-7] with severe 3-vessel disease) who p/w acute shortness of breath, R-back pain. Pt was treated at OSH emergency dept with solumdedrol, lasix, ASA, lovenox. Cardiac enzymes were elevated at OSH; ECG reportedly with St depressions anterolat leads, transferred to [Hospital1 18] for cardiac cath, which showed 90% left main disease. Post-procedure, in cath holding area, pt developed bradycardia, hypotension, and RLQ abdom pain. Dopamine & IV fluids were given without much effect. Stat CT scan showed large retroperitoneal bleed. Pt was taken back to cath lab for peripheral images/tamponade of bleeding artery and then admitted to CCU. Past Medical History: CAD s/p CABG; myocardial infarction in [2150] diabetes mellitus asthma COPD abdominal aortic aneurysm repair Social History: previous smoker Family History: noncontributory Physical Exam: afebrile, HR 100, BP 121/85, 95% on 2L NC +RLQ abdom tenderness S1S2 RRR, no murmurs lungs CTA bilat no femoral bruits 2+ DP pulses Pertinent Results: CT: large RP bleed CK 231 BM 8.4 ABG 7.42 / 37/ 99 WBC 9.3 Hct 40.5 Plt 201 ECG: sinus. Poor R-wave progression. L-axis, Incomplete RBBB. Brief Hospital Course: 75M with h/o DM, HTN, COPD, AAA, and known severe CAD p/w chest pain, s/p cath with PTCA of LM->ramus. Found to have retroperitoneal bleed stabilized by balloon tamponade, admitted to CCU for close observation. # Retroperitoneal bleed: seen on CT scan after suggestive symptoms and signs in cath holding area post-procedure. Bleeding femoral artery was successfully stabilized in 2nd cath procedure via balloon tamponade. Hct was followed closely. Vascular surgery followed pt closely. Repeat CT scan on [2171-1-12] showed an unchanged RP bleed. # Coronary artery disease: NSTEMI at OSH, s/p LM->ramus stent at cath here, but severe native and graft disease seen at cath. Plavix & integrillin were held due to large RP bleed. ASA & lipitor were continued. # Hypotension: patient remained hypotensive despite being on multiple pressor agents including dopamine & neosynephrine. At 7:10 pm on [1-12], pt suddenly became bradycardic to 30s and hypotensive to 60s despite being on multiple pressors. Pt was coded, including atropine, bicarbonate. Pt did not recover and he was pronounced dead at 9:06 pm by CCU fellow. # Respiratory: pt was intubated on [2171-1-11] for respiratory distress and RR>30. Pt remained intubated until he expired. # Acute renal failure: creatinine increased from 1.1 at transfer to >2. Pt became anuric. Likely secondary to hypotension from large bleed. Renal was consulted & followed closely. Patient became increasingly acidemic despite full resuscitative efforts, likely as a result of continued hypotension despite being on multiple pressors. Patient's lactate increased to 14.2. On [1-12], CVVH was initiated for K+ 5.7 and continued renal failure & acidemia. # Communicated with family several times per day with all changes in status. Medications on Admission: aspirin 325, glyburide, lipitor 80, plavix 75, advair, albuterol, atenolol Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: myocardial infarction coronary artery disease retroperitoneal hematoma / bleed congestive heart failure Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[2173-5-13]	[ "996.72", "410.71", "998.11", "486", "584.5", "276.2", "997.3", "518.5", "997.5" ]	icd9cm	[ [ [] ] ]	[ "88.53", "36.06", "88.56", "99.20", "37.23", "96.71", "96.04", "89.64", "99.04", "36.01", "39.50", "39.95" ]	icd9pcs	[ [ [] ] ]	3496, 3505	1542, 3331	287, 297	3653, 3663	1380, 1519	3720, 3759	1196, 1213		3456, 3473		3526, 3632		3357, 3433			3687, 3697											1228, 1361																				237, 249								325, 1011														1033, 1147	1163, 1180
32,441	172,750	27618	Discharge summary	report	Admission Date: [2180-6-3] Discharge Date: [2180-6-5] Date of Birth: [2147-6-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2234] Chief Complaint: AMS Major Surgical or Invasive Procedure: Endotracheal Intubation, ICU monitoring History of Present Illness: 32M with EtOH cirrhosis, h/o SIs, HTN brought to ED after excessive EtOH followed by ?seroquel and tramadol intoxication, intubated for AMS. . Pt has longstanding history of EtOH abuse. Has been excessively drinking the day PTA in [Location (un) 3844]. His family brought him back to [Location (un) 86] at 3AM. At about 5AM, he took a large amount of pills out of a bag, likely seroquel and/or ultram per family report (unkown quantity). He was driven to the ED, had difficulties getting out of the car. . In the ED, his VS were stable (T96.7, 80, 91/65, 19, 100%RA) but his pupils were 1mm b/l and he did not respond to painful stimuli. EtOH level of 225. Serum tox positive for BZD. He was given Narcan 0.4, followed by 2 mg with no improvement. EKG was unremarkable. Head CT without acute findings. A nasal airway was placed, pt did not have a gag. He was intubated without complications. He also received 50 gm of activated charcoal 100mg of IV thiamine. Toxicology was consulted. His meds in his bag were reviewed and were identified as seroquel, tramadol, klonopin, antabuse and clonidin. Recommendations were supportive care only. Post-intubation CXR with signs of lingular PNA. Pt received levaquin and CTX x1 in the ED and was admitted to the ICU for further care. . On arrival to the ICU, pt was intubated, sedated on propofol gtt. . ROS could not be obtained. Past Medical History: Chronic Alcholism ETOH cirrhosis fatty liver disease Hypertension Anxiety Social History: Lives in [Location ] in an apartment with one roomate. Currently employed as an administratory at BU. Denies smoking or illicit drug use. No hx of IVDU. Drinks 2 bottles vodka per day. Family History: Uncle and Grandfather died of chronic alcoholism Mother: Hx. MI, CAD. HTN. No DM or cancer. Father: HTN, no DM, CAD or Cancers. Physical Exam: VS: Temp: 96.6 BP: 128/82 HR: 94 RR:14 O2sat96% on AC 550x14, 0.4, PEEP of 5 GEN: Intubated, sedated HEENT:pupils symmetric, ~3cm, slowly responsive to light. No scleral icterus. ETT in place. NECK: supple RESP: CTA b/l anteriorly, no r/w/r CV: RR, S1 and S2 wnl, no m/r/g ABD: mildly distended. grimaces to deep palpation diffusely. + BS EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: sedated on propofol gtt, opens eyes and squeezes hand to command. Pertinent Results: [2180-6-3] 08:15AM WBC-3.6* RBC-3.59* HGB-10.4* HCT-31.7* MCV-88 MCH-28.9 MCHC-32.7 RDW-16.3* [2180-6-3] 08:15AM NEUTS-24.5* BANDS-0 LYMPHS-62.6* MONOS-8.2 EOS-2.9 BASOS-1.8 [2180-6-3] 08:15AM PLT SMR-HIGH PLT COUNT-489* [2180-6-3] 08:15AM PT-16.0* PTT-29.2 INR(PT)-1.4* [2180-6-3] 08:15AM GLUCOSE-108* UREA N-19 CREAT-1.2 SODIUM-143 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [2180-6-3] 08:15AM ALT(SGPT)-53* AST(SGOT)-66* LD(LDH)-226 ALK PHOS-111 TOT BILI-0.8 [2180-6-3] 12:30PM LACTATE-4.3* [2180-6-3] 09:15PM LACTATE-2.2* . 143 105 19 ============ 108 4.0 26 1.2 . Ca: 9.2 Mg: 2.0 P: 3.3 D Serum EtOH 225 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . WBC 3.6 Hb 10.4 Hct 31.7 Plt 489 N:24.5 Band:0 L:62.6 M:8.2 E:2.9 Bas:1.8 . PT: 16.0 PTT: 29.2 INR: 1.4 . Lactate:4.3 pH 7.40 pCO2 40 pO2 433 Intubated; FiO2%:100, AC 550x14, PEEP 5 . Studies: . EKG in ED: NSR at 78, nl axis, nl intervals, no acute ST changes. . CXR [6-3] pre-intubation: Low lung volumes with basilar atelectasis. . CXR [6-3] post-intubation: The lung volumes are low, however, somewhat improved from interval study. ET tube is 3.8 cm from the carina. The left lingular opacity is again seen. The interstitial markings are slightly less prominent than on prior. There is an ovoid radiodensity projecting over the heart, which is likely outside the patient. There is no effusion. There is no pneumothorax. IMPRESSION: ET tube in standard position. Lingular pneumonia. . Head CT [6-3]: no acute findings. . CXR [6-4]: Single portable radiograph of the chest demonstrates low lung volumes. Patchy airspace opacity projecting over the left lower lung persists, but is improved in the interval when compared with [2180-6-3]. The endotracheal tube has been removed. The nasogastric tube has been removed. The right lung is clear. No pneumothorax. Brief Hospital Course: 32M with EtOH cirrhosis, h/o SIs, HTN brought to ED after excessive EtOH followed by ?seroquel and tramadol intoxication, intubated for AMS. Pt self-extubated on [6-3]. MS [First Name (Titles) 21299] [Last Name (Titles) 67475]t. He was continued on CIWA scale for withdrawal symptoms. The patient was called out to the floor on HD1, and was stable on the floor with normal vital signs. He was well appearing and taking good po diet and put back on his home medications except tramadol and seroquel. He did not require any ativan on a CIWA scale, with a max CIWA score of 7. Despite heavy encouragement from the medical team and social work, the pt refused placement in an inpatient alcohol treatment facility. He was discharged in stable condition on HD3 with a list of resource numbers for alcohol cessation support and for psychiatric follow-up. . # Intoxication: Unknown quantities of seroquel and tramadol at 5AM on day of admit. Received charcoal and narcan in the ED. EKG with narrow QRS and normal QTc. Was intubated and sedated but self-extubated on [6-3]. MS rapidly cleared on HD 1, remained A&Ox3 for remainder of the hospitalization, with no s/sx of alcohol withdrawal, or residual effects of possible seroquel/tramadol OD. . # Lingular Infiltrate: Found to have lingular infiltrate on CXR. Lactate 4.3 in setting of intoxication. WBC 3.6 with lymphocytosis in ED but chronically leukopenic down to 2.6 intermittently since [Month (only) 404]. Received Levo and CTX in ED empirically. Lingular opacity likely only atelectasis in setting of hypoventilation. - f/u Bcx- neg to date - no abx given, pt clinically well with improved CXR - repeat lactate trended down - repeat CXR improved . # EtOH intoxication: Admitted in [3-23] with EtOH intoxication. Per last DC summary, no prior withdrawal seizures, but hallucinations on prior detox attempts. - monitored on ativan CIWA scale- no ativan needed - MVI, thiamine and folate - S/W c/s: long discussion with pt re: detox and alcohol cessation as above. See SW notes in OMR. Pt refused assistance with going directly to inpatient treatment, but was given multiple follow-up options with contact information. [Name2 (NI) ] was also given psych f/u information as per dc instructions. . # Pancytopenia: WBC around [3-20], Hct around 31-35, Plt around 130s-200s. Likely due to chronic alcohol abuse with marrow suppression. Currently high-normal plt, WBC at baseline and Hct baseline. . # Psych: h/o SI in the past. Per pt, intoxication was not suicide attempt. S/w c/s as above, psych felt not necessary as pt was able to contract for safety, did not endorse current SI. Despite not currently a threat to self or others, pt strongly recommended to f/u with psych as outpatient. f/u numbers provided as above. . # Liver dz: ?EtOH cirrhosis per last DC summary. CT abdomen from [2178] with diffusely fatty liver. Cirrhosis cannot be excluded per radiology read. Mildly elevated LFTs on [2180-5-16], stable on admission. INR of 1.4. . # FEN: tolerating regular diet . # Code: full . # Dispo: dc to home with recommended follow-up as above . # Comm: Mother [Name (NI) ] [Telephone/Fax (1) 67476] Medications on Admission: per last DC summary from [3-24]: Seroquel 25mg nightly for insomnia at night Thiamine HCl 100 mg Tablet daily Cyanocobalamin 100 mcg Tablet daily Folic Acid 1 mg Tablet daily Hexavitamin 1 tab daily Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: Do not exceed 2gm per day . 7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 8. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Altered mental status, likely due to intoxication and overdose 2. Overdose, likely accidental 3. Alcohol Abuse Secondary: 1. Hypertension 2. Anxiety 3. Alcoholic Liver Disease Discharge Condition: Good Discharge Instructions: You were evaluated and treated after your alcohol intoxication, made worse by your ingestion of seroquel and tramadol. You are STRONGLY encouraged to STOP drinking alcohol, as you have had serious health consequences from your alcohol as discussed. . Please call your physician or go to the emergency room if you develop any further altered mental status from alcohol or drugs, any chest pain, shortness of breath, lightheadedness, fever greater than 101.5, severe abdominal pain or distention, persistent nausea or vomiting, diarrhea, inability to eat or drink, or any other symptoms which are concerning to you. . Activity: You may resume your usual activity as tolerated. Again, you are strongly encouraged to seek help regarding your alcohol abuse, as discussed with your physicians and social workers. . Diet: You may resume your usual diet. . Medications: Resume your usual home medications. Be sure to only take your prescribed doses of seroquel, and you should stop taking tramadol. DO NOT drink alcohol with ANY of your medications. . Please enter an alcohol rehabilitation program of your choosing. Also, please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], in [2-16] weeks after discharge. Please call [Telephone/Fax (1) 67474] to arrange an appointment. In addition, you are heavily encouraged to follow-up with the [Location (un) 86] Institute for Psychotherapy, as discussed with your social worker. [Name (NI) ] should have a counselor and a psychiatrist at The Institute. Please call [Telephone/Fax (1) 67477] to arrange an appointment. Followup Instructions: Please enter an alcohol rehabilitation program of your choosing. Also, please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], in [2-16] weeks after discharge. Please call [Telephone/Fax (1) 67474] to arrange an appointment. In addition, you are heavily encouraged to follow-up with the [Location (un) 86] Institute for Psychotherapy, as discussed with your social worker. [Name (NI) ] should have a counselor and a psychiatrist at The Institute. Please call [Telephone/Fax (1) 67477] to arrange an appointment.	[ "E853.8", "E850.2", "300.00", "965.00", "571.2", "284.1", "303.01", "780.39", "518.0", "401.9", "969.3", "780.97" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	9016, 9022	4673, 7872	317, 359	9244, 9250	2729, 4650	10970, 11599	2088, 2220		8130, 8993		9043, 9223		7898, 8107			9274, 10947											2235, 2710																				274, 279								387, 1768														1790, 1865	1881, 2072
52,012	146,937	39917	Discharge summary	report	Admission Date: [2162-10-15] Discharge Date: [2162-10-18] Date of Birth: [2117-8-30] Sex: F Service: MEDICINE Allergies: Fluconazole / Ceftriaxone / Ampicillin Attending:[First Name3 (LF) 1257] Chief Complaint: Rash Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 87785] is a 45 F with a medical history notable for mild mental retardation/developmental delay, COPD, hypertension, psorias, and recurrent UTIs. She was brought to [Hospital1 18] on [10-15] from an outside hospital for a diffuse rash involving her mucus membranes. Her recent history is notable for dysuria that began at the end of [Month (only) ]. She received amoxicillin from [Date range (1) 87786] for this and was eventually noted to have a rash and prurits in her groin. She was then given a course of Diflucan starting on [10-6]. She then developed oral mucositis and a diffuse red rash all over her body on approximately [10-13]. She originally presented to her PCP and was referred to an OSH. While there, she received ceftriaxone and was then transferred to [Hospital1 18]. While in the ED her T 101.2 and her SBP was in the 80s. She was admitted to the [Hospital Unit Name 153] and required IV fluids but was able to maintain her blood pressure. While in the [Hospital Unit Name 153] she was seen by dermatology, opthalmology, and OB-GYN. She was also treated for a UTI with ciprofloxacin. On arrival to the floor she felt well. She did have pain in her mouth but was tolerating a soft diet. She had no pruritis, SOB, vision changes, or urinary symptoms. Past Medical History: Mild mental retardation/developmental delay Hyperlipidemia Hypertension COPD History of UTIs Psoriasis Vaginitis Leg edema Mitral valve prolapse History of abnormal thyroid tests History of abnormal pap smear Amenorrhia Depression Social History: Lives with the Shared Living Collaborative. Her primary caretaker is named [Name (NI) ]. She is her own guardian. [Name (NI) 1403] on a farm in [Location (un) 32944]. - Tobacco: smokes ~[1-2] ppd x many years - Alcohol: None - Illicits: None Family History: She does not know her family history. Physical Exam: Physical examination on arrival to the floor: - Vital Signs: T 98.9, P 92, BP 116/76, 96% on RA. - Gen: Obvious rash and crusting on face. Sitting upright eating dinner in NAD. - HEENT: Conjunctiva now appear normal. Rest of eye exam within normal limits. Hearing grossly normal bilaterally. Oropharynx with multiple open, crusting lesions over lips and white-plaque like lesions on tongue. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP cannot be visualized. - Abdomen: Normal bowel sounds. Soft, nontender, nondistended. - Extremities: No ankle edema. - MSK: Joints with no redness, swelling, warmth, tenderness. - Skin: Her rash is primarily erythematous macules and plaques that are confluent in most areas. Areas primarly involved include patches on face, tunk, UE, prox LE, palms, soles. Her inguinal region has erosions on the vulva and erythematous patches in inguinal folds. - Neuro: Alert, oriented x3. Able to discuss current events and memory is intact about recent hospitalization. She does not know her medications or all details of medical history. CN 2-12 intact. Speech and language are normal. Gait normal. - Psych: Appearance, behavior, and affect all normal. Pertinent Results: ADMISSION LABORATORY STUDIES: - [2162-10-15] 08:49PM GLUCOSE-155* UREA N-8 CREAT-0.7 SODIUM-135 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-23 ANION GAP-14 ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-43 TOT BILI-0.7 LACTATE-1.2 - [2162-10-15] 08:49PM WBC-9.4 (NEUTS-83.5* LYMPHS-13.4* MONOS-2.6 EOS-0.4 BASOS-0.3) RBC-4.10* HGB-12.7 HCT-35.8* MCV-87 MCH-31.0 MCHC-35.4* RDW-14.2 PLT COUNT-107* - [2162-10-15] 08:59PM [2162-10-15] 10:00PM URINE UCG-NEGATIVE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-[11-20]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0 DISCHARGE LABORATORY STUDIES: - [2162-10-17] 06:45AM BLOOD Glucose-143* UreaN-4* Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-24 AnGap-14 Calcium-7.5* Phos-4.1 Mg-2.1 calTIBC-246* VitB12-142* Folate-10.9 Ferritn-164* TRF-189* - [2162-10-17] 06:45AM BLOOD WBC-5.6 (Neuts-60.2 Lymphs-31.6 Monos-4.4 Eos-3.5 Baso-0.4) RBC-3.64* Hgb-11.4* Hct-31.7* MCV-87 MCH-31.3 MCHC-35.9* RDW-12.9 Plt Ct-95* - [2162-10-17] 06:45AM BLOOD HIV Ab-PND [2162-10-15] 10:00 pm URINE Site: CLEAN CATCH FINAL REPORT [2162-10-17] URINE CULTURE (Final [2162-10-17]): <10,000 organisms/ml. Skin Biopsy: Prelim result consistent with [Doctor Last Name ]-[Location (un) ] Syndrome. Final read pending. HSV and VZV swab of oral lesions: pending. Brief Hospital Course: 1. Rash: Ms. [Known lastname 87785] presented with a rash and mucositis consistent with [Doctor Last Name ]-[Location (un) ] syndrome after receiving amoxicillin and Diflucan. She was initially admitted to the ICU for fluid-responsive hypotension and then transferred to the floor. Dermatology was consulted (contact, Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ]) and a biopsy was performed. The preliminary results were consistent with SJS. The dermatology team recommended clobetasol to closed skin lesions to prevent pruritus (avoiding face and inguinal region) and mupirocin to open skin lesions. She will follow-up with the dermatology team within 1 week (clinic phone [Telephone/Fax (1) 1971]). She also used viscous Lidocaine for symptom relief of her oral lesions. The differential for her skin lesions also included erythema multiforme. Her oral lesions were swabbed for HSV, VZV and she was treated with 2 doses of Valtrex. The HSV and VZV studies were pending at discharge. 2. Yeast infection: The examination of her vulva and groin was also consistent with a preceding fungal infection. Given the possible reaction to oral Diflucan she was recommended to receive 7 days of topical nystatin powder. 3. UTI: - her admission urinalysis was consistent with a UTI and she was briefly treated with ciprofloxacin until her culture returned with <10,000 CFUs. Ms. [Known lastname 87785] had no urinary symptoms or fevers at discharge. 4. Anemia and Thrombocytopenia - evaluation was consistent with B12 and Iron deficiency. She also has a history of vitamin D deficiency and had a borderline low calcium on admission. For this, she should be evaluated for sprue as an outpatient. She was started on replacement B12, Vitamin D, and iron (she also has a history of menometrorrhagia). No other changes were made to her regimen for her COPD or depression. Medications on Admission: Medications: (from group home list) Lisinopril 10 mg daily Proair 2 puffs Q4H prn Spiriva 18 mcg daily Trazodone 100 mg HS Abilify 10 mg daily Remeron 60 mg HS Fish oil 2400 mg [Hospital1 ] Tylenol 650 mg PO Q6H prn pain, fever Robitussin 2 tsp PO Q4H prn cough Milk of magnesia 2 tsp PO Q6H prn upset stomach or constipation Fluconazole 200 mg PO daily x 5 days beginning [2162-10-6] Amoxicillin 500 mg PO TID x 7 days ending [2162-10-5] Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [1-2] puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. mirtazapine 15 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 7. omega-3 fatty acids 1,250 mg Capsule Sig: Two (2) Capsule PO twice a day. 8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Lidocaine Viscous 2 % Solution Sig: Fifteen (15) mL Mucous membrane three times a day as needed for mouth pain for 7 days: swish in the mouth and spit out. Disp:qs Refills:0 13. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash: use on closed lesions on trunk, arms, legs to prevent itching; do not apply to groin or face. Disp:1 tube Refills:0 14. nystatin 100,000 unit/g Powder Sig: One (1) application Topical twice a day for 7 days. Disp:qs Refills:0 15. mupirocin 2 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 14 days: to open skin lesions. Disp:qs Refills:0 Discharge Disposition: Home Discharge Diagnosis: [Doctor Last Name ]-[Location (un) ] syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. She had a maculopapular rash that covered parts of her face, her ant/post trunk, most of her upper extremities, and her proximal lower extremities including her pelvis. Her mouth had diffuse peeling tissue and blistering over the lips. Her vulva and labia had similar lesions. Discharge Instructions: Dear Ms. [Known lastname 87785], You were admitted with a rash after receiving amoxicillin and Diflucan. We think your rash was from a condition called [Doctor Last Name ]-[Location (un) ] syndrome and was a reaction to your exposure to either amoxicillin or Diflucan. While you are doing better now, [Doctor Last Name ]-[Location (un) ] syndrome can be a life-threatening condition and it is very important that you never receive either amoxicillin or Diflucan again. For your rash, you can apply topical steroids (clobetasol) to prevent pruritis. Please apply this only to areas without open blisters and do not apply this to your groin or face. You can apply mupirocin ointment to areas of the skin with open blisters. You can also use Lidocaine mouthwash for mouth pain but do not swallow this. During this admission you were also noted to have low levels of vitamin D, vitamin B12, and iron. You should start taking replacement doses for these and follow-up with Dr. [Last Name (STitle) 4401] this week. She may want to evaluate you for a condition called celiac sprue. You can also apply topical nystatin to your groin for the next 7 days. Please call Dr. [Last Name (STitle) 4401] or return to the hospital if you note fevers, chills, worsening rash, or any other concerning symptoms. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 4401] in the next 1-2 weeks regarding your rash and low vitamin levels. Please also follow-up with our dermatology department this week. They are setting up this appointment for you. You can call to see the time of appointment, [Telephone/Fax (1) 1971].	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16,655	115,110	7783	Discharge summary	report	Admission Date: [2162-1-4] Discharge Date: [2162-2-2] Date of Birth: [2108-11-18] Sex: F Service: TRANSPLANT HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 28181] is a 53 year-old female who is status post cadaveric renal transplantation in [2161-8-3] for end stage renal disease and polycystic kidney disease who had an uneventful postoperative course, but developed increasing shortness of breath and dyspnea on exertion with abrupt worsening at the end of [2161-12-3]. She also expressed concern about weight gain and pedal edema. She was eventually diuresed at outside hospital, but was found to have elevated creatinine and was subsequently transferred to the [Hospital1 69] for management. At the tine of transfer the patient's creatinine was elevated at 3.0. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Polycystic kidney disease. 4. Hypercholesterolemia. 5. Uterine fibroids. 6. Nasal polyps. 7. Status post cadaveric renal transplant [2161-8-3]. 8. Status post total abdominal hysterectomy. 9. Status post tubal ligation. 10. Asthma. MEDICATIONS AT HOME: 1. Tacrolimus 8 mg po b.i.d. 2. Rapamycin 5 mg po q.d. 3. Prednisone 5 mg po q day. 4. NPH insulin 30 units subq q.a.m. and 12 units subq q.p.m. 5. Lasix 20 mg po q day. 6. Atovaquone 1500 mg po q day. 7. Advair 1 mg inhaler b.i.d. 8. Aciphex 20 mg po q day. 9. Epogen 10,000 units subcutaneously q week. 10. Lipitor 10 mg po q day. 11. Albuterol inhaler prn. 12. Iron 325 mg po q day. ALLERGIES: 1. Zestril. 2. Sulfa. 3. Environmental. FAMILY HISTORY: Polycystic kidney disease. SOCIAL HISTORY: The patient denies tobacco use and states that she uses alcohol occasionally. PHYSICAL EXAMINATION: Vital signs temperature 98.8. Blood pressure 122/64. Heart rate 94. Oxygen saturation 95% on 3 liters nasal cannula. In general, the patient is an obese African American female who appears to be in mild distress. HEENT clear oropharynx. Mucous membranes are moist. Neck supple, nontender without lymphadenopathy. Heart regular rate and rhythm. No murmurs. Lungs decreased at the bilateral bases. Abdomen soft, obese, nontender, nondistended. Extremities 2+ pedal edema bilaterally. LABORATORY STUDIES: White blood cell count 4.5, hematocrit 27.2, platelet count 276, PT 13.6, PTT 30.6, INR 1.2, sodium 140, potassium 5.5, chloride 103, bicarb 27, BUN 31, creatinine 3.1, glucose 223, AST 23, ALT 11, alkaline phosphatase 93, amylase 49, total bilirubin 0.2, lipase 30. IMAGING: Chest x-ray performed on admission demonstrated a globular appearing cardiac silhouette with small bilateral effusions and an overall picture concerning for pericardial effusion. HOSPITAL COURSE: After the patient was transferred to the [Hospital1 69] on [2162-1-4] a pericardial drain was placed to treated the pericardial effusion. This drained approximately 1 liter in the immediate period and she therefore underwent a pericardial window procedure on [2162-1-8] for persistent fluid reaccumulation. The patient tolerated this procedure well and was admitted to the Coronary Care Unit postoperatively for close observation. She was extubated on postoperative day one with two chest tubes in place and was transferred to the [Hospital3 ] floor on postoperative day two in stable condition. The patient did well, but developed a temperature spike on postoperative day six along with increased shortness of breath. A chest x-ray at this time demonstrated hydropneumothorax. This was treated without intervention and subsequently resolved. The patient did have another temperature spike to 103.6 and was subsequently found to have MRSA bacteremia. This was treated with intravenous Vancomycin. A transesophageal echocardiogram was done to evaluate the heart valve given the recent procedure and persistent bacteremia. This finding was consistent with endocarditis. The infectious disease team was therefore consulted for management. Per their recommendations, the patient was treated with Levofloxacin for gram negative coverage along with Vancomycin for MRSA bacteremia and presumed endocarditis. She was also on Valcyte for a positive CMV antibody titer. Around this time the patient developed severe right hip pain permitting her from ambulating. An MRI was performed, which was negative for infection, but did show mild degenerative joint disease. The patient was focally tender over the greater trochanter area and an orthopedic consultation was therefore obtained for possible trochanteric bursitis. Per their recommendations given that the patient was already on steroids they felt that it would be unuseful to treat her with additional steroid medications as it might potentiate her dependence on steroids. The patient was therefore treated with aggressive physical therapy and was seen by the acute pain service. An MRI was obtained to rule out radiculopathy, which was negative. She was treated with Tylenol #3 with Percocet for breakthrough pain and is scheduled to see the pain service as an outpatient. During her hospitalization, a biopsy of the transplant kidney was performed, which was negative for rejection. After remaining afebrile for greater then 48 hours the patient was discharged to rehab for physical therapy and intravenous antibiotics. DISCHARGE DIAGNOSES: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. Polycystic kidney disease status post cadaveric renal transplant. 4. Hypercholesterolemia. 5. Uterine fibroids. 6. Nasal polyps. 7. Status post total abdominal hysterectomy. 8. Status post tubal ligation. 9. Asthma. 10. MRSA bacteremia. 11. Endocarditis. 12. Pericardial effusion status post pericardial window procedure. 13. CMV infection. DISCHARGE MEDICATIONS: 1. Tylenol prn. 2. Tylenol #3 one to two tablets po q 4 to 6 hours prn pain. 3. Advair inhaler q 12 hours prn. 4. Albuterol inhaler prn. 5. Lipitor 10 mg po q day. 6. Atovaquone 1500 mg po q day. 7. Clotrimazole one lozenge po q.i.d. prn. 8. Colace 100 mg po b.i.d. 9. Erythropoietin 10,000 units subcutaneously q Friday. 10. Iron 325 mg po q day. 11. Lasix 10 mg po q day. 12. Neurontin 300 mg po q.h.s. 13. Sliding scale and NPH insulin as directed. 14. Prevacid 30 mg po q day. 15. Levofloxacin 500 mg po q day times three days for a total of a 14 day course. 16. Montelukast 10 mg po q day. 17. Multivitamin one tablet po q day. 18. Nifedipine CR 30 mg po q day. 19. Zofran 2 mg intravenously q 6 hours prn nausea. 20. Oxycodone 5 mg po q 4 to 6 hours prn pain. 21. Prednisone 5 mg po q day. 22. Senna one tablet po b.i.d. prn. 23. Tacrolimus 4 mg po b.i.d. 24. Vancomycin 1000 mg intravenously q day times four weeks. 25. Valganciclovir 450 mg po q day times six weeks. 26. Ambien 10 mg po q.h.s. prn insomnia. FOLLOW UP PLANS: The patient was instructed to follow up with the [Hospital 1326] Clinic in approximately one week. She should have a CBC, chem 7, calcium, magnesium, phosphate, albumin, AST, ALT, alkaline phosphatase, T bilirubin, D bilirubin, and FK506 levels drawn every Monday and Thursday in the morning while at rehab. These results can be faxed to [Telephone/Fax (1) 697] for dosing changes. The patient was instructed to follow up with the [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Service at the [Hospital1 346] as needed for her right hip pain. The patient was also instructed to follow up if she had fevers greater then 101.5 degrees Fahrenheit, intractable vomiting or any other questions or concerns. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 26023] MEDQUIST36 D: [2162-2-2] 11:11 T: [2162-2-2] 11:20 JOB#: [Job Number 28182]	[ "996.62", "041.11", "996.81", "726.5", "421.0", "250.00", "078.5", "486", "420.0" ]	icd9cm	[ [ [] ] ]	[ "37.24", "55.23", "37.12", "38.93", "37.0", "88.72" ]	icd9pcs	[ [ [] ] ]							1641, 1669	5406, 5821	5844, 7902					2779, 5385							1170, 1624																			1788, 2761															171, 820														842, 1149	1686, 1765
8,556	167,811	4556+4557	Discharge summary	report+report	Admission Date: [2113-10-3] Discharge Date: [2113-10-12] Service: man with a complicated history including MVR/TVR in [2113-7-13] with multiple medical complications as described by previous discharge summary from earlier this month. to wean from the vent status post trach and PEG placement, effusion status post VATS. The patient was briefly discharged from [9-6] to [2113-9-10], and was readmitted for pneumonia. He was discharged to [Hospital1 1319] on [9-19]. He returned on The patient also had vague abdominal and chest discomfort which often happens when the patient gets anxious. He denied In the Emergency Department, the patient received 5 mg IV Lopressor which brought his heart rate down to the 140s to 120s while at the same time dropping his systolic blood pressure from the 120s to 80s. He did respond to an intravenous fluid bolus. PAST MEDICAL HISTORY: MVR/TVR with mosaic valve on [2113-8-9], complicated by failure to wean from the vent status post trach and PEG placement. MRSA pneumonia. Serratia pneumonia. Loculated effusion status post VATS. Question of Dressler syndrome treated with steroids. Coronary artery disease status post coronary artery bypass grafting in [2097]. Paroxysmal atrial fibrillation on Coumadin. Prostate cancer status post prostatectomy in [2108], status post penile implant. Status post ureteral stent and urostomy. Colon cancer status post colectomy in [2107]. Pancytopenia with question of myelodysplastic syndrome. HIT antibody positive. Mild chronic obstructive pulmonary disease. SOCIAL HISTORY: He lived in [Location (un) 3844] prior to his mitral valve replacement. He is currently living at [Hospital3 7558]. He has a 120 pack-year tobacco history. He quit 35 years ago. He is widowed. Daughter is the closest family member. MEDICATIONS ON TRANSFER: Ceftazidime 1 g IV t.i.d. day 6, Prednisone 40 q.d., Digoxin 0.125 q.d., Protonix 40 q.d., Prozac 40 q.d., Flovent 220 mcg 2 puffs twice a day, Ativan 0.5 q.i.d., Albuterol p.r.n., Ambien p.r.n., Atrovent q.i.d., Serevent b.i.d., Lasix 80 mg b.i.d., Potassium Chloride 60 mg q.d., Diflucan 200 mg q.d. day 5, Captopril 6.125 mg t.i.d., Lopressor 25 mg b.i.d., Aspirin 81 mg q.d., Tigan 100 mg IM q.6 hours p.r.n., regular Insulin sliding scale. PHYSICAL EXAMINATION: Vital signs: Temperature 99.9??????, heart rate 124, blood pressure 124/70, respirations 22, oxygen saturation 100% on pressure support 5 and 5, FIO2 50%. General: The patient was in no acute distress. HEENT: Dry mucous membranes. Pupils equal, round and reactive to light. Neck: No jugular venous distention. No lymphadenopathy. Chest: Decreased breath sounds of the right base and right lateral lung fields. No wheezes. No rales. Heart: Irregularly irregular rhythm. Normal S1 and S2. No murmur appreciated. Abdomen: Positive PEG tube, colostomy, urostomy bags. Minimal bowel sounds. Soft, nontender, nondistended. No guarding or rebound. Extremities: Cool and dry. No edema. There were 1+ distal pulses. Neurological: The patient was alert and oriented times three times one. Cranial nerves intact. LABORATORY DATA: White count 29.6, hematocrit 33, platelet count 256; sodium 149, potassium 5.6, chloride 105, bicarb 29, BUN 96, creatinine 1.4, glucose 159, calcium 9.9, magnesium 2.4, phosphate 3.6; urinalysis with greater than 50 white cells from the urostomy bag. Chest x-ray showed elevated right hemidiaphragm, interval development of right upper lobe infiltrate. Electrocardiogram showed atrial fibrillation at 116, normal axis, narrow QRS, T-wave inversions in II, III, and AVF. Electrocardiogram from the Emergency Department similarly showed 134 beats per minute with ST depression in V3-V6. HOSPITAL COURSE: 1. Cardiovascular: The patient was rate controlled with beta-blockers. His ST depressions resolved. The patient was ruled out by cardiac enzymes. His Digoxin was continued, and the level was normal. After initial rate control, problems with atrial fibrillation did not occur throughout his hospital stay. He did intermittently have low blood pressures which responded to fluid resuscitation. The patient was considered to be quite dry on admission. 2. Pulmonary: The patient appeared to have a new right upper lobe pneumonia. He was started on Vancomycin and Zosyn given his history of MRSA and coverage for vent acquired/nursing home acquired pneumonia. He eventually did grow both MRSA and serratia from his sputum. He was placed on a 14-day course of Vancomycin and Zosyn. Initially the patient was requiring pressure support at 18 and 5 at night and 5 and 5 during the day. Failure to wean from the vent had been a [Last Name 19390] problem. Several days into his hospital course, the Psychiatric Service was consulted for anxiety and depression as possible complications in weaning from the ventilator. After the patient was put on Zyprexa, his anxiety level decreased markedly, and we were able to maintain him on a trach mask without further need for the ventilator. He did well on the trach mask at 50% FIO2 requiring frequent suctioning but with significantly improved respiratory status. He did require one dose of Lasix for shortness of breath after being several liters positive and blood products positive, and his shortness of breath improved dramatically after the Lasix dose. 3. Renal function: The patient's creatinine and BUN improved with hydration and remained stable throughout his hospital stay. 4. Heme: The patient is anticoagulated for atrial fibrillation with a goal range of [1-15]. The specific nature of his heart valves did not require higher levels of anticoagulation, as they are mosaic valves. The patient is HIT antibody positive. He was maintained off all Heparin products. 5. FEN: The patient has had persistently elevated sodiums. He received free-water boluses for elevated sodium, and eventually his sodium returned to the normal range. 6. Rheumatology: The patient had been started on the previous hospital stay with steroids for a question of Dressler syndrome presenting as postcardiotomy pain. He had been on Prednisone 40 mg q.d. There was some evidence of myopathy, and so during this hospitalization, his steroid dose was tapered. At the time of discharge it should be 50 mg q.d. with gradual taper to off. 7. Wound care: The patient had a wound at the medial edge of this thoracotomy scar that had enlarged since his previous hospital stay. He was seen by Plastic Surgery who felt that wet-to-dry dressings were adequate therapy. In the surgical wound, there was a sinus track which was probed by Plastic Surgery who felt that it was shallow and did not require any different care. 8. Pleural effusion: Late in the hospital course, the patient was noted to have a pleural effusion on the right side. An ultrasound was obtained with the intention of tapping the effusion. It was felt that there was not enough fluid to tap. The patient was sent for a CT scan to evaluate the effusion and is pending at this time. CONDITION ON DISCHARGE: Now much improved. DISPOSITION: The plan is to discharge the patient on [10-12] to rehabilitation. An addendum with a list of discharge medications and follow-up plans will be included at the time of discharge. [Name6 (MD) 2467] [Last Name (NamePattern4) 10404], M.D. [MD Number(1) 10405] Dictated By:[Last Name (NamePattern4) 19391] MEDQUIST36 D: [2113-10-10] 16:51 T: [2113-10-10] 15:03 JOB#: [Job Number 19392] Admission Date: [2113-10-3] Discharge Date: [2113-10-13] Service: ADDENDUM: DISPOSITION: The patient was discharged to [Hospital3 6373] in stable condition. aureus pneumonia. Serratia pneumonia. Rapid atrial fibrillation. Depression. Hyponatremia. Dressler's syndrome. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: The patient's discharge medications are as follows, 1) Coumadin 2.5 mg once a day, 2) Captopril 6.125 mg three times a day, 3) Zyprexa 5 mg in the evening, 2.5 mg in the morning, 4) Lopressor 25 mg twice a day, 5) Atrovent nebulizers four times a day, 6) regular insulin sliding scale, 7) free water boluses 250 cc four times a day, 8) ProMod with fiber 75 cc per hour, 9) Prednisone taper at 15 mg by mouth every day times three days, 10 mg by mouth every day times three days and 5 mg by mouth every day times three days, 10) Digoxin 0.125 mg by mouth every day, 11) Protonix 40 mg by mouth every day, 12) Prozac 40 mg by mouth every day, 13) Fluticasone 2 puffs twice a day, 14) aspirin 81 mg every day, 15) Vancomycin 1 gm every twenty-four hours times four days, 16) Zosyn 2.25 mg intravenous every six hours times four days, 17) Lasix 40 mg by mouth every day, 18) Albuterol nebulizers as needed, 19) Ocean spray nasal as needed. TREATMENT GOALS: 1) International normalized ratio 2 to 3. 2) Goal weight 70 kg, dose Lasix accordingly. 3) Twice a day wet to dry dressings to the patient's back wound. 4) Follow potassium regularly. 5) The patient can eat as tolerated. The patient will need pulmonary follow-up at the [Hospital1 346] Pulmonary Clinic, following his discharge from [Hospital3 ]. Please call the Pulmonary Department [Telephone/Fax (1) 5091] to set up an appointment. [Name6 (MD) 2467] [Last Name (NamePattern4) 10404], M.D. [MD Number(1) 10405] Dictated By:[Name8 (MD) 19393] MEDQUIST36 D: [2113-10-13] 13:18 T: [2113-10-13] 14:17 JOB#: [Job Number 19394] [Hospital3 ]	[ "427.31", "458.2", "276.1", "496", "V44.0", "482.41", "411.0", "428.0", "238.7" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "34.91" ]	icd9pcs	[ [ [] ] ]									8150, 9838					3815, 6418																										2364, 3797												6431, 7131																1895, 2341	918, 1606	1623, 1869	7156, 8127
68,785	165,846	38876	Discharge summary	report	Admission Date: [2113-4-7] Discharge Date: [2113-4-18] Date of Birth: [2077-9-13] Sex: M Service: NEUROSURGERY Allergies: Dilaudid Attending:[First Name3 (LF) 78] Chief Complaint: CC:[CC Contact Info 86269] Major Surgical or Invasive Procedure: angiogram with repeat coiling of aneurysm [2113-4-7] Angiogram [2113-4-17] History of Present Illness: 35y/o male s/p coiltal SAH on [2113-3-6] was found to have a right P-Comm anuerym and was successfully coiled with no residual seen on last angiogram on [3-14]. The patient did have episode of vasospasm treated with intrarterial tpA. He was discharged home on [3-21]. His wife reports he has trouble with decreased energy, sleeping frequently and depressed. He has had some residual headache but those were improving. On [4-6] he was having a BM and felt a sudden "[Doctor Last Name ]" in his head and was then sudden onset of headache (not as bad as initial presentation). He became naseous and diaphoretic, he called our service this evening and was told to come in. He denies any visual changes, weakness, or any other problems Past Medical History: pcomm aneurysm / previously coiled [2113-3-6] Social History: Per report denies alcohol, tobacco ( wife reports [Name2 (NI) 86270] use at home) Family History: unknown Physical Exam: PHYSICAL EXAM: O: T:99.6 BP:152/92 HR:119 R22 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [8-10] bilaterally EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: Remember both examiners names from previous admission. 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, 8to5 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 [5-10] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger Discharge exam: Non focal Pertinent Results: [Known lastname 86271],[Known firstname 86272] [Medical Record Number 86273] M 35 [2077-9-13] Cardiology Report ECG Study Date of [2113-4-7] 2:02:36 AM Baseline artifact. Sinus tachycardia. Early R wave progression. No previous tracing available for comparison. Clinical correlation is suggested. Read by: [Last Name (LF) ],[First Name3 (LF) 900] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 114 164 90 302/396 57 59 28 Display/Print ECG (Requires a Software Download) [Known lastname 86271],[Known firstname 86272] [Medical Record Number 86273] M 35 [2077-9-13] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [2113-4-7] 2:08 AM GROSS,[Doctor Last Name 2053] EU [2113-4-7] 2:08 AM CTA HEAD W&W/O C & RECONS Clip # [Clip Number (Radiology) 86274] Reason: eval for bleed, known aneurysm s/p coiling Contrast: OPTIRAY Amt: 70 [Hospital 93] MEDICAL CONDITION: 35 year old man with h/o SAH w/ bleed, CTA if negative REASON FOR THIS EXAMINATION: eval for bleed, known aneurysm s/p coiling CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: RSRc FRI [2113-4-7] 3:08 AM Noncontrast: SAH emanating from right sylvian fissure; PCOM coil again seen. CTA: New 4 mm saccular aneurysm at superior aspect of PCOM coil not seen [2113-3-16]. D/W Dr. [Last Name (STitle) 24177] [Name (STitle) ] (neurosurgery) 2:30 am [2113-4-6]. [Doctor Last Name ] Final Report EXAMINATION: Head CTA. HISTORY: 35-year-old male presents with history of subarachnoid hemorrhage, status post aneurysm coiling. COMPARISON: Multiple prior head CTs, CTAs and arteriograms [3-6], [2113] through [2113-3-19]. TECHNIQUE: Non-contrast images through the brain were obtained followed by angiographic phase images through the head after administration of intravenous contrast. FINDINGS: Initial non-contrast images through the brain demonstrate new volume of moderate subarachnoid hemorrhage centered along the right sylvian fissure and extending medially towards the interhemispheric fissure. Artifact from coiling of the posterior communicating artery aneurysm is present. The ventricles are prominent, though unchanged from the prior examination. CTA: Appearance of the high cervical internal carotid arteries is stable with tortuosity of the left. The petrous and cavernous segments of the internal carotid arteries are normal. There is a progressive 4- to 5-mm outpouching along the superior and anterior aspect of the aneurysm coil pack. The previous CTA demonstrated a tiny outpouching (4:81) which has markedly expanded. It is unclear whether this represents a new aneurysm or pseudoaneurysm versus a previously thrombosed portion of the aneurysm. This is likely source of the patient's new subarachnoid hemorrhage. Evaluation of the remaining intracranial circulation demonstrates no evidence for ongoing vasospasm. IMPRESSION: There is new right hemispheric subarachnoid hemorrhage associated with expanded saccular filling along the anterior and superior aspect of the coil pack which may represent a new pseudoaneurysm or aneurysm, or potentially could have been a thrombosed portion of the aneurysm on the presenting examination which was not visualized. This, however, is the likely source of the new subarachnoid hemorrhage. The findings were discussed with Dr. [Last Name (STitle) 24177] [Name (STitle) 3903] of neurosurgery at 2:30 a.m. on [2113-4-6] by the radiology resident, Dr. [First Name (STitle) ]. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name (STitle) ] [Name (STitle) 12563] Approved: FRI [2113-4-7] 1:22 PM Imaging Lab Brief Hospital Course: This patient was admitted through the emergency room for c/o headache with SAH. He was admitted to the ICU and placed on seizure prophylaxis and nimodipine. He underwent a cerebral angiogram with repeat coiling of P-comm aneurysm. He was continuously monitored in the ICU. On [4-11], patient had a repeat CTA which was negative for vasospasm and he was transferred to step down for further observation. On [4-13], patient developed worsening headache which was treated with IV Dilaudid. A rash then developed with pruritus. Benadryl was given x2 to relieve symptoms. On [4-14], patient reported that his symptoms were much improved and his rash has disappeared. He continued to be monitored without clinical sign of vasospasm. His angiogram was repeated on [2113-4-17]. This showed no vasospasm per the prelim verbal report of the attending that performed the study. The plan is d/c to home in the am. He agrees with the plan. Medications on Admission: Fiorcet, Colace, ASA Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for temp/pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [1-7] Tablets PO Q6H (every 6 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: re-rupture of pcomm aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Coiling / Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call the office at [Telephone/Fax (1) ] to be seen by Dr. [First Name (STitle) ] to be seen in 4 weeks. You will not need any imaging at that time. Completed by:[2113-4-17*]	[ "430", "693.0", "E935.2" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.72" ]	icd9pcs	[ [ [] ] ]	8188, 8194	6679, 7630	301, 386	8267, 8267	2820, 3741	10370, 10565	1360, 1369		7702, 8165	3781, 3836	8215, 8246		7656, 7679			8418, 9428	9454, 10347										1399, 1646							2789, 2801													231, 263	3868, 6656							414, 1167	1961, 2773								8282, 8394					1189, 1240	1256, 1344
31,779	179,455	34209	Discharge summary	report	Admission Date: [2103-10-8] Discharge Date: [2103-10-29] Date of Birth: [2042-8-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal cancer, Tracheoesophageal fistula Major Surgical or Invasive Procedure: Rouex-N-Y gastrojejunostomy, esophageal conduit, jejunostomy, small bowel resection, thoraco-abdominal incision with anastomosis PICC line SVC filter Intubation Arterial line Right IJ venous catheter Left subclavian venous catheter History of Present Illness: Dr. [Known lastname 31624] is a 61-year-old M, now 12 years after trimodality therapy for esophageal cancer. He was recently diagnosed with a fistula from the carina of the trachea to the gastric conduit, presumably based on the foreign body of the lesser curvature staple line eroding into the airway. Biopsies of both the bronchial and gastric side of this had not shown any malignancy, nor was there any mass lesion visible by CT scan. His Y-stent is effectively controlling and preventing ongoing biliary soilage of the lower lobe at this time. He remains nutritionally behind, and given the irradiated field, a feeding jejunostomy was placed on [2103-7-2] for his nutritional gains and to divert the pancreatic and biliary drainage, which tends to reflux into the gastric conduit, to allow unrestricted healing of this site. Patient returns on this admission for further surgical repair of his tracheoesophageal fistula repair. Past Medical History: Past Medical History: Esophageal Cancer, bowel obstruction, TEF, Left vocal cord paralysis, Depression s/p ECT (following [2091] surgery), Anxiety . Past Surgical History: Esophagectomy at [Hospital1 112] in [2091] complicated by stricture and tracheal esophageal fistula s/p dilation x2 and Y-stent for the TEF on [6-24], exploratory laparotomy/LOA/biliary diversion with G and J Tube placement [2103-7-9], Repair of TE fistula w/intercostal flap [8-20], Roux-n-Y gastrojejunostomy (esophageal conduit) with intra-thoracic anastomosis, small bowel resection, J-tube on [10-8] Social History: General Surgeon, lives w/ wife and 2 small children ages 5 and 7. non-smoker Family History: non-contributory Physical Exam: Admission Physical Exam Vitals: 96.7 77 126/74 16 97% Rm Air Gen: No acute distress Cardio: RRR, no RMG Pulm: CTA, lower BS to right bases Abd: soft, NT/ND, active BS, j-tube in place (TF at goal) Ext: No C,C,E Pertinent Results: [2103-10-8] 11:04PM BLOOD WBC-8.6 RBC-3.36* Hgb-9.9* Hct-28.3* MCV-84 MCH-29.5 MCHC-35.0# RDW-16.3* Plt Ct-242# [2103-10-9] 04:36AM BLOOD WBC-11.5* RBC-3.52* Hgb-9.9* Hct-30.4* MCV-87 MCH-28.1 MCHC-32.5 RDW-15.6* Plt Ct-248 [2103-10-12] 07:35AM BLOOD WBC-8.5 RBC-2.29* Hgb-6.6* Hct-20.1* MCV-88 MCH-28.7 MCHC-32.8 RDW-16.1* Plt Ct-249 [2103-10-14] 07:00AM BLOOD WBC-10.1 RBC -3.12* Hgb-9.3* Hct-27.6* MCV-88 MCH-29.7 MCHC-33.6 RDW-15.4 Plt Ct-317 [2103-10-17] 05:26AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.8* Hct-29.8* MCV-91 MCH-29.7 MCHC-32.8 RDW-15.4 Plt Ct-440 [2103-10-18] 05:31AM BLOOD WBC-12.2* RBC-3.04* Hgb-8.9* Hct-27.2* MCV-90 MCH-29.4 MCHC-32.8 RDW-15.3 Plt Ct-568* [2103-10-22] 05:58AM BLOOD WBC-12.2* RBC-3.12* Hgb-8.8* Hct-27.9* MCV-89 MCH-28.4 MCHC-31.7 RDW-15.0 Plt Ct-815* [2103-10-23] 05:25AM BLOOD WBC-12.3* RBC-3.00* Hgb-8.8* Hct-26.4* MCV-88 MCH-29.4 MCHC-33.4 RDW-15.8* Plt Ct-885* [2103-10-23] 11:53AM BLOOD WBC-13.3* RBC-2.94* Hgb-8.4* Hct-25.9* MCV-88 MCH-28.8 MCHC-32.6 RDW-15.0 Plt Ct-923* [2103-10-24] 04:01AM BLOOD WBC-10.4 RBC-3.26* Hgb-9.6* Hct-28.0* MCV-86 MCH-29.5 MCHC-34.4 RDW-15.3 Plt Ct-629* [2103-10-25] 01:27AM BLOOD WBC-11.3* RBC-3.36* Hgb-10.0* Hct-28.8* MCV-86 MCH-29.9 MCHC-34.8 RDW-15.4 Plt Ct-554* [2103-10-27] 04:58AM BLOOD WBC-7.6 RBC-3.70* Hgb-10.6* Hct-31.9* MCV-86 MCH-28.7 MCHC-33.3 RDW-14.2 Plt Ct-568* [2103-10-21] 04:41PM BLOOD PT-15.8* PTT-26.9 INR(PT)-1.4* [2103-10-21] 10:51PM BLOOD PT-15.2* PTT-31.4 INR(PT)-1.3* [2103-10-22] 05:58AM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3* [2103-10-23] 11:53AM BLOOD PT-16.5* PTT-59.1* INR(PT)-1.5* [2103-10-24] 04:01AM BLOOD PT-15.0* PTT-29.7 INR(PT)-1.3* [2103-10-26] 03:31AM BLOOD PT-14.3* PTT-28.6 INR(PT)-1.2* [2103-10-8] 11:04PM BLOOD Glucose-128* UreaN-19 Creat-0.8 Na-138 K-4.7 Cl-107 HCO3-24 AnGap-12 [2103-10-17] 06:27PM BLOOD Glucose-173* UreaN-11 Creat-0.8 Na-136 K-4.2 Cl-104 HCO3-26 AnGap-10 [2103-10-27] 04:58AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [2103-10-19] 05:02AM BLOOD calTIBC-243* Ferritn-211 TRF-187* [2103-10-19] 05:02AM BLOOD Triglyc-139 Upper GI SBFT [2103-10-19]: Status post esophagectomy, with Roux-en-Y gastrojejunostomy anastomosis. No evidence of leak or obstruction at the GJ anastomosis, although contrast is slow flowing through the anastomosis, consistent with postoperative edema. Although incompletely assessed, contrast has likely traversed through the JJ anastomosis. CTA [2103-10-21] 1. Interval development of bilateral segmental and subsegmental pulmonary emboli. 2. Decreasing size of posterior mediastinal collection in comparison to prior study. 3. Persistent bilateral pleural effusions. Continued airspace disease at right lung base. Development of ground-glass attenuation in bilateral lung fields, which can be consistent with worsening infection or infarcts. LE US No evidence of acute DVT involving the right or left lower extremities. UP US Partially occlusive thrombus of the right axillary vein. These findings were discussed in person with the medical resident caring for the patient. CXR Large round opacity in left lower lung, in part due to loculated intrafissural fluid, but also raising the possibility for either a rounded pneumonia or evolving lung abscess Brief Hospital Course: Patient was taken to the OR by Dr. [Last Name (STitle) ] for Roux-n-Y gastrojejunostomy (esophageal conduit) with intra-thoracic anastamosis, small bowel resection, and J-tube for repair of his tracheoesophageal fistula on [2103-10-8]. Epidural placed and split with PCA to provide additional pain control. He was transferred to the thoracic surgical floors for further postoperative recovery. [Date range (3) 78800]: Patient followed a normal postoperative course. He ambulated without any difficulty with assistance. He was kept NPO with tube feeds at goal via J-tube. Patient transfused 2 units pRBC for Hct of 20. Post-transufion Hct showed adequate response with Hct of 31. The plan was for upper GI study one week after his surgery to assess anastomosis before starting his diet. [2103-10-14]: Patient was febrile to 101.9. Vancomycin and Zosyn started for empiric coverage. Patient also developed atrial fibrillation with HR > 170's. He was not able to convert with lopressor and became hypotensive despite multiple fluid boluses. Cardiac enzyme panel were negative. Electrolytes checked and were repleted. Transferred to the intensive care unit for symptomatic atrial fibrillation. Amiodarone started and he converted to sinus that evening. HIs epidural was removed by APS for possible bacteremia. He kept on PCA for pain control. [2103-10-15]: Patient with tachypnea secondary to his abdominal distention. Oxygen saturations were > 93% and blood gases showed normal gas exchange. Pulmonary toilet with nebulizer to help with his respiratory status. Patient complained of a "reflux" that is not GERD-like but exacerbated when he lays flat. With his constipation and ileus, full bowel regimen with laxatives started. Golytely started at 40ml/hr via his J-tube to encourage bowel movements. Patient remained NSR. [2103-10-16] -[2103-10-18]: Right picc line provided for additional venous access while patient remained on amiodarone drip. PIV removed for phlebilits most likely [2-17] amiodarone drug reaction. He remained NSR. Golytely continued to be fed via J-tube. Patient able to pass flatus and stool. He was kept on antibiotics for a incisional wound cellulitus that was indurated, tender and erythematous. [Date range (1) 78801]: Patient with improving dyspnea. Regular BM. Subjectively feels improved overall. Barium swallow showed no leak and tube feeds (Replete with fiber) was restarted. His chest tube was also removed. Patient started on sips and advanced to clears for comfort. Tube feeds advanced to goal. Began diuresis which slightly improved his dyspnea. He remained at 4L oxygen via NC, RR at 32. Serial cxr continued to show bibasilar atelectasis. [2103-10-22]: With continued and worsening dyspnea, CT scan of chest showed bilateral pulmonary embolism. Heparin drip started, PTT goal of 60-80. No heparin bolus was given and PTT checked every 6 hrs to adjust heparin drip. [2103-10-23]: Patient transferred to ICU for ~ 500ml of bloody emesis. Heparin drip stopped. He remained hemodynamically stable. Hct at 26. NGT was placed for decompression. Planned for elective intubation, EGD and bronchoscopy. EGD showing clots at esophageal conduit. Bronchoscopy showed mild blood in LLL bronchus. No areas of active bleeding found. Protonix also started. Patient transfused 2u pRBC. With pulmonary emboli and upper GI bleed, vascular surgery consulted to place IVC filter. LENI were negative for any DVT. [2103-10-24]: SVC filter placed by vascular surgery without complications.Please see dictated note for more detail. Patient remained intubated and taken back to ICU after surgery. RIJ wire removed (proximity to SVC filter) and left subclavian central venous line placed. Patient was weaned from ventilator for extubation. US of upper extremity showed partially occlusive thrombus of the right axillary vein. Additional unit of blood given to keep Hct > 30. [Date range (1) 78802]: Patient extubated and returned to general surgical floor. NG removed and tube feeds restarted with goal of 90ml/hr. His diet advaced to clears and fulls. Continued to have bowel movements. Patient weaned from oxygen use and with normal oxygenations even with ambulation. Less abdominal distention as he tolerated diet without nausea or vomiting. He is being discharged home with tubefeeds on [2103-10-29]. Medications on Admission: Ativan 0.25-0.5mg PO PRN, Roxicet PRN at meal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:500 ML(s) Refills:0 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days: Take from date of discharge until [11-3]. Disp:22 Tablet(s) Refills:0 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks: Take from [2103-11-4] until [2103-11-17]. Disp:14 Tablet(s) Refills:0 4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety/insomnia. Disp:30 Tablet(s) Refills:1 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Esophageal Cancer tracheoesophageal fistula Left vocal cord paralysis Depression Anxiety disorder Pulmonary embolism Upper GI bleed respiratory failure requiring intubation atrial fibrillation Discharge Condition: Stable On tube feeds and tolerating regular diet Meeting discharge criteria Discharge Instructions: General: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 week Follow up with PCP [Last Name (NamePattern4) ] [1-17] weeks	[ "427.31", "608.86", "E879.8", "519.19", "530.84", "682.2", "E878.2", "999.2", "478.32", "578.0", "518.81", "998.6", "560.1", "564.00", "V10.03", "415.11", "451.82" ]	icd9cm	[ [ [] ] ]	[ "03.90", "96.08", "42.54", "38.93", "45.13", "96.6", "38.7", "96.04", "46.39", "33.22", "45.62", "96.71" ]	icd9pcs	[ [ [] ] ]	11299, 11305	5948, 10329	366, 599	11542, 11619	2574, 5925	13163, 13296	2310, 2328		10425, 11276		11326, 11521		10355, 10402			11643, 12802								12817, 13140	1768, 2199		2343, 2555																				282, 328								627, 1570														1614, 1745	2215, 2294
79,407	157,423	37843	Discharge summary	report	Admission Date: [2131-10-19] Discharge Date: [2131-10-22] Date of Birth: [2085-11-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9454] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: intubation for airway protection History of Present Illness: This is a 45 y.o. male with past medical history of depression/anxiety presenting with unresponsiveness. Per the patient's wife he has been dealing with increased anxiety over the past few month. For this he had been prescribed buproprion and increased doses of alprazolam (though according to his wife he had reported not starting his buproprion). Then over the last three days he has developed strange behaviors and thought patterns. He has been paranoid and suspecting individuals at work of investigating and planning to accuse him of ethical violations. He has been worried that his conversations with Human Resources have been bugged. There has also been a question of increasing depression and possible suicidality. The patient denied suicidal ideation when asked directly about it by his wife. This evening of admission he went into the garage while his wife did something inside their home. As he came back in, he called for her but his speech was garbled and incomprehensible. She sat with him and over a period of minutes went from attempting speech to basically unresponsive and then to dozing. She called EMS who initially brought him to [Location (un) ]. En route to [Location (un) ] he received IV naloxone (due to pinpoint pupils suspicion for opiate intoxication) and lorazepam for concern of seizure (unsure why) without any effect. At [Location (un) ] ED he was intubated for airway protection (no desaturations or apneas per records), had a benign head CT, and then was sent here for further management. . In the ED initial vital signs were 97.7, 70, 117/84, 100% intubated. Patient had a stroke work-up with head and neck CTA, which were benign. Lytes and labs were also normal. Neurology saw the patient and thought unlikely to be cerebrovascular accident. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Depression/Anxiety Social History: married, lives with wife Family History: noncontributory Physical Exam: On transfer: VS: 100.3, 125/88, 92, 18, 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2131-10-21] CXR Imaging: IMPRESSION: Normal heart, lungs, hila, mediastinum and pleural surfaces. No evidence of pneumonia. . [2131-10-19] CXR: IMPRESSION: Low lung volumes and atelectasis, without other acute cardiopulmonary abnormality. . [2131-10-19] CTA head neck: IMPRESSION: 1. No acute intracranial hemorrhage or acute territorial infarct. 2. Unremarkable CTA of the head and neck without evidence of hemodynamically significant stenosis, dissection or aneurysm. 3. Unerupted maxillary and mandibular third molars, at least the right mandibular third molar is impacted. . Microbiology: [2131-10-22] U/A - mod leukocytes, pos nitrite, mod bacteria, [12-7] WBC [2131-10-22] Urine culture - NGTD [2131-10-21] Blood culture - NGTD . Tox ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . EKG: RVR in AVr and termninal S, QRS and QT normal . ON ADMISSION: [2131-10-19] 01:00AM BLOOD WBC-8.7 RBC-4.48* Hgb-13.5* Hct-39.1* MCV-87 MCH-30.1 MCHC-34.5 RDW-13.2 Plt Ct-230 [2131-10-19] 01:00AM BLOOD PT-13.8* PTT-24.4 INR(PT)-1.2* [2131-10-19] 01:00AM BLOOD Glucose-110* UreaN-10 Creat-1.0 Na-143 K-4.1 Cl-109* HCO3-24 AnGap-14 [2131-10-19] 01:00AM BLOOD ALT-23 AST-20 AlkPhos-50 TotBili-0.9 [2131-10-19] 01:00AM BLOOD Lipase-20 [2131-10-19] 01:00AM BLOOD cTropnT-<0.01 [2131-10-19] 01:00AM BLOOD Calcium-8.6 Mg-1.9 [2131-10-19] 01:00AM BLOOD Osmolal-296 [2131-10-19] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2131-10-19] 05:20AM BLOOD Type-ART pO2-406* pCO2-42 pH-7.42 calTCO2-28 Base XS-3 [2131-10-19] 01:12AM BLOOD Glucose-113* Lactate-1.0 Na-142 K-4.0 Cl-103 calHCO3-27 [2131-10-19] 01:12AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-86 COHgb-1 MetHgb-0 [2131-10-19] 01:12AM BLOOD freeCa-1.06* . ON DISCHARGE: [2131-10-22] 07:05AM BLOOD WBC-13.2* RBC-4.68 Hgb-14.0 Hct-40.9 MCV-87 MCH-30.0 MCHC-34.3 RDW-12.5 Plt Ct-200 [2131-10-22] 07:05AM BLOOD Plt Ct-200 [2131-10-22] 07:05AM BLOOD Glucose-95 UreaN-12 Creat-1.0 Na-140 K-4.3 Cl-102 HCO3-26 AnGap-16 [2131-10-22] 07:05AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9 Brief Hospital Course: 45 year old male h/o depression/anxiety who presented with altered mental status/unresponsiveness s/p overdose of alprazolam, lorazepam, amitriptylene, and wellbutrin. . 1) Altered Mental Status/toxic overdose: Pt initially presented with altered mental status of unclear etiology. Unclear whether secondary to toxic/metabolic vs infectious vs vascular. Patient had negative work up including tox screen (negative for aspirin, EtOH, tylenol, barbiturates, tricyclics), negative CTA of his head. He was given flumazenil, which improved his sedation and allowed for extubation. Upon awakening, he gave a history of overdose of one bottle each of alprazolam and wellbutrin. After speaking with wife, she has brought in emptry bottles of alprazolam, lorazepam, amitriptylene, and wellbutrin. Trigger appears to have been high stress related to workplace. Neuro examination after clearing was also unremarkable. Hemodynamically stable, with support of his airway, he was transferred to the floor. On the medical floor, patient had routine daily EKG's which were normal, with normal QRS complexes and normal QTc interval. No events on telemetry. In addition, he was placed on suicide precations, with 1:1 sitter. He denied repeat SI/HI. Social work and psychiatry were consulted. . 2) Depression/Anxiety/Delusions: Patient's history of delusions were concerning for a psychiatric decompensation vs depression with psychotic features. Psych was consulted. Pt was maintained on 1:1 sitter once extubated. . 3) Low grade fever/UTI: patient developed low grade fever. CXR negative for cardiopulm disease. Blood cultures no growth to date. U/A was positive for nitrite, positive for leuk esterase, moderate bacteria, WBC [12-7]. Urine culture was pending at time of transfer. Patient empirically started on ciprofloxacin 500 mg [Hospital1 ] x 7 days (day 1 = [2131-10-22]) given evidence of urinary tract infection, likely from catheter use in setting of unresponsiveness. . 4) Acute renal insufficiency: Cr 1.5 yesterday, but resolved to 1.0 with IVF overnight. Suspect some component of dehydration/hypovolemia. Cr 1.0 and normal on discharge. . Transfer care and medically cleared for psychiatry. Medications on Admission: Wellbutrin XR 150 mg [Hospital1 ] Extended release Alprazolam Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia Discharge Disposition: Extended Care Facility: [Hospital3 3765] - [Location (un) 1514] Discharge Diagnosis: PRIMARY: 1. toxic/metabolic overdose, felt to be benzodiazepenes . SECONDARY: 1. depression/anxiety Discharge Condition: good, without suicidal/homicidal thoughts, ambulatory, tolerating food without difficulty, on antibiotic for urinary tract infection Discharge Instructions: You were admitted for evaluation and treatment of ingestion overdose after taking too much of your psychiatric medications. You were intubated to protect your airway. The breathing tube was removed once you were fully conscious. You did not have any direct complications of this particular ingestion. Your heart rhythm was closely monitored without events. . You were noted to have low grade fever and a urine sample suggestive of a urinary tract infection. We will continue you on antibiotics for this. . NEW MEDICATIONS: - ciprofloxacin 500 mg twice a day for 7 days . Please seek medical attention for suicidal or homicidal thoughts, depression or anxiety that feels overwhelming, fevers, chest pain, abdominal pain, shortness of breath, or any other concerns. Followup Instructions: Please call [Telephone/Fax (1) 84656] to make an appointment in [1-19] weeks time with Dr. [Last Name (STitle) 84657], your primary care doctor. Completed by:[2131-10-22]	[ "518.81", "E950.3", "041.4", "298.9", "799.02", "300.4", "969.4", "349.82", "276.52", "584.9", "996.64", "969.09", "599.0", "969.05" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	8151, 8225	5417, 7628	335, 369	8369, 8504	3239, 4131	9318, 9506	2689, 2706		7744, 8128		8246, 8348		7654, 7721			8528, 9295											2721, 3220																5080, 5394		2209, 2589		279, 297								397, 2190							4145, 5066							2611, 2631	2647, 2673
58,968	106,443	4762	Discharge summary	report	Admission Date: [2145-2-9] Discharge Date: [2145-2-12] Date of Birth: [2104-8-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: intoxication Major Surgical or Invasive Procedure: intubation [2145-2-9], extubated [2145-2-9] History of Present Illness: This is a 40 year-old female BIBA after being found down at court house. According to her family, she drank a pint of vodka last night and came home around 1am, visibly intoxicated. Became more lucid during the early morning, and then told her of their plans to take her to court for a section 35/court ordered rehab. She then drank a second pint of vodka prior to going to court. Shortly after arriving at court, she slumped over and became unresponsive. EMS was called, and found her unresponsive to sternal rub but with normal vital signs. An oral airway was placed and she was bag-valve ventilated on the way to [Hospital1 18]. To the best of the family's knowledge, she did not consume any other drugs or medicines. They say she has been on a "binge" for the last 24 hours or so, with no clear trigger; drinking binges in the past have been associated with breakups or other social stressors. Between drinking binges, she is stable and holds down a job. In the ED, she was intubated for airway protection. She was briefly hypotensive to 90s systolic, fluid responsive. Tox screens showed alcohol level of 638 but were otherwise negative. First CXR showed R mainstem intubation; ETT was withdrawn and is now in good position above the carina. Vital signs prior to transfer to ICU: 97.4, 119/93, 16, 76, 100% on vent. Past Medical History: Thyroidectomy for (malignant) nodule Insomnia Bipolar Disorder Social History: Works as a 5th grade teacher in JP, has son and [Name2 (NI) ]. Has been hospitalized at least 5 times for alcoholism, most recently in 10/[2144]. Family thinks she may have had a withdrawal seizure in [Month (only) 359], no history of DTs. Does smoke tobacco, no known IV or other drug use. Family History: Non contributory. Physical Exam: Vitals: Tm 99.7 Tc 97.2 115/80 p75 R18 96%RA GEN: Well-appearing, well-nourished, appears sad/anxious HEENT: EOMI, PERRL, COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords Neuro: CN2-12 intact. No asterixis SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ADMISSION LABS: [2145-2-9] 12:58PM WBC-11.9* RBC-4.89 HGB-15.0 HCT-42.4 MCV-87 MCH-30.6 MCHC-35.3* RDW-15.1 [2145-2-9] 12:58PM PT-14.6* PTT-22.6 INR(PT)-1.3* [2145-2-9] 12:58PM PLT COUNT-343 [2145-2-9] 12:58PM FIBRINOGE-204 . [2145-2-9] 12:58PM ASA-NEG ETHANOL-638* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [2145-2-9] 12:58PM OSMOLAL-467* [2145-2-9] 12:58PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.2 [2145-2-9] 12:58PM LIPASE-39 [2145-2-9] 12:58PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-51 TOT BILI-0.2 [2145-2-9] 01:00PM GLUCOSE-106* LACTATE-2.1* NA+-150* K+-4.3 CL--108 TCO2-25 [2145-2-9] 12:58PM UREA N-13 CREAT-0.7 [2145-2-9] CXR: FINDINGS: Endotracheal tube has been repositioned with tip approximately 3.5 cm from the carina. NG tube courses through the mediastinum with tip and side port within the expected region of the stomach. Superior mediastinal widening is minimal and likely due to positioning. The heart size is within normal limits. Low inspiratory volumes are present. Opacities within the left upper and lower lobes are less conspicuous on current study and may reflect aspiration or atelectasis. No effusion or pneumothorax detected. IMPRESSION: 1. Standard position of endotracheal tube after repositioning. 2. Left upper and lower lobe opacities may reflect atelectasis or aspiration. [2145-2-9] NONCONTRAST HEAD CT: No edema, mass effect, acute hemorrhage, or major vascular territorial infarction is detected. The ventricles and sulci are normal in size and configuration. There is a mucus retention cyst in the right maxillary sinus. There are aerosolized secretions in the sphenoid sinus, which is not divided into right and left compartments. There is mild mucosal thickening in the ethmoid sinuses. There is fluid in the nasal cavity and nasopharynx, which may be related to the presence of the endotracheal tube. The bones are unremarkable. IMPRESSION: No evidence of acute intracranial abnormalities. [2145-2-9] CT of Cervical Spine: There is no fracture or malalignment. Disc space height is preserved. No paravertebral soft tissue swelling is noted. Small enplate osteophytes are noted at C6-C7 without evidence of high-grade spinal canal stenosis. Evidence of thyroidectomy is seen. Endotracheal and nasogastric tubes are present. IMPRESSION: No fracture or malalignment. . [2145-2-11] 08:45AM BLOOD WBC-7.3# RBC-4.05* Hgb-12.6 Hct-36.1 MCV-89 MCH-31.0 MCHC-34.8 RDW-14.9 Plt Ct-202 [2145-2-11] 08:45AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-138 K-3.4 Cl-103 HCO3-27 AnGap-11 [2145-2-10] 04:20AM BLOOD ALT-14 AST-19 AlkPhos-51 TotBili-0.5 [2145-2-11] 08:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 [2145-2-9] 12:58PM BLOOD TSH-1.0 Brief Hospital Course: Ms. [Known lastname 19987] is a 40 year-old female with reported bipolar disorder, hypothyroidism, and ongoing alcohol abuse who was admitted with alcohol intoxication and intubation for airway protection. . # Decreased level of consciousness: History of heavy alcohol consumption immediately prior to event and lab studies consistent with alcohol intoxication. Admission bicarb was normal, so low suspicion for methanol or other concomitant intoxication. Intubated for airway protection in ED. The osm gap of 17 even after correcting for ethanol on admission suggested there may have been some element of alcoholic ketoacidosis. Head and C Spine CTs were negative for evidence of trauma. During ICU stay [2-9] she became more and more awake needing higher and higher levels of sedation leading to a self-extubation. She did well after this, protected her own airway with good O2 Sat. . # alcohol abuse: According to EMS report, patient had just been committed for rehab, and by history is actively using alcohol until admission. Therefore, low threshold for withdrawal until 48-72 hours out from last use, which was [2-9] around noontime. We gave pt IVF with folate, thiamine, multivitamin empirically x3 days. On [2-9], we gave the family a letter of medical necessity to petition joudge to extend Section 35 for 48 more hours. She was placed on a CIWA scale with PO Valium on [2-10]. SW was consulted for transition to rehab. . After transfer out of the ICU, patient was continued on CIWA scale, but symptoms of anxiety predominated. Patient was started on Diazepam 2 mg po q8hr scheduled beneath the CIWA scale to help reduce baseline anxiety level. On [2144-2-11] (early am), patient did feel what may have been tactile hallucinations, with sense of someone tugging on her sheets. These symptoms did not recur. On [2144-2-12], pt appeared much more comfortable, with less anxiety, and no signif tremor. . # Chest pains: pain on sternal palpation, likely d/t sternal rub in field. Not suggestive of rib fracture on exam. Breathing comfortably. - NSAIDS and Tylenol . # Hypothyroidism: - synthroid 175 mcg . # Bipolar do: - Seroquel q hs for sleep and reported history of Bipolar d/o . # Comm: with [Name2 (NI) ] and sister, who is a lawyer and has been very active w/ dealing with problems related to alcoholism . CODE: presumed full DISPO: to alcohol rehab, today under Section 35 via family. Medications on Admission: Unable to obtain accurate meds on admission due to unresponsiveness. Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO q8 HR prn. 4. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for CIWA >10 for 2 days: for alcohol withdrawl symptoms. 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: # Acute alcohol intoxication requiring intubation # Chronic alcohol abuse # Musculoskeletal chest pains (from sternal rubs in field) # Hypothyroidism Discharge Condition: stable Discharge Instructions: Discharge to [Hospital ] rehab program under Section 35. Completely abstain from alcohol, and complete alcohol rehab program. Please seek medical attention if you develop fevers, chills, cough, difficulty breathing, worsening tremor, hallucinations, seizures, or any other concerns. Followup Instructions: Please follow up with your primary care provider [Name Initial (PRE) 176] [2-12] weeks, or sooner if you develop any problems such as fevers, cough, difficulty breathing. . Continue to use incentive spirometer 4-5 times per hour for the next 2-3 days.	[ "780.09", "303.01", "786.2", "786.59", "780.52", "291.81", "276.2", "244.9", "276.0", "296.80" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	8497, 8512	5402, 7837	327, 380	8706, 8715	2594, 2594	9050, 9313	2160, 2179		7956, 8474		8533, 8685		7863, 7933			8739, 9027											2194, 2575																				275, 289								408, 1737				4024, 5379	2610, 4015									1759, 1824	1840, 2144
16,976	171,604	46828	Discharge summary	report	Admission Date: [2167-2-28] Discharge Date: [2167-3-19] Date of Birth: [2105-6-4] Sex: F Service: [Year (4 digits) 662] Allergies: Haldol / Darvon / Keppra Attending:[First Name3 (LF) 1377] Chief Complaint: transfer from [Hospital Ward Name ] for paralytic ileus Major Surgical or Invasive Procedure: Diagnostic paracentesis History of Present Illness: 61 yo F w/PMHx sx for cirrhosis, Hepatitis C, COPD, MGUS, and hx of lower GI bleeds presents w/ one week of fatigue, dizziness, and recent BRBPR, of unclear duration, which patient states were likely related to her hemorrhoids. Patient with chronic constipation, and states that over the last few weeks she has had bright red blood with her stools, as well as black tarry stools. Patient has also noted recent fall 3 days prior w/resultant LUQ pain. Patient has also noted 1-2 weeks of abdominal distension. She also notes some fever and chills at home. Of note, patient is very poor historian. . Patient has a history of known hemorrhoids and constipation, most recently admitted to [Hospital1 18] in [2-/2166], where she was found to have a hematocrit of 19, and had an endoscopy, sigmoidoscopy, and colonoscopy performed, which were remarkable for portal gastropathy, duodenitis, Schatzki's rings, and large internal hemorrhoids which were thought to be responsible for the bleeding. Patient was seen by GI and surgery during that admission, and banding of the internal hemorrhoids was performed. She required blood transfusions during this admission. . In the ED, patient was found to be febrile to 100.0. She was also found to have a tender abdomen, with new ascites, with diagnostic paracentesis performed. Patient's hct was found to be 14 (31 on last check), and received FFP and 2u pRBC. Patient had a negative NG lavage. Her first set of CE were negative. . EGD [2-/2167] showed no varices and + Portal gastropathy. Colonoscopy with internal hemorrhoids in [2-/2166] which were banded at that time. While prepping for colonoscopy with golytely, abd became distended. Anoscopy performed at bedside revealed internal hemorrhoids with no evidence of bleeding. AXR consistent with possible small bowel ileus versus obstruction. Hematocrit has been stable throughout her stay. The patient then became encephalopathic, anuric and was sent to the [Hospital Unit Name 153]. . NGT was placed for decompression and she was kept NPO. Foley was placed and diuretics were d/ced. She was started on PR lactulose for encephalopathy and improved. Her creatinine improved as well. While in the unit she was found to have a pansensitive Klebsiella UTI which was treated with 7d of CTX. On Monday the pt was passing flatus and had no N/V so NGT was d/ced, however the next day repeat AXR showed continued distended small bowel so the NGT was placed again. She was kept NPO with TPN started at that time. . During the early part of the hospital course, the patient became agitated and wanted to leave AMA. She was seen by psych who deemed her to have no insight into her medical condition and to have no capacity, so if she attempts to leave she should be sectioned. They spoke extensively with her daughter (and HCP) who agreed. Apparently the patient had said she needed to leave and see her dying aunt in [Name (NI) 3908] (per daughter this is not true). While on the [Hospital Ward Name ] she began calling 911 to get out of the hospital, cut her IV lines with a scissor, and alled the patient advocate repeatedly until phone was removed from her room. She was kept on 1:1 sitter subsequently. She was givne olanzapine 5mg x 1 which made her quite lethargic the following day, but has since received 2.5mg without problem. Repeat abdominal XR today shows no change in SBO. . She was transferred from the [Hospital Ward Name ] [Hospital Ward Name ] service to the [Hospital Ward Name ] liver service for closer follow up by the liver team. . PMH, FH, SH, Meds at home, All: reviewed, see admission note of [2167-2-28] by Dr. [First Name4 (NamePattern1) 2127] [Last Name (NamePattern1) ]. Past Medical History: 1) iron deficiency anemia 2) GI bleed - presumed secondary to hemorrhoids 3) Sigmoid diverticulosis 4) Schatzki's ring 5) Duoenal polyps and duodenitis 6) MGUS 7) ?etoh/ HCV cirrhosis followed by Dr. [Last Name (STitle) 497] (vl 9k in [5-15]) 8) psychotic disorder 9) remote polysubstance abuse - etoh, cocaine, marijuana 10) COPD 11) compex partial seizures Social History: Lives alone in [Location (un) ], has home physical therapy and a homemaker. She reports that she has quit tobacco ~ 1 month ago. She denies recent EtOH, howevert reported to have heavy drinking 6 months ago. She denies recent marijuana, cocaine use. Contacts: daughter ([Doctor First Name ] [Telephone/Fax (1) 99373])' son (mark [Doctor Last Name ]) [Telephone/Fax (1) 99374]. Family History: M-asthma, GM-CAD, HTN, denies any h/o liver disease or bleeding disorders; great aunt with epilepsy; Physical Exam: 98.6, 135/69, 89, 97% RA, FS 139 Gen: cachectic, NAD, pleasant, lacks insight HEENT: icteric sclerae, MM dry, no sinus tenderness, pupils small bilaterally Cor: RRR, no r/g/m, nl s1s2 Pulm: CTAB anteriorly Abd: distended, decreased high pitch BS, + ascites, NT Ext: no c/c/e, cachectic, 2+ bilat PT pulses and radial pulses Genitalia: red blood seen in diaper and on vulva near urethral meatus, foley in place Pertinent Results: [2167-2-27] 08:10PM BLOOD WBC-11.7* RBC-1.85# Hgb-4.0# Hct-14.6# MCV-79# MCH-21.8# MCHC-27.6# RDW-22.3* Plt Ct-205 [2167-3-19] 05:07AM BLOOD WBC-8.3 RBC-2.86* Hgb-8.1* Hct-25.7* MCV-90 MCH-28.2 MCHC-31.4 RDW-23.0* Plt Ct-205 [2167-2-27] 08:10PM BLOOD Neuts-84.3* Lymphs-11.0* Monos-3.9 Eos-0.5 Baso-0.2 [2167-3-10] 04:55AM BLOOD Neuts-81.7* Lymphs-11.8* Monos-5.1 Eos-1.4 Baso-0.1 [2167-2-27] 10:03PM BLOOD PT-16.9* PTT-44.3* INR(PT)-1.6* [2167-3-19] 05:07AM BLOOD PT-17.3* PTT-49.5* INR(PT)-1.6* [2167-2-28] 05:01AM BLOOD Ret Man-2.9* [2167-2-27] 08:10PM BLOOD Glucose-65* UreaN-15 Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-22 AnGap-17 [2167-3-19] 05:07AM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-135 K-4.1 Cl-106 HCO3-20* AnGap-13 [2167-2-27] 08:10PM BLOOD ALT-18 AST-45* LD(LDH)-143 CK(CPK)-39 Amylase-50 TotBili-1.1 [2167-3-19] 05:07AM BLOOD ALT-48* AST-45* LD(LDH)-143 AlkPhos-99 TotBili-2.2* [2167-2-27] 08:10PM BLOOD Lipase-46 [2167-3-7] 04:09AM BLOOD Lipase-156* [2167-2-27] 08:10PM BLOOD CK-MB-NotDone cTropnT-0.01 [2167-3-4] 05:30AM BLOOD CK-MB-9 cTropnT-0.05* [2167-2-28] 05:01AM BLOOD Calcium-8.2* Phos-3.5# Mg-2.0 Iron-97 [2167-3-19] 05:07AM BLOOD Albumin-2.5* Calcium-8.9 Phos-3.2 Mg-2.0 [2167-2-28] 05:01AM BLOOD calTIBC-103* VitB12-[2140]* Folate-6.9 Ferritn-23 TRF-79* [2167-3-6] 02:28AM BLOOD calTIBC-72* Ferritn-455* TRF-55* [2167-3-11] 05:19AM BLOOD Triglyc-46 [2167-3-1] 02:05AM BLOOD Ammonia-50* [2167-3-12] 07:50PM BLOOD Ammonia-33 [2167-3-14] 05:07AM BLOOD TSH-3.8 [2167-3-5] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE [2167-2-28] 05:01AM BLOOD AFP-3.8 [2167-3-6] 02:28AM BLOOD [Doctor First Name ]-NEGATIVE [2167-2-28] 05:01AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2167-2-27] 08:49PM BLOOD Lactate-3.1* [2167-3-5] 10:28AM BLOOD Lactate-1.9 [2167-3-6] 02:28AM BLOOD ALPHA-1-ANTITRYPSIN-Test . DIAGNOSTICS: ECG Study Date of [2167-2-27] 11:22:10 PM Baseline artifact Sinus tachycardia Generalized low voltage - clinical correlation is suggested Otherwise baseline artifact makes comparison difficult Since previous tracing of [2166-6-4], may be no significant change but baseline artifact makes comparison difficult . ABDOMEN U.S. (COMPLETE STUDY) [2167-2-28] 9:54 AM 1. Hepatomegaly and coarse ecotexture consistent with known hystory of HCV cirrhosis. No evidence of focal lesions. 2. Ascites. 3. Normal renal ultrasound. . CHEST (PORTABLE AP) [2167-2-28] 5:25 AM The heart is not enlarged. The aorta is slightly unfolded. There is no CHF, focal infiltrate, or effusion. There is minimal atelectasis and/or scarring at the left base. Attenuation of the peripheral pulmonary vessels raises the question of underlying COPD. . ABDOMEN (SUPINE ONLY) [2167-3-2] 10:25 AM Dilated loops of small bowel and nondilated loops of colon through the level of the sigmoid. Differential diagnosis includes early or partial small-bowel obstruction or ileus. . HIP UNILAT MIN 2 VIEWS LEFT [2167-3-2] 10:25 AM There is severe diffuse osteopenia. However, no fracture is detected involving the left proximal femur. No gross degenerative changes are identified. Increased density over the lower pelvis most likely represents a full bladder. There are degenerative changes in the lower lumbar spine, not fully evaluated here. . CT ABDOMEN W/O CONTRAST [2167-3-4] 1:47 PM 1. Dilated and fluid filled loops of small bowel, without specific transition point. These findings are consistent with ileus. The large bowel remains decompressed. 2. Moderate amount of ascites and bilateral pleural effusions. . CHEST (PORTABLE AP) [2167-3-4] 6:08 AM 1. No acute cardiopulmonary process identified. Bilateral lower lobe atelectasis. . PORTABLE ABDOMEN [2167-3-14] 11:29 AM Dilated small bowel, collapsed large bowel, representing partial obstruction or ileus. . US ABD LIMIT, SINGLE ORGAN [2167-3-17] 3:41 PM Successful ultrasound-guided diagnostic paracentesis. . CHEST (PORTABLE AP) [2167-3-17] 2:24 PM Nasogastric tube has been removed. Right PICC line remains in place. Cardiac and mediastinal contours are stable allowing for rightward patient rotation. Patchy and linear opacity in the left retrocardiac region have slightly worsened. Although the linear component is consistent with atelectasis, the more patchy component could be due to either atelectasis or pneumonia. There is some crowding of vasculature in the right lower lobe related to low lung volumes, but there are no focal areas of consolidation. Brief Hospital Course: 61yo woman with ETOH and HCV cirrhosis, hemorrhoids, presented with BRBPR and anemia, MS change and agitation found to have UTI. Developed small bowel ileus during hospital course. . MICU Course: [2-28]: s/p 4 units of pRBC, Hct 14 on admission to 30.5. Seen by GI and general surgery for hemorrhoids. GI will perform EGD and colonoscopy on Tuesday, EGD to check for varices and colonoscopy to search for source of bleeding. Anoscopy performed at bedside revealed internal hemorrhoids with no evidence of bleeding. Abdominal US showed ascites and gastric thickening. Will need repeat paracentesis to send for cytology given signet cells. Not done given tenuous creatinine and concern for hepatorenal syndrome and causing problem with massive fluid shifts. AFP low at 3.8. Tox screen cocaine POSITIVE. Tbili increased from 1.1 --> 5.4 over last 24 hours. Hepatology consulted. Daughter official health care proxy. . Below is the course by problem list while on the [Name (NI) ] service: . # Small bowel ileus: Unchanged on AXR with NGT in place. Abd CT still with dilated bowel loops. KUB showing that contrast made its way through. Paracentesis done for diagnostics on [3-14] and was negative. Pt pulled NGT and started on PO diet, tolerating. Having BMs and flatus. Started on clear liquids, reglan advanced diet to regular as patient tolerating without problems. Turned off TPN and removed PICC line. Surgery did not think patient still had ileus based on clinical assessment. Continue regular diet on discharge. . # ETOH cirrhosis with ascites: AFP WNL, no varices. Pt not current transplant candidate as actively drinking and not compliant with liver appointments. Continued lactulose PO tid for [3-15] BM per day, lasix PO 40mg qd, aldactone PO 50mg qd, rifaximin as no longer has ileus. . # GI bleed: Colonoscopy 1y ago showed hemorrhoids only. EGD with portal gastropathy. Flex [Month/Day (3) 65] on [3-16] with internal/external hemorrhoids, otherwise normal. Received 2u FFP. Hct remaining stable. . # Fevers: Likely due to UTI. now s/p 7d CTX. Afebrile since day of admission. CXR negative at that time. No SBP on repeat paracentesis on [3-18]. CXR again negative on [3-18]. Now afebrile, leukocytosis resolved. Blood cultures, so far NGTD. Removed PICC line for tip culture given fevers and cultures still pending on discharge, likely negative. . # Bleeding at urethral meatus: Question whether this is urethral due to foley truma (pt seen to tug on her foely repeatedly on other cmapus) versus hemorrhoidal bleeding. Removed foley on admission. Hct remaining stable. . # Anemia: Iron studies c/w ACD. Pt with stable hct at this time s/p 4 units PRBC initially. continue to monitor hct and guaiac stools. B12 and folate nl. No evidence of hemolysis on labs. . # Hx of polysubstance abuse: This admission denies use but positive cocaine on arrival. Per daughter drinks a great deal of Etoh, now here for 13 days so out of withdrawal window. Prior to discharge will need to be evaluated for services lives alone at home, although children in MA area. . # Delta MS: On arrival may have been related to cocaine use plus hepatic encephalopathy versus UTI. s/p UTI treatment, continue lactulose. Appreciate psych input for agitation. Mental status return to baseline, patient likely safe to go home per daughter. Give olanzapine 2.5mg po bid prn agitation, insomnia. . # L hip pain: s/p fall; plain films negative for fracture or degenerative changes. no complaints of pain at present. Full ROM. . # ?COPD: On CXR but pt without complaints and satting well. Respiratory saturations stable on room air, no dyspnea on exertion. . # Partial complex seizures: Currently stable. . # FEN: regular diet Repleted lytes prn. No electrolyte abnormalities on discharge. . # Prophylaxis: PPI, pneumoboots, bowel regimen . # Code: Full . #: Dispo: cleared by PT, ileus resolved, tolerating PO, DC to extended care facility. . # Communication: Daughter ([Doctor First Name 4850] [Telephone/Fax (1) 99373]) who is HCP, [Name (NI) ] [Name2 (NI) ] [Name (NI) 5857]) [Telephone/Fax (1) 99374] Medications on Admission: lactulose 300ml PR tid lansoprazole disintegrating tabs 30mg po qday colace [Hospital1 ] anzemet prn anusol topical and suppository ISS olanzapine 2.5mg po qhsprn and [Hospital1 ] prn agitation ativan prn agitation Discharge Medications: 1. Hydrocortisone 2.5 % Cream [Hospital1 ]: One (1) Appl Rectal [Hospital1 ] (2 times a day). 2. Hydrocortisone Acetate 25 mg Suppository [Hospital1 ]: One (1) Suppository Rectal QD (). 3. Lidocaine HCl 2 % Gel [Hospital1 ]: One (1) Appl Mucous membrane PRN (as needed). 4. Camphor-Menthol 0.5-0.5 % Lotion [Hospital1 ]: One (1) Appl Topical QID (4 times a day) as needed. 5. Albuterol Sulfate 0.083 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Insulin Regular Human 100 unit/mL Solution [Hospital1 ]: SLIDING SCALE Injection WITH MEALS AND AT BEDTIME. 7. Olanzapine 2.5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime) as needed. 8. Olanzapine 5 mg Tablet, Rapid Dissolve [Hospital1 ]: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Lactulose 10 g/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO TID (3 times a day). 11. Spironolactone 25 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 12. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 13. Rifaximin 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 14. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever or pain: Limit to 2 grams per day. Discharge Disposition: Extended Care Facility: Radius [Hospital 7755] Hospital Discharge Diagnosis: Alcoholic cirrhosis with ascites Paralytic small bowel ileus External/internal hemorrhoids Anemia Polysubstance abuse Altered mental status COPD Partial complex seizures Left hip pain Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. . Call your PCP or return to the ED if you experience abdominal pain, nausea, vomiting, fevers, chills, note persistent bleeding per rectum, feel light-headed, dizzy. Followup Instructions: Please follow up with [Hospital1 18] Liver Clinic in 2 weeks. Call number below to make an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] at [Hospital1 18]. ([Telephone/Fax (1) 3618] . Please followup with your PCP [Name Initial (PRE) 176] 2 weeks for further medical management. Call number below to be established as a new patient at [Hospital 18] [Hospital 191] Clinic: ([Telephone/Fax (1) 1300] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "280.0", "599.0", "584.9", "572.2", "578.9", "789.5", "455.0", "305.01", "455.3", "305.61", "571.2", "345.50", "530.5", "070.54", "496", "560.1", "276.8" ]	icd9cm	[ [ [] ] ]	[ "45.13", "49.21", "54.91", "99.15", "45.24", "38.93" ]	icd9pcs	[ [ [] ] ]	16162, 16224	10216, 14356	361, 386	16452, 16462	5515, 10193	16720, 17315	4967, 5070		14629, 16139		16245, 16431		14382, 14606			16486, 16697											5085, 5496																				262, 323								414, 4147														4169, 4537	4553, 4951
7,648	187,053	46482	Discharge summary	report	Admission Date: [2130-3-27] Discharge Date: [2130-5-5] Date of Birth: [2074-9-17] Sex: F Service: Surgery HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female with a past medical history significant for right lower quadrant mass suspicious for cancer, status post percutaneous drainage of the right lower quadrant mass in [2129-12-16]. The patient had initially presented on [2129-12-28], with abdominal pain and a pelvic mass. CT scan of her abdomen at the time showed a large 7-cm fluid collection in the subcutaneous tissues of the right lower quadrant, and inflammatory process involving the cecum and proximal ascending colon; ascending was suspected. It appeared that the inflammatory process predominately involved the cecum. CT-guided drainage of the cecal mass on [2129-12-29], was nondiagnostic. Pathology results from the right lower quadrant mass showed benign fibroblastic changes of chronic inflammation which could not rule out overlying cancer. She was to undergo surgery for the right lower quadrant mass on [2130-2-5]; however, after long discussions with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 8488], the patient decided to wait a few weeks to build up her strength before having surgery. The elective resection was planned for [2130-4-13]; however, the patient presented on [2130-4-10], with right upper quadrant abdominal pain and a fever to 102. PAST MEDICAL HISTORY: (Significant for) 1. Methicillin-resistant Staphylococcus aureus in her sputum. 2. Status post an appendectomy. 3. Status post a cesarean section. 4. Cecal mass. 5. History of a seizure disorder first diagnosed on her last admission in [2129-12-16]. MEDICATIONS ON ADMISSION: Dilantin, Prilosec, valproic acid, iron, multivitamin, Tylenol, and Dulcolax. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a former nursing aide at [Hospital1 1444]. She denied tobacco or alcohol use, and lives with her son. FAMILY HISTORY: Significant for mother with hypertension. There is no family history of cancer. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 100, blood pressure 90/56, respiratory rate 18. In general, the patient was awake and alert. Breath sounds were equal bilaterally. Heart had a regular rate and rhythm. Abdomen was flat, soft, right lower quadrant mass palpable and nontender. Right upper quadrant tender to palpation. Extremities were warm and well perfused. LABORATORY ON ADMISSION: White blood cell count 15.6, 82 neutrophils, 1 band, 8 lymphocytes, hematocrit 28.2, platelets 913. PT 13.5, PTT 27.8, INR 1.2. Chem-7 revealed sodium of 137, potassium 4.1, chloride 101, bicarbonate 22, BUN 11, creatinine 0.5, glucose 86. CT scan showed a small fluid collection adjacent to the right colonic mass extending up to and around the gallbladder. There was no extravasation of contrast. There was an increase in size of the right colonic mass pushing through the abdominal wall. HOSPITAL COURSE: The patient was admitted to General Surgery. Given the increase in the right colonic mass with possible reperforation, she was kept n.p.o., started on intravenous fluids and intravenous antibiotics (ceftriaxone, Flagyl, and ampicillin). Drainage of the new fluid collection failed. On [4-13], the patient underwent right hemicolectomy with ileotransverse colon anastomosis for presumed colon cancer. Please see the dictated Operative Note for details. She also underwent a cystoscopy and right ureteral stent placement by Urology. Postoperatively, the patient was transferred to the surgical intensive care unit for postoperative management. 1. GASTROINTESTINAL: On postoperative day one, the patient was started on total parenteral nutrition. She received a right femoral line for this in the surgical intensive care unit. She was kept n.p.o. and started on intravenous Zantac. She also had a nasogastric tube placed at the time of surgery. This was kept to wall suction. On postoperative day six, tube feeds were attempted; however, the patient developed diarrhea on the tube feeds, therefore they had to be discontinued. The patient was maintained on total parenteral nutrition. On postoperative day six, the patient was passing flatus and had large watery bowel movements on postoperative day seven. The stool was sent for Clostridium difficile times three and was negative. On postoperative day 10, the nasogastric tube had fallen out. It was not replaced. The patient denied any nausea or vomiting. On postoperative day 11, a Speech and Swallow consultation was obtained for a bedside swallow evaluation. At that time the patient was not cooperating with the study; however, on postoperative day 12, she did cooperate and it was felt that she would be able to tolerate a ground diet with thin liquids. Therefore, her diet was advanced at that time without complications. Postoperatively, the patient had been receiving intravenous fluid hydration; however, that was hep-locked on postoperative day eight. At the time of discharge the patient was tolerating p.o. well and was not requiring any maintenance fluids. 2. INFECTIOUS DISEASE: Postoperatively, given the macroperforation, the patient was started on a 10-day course of ceftriaxone, Flagyl, and ampicillin which she completed. The PICC line was attempted to be placed; however, it was discovered that the patient had bilateral upper extremity deep venous thromboses as well as occlusion of the superior vena cava; therefore, the PICC lines had to be discontinued, and the patient received her antibiotics through peripheral IVs. The patient remained afebrile until postoperative day 15, at which time she spiked a temperature to 102.6. At this time her right groin line was pulled. It was day 15 of the right groin line. It was unable to be discontinued earlier given that the patient had no intravenous access secondary to her bilateral upper extremity deep venous thrombosis. In addition, blood cultures, urine cultures, and chest x-ray were sent, and the patient was started on vancomycin, ceftriaxone, and Flagyl. Her temperature maximum at this time was 104.6. Infectious Disease was consulted on postoperative day 17. Blood cultures at the time the patient spiked grew out coag-negative Staphylococcus resistant to oxacillin. In addition, a urine cultures grew out greater than 100,000 colonies of enterococcus and greater than 100,000 colonies of coag-negative Staphylococcus. The ceftriaxone and Flagyl were discontinued after two days given that the patient defervesced nicely, and there was a known source from the blood and the urine coag-negative Staphylococcus which the vancomycin would cover. A 14-day course of the vancomycin was recommended. Subsequent blood cultures and urine cultures were negative. On postoperative day 21, vancomycin day six, the patient was changed from vancomycin to linezolid per Infectious Disease recommendation for a total of nine more days. At the time of discharge the patient was afebrile, and there were no active infectious disease issues. 3. HEMATOLOGY: The patient had received 2 units of packed red blood cells prior to her surgery. In addition, she subsequently received several units of blood postoperatively. As previously, a PICC line was attempted on postoperative day four. At that time, imaging revealed a left arm with central venous occlusion and venous outflow through numerous collaterals, and in the right arm central venous occlusion at the right axillary vein. The patient had had a history of right upper extremity deep venous thrombosis, and at physical examination she did have right upper extremity swelling. Vascular Surgery was consulted regarding the deep venous thrombosis. They recommended systemic heparin with long-term Coumadin therapy. Therefore, the patient was started on intravenous heparin until her Coumadin was in the therapeutic range. The heparin was eventually changed to Lovenox while awaiting the Coumadin to become therapeutic. At the time of discharge the patient's INR was therapeutic. In addition, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from interventional radiology was consulted regarding possible recannulization procedure. Their recommendations were that the superior vena cava and subclavian brachiocephalic veins could be recannulized; although, it would be a lengthy procedure requiring bilateral arm and right groin approach. The patient and her family members felt that they would like to hold off at this time given all of the other medical issues. The plan was if the superior vena cava syndrome symptoms persisted and/or central access was needed for central chemotherapy therapy, interventional radiology could recanalize. The patient's superior vena cava symptoms did resolve during the hospital course. Therefore, there was no immediate need to recannulize at this time. This will need to be addressed as an outpatient if central chemotherapy was warranted. 4. ONCOLOGY: The surgical specimen was read by pathology as poorly differentiated adenocarcinoma with 3/16 positive lymph nodes. Their impression was stage III adenocarcinoma of the ascending colon with abscess extending to abdominal wall. They believed that the patient was at high risk for recurrence and recommended adjuvant chemotherapy four to six weeks postoperatively. A discussion was held with the patient and her family members regarding 5-[Name2 (NI) ] and leucovorin. First 5-FU, leucovorin, and CPT-11. The patient will need to follow up with Dr. [Last Name (STitle) ] in his clinic (phone number [Pager number ]), with Dr. [Last Name (STitle) 98753] (the hematology/oncology fellow). The patient will need to be seen at the end of [Month (only) 547] at Dr. [Last Name (STitle) ]. In addition, Dr. [Last Name (STitle) ] was consulted from radiation/oncology. They believed that there was little call for radiation. Dr. [Last Name (STitle) ] agreed to see the patient in his clinic in three weeks. Therefore, the patient should have an appointment scheduled for the end of [Month (only) 547]. 5. NEUROLOGY: During the patient's previous hospitalization in [Month (only) 1096] she developed status epilepticus and was in the medical intensive care unit for an extended period of time. She had been started on Dilantin; however, was not compliant with taking her medications. Neurology was consulted on postoperative day seven because the patient had been refusing her Dilantin, and her Dilantin level was extremely low. They had a long discussion with the patient regarding the risks and benefit of her seizure medication and informed her that her risks for further seizure and possibly status epilepticus was high. She was also informed that if she developed status epilepticus there would be a change that they would be unable to stop her seizures. The patient reported that the reason she did not want to take the Dilantin was because it caused burning. Therefore, she was started on phosphophenytoin. On the evening of postoperative day 10, the patient developed left upper extremity weakness at approximately 8 o'clock at night. On physical examination, her cranial nerves were grossly intact, but she had decreased motor strength in her left upper extremity and decreased tone. Concern was for a stroke (embolic versus hemorrhagic) versus seizure. Her heparin was stopped at this time and Neurology was called. A head CT was obtained which was negative for a bleed. A head MRI was also obtained which was negative for stroke. Toxic metabolic workup including complete blood count, urinalysis, liver function tests, and chest x-ray were all unremarkable. The chest x-ray showed bilateral pleural effusions; however, no evidence of infection. According to Neurology recommendations, the patient was reloaded with her phosphophenytoin. By the following morning her left upper extremity weakness had resolved. An electroencephalogram was obtained which showed diffuse swelling with right temporal spikes consistent with a epileptogenic focus but no seizure activity. Throughout the rest of the hospital course there was no evidence of seizures or stroke. The patient continued to refuse her Dilantin even after several discussions regarding the importance of seizure prevention. 6. POSTOPERATIVE ISSUES: The patient's pain was controlled with a morphine PCA well. When she was tolerating adequate p.o. she was converted to Percocet for the pain which provided adequate pain relief. The patient had retention sutures and staples of her incision. These will be discontinued by her attending after three weeks. The patient did have a Foley postoperatively. This was discontinued on postoperative day 16. There were issues of low urine output immediately postoperatively, and the patient did require albumin; however, her urine output improved and was adequate throughout the rest of the hospital course. Intravenous access was an issue as previously described. Therefore, her right groin line was her primary intravenous central access for approximately two weeks. Once the right groin line was discontinued the patient had peripheral IVs for intravenous access. Intravenous access will need to be addressed if the patient does require central chemotherapy because of the bilateral upper extremity deep venous thrombosis. DISCHARGE DIAGNOSES: 1. Colon cancer. 2. Status post right hemicolectomy. 3. Bilateral upper extremity deep venous thrombosis and superior vena cava syndrome. 4. Seizure disorder. 5. Status post methicillin-resistant Staphylococcus aureus, coag-negative Staphylococcus bacteremia. MEDICATIONS ON DISCHARGE: 1. Coumadin 7.5 mg p.o. q.d. 2. Linezolid 600 mg p.o. b.i.d. times eight days. 3. Boost 1 can p.o. t.i.d. with meals. 4. Dilantin 300 mg p.o. b.i.d. 5. Multivitamin 1 tablet p.o. q.d. 6. Tylenol 650 mg p.o. q.4-6h. p.r.n. CONDITION AT DISCHARGE: Stable. FOLLOW-UP APPOINTMENTS: Follow-up appointments will need to be made for the end of [Month (only) 547] with Dr. [Last Name (STitle) ] in Oncology, and Dr. [Last Name (STitle) ] in Radiation/Oncology, as well as Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for postoperative followup. [First Name11 (Name Pattern1) 4952] [Last Name (NamePattern1) 4953], M.D. [MD Number(1) 4954] Dictated By:[Name8 (MD) 2409] MEDQUIST36 D: [2130-5-4] 18:04 T: [2130-5-4] 20:01 JOB#: [Job Number 40190]	[ "682.3", "153.6", "V09.0", "276.5", "780.39", "196.2", "041.19", "197.4", "453.9" ]	icd9cm	[ [ [] ] ]	[ "99.15", "38.93", "96.71", "59.8", "45.73" ]	icd9pcs	[ [ [] ] ]							2053, 2155	13515, 13781				13807, 14046	1778, 1895	3052, 13494																							14095, 14658					14061, 14070													168, 1468							2538, 3034							1491, 1751	1912, 2035
45,169	104,356	37698	Discharge summary	report	Admission Date: [2191-12-11] Discharge Date: [2191-12-17] Date of Birth: [2113-2-15] Sex: M Service: MEDICINE Allergies: Pollen Extracts / IV Dye, Iodine Containing Attending:[First Name3 (LF) 12] Chief Complaint: fever and weakness Major Surgical or Invasive Procedure: None History of Present Illness: Dr. [Known lastname 84496] is a 78 year-old man with history of unresectable intrahepatic cholangiocarcinoma s/p nine cycles of cisplatin/gemcitabine last in [2191-7-7] who presents with persistent fevers and weakness of unclear etiology. His course was complicated by E. faecium and Klebsiella bacteremia in 8/[2191]. This was presumably due to a biliary source and because his biliary stent was not removable he was treated with IV antibiotics then started on chronic augmentin therapy. Patient represented to [Hospital3 ] hospital in [9-/2191] with recurrent fevers and was treated with IV antibiotics for two days without positive cultures or clear source of infection and discharged home on augmentin. He returned again to [Hospital3 ] hospital where he had a similar admission on [2191-12-3]. He was discharged home on [2191-12-7] but returned again to their ED with fevers and weakness on [2191-12-10]. He was found to have a temperatoure of 102.9 F. He was given 1.5 L NS, vancomycin 500 mg IV, zosyn 4.5 g IV, and Acetaminophen 650 mg po. As patient receives his oncology and infectious disease care at [Hospital1 18] he was transferred to our ED for further evaluation. In the ED his initial vitals were, T 100.4 HR 86 BP 146/70 RR 18 96% RA. Patient denied any localizing symptoms but was visibly rigoring. Labs were notable for WBC 11.8, Hct 31, negative UA. He was given additional 500 mg vancomycin as he had already received 500 mg at [Hospital3 ] hospital, acetaminophen 1 g po, zofran 4 mg IV, ranitidine 150 mg po, and 1 L NS IV. On presentation he was in sinus rhythm but during ED evaluation went into atrial fibrillation with heart rates as high as 150s. He was given diltiazem mg 10 mg IV x 2 and metoprolol 25 mg po with little response. Due to persistent HR > 120 he was started on a diltiazem gtt and admitted to the ICU. On arrival to the ICU, patient denies any focal complaints. He denies recent travel, sick contacts, new pets. He denies headache, abdominal pain, nausea, diarrhea, dark or bloody stools, chest pain, shortness of breath, productive cough, back pain. He admits to poor appetite, intermittent inability to get out of bed. He has a chronic dry cough that is unchanged x years. He had one episode of emesis associated with coughing yesterday. Past Medical History: - Cholangiocarcinoma dx [10/2190] with metal biliary stents s/p 9 cycles of cisplatin/gemcitabine - s/p CCY [10/2190] - Enterococcal (vanc sensitive) and Klebsiella bacteremia [8-/2191] - Hypertension - Glaucoma - Borderline diabetes mellitus - Status post knee surgery Social History: Dr. [Known lastname 84496] is a retired Ph.D. in immunology. He currently lives with his wife in [Hospital3 ] where he has resided for the past 17 years. He denies any history of tobacco or illicit drug use. He no longer drinks alcohol. He has a cat and a dog (35lbs Bichon Frise). Family History: The patient's mother died at 85 of complications of diabetes mellitus. The patient's father died in his 80s of complications of diabetes mellitus. The patient's brother died in his 70s of Alzheimer's disease. He has a brother who is 88 years old alive with diabetes mellitus who was also treated for cancer of the sinus two years ago. His maternal grandfather and mother's three siblings all died of complications of diabetes mellitus. Physical Exam: Physical Exam on Admission to [Hospital Unit Name 153] . VS: Temp: 96 BP: 123/72 HR: 82 RR: 13 O2sat 91% RA GEN: pleasant, flat affect, weak voice, comfortable, diaphoretic, NAD, poor hearing acuity HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: nonlabored breathing, dry cough, CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. . Physical exam on discharge from the floor . Tc: 97 Tm:99 BP 146/77 (140-150/65-77) HR: 68 (68-88) RR: 20 O2: 95% RA GEN: NAD, hiccuping, conversant. He is A/Ox3 HEENT: sclera anicteric, MMM, no LAD Cards: RRR S1/S2 normal. no murmurs/gallops/rubs. Pulm: non-labored breathing, clear to auscultation bilaterally, no crackles or wheezes, but occasional cough Abd: soft, NT, +BS. no rebound/guarding. no HSM. Extremities: wwp, no edema. Neuro/Psych: AOx3, CNs II-XII grossly intact. Pertinent Results: ADMISSION LABS . [2191-12-10] 11:40PM BLOOD WBC-11.9* RBC-3.51* Hgb-11.1* Hct-31.4* MCV-90 MCH-31.5 MCHC-35.2* RDW-16.2* Plt Ct-175 [2191-12-10] 11:40PM BLOOD Neuts-93.3* Lymphs-3.7* Monos-2.4 Eos-0.4 Baso-0.2 [2191-12-10] 11:40PM BLOOD PT-14.6* PTT-24.8 INR(PT)-1.3* [2191-12-10] 11:40PM BLOOD Glucose-173* UreaN-13 Creat-0.9 Na-132* K-3.7 Cl-101 HCO3-25 AnGap-10 [2191-12-10] 11:40PM BLOOD ALT-193* AST-168* AlkPhos-344* TotBili-1.7* [2191-12-11] 10:45AM BLOOD CK-MB-5 cTropnT-<0.01 [2191-12-10] 11:40PM BLOOD Lipase-24 [2191-12-11] 10:45AM BLOOD Albumin-2.5* Calcium-8.3* Phos-2.3* Mg-1.9 [2191-12-11] 12:00AM BLOOD Lactate-1.7 K-3.7 . DISCHARGE LABS . [2191-12-16] 06:00AM BLOOD WBC-4.8 RBC-3.05* Hgb-9.5* Hct-28.2* MCV-93 MCH-31.2 MCHC-33.7 RDW-16.7* Plt Ct-135* [2191-12-16] 06:00AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-138 K-3.7 Cl-103 HCO3-29 AnGap-10 [2191-12-16] 06:00AM BLOOD ALT-158* AST-116* AlkPhos-511* TotBili-1.2 [2191-12-15] 06:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8 Micro: . Blood Cx [12-10], [12-11], [11-22]: Positive for Klebsiella oxytoca. _________________________________________________________ KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Blood Cx [12-13]: PND on discharge . Urine Cx [12-10], [12-12]: Negative . IMAGING: . [2191-12-12] - Transthoracic Echocardiogram: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the apical segments and apex. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. A mass is present on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with mild focal hypokinesis. There is small calcified mass on the aortic valve that could be focal calcification or a small, healed vegetation. No significant valvular abnormality seen. . Abd U/S [2191-12-13]: ABDOMINAL ULTRASOUND: The liver is echogenic, consistent with fatty infiltration or fibrosis/cirrhosis. There are multiple simple cysts within the liver as seen on prior CT. The largest within segment VIII measures 3.9 cm. The left lobe is atrophied with an ill-defined mass, consistent with known cholangiocarcinoma. There is no intrahepatic biliary ductal dilation. Two stents are seen within the common bile duct and extending towards the pancreatic head. The portal vein is patent with antegrade flow. There is no ascites. IMPRESSION: 1. Common bile duct stents in situ, with no intrahepatic biliary ductal dilation or evidence of abscess. 2. Redemonstration of left lobe cholangiocarcinoma and hepatic cysts. . CXR [2191-12-15]: FINDINGS: In comparison with the study of [12-10], there is little overall change. The heart remains within normal limits and the lungs are free of acute infiltrate. There is blunting of the costophrenic angles posteriorly. Hyperexpansion of the lungs is consistent with chronic pulmonary disease. Central catheter remains in place with the tip at the level of the mid portion of the SVC. Brief Hospital Course: 78 year-old man with history of unresectable intrahepatic cholangiocarcinoma s/p nine cycles of cisplatin/gemcitabine last in [2191-7-7] who presents with persistent fevers and weakness. # GNR Bacteremia. Likely [2-22] to a biliary source with a possible nidus in the CBD metal stent. He also recently stopped his augmentin as an outpatient which could likely have contributed. GNR bacteremia was confirmed by OSH (4 cultures) as well as here at [Hospital1 18] with further speciation significant for Klebsiella Oxytoca. He was initially started on vanc/zosyn in the ICU which was changed to vanc/meropenem on [12-12]. Pt did quite well on the regimen without any recurrence of fevers/rigors after transfer to the floor on [12-12]. Vanc was d/c'd given no evidence of gram positive bacteremia, and ID was consulted who recommended chaning meropenem to outpatient course of ertapenem. He received one dose of this prior to discharge which he tolerated well, and was sent home with IV VNA services to continue the IV ertapenem for a total of 2 weeks retroactive to initiation of antibiotics. He will then be put on suppressive levofloxacin therapy 500mg daily thereafter. He will be set up with ID follow up. Of note, MRCP was considered to assess for abcess vs progression of cholangiocarcinoma, but given patient's clinical stability, this was not further pursued. He is scheduled for an outpt CT scan to further assess his disease in early [Month (only) 1096]. . # Transaminitis. Likely from underlying cholangiocarcinoma and bacteremia. He does not have any abdominal discomfort or GI symptoms. Of note, his transaminitis is worse than baseline. It trended down throughout admission, with the exception of his alk-phos which trended from 291 to 511 indicating an obstructive process likely related to malignancy. He is scheduled for an outpatient CT to assess for disease progression. . # Cholangiocarcinoma, s/p metal stent & 9 cycles of cisplatin/gemcitabine. No chemotherapy given in-house. . # Weakness, generalized. Likely [2-22] bacteremia and underlying malignancy. No focal weakness or neurological defict was noted on physical exam. His strength improved throughout admission, and he was discharged home with PT services. . # Normocytic Anemia, baseline. Iron studies were consistent with anemia of chronic disease. Hct remained stable between 26.6-30.9 throughout admission. . # Sinus tachycardia: Patient initially thought to have atrial fibrillation in the Emergency Department and was started on dilt ggt. However, upon reviewing, it was found to be in sinus tachycardia. Diltiazem gtt was stopped. Sinus tachycardia resolved with 4.5 L of fluid resuscitation, and was not tachycardic for rest of admission. . # Hyponatremia: Na 132 on presentation which was down from recent baseline. Given persistent fevers, chills, and poor appetite this was likely due to hypovolemia. Urine lytes FeNa 0.5%, suggesting pre-renal as well. It resolved with fluid resuscitation, and sodium was 138 on discharge. . # Hiccups: Pt with persistent hiccups throughout admission likely due to malignancy and phrenic nerve irritation. They were unresponsive to thorazine, reglan, reglan/baclofen, and baclofen/gabapentin. He was sent home with Rx's for baclofen and reglan to take PRN if he feels that it begins to help. Medications on Admission: **PATIENT's PRIMARY CARE PROVIDER INSTRUCTED HIM TO DISCONTINUE ALL MEDICATIONS ONE WEEK PRIOR TO ARRIVAL - AMOXICILLIN-POT CLAVULANATE- 875 mg-125 mg Tablet- 1 Tablet(s) by mouth two times a day - LATANOPROST [XALATAN]- (Prescribed by Other Provider) - 0.005 % Drops - 1 in each eye once a day - PANTOPRAZOLE- (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every twenty-four(24) hours - CETIRIZINE- (OTC)- 5 mg Tablet- Tablet(s) by mouth as needed for allergies - MULTIVIT WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S]- (Prescribed by Other Provider; OTC)- 0.4 mg-600 mcg Tablet- 1 Tablet(s) by mouth daily Discharge Medications: 1. ertapenem 1 gram Recon Soln Sig: One (1) g Intravenous once a day for 8 days: take your next dose on [12-18] and last dose [12-25*]. Disp:qs * Refills:0 2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:1 3. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for hiccups. Disp:90 Tablet(s) Refills:2 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for hiccups. Disp:90 Capsule(s) Refills:2 6. guaifenesin 50 mg/5 mL Liquid Sig: [5-30] ml PO every six (6) hours as needed for cough. Disp:qs Refills:0 7. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: start this on [12-26] after you finish ertapenem on [12-25]. Disp:30 Tablet(s) Refills:2 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: chatam-[Location (un) ] VNA Discharge Diagnosis: Primary: Klebsiella Oxytoca bacteremia Intractable Hiccups Secondary: Intrahepatic cholangiocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 84496], You were admitted to the hospital for fevers and chills. We found that you had an infection in your blood, likely from your billiary tract. We have treated you with antibiotics and you have done well without new fevers or pain. We determined that it was not necessary to do the MRCP since you seemed to be improving. You should continue to keep your appointment for follow up CT scan next week Please note thes following medication changes: STARTED: Ertapenem 1g IV daily. Last dose [2191-12-25] STARTED: Levofloxacin 500mg by mouth daily. You will start this medication on [12-26] after you finish your ertapenem course on [12-25]. You will need to take this ongoing to prevent further infections STARTED: Benzonatate 100mg by mouth 3 times daily as needed (for cough) STARTED: Baclofen 10mg by mouth 3 times daily as needed (for hiccups) STARTED: Gabapentin 100mg by mouth 3 times daily as needed (for hiccups) STARTED: Ranitidine 150mg by mouth twice daily STOPPED: Protonix (pantoprazole) Followup Instructions: Department: RADIOLOGY When: WEDNESDAY [2191-12-28] at 11:00 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2192-1-6] at 12:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2192-1-6] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD [Telephone/Fax (1) 8770] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 84497],MD Department: Internal Medicine Address: [Location (un) 10215], [Location (un) ],[Numeric Identifier 58635] Phone: [Telephone/Fax (1) 77632] Please call your primary care physician to make an appointment to see him within the next 2 weeks. The office will be open Monday morning at 9am for you to call. You need to be seen by one of the physicians in the Infectious Disease Department here at [Hospital1 18] within the next 2 weeks. Please call [Telephone/Fax (1) 457] on Monday morning to make the appointment.	[ "780.60", "V49.86", "288.60", "996.69", "041.85", "E878.1", "V87.41", "276.1", "790.7", "786.8", "780.79", "427.89", "285.29", "155.1", "427.31", "365.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14059, 14121	8947, 12324	323, 330	14268, 14268	4943, 8924	15489, 16984	3333, 3776		13028, 14036		14142, 14247		12350, 13005			14419, 14878											3791, 4924																			14898, 15466	265, 285								358, 2701									14283, 14395					2723, 3006	3022, 3317
29,214	163,473	46400	Discharge summary	report	Admission Date: [2175-2-12] Discharge Date: [2175-3-7] Date of Birth: [2110-12-10] Sex: F Service: MEDICINE Allergies: Gold Salts / Penicillins Attending:[First Name3 (LF) 1145] Chief Complaint: Cough, Shortness of breath Major Surgical or Invasive Procedure: selective coronary artery angiography with percutaneous coronary invention and bare metal stent delivery to the LAD ICD placement intubation and mechanical ventilation, now extubated temporary transvenous pacemaker insertion and removal right subclavian central venous line insertion and removal History of Present Illness: 64 year old female with history of rheumatoid arthritis and diabetes who presents with progressive shorntess of breath. Patient first noted cough about 1 month prior to presentation associated with some viral URI symptoms. She completed a course of azithromycin and the cough improved. The symptoms returned and the patient again noted cough, fatigue, and chills for 1 week. She did not seek medical help at this time and took over the counter medicines. 1 week prior to presentation, she again noted onset of a non productive cough, but this time was worse and more progressive. She had a dose of remicade and also took a trip to [Country ] to visit family. She notes multiple sick contacts in [Name (NI) ]. After returning, her cough was now productive or yellow, white, foamy sputum. She called her PCP who gave her a course of a steroid taper. . She has noted some chills, but no clear fevers. She has progressive DOE going from able to walk miles to now SOB when walking across the room. She also has orthopnea. Since returning from [Country ], she has noted some peripheral edema. She denies chest pain or chest pain with extertion, but has noted discomfort with cough. Otherwise review of systems is negative for abdominal pain, nausea, vomiting, urinary complaints. She has noted loose stools x 1 day and increased urinary frequency. Also decreased appetite. . She was clinically diagnosed with CHF and aggressively diuresed. She subsequently had a V fib arrest requiring 2 shocks to return her to NSR. She was awke and alert after the code and repeat ECG revealed NSR with RBBB, QR V1-V2, no ST elevations or depressions. She was transferred to the CCU service and started on lidocaine drip, heparin drip, levophed drip, given plavix 600 mg x1 and aspirin. Stat bedside echo was performed and again revealed hypokinesis in the LAD territory and could not r/o thrombus. Left ventricular walls appears thin. . In the ICU she reports some reproducible chest soreness and difficulty in taking a deep breath given pain. Her breathing feels slightly worse because of this, but she is able to lie flat. Denies palpitations, dizziness. Past Medical History: Rheumatoid Arthritis, on MTX since age 35. Now on Infliximab and daily Prednisone. -Diabetes secondary to Prednisone -Pulmonary Fibrosis -Osteoporosis -GERD -Hypercholesterolemia -Sicca Syndrome. . PSH: -Toe surgery to correct structural deformity Social History: Denies tob, EtoH. Lives alone and works in a catering business Family History: history of arthritis, kidney disease, hypertension. sister died from MI at 71 Physical Exam: VS: T 95.3 (ax), BP 96/59, HR 91 , RR 28 , O2 100% on NRB Gen: Middle aged female lying in bed on 1 pillow appearing in mild distress and slightly lethargic but awakens to voice and is oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: JVP approximately 10 cm CV: RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at LSB Chest: No chest wall deformities but had tenderness to palpation over sternum. No diffuse wheezes and crackles bilaterally anteriorly. Abd: soft, mild diffuse tenderness, No HSM or tenderness. No abdominial bruits. Ext: Trace LE edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2175-2-12] 03:15AM WBC-4.9# RBC-4.42 HGB-9.5* HCT-32.6* MCV-74* MCH-21.5# MCHC-29.2 RDW-17.4* [2175-2-12] 03:15AM NEUTS-48* BANDS-0 LYMPHS-43* MONOS-7 EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [2175-2-12] 03:15AM PLT SMR-NORMAL PLT COUNT-372 [2175-2-12] 03:15AM GLUCOSE-166* UREA N-20 CREAT-0.6 SODIUM-136 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-20* ANION GAP-18 [2175-2-12] 03:15AM WBC-4.9# RBC-4.42 HGB-9.5* HCT-32.6* MCV-74* MCH-21.5# MCHC-29.2 RDW-17.4* [2175-2-12] 03:15AM CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-1.7 [2175-2-12] 03:15AM CK-MB-5 cTropnT-0.11* proBNP-7602* [2175-2-12] 03:15AM LD(LDH)-309* CK(CPK)-93 . Chest Xray: Cardiac silhouette appears slightly enlarged compared to prior study. Mediastinal contours appear stable. There is increased cephalization of the vessels, with increased interstitial and alveolar capacities most suggestive of CHF. Moderate-to-large bilateral pleural effusions are seen. No definite focal consolidation identified. Lumbar scoliosis noted. IMPRESSION: Findings suggestive of CHF with moderate-to-large bilateral pleural effusions . EKG: sinus rhythm with LAD, small Qs anterioseptal, poor R wave progression, TWI 1 avL CORONARY ANGIOGRAPHY WITH PCI, [2175-2-17] 1. Emergency selective coronary angiography of this right dominant system demonstrated severe single vessel disease. The LMCA had mild luminal irregularities. The LAD was subtotally occluded proximally and totally occluded after a small D2 branch. Thrombus was visible within the LAD system and faint right-to-left collaterals. The LCX as well as the proximal and distal RCA had mild luminal irregularities. The R-PDA had an 0% distal lesion. 2. Resting hemodynamic assessment revealed cardiogenic shock with cardiac output of 2.67 l/min and cardiac index of 1.62 l/min/m2, both obtained after placement of an intra-aortic balloon pump. The systemic systolic arterial blood pressure ranged from 60 mmHg prior to placement of the IABP to a mean augmented BP of 80-95 mmHg after the pump placement. The pulmonary arterial pressure was moderately elevated at 39/21/28 mmHg. The filling pressures were moderately-to-severely elevated with mean PCWP of 22 mmHG. 3. Left ventriculography was deferred. 4. An IABP was successfully placed at the beginning of this procedure via the right groin 8 French sheath and a 6 French sheath was placed in the left groin. 5. Successful PTCA and stenting of the proximal and mid LAD with an overlapping 2.5x24mm driver stent in the mid vessel and a 3.0x18mm driver stent more proximally. The stent overlap segment was dilated to 3.0mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and timi 3 flow. The patient left the lab free of angina and in critical condition. ECHOCARDIOGRAM, [2175-2-20] (POST-ARREST) The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %) with akinesis of the mid to distal septum, anterior wall, distal LV and apex. There is no ventricular septal defect. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2175-2-17], the LVEF is slightly lower. Brief Hospital Course: 64 yo female admitted [2-12] with worsening dyspnea and orthopnea found to have new acute systolic heart failure with an EF of 30-35% and akinesis of septum, anterior wall and apex consistent with LAD distribution. Sustained a witness ventricular tachycardia cardiac arrest in setting of aggressive diuresis, resuscitated and emergently taken to the cardiac catheterization laboratory where a subtotal occlusion of the LAD was treated with bare metal stenting and subsequently had a prolonged CCU course complicated by aspiration pneumonia and recurrent ventricular tachycardia resolved status post ICD placement and sotalol and mexilitene. . # Recurrent Ventricular fibrillation/ Ventricular tachycardia arrest Patient found to have new acute heart failure, cardiac MR showing LAD infarcted territory, patient was being aggressively diuresed at the time with possible electrolyte changes contributing. Had v. fib arrest on [2-17] requiring 2 shocks and lidocaine gtt. Patient transferred to CCU that night and sent to cath lab in morning where patient found to have 99% subtotal occlusion of the proximal LAD followed by total occlusion with very faint L to L and R to L collaterals. Patient suffered another VT arrest in cath lab requiring addition of amiodarone, hypotensive requiring intubation and pressors, IABP was placed. That night patient had complete heart block while on amiodarone requiring temporary pacer placement, amiodarone stopped and continued on lidocaine. On [2-19] patient had a VF arrest triggered by PVC requring 1 shock and increase in lidocaine gtt. Recurrent ventricular tachycardia which required standing Mg and K to mantain above 2 and 4 respectively. Patient would have runs of NSVT whenever lidocaine gtt was weaned. Eventually loaded with mexiletine and sotalol as patient is not a candidate for amiodarone with her comorbid lung disease. Patient eventually had an ICD placed on [3-2] and with antiarrhythmics did not have any recurrent NSVT. Patient discharged on sotalol 80mg [Hospital1 ] and mexilitene 150mg TID with plans to follow up in device clinic and with Dr. [Last Name (STitle) ]. . # CAD/Ischemia No history of CAD prior, her course was most consistent with patient suffering MI in the past weeks prior to presentation leading to ischemic cardiomyopathy. Patient's CK levels remained flat upon admission and troponin peaked at 0.21. Patient did have new RBBB with TWI in anteroseptal leads and suffered vfib arrest on night prior to emergent morning catheterization Echocardiographic WMA consistent with likely LAD lesion, which was confirmed by catheterization and treated with bare metal stenting. Plavix 150mg was started because of thrombocytosis; once the platelet count is less than 400 patient may have dose decreased to 75mg daily. Aspirin should be continued indefinitely. Atorvastatin 80mg daily. . # Pump EF 25-30 by last TTE, patient on CAD regimen as above. Patient was started on furosemide 20mg daily and has mantained euvolemia on this dose. Titrate up lisinopril as tolerated. Patient educated on cardiac diet, low sodium, daily weights prior to discharge. Will follow up with Dr. [Last Name (STitle) ] as outpatient. . # RA Pulmonary consulted, no change in fibrosis based on CT chest obtained from the [Hospital1 756], was given stress steroids with eventual taper to her home dose of 2mg daily. Patient's MTX and Remicade were stopped since admission. Patient's [Hospital1 112] rheumatologist is aware of situation and will discuss with patient further treatment options not involving infliximab. . # Hospital acquired pneumonia Sputum cx grew MRSA and H. Influenzae, was treated with 10 day course of Vancomycin and Aztreonam. Received an extra 3 days Vanco in setting of ICD placement on [3-2]. CXR with resolution of infiltrate on [3-3]. . # UTI Patient treated with 7 day course of Cipro for Klebsiella and E.coli sensitive to ciprofloxacin. Repeat urine cx no growth. . # DM Placed on SSI and Lantus 5 units while inpatient with good glucose control. Continued on Byetta and metformin at discharge. Medications on Admission: Prednisone 2mg daily (had taken 40mg for two days a beginning of taper) MTX 20mg qthursday Metformin 1000 [Hospital1 ] Calcium 400 TID Vit D 50,000 units twice weekly Restasis 1gtt ou [Hospital1 ] folic Acid 1mg daily Multivitamin Zometa once yearly omeprazole 20mg daily lipitor 10mg daily Byetta 10mg SQ [Hospital1 ] Lub eye drops Remicade Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): at least one month of plavix therapy, until directed otherwise by your cardiologist. Disp:60 Tablet(s) Refills:3 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for fluid balance. Disp:30 Tablet(s) Refills:2 3. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: for heart and blood pressure. Disp:30 Tablet(s) Refills:2 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): for heart rhythm. Disp:60 Tablet(s) Refills:2 6. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): for heart rhythm. Disp:90 Capsule(s) Refills:2 7. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane TID (3 times a day) as needed. Disp:1 tube Refills:3 8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: for diabetes. Disp:60 Tablet(s) Refills:2 9. Exenatide 10 mcg/0.04 mL Pen Injector Sig: Ten (10) mcg Subcutaneous twice a day: for diabetes. Disp:QS 1 month Refills:2 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 Tablet(s) Refills:2 11. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): for rheumatoid arthritis. Disp:60 Tablet(s) Refills:2 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-28] Drops Ophthalmic PRN (as needed): for dry eyes. Disp:QS 1 month Refills:2 13. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [Hospital1 ] (2 times a day): for dry eyes. Disp:60 Dropperette(s) Refills:2 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): for anemia. Disp:100 Tablet(s) Refills:2 15. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): high dose for recent heart attack; discuss dose with your cardiologist when prescription runs out. Disp:30 Tablet(s) Refills:0 16. Calcium 600 + D 600 (1,500)-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day: for bone health. Disp:60 Tablet(s) Refills:2 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: for GERD. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. ventricular tachycardia/ventricular fibrillation cardiac arrest, s/p ICD placement 2. coronary artery disease s/p PCI with bare metal stent to LAD 3. rheumatoid arthritis, treated with methotrexate in the past and currently maintained on prednisone and infliximab, with sicca syndrome 4. methotrexate-related pulmonary fibrosis 5. osteoporosis 6. GERD Discharge Condition: Alert and oriented, ambulatory, afebrile, tolerating regular diet; chest pain free Discharge Instructions: You were admitted with shortness of breath and found to have a heart attack, which was treated with a bare metal stent placed in the LAD (artery to the heart). Continue taking Plavix (clopidogrel) at least 1 month or until directed to stop by your cardiologist. Do not stop Plavix, even if told to do so by another doctor, until speaking with your cardiologist. You will need to take aspirin daily from now on. Also for your heart attack we started a high dose (80mg daily) of atorvastatin (lipitor), which you should take for the next month and then discuss with your doctor returning to 10mg daily. You also had cardiac arrest from ventricular tachycardia (a heart arrhythmia). To suppress this, you were started on drugs called mexiletine and sotalol. Because these drugs can interact with many other drugs, you should tell all of your doctors that [Name5 (PTitle) 17773] are taking these and ask them to call your cardiologist if there are any questions about interactions. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2175-3-8] 4:00 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2175-3-10] 8:30 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2175-3-10] 9:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2175-6-29] 8:50 You should also follow up with Rheumatology within 1-2 weeks of discharge from the hospital. There have been reports of increased incidence of MI in patients on infliximab, so the risks and benefits of continued infliximab treatment versus the risks and benefits of other therapies for RA should be discussed with your rheumatologists.	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47,277	126,906	40915	Discharge summary	report	Admission Date: [2181-4-25] Discharge Date: [2181-4-28] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7015] Chief Complaint: S/P Fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [Age over 90 ] y/o M with a past medical history of CAD s/p CABG, hypertension, recent diagnosis of dementia, multiple recent falls at home presenting from OSH s/p fall at home. He apparently fell out of bed at 5 am, and a home health aid noticed abrasions on his head this morning, and thus took him to the ED. In the OSH ED, he had a CT scan showing a SDH without mass effect. He also had a run of 7 beats VTach, was started on an amiodarone drip, and sent to [Hospital1 18] ED for further evaluation. Of note, patient has been taking Plavix until 10 days ago, when his PCP told him to stop due to the frequent falls at home. . In the ED, initial vs were: 96.8 68 221/104 18 97% RA. Repeat BPs in the ED ranged from 150s-160s. Repeat CT Scan confirmed SDH without mass effect, CT C spine was negative. Neurosurgery evaluated the patient and recommended repeat CT scan in the AM, control of SBP < 160, along with frequent neuro checks overnight. Cardiology was also consulted and recommended stopping the amiodarone drip as the runs of VT were short. C spine cleared in the ED. VS on transfer were 98.4 63, 98% on RA, 156/80. . On the floor, initial VS were: 65, 151/76, 16, 94% on RA. Past Medical History: - CAD s/p CABG - Hypertension - Hyperlipidemia - ? Aortic Valve replacement - Prostate Cancer Social History: lives alone, has a home health aid, no smoke, occasional ETOH, no drug use. Family History: NC Physical Exam: On admission: Vitals: 65, 151/76, 16, 97% on RA General: Alert, oriented x 1, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 7 cm, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular with ocassional premature beats, normal S1 + S2, III/VI blowing SEM at base Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Neuro: A+O X 1, does not know president, CN II-XII grossly intact, motor and sensory intact, no pronator drift Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . On Discharge: Vitals: 98.3 149/82 92 20 97%RA General: Alert, oriented x 1 (to person), no acute distress HEENT: Large scab over the right forehead, Sclera anicteric, MMM, oropharynx clear, surgical lens in the left eye Neck: No LAD, no elevated JVP, large right lobe of the thyroid visualized and soft at the base of his neck. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular, normal S1 + S2, III/VI blowing crescendo/decrescendo murmur with mid peak heard best at the Left and right upper sternal border. Abdomen: firm, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Neuro: A+O X 1, does not know president, cannot say months forwards or backwards, CN II-XII grossly intact (left eye surgical pupil) Ext: warm, well perfused, 2+ radial pulses, 1+ PT and DP pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [2181-4-25] 07:10PM BLOOD WBC-4.8 RBC-4.12* Hgb-12.3* Hct-34.9* MCV-85 MCH-29.7 MCHC-35.1* RDW-13.9 Plt Ct-124* [2181-4-25] 07:10PM BLOOD PT-12.8 PTT-26.7 INR(PT)-1.1 [2181-4-25] 07:10PM BLOOD Glucose-127* UreaN-20 Creat-0.8 Na-139 K-4.0 Cl-105 HCO3-27 AnGap-11 [2181-4-25] 07:10PM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0 . DISCHARGE LABS: [2181-4-27] 06:00AM BLOOD WBC-4.7 RBC-3.90* Hgb-11.8* Hct-32.8* MCV-84 MCH-30.1 MCHC-35.9* RDW-13.8 Plt Ct-107* [2181-4-27] 06:00AM BLOOD PT-12.9 PTT-29.0 INR(PT)-1.1 [2181-4-27] 06:00AM BLOOD Glucose-136* UreaN-19 Creat-0.9 Na-136 K-3.9 Cl-100 HCO3-26 AnGap-14 [2181-4-27] 06:00AM BLOOD ALT-19 AST-21 LD(LDH)-225 AlkPhos-95 TotBili-0.4 [2181-4-27] 06:00AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0 [2181-4-27] 06:00AM BLOOD VitB12-506 Folate-GREATER TH Hapto-96 [2181-4-27] 06:00AM BLOOD TSH-4.4* . CT Scan HEAD: 1. Left parafalcine subdural hematoma, stable. 2. Right tentorial hyperdense extraaxial mass which most likely represents a meningioma. However, further evaluation is recommended with MR. 3. Lucency in the left frontal [Month/Day/Year 500] for which MR is recommended for further evaluation. Alternatively, attention on follow up imaging is recommended. . CT Scan C spine: Degenerative changes and demineralization without evidence for acute fracture or malalignment. . [2181-4-26] CT Head w/o Constrast: 1. Stable left parafalcine subdural hematoma. No significant mass effect. 2. Unchanged right tentorial extra-axial mass lesion arising from the right tentorium, consistent with a meningioma 3. Stable lucencies in the left frontal [Last Name (LF) 500], [First Name3 (LF) ] MRI can be obtained for further evaluation. . EKG: Sinus bradycardia with A-V conduction delay. Left atrial abnormality. Low lateral precordial lead QRS and T wave voltages are non-specific. No previous tracing available for comparison. . . MICR: RPR- PENDING Brief Hospital Course: [Age over 90 ] year old male with frequent falls at home presenting with stable subdural hematoma. . #. Subdural Hematoma: Currently no major focal neurologic findings, stable on CT scan. Patient is on full dose aspirin at home, likely increasing risk with trauma. Neurosurgery following. C spine has been cleared. Overnight, neuro checks were WNL with no focal findings. SBP < 160. Holding aspirin for at least 48 hours per neurosurgery. He was transferred to the floor and his neuro checks remained stable. Repeat CT scan showed unchanged hematoma. I spoke with neurosurgery and they recommended MRI in the outpatient setting to evaluate meningioma and follow up in clinic within 1 month. He was [Doctor Last Name ] by PT who recommended rehab. He will be discharged to rehab. . #. Possible Meningioma on Head CT: Neurosurgery recommended MRI with and without contrast for further classification. Spoke with neurosurgery and they are comfortable with outpatient MRI. This was scheduled for the patient prior to discharge from the hospital . #. Frequent falls at home: Fall may be arrythmigenic, especially given NSVT documented at OSH. Patient was monitored on tele, which showed no events overnight. He is also legally blind, which could be contributing to his unsteadiness and falls. PT was consulted and they recommended Rehab. He was discharged to Rehab for further strength and git training . # Dementia: At baseline. As per family, there were no changes in mental status as related to his fall and intracranial hemmorhage. He is A&Ox1 at baseline. . #. CAD: s/p CABG. Patient on statin, beta blocker. Holding aspirin as above; was also recently on plavix, stopped 10 days ago. No evidence of acute ischemia currently. . #. Hypertension: Patient on ACE-Inhibitor, HCTZ, and metoprolol at home. His blood pressure was well controlled throughout the admission and at the time of discharge. . #. Diabetes: Will hold metformin and start insulin sliding scale. His metformin was restarted at the time of discharge. . # Code: DNR/DNI . TRANSITIONAL ISSUES: - Follow up pending RPR - Follow up that patient gets IMAGING as well as follows up with neurosurgery. Medications on Admission: Prinivil 5 mg Tab Aspirin 325 Lipitor 20 mg once a day Colace 100 mg [Hospital1 ] Metoprolol tartrate 50 mg once a day Metformin 500 mg [Hospital1 ] HCTZ 12.5 mg once a day Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO once a day. 3. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Hold for loose stools. 5. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 25112] at [Location (un) ] - [Location (un) 1456] Discharge Diagnosis: Primary Diagnosis: Intracranial Hemorrhage . Secondary Diagnosis: - CAD s/p CABG - Hypertension - Hyperlipidemia - Prostate Cancer Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You are being discharged from [Hospital1 1170]. It was a pleasure taking care of you. You were admitted to the hospital after a fall and bleeding in your head. You were monitored for 48 hours and your clinical exam was stable. You repeat catscan was also unchanged. You are ready for discharge with repeat imaging and follow up with neurosurgery. . The following medication was STOPPED: Aspirin 325mg PO Daily . Please take your other medications as prescribed Followup Instructions: Department: RADIOLOGY When: TUESDAY [2181-5-22] at 10:45 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SPINE CENTER When: TUESDAY [2181-5-22] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6214], MD [Telephone/Fax (1) 3736] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ***Attending Addendum*** After discharge, team discussed the need to restart aspirin, as it was held during the SDH and neurosurgery recommendations were for holding for 48 hours. The medicine resident called facility and asked for this to be restarted - see OMR. The plavix was held, reportedly, 10 days prior and it is unclear to me if this should be restarted, if at all. This will need to be addressed.	[ "362.50", "401.9", "E884.4", "185", "852.20", "V45.81", "294.8", "427.1", "225.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8158, 8261	5292, 6116	262, 268	8436, 8483	3315, 3315	9112, 10079	1741, 1745		7716, 8135		8282, 8282		7510, 7693			8618, 9089			3681, 5269								1760, 1760																2413, 3296	7379, 7484			213, 224								296, 1515			8348, 8415	6125, 7358	3331, 3665	8301, 8327	1774, 2399		8498, 8594					1537, 1632	1648, 1725
54,691	165,060	6479	Discharge summary	report	Admission Date: [2121-2-11] Discharge Date: [2121-3-5] Date of Birth: [2046-10-11] Sex: F Service: CARDIOTHORACIC Allergies: Blue Dye Attending:[First Name3 (LF) 165] Chief Complaint: fatigue, weak and dry cough Major Surgical or Invasive Procedure: [2121-2-18]: 1.aortic valve replacement with size 21 [Last Name (un) 3843]-[Doctor Last Name ] Magna Ease tissue valve 2. Coronary artery bypass graft x1 with saphenous vein graft to obtuse marginal-2 artery. 3. aortic endarterectomy History of Present Illness: 74 year old female who presented to [Hospital1 18] [Location (un) 620] with a dry cough for the last month. She tried different cough medications with no relief. She has been feeling progressively weak and tired despite minimal activity. She also has been feeling nauseated lately. She was found to be tachycardic up to 120 in the ED. She also became short of breath and chest xray showed worsening CHF and was treated with Lasix with good effect. She was also found to have new anemia but guaiac negative. Upper endoscopy revealed stomach ulcer. She was started on PPI, transfused and reports relief of GI symptoms. Echo revealed critical aortic stenosis. She was transferred to [Hospital1 18] for further evaluation on aortic stenosis. Past Medical History: Diabetes Mellitus type 2 Gastresophageal reflux disease Hypertension Hyperlipidemia Benign left breast lump Chronic kidney disease stage III (baseline Crt 1.2) Morbid obesity moderate Aortic stenosis Depression Past Surgical History: s/p cholecystectomy s/p appendectomy s/p left knee torn ligament repair s/p breast cyst removed s/p Hysterectomy s/p catarct surgery both eyes Social History: Race:Caucasian Last Dental Exam: upon admission to [Hospital1 18] now s/p extractions Lives with:alone, was in an abusive relationship with her husband Occupation: retired Tobacco: quit at 27 ETOH: denies Family History: non contributory Physical Exam: Pulse:95 Resp:18 O2 sat: 95/Ra B/P 143/77 Height: 64 inches Weight:104 kgs General: NAD, obese Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] s/p lens implants Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [2-2] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: None [] mild spider veins Neuro: Grossly intact x Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit: none Pertinent Results: [2121-2-28] 04:20AM BLOOD WBC-14.2* RBC-3.77* Hgb-10.2* Hct-31.3* MCV-83 MCH-27.1 MCHC-32.6 RDW-16.5* Plt Ct-368 [2121-2-23] 02:13AM BLOOD PT-14.5* PTT-28.7 INR(PT)-1.3* [2121-2-28] 04:20AM BLOOD Glucose-55* UreaN-40* Creat-1.7* Na-139 K-3.9 Cl-103 HCO3-26 AnGap-14 Pre-op labs [2121-2-11] 04:45PM PT-12.0 PTT-22.1 INR(PT)-1.0 [2121-2-11] 04:45PM PLT COUNT-305# [2121-2-11] 04:45PM WBC-12.2# RBC-3.88 HGB-9.7# HCT-30.6 MCV-79# MCH-24.9# MCHC-31.5 RDW-16.5* [2121-2-11] 04:45PM %HbA1c-7.9* eAG-180* [2121-2-11] 04:45PM ALBUMIN-3.5 CALCIUM-8.6 PHOSPHATE-4.9* MAGNESIUM-2.1 [2121-2-11] 04:45PM ALT(SGPT)-25 AST(SGOT)-20 LD(LDH)-249 ALK PHOS-83 TOT BILI-0.1 [2121-2-11] 04:45PM GLUCOSE-263* UREA N-30* CREAT-1.3* SODIUM-137 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [2121-2-11] 06:53PM URINE MUCOUS-RARE [2121-2-11] 06:53PM URINE HYALINE-4* [2121-2-11] 06:53PM URINE RBC-3* WBC-17* BACTERIA-FEW YEAST-NONE EPI-3 TRANS EPI-<1 [2121-2-11] 06:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2121-2-12] 9:07 am Staph aureus Screen Source: Nasal swab. Staph aureus Screen (Final [2121-2-15]):STAPH AUREUS COAG +. SPARSE GROWTH. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Aorta - Sinus Level: 3.7 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aortic Valve - Peak Gradient: 44 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: 0.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. No mass/thrombus in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Critical AS (area <0.8cm2). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [Name13 (STitle) 650] mitral annular calcification. Minimally increased gradient consistent with trivial MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing for slow sinus and transient first degree block. Well-seated bioprosthetic valve in the aortic position. No AI. Gradient is now 15 mmHg. Biventricular systolic function is now improved post- CPB. LVEF = 60%. Trace MR. Aortic contour is normal post decannulation. Brief Hospital Course: Ms [Known lastname 24876] was transferred from [Hospital1 18]-[Location (un) 620] to determine if she was a surgical candidate after echocardiogram revealed severe aortic stenosis. She underwent the usual cardiac surgery workup including dental exam, carotid US and cardiac catheterization. She needed extractions and was seen by oral surgery and had extractions of: teeth #3 and #28 on [2-13]. She was then brought to the operating [2121-2-18] for aortic valve replacement and coronary bypass grafting, please see operative report for details. In Summary she had: 1. Urgent aortic valve replacement with size 21 [Last Name (un) 3843]-[Doctor Last Name ] Magna Ease tissue valve. 2. Coronary artery bypass graft x1 with saphenous vein graft to obtuse marginal-2 artery. 3. Endoscopic harvesting of the long saphenous vein. 4. Aortic endarterectomy. Her bypass time was 110 minutes with a crossclamp of 95 minutes. She tolerated the operation well and post-procedure was transferred from the operating room to the cardiac surgery ICU in stable condition on Epinephrine and Neosynephrine infusions. Post-operatively she woke neurologically intact and was extubated on POD1. Additionally the Epinephrine and Neosynephrine infusion was weaned to off. She remained in the ICU to monitor cardiopulmonary status. On POD2 she had episodes of atrial fibrillation that were treeated with BBlockers and amiodarone, following which she converted to sinus rhythm at times requiring atrial pacing to support her hemodynamically. She remained hemodynamically stable over the next 48 hours and on POD4 was transferred to the cardiac stepdown floor for continued post-operative recovery. The remainder of her post-operative course was uneventful. All tubes lines and drains were removed per cardiac surgery protocol. She was seen by physical therapy to help with coordination and strengthening. On POD6 she developed an elevated white blood cell count, a urine culture revealed enterococcus and she was started on Augmentin. Her urine was resistant to Vancomycin and as discussed with ID, Linezolid was started and Augmentin discontinued. Here creatinine was slightly elevated to 1.7 with abaseline of 1.3- the lasix was discontinued. Requested renal labs to be checked on [2121-3-7]. On post-op day #15 she was transferred to rehabilitation at Newbridge on the [Doctor Last Name ]. All follow up appointments were advised. Medications on Admission: Medications at home: Lamictal ER 200mg Daily Bupropion SR 200mg Daily Prilosec 20mg Daily Zocor 20mg Daily Diovan 160mg Daily Levoxyl 75mcg Daily Novalog 14 units at 5pm Novolin 33 units at 8am and Novolin 58 units at HS Medications at [Hospital1 18] [Location (un) 620] Flagyl 500mg IV TID until Cdiff ruled out Cipro 250mg PO BID for 7 days Ferrous Sulfate 225 mg PO Daily Insulin NPH 36 units in am and 15 units at night plus aspart sliding scale with pre-meal Diovan 160mg Daily Metoprolol XL 50mg PO Daily Simvastatin 20mg Daily Lamictal 20mg Daily Levoxyl 75mcg Daily Prilosec 40mg PO BID for 1 month and then Daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO QAM (once a day (in the morning)). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 15. insulin regular human 100 unit/mL Solution Sig: sliding scale sliding scale Injection Q AC&HS. 16. NPH insulin human recomb 100 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: 20 units QAM 25 units QPM. 17. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 18. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 19. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 20. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: s/p AVR/CABG [2121-2-18] PMH Diabetes Mellitus type 2 GERD Hypertension Hyperlipidemia Chronic kidney disease stage III (baseline Crt 1.2) Morbid obesity moderate Aortic stenosis Depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- 2+ bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) 7772] on [2121-3-31] at 1:30 PM Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) ] [Telephone/Fax (1) 17753] on [2121-3-12] at 2:30PM Please call to schedule appointments with your Cardiologist: Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2121-3-5]	[ "V09.80", "250.00", "585.3", "428.23", "414.01", "530.81", "272.4", "403.90", "428.0", "599.0", "611.72", "285.1", "521.00", "278.01", "041.04", "424.1" ]	icd9cm	[ [ [] ] ]	[ "88.56", "39.61", "35.21", "23.19", "37.22" ]	icd9pcs	[ [ [] ] ]	12640, 12734	7570, 10015	303, 551	12972, 13200	2675, 5963	14116, 14710	1977, 1996		10697, 12617		12755, 12951		10041, 10041			13224, 14093					10062, 10674				1589, 1734	6007, 7547	2011, 2656																				235, 265								579, 1333														1355, 1566	1750, 1961
26,932	123,333	7266	Discharge summary	report	Admission Date: [2179-8-17] Discharge Date: [2179-8-22] Date of Birth: [2105-12-15] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 19836] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 73 yo female w PMH of Type I DM w CRI (BL Cr 1.3) and anemia of chronic disease, presented yesterday with SOB and reports of chest heaviness. Pt was in USOH until 1 wk ago when noted onset of cough and decreased urine output. [Name (NI) 1094] husband has cold and pt felt cough was secondary to viral illness. Cough was dry and awakening patient during the night. Denies fevers, chills, sore throat, runny nose. Also reports 12 pound weight gain and swelling in feet, legs up to abdomen. Pt denies similar symptoms in past. She denies syncope, however does report abdominal fullness, light-headedness and dizzyness. Per prior notes pt reported L sided chest discomfort, [3-6]. . In ED, patient was noted to have ST depression in lateral leads and was felt to be in ACS. Pt was given ASA 325, Heparin gtt, metoprolol, plavix load, SLNTG w/ relief. Pt was also found to be in ARF w/ Cr of 3.4. Therefore, Cath team decided to hold off on cath and proceed with medical management. Past Medical History: - Type 1 diabetes with renal insufficiency (Dr. [Last Name (STitle) 978] and Dr. [First Name (STitle) 10083] at [Last Name (un) ]); baseline creatinine 1.4, HgbA1C 7.8% - Anemia (~29-30), on Procrit BIW - Prepatellar bursitis - Bilateral foot drop - Osteoporosis - Hypothyroidism - Hyperhomocysteinemia Social History: Lives in [Location 3307] with her husband. Two married children. No tobacco, occasional EtOH, no illicits. Family History: Mother died at age [Age over 90 ] of old age. Sister died of ovarian CA in her 50's. Sister still alive at age [Age over 90 ]. No family history of stomach or esophageal cancer. Physical Exam: PHYSICAL EXAMINATION: VS: T BP 116/44 (94-116/40-44) HR 76 (76-89)92% on 4L NC I/O: Net negative [2131] Gen: WDWN female appearing younger than stated age lying comfortably in bed. AAOx3. Mood, affect appropriate. Pleasant. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: JVP to jawline. Supple. No [Doctor First Name ] CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. III/VI Holosystolic murmur heard best at LLSB Chest: Resp were unlabored, no accessory muscle use. Decreased BS at bases B/L. Crackles at L and R middle lung field posteriorly. No wheezes or rhonchi. Abd: thin, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: [1-30] + pitting edema bilaterally up to mid calf. No clubbing/cyanosis. Ecchymoses at R 3rd toe. erythema of dorsum R foot. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 1+ DP Left: 1+ DP Brief Hospital Course: 73 yo female w/ PMH Type I DM, chronic kidney disease, presented with weight gain, SOB, found to have bilateral pleural effusions, and acute renal failure. . #Acute Renal Failure Pt had a baseline creat of 1.3 prior to admission. At time of admission patient was noted to be in acute renal failure with creatinine of 3.4. Urine studies revealed a FeNa 4% and FeUrea 22% consistent w/ prerenal cause of renal failure. On thiazides, FeNa is likely inaccurate. Urine sediment was bland and there was an absence of urine eosinophils. Renal ultrasound demonstrated mild caliectasis of Right kidney. Ultrasound findings were not definitive for obstructive cause. Pelvic u/s and abdominal u/s were unrevealing. Patient was followed by renal team who felt etiology of renal failure was unclear. [Name2 (NI) ] showed rapid improvement with diuresis, however did not return to baseline. Pt may have established new baseline at 2.0. At time of discharge patient was at regular weight. Patient was sent home without thiazide or loop diuretic. . # Bilateral pleural effusions In the setting of depressed systolic funtion and acute renal failure, pleural effusions were likely secondary to volume overload and transudative fluid shifts. Patient initially required oxygen via nasal cannula, but with diuresis, we were able to wean her from her oxygen requirement. Patient was diuresed with lasix. . # Right foot erythema Patient was noted to have erythema and ecchymoses at base of third toe. Ecchymoses resolved but redness persisted. There was concern for fracture but foot films were negative. ERythema did not worsen and patient was sent home without antibiotics. DIrected to follow up with [Hospital6 ] within 1 week, earlier of redness worsened. . #CAD- Patient had signs of lateral ischemia on ECG. However had 3 sets of negative cardiac enzymes. ECG changes likely to be due to demand ischemia in setting of heart failure. We were unable to do cardiac catheterization while in acute renal failure. Patient will likely require stress test as outpatient. Pt was continued on betablocker and statin. . #DMT1- Patient was managed on home regimen of lantus 9 units in AM and was covered with novolog sliding scale. Medications on Admission: Asa 325 Amlodipine 10mg Hctz 50 mg Levothyrixine 25 mcg Irbesartan 150 mg daily Prilosec 9 units glargine qam; novolog sliding scale insulin prn pre meals Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Toprol XL 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:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Acute renal failure Congestive heart failure Diabetes Mellitus Type I Discharge Condition: Stable, no shortness of breath, resolved peripheral edema. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please set up follow up appointment in [Hospital6 733] with your primary care physician. [Name Initial (NameIs) ] ([Telephone/Fax (1) 26876] to set up an appointment. Also set up an appointment at [Last Name (un) ] to see Dr. [First Name (STitle) 10083] at [Hospital ] Clinic ([Telephone/Fax (1) 17484]. We have changed some of your medications. Changes include: Atorvastatin 80mg once daily Toprol XL 25mg once daily We have discontinued the following: Amlodipine 10mg Hctz 50 mg Irbesartan 150 mg daily Please avoid taking these medications unless otherwise directed by your physician. If you have shortness of breath, chest pain, swelling of your lower extremities, please contact your primary care physician or return to the emergency room. Followup Instructions: Follow up with Dr. [Last Name (STitle) 9006] in [Company 191] and Dr. [First Name (STitle) 10083] at [Last Name (un) ]. See phone numbers above. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD, [MD Number(3) 19838]	[ "270.4", "428.0", "585.9", "250.41", "285.21", "511.9", "414.01", "584.9", "244.9", "411.1", "733.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5990, 5996	3027, 5243	337, 343	6118, 6179		7108, 7382	1843, 2030		5449, 5967		6017, 6097		5269, 5426			6203, 7085											2045, 2045													2067, 3004							278, 299								371, 1359														1381, 1698	1714, 1827
48,005	156,628	36471	Discharge summary	report	Admission Date: [2154-3-12] Discharge Date: [2154-3-29] Date of Birth: [2073-9-15] Sex: F Service: MEDICINE Allergies: Cefazolin / Heparin Agents Attending:[First Name3 (LF) 458] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Transesophageal Echocardiogram Cardiac catheterization x2 with bare metal stent to Right coronary Artery DC Cardioversion History of Present Illness: Mrs. [Known lastname ] is an 80 yo woman with HTN HL CAD who p/w abd pain to OSH. She was hypotensive in the ER there. started on dopamine. CK 65 trop 0.19, bmp 463. new onset afib. started on heparin. EKG showed STE in II III aVF. given aspirin and plavix. ?LLL infiltrate. recd aztreonam. was xferred here for PCI. . She reports no CP/abd pain here in CCU . In the cath lab, she had a mid-RCA total occlusion with thrombus. She underwent thrombectomy and eventual BMS implantation. She required dopamine for blood pressure support through the case. Past Medical History: CAD s/p LAD stent in 03 SSS s/p pacemaker CRI CHF MR [First Name (Titles) ] [Last Name (Titles) 2182] Hyperparathyroidism HTN HL . Cardiac Risk Factors: Dyslipidemia, Hypertension Social History: tob:quit in 82. smoked 1 ppd for 20 yrs. no etoh. no illicits. lives with youger sister. drives regularly. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 98.9 86 113/58 14c 100/2l Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic murmur best heard at apex. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [2154-3-12] 09:05PM LACTATE-1.1 [2154-3-12] 05:39PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.036* [2154-3-12] 05:39PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2154-3-12] 05:39PM URINE RBC-[1-31]* WBC-[1-31] BACTERIA-OCC YEAST-NONE EPI-0 [2154-3-12] 05:25PM POTASSIUM-4.3 [2154-3-12] 05:25PM CK(CPK)-3391* [2154-3-12] 05:25PM CK-MB-486* MB INDX-14.3* [2154-3-12] 05:25PM HCT-28.4* [2154-3-12] 05:25PM PLT COUNT-186 [2154-3-12] 02:54PM GLUCOSE-105 UREA N-72* CREAT-2.0* SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 [2154-3-12] 02:54PM CK(CPK)-3422* [2154-3-12] 02:54PM CK-MB-GREATER TH cTropnT-14.93* [2154-3-12] 02:54PM CALCIUM-7.3* PHOSPHATE-5.8* MAGNESIUM-1.4* [2154-3-12] 02:54PM WBC-20.5* RBC-3.24* HGB-9.5* HCT-28.9* MCV-89 MCH-29.3 MCHC-32.9 RDW-17.7* [2154-3-12] 02:54PM NEUTS-94.8* LYMPHS-3.0* MONOS-2.0 EOS-0.1 BASOS-0 [2154-3-12] 02:54PM PLT COUNT-180 [2154-3-12] 02:54PM PT-13.5* PTT-140.3* INR(PT)-1.2* [2154-3-12] 02:36PM TYPE-ART TEMP-37.1 O2-100 PO2-141* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 AADO2-548 REQ O2-89 INTUBATED-NOT INTUBA COMMENTS-NRB [2154-3-12] 02:36PM O2 SAT-98 [2154-3-12] 11:20AM TYPE-ART O2 FLOW-45 PO2-64* PCO2-42 PH-7.35 TOTAL CO2-24 BASE XS--2 COMMENTS-NP [2154-3-12] 11:20AM HGB-10.6* calcHCT-32 O2 SAT-91 [2154-3-12] 09:30AM GLUCOSE-125* UREA N-69* CREAT-2.0* SODIUM-133 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-18 [2154-3-12] 09:30AM estGFR-Using this [2154-3-12] 09:30AM CK(CPK)-2296* ALK PHOS-89 [2154-3-12] 09:30AM ALBUMIN-3.2* EKG demonstrated STE in II III aVF . CARDIAC CATH:1. Selective coronary angiography demonstrated two (2) vessel coronary artery disease. The right coronary artery was diffusely diseased with a total occlusion in the mid-distal portion of the vessel without any flow. The left main demonstrated no flow limiting lesions. The left anterior descending artery demonstrated a 30% proximal lesion along with a widely patent stent in the mid portion of the vessel. The left circumflex demonstrated demonstrated mild luminal irregularities throughout. 2. Limited hemodynamics demonstrated low central aortic pressure (100/70 mm Hg) while on dopamine gtt. The rhythm throughout the case was atrial fibrillation with occasional pacing from her pacemaker. 3. Successful PTCA, thrombectomy and stenting of the mid-distal RCA with a Vision (3x18mm) bare metal stent. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI II flow throughout the vessel (See PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA, thrombectomy and stenting of the mid-distal RCA with a bare metal stent. . TTE:The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with moderate to severe hypokinesis of the basal to mid inferior and inferolateral segments. The other segments have hyperdynamic function. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are mildly thickened. There is partial mitral leaflet flail. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional LV systolic dysfunction consistent with inferior infarction/ischemia. Moderate to severe mitral regurgitation with poor leaflet apposition. This may be due to ischemic papillary muscle dysfunction or possible partial flail of the mitral leaflet. At least mild aortic stenosis. Moderate pulmonary artery systolic hypertension. If clinically indicated, a TEE may better define mitral valve pathology. . TEE: The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left or right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%) with inferolateral hypokinesis. The aortic valve leaflets are moderately-to-severely thickened/deformed. No masses or vegetations are seen on the aortic valve. There is moderate aortic valve stenosis (area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IABP seen in the descending aorta. IMPRESSION: Thickened mitral valve leaflets with moderate (+2) MR. Posterior mitral leaflet appeared teathered, likely secondary to ischemia. No mitral leaflet flail seen. Severely thickened aortic valve leaflets with moderate aortic stenosis. IABP seen in the descending aorta. Dr. [Last Name (STitle) ] was notified in person of the results at the end of study. Compared with the prior study (images reviewed) of [2154-3-13], the mitral valve is more clearly seen. The anterior leaflet appears thickened and does not properly appose with the posterior leaflet, likely due to ischemic dysfunction of the postero-medial papillary muscle. The aortic valve stenosis appears moderate on the current study. . Renal US: 1. No hydronephrosis. 2. Simple renal cysts bilaterally. 3. Arterial and venous flow documented in each renal hilum, but overall this is a very limited Doppler examination and no further assessment can be made. . Lower extremity ultrasound: 1. No evidence of arterial occlusion or thrombus. 2. Monophasic waveforms, suggestive of focal or multifocal stenoses. Recommend further evaluation with dedicated noninvasive arterial imaging. Evaluation or CTA or MRA can be obtained if clinically indicated. . Discharge labs: Brief Hospital Course: #. Inferior STEMI: s/p primary PCI to the mid-RCA. Was continued on aspirin 325, clopidogrel 75. Patient was started on amiodarone therefore home dose of simvastatin 80mg was decreased to 20mg. Coreg and lisinopril were held in setting of hypotension (see below). Patient did not have any further episodes of chest pain. # Hypotension: Initially the differential was cardiogenic vs septic shock. Although she had leukocytosis this could be explained by the STEMI and she had no fevers or signs of infection so the conclusion was that this was secondary to cardiogenic shock. She was started on dopamine for inotropic and pressure support. Despite the small area of RV that was affected by the STEMI and the very good angiographic result she continued to require large [Year (4 digits) 4319] of dopamine and her urine output continued to be minimal. A DCCV was done as it was thought that with NSR she would have more CO and shock would get better, however the patient converted back into a fib/flutter within one day. A TTE was done to assess her cardiac function. This showed flail mitral leaflet. In the setting of this an IABP was inserted to help with her pressures and a TEE was done to further assess the valve. On TEE there was no evidence of a flail leaflet but she did have ischemic changes of her posterior chordae consistent with her RCA infarct. A repeat cath was done and the RCA stent continued to be patent. She was continued on dopamine and because of severe volume overload a lasix gtt was started. She continued to have poor urine output despite the lasix and thus CVVH was initiated. On [2154-3-17], pacer termination was attempted, and the patient converted into normal sinus rhythm. Despite being in this a sensed, v paced rhythm, her pressures did not improve. She also had a repeat TTE the same day which showed no improvement in MR despite volume removal. She was started on dobutamine with improvement in her hemodyamics and the balloon pump was able to be weaned and discontinued on [3-19]. Dobutamine weaned off by [3-20]. She remained hemodyamically stable even with fluid removal during dialysis. She was continued on hydralazine and imdur. . # ARF: Patient developed ARF after catheterization and in setting of cardiogenic shock/CHF. She was initially started on lasix gtt to improve diuresis, forward flow, and potentially kidney function, however she continued to be oliguric and thus was started on CVVH for volume management. After almost 2 weeks of supportive care with no improvement in creatinine or urine output, a decision was made to initiate hemodialysis to be continued short vs long term as an outpatient. . # Diarrhea: Patient developed intermittent diarrhea, however C Diff was negative x4 during hospital course. #. Rhythm: On admission patient had new onset afib. She was started on a heparin gtt. A DCCV was done to improve CO as above but the patient converted back into AF after 1 day. It was noted that when the patient was a-paced her BPs were better, however, it was difficult to keep her out of AF. She also developed pacemaker mediated tachycardia. Her ppm was interrogated and the PVARP was increased to keep this from happening and she continued to be a-v paced. She was started on amiodarone with improvement in her rate control and cardiac output. It was felt that given her low platelets, she should not be on full anti-coagulation at this time and was continued on a full dose aspirin. # HTN: Held amlodipine, BB, ACE as pt hypotensive as above. She continued to have systolic blood pressures in 80-110's despite all anti-hypertensives being held but with stable hemodynamics. #. [Month/Year (2) 2182]: Continued home combivent #. Hyperparathyroidism: Continued sensipar #. Thrombocytopenia: Platelet count on admission was 180K, however it subsequently underwent gradual decline with waxing ad [Doctor Last Name 688] course with nadir of 44K. Initially it was thought to be secondary to intr-aortic balloon pump and indeed improved slightly after removal of the pump. It remained low however. DIC labs were negative and HIT antibody was negative x1. Hematology-oncology was consulted for further recommendations who felt that it was most likely due to medication effect versus decreased production possibly with underlying undiagnosed MDS contributing. Repeat HIT testing was marginally positive however heme-onc felt that this was most likely false positive and recommended confirmatory serotonin assay which is pending at time of discharge. They felt that there was less than 5% chance that this represents HIT, however will avoid heparin exposure and monitor platelet count daily until confirmatory testing available. Heme-onc outpatient appointment scheduled. Medications on Admission: allopurinol 100 sensipar 30 qhs combivent 1-2 puffs q 6h carvdilol 6.25 [Hospital1 ] ferrous sulfate 325 TID klor con 10meq tab daily lasix 120 [Hospital1 ] nexium 40mg daily amlodipine 10mg daily robitussin 10cc q4h prn simvastatin 80 qhs lisinipril 20mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): give every day, do not miss [First Name (Titles) 691] [Last Name (Titles) 4319]. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours): apply to neck area. 8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [11-30] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 700] TCU - [Location (un) 701] Discharge Diagnosis: ST Elevation Myocardial Infarction Coronary Artery Disease Hyperlipidemia Hypertension Acute Renal Failure secondary to Acute Tubular Necrosis Thrombocytopenia Peripheral Vascular Disease with transient ischemia Left lower extremity. Discharge Condition: Stable Discharge Instructions: You had a heart attack and a bare metal stent was placed in your right coronary artery. You will need to take Plavix for one month, do not miss any days or stop taking Plavix unless Dr. [Last Name (STitle) ] tells you to. You also had acute kidney failure because of the contrast during your catheterization. You will need hemodialysis to remove wastes from your blood. Your platelets dropped to a very low level, we are monitoring this closely and expect them to go back up again. A lot of your medications were changed during this hospital admission. Please refer to the discharge paperwork for your new list of medications. . Please call Dr. [Last Name (STitle) ] if you notice any bleeding, increasing bruising, chest pain, trouble breathing, increasing cough, fevers or any other unusual symptoms. Followup Instructions: Primary care: [Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 17919] Please make an appt to see Dr. [Last Name (STitle) 17918] 2 weeks after to leave the rehabilitation facility Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5448] and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 62] Date/time: [4-26] at 10:00am. [Location (un) 436]. [Hospital Ward Name 23] clinical Center, [Hospital Ward Name 516], [Hospital1 18], [Location (un) 830] Cardiac Surgery: Dr. [Last Name (STitle) 914] Phone:([Telephone/Fax (1) 11763] [Location (un) ]. [Hospital Ward Name ] Office Building, [Last Name (NamePattern1) 439], [Location (un) 86]. Date/time: [4-23] at 1:15pm. You will need a referral to see Dr. [Last Name (STitle) 914] from your primary care doctor Completed by:[2154-4-3]	[ "V45.01", "584.5", "428.33", "427.31", "276.1", "496", "E947.8", "997.5", "440.21", "416.8", "707.21", "E879.8", "414.2", "585.9", "274.9", "300.00", "998.12", "707.07", "424.1", "424.0", "E879.0", "285.9", "287.5", "414.01", "428.0", "272.4", "V45.82", "410.41", "788.5", "252.00", "787.91", "403.90", "785.51" ]	icd9cm	[ [ [] ] ]	[ "37.61", "00.45", "88.72", "00.40", "00.66", "88.56", "38.91", "37.21", "39.95", "96.71", "38.95", "37.22", "99.61", "96.04", "36.06" ]	icd9pcs	[ [ [] ] ]	14877, 14953	8447, 13209	297, 421	15231, 15239	2297, 2297	16099, 17047	1360, 1442		13530, 14854		14974, 15210		13235, 13507		5086, 8406	15263, 16076			8424, 8424								1457, 2278																				247, 259								449, 1007					2313, 5069									1029, 1219	1235, 1344
19,879	136,832	28677	Discharge summary	report	Admission Date: [2156-9-19] Discharge Date: [2156-9-23] Date of Birth: [2100-8-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 56m with HTN, DM2, PVD, ESRD on MWF-HD, and a recent admit with rehab stay for finger/toe osteomyelitis s/p amputations presents with LH and hypotension. For the past 5d he noted watery, non-bloody diarrhea, with approximately [5-5] stools per day; he notes that his rehab roomate was diagnosed with C. difficile. He underwent full HD 2d PTA. The morning of admission, his systolic bp was in the 150's, similar to usual. About 1.5h after taking all of his medications (which have not undergone any recent significant change) together, he became lightheaded and found his systolic to be in the 60's. He called EMS who confirmed the BP. In the ED he was given 4L NS, and was found to be hyperkalemic at 6.4 and received calcium, bicarbonate, insulin/glucose, and kayexylate. He also received levofloxacin, metronidazole, and vancomycin for possible sepsis. . In the midst of fluids, treament of his hyperkalemia, and treament of his subsequent hypoglycemia, his SBPs rebounded to the 140's. . In the ED lateral ST depressions were noted on his ECG, which were felt to be due to LVH. Upon arrival to the ICU, he developed 6/10 chest pain and dyspnea that gradually resolved completely with 2 sl ntg, 6mg of morphine, and a ntg gtt that were all started roughly at the same time. He denies any history of CAD, prior caths, prior chest pain, or prior dyspnea episodes. . No recent fever/chills, sweats a few days ago, no ha, cough, sputum, hemoptysis, abd pain, n/v. Makes no urine. Past Medical History: -HTN -DM2 -PVD s/p multiple amputations -ESRD on HD MWF; s/p failed xpl in [2145] (lasted until [5-/2155]), back on hd since [5-/2155] -Recent osteomyelitis 2nd left toe, tip of left forefinger s/p amputations -History of meningitis -History of C. diff colitis Social History: Lives alone at home. His brother and brother's wife (an aide) are in close and nearly constant contact, as are his three children. They are very involved in his care and provide a great deal of support. In addition, he has a VNA who comes to help. He denies ever smoking, but was exposed to cigarettes as a child. No significant etoh abuse. Family History: His parents were healthy as far as he knows, as are his kids. All of his siblings suffer from DM, HTN, and PVD. No known fhx of CAD. Physical Exam: PE: t 97.7, bp 163/67, hr 98, rr 16, spo2 100% 2Lnc gen- chronically but not acutely ill-appearing, pleasant, fair functioning, non-tox, nad heent- anicteric, op with mmm neck- no jvd/lad/thyromegaly cv- rrr, s1s2, [3-8] systol murmur at ulsb chest- no chest wall tenderness, no tenderness at right HD-line site or tenderness along line pul- moves air fairly well, decreased at bases with few bibasilar rales abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm/dry, multiple digital amputations nails- no clubbing neuro- a&ox3, no focal cn deficits Pertinent Results: 133 98 81 -------------< 138 6.4 19 7.3 Ca: 8.3 Mg: 2.1 ALT: 24 AP: 211 Tbili: Alb: 3.9 AST: 23 [Doctor First Name ]: 136 Acetone:Negative 88 7.0 > 11.8 < 183 35.0 PORTABLE AP CHEST RADIOGRAPH: There is a hemodialysis catheter within the right subclavian vein, with the tip positioned in the right atrium. The heart and mediastinal contours are normal. Pulmonary vasculature is within normal limits. The lungs are clear. No pleural effusion or pneumothorax is seen. The soft tissue and osseous structures are within normal limits. IMPRESSION: No acute cardiopulmonary abnormalities are identified ECHO: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: A/P: 56m with HTN, DM2, ESRD on HD presents with lightheadedness and hypotension likely due to volume shifts and hypovolemia. . #Hypotension: The most likely explanation is a combination of dialysis, diarrhea, and multiple blood pressure medications. He had no additional signs to support sepsis or adrenal insufficiency. His exam, ECG, and enzymes don't support ACS or cardiogenic shock. A TTE showed mild LVH, normal EF, and diastolic dysfunction. After IVFs and withholding his medications, his blood pressure became normo-, then hypertensive. The hypertension was eventually controlled by re-instituting his regular medications and increasing his dose of lisinopril. . #Chest pain: His ECG showed T wave changes consistent with LVH and these changes were not dynamic with the pain. In addition though he had mildly elevated troponin, he had no CK elevation and has concurrent renal failure. He was continued on asa and labetalol and atorvastatin was started. . #Diarrhea: A C. Diff toxin assay was negative, and his diarrhea did not continue during his hospitalization. . # ESRD: He tolerated HD without further hypotension or complications. . # DM2: He continued his home regiemn of glargine and sliding scale insulin; [Doctor First Name ] diet. Medications on Admission: -Labetalol 800mg [Hospital1 ] -Lisinopril -Nifedipine -Novolog SSI -Glargine 8units qHS Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 7. Insulin Lispro (Human) 100 unit/mL Solution Sig: Six (6) units Subcutaneous three times a day: Pre-meal dose. 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: Sliding scale units Subcutaneous four times a day: For glucose 151-200: 2U; 201-250: 4U; 251-300, 6U; 301-350, 8U; 351-400: 10U, >400: 12U. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Diagnosis: Hypotension Secondary: End Stage Renal Disease Hypertension Perpheral vascular disease Diabetes Mellitus type II History of osteomyelitis Discharge Condition: Stable Discharge Instructions: Please take your medications as noted. You take 800 mg Labetolol one tablet in the morning and one in the evening, 120 mg Nifedipine once a day, and we increased your Lisinopril to 40 mg once a day. Please contact your doctor if you have fever, lightheadedness, dizziness, shortness of breath, headache, chest pain, or other concerning symptoms. Followup Instructions: Please see Dr. [Last Name (STitle) 118] if you are unable to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 25699] at the VA in the near future. The phone number to call for Dr. [First Name (STitle) 25699] is [Telephone/Fax (1) 69372]. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 435] Date/Time:[2156-11-2] 10:30	[ "V58.67", "275.41", "276.50", "403.01", "585.6", "276.2", "250.80", "786.50", "276.7", "414.01", "787.91", "V49.72" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.93" ]	icd9pcs	[ [ [] ] ]	6770, 6827	4505, 5764	325, 339	7029, 7038	3249, 4482	7433, 7874	2521, 2656		5907, 6747		6848, 6848		5790, 5884			7062, 7410											2671, 3230																				274, 287								367, 1851						6867, 7008								1873, 2147	2163, 2505
57,467	173,831	36950	Discharge summary	report	Admission Date: [2142-7-17] Discharge Date: [2142-7-18] Date of Birth: [2080-3-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7333] Chief Complaint: fatigue, increased leg edema, dyspnea on exertion, recurrent atrial fibrillation/flutter Major Surgical or Invasive Procedure: Atrial Tachycardia Ablation History of Present Illness: 62 year old patient of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 65453] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] with recurrent atrial fibrillation, who underwent left atrial tachycardia ablation, now transferred to the CCU for closer monitoring. . This 62 year old gentleman has a long history of atrial fibrillation/atrial flutter dating back to [2130]. He has had multiple cardioversions over the year and ultimately had an atrial flutter ablation in [2132]. He developed recurrent atrial fibrillation in [2133]-[2134] and had an atrial fibrillation ablation that was complicated by a pericardial effusion in [2136]. He developed recurrent atrial fibrillation about 6 months later. He reports that had another type of atrial ablation in [2138]. He had been doing well from [2138] to [2142-4-6]. He had suffered a fall with an injury to his ankle. He also had a lapse in his Flecainide for approximately 10 days. He underwent cardioversion in [2142-5-7] on [Hospital3 ] and then went back into afib/flutter again 4-5 days later and had another cardioversion in early [Month (only) 205] [2141]. He remained in sinus rhythm for about 2 days when he reverted again back to atrial fibrillation accompanied by severe shortness of breath. He was started on Diltiazem in addition to his Flecainide and Amiodarone and reports that he has spontaneously converted back to ? atrial tachycardia, according to the patient. . Admitted for ablation yesterday. Was cardioverted into junctional rhythm after procedure then sent to PACU- remained intubated. Extubated around midnight and observed before being sent to the CCU. Sheath removed at 2045. . On arrival to the CCU, vitals are T 99.1, HR 80, BP 125/75, RR 18, Sa02- 95% on CPAP. Patient doing well. Stable. No clinical complaints. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . While in atrial fibrillation, he experiences fatigue, increased leg edema and dyspnea on exertion. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertensive heart disease Asthma Hyperlipidemia Atrial fibrillation/atrial flutter s/p atrial fibrillation ablation Obstructive sleep apnea, uses CPAP (requested to bring with pt) cardiomyopathy Hypothyroidism Social History: Lives with: Married and has an 18 year old son and 14 year old daughter. Occupation: Owns a broadcasting company for radio stations on [Hospital3 ] ETOH: No Tobacco: No Contact person upon discharge: Wife: [Telephone/Fax (1) 83360]. Home Services: No Family History: father died of [2142-2-4] at age 88 . Had CABG in his 70s. Mother has afib. 2 brother have afib, 1 has had ablation. 3 sisters are healthy. . (-) TIA (-) CVA (-) Melena/GIB Physical Exam: VS: T 99.1, HR 80, BP 125/75, RR 18, Sa02- 95% on CPAP GENERAL: Awake, alert. NAD. Oriented, pleasant. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: No LAD. Supple. JVP unable to be assessed. CARDIAC: 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: Obese. Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: Trace-1+ pitting edema b/l. No cyanosis or clubbing. No femoral bruits. No hematoma, ecchymosis or signs of infection at sheath site. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP dopplerable PT dopplerable Left: Radial 2+ DP 2+ PT dopplerable Pertinent Results: No studies/additional imaging on this admission. . On admission: WBC 7.6, Hb 13.1, Hct 41.1, plt 303 Na 139, K 4.0, Cl 106, bicarb 25, BUN 17, Cr 1.1, glu 117 . On discharge: WBC 11, Hb 12.4, Hct 38.8, plt 281 Na 143, K 4.0, Cl 106, bicarb 26, BUN 16, Cr 1.2, glu 108 Brief Hospital Course: 62 y/o male with long-standing history of refractory and recurrent A-fib/flutter despite multiple ablations and antiarrhythmic treatments admitted to the CCU s/p repeat atrial ablation. . # RHYTHM: s/p left sided AT ablation [2142-7-17]. Had to be cardioverted post ablation into junctional rhythm. Held all nodal blocking agents for 12 hours, and patient remained in NSR. Prior to discharge, pt had been in NSR x 24 hours, and was restarted on his home amiodarone and flecainide. His diltiazem was discontinued, as it was originally started for rate control, and he does not require rate control currently. Pt was re-started on his home coumadin regimen. INR 2.7 on discharge. . # Visual disturbance - pt mentioned mild visual disturbance, left eye, felt to be related to retinal artery floaters, post-procedure. Visual field testing performed without deficits and neurologic exam without abnormalities. Patient instructed to see opthalmology if persistent, although symptoms are expected to resolve within 24-48 hours. . # CORONARIES: pt was continued on his home aspirin and zocor. He was discharged on this regimen. . # PUMP: EF of 40-45%. No signs of overt fluid retention on exam, with trace BLE edema. Pt was given lasix 20 mg IV prior to discharge. . # OSA - CPAP per home settings were continued. Per respiratory therapy, pt was requiring increased CPAP settings to maintain oxygenation. Given his 60-80 lb weight gain, and the fact that his last sleep study was 8+ years ago, pt was referred for another sleep study at [Hospital1 18]. . # Hyperlipidemia - low fat, low cholesterol diet was continued. Zocor per home regimen was continued. . # HTN - stable, continued on low Na diet. . # Hypothyroidism - stable, was continued on home Lexothyroxine 75mcg daily. . # Anticoagulation - INR 2.7 on discharge. Goal INR [1-9]. Patient will resume home regimen of coumadin on discharge. . # Dispo: discharge to home Medications on Admission: Amiodarone 100mg daily ([12-8] of 200mg) Flecainide 150mg [Hospital1 ] Cardizem 60mg 1 tablet 3 times daily Levothyroxine 75mcg daily Warfarin 5mg/7.5mg alternating doses, instructed to take 5mg MON night per Dr. [Last Name (STitle) ] for INR of 2.9 on Monday Zocor 20mg daily Aspirin 325mg daily Vitamin C 2000mg daily Vitamin D3 2000mg [Hospital1 ] Vitamin E 4000 IU daily Salmon oil 1000 daily DHA daily Cod liver oil daily Carnatine daily L- carnatine Tumeric daily Cursamin daily Alphalipoic acid 600mg daily Calcium-magnesium-potassium [Hospital1 ] Magnesium 400mg [Hospital1 ] Arginine daily Boron daily Chromium Albuterol PRN for SOB Discharge Medications: 1. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. Flecainide 150 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day. 4. Warfarin 5 mg Tablet Sig: 1 - 1 [12-8] Tablet PO once a day: Per INR. 5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. Vitamin C 1,000 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Vitamin D-3 2,000 unit Tablet Sig: Two (2) Tablet PO once a day. 9. Vitamin E Oral 10. Salmon Oil-1000 1,000-200 mg Capsule Sig: One (1) Capsule PO once a day. 11. DHA-EPA-Policos-B6-B12-FA-Phyt Oral 12. Cod Liver Oil Capsule Sig: One (1) Capsule PO once a day. 13. carnatine Sig: One (1) once a day. 14. l-carnatine Sig: One (1) once a day. 15. tumeric Sig: One (1) once a day. 16. cursamin Sig: One (1) once a day. 17. Alpha Lipoic Acid 300 mg Capsule Sig: Two (2) Capsule PO once a day. 18. calcium magnesium potassium Sig: One (1) twice a day. 19. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Arginine (L-Arginine) Oral 21. boron Sig: One (1) once a day. 22. Chromium Oral 23. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation q 4-6 hours as needed for shortness of breath or wheezing. 24. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: For 4 weeks. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 25. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 26. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for chest pain. Discharge Disposition: Home Discharge Diagnosis: Atrial Tachycardia Ablations Atrial Fibrillation/Atrial Tachycardia Hypertension Hyperlipidemia Asthma OSA Hypothyroidism Discharge Condition: v/s: afeb, 91% on RA, HR 82, BP Lungs: CTAB CV: RRR Ext: mile peripheral chronic edema Discharge Instructions: You had an atrial tachycardia ablation for recurrent atrial arrhythmias. There were no complications. You were in the CCU overnight so we could monitor your breathing. You are now in normal sinus rhythm. You had some visual changes that may be from a tiny blood clot in the vessels near your eye. This should resolve on its own. Please make an appt to see your opthamologist to get a thorough eye exam. The opthamologist will tell you if your vision is adequate for driving. Please take all medications as prescribed. No pools or baths for one week. You may shower and cover the groin access sites with a band-aid. No driving for 48 hours. . Medication changes: 1. You will be started on omeprazole 40 mg daily for 4 weeks. 2. Start a baby aspirin 81 mg daily 3. STOP taking Cardizem If you have chest pain, shortness of breath, pain/swelling at groin sites, fever - please call Dr. [First Name (STitle) 65453] Followup Instructions: Cardiology electrophysiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 33732] Date/time: [8-10] at 1:00pm. . Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 65453] Phone: [Telephone/Fax (1) 77632] Date/time: Please keep your previously scheduled appt on [8-2] Completed by:[2142-7-18]	[ "427.89", "327.23", "272.0", "427.32", "425.4", "402.90", "427.31", "244.9" ]	icd9cm	[ [ [] ] ]	[ "37.27", "37.34" ]	icd9pcs	[ [ [] ] ]	9215, 9221	4840, 6782	404, 433	9387, 9475	4548, 4599	10440, 10837	3479, 3662		7499, 9192		9242, 9366		6808, 7476			9499, 10142											3677, 4529																4723, 4817			10162, 10417	276, 366							3407, 3463	461, 2952							4613, 4709							2974, 3186	3202, 3390
52,467	175,409	27799	Discharge summary	report	Admission Date: [2147-1-27] Discharge Date: [2147-1-31] Date of Birth: [2077-12-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Central Venous Line x2 Arterial Line History of Present Illness: This is a 69M with CAD, CHF, PVD, aplastic anemia (last transfusion [1-25]), and DM2, who presented to the ED after his family called EMS for agonal breathing. He was intubated in the field and brought to the ED. As he is intubated and sedated, history is obtained from the online medical record and family. In the ED, he was fighting the vent; he had poor peripheral access, so a groin line was placed. While placing the groin line, no femoral pulse was present and the rhythm on the bedside monitor was wide complex. Epinephrine was given via ETT and once venous access was obtained, CaCl2, bicarb, and insulin were administered. He never received chest compressions, as spontaneous circulation returned quickly (<45 seconds, according to ED resident). He received kayexalate via OG tube. He is receiving 2 units of PRBCs for Hct of 21. Vital signs at the time of transfer were afebrile, pulse 120s, SBP 130s-140s, vented with good O2 saturation. ROS: Unable to obtain Past Medical History: # Diabetes Mellitus type 2 # Hypertension # Chronic Kidney Disease, Cr 1.6-1.9 # Coronary Artery Disease s/p balloon angioplasty in [2133] & NSTEMI in [9-/2146] # scar-mediated VT, s/p failed ablation # aplastic anemia/MDS, Hct 25-28 & transfusion dependent (most recent was [1-25] for Hct of 22.1); platelets usually 70-130k; WBC usually 3.0-4.0k. # Peripheral Vascular Disease s/p R fem-[Doctor Last Name ] bypass in [Month (only) 216], [2138] # s/p right Carotid Endarterectomy in [2135-1-26]; left carotid artery completely occluded but asymptomatic # s/p right 5th toe amputation in [2137-6-25] Social History: He is retired. He worked as a maintenance worker at [Hospital1 2177] for 25 yrs. He is widowed but has a son and daughter-in-law in town who he stays in close touch with. He lives by himself in poor financial circumstances. He has smoked one and a half packs of cigarettes/day for at least 50 years. He denies alcohol or other drugs. Family History: His mother and sister have diabetes mellitus type two. Many members of his family have hyptertension. Physical Exam: On Presentation: Vitals: T:92.6 BP:133/83 HR:65 Vent: AC 600x14(24), 5 PEEP, 40% FiO2 O2Sat: 99% GEN: thin elderly male intubated, nonresponsive, after receiving versed in the ED HEENT: EOMI, PERRL 4-2mm and brisk, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses doppler on R, 1+ on Left, where there is a large hematoma PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: + gag, + corneals, but no withdrawal to pain/noxious stimuli SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. No petechiae Pertinent Results: IMAGING: CT A/P: Prelim read: Limited noncontrast evaluation. Bilateral moderate pleural effusions and bibasilar consolidations likely representing aspiration in the setting of recent cardiac/respiratory arrest. Mild free abdominal fluid and anasarca. Large gallstone. No definite evidence for acute intra-abdominal process. HEAD CT: No evidence of hemorrhage. Multifocal areas of cortical and subcortical hypodensity represent chronic infarct, though further evaluation with MRI may be pursued to evaluate for acute or subacute components. ECHo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with akinesis of the inferior, infero-lateral, distal LV/apical segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. ADMISSION LABS: -[2147-1-27] BLOOD WBC-3.2* RBC-1.83* Hgb-6.8* Hct-21.0* MCV-116* MCH-37.1* MCHC-32.1 RDW-20.9* Plt Ct-28# -[2147-1-27] BLOOD PT-28.8 PTT-90.5* INR(PT)-2.9* -[2147-1-28] BLOOD FDP->1280* -[2147-1-28] BLOOD Glucose-235* UreaN-120* Creat-4.7* Na-142 K-5.7* Cl-107 HCO3-10* AnGap-31* -[2147-1-28] BLOOD ALT-1592* AST-1808* LD(LDH)-2890* CK(CPK)-9394* AlkPhos-147* TotBili-4.3* DirBili-2.6* IndBili-1.7 -[2147-1-28] BLOOD CK-MB-60* MB Indx-0.6 cTropnT-1.14* -[2147-1-28] BLOOD Albumin-3.6 Calcium-10.2 Phos-10.6# Mg-3.5 -[2147-1-28] BLOOD Hapto-<20* -[2147-1-28] BLOOD D-Dimer-8754* -[2147-1-28] BLOOD Cortsol-158.6* -[2147-1-27] BLOOD [Year/Month/Day ]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG -[2147-1-27] BLOOD pO2-502* pCO2-23* pH-7.05* calTCO2-7* Base XS--23 -[2147-1-27] BLOOD Glucose-GREATER TH Lactate-12.5* Na-134* K-6.3* Cl-106 calHCO3-9* Brief Hospital Course: 69M with multiple medical problems including DM2, CAD, CHF, aplastic anemia, CKD, who presented to the ICU s/p respiratory and cardiac arrests with hyperkalemia, acute on chronic renal failure, and DIC. The exact nature of these events is unclear, but he has had worsening renal function over the past week, leading to electrolyte disturbances and possibly an arrhythmogenic cardiac arrest with spontaneous return of circulation prior to the arrival of EMS. On admission, patient was intubated, unresponsive, in acute renal failure, liver failure and had cardiac damage as evidenced by elevated cardiac biomarkers. He was aggressively fluid recussitated, started on broad spectrum antibiotics for presumed sepsis, transfused RBC's and started on pressors for blood pressure support. Heme/onc was consulted and patient was determined to be in DIC. Renal was consulted and it was determined that renal replacement therapy was not indicated. Patient was maintained on vent, antibiotics and pressors but continued to deteriorate with worsening renal function, no improvement in respiratory status, and decreasing blood pressure to systolics of 30 in spite of pressor support. The decision was made by his family to make patient comfort measures only. He was started on a morphine drip for comfort, extubated and all non-comfort medications were discontinued. He expired on [2147-1-31] at 12:10pm. Medications on Admission: Folic Acid 2 mg daily Clopidogrel 75 mg daily Aspirin 325 mg daily pravastatin 10 mg daily Isosorbide Dinitrate 60mg tid Hydralazine 25 mg tid Metoprolol Tartrate 75mg [Hospital1 ] furosemide 20mg daily Neoral 50mg QAM and 25 mg QPM -- HELD for elevated Cr since [1-25] Procrit everyother week, started [1-25] novolin 70/30 insulin, unknown dose Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: none Discharge Condition: Expired. Discharge Instructions: none Followup Instructions: none	[ "427.5", "585.9", "286.6", "414.01", "995.92", "276.7", "570", "428.0", "518.81", "287.5", "250.00", "403.90", "038.9", "V45.82", "284.9", "785.52", "584.9", "412", "785.51" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	7753, 7762	5911, 7315	323, 361	7811, 7821	3258, 3584	7874, 7882	2396, 2500		7724, 7730		7783, 7790		7341, 7701			7845, 7851											2515, 3239																				276, 285								389, 1368				3593, 4943	4959, 5888									1390, 2024	2040, 2380
21,419	176,829	12507	Discharge summary	report	Admission Date: [2110-3-28] Discharge Date: [2110-4-9] Date of Birth: [2052-12-2] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with a history significant for hypertension who presented initially to [Hospital3 15174] with neck pain and was found to have 2-mm to 4-mm anterior [Hospital ] Medical Center for primary percutaneous transluminal coronary angioplasty. The patient initially developed neck pain while exercising on a treadmill at approximately 4 p.m. today with progressive substernal heaviness and left arm pain along with significant sweating. There was some mild nausea and shortness of breath, but no fevers or chills. No lightheadedness or dysuria. The patient presented to anterior ST elevations with new onset right bundle-branch block. The patient was placed on heparin, nitroglycerin and TNK and immediately transported to [Hospital1 188] for primary intervention. On arrival, the patient's diagnostic angiogram was notable for diffuse left anterior descending artery disease with slow flow consistent with thrombus. Thus, the patient underwent proximal left anterior descending artery intervention. After having a left anterior descending artery stent placed, the patient was hemodynamically stable. He was noted to have increased filling pressures, with a pulmonary capillary wedge pressure of 26, pulmonary artery pressure of 56%. After catheterization he was transferred to the Coronary Care Unit. The patient was enrolled in the Cool myocardial infarction study. Aside from hypertension and age, the patient denies any cardiac risk factors. Currently, the patient denies any chest pain, lightheadedness, nausea, diaphoresis or shortness of breath. PAST MEDICAL HISTORY: Past Medical History significant for hypertension. MEDICATIONS ON ADMISSION: Zestril 10 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco, positive alcohol use. No recreational drug use. FAMILY HISTORY: Family history was negative for coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed vital signs with temperature of 96, heart rate of 92, blood pressure of 138/96. The patient's oxygen saturation was 92% to 96%, respiratory rate of 19. The patient's head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Neck was supple. No lymphadenopathy. No bruits, lying flat. Chest was clear to auscultation anteriorly. Cardiovascular examination revealed distant heart sounds. Normal first heart sound and second heart sound. No murmur, rubs or gallops. Abdomen was soft and nontender, positive bowel sounds. Extremities revealed no edema. Distal pulses were weakly palpable bilaterally. Neurologic examination was nonfocal. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from Emergency Department revealed white blood cell count of 14, hematocrit of 41.6, platelets of 260. Differential showed 87 neutrophils, 10 lymphocytes, 2 monocytes. Sodium of 140, potassium of 4.1, chloride of 103, bicarbonate of 25, blood urea nitrogen of 24, creatinine of 1.2, and glucose of 149. The patient's PT was 15.8, PTT of 150. Calcium of 7.7, magnesium of 1.5, albumin of 3.5, phosphorous of 4.6. Creatine kinase was 6106, MB of 683, MB index of 11.2. The patient's blood gas was pH of 7.35, PCO2 of 43, and PO2 183. Liver function tests were pending. RADIOLOGY/IMAGING: The patient's electrocardiogram revealed tachycardic, 2-mm to 4-mm ST elevations in V2 through V5, 2-mm to 5-mm ST depressions in I, II, and aVF. Right bundle-branch block, leftward axis, frequent ectopy. Q waves in V1 through V5. Status post catheterization the patient had normal sinus rhythm, right bundle-branch block, some resolution of ST elevations, resolution of ST depressions, large Q waves across precordium. In the morning, further resolution of ST elevations. The patient's cardiac catheterization showed coronary angiography was right dominant, 2-vessel coronary artery disease, left main coronary artery was normal, left anterior descending artery had 70% ulcerative plaque with TIMI-II flow. Left circumflex had mild luminal irregularities. The right coronary artery had a 50% distal lesion. Resting hemodynamics demonstrated an initial narrow pulse pressure with a blood pressure of 100/80, improved during his gait. He had elevated left-sided filling pressures with a wedge of 25, cardiac index was 1.7. The patient had an intra-aortic balloon pump placed via left femoral access. A cooling catheter was placed for the Cool myocardial infarction protocol which was in the left femoral vein. ASSESSMENT AND PLAN: In summary, Mr. [Name14 (STitle) 38782] is a 57-year-old male with a history of hypertension who now presents with an acute anterior myocardial infarction complicated by increased filling pressures. Now, is status post left anterior descending artery stent and intra-aortic balloon pump placement. 1. The patient is status post left anterior descending artery intervention. Would like to stabilize the patient in the Coronary Care Unit. Magnitude of infarct is high. Evidence indicates that left anterior descending artery lesion was the culprit.Continue temperature regulation as per Cool myocardial infarction protocol; which is to cool the patient's core temperature down to 33 degrees Centigrade, continue the patient on aspirin, Plavix, and heparin. No Integrilin, and no 2B3A inhibitor is indicated here due to his lytic usage. We will monitor CK/MB, add a cholesterol battery. We will start Lipitor pending cholesterol. We will get serial electrocardiograms. 2. PUMP: Based on filling pressures, the patient's left ventricular function is significantly depressed. Of great concern is his index. His cardiac index was 1.7. The patient looks well. We will continue to monitor. We will continue with intra-aortic balloon pump and re-address its use every day. We will hold the ACE inhibitor due to his blood pressure being low, and we will start a low-dose beta blocker. We will consider a repeat echocardiogram in the next couple of days. We will get a chest x-ray in the morning. 3. RHYTHM: The patient's anterior myocardial infarction places the patient at risk for both arrhythmias and high-grade ABB. He already demonstrates evidence of new right bundle-branch block. If indicated, we will start a beta blocker. A temporary pacing wire may be indicated. 4. PULMONARY: The patient did not appear to be in pulmonary edema at this time. We will monitor his saturations and use oxygen monitor, and we will use oxygen supplement as needed to keep saturations greater than 95%. 5. HEMATOLOGY: The patient was on a major anticoagulation regimen. We will need to monitor his hematocrit and platelets and watch for bleeding. 6. RENAL: Given contrast load and acute decrease in his cardiac output the patient was at risk for renal injury. We will follow his urine output, follow his blood urea nitrogen and creatinine and his electrolytes. We will consider sending urine studies if indicated. 7. FLUIDS/ELECTROLYTES/NUTRITION: The patient appeared dry The patient was treated for nausea with Compazine. 8. PROPHYLAXIS: The patient is on heparin, aspirin, Plavix, and Protonix. 9. LINES: The patient has an intra-aortic balloon pump with sheath. He has a venous sheath, peripheral lines, Foley catheter. 10. CODE STATUS: The patient is a full code. HOSPITAL COURSE: As outlined in the History of Present Illness, the patient received cardiac catheterization with a stent to the left anterior descending artery and intra-aortic balloon pump placement. The patient did well and was stable. The patient had a slightly low urine output on the first day of admission. After his cardiac catheterization, he was given some Lasix and then continued to diurese well. The patient had no clinical evidence of pulmonary congestion or heart failure. The patient's intra-aortic balloon pump was removed. The patient remained stable. The patient's heparin was weaned to off. The patient was started on Coumadin and Lovenox as a bridge until the Coumadin was therapeutic. The patient was placed on ACE inhibitor (captopril) and continued on beta blocker (Lopressor). The patient did not need Lasix. He had no clinical signs of congestive heart failure. The patient continued to do well and was transferred to a regular floor with telemetry monitoring for one day. The patient did have an episode of nonsustained ventricular tachycardia in the Coronary Care Unit; which was concerning due to a large anterior myocardial infarction with the possibility of arrhythmias. An electrophysiology study was performed. The patient's electrophysiology study showed he was not inducible. No implantable cardioverter-defibrillator was required. A request for a recheck with an echocardiogram in six weeks was recommended; which will be done in follow up with his cardiologist, Dr. [Last Name (STitle) 11493]. The patient's echocardiogram performed on [2110-4-1] showed left atrium was mildly dilated, moderate symmetric left ventricular hypertrophy, severe regional left ventricular systolic dysfunction. Apex, anterior, septal, apical, and distal lateral walls of the left ventricle were akinetic. Left ventricular contraction was best preserved at the [Doctor First Name ], inferior, and lateral walls. Small circumferential pericardial effusion with fiber deposits on the surface of the heart. The patient's creatine phosphokinases peaked at 10,126 and were trending downward. Last checked on [2110-3-31] at 692. The patient's CK/MB peaked at 1187; last checked on [2110-3-31] was down to 19. The patient was trending down to normal. In light of large anterior myocardial infarction, the patient will go home on Coumadin. His INR level on discharge was 2.1. He was sent out on 7 mg of Coumadin per night. His INR level will be checked in two days (on Friday); per the visiting nurse and the results to be called into to Dr. [Last Name (STitle) 11493] who will then inform the patient on if he needs any changes in his Coumadin level dose. The patient did have elevated liver function tests, status post his large anterior myocardial infarction. They did trend toward normal. Lipitor was started at 20 mg p.o. q.d. The patient's liver function tests then started to increase on discharge. The patient's liver function tests were slightly elevated with an AST level of 108, with an ALT level of 140. The Lipitor was discontinued. His liver function tests will be checked by the [Hospital6 407] to see if this will continue to trend downward; as the possible cause of increased liver function tests and transaminase might be due to the Lipitor as well as the antibiotics the patient was on, or from the recent stress of his heart attack. These will be followed as an outpatient each week. On [2110-4-1], the patient developed a low-grade fever which was monitored. The patient was blood cultured at that time. The patient was given Tylenol and had no other symptoms of infection. The patient's blood cultures then grew out Staphylococcus aureus in [7-9] bottles. The patient was started on vancomycin; then sensitivities were finalized, and the patient was put on oxacillin and gentamicin to cover for possible endocarditis. The patient had a transesophageal echocardiogram which ruled out vegetations on the heart and showed a continued small pericardial effusion; not suspected to be from an infectious source. The patient also had a CT of his abdomen with contrast to rule out an infection, fluid collection or hematoma. The patient had no retroperitoneal fluid collection, no abscesses, and no hematoma. Of note, on the abdominal CT the patient had a 2-cm narrowing in the sigmoid region; which, when discussed with Radiology, was felt most likely strictly peristalsis and not concerning, but the patient will have a follow-up colonoscopy as an outpatient and will make this appointment for a normal preventative care colonoscopy in six weeks. Blood cultures were drawn daily. The patient has had no growth to date from blood culture dating [2110-4-6]. The patient then had a peripherally inserted central catheter line placed for long-term antibiotic use due to sensitivities and due to recent stent placement. Infectious Disease would like to consider this infection similar to a valve replacement type coverage that is needed for Staphylococcus aureus. The patient will go home on a 6-week course of oxacillin 12 g per day in divided doses of 2 g q.4h. intravenously. The patient will also take rifampin 300 mg p.o. b.i.d. for coverage. The patient was also positive for Clostridium difficile and was treated with Flagyl 500 mg p.o. t.i.d. for a total of 14 days. The patient has a follow-up appointment with Dr. [Last Name (STitle) 11493] on Monday, [2110-4-14]. The patient also has a follow-up appointment with Infectious Disease, Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057], on [2110-5-2] at 9:30 a.m. in the [Doctor Last Name 780] Building. The patient was to have his INR, liver function tests, complete blood count, blood urea nitrogen, and creatinine all checked via the [Hospital6 407] each week; especially while on rifampin and oxacillin. The patient was aware that when done with his six weeks of rifampin he will need to closely monitor his INR, as it will increase since rifampin is competitive with the P450 enzyme system in the liver, increasing Coumadin requirements while on rifampin. The patient was told that when the rifampin is stopped his INR will probably elevate and he will need less Coumadin, and he knows to be aware of this. The patient's creatinine remained stable during this hospitalization, status post cardiac catheterization. His hematocrit on discharge was 31.5 and trending upward. His INR (as before) was 2.1; which was therapeutic between 2 and 3. The patient's blood urea nitrogen, creatinine, and sodium were all within normal limits. The patient's alkaline phosphatase and total bilirubin were within normal limits. The patient's chest x-ray on the day of discharge showed his peripherally inserted central catheter line was in the normal position in the superior vena cava just beyond the brachiocephalic junction. The patient did speak with a [Hospital6 407] nurse. He is aware of how to administer the intravenous antibiotics and was given a special pump for continuous intravenous antibiotic administration into his peripherally inserted central catheter line. The patient knows to discuss the issue of his slightly elevated liver function tests with his primary care physician/cardiologist, Dr. [Last Name (STitle) 11493], and the decision will be made whether to restart Lipitor based on the re-checked liver function test values. The patient with a normal white blood cell count on the day of discharge. The patient had been afebrile for the past three days. Follow-up appointments as above. MEDICATIONS ON DISCHARGE: 1. Zestril 10 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Coumadin 7 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. 6. Oxacillin 2 g q.4h. intravenously. 7. Rifampin 300 mg p.o. b.i.d. times six weeks. 8. Flagyl 500 mg p.o. t.i.d. times 10 days. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Anterior myocardial infarction. 2. Hypercholesterolemia. 3. Hypertension. 4. Staph sepsis 5. Cardiogenic shock [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 4724] MEDQUIST36 D: [2110-4-9] 14:13 T: [2110-4-11] 14:55 JOB#: [Job Number 38783] cc:[Numeric Identifier 38784]	[ "008.45", "038.11", "410.41", "785.51", "401.9", "414.01", "427.1" ]	icd9cm	[ [ [] ] ]	[ "42.23", "36.06", "88.56", "37.22", "88.53", "38.93", "37.61", "37.26", "36.01" ]	icd9pcs	[ [ [] ] ]							2010, 7631	15667, 16100				15297, 15582	1851, 1913	7649, 15271																												15597, 15646													146, 1749														1772, 1824	1930, 1992
46,264	115,229	42806	Discharge summary	report	Admission Date: [2200-2-6] Discharge Date: [2200-2-13] Date of Birth: [2114-4-19] Sex: M Service: CARDIOTHORACIC Allergies: Levaquin / Macrodantin / Propranolol / ibuprofen Attending:[First Name3 (LF) 1406] Chief Complaint: Coronary artery disease. Major Surgical or Invasive Procedure: [2200-2-7]: Coronary artery bypass grafting x3 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery and obtuse marginal artery. History of Present Illness: 85 year old male that presented to [Hospital3 ] hospital after awaking from sleep [2-3] night with severe cough, nausea, and chest discomfort. In the emergency room he was treated for rapid atrial fibrillation and with Duonebs, unasyn, azithromycin, and IV solumedrol due to wheezing. On [2-4] he became acutely short of breath in the hospital and was placed on bipap and treated with IV lasix due to pulmonary edema. He ruled in for non st elevation myocardial infarction with troponin 4.01 and was referred for cardiac catheterization that he had [2-7] which revealed significant coronary artery disease. He is now transferred for surgical evaluation Past Medical History: Congestive heart failure Atrial fibrilliation no Coumadin high risk of falls Non ST elevation myocardial infarction ([Hospital3 ] [1-/2200]) Hypothyroid Lumbar stenosis Compression fracture L5 Right Thyroid nodule Hypertension CKD stageIII GERD Hypercholesterolemia Osteoarthritis Diabetes mellitus type 2 Neurogenic bladder(chronic Foley) Past Surgical History Rt carpel tunnel Total hip replacment, right [2195] TURP [2186] Appendectomy Biliary bypass [2193] decompressive laminectomy at L4 and L5,microdiskectomy at L4 L5 Kyphoplasty L5 [2-/2197] Social History: Lives with: wife and son (at son's home) Contact: [Name (NI) ] (wife) Phone # [Telephone/Fax (1) 92469] Occupation: retired firefighter Cigarettes: Smoked no [] yes [x] last cigarette 50 years ago ther Tobacco use: denies ETOH: < 1 drink/week [x] Family History: mother deceased 82 diabetes, father deceased 48 [Name2 (NI) 92470], brother DM, heart disease deceased ? 60's, brother sudden death 70's, brother diabetes deceased 85, brother mastoid cancer deceased in 50's, sister diabetes, coronary disease s/p stent alive, brother alzheimer alive, brother diabetes, vascular disease deceased 60's, son s/p cabg in his 40's Physical Exam: Pulse: 38 Resp: 18 O2 sat: 97 RA B/P Right: 107/65 Left: 115/63 General: Resting in be no acute distress Skin: Dry [x] intact [x] right groin cath site HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] HOH Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: Admission Labs: [2200-2-6] 01:18PM URINE RBC-3* WBC-29* BACTERIA-NONE YEAST-NONE EPI-3 [2200-2-6] 01:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-MOD [2200-2-6] 01:18PM PT-11.6 PTT-25.7 INR(PT)-1.1 [2200-2-6] 01:18PM NEUTS-61.4 LYMPHS-29.8 MONOS-5.9 EOS-2.5 BASOS-0.4 [2200-2-6] 01:18PM WBC-8.7 RBC-3.28* HGB-10.2* HCT-30.5* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.7 [2200-2-6] 01:18PM %HbA1c-7.8* eAG-177* [2200-2-6] 01:18PM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-2.1 [2200-2-6] 01:18PM CK-MB-5 cTropnT-0.64* [2200-2-6] 01:18PM ALT(SGPT)-52* AST(SGOT)-69* LD(LDH)-244 CK(CPK)-78 ALK PHOS-61 TOT BILI-0.3 [2200-2-6] 01:18PM GLUCOSE-182* UREA N-54* CREAT-1.4* SODIUM-139 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-34* ANION GAP-9 Discharge labs: [2200-2-13] 04:20AM BLOOD WBC-14.0* RBC-3.10* Hgb-9.6* Hct-28.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 Plt Ct-203 [2200-2-13] 04:20AM BLOOD Plt Ct-203 [2200-2-13] 04:20AM BLOOD Glucose-114* UreaN-39* Creat-1.6* Na-138 K-4.5 Cl-103 HCO3-28 AnGap-12 [2200-2-13] 04:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [2200-2-11] 04:20AM BLOOD ALT-26 AST-39 AlkPhos-73 Amylase-12 TotBili-0.4 TTE [2200-2-7] Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. No spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in ascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot exclude AS. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild to moderate ([2-10]+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. GENERAL COMMENTS: The patient was under general anesthesia throughout the procedure. No TEE related complications. Suboptimal image quality. Results were personally reviewed with the MD caring for the patient. Conclusions Due to the patient's history of dysphagia and resistance felt at 40cm, the probe was not advanced past 40cm. PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricle was assessed in the mid esophageal views. There is mild LV septal hypokineses. The remaining segments move and thicken well, estimated EF 50-55% from limited study. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis but leaflets appear to have normal motion in the available views. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([2-10]+) mitral regurgitation is seen. Radiology Report CHEST (PA & LAT) Study Date of [2200-2-12] 1:56 PM Final Report FINDINGS: As compared to the previous radiograph, there is substantially increased ventilation of the lung parenchyma. No pulmonary edema. On the left, a small retrocardiac atelectasis persists and on the right, seen mainly on the lateral radiograph, a small pleural effusion is present. No other pleural or parenchymal changes. Borderline size of the cardiac silhouette. Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of [2200-2-12] 1:55 [Hospital 93] MEDICAL CONDITION:85 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for aspiration Preliminary Report Swallowing video fluoroscopy: oropharyngeal swallowing video fluoroscopy was Preliminary Reportperformed in conjunction with the speech and swallow division. Multiple Preliminary Reportconsistencies of barium were administered. Oral and pharyngeal swallow delay were observed. There was aspiration of thin liquids and penetration with nectar. Brief Hospital Course: 85 year old male that presented to OSH after awaking from sleep [2-3] night with severe cough, nausea, and chest discomfort. In the emergency room he was treated for rapid atrial fibrillation and with Duonebs, Unasyn, azithromycin, and IV solumedrol due to wheezing. He ruled in for non st elevation myocardial infarction with troponin 4.01 and was referred for cardiac catheterization. He underwent cath on [2-7] which revealed significant coronary artery disease. He was now transferred for surgical evaluation to [Hospital1 18]. After preoperative work up was complete, he was brought to the operating room on [2-8] where the patient underwent a coronary artery bypass grafting x3 with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery and obtuse marginal artery. CROSS-CLAMP TIME:69 minutes PUMP TIME:79 minutes. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was in a atrial fibrillation/flutter with rates from 60-120's. Lopressor was titrated and he was placed back on his home dose of Digoxin for better rate control. He had up to 2.6 second pauses in his chronic atrial fibrillation and EP was consulted. Digoxin was stopped and Lopressor was titrated. He was not anticoagulated for his atrial fibrillation due to his high risk of falls. He had a chronic Foley in place for a history of neurogenic bladder. He also had a swallow evaluation postop due to a preoperative history of dysphagia which showed possible aspiarion and he underwent a video study which showed aspiration of thin liquids, penetration of nectar, and he was put on a modified diet. He had a poor oral intake and was started on supplements. His po intake improved at the time of discharge. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued per cardiac surgery protocol without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was able to stand at bedside with assistance, but required [Doctor Last Name 2598] lift to get OOB to chair. His wound was healing and pain was controlled with oral analgesics(Tylenol). He failed to void after Foley catheter removal and required reinsertion of catheter, of note patient with neurogenic bladder had chronic foley for 5 years prior to surgery. The patient was discharged to [Hospital 38] rehab on POD 6 in good condition with appropriate follow up instructions. Medications on Admission: Simvastatin 5 mg daily Prilosec 20 mg daily Neurontin 600 mg [Hospital1 ] Levothyroxine 25 mcg daily Ferrous sulfate 325 mg daily Glipizide 2.5 mg [Hospital1 ] Aspirin 325 mg Daily Diltiazem 120 mg daily Digoxin 0.125 mg daily Bethanechol 25 mg TID Centrum silver daily Calcium 500 with Vitamin D [Hospital1 ] Medications outside hospital at transfer: Unasyn 1.5 gm q12h Heparin gtt Aspirin 81 mg daily zocor 5 mg daily multivitamin 1 tab daily glipizide 2.5 mg [Hospital1 ] Gabapentin 600 mg [Hospital1 ] Diltazem 120 mg daily Digoxin 0.125 mg daily Calcium/vitamin D 2 tabs daily Bethanechol 25 mg TID Insulin SS Lopressor 5 mg q6h Protonix 40 mg IV daily Levothyroxine 12.5 mcg IV daily Atrovent nebs prn Albuterol nebs prn Nitrostat prn Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. bethanechol chloride 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 16. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 19. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day. 20. insulin regular human 100 unit/mL Solution Sig: sliding scale units Injection Q AC&HS. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: [Last Name (un) 72255] Artery disease s/p CABG x3 Congestive heart failure Atrial fibrilliation no Coumadin-high risk of falls Non ST elevation myocardial infarction ([Hospital3 ] [1-/2200]) Hypothyroid Lumbar stenosis Compression fracture L5 Right Thyroid nodule Hypertension CKD stageIII GERD Hypercholesterolemia Osteoarthritis Diabetes mellitus type 2 Neurogenic bladder(chronic Foley) Past Surgical History Rt carpel tunnel Total hip replacment, right [2195] TURP [2186] Appendectomy Biliary bypass [2193] decompressive laminectomy at L4 and L5,microdiskectomy at L4 L5 Kyphoplasty L5 [2-/2197] Discharge Condition: Alert and oriented x3 nonfocal Able to stand at bedside w/assistance. Requires [Doctor Last Name ] lift to get OOB-chair Sternal pain managed with oral analgesics-Tramadol Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Wound Check at 1/12 at 10:15am, Cardiac Surgery [Hospital Ward Name 92471] Medical Office Building [Hospital Unit Name ] [Telephone/Fax (1) 170] Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [3-20] at 1:00pm, Cardiac Surgery [Hospital Ward Name 92471] Medical Office Building [Hospital Unit Name ] [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) ] on [3-5] at 11:00am Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 25693] in [5-15] weeks [Telephone/Fax (1) 25694] **Needs outpatient video swallow before advancing diet Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2200-2-13**]	[ "724.02", "596.54", "244.9", "285.9", "272.0", "428.0", "427.32", "787.20", "V43.64", "458.29", "403.90", "424.0", "585.3", "427.31", "287.5", "599.0", "410.71", "041.85", "414.01", "250.02", "530.81", "241.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.12" ]	icd9pcs	[ [ [] ] ]	13486, 13583	7918, 10926	340, 561	14256, 14491	3236, 3236	15172, 16056	2154, 2520		11739, 13463	7456, 7481	13604, 14235		10952, 11716			14515, 15149			4099, 7420								2535, 3217																				275, 302	7510, 7895							589, 1263					3252, 4083									1285, 1861	1877, 2138
3,368	166,325	47686	Discharge summary	report	Admission Date: [2130-4-6] Discharge Date: [2130-4-14] Service: MEDICINE Allergies: Penicillins / Tylenol Attending:[First Name3 (LF) 317] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Thorocentesis [2130-4-6] Thorocentesis [2130-4-11] History of Present Illness: Pt is a [Age over 90 ] yo woman w/ h/o esophageal ca s/p palliative XRT ending in [12-7], chronic cough, h/o angina and CHF with EF >55%, who presents with 2 weeks of progressive SOB acutely worse over that past few days. Of note, she was recently discharged from [Hospital1 18] on [3-10] at which time she was admitted for CHF exacerbation, was diuresed with improving respiratory status and was sent home on lasix 10 mg PO QOD. Since her discharge she has become progressively SOB, worse over the past 2 weeks and much worse over the past couple of days. Her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] increased her Flovent dosing and added proventil, which helped but she began using more and more frequently. At baseline she is able to walk around her house with a cane. She denies CP and denies any worsening of her LE edema. She reports that on her last admission they talked to her about getting a thoracentesis but did not want it at the time as she did not think she could tolerate the procedure. She otherwise denies any chest pain/pressure (her anginal equivalent), PND, palpitations, N/V, diarrhea, BRBPR, dysuria, fevers. In the ED, she was noted to have a T 99.0 BP 118/64 RR 24 O2 sats 96% on NRB and then started on BiPAP (setting not documented) satting 98%. She was started on a nitro drip, given lasix 30 mg IV x1 with little UOP, combivent nebs, ASA PR. . Currently pt states she still feels SOB, denies any CP, palpitations, abd pain. She did not feel she can tolerate the BiPAP mask and feels better on NC and face mask. Past Medical History: Esophageal cancer, s/p palliative XRT ending in [12-7]. She does not have an medical oncologist. Has difficulty swallowing. Can only swallow liquids breast cancer, underwent lumpectomy x 2 gastroesophageal reflux disease hypertension angina, previously used NGL, no longer uses CRI (baseline Cr 1.2-1.4) s/p appendectomy s/p cholecystectomy s/p cataract surgery Social History: Pt is a holocaust survivor from [Country 12392]. She denies any tobacco or alcohol use and lives in [Location ], MA with her son. [Name (NI) 6934] with a crutch from old b/l ankle fractures Family History: H/o heart disease, not specified, Colorectal ca - son Physical Exam: Vitals - T 96.8 BP 103/65 HR 80s O2 sats 88% on 6L NC Gen - cachetic, awake, alert, pleasant, lying in bed using accessory muscles to breath, answering questions appropriately HEENT - PERRL, b/l cataracts, EOMI NECK - no LAD, could not assess JVD CV - RRR nl S1 S2, Grade III/VI SEM RUSB. Lungs - Decreased BS at bases L>R, b/l crackles Abd - flat, soft, NT/ND + NABS Ext - 2+ b/l LE edema, venous stasis changes, 1+ DP pulses, warm Neuro - AAOx3, CN II-XII intact, strength 5/5 and equal Pertinent Results: [2130-4-6] CXR: 1. CHF with left greater than right pleural effusions and interstitial edema, significantly worse since [2130-3-9]. 2. Left retrocardiac opacity, likely related to above; focal consolidation cannot be excluded. . [2130-4-8] CXR PA/Lat: IMPRESSION: No major change in the appearance of the previously described pulmonary edema with bilateral pleural effusions. . [2130-4-11] CXR: AP: IMPRESSION: Successful left-sided pleurocentesis without evidence of pneumothorax. . Labs: [2130-4-6] Pleural fluid-cytology: adenocarcinoma- IHC showed esophageal in origin. . Admission CBC: WBC-8.7 RBC-4.31 Hgb-13.4 Hct-40.1 MCV-93 MCH-31.0 MCHC-33.3 RDW-15.9* Plt Ct-242 CHEMISTRIES: Glucose-135* UreaN-69* Creat-2.8# Na-133 K-6.5 Cl-95* HCO3-23 TotProt-5.3* Albumin-2.8* Globuln-2.5 Calcium-8.9 Phos-5.2* Mg-2.8* Other labs: proBNP-5433* . Discharge CHEMISTRIES: Glucose-98 UreaN-35* Creat-0.9 Na-139 K-3.8 Cl-96 HCO3-35* . MICRO: pleural fluid cultures negative Brief Hospital Course: Ms. [Known lastname 100726] is a [Age over 90 ] year old woman with a history of esophageal cancer s/p palliative XRT in [12-7], h/o angina, who presents with progressive SOB with worsening pleural effusion and pulmonary edema. She had a brief stay in the MICU upon admission to the hospital until her respiratory failure stabilized. She was then transferred to the medical floor for continued care. . # Hypoxic respiratory failure: She was admitted to the MICU with th ddx for her hypoxic respiratory failure included CHF exacerbation, malignant pleural effusion, lymphangitic [Last Name (LF) 100727], [First Name3 (LF) ], worsening renal failure. She had a thorocentesis on [2130-4-6] which ultimately showed malignant cells consistent with esophageal adenocarcinoma. Over 1L of fluid was removed and she tolerated the procedure well and was less symptomatic afterwards. Her oxygen was weened down to a NC and she was diuresed with furosemide prn. She was also continued on ipratropium and fluticasone nebs/IH. She was then transferred to the medical floor. On [2130-4-11] she had another thorocentesis for symptomatic relief and about 800mL was removed at that time. This second procedure was more difficult for her to tolerate and was more painful. She received some symptomatic relief afterwards with regards to her breathing. At discharge she had stable oxygen saturations in the mid to low 90's on 5L NC. She is being discharged with 5L NC, fluticasone IH, and furosemide 10mg daily to help relieve her shortness of breath from fluid overload. . # Malignant pleural effusions: The pleural fluid suggested it was an exudate (LDH ratio 0.6 (right on the border), protein ratio 0.58) which was concerning for malignant effusion given her clinical history. The cytology returned with esophageal adenocarcinoma cells and no organisms. Intervential pulmonology suggested a pleurex catheter to help drain the fluid. At this time, the patient does not want another procedure done. She will consider this for symptomatic relief in the future. . # ARF: The reason for her acute renal failure was unclear. [Name2 (NI) ] Cr was 2.8 on admission (baseline 1.2). She was likely intravascularly dry despite her pulmonary edema. Her Cr continued to trend down throughout her admission and was 0.9 on discharge. . # Esophageal Ca: She has received palliative XRT in [12-7]. The patient does not have an outpt oncologist. XRT done by Dr. [Last Name (STitle) ]. Her cancer and the XRT has made it difficult for her to eat. She tolerates a liquid diet and can take some medications as well. While in the MICU, a palliative care consult was obtained. Once the diagnosis of malignant pleural effusion was made, the palliative care team and social work helped to organize home hospice after conversations with Dr. [Last Name (STitle) ], the attending, and the patient and her son. . # Pain control: She has an allergy to aspirin and acetaminophen which cause breathing difficulties and rashes. She was treated with round the clock ibuprofen liquid solution 400-800mg q8hrs. For breathrough pain, she was given morphine elixor 2-5mg q4-6hrs. . # ARF: The reason for her acute renal failure was unclear. [Name2 (NI) ] Cr was 2.8 on admission (baseline 1.2). She was likely intravascularly dry despite her pulmonary edema. Her Cr continued to trend down throughout her admission and was 0.9 on discharge. . # Anxiety: Given patient's anxiety/palpitations, we will discharge her on toprol XL to help with those symptoms. . # HTN: The patient was hypotensive initially and then her blood pressure increased to the low 100's. Her outpatient medications were held initially. Metoprolol XL 12.5mg was added back. Her SBP remained around 100 and her HR was in the 80's. . # GERD: She has a history of hiatal hernia and GERD for which she often sleeps sitting up in bed to limit the acid reflux. She took prilosec at home and was switched to lansoprazole dissolving tabs to help ease her ability to take the medication. She will remain on this medication to help give her symptomatic relief. . # Code: Patient expresses that she would not want to be intubated or have CPR. Son had further discussions with her and discussed with Dr. [Last Name (STitle) ] who confers. She is being discharged home with hospice. . # Dr. [Last Name (STitle) 2204] will be the primary physician involved with the hospice care. Medications on Admission: Norvasc 5mg qAM, 5mg QPM Toprol XL [1-5] of a 50mg tab qam Prilosec 20mg [Hospital1 ] Proventil 90 mcg 3 puffs 5x/day Flovent 110 mcg 2 puffs [Hospital1 ] darvocet [Hospital1 ] Zofran 8 mg PRN Azopt Lasix 10 mg QOD advil PRN Discharge Medications: 1. Ibuprofen 100 mg/5 mL Suspension [Hospital1 ]: 400-800 mg PO Q8H (every 8 hours): PLEASE TAKE WITH ENOUGH WATER FOLLOWING THIS MEDICIANT TO PREVENT THROAT BURNING. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] daily (). 3. Fluticasone 110 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr [Hospital1 ]: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): for anxiety/palpitations. 5. Furosemide 20 mg Tablet [Hospital1 ]: 0.5 Tablet PO once a day: to help relieve fluid overload and shortness of breath. 6. Morphine Concentrate 20 mg/mL Solution [Hospital1 ]: 1-5 mg PO every 4-6 hours as needed for pain. Disp:30 mL Refills:0 Discharge Disposition: Home With Service Facility: Hospice of the Good [Doctor Last Name 9995] Discharge Diagnosis: Primary diagnosis: Esophageal cancer Malignant pleural effusion Hypoxia . Discharge Condition: Stable on 5L NC. Discharge Instructions: You were admitted with shortness and breath and were found to have fluid around your lungs. This was removed twice with a procedure called a thorocentesis. . You are going home with hospice care. You should call Dr. [Last Name (STitle) 2204] or Dr. [Last Name (STitle) ] with any questions or problems which arise once you are home. Followup Instructions: Please call Dr.[Name (NI) 2935] office at [Telephone/Fax (1) 2936] as needed for follow up care. Completed by:[2130-4-14]	[ "530.81", "787.2", "197.2", "707.03", "428.30", "518.81", "401.9", "584.9", "276.8", "414.01", "V66.7", "V10.3", "150.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "34.91" ]	icd9pcs	[ [ [] ] ]	9781, 9859	4142, 8606	235, 296	9977, 9996	3123, 3966	10387, 10523	2540, 2596		8898, 9758		9880, 9880		8632, 8875			10020, 10364											2611, 3104																				188, 197								324, 1914						9899, 9956								1936, 2304	2320, 2524			3979, 4119
31,923	192,162	25235	Discharge summary	report	Admission Date: [2197-10-22] Discharge Date: [2197-10-22] Date of Birth: [2117-10-9] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 5880] Chief Complaint: Patient presented to ED s/p witnessed fall, unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 80yo M s/p fall, non responsive, GCS 3 at OSH and [Hospital1 18]. Past Medical History: Alzheimers Dememtia "Mini strokes" Social History: Married and lives with wife Family History: Noncontributory Physical Exam: expired Pertinent Results: CT HEAD W/O CONTRAST [2197-10-22] Large bilateral SDH, left greater than right, with 9 mm midline shift. Extensive sub-arachnoid hemorrhage. Blood dissecting into ventricles, 4th ventricle, ambient cisterns, and thecal sac. Mild hydrocephalus. Skull fracture involving right occipital bone, extending into skull base and petrous apex. Brief Hospital Course: The patient was transferred from an OSH intubated, unresponsive. He had a repeat CT head here which showed Large bilateral SDH, left greater than right, with 9 mm midline shift. Extensive sub-arachnoid hemorrhage. Blood dissecting into ventricles, 4th ventricle, ambient cisterns, and thecal sac. Mild hydrocephalus. Skull fracture involving right occipital bone, extending into skull base and petrous apex. Patient received mannitol and dilantin loading doses, fluid boluses for low blood pressure and a dopamine drip was started. Following a family meeting with neurosurgery, it was agreed to make the patient CMO. The patient expired at 1055 am Discharge Disposition: Expired Discharge Diagnosis: subarachnoid hemorrhage s/p fall Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "801.25", "438.9", "159.9", "294.10", "780.01", "722.4", "331.0", "197.6", "E849.9", "E880.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	1662, 1671	983, 1639	330, 337	1748, 1758	617, 960	1811, 1819	557, 574				1692, 1727					1782, 1788											589, 598																				234, 292								365, 436														458, 495	511, 541
68,300	128,859	37877	Discharge summary	report	Admission Date: [2143-8-30] Discharge Date: [2143-10-15] Date of Birth: [2090-5-5] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Keflex Attending:[First Name3 (LF) 2195] Chief Complaint: left parietal mass Major Surgical or Invasive Procedure: Craniotomy and empyema evacuation Stereotactic evacuation of abscess and burr hole drainage of subdural empyema PICC Placement History of Present Illness: 53 yo female with a history of non-Hodgkin's lymphoma, s/p BMT ([2118]), [Year (4 digits) 1291], atrial fibrillation not on coumadin, cardiomyopathy (EF 45%) who was transferred to [Hospital1 18] on [2143-8-30] for further management of left parietal mass. Patient initially presented to an OSH on [8-29] after nearly a week of left frontal headaches, right sided arm and leg weakness and progressive aphasia. At the OSH neuroimaging revealed a ring enhancing left parietal mass with extensive surrounding edema. Following transfer to [Hospital1 18] and admission to the neurosurgery service patient developed worsening aphasia and right hemiparesis. On [8-30] brain MRI demonstrated a rim-enhancing left parietal lesion measuring approximately 5 mm,suggestive of abscess with subdural empyema. On [8-31] she underwent L sided stereotactic evacuation of abscess and bur hole drainage of subdural empyema. An MRI from [9-2] showed interval decrease in size of the left parietal abscess status post surgical evacuation. Notably, there was a small new multiloculated subdural collection in the left parieto-occipital region. Wound cx from evacuation growing strep, unspeciated at time of transfer to medicine. Since pt has PCN and cephalosporin allergy she was started on vancomycin for strep coverage. The consulting ID team stongly recommended PCN desensitization so pt would be able to receive a beta lactam antibiotic. Notably, CT torso done given patient's presenting complaint of LUQ abd pain. Study on [8-30] showed air and fluid in the splenic hilum, suggesting recent leakage vs stump carcinoma. Patient was started on cipro/flagyl for concern of infection. IR felt this was likely a more chronic collection. Course to date also c/b refractory seizure activity on continuous EEG monitoring. Past Medical History: Gastric bypass [2135] per husband (outside records not available to confirm date/exact procedure) Roux-en-Y gastrojejunostomy [2140] for "perforated ulcers" per husband (outside records not available to confirm date/exact procedure) -Atrial fibrillation s/p successful cardioversion [1-9], taken off coumadin given h/o UGIB [2140] -Bovine [Year (4 digits) 1291] for AS [3-8] -Hypertension -Non-Hodgkin's lymphoma, status post chemotherapy [2138], s/p partial splenectomy [2139], in remission since [2139] CAD Cardiomyopathy (EF 45%) Social History: She lives with her husband. Social ETOH. Denies drugs in the present or the past. She quit smoking 20 years ago - 37 pack year history Family History: Two brothers with neoplasms. Mother with lung Ca No CNS tumors. No seizures. No early strokes or CNS bleeds Physical Exam: Discharge Exam: VS: 97.7 113/71 69 20 100% on RA with ambulation Gen: Pleasant female in no acute distress HEENT: Healing surgical wound, not erythematous or infected-appearing. Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior lung exam clear, no wheezes or crackles appreciated CV: S1 & S2 regular without murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3, 4+/5 RUE strength, 5/5 strength all other extremities Pertinent Results: Discharge Labs: WBC 2.5, Hct 26.6 (stable), plts 277 INR: 1.7 ALT 17, AST 30 Valproate: 38 Pertinent Labs: [2143-8-30] 09:20AM SED RATE-135* CRP-GREATER THAN ASSAY [2143-8-30] 09:20AM PT-12.7 PTT-26.1 INR(PT)-1.1 [2143-8-29] 11:55PM LACTATE-0.9 [2143-8-29] 11:45PM WBC-9.3 RBC-3.54* HGB-9.8* HCT-30.7* MCV-87 MCH-27.6 MCHC-31.8 RDW-14.7 [2143-8-29] 11:45PM NEUTS-81.6* LYMPHS-14.6* MONOS-3.3 EOS-0.4 BASOS-0.1 [2143-8-29] 11:45PM GLUCOSE-126* UREA N-12 CREAT-0.6 SODIUM-137 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-20 Imaging: [2143-8-30]: CT C/A/P: Air-fluid collection centered in splenic hilum near an apparent site of gastrojejunostomy [2143-8-30]: CT Head: Left parieto-occipital vasogenic edema with the suggestion of a central lesion within that area. [2143-8-30]: MR [Name13 (STitle) 430]: Rim-enhancing left parietal lesion with surrounding edema with enhancement of the adjacent leptomeninges and pachymeninges with subdural collection in the left frontoparietal region measuring approximately 5 mm. Suspicious for an abscess with a question of subdural empyema. No midline shift is seen. Mild mass effect on the left lateral ventricle [2143-8-31]: CXR no infiltrates, line OK, no PTX [2143-9-2]: TTE no vegetations, EF 50%, trivial MR. [First Name (Titles) ] [Last Name (Titles) 1291]. [2143-9-6]: CT Interval increase size of L prefrontal subdural collection, 1.6 x 5.6 cm in widest dimensions. Unchanged L posterior frontal cerebral abscess 1.6 x 0.7 cm. Mass effect from left prefrontal subdural empyema w/4 mm rightward deviation of falx. [2143-9-8]: The small air-fluid collection at splenic hilum, slightly decreased in size. Still tracks through spleen an unusual wedge-shaped configuration to subcapsular region associated with small pleural effusion and LLL atelectasis. ? cause of collection. Wedge-shaped low-attenuation abnormalities in periphery of spleen could represent prior infarcts. Collection would be difficult to access percutaneously, probably require trans-splenic approach. New RLL centrilobular nodules w/ tree-in-[Male First Name (un) 239] configuration and atelectasis suggests recent infection or inflammation d/t ?aspiration. L adnexal ovoid homogeneous cystic abnormality f/u by U/s. [2143-9-8]: CXR NG tip in stomach. RIJ tip at cavoatrial junction. There LLL volume loss and RLL volume loss w/obscuration of hemidiaphragms. ?underlying infectious infiltrate. [2143-9-8]: CXR L PIC catheter terminates in the lower superior vena cava. [2143-9-11]: CT new hypodense lesion w/hyperdense rim L frontal region,highly suspicious for evolving abscess vs. postop change. Interval increase in L centrum semiovale edema, w/ 2mm shift of midline structures. [2143-9-11]: MRI prelim no interval change in dominant ring-enhancing intraparenchymal fluid collection in L parietal lobe and associated subdural fluid, slightly increased parenchymal edema w mass effect and meningial enhancement [2143-9-12] Sinus CT: Heterogeneous opacification of multiple paranasal sinuses and mastoid air cells and right middle ear cavity,with no evidence of bony erosions. [2-4] sinusitis or h/o intubation. [2143-9-12]: TEE IMPRESSION: No valvular vegetation or abscess seen [2143-9-7]: EEG: This telemetry captured no pushbutton activations but it did capture several events of rhythmic activity seen predominantly in the right frontal area and suggestive, although not clearly so, of a seizure activity. There were no clear interictal spikes seen in this recording. The background activity was slow suggestive of a moderate encephalopathy with slower frequencies seen in the left posterior quadrant suggestive of functional and probably structural abnormality in that area. [10-9] Lower Extremity U/S: IMPRESSION: Occlusive thrombus from the proximal right SFV to at least the level of the popliteal vein. [10-9] CT Ab/Pelvis: IMPRESSION: 1. No change in size of perisplenic fluid collection. A small amount of oral contrast and air tracking from anastomotic site to splenic hilum is most compatible with contained leak, unchanged since prior examination from [2143-10-1]. 2. Asymmetric enlargement with hypodensity in the right versus left femoral veins that could indicate right venous thrombus. Recommend correlation with ultrasound. 3. Stable appearance of left adnexal cystic lesion since earliest available examination of [2143-8-30]. Recommend pelvic ultrasound be performed within six weeks in outpatient setting or when clinically feasible for further evaluation. 4. Slight decrease in size of right obturator internus muscle with 15-mm area of hyperdensity suggestive of calcification. This is likely related to resolving hematoma or myositis ossificans. No fluid collection in this area to suggest abscess formation. 5. Transverse colonic [Doctor Last Name ] hernia with no evidence of obstruction. [10-4] Head MRI: Interval resolution of previously seen abscess cavities. A small amount of enhancement in the left parietal lobe is noted which has decreased considerably compared to the prior examination. Previously noted subdural collections have resolved. There is decreased mass effect. Microbiology: MRSA screen: positive Blood Cultures: [Date range (1) 84706] Negative Urine Cultures: Negative Abscess Culture [8-31]: Strep species x 2 Wound swab- strep milleri Repeat Wound Cultures: Negative HELICOBACTER PYLORI ANTIBODY TEST (Final [2143-9-9]): NEGATIVE BY EIA. Brief Hospital Course: 53 YO F with a history of non-Hodgkin's lymphoma s/p BMT ([2138]), Aortic valve replacement (biological), atrial fibrillation not previously on coumadin, prior report of cardiomyopathy (EF 45%) who was transferred to [Hospital1 18] on [2143-8-30] for management of left parietal mass found to have a parietal Strep Milleri abscess c/b subdural empyema s/p craniotomy with evacuation. 1. Brain Abscesses (Seizures): The patient initially presented to an OSH on [8-29] after nearly a week of left frontal headaches, right sided arm and leg weakness and progressive aphasia. At the OSH neuroimaging revealed a ring enhancing left parietal mass with extensive surrounding edema. On [8-31] morning rounds, patient was witnessed to have ongoing seizures characterized with right arm tremor despite Keppra loading. Respiratory status was marginal with acute tachypnea and so she was transferred to the ICU at this time. MRI read came back indicating a intracranial abscess with a subdural empyema. The patient was taken emergently to the OR for drainage. She was left intubated post operatively and maintained on a midazolam gtt, which was slowly weaned and the patient was transitioned to Keppra and dilantin. An MRI from [9-2] showed interval decrease in size of the left parietal abscess status post surgical evacuation. There was also a small new multiloculated subdural collection in the left parieto-occipital region which worsened and repeat craniotomy was performed on [2143-9-6]. She has been without seizure activity since [2143-9-4]. Her motor exam improved slightly in UE and significantly in LE on the Right. On transfer to the internal medicine service, the patient left sided strength continued to improve. She is to continue Pencillin, Cipro and Flagyl for at least 3 more weeks as directed by Infectious disease. Her recent repeat head MRI showed significant interval improvement. The patient has Neurology & Neurosurgical follow-up in the next several weeks with a repeat MRI scheduled. She will continue on Keppra, Phenytoin taper and Divalproex with levels followed by Neurology. The patient continues to have head pain which is currently controlled on a Fentanyl Patch and Dilaudid PO prn. It is expected that her need for these medicines will diminish over the coming weeks. 2. Anastamotic Leak/Splenic Abscess: Patient was noted to have multiple abscesses on head imaging. Ciprofloxacin 400 mg IV Q12H, MetRONIDAZOLE 500 mg IV Q8H and Fluconazole 400 mg IV Q24H were started empirically as was vancomycin. The cultures from burhole surgical site on [8-31] grew STREPTOCOCCUS ANGINOSUS (MILLERI) for which she was desensitized and started on Penicillin G on [2143-9-3], vancomycin was discontinued as was fluconazole. She has remained afebrile since [2143-9-6]. She underwent infectious work up which revealed negative UCx, CXR, [2143-9-12] TEE showed no vegetations. Her CT abdomen showed a small air-fluid collection at the splenic hilum, tracking through the spleen in a wedge-shaped configuration, w/ small pleural effusion and left lower lobe atelectasis as well as a possible ulceration at the old roux en y site. She was also noted to have opacities in her sinuses (maxillary, sphenoid, but not frontal). It was felt that the source for the infection was either splenic abscess, a possible ulceration vs. extension from the sinuses (unlikely based on ENT evaluation). Given difficult approach, it was felt that she could not undergo drainage by IR. The obturator abscess was ruled a hematoma and the splenic abscess was ruled a remant of the leak. The patient will continue Cipro/Flagyl for 3 more weeks under the guidance of Infectious Disease. Surgery was consulted for a thorough evaluation of her anastamotic leak. After a period of NPO with repeat studies by CT and X-ray, as well as consultation with bariatric surgery, it was decided that this leak was likely chronic, and although possibly the source of the abscesses, did not pose an active risk with regards to nutrition. The patient was maintained on TPN while this was under evaluation, but ultimately was able to be discharged on a regular diet without issue. 3. R Iliac Deep Vein Thrombosis: The patient developed a DVT discovered on CT and confirmed with ultrasound. Given her recent brain surgery and history of GI bleeds, the pros and cons of anticoagulation were weighed with her neuro- and general surgeons. Based on obtained old records and a discussion with the above parties, it was determined that the benefits of anticoagulation outweighed the risks. The patient has been briefed on concerning signs of GI Bleed and pulmonary embolism. Her PCP agreed to manage her coumadin as an outpatient. The patient tolerated 48 hours of a heparin drip and was transitioned to Lovenox/Coumadin which she will continue until therapeutic at 2-3. 4. Atrial fibrillation s/p cardioversion: The patient was admitted on Sotalol but converted to metoprolol on this hospitalization. She was rate controlled in the 60s-80s and will continue 12.5mg PO BID on discharge. Anticoagulation per problem DVT above. 5. Leukopenia/Anemia: The patient developed a stable and non-hemodynamically significant leukopenia and anemia while admitted. These problems have been variously attributed to Dilantin, Penicillin and her underlying history of lymphoma s/p BMT. She was repleted with Vitamin B while admitted. We have left the patient instructions to follow up with her PCP & Oncologist to monitor these values. Infectious disease will also monitor her blood counts weekly. 6. Hypertension: The patient had no signs of hypertension and will continue on Metoprolol. 7. CAD, s/p MI, CABG. The patient was not continued on Aspirin due to risk of GI bleed and anticoagulation. She will follow with her PCP on this issue. 8. Anxiety: The patient was continued on Ativan. Medications on Admission: Home Meds -Sotalol 40 mg [Hospital1 ] -Ativan 1mg qhs -Protonix 20 qd -Hydromorphone 0.5mg IV PRN -Acetaminophen 325-650 mg PRN Discharge Medications: 1. Outpatient Lab Work Please draw weekly on Wednesdays CBC with diff, BUN, Cr, AST, ALT, Alk Phos, T bili and forward results to Infectious disease R.Ns. at ([Telephone/Fax (1) 6313] ATTN Dr. [Name (NI) 1420] & [Last Name (LF) 84707],[First Name3 (LF) ] C Address: 128 STATE RT 27, [Location (un) ],[Numeric Identifier 84708] Phone: [Telephone/Fax (1) 84709] Fax: [Telephone/Fax (1) 84710] 2. Outpatient Lab Work Please draw a Depatoke level Wed [10-16] and forward to Dr. [First Name (STitle) ] Phone ([Telephone/Fax (1) 35413] Fax ([Telephone/Fax (1) 67774] and Dr. [Last Name (STitle) 84707],[First Name3 (LF) ] C Address: 128 STATE RT 27, [Location (un) ],[Numeric Identifier 84708] Phone: [Telephone/Fax (1) 84709] Fax: [Telephone/Fax (1) 84710] 3. Outpatient Lab Work Please draw PTs (first draw Wed [10-16]) as directed by Dr. [Last Name (STitle) 84707],[First Name3 (LF) ] C Address: 128 STATE RT 27, [Location (un) ],[Numeric Identifier 84708] Phone: [Telephone/Fax (1) 84709] Fax: [Telephone/Fax (1) 84710] 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for skin folds. [Telephone/Fax (1) ]:1 Bottle Refills:0 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation every six (6) hours as needed for wheezing. [Telephone/Fax (1) ]:1 HFA Refills:0 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. [Telephone/Fax (1) ]:1 Aerosol Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Telephone/Fax (1) ]:60 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Lorazepam 1 mg Tablet Sig: 0.5-1 Tablet PO every eight (8) hours as needed for anxiety. [Telephone/Fax (1) ]:42 Tablet(s) Refills:0 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache. 10. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). [Telephone/Fax (1) ]:240 Tablet(s) Refills:0 11. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 weeks. [Telephone/Fax (1) ]:84 Tablet(s) Refills:0 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 weeks. [Telephone/Fax (1) ]:63 Tablet(s) Refills:0 13. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). [Telephone/Fax (1) ]:10 Patch 72 hr(s) Refills:0 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. [Telephone/Fax (1) ]:30 Tablet(s) Refills:0 16. Enoxaparin 100 mg/mL Syringe Sig: One (1) Syringe Subcutaneous Q12H (every 12 hours): Please take until stopped by your Primary Care Physician. [Name Initial (NameIs) ]:14 Syringe Refills:0 17. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4,000,000 (4 Million) Units Injection Q4H (every 4 hours) for 3 weeks: Until [11-1]. [Month/Year (2) ]:26 Units Refills:0 18. PICC Care Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 19. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. [Month/Year (2) ]:30 Tablet(s) Refills:0 20. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). [Hospital1 ]:1 Aerosol Refills:0 21. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. [Hospital1 ]:168 Tablet(s) Refills:0 22. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Total divalproex dose 1250mg twice daily. . [Hospital1 ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 23. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day): Total divalproex dose 1250mg twice daily. . [Hospital1 ]:120 Tablet, Delayed Release (E.C.)(s) Refills:2 24. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). [Hospital1 ]:180 Tablet, Chewable(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA Discharge Diagnosis: Primary Diagnoses: 1. Brain Abscess 2. s/p Roux-en-y Bypass with anastamotic leak 3. R femoral deep vein thrombosis 4. Simple partial seizures Secondary Diagnoses: Atrial Fibrillation Aortic Stenosis s/p Aortic valve replacement Hypertension Coronary artery disease Non-hodgkin lymphoma Discharge Condition: Hemodynamically stable with normal vital signs. Ambulating without difficulty. Discharge Instructions: You have been admitted to the hospital for evaluation of a brain abscess. While you were here, our Neurosurgical team was successful in draining these abscesses. Our Infectious Disease and Surgical teams evaluated you for a source of infection and found that your old bypass surgery had a small but stable leak, and this was likely the cause of your infection. Unfortunately while you were here you also developed a blood clot which obligates you to 6 months of anticoagulation therapy. It has been a long and difficult hospital course and I commend you on your continued positive spirits. It has been a true pleasure caring for you during this difficult time. There have been many changes to your medications including antibiotics. Please ask the nurse for a full print out of your medications as the most accurate and up to date list. Of note: Please stop Sotalol, you will not need this medication at this time Please take your Cipro & Flagyl (antibiotics) every day as directed Please take your Warfarin (Coumadin, blood thinner) as directed and follow with Dr. [Last Name (STitle) ] to guide you on dose. Please continue enoxaparin until Dr. [Last Name (STitle) ] tells you otherwise. Please take valproate, levatiracetem, and fosphenytoin at the currently prescribed doses until you are told otherwise by your seizure doctor. While on these medications, you should have your liver function, platelet count and drug levels drawn and monitored by either Dr [Last Name (STitle) ] or your seizure doctor. Please make all appointments as directed. For many of our specialists, we have made appointments for you but you can find a specialist closer to home. Please make all appointments as scheduled and recommended: 1. Primary Care: [Last Name (LF) 84707],[First Name3 (LF) ] C [Telephone/Fax (1) 84709], Monday [10-21] @ 11am Please tell your Primary care doctor that you need a pelvic ultrasound 6 weeks post discharge to evaluate an adnexal cyst 2. Infectious Disease: [2143-10-24] @ 10:00a with Dr. [Last Name (STitle) ] at the: LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT ID WEST (SB) 3. Neurology (Epileptology): [2143-11-1] 01:00p [Last Name (LF) ],[First Name3 (LF) ] T. SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] NEUROLOGY UNIT CC8 (SB) (This appointment can be made with your own neurologist/epileptologist) 4. Neurosurgery: On [2143-11-26] at 1:40pm you are scheduled for a brain MRI, at 2:30pm on the same day you will see Dr [Last Name (STitle) ]. The MRI is located on the [Hospital Ward Name ] basement of the clinical center. Dr [Last Name (STitle) ] is located on the [Location (un) 9998] of the [Hospital Unit Name ] behind the clinical center [Last Name (NamePattern1) 51019]. Dr [Name (NI) 28838] office can be reached at ([Telephone/Fax (1) 88]. We recommend the following appointments: 1. Hematologist/Oncologist: Your blood counts were low on this admission and this should be followed. 2. Gastroenterologist/Bariatric Surgeon: Our surgeons have no operative recommendations regarding your bypass leak, but your surgeons may care to re-evaluate you. Please call your doctor or 911 if you experience worsening or uncontrolled head pain, confusion, chest pain, difficulty breathing, nausea, vomiting, abdominal pain, black or bloody stools or any other concerning medical symptom. Neurosurgical Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may 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. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Please make all appointments as scheduled and recommended: 1. Primary Care: [Last Name (LF) 84707],[First Name3 (LF) ] C [Telephone/Fax (1) 84709], Monday [10-21] @ 11am Please tell your Primary care doctor that you need a pelvic ultrasound 6 weeks post discharge to evaluate an adnexal cyst 2. Infectious Disease: [2143-10-24] @ 10:00a with Dr. [Last Name (STitle) ] at the: LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT ID WEST (SB) 3. Neurology (Epileptology): [2143-11-1] 01:00p [Last Name (LF) ],[First Name3 (LF) ] T. SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] NEUROLOGY UNIT CC8 (SB) (This appointment can be made with your own neurologist/epileptologist) 4. Neurosurgery: On [2143-11-26] at 1:40pm you are scheduled for a brain MRI, at 2:30pm on the same day you will see Dr [Last Name (STitle) ]. The MRI is located on the [Hospital Ward Name ] basement of the clinical center. Dr [Last Name (STitle) ] is located on the [Location (un) 9998] of the [Hospital Unit Name ] behind the clinical center [Last Name (NamePattern1) 51019]. We recommend the following appointments: 1. Hematologist/Oncologist: Your blood counts were low on this admission and this should be followed. 2. Gastroenterologist/Bariatric Surgeon: Our surgeons have no operative recommendations regarding your bypass leak, but your surgeons may care to re-evaluate you.	[ "V45.81", "300.00", "285.9", "414.00", "425.4", "324.0", "401.9", "518.81", "427.31", "412", "V42.2", "V42.81", "041.02", "288.50", "997.4", "V43.3", "453.41", "345.70", "V10.79", "289.59" ]	icd9cm	[ [ [] ] ]	[ "01.31", "96.72", "96.04", "01.39" ]	icd9pcs	[ [ [] ] ]	20061, 20120	9436, 15362	310, 439	20452, 20533	3828, 3828	25292, 26766	3069, 3178		15545, 20038		20141, 20285		15388, 15522			20557, 25269			3844, 3920								3193, 3193		20306, 20431					3209, 3809													252, 272								467, 2308		4545, 9413								3936, 4536				2330, 2901	2917, 3053
45,284	120,883	41893	Discharge summary	report	Admission Date: [2176-10-2] Discharge Date: [2176-10-4] Date of Birth: [2111-1-4] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / caffeine Attending:[First Name3 (LF) 2265] Chief Complaint: ASA desensitization Major Surgical or Invasive Procedure: placement of DES in LAD with jailing of diagonal vessel History of Present Illness: 65 year old female with no previous history of CAD, GERD, COPD admitted to [Hospital6 ] with chest pain, found to have 95-99% LAD bifurcating lesion, transferred to [Hospital1 18] for intervention and ASA desensitization. Admitted earlier this week to [Hospital3 ] for chest pain with negative CT, negative imaging stress test, and negative nuclear ETT. Discharged yesterday ([10-1])from [Hospital3 ], but then brought in by ambulance to [Hospital3 ] with recurrent chest pain radiating to her back and both arms, similar to the symptoms that prompted her previous admission a few days earlier, CE's negative x 2. Upon her first admission, she refused cardiac catheterization, but underwent cath upon the second admission with the above noted LAD lesion. Transferred to [Hospital1 18] for intervention with necessity for ASA desensitization due to allergy. Reported to be chest pain free, with 5 French in RFA, distal pulses intact. Loaded with 600 mg plavix and IV heparin/Integrillin. In the cath lab, DES was placed in the proximal LAD, and is now in the CCU for aspirin desensitization. . Pt denies any current chest pain/discomfort, shortness of breath, or nausea. She reports back pain due to positioning secondary to her "sciatica pain" that is starting to sit in her abdomen. . 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, 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - GERD - COPD - Asthma - Tubal Pregnancy - Appendectomy - Carpal Tunnel Syndrome, finger in splint - Environmental Allergies - Left Knee Arthroscopy - Angina Social History: - Tobacco history: [12-31] PPD 50+ years - ETOH: denies - Illicit drugs: denies Family History: - Has five children, alive and well - Mother: healthy - Father: deceased, CAD s/p MI in his 60s, cancer, DM, emphysema Physical Exam: Admission Exam VS: T BP= 147/77 (132-147/73-84) HR= 63 (71-77) RR= 15 (13-26) O2 sat= 95% (91-95% RA) GENERAL: 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: No JVD appreciated. 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 assessed anteriorly due to venous sheath in place, no crackles, wheezes or rhonchi. ABDOMEN: Soft, ND. Slight TTP in the epigastrum region. No HSM or tenderness. Abd aorta not palpable. No abdominial bruits. EXTREMITIES: No c/c/e. Venous sheath in right [Last Name (un) ] in place, c/d/i. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ DP 2+ PT 2+ Discharge exam VS: T 97.9 BP= 122/67 HR= 78 RR= 18O2 sat= 100% ra GENERAL: 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: No JVD appreciated. 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 assessed anteriorly due to venous sheath in place, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NT, ND. No HSM or tenderness. Abd aorta not palpable. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Radial 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [2176-10-2] 08:41PM BLOOD WBC-13.2* RBC-4.22 Hgb-12.5 Hct-36.3 MCV-86 MCH-29.6 MCHC-34.3 RDW-13.3 Plt Ct-218 [2176-10-2] 08:41PM BLOOD PT-14.4* PTT-150* INR(PT)-1.2* [2176-10-2] 08:41PM BLOOD Glucose-163* UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-108 HCO3-16* AnGap-19 [2176-10-2] 08:41PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 Cholest-152 [2176-10-2] 08:41PM BLOOD Triglyc-104 HDL-46 CHOL/HD-3.3 LDLcalc-85 [2176-10-3] 05:59AM BLOOD CK-MB-84* MB Indx-11.8* cTropnT-0.81* Discharge Labs [2176-10-4] 06:30AM BLOOD WBC-8.6 RBC-3.95* Hgb-11.9* Hct-34.9* MCV-88 MCH-30.1 MCHC-34.1 RDW-13.4 Plt Ct-199 [2176-10-4] 06:30AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-143 K-4.2 Cl-109* HCO3-25 AnGap-13 [2176-10-4] 06:30AM BLOOD CK(CPK)-360* [2176-10-4] 06:30AM BLOOD CK-MB-32* MB Indx-8.9* cTropnT-0.67* [2176-10-4] 06:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2 [2176-10-2] 08:41PM BLOOD Triglyc-104 HDL-46 CHOL/HD-3.3 LDLcalc-85 Cath report: 1. Coronary angiography in this right dominant system demonstrated 95% proximal LAD stenosis involving the origin of a large D1 with ostial 70% stenosis. The LMCA, LCx, and RCA had no angiographically apparent disease. 2. Limited resting hemodynamics revealed mild systemic arterial systolic hypertension with SBP 164 mmHg. 3. Successful PCI of the LAD with 2.5x18mm Promus DES and overlapping 3.0x8mm Promus post-dilated to 3.0mm distally and 3.25mm proximally (see PTCA comments). 4. Procedure complicated by transient closure and dissection of D1, which was successfully rescued (see PTCA comments). 5. Manual 8F RFA sheath pull. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful PCI of LAD with DES complicated by transient closure and dissection of D1 successfully rescued (see PTCA comments). 3. Plavix for minimum 12 months. 4. Aspirin desensitization immediately in CCU per protocol, and then continue indefinitely. 5. Integrillin to continue for 18 hours post-PCI. 6. Hydrate for prevention of contrast nephropathy. 7. Check cardiac enzymes and monitor clinical status closely. 8. Manual sheath pull when ACT<170s. TTE The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with akinesis of the mid to distal septum and hypokinesis of the apex. 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 leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with mild regional left ventricular systolic dysfunction as described above. No clinically significant valvular disease. Normal pulmonary artery systolic pressure. Brief Hospital Course: 65F with GERD, COPD with unstable angina with negative cardiac enzymes found to have 95-99% bifucating LAD lesion now s/p cath with [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5175] in proximal LAD, admitted to CCU for aspirin desensitization, chest pain free. . # Unstable angina: Presented to OSH with chest pain, negative enzymes, found to have 80% bifurcating lesion to LAD. Transferred to [Hospital1 18] for intervention. A DES was placed in the LAD, with jailing of diagonal branch. She remained chest pain free after the procedure, although cardiac enzymes did rise (consistent with jailing). Because she has a allergy to aspirin, she was then transferred to the CCU for aspirin desensitization, which was successful. She was started on ASA 325mg PO daily, plavix 75mg PO daily, lisinopril 5mg daily. Metoprolol not started for the time being as her pressures were in 90's on lisinopril. PCP or cardiologist can consider starting beta-blocker in the future. Repeat TTE showed EF45-50% with akinesis of the mid to distal septum and hypokinesis of the apex. . # ASPIRIN DESENSITIZATION: Reported hives/mouth sensation with prior use. Transferred briefly to CCU for asa desensitization, which was successfully completed without incident. She was started on ASA 325mg PO daily. . # COPD - chronic, breathing at baseline throughout admission. Continued on spiriva and advair-diskus (substituted from symbicort as that is non-formulary) . # SMOKING History - nicotine patch while in-house. Smoking cessation councelling provided at length. Nicotine patch prescription given for outpatient setting. She should follow closely with her PCP regarding smoking cessation. Medications on Admission: - Accolate - Symbicort 160/4.5 2 puffs inh qAM - Zyrtec - Nexium 20mg daily - Nitrostat - Spiriva 1 puff inh qAM - Metoprolol 25 mg twice daily - simvastatin 20 mg daily - lorazepam 1mg twice daily as needed for anxiety Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 21 days. Disp:21 Patch 24 hr(s) Refills:0 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: [12-31] Inhalation 2 puffs () as needed for [Hospital1 ]. 7. 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 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN chest pain: [Month (only) 116] take again after 5 minutes if chest pain persists, and then a 3rd dose 5 minutes later if still having chest pain. 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Accolate Oral 11. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: unstable angina s/p DES to LAD with jailing of diagonal artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [Known lastname ], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for an interventional cardiac procedure to open-up a partially blocked blood vessel to your heart. This blockage had been causing you chest pain. A drug eluting stent was placed in this blood vessel. These stents require that you take aspirin and clopidogrel (Plavix) for at least one year or possibly longer. Do not stop taking aspirin and clopidogrel for any reason unless Dr. [Last Name (STitle) 33746] tells you this is OK. You risk clotting off the stent and causing another heart attack if you do not continue these medicines. Because aspirin is an important blood thinner, and you were allergic to it, you had aspirin desensitization. This was successful and you can now take aspirin and should take this medicine every day for the rest of your life. The following changes were made to your medications: STOP nexium, take pantoprazole instead for your heartburn. START aspirin 325mg by mouth once daily for at least one year to prevent the stent from clotting off. START Plavix (clopidogrel) 75mg by mouth once daily for at least one year to prevent the stent from clotting off START lisinopril 5mg by mouth once daily to lower your blood pressure STOP taking simvastatin, start atorvastatin 80mg by mouth once daily to lower your cholesterol START nicotine patch every day to help you quit smoking. This is the most important thing you can do for your health. STOP taking metoprolol for now, Dr. [First Name (STitle) ] can restart this medicine next week if your blood pressure has improved Followup Instructions: Pt has appt with Dr. [First Name (STitle) ] on Tuesday [10-8] and Dr. [First Name (STitle) ] will arrange for a cardiology appt at that time. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2273**]	[ "272.4", "305.1", "250.00", "E879.0", "997.1", "493.20", "V07.1", "414.01", "530.81", "414.12", "401.9", "411.1" ]	icd9cm	[ [ [] ] ]	[ "88.52", "00.41", "00.46", "00.44", "37.22", "36.07", "00.66", "99.20" ]	icd9pcs	[ [ [] ] ]	11043, 11049	7749, 9435	336, 393	11155, 11155	4699, 6314	12971, 13239	2711, 2833		9705, 11020		11070, 11134		9461, 9682		6331, 7726	11306, 12948											2848, 4680			2323, 2401																	277, 298								421, 2219									11170, 11282		2432, 2592			2241, 2303	2608, 2695
10,502	130,571	43457	Discharge summary	report	Admission Date: [2160-7-17] Discharge Date: [2160-7-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2698] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 86 y/o female with DM2, HTN, Hyperlipidemia, Breast Ca who presents with chest tightness. Reports that she has been having SSCP off and on for several weeks. Pain is unrelated to exertion or food. There is no radiation, although she reports some associated back pain today. Has associated nausea and vomited today. Denies SOB, diaphoresis. Pain not pleuritic. Also reported transient right ankle swelling. Uses pepcid which helps the discomfort. Had a cardiac cath about 3 yrs ago which showed 40% narrowing of the proximal LAD w/ at least 40% stenosis 1st diagonal, tortuosity of the epicardial coronary vessels [3-12] HTN, nl LV size, function and contraction pattern; this was medically managed. She had no change in these symptoms but called her PCP here in [Name9 (PRE) 86] today who sent her to the ED due to above sx. . At this time, the patient denies frank CP, chest tightness, n/v, sob, or HA but does report a tightness at the skin level that she compares to a tight brazier. . In ED, received IV hydral 10mg X 1, mucomyst, bicarb, esmolol gtt and nipride gtt. CT [Doctor First Name ] was consulted and recommended medical management. Has not yet received regular PM meds. Past Medical History: 1. Type 2 DM--diet controlled 2. HTN 3. H/o ?Pancreatitis [10-12]; normal MRCP [11-11] 4. Hyperlipidemia 5. BRCA dx'd [2145] s/p Lumpectomy and XRT 6. R>L RAS 7. herniated disc 8. cri (baseline 1.2-1.6) Social History: lives in [State ]; 3-+py tob. husband deceased and then 2nd partneser deceased 1.5 yrs ago Former work at [First Name8 (NamePattern2) ] [Doctor Last Name 1104] Family History: NC Physical Exam: 97.3 66 168/49 12 100RA Pleasant woman in NAD Neck supple, M&O moist and clear, no LAD JVP @ 9cm; Nl S1/S2 CTAB Soft, NT, ND, NABS Warm X 4 w/pulses X 4; bipedal trace edema @ ankles ... On DC: 97.4 170/76 84 96ra Pleasant woman in NAD Neck supple, M&O moist and clear, no LAD JVP @ 6cm; Nl S1/S2 CTAB Soft, NT, ND, NABS Warm X 4 w/pulses X 4; bipedal trace edema @ ankles Pertinent Results: [2160-7-17] 08:30PM CK(CPK)-75 [2160-7-17] 08:30PM CK-MB-NotDone cTropnT-<0.01 [2160-7-17] 01:30PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2160-7-17] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2160-7-17] 12:30PM GLUCOSE-126* UREA N-43* CREAT-1.5* SODIUM-140 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17 [2160-7-17] 12:30PM CK(CPK)-92 [2160-7-17] 12:30PM CK-MB-NotDone cTropnT-<0.01 [2160-7-17] 12:30PM NEUTS-63.6 LYMPHS-22.4 MONOS-6.6 EOS-6.8* BASOS-0.5 [2160-7-17] 12:30PM WBC-11.0# RBC-4.83 HGB-14.4 HCT-42.1 MCV-87 MCH-29.9 MCHC-34.3 RDW-14.6 [2160-7-17] 12:30PM PLT COUNT-289 [2160-7-17] 12:30PM D-DIMER-1279* CTA chest: 1. Extensive atherosclerotic disease of the thoracic aorta with diffuse irregularity of the aortic wall contour with multiple possible areas of penetrating ulceration notably with a penetrating ulcer located in the descending thoracic aorta at the level of the tracheal bifurcation after the take off of the great vessels. 2. No evidence of pulmonary embolism. 3. Small right thyroid nodule. ... ECG: Sinus brady @ 54bpm w/ prolonged QTc @ .452 and LAD. Flipped T in II, 1mm ST elevation V2, 2mm ST elevation in V3 old compared to [2160-1-12]. Interpreation: LAD w/LAFB and LVH. No ischemia. . Bil LENIs: No DVT . [7-11] 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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: This 86 y/o female with DM, HTN, and high chol presented with extensive ulcerated atherosclerotic disease of the aorta and with intermittent chest pain and poorly controlled blood pressure. . Chest pain: Diff dx at presentation included angina, dissection (given high BP), PE (+Ddimer, ?right ankle swelling, relatively recent plane trip), GI cause (relieved by pepcid). 2w time course was felt most c/w GERD and most concerning for slow dissection. Ultimately felt likely [3-12] GERD, HTN. - Ruled out for MI with serial enzymes, EKGs - Continued ASA, bblocker, statin - Agressive BP control as below in detail - CTA negative for PE; FU CTA 1month for atherosclerotic lesions; negative LENI studies -PPI -Plan for atherosclerotic lesions is repeat CTA in one month and followup with Dr. [First Name (STitle) ]. . HTN: Likely [3-12] RAS. RA US performed pre-DC for better characterization to aid outpatient managment. Much improved on HCTZ, and labetalol with [Last Name (un) ] added on day of DC. Control still not optimal; to be seen as epi @ [Company 191] this week, with likely addition of CCB at that time. . CRI: Cr at baseline. . LE swelling- In context of positive D-Dimer in a patient w/hx malignancy, was concerning for DVT; LENIs negative. Likely mild CHF. . DM: HSS, [Doctor First Name ] diet . FC . FEN- Cardiac/DM diet . PPx- SQ heparin, PPI . Access- Currently PIV . [Name (NI) ] Pt . Dispo- Discharged to home. FU w/Dr. [First Name (STitle) ], Dr. [First Name (STitle) ]. Medications on Admission: Medications: Aspirin 325 QD HCTZ 25 QD Toprol XL 100AM 50QPM Sular (nisoldipine) 20 QD Lovastatin 40mg QHS Claritin NSAID Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Lovastatin 20 mg Tablet Sig: Two (2) Tablet PO qD (). 3. Meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO qD (). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Labetalol HCl 200 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). Disp:300 Tablet(s) Refills:2 6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Atherosclerotic disease of the thoracic aorta with evidence of ulceration 2. HTN Secondary Diagnosis: 1. Type 2 DM--diet controlled 2. CRI (BL 1.2-1.6) 3. H/o ?Pancreatitis [10-12]; normal MRCP [11-11] 4. Hyperlipidemia 5. BRCA dx'd [2145] s/p Lumpectomy and XRT 6. R> L Renal Artery Stenosis Discharge Condition: fair Discharge Instructions: Please call your PCP or return to the emergency department if you develop chest pain, shortness of breath, headaches, or other worrisome symptom. Please take all medications as prescribed. Please follow up with all appointments as listed below. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 5250], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 5251] Date/Time:[2160-8-8] 10:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1843], RN Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2207] Date/Time:[2160-8-8] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5912], MD Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2160-8-13] 1:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2160-7-23] 3:30 Please call Dr.[Name (NI) 3101] office at [Telephone/Fax (1) 920] to schedule a follow up appointment in one month. At that time, a follow up CT scan to evaluate aorta and further recommendations will be discussed.	[ "458.29", "440.0", "447.2", "V10.3", "428.0", "447.8", "440.1", "250.00", "272.4", "593.9", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6905, 6963	4453, 5985	273, 279	7315, 7321	2375, 4430	7614, 8651	1956, 1960		6157, 6882		6984, 7068		6011, 6134			7345, 7591											1975, 2356																				223, 235								307, 1507			7089, 7294											1529, 1750	1766, 1940
63,461	155,348	17637	Discharge summary	report	Admission Date: [2159-2-26] Discharge Date: [2159-3-13] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [2159-3-6] - 1. Urgent aortic valve replacement with a 25-mm Biocor Epic tissue valve. 2. Mitral valve repair with a triangular resection of middle scallop of the posterior leaflet P2 and a mitral valve annuloplasty with a 30 mm [Doctor Last Name 405] annuloplasty band. 3. Coronary artery bypass grafting times 1 with reverse saphenous vein graft to the marginal branch. [2159-2-27] - Cardiac Catheterization History of Present Illness: 88 y/o male with HTN, HLD, LE claudication, AF on coumadin, MDS, moderate to severe AS, who initially presented on [2159-2-24] to [Hospital3 417] Hospital via EMS with 2-3 days of nausea, vomiting, diarrhea, diaphoresis, ? viral prodrome. During the days up to admission, he also developed DOE and had progressively more difficulty climbing stairs, requiring rest, which was a change in baseline. In hindsight, he actually reports progressive dyspnea while walking for the past several months (4-6 months), when he was evaluated for LE claudication. Functionally, he feels he can no longer walk 1 block or do 1 flight of stairs due to his breathing. He also reported weakness and fatigue. En route, he received 4 aspirin tablets, 81 mg, along with CPAP. . At [Hospital3 417] ED, his HR was 113, RR 30s, BP 149/109. He was in tripod position while breathing. On ROS, he reported cough for 3-4 days without fever or sputum. He denied abdominal pain or headache. Denied dizziness. Denies syncope. He also reported pressure in his epigastrium. He was noted to be tachypnic, eventually requiring Bipap. X-ray confirmed acute CHF exacerbation with ? RML infiltrate, and he was placed on nitro gtt. He was also in rapid AF with ? rate related ST depressions, requiring lopressor. Once nitro was weaned off, he again went into flash pulmonary edema. On saturday, he again went into rapid AF, and developed chest pressure with acute CHF exacerbation. He has intermittently required Bipap, lasix, and nitro gtt in CCU. Echo there showed critical AS with valve area 0.4 cm2, and he is transferred for consideration of aortic valve intervention. Of note, cardiac enzymes were notable for negative troponin x 2 and BNP 268 then 560. . Per review of [Hospital3 417] admission note, suspicion was for congestive heart failure possibly triggered by early pneumonia. He improved with Bipap, nitro gtt, lasix gtt. He also received ceftriaxone and azithromycin, but this was discontinued prior to transfer. . Vitals on transfer - afebrile, 95, 116/74, 16, 94% on 3L NC . On review of systems, patient reports that his baseline SBP is 110-120. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is positive for epigastric discomfort, DOE, and PND. Reports sleeping on 1 pillow. Notable for absence of palpitations, syncope or presyncope. Past Medical History: Aortic stenosis Coronary artery disease Mitral valve regurgitation Dyslipidemia Hypertension Peripheral vascular disease (no interventions) Atrial fibrillation on Coumadin Myelodysplasia (no need for frequent transfusions, no prior chemo) Congestive heart failure GERD neuromuscular disorder affecting leg strength arthritis Social History: - Tobacco history: quit smoking more than 40 years ago. - ETOH: 1 drink per night - Illicit drugs: denies - Has one daughter. Very involved son and wife at bedside. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: died from "old age" - Father: died from leukemia - Brother: kidney cancer - Daughter: colon cancer Physical Exam: VS: T=97.0 BP=91/68 HR=74 RR=18 O2 sat=93% 2L NC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Does have L eye ptosis. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [10-12] cm CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregular rhythm. Grade III/VI holosystolic murmur heard best at LSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diffuse rhonchi and crackles at bases, without wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c. Compression stockings present with trace edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength UE and LE, 2+ reflexes biceps, brachioradialis, patellar, ankle. 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: ECHO [2159-3-6] 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>55%). with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is no pericardial effusion. Post bypass The patient is s/p Mitral valve repair with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] 30 ring and an 25 [First Name8 (NamePattern2) ] [Male First Name (un) 923] bioprosthetic aortic valve replacement The patient is on an Norepinephrine drip at 0.05 mcg/kg/min and a milrinone drip at 0.5 mcg/kg/min The cardiac index is 2.9 The mitral ring is well seated with no peri/paravalvular leaks seen.The mean gradient across the mitral valve is 3 mmhg The aortic valve is well seated with no peri/paravalvular leaks.The mean gradient across the aortic valve is 11 mm hg There is persistent moderate to severe tricuspid regurgitation The aorta is intact post decannulation LV function is preserved at an EF of>55% Cardiac Catheterization [2159-2-27] 1. Coronary angiography in this right dominant system demonstrated two vessel CAD. The LMCA was patent. The LAD had diffuse mild plaquing with sever fal disease in the mid diagonal branch. The Lcx had a sever proximal lesion with focal stenosis and diffuse mild to moderate stenosis distally. The RCA was mildly ectatic with diffuse mild plaquing and TIMI 2 flow. 2. Resting hemodynamics demonstrated elevated left sided filling pressures with a mean PCWP of 28mm Hg. The was moderate to severe pulmonary pressure with a PASP of 58mm Hg and an elevate PVR. The was low normal systemic systolic pressure of 90mm HG with severely depressed cardiac index of 1.8 l/min/m2. CTA [2159-3-5] 1. Bilateral pulmonary edema appears slightly increased compared to the prior examination. 2. Bilateral pleural effusions, stable on the right and decreased on the left compared to the prior examination. 3. Resolution of multifocal consolidative nodules. 4. Severe aortic valve calcification and atherosclerosis of the coronary vessels. Stable dilatation of the ascending thoracic aorta measuring up to 4.7 cm in diameter. 5. Upper and lower pole left renal cysts. [2159-3-13] 04:20AM BLOOD Hct-27.8* [2159-3-12] 03:15PM BLOOD WBC-7.1 RBC-3.07* Hgb-10.5* Hct-29.7* MCV-97 MCH-34.1* MCHC-35.2* RDW-15.7* Plt Ct-106* [2159-3-12] 11:10AM BLOOD WBC-7.0 RBC-3.11* Hgb-10.4* Hct-30.1* MCV-97 MCH-33.3* MCHC-34.5 RDW-15.7* Plt Ct-101* [2159-3-11] 05:30AM BLOOD WBC-6.1 RBC-2.93* Hgb-9.9* Hct-28.2* MCV-96 MCH-33.8* MCHC-35.2* RDW-15.3 Plt Ct-84* [2159-3-10] 09:25AM BLOOD WBC-8.0 RBC-3.17* Hgb-10.6* Hct-30.3* MCV-96 MCH-33.4* MCHC-35.0 RDW-15.6* Plt Ct-93* [2159-3-13] 04:20AM BLOOD PT-23.8* INR(PT)-2.3* [2159-3-12] 03:15PM BLOOD PT-25.1* INR(PT)-2.4* [2159-3-12] 11:10AM BLOOD PT-23.4* PTT-26.3 INR(PT)-2.2* [2159-3-12] 04:20AM BLOOD PT-22.9* INR(PT)-2.2* [2159-3-11] 05:30AM BLOOD PT-17.8* INR(PT)-1.7* [2159-3-10] 04:15AM BLOOD PT-16.5* INR(PT)-1.6* [2159-3-9] 05:53AM BLOOD PT-15.8* PTT-28.7 INR(PT)-1.5* [2159-3-6] 01:45PM BLOOD PT-18.1* PTT-27.9 INR(PT)-1.7* [2159-3-6] 11:51AM BLOOD PT-25.7* PTT-38.4* INR(PT)-2.5* [2159-3-4] 06:40AM BLOOD PT-17.0* PTT-81.7* INR(PT)-1.6* [2159-3-3] 07:13AM BLOOD PT-16.5* INR(PT)-1.6* [2159-3-13] 04:20AM BLOOD UreaN-30* Creat-0.9 Na-144 K-4.0 Cl-107 [2159-3-12] 04:20AM BLOOD Glucose-136* UreaN-33* Creat-0.9 Na-143 K-4.0 Cl-105 HCO3-28 AnGap-14 [2159-3-11] 05:30AM BLOOD Glucose-129* UreaN-33* Creat-0.9 Na-141 K-3.6 Cl-104 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [Known lastname 3075] was admitted to the [Hospital1 18] on [2159-2-26] via transfer from [Hospital3 417] Hosipital. He initially presented on [2159-2-24] to [Hospital3 417] Hospital with progressive dyspnea and acute congestive heart failure exacerbation, and was thus transferred for consideration of aortic valve intervention given concern for critical/severe aortic stenosis. He was worked-up in the usual preoperative manner which included a carotid duplex ultrasound which shoed less then 40% stenosis of the bilateral internal carotid arteries. A cardiac catheterization was performed which showed single vessel coronary artery disease. A chest CT scan was performed which showed a stable dilatation of the ascending thoracic aorta measuring up to 4.7 cm in diameter and likely pneumonina. Levofloxacin was started for pneumonia. Multifocal consolidative nodules were also noted predominantly right upper lobe. As there was some concern that these lesions could also represent bronchogenic carcinoma, a repeat CT scan was done. This showed resolution of the nodules. Heparin was continued for his atrial fibrillation. He was diuresed for pulmonary edema. A dental consult was obtained for oral clearance for surgery. No evidence of infection was identified on exam or by panorex and he was cleared for surgery from an oral standpoint. On [2159-3-6], Mr. [Known lastname 3075] was taken to the operating room where he underwent replacement of his aortic valve, a mitral valve repair and cornary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Pressors and inotropes were slowly weaned off. A mild acidosis was allowed to recover. On postoperative day one, he was extubated. Mr. [Known lastname 3075] was noted to have some difficulty swallowing. A speech and swallow consult was obtained which showed evidence of aspiration with thin liquids. A thickened liquid diet was recommended with moist solids and continued aspiration precautions. Diuresis was intiated. On [2159-3-8], Mr. [Known lastname 3075] was transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and recovery. Coumadin was resumed for his chronic atrial fibrillation. The patient developed ecchymosis at the vein harvest site of the right lower extremity. Keflex was started for this. He remained afebrile with a normal WBC count. A copious amount of dark blood and clot was milked from the vein harvest site on POD 6. The leg was wrapped tightly with ACE. Hematocrit remained stable and bleeding stopped. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [Hospital 19771] rehab in [Location (un) 2624] in good condition with appropriate follow up instructions. Medications on Admission: HOME MEDICATIONS: - digoxin 0.125 mg daily - coumadin 10 mg MWF, 5 mg rest of days - metoprolol 25 mg [Hospital1 ] - omeprazole 20 mg qAM - B12 1000 mcg daily . Medications on transfer: - coumadin (last dose Fri AM) - maalox prn dyspepsia - morphine sulfate 2 mg q2 hrs prn chest pain - magnesium hydroxide prn - lopressor 25 mg [Hospital1 ] - docusate - aspirin 325 mg daily - tylenol - lasix gtt Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours). 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 11. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once): MD to dose daily for goal INR [2-2], dx: afib. Discharge Disposition: Extended Care Facility: Hellenic - [Location (un) 2624] Discharge Diagnosis: Aortic stenosis Coronary artery disease Mitral valve regurgitation Dyslipidemia Hypertension Peripheral vascular disease (no interventions) Atrial fibrillation on Coumadin Myelodysplasia (no need for frequent transfusions, no prior chemo) Congestive heart failure GERD neuromuscular disorder affecting leg strength arthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assist Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage right leg- healing well, no erythema or drainage,right thigh ecchymotic trace edema left leg, 1+ edema right leg Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2159-4-11] 1:15 Cardiologist: Dr. [Last Name (STitle) 2262] [2159-3-26] at 11:30a Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 34561] in [4-5] weeks [Telephone/Fax (1) 3183] 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 a-fib Goal INR 2-2.5 First draw day after discharge- [2159-3-14] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. Please arrange for coumadin follow-up on discharge from rehab Completed by:[2159-3-13]	[ "416.8", "788.20", "238.75", "E878.8", "427.31", "V70.7", "396.2", "428.0", "V58.61", "414.01", "486", "716.90", "358.9", "272.4", "443.9", "276.2", "998.11", "530.81", "401.9", "428.33", "E915", "E849.7", "933.1" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.21", "35.12", "39.61", "35.21", "36.11" ]	icd9pcs	[ [ [] ] ]	13810, 13872	9127, 12134	265, 689	14241, 14514	5178, 9104	15402, 16242	3827, 4053		12590, 13787		13893, 14220		12160, 12160			14538, 15379											4068, 5159				12178, 12325																218, 227								717, 3281													12350, 12567	3303, 3629	3645, 3811
48,391	128,847	13305	Discharge summary	report	Admission Date: [2134-8-16] Discharge Date: [2134-8-23] Date of Birth: [2055-5-20] Sex: F Service: MEDICINE Allergies: cats Attending:[First Name3 (LF) 4327] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: 1. Emergent mediastinal re-exploration. 2. Drainage of pericardial effusion. 3. Cardiac Catheterization 4. IABP placement 5. Swan catheter placement History of Present Illness: (all information obtained via OMR and patients chart. She is intubated and sedated) 79 year old female who presented to emergency room with the complaints of nausea,vomitting, unsteady gait and feeling disoriented. Upon arrival to emergency room she was able to answer yes and no questions and then suddenly became unresponsive. She was intubated, and appeared to be in shock according to EKG. She continued to have signs of shock, with low blood pressure, requiring dopamine and Levophed. On bedside ultrasound she had poor wall motion, no clear effusion. She was transferred to [Hospital1 18] for cardiac catheterization. Past Medical History: Hypertension Atrial Fibrillation CAD (exercise stress test/stress echo [2127] WNL) hypercholesterolemia OSA on CPAP C-scope ([2127]-WNL) CKD - presumed [2-18] HTN(baseline Cr: 1.5) Hx SCC L chest wall rx with topical agents ([2132]) LCIS([2127]) Lumbar stenosis idiopathic B/L LE numbness Syncopal episodes (since teen years), Breast Cancer Social History: Lives alone - widowed [1-27]. Retired credit analyst. Denies tobacco, EtOH, recreational drugs Family History: Non-contributory Physical Exam: GENERAL: pt intubated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, collar in place. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2134-8-16]: Cardiac Cath: 1.Delayed presentation of posterior wall STEMI 2.Cardiogenic shock 3.Lateral wall myocardial rupture 4.Successful recanalization of the left circumflex with balloon angioplasty 5.Emergency surgery for myocardial rupture [8-16] Echo: 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 severe hypo/akinesis of the basal inferolateral wall with a discontuity and the basal wall at the annulus level with apparent communication with the pericardial space. Color flow Doppler is inadequate to define flow. The remaining segments contract normally (LVEF = 45-50 %). Right ventricular chamber size is normal. The free wall is not well seen. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. There is a moderate sized circumferential pericardial effusion. Tamponade could not be assessed. [8-16] Echo: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with akinesis of the basal inferolateral wall. There appears to be a rupture of the basal inferolateral wall immediately apical to the mitral annulus with color flow Doppler through this area in to the pericardial space. The remaining segments contract normally (LVEF = 55 %). There is a moderate sized circumferential pericardial effusion. No right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of earlier in the day of [2134-8-16], the pericardial effusion is slightly larger and flow from the left ventricle into the pericardial space is now more clearly defined. [8-16] EKG: Sinus rhythm. Left atrial abnormality. A-V conduction delay. Diminished voltage as compared to the previous tracing of [2133-8-25] and increase in rate. There is ST segment elevation in leads I and aVL with biphasic T waves in leads I and aVL. Right precordial ST segment depression. These findings are new as compared to the previous tracing of [2133-8-25] and are consistent with active posterolateral ischemic process, rule out myocardial infarction. There is Q-T interval prolongation. Clinical correlation is suggested [8-16] Echo: PRE-CPB:The patient was brought to the operating room on IABP with infusions of norepinephrine and dopamine. 1. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). There is evidence of a lateral free wall rupture and contained hematoma. 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The IABP is in good positoipn 3 cm below the LSCA. 6. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral doppler evidence for mitral stenosis. 8. There is a moderate sized pericardial effusion. The effusion appears loculated. There is left atrial diastolic collapse. Drs. [Last Name (STitle) ] and [Doctor Last Name 40507] notified in person of the results. POST CPB: On infusion of epinephrine. Reduced size of pericardial effusion with significant compression of left atrium. The lateral free wall has a smaller rupture than pre bypass. LVEF = 60%. Aortic contour is normal post decannulation. [8-16] CXR: The ET tube tip is approximately 4.3 cm above the carina. The intra-aortic balloon pump is very low, at least 8 cm below the roof of the aortic arch. Mediastinal drains are in place. The Swan-Ganz catheter inserted through the right internal jugular approach terminates at the level of the low right ventricle. Right chest tube is in place. Mediastinal drains are in place. Heart size and mediastinum are grossly stable. Left pleural effusion and left lower lung consolidation is noted. [8-20] Echo: Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal inferolateral wall. The remaining segments contract normally (LVEF >50 %). The mitral valve leaflets are not well seen. There is no definite pericardial effusion. No definite extravasation of blood is identified. IMPRESSION: Suboptimal image quality. Regional left ventricular systolic dysfunction c/w CAD. No definite pericardial effusion identified. [8-20] CXR: In comparison with the earlier study of this date, the endotracheal tube has been removed. The Swan-Ganz catheter has been removed and replaced with a jugular shunt. Nasogastric tube remains in place. IABP has been removed. There are still hazy opacifications bilaterally, more prominent on the right, consistent with bilateral pleural effusions and pulmonary vascular congestion. No evidence of acute pneumonia. [8-22] CXR: An ET tube is present, tip approximately 5.9 cm above the carina. NG tube is present, tip extends beneath the diaphragm, off the film. A right IJ sheath is present, tip overlying lower IJ above the level of the clavicle. The patient is status post sternotomy, with a prominent cardiomediastinal silhouette. There is upper zone redistribution and diffuse vascular blurring, asymmetrically more pronounced on the right. There is obscuration of the right inferior lung likely reflecting combination of pleural fluid and underlying collapse and/or consolidation. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation, likely with a small amount of pleural fluid. Some subcutaneous emphysema is noted over the right greater than left chest. The possibility of a small right apical pneumothorax cannot be excluded. Linear lucency traversing the right posterior third rib may represent artifact due to subcutaneous emphysema, but the differential diagnosis would include a non-displaced rib fracture. Compared with [2134-8-21] at 8:27 a.m., lung findings are similar. Right apical pneumothorax and possible right posterior third rib fracture, if real, are new. [2134-8-16] 01:45PM BLOOD WBC-17.5# RBC-3.59 Hgb-11.7* Hct-35.1* MCV-98 MCH-32.5* MCHC-33.3 RDW-13.4 Plt Ct-170 [2134-8-17] 02:45AM BLOOD WBC-9.2 RBC-3.42# Hgb-10.7# Hct-31.1* MCV-91 MCH-31.3 MCHC-34.4 RDW-15.2 Plt Ct-88* [2134-8-18] 04:48AM BLOOD WBC-11.4* RBC-3.34* Hgb-10.4* Hct-29.8* MCV-89 MCH-31.0 MCHC-34.7 RDW-15.4 Plt Ct-77* [2134-8-19] 05:28AM BLOOD WBC-14.8* RBC-3.34* Hgb-10.3* Hct-30.5* MCV-91 MCH-30.9 MCHC-33.8 RDW-15.6* Plt Ct-55* [2134-8-20] 03:53AM BLOOD WBC-17.9* RBC-3.42* Hgb-10.5* Hct-31.2* MCV-91 MCH-30.8 MCHC-33.8 RDW-15.2 Plt Ct-66* [2134-8-21] 02:46AM BLOOD WBC-18.9* RBC-3.24* Hgb-10.3* Hct-30.2* MCV-93 MCH-31.7 MCHC-34.0 RDW-15.2 Plt Ct-73* [2134-8-22] 05:12AM BLOOD WBC-29.2# RBC-3.24 Hgb-10.0* Hct-30.1* MCV-93 MCH-30.9 MCHC-33.3 RDW-15.9* Plt Ct-150# [2134-8-17] 03:48PM BLOOD Fibrino-195 [2134-8-19] 05:28AM BLOOD Fibrino-165* [2134-8-16] 01:45PM BLOOD Glucose-200* UreaN-51* Creat-2.8* Na-139 K-5.5* Cl-103 HCO3-14* AnGap-28* [2134-8-17] 02:45AM BLOOD Glucose-140* UreaN-49* Creat-2.8* Na-144 K-5.0 Cl-110* HCO3-20* AnGap-19 [2134-8-18] 03:21AM BLOOD Glucose-99 UreaN-52* Creat-3.0* Na-141 K-4.1 Cl-110* HCO3-21* AnGap-14 [2134-8-19] 05:28AM BLOOD Glucose-128* UreaN-70* Creat-4.0* Na-137 K-4.2 Cl-104 HCO3-21* AnGap-16 [2134-8-20] 03:53AM BLOOD Glucose-118* UreaN-92* Creat-4.9* Na-138 K-3.8 Cl-103 HCO3-22 AnGap-17 [2134-8-21] 02:46AM BLOOD Glucose-350* UreaN-100* Creat-5.2* Na-134 K-3.4 Cl-94* HCO3-21* AnGap-22* [2134-8-22] 05:12AM BLOOD Glucose-137* UreaN-120* Creat-5.5* Na-142 K-4.0 Cl-102 HCO3-23 AnGap-21* [2134-8-16] 01:45PM BLOOD ALT-1025* AST-808* CK(CPK)-739* AlkPhos-49 Amylase-52 TotBili-0.8 DirBili-0.4* IndBili-0.4 [2134-8-17] 02:45AM BLOOD ALT-3259* AST-4504* AlkPhos-37 Amylase-101* TotBili-0.7 [2134-8-20] 03:53AM BLOOD ALT-41* AST-298* LD(LDH)-747* AlkPhos-53 TotBili-1.9* [2134-8-22] 05:12AM BLOOD ALT-26 AST-94* LD(LDH)-720* AlkPhos-57 TotBili-1.5 [2134-8-16] 12:46PM BLOOD Glucose-243* Lactate-7.8* K-5.2* [2134-8-16] 01:54PM BLOOD Lactate-10.0* [2134-8-16] 04:22PM BLOOD Glucose-137* Lactate-9.2* Na-139 K-5.0 Cl-108 [2134-8-16] 09:23PM BLOOD Lactate-5.2* K-4.8 [2134-8-17] 04:02PM BLOOD Glucose-126* Lactate-2.6* K-4.8 [2134-8-19] 12:09PM BLOOD Lactate-1.6 [2134-8-22] 02:08AM BLOOD Lactate-1.9 Brief Hospital Course: 80yo F presented to [Hospital1 18] on [8-16] w/ n/v, ataxia, and disorientation several days following a suspected MI. She collapsed and was found to be in shock. After reperfusing an occluded circumflex in cathlab she remained in cardiogenic shock. A TEE revealed a left ventricular free wall rupture. In Cardiothoracic OR she underwent clot evacuation without any identifiable bleeding source, surmising a contained rupture. She was post-operatively managed on CCU for the following problems: #Delayed presentation of posterior wall STEMI: The patient had endorsed several days of pain radiation to the jaw. She initally presented to an OSH where she was found to be in cardiogenic shock. She was intubated and placed on pressors and transfered to [Hospital1 18] where she was taken to the cardiac cath lab where she was found to have a fully occuled LCx artery and a free wall rupture of the LV. She was taken to the OR by CT surgery who performed an emergent mediastinal re-exploration and drainage of pericardial effusion. They discovered a clot that tampanaded the free wall rupture. She was taken to the ICU following surgery where the patient SBPs were initially in the 80s and continued to require pressor support. She had an IABP that had been placed at time of cardiac cath and she was maintained on pressor support and IABP. She developed shock liver and her renal function deteriorated. Her cardiac output initially worsened but were stabilized with the addition of inotropic support. In this setting she was able to be weaned off the IABP. Following the removal she became hypertensive and became less reactive to stimuli. There was growing concern for a septic component to shock as WBC count bumped and temp persisted. Sputum culture notable for gram neg rods and WBC increased to 19 so pt started on renally dosed cefepime and vancomycin. On [8-22] after a family meeting and in keeping with the patients wishes and given the clinical status of the patient the decision was made to make her CMO. She was extubated and given fentanyl and morphine. The family was present and the patient passed peacefully on [2134-8-23]. # Ventricular Rupture. Good hemostasis achieved in OR, w/CT placement then removed [8-18]. Repeat echo confirmed effusion-free and good hemostasis. Clopidogrel held due to rebleeding risk. CXR [8-18] showed vascular congestion. Patient diuresed furosemide and metolazone. After several liters removed, diuretics were scaled back with target net negative .5L daily. A repeat echo on [8-20] showed continued hemostasis with no new effusion. There was no observed pulsus paradoxis. He recovery was complicated by the above issues issues. # CORONARIES: LCA and [Female First Name (un) ] occlusions reperfused with angioplasty. Stenting was not indicated given the clinical situation and extensive coronary disease. Echo [8-17] showed akinesis in distribution of infarct with relatively well preserved EF . She was started on ASA but clopidogel was held in setting of high bleeding risk. BB, ACEI, and statin were held in setting of acute comorbidities(hypotension, [Last Name (un) ], transaminitis, respectively) # Afib: Pre-admission history of sinus bradycardia with apparently new AF this admission. Bursts of return to sinus beginning on [8-18]. Rates in 120s, so given amiodarone 150 bolus and then ggt started. Drip stopped after pt found to be in sinus for several hrs. However, she continued to flip in and out of afib over next several days. Amio was kept on at .5mg/min. Rate was controlled with IV metoprolol to prevent further heart strain. #Fever:Uncertain etiolgy at this time. Thought to be secondary to inflammation at site of ventricular rupture given persistence through broad spectrum antibiotics. Abx were stopped as WBC was normal and cultures negative. On [8-21], WBC trended up to 19 and gram neg rods were isolated in sputum culture. Cefepime and vancomycin was restarted for VAP coverage. A repeat CXR did not show any consolidation or new infiltrate WBC not significantly elevated. # Acute on chronic renal insufficiency. Appears baseline Cr prior to transfer was transfer 3.2 Most likely secondary to cardiogenic shock and poor profusion with secondary ATN. FeUrea was >40% indicating an intrarenal component. No eos seen on UA decreasing the likelihood for AIN. Renal was consulted and diuresis was achieved with lasix and metolazone. #Thrombocytopenia: plt dropped from admission 170->66 presumed due to IABP. No bleeding. HIT suspicion low, due to plt drop within 3 days of heparin. TTP considered re: AMS and renal failure, though stable Hct and no schistocytes seen on smear. DIC considered, though marginally low fibrinogen (165) thought consistent with traumatic hx. Smear was normal and HCT and platlets remained stable following balloon removal. Medications on Admission: Diltiazem ER Cap spironolactone atenolol valsartan 80 mg Tab lovastatin 10 mg Aspirin 81 mg Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: ST-Elevated Myocardial Infarction with left ventricular free wall rupture Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "570", "410.51", "410.61", "276.2", "427.31", "995.94", "403.90", "584.5", "327.23", "423.3", "780.61", "785.51", "585.9", "272.0", "287.49", "V66.7" ]	icd9cm	[ [ [] ] ]	[ "00.40", "00.66", "37.61", "37.12", "96.72", "39.61" ]	icd9pcs	[ [ [] ] ]	16268, 16277	11215, 16094	276, 427	16394, 16403	2308, 5881	16459, 16469	1603, 1621		16236, 16245		16298, 16373		16120, 16213			16427, 16436											1636, 2289																				226, 238								455, 1085														1107, 1469	1485, 1587					5891, 11192
51,894	152,463	288	Discharge summary	report	Admission Date: [2118-7-28] Discharge Date: [2118-8-1] Date of Birth: [2066-5-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2736] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [7-29] pericardiocentesis History of Present Illness: This is a 52 year old female with PMHx of hyperlipidemia who presents to the CCU tonight after her PCP sent her to [Hospital1 18] Emergency department for an enlarged heart on CXR. The patient's history begins about 5 weeks ago when she experienced left anterior chaest pain which woke her around 0500 that mornig. Pain is worse with breathing and radiated into her left arm and left side of the neck. She went to [Hospital3 2737] (which records were obtained) and had an MI workup including 2 sets of negative cardiac enzymes, a negative stress test, and an unremarkable echo. She also with CT scan for r/o PE which found a 5 mm nodule in the RUL but not other findings. Patient was discharged from the hospital with no clear diagnosis. Prior to onset of symptoms, she denied any recent local or foreign travel or cough/cold symptoms. Patient continued to have chest pain over the next month. Earlier this week she started having fevers, chills, and night sweats. Temperature taken at home was max 100.8. She did experience some SOB and nausea, but no vomiting. She presented to an OSH where she refused labs as she had already undergone workup and was discharged with a Zpack. She noted continued symptoms and decided to see her PCP today who ordered a CXR and saw cardiomegaly, pleural and pericardial effusion and sent her to the ED. In the ED, initial vitals were 18:04 8 99.2 106 116/72 20 97%. She was having [8-12] pain worse while lying supine and relieved sitting upright. Pt states pain in chest, neck, upper abdomen and upper back. Pt with some sob with exersion. Patient given toradol IV and Zosyn, 1L NS, fentanyl. Pulses done at bedside by cardiology fellow which revealed only 10 mmHg. Bedside echo showed moderate to large pericardial effusion with right atrial diastolic collapse and impaired R ventricular filling upon inspiration. . On arrival to the CCU patient has an aching pain [8-12] with family at the bedside. . REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -Intimal thickening in R carotid artery Hystectomy for fibroids Hemorrhoids, recent negative colonoscopy 5 years ago Mammogram one month prior- normal . MEDICATIONS: Pravastatin 40mg daily Docusate sodium 100 mg daily Lactobacillus Rhamnosus Gg 1 capsule daily ALLERGIES: NKDA Social History: -Tobacco history: none -ETOH: occasional -Illicit drugs: none -Works for shoe store in inventory moving boxes Family History: FAMILY HISTORY: Family history of CAD in grandparents at older age. Breast cancer in grandmother and pancreatic cancer in another relative . Physical Exam: PHYSICAL EXAMINATION: VS: T=99.8 BP=113/70 HR=102 RR=25 O2 sat= 98% GENERAL: NAD, appears somewhat tired HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2, no pericardial rub heard LUNGS: No chest wall deformities, scoliosis or kyphosis. Mild crackles auscultated bilaterally but L>R 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: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: On Admission: [2118-7-28] CBC: 13.1/9.2/28.3/322 Differential: 82%N, 13%L, 4%mono, 0.1%E, 0.2%B 139 100 14 105 AGap=16 4.4 27 0.6 Lactate: 1.6 LFTS: [7-30] ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili 37 22 160 153* 0.4 Lipase: 18 Iron Studies: calTIBC Ferritn TRF 195* 418* 150* Complement Levels: C3: 124 C4: 28 HIV: negative TSH: 0.95 On Discharge: [8-1] WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.6 2.99* 8.2* 26.1* 87 27.6 31.6 12.3 459* Glucose UreaN Creat Na K Cl HCO3 AnGap 87 9 0.4 143 4.0 106 29 12 UA: Color Yellow Appear Clear SpecGr 1.011 pH 6.0 Urobil Neg Bili Neg Leuk Neg Bld Tr Nitr Neg Prot Tr Glu Neg Ket Neg RBC 1 WBC 1 Bact None Yeast None Epi <1 Other Urine Counts CastHy: 4 Mucous: Rare EKG: Sinus Tachy, rate 103, normal Axis and intervals, no ST changes, low voltage 2D-ECHOCARDIOGRAM: [7-28] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a moderate to large sized pericardial effusion. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. . TTE [7-30] Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2118-7-29], the findings are similar. . CXR: IMPRESSION: Overall cardiac contour appears somewhat smaller than on previous study in this patient status post pericardiocentesis for a pericardial effusion. There continued to be layering bilateral effusions with associated bibasilar airspace opacities, which most likely represent partial lower lobe atelectasis, although pneumonia cannot be entirely excluded. There is cephalization of the pulmonary vasculature consistent with pulmonary venous hypertension but no overt pulmonary edema. No pneumothorax is seen, although the sensitivity to detect pneumothorax is diminished given supine technique. Overall mediastinal contours are stable. . Pericardial Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS. . Micro: URINE CULTURE (Final [2118-8-1]): NO GROWTH. PERICARLIAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. PERICARLIAL FLUID. GRAM STAIN (Final [2118-7-29]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2118-8-1]): NO GROWTH ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2118-7-30]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . BLOOD CULTURE: [7-28]: NGTD Brief Hospital Course: ASSESSMENT AND PLAN Ms [Known lastname 2738] is a 52 y/o female with no significant past medical history who initially presented with constitutional symptoms for 1 week found to have pericardial effusion transferred to CCU for pericardial drainage. # Pericardial effusion: Ddx was infectious vs. neoplastic vs. autoimmune. Symptoms likey represent viral pericarditis with effusion development however in the setting of systemic complaints a broad ddx was entertained. She underwent an uncomplicated pericardicentesis on [7-29] with drain placed. 400 cc serosanginous fluid was initially drained; additional 200cc drained thereafter. Once fluid slowed drain was pulled. Fluid analysis: WBCs 275, 69% lymphs; cytology returned negative and cultures without growth. Additional work-up notable for TSH: 0.95, [Doctor First Name ]: 1:40, complement levels wnl, cardiac enzymes negative x3. Quantiferon gold (ordered on [8-1]) was pending at time of discharge. Of note, patient reports cancer screening uptodate with nl mammography in [2118] and c-scope ~7years prior. Due to concern for underlying pericarditis patient was started on ibuprofen and colchicine and patient symptomatically improved. Discharged with plan to continue ibuprofen [Hospital1 ] and colchicine for 2 weeks. Patient instructed to take NSAIDS with food to avoid gastritis FOLLOW-UP: [] Obtain repeat TTE in 1 week to ensure resolution of effusion [] Follow-up quantiferon gold [] Continue treatment of presumed pericarditis x2weeks. . # Bilateral pleural effusions. On admission CXR with enlarged cardiac siluette and clear lung fields. On [7-30] patient developed fever to 101 and CXR was obtained in broad fever work-up. Imaging revealed interval development of small bilateral pleural effusions and mild interstitial markings. DDx: cardiac congestion/pulmonary edema vs serositis. Repeat CXR confirmed findings of fluid overload. Remainder of exam was without signs of heart failure (elevated JVP, LE edema) or signs of reaccumulation of pericardial effusion leading to heart failure. Patient was completely asymptomatic with O2 saturation wnl. At time of discharge patient was saturating >95%RA with respiratory rates [12-16]. OUTPATIENT ISSUES: [] Repeat CXR in 1 week to assess effusions # Hyperlipidemia: Patient continued on Pravastatin 40 mg daily # Normocytic Anemia: Patient with baseline normocytic anemia. Previous etiology thought to be fibroid uterus (she is now s/p hysterectomy) as well as potential GI bleed (c-scope ~7yrs ago without overt pathology per patient) On admission no signs of blood loss - denying melena, hematchezia, hematemesis. Iron studies were suggestive of anemia of chronic disease. OUTPATIENT ISSUES: [] Trend hematocrit [] Consider further GI work-up # Hypoalbumenia. On admission albumin 2.9. INR on discharge 1.2. Remaining LFTs wnl. No preceding hx of liver disease; no stigmata of concern liver disease on exam OUTPATIENT ISSUE: [] Repeat albumin and LFTs as outpatient Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Pravastatin 40 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. lactobacillus acidoph & bulgar NF 1 million cell Oral daily Discharge Medications: 1. Colchicine 0.6 mg PO BID RX Colcrys 0.6 mg one tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 2. Ibuprofen 400 mg PO BID Please take with food to avoid gastritis 3. Docusate Sodium 100 mg PO BID 4. Pravastatin 40 mg PO DAILY 5. lactobacillus acidoph & bulgar NF* 1 million cell Oral daily Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Pleural Effusions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You were found to have an effusion or collection of fluid in your lungs and surrounding your heart. We think this is because of a virus but we have sent tests to look for other causes. These test results will be communicated to you by Dr. [Last Name (STitle) 2739] next monday. We drained the fluid around your heart it does not seem to have reaccumulated. You will need to have an echocardiogram and a chest Xray done on Friday. Please take colchicine and ibuprofen twice daily for two weeks to decrease the pain and inflammation. Followup Instructions: Name: [Doctor Last Name ],[Initials (NamePattern4) ] [Last Name (NamePattern4) ] Specialty: Primary Care When: Monday [8-8] at 11:30am Address: [Street Address(2) 2687],STE 5A, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 2740] . Echocardiogram and chest Xray [2118-8-5]. This will be done at [Hospital1 18]. Please call [Telephone/Fax (1) 62] if you have not heard about this test in the next 1-2 days.	[ "420.91", "285.9", "423.3", "511.9", "427.89", "272.4", "273.8" ]	icd9cm	[ [ [] ] ]	[ "37.0", "37.21" ]	icd9pcs	[ [ [] ] ]	11381, 11387	7751, 10772	313, 344	11470, 11470	4462, 4462	12241, 12715	3507, 3634		11049, 11358		11408, 11449		10798, 11026			11621, 12218											3649, 3649			2977, 3035		7639, 7639			7672, 7728					3671, 4443			4884, 7469				263, 275								372, 2851							4476, 4870	7505, 7606	11485, 11597		3066, 3346			2895, 2957	3362, 3475
2,874	192,692	24399	Discharge summary	report	Admission Date: [2136-3-26] Discharge Date: [2136-4-5] Date of Birth: [2063-7-5] Sex: M Service: CARDIOTHORACIC Allergies: Cephalosporins Attending:[First Name3 (LF) 1283] Chief Complaint: DOE Major Surgical or Invasive Procedure: Aortic Valve Replacement w/ 25mm CE Pericardial Tissue Valve and Ascending Aorta/Hemiarch Replacement w/ 26mm Gelweave Graft on [2136-3-27] History of Present Illness: 72 y/o male who was initially seen in clinic on [2136-3-21] and was asymptomatic at the time, but at time of admission on [3-26], pt was c/o DOE and chest discomfort. During his previous work-up for a kneee replacement, he was found to have critical AS and a dilated Ascending Aorta. Past Medical History: Hypertension GERD Hepatits A ?75 s/p R. TKR s/p L Knee Arthroscopy s/p TURP Social History: Lives with wife. Quit smoking 20 yrs ago. Drinks 1 alcoholic beverage/wk. Family History: Father died of MI at 75 Physical Exam: VS: HR 57 BP R117/70 L134/80 Ht 5'8" Wt 92.5kg General: NAD Skin: Unremarkable, -lesions HEENT: EOMI, PERRLA, NC/AT NECK: Supple, FROM, -bruits Chest: CTAB, -w/r/r Heart: RRR, +S1S2, 3/6 SEM Abd: Soft NT/ND, +BS Ext: Warm, well-refused, -edema, -varicosities Neuro: Grossly intact, follows commands Pulses: BRA 2+, BFA 2+, BPT 2+, BDP NT Pertinent Results: [2136-3-27] 08:03PM BLOOD WBC-13.1* RBC-2.75# Hgb-8.5# Hct-24.2# MCV-88 MCH-30.8 MCHC-35.1 RDW-12.7 Plt Ct-169 [2136-4-4] 06:00AM BLOOD WBC-16.8* RBC-3.51* Hgb-10.4* Hct-31.6* MCV-90 MCH-29.5 MCHC-32.9 RDW-13.4 Plt Ct-228 [2136-3-27] 08:03PM BLOOD PT-16.3* PTT-50.7* INR(PT)-1.8 [2136-4-2] 01:30AM BLOOD PT-13.3 PTT-23.3 INR(PT)-1.2 [2136-3-27] 08:49PM BLOOD UreaN-16 Creat-0.9 Cl-107 HCO3-26 [2136-4-4] 06:00AM BLOOD Glucose-126* UreaN-27* Creat-1.1 Na-138 K-4.6 Cl-100 HCO3-27 AnGap-16 [2136-4-2] 01:30AM BLOOD Calcium-8.3* Phos-3.1# Mg-2.5 [2136-4-2] 05:04PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.018 [2136-4-2] 05:04PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG Brief Hospital Course: As mentioned earlier, pt was initially pain free but upon admission was c/o DOE and chest pressure. EKG on admission showed 2mm ST elevation. Pt. was given 2 SL NTG with relief. He was started on a NTG and heparin gtt. Pt. admitted pre-operatively for a chest CT to evaluate size of aorta. On [2136-3-27], pt was brought to the operating room and underwent an AVR and Asc. Aorta/Hemiarch replacement. Please see op note for surgical details. Pt. tolerated the procedure well and had a total bypass time of 138 minutes, cross clamp time of 102 minutes, and circ. arrest time of 12 minutes. He was transferred to the CSRU in stable condition with a MAP of 76, CVP 13, PAD 12, [Doctor First Name 1052] 14, HR 86 A-paced, and receiving neo and propofol gtts. Pt. remained on mechanical ventilation until POD #2 b/c pt. was unable to clearly follow commands. After extubation pt. was able to follow commands and move all extremities. By POD #3 pt was off all drips. Chest tubes and pacing wires were removed per standard protocol. Pt. was diuresed with Lasix and Lopressor were started per protocol. Pt. slowly improved while in CSRU and cont. to receive PT throughout hospital course. POD #6 his Foley and central line were removed. He remained in the CSRU until POD #6 for being lethargic, general weakness, some uncoordination, and had poor oxygenation. He was transferred to telemetry floor and on POD #7 he was improving well but still c/o some uncoordination. PT/OT cont. to work with pt and he ambulated as tolerated. He was transferred to Rehab facility on POD #8 to maximize functional status before going home since pt. lives in 2 level home. Medications on Admission: 1. Lisinopril 20mg qd 2. Atenolol 25mg qd 3. Prevacid 30mg qd 4. Celebrex 200mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Doctor Last Name ] [Doctor Last Name ] hospital Discharge Diagnosis: Aortic Stenosis w/ Bicuspid Aortic Valve, Ascending Aortic Aneurysm s/p Aortic Valve Replacement and Ascending Aorta/Hemiarch Replacement Hypertension GERD Hepatits A ?75 s/p R. TKR s/p L Knee Arthroscopy s/p TURP Discharge Condition: Good Discharge Instructions: Can take shower. Wash incision with warm water and gentle soap. Gently pat dry. Do not bath or swim. Do not apply lotions, creams, or ointments to incision. Do not lift more than 10 pounds for 2 months. Do not drive for 1 month. Make/keep all appointments. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. Follow-up with Dr. [Last Name (STitle) 61775] in [11-20] weeks. Follow-up with Dr. [Last Name (STitle) 32255] in [12-22] weeks. Completed by:[2136-4-5]	[ "V43.65", "401.9", "441.4", "746.4", "530.81", "997.1", "414.01", "423.9" ]	icd9cm	[ [ [] ] ]	[ "88.60", "35.21", "99.04", "39.61", "38.44" ]	icd9pcs	[ [ [] ] ]	4975, 5058	2164, 3821	283, 429	5315, 5321	1354, 2141		956, 981		3954, 4952		5079, 5294		3847, 3931			5345, 5603				5654, 5886							996, 1335																				240, 245								457, 750														772, 849	865, 940
11,318	151,558	50707	Discharge summary	report	Admission Date: [2122-11-28] Discharge Date: [2122-12-3] Date of Birth: [2052-2-14] Sex: F Service: MED Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 30] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: PICC line placement. History of Present Illness: 70 yo woman with a pmh sig for CHF, COPD, pulm htn, Afib, MRSA endocarditis, pseudomonas bacteremia, chronic rlq pain, who presented with hypotension, bandemia, and a UTI. She originally required dopamine for blood pressure support, but was hemodynamically stable once admitted to the ICU. She was started on Vancomycin and Aztreonam given her history of MRSA. Pt was discharged from [Hospital1 18] several weeks ago for treatment of C. difficile colitis (she had finished treatment) and was in USOH where she lives at [Hospital3 ] Center until the day prior to presentation when she was found to be hypotensive. On day of presentation she became confused and was brought to ED where found to have UTI with bandemia and hypotension though afebrile. She was transfered to the ICU. Past Medical History: CHF DM on insulin AFib Anemia CAD Pulmonary HTN Hypercholesterolemia COPD/BOOP on home O2 Thyroid CA s/p resection/now hypothryoid Myoclonic tremors H/O PE OSA on CPAP Depression/Anxiety MRSA/VRE Social History: Divorced, with 3 childrenRetired Accountant VNA assistant at home Family History: NC Physical Exam: Tc=98.4 P=85-104 BP=87-108/60-46 RR=16-22 O2 96-100% on RA I/O (24h) 2200/1750 Gen - NAD, AOX3, not confused, resting comfortably HEENT - PERLA, EOMI, MMM Heart - Irregular, no M/R/G, no JVD Lungs - Bibasilar minimal crackles Abd - tender R and LUQ, + BS, no rebound/guarding Ext - cyanotic, +1 d. pulses, chronic pain to palpation, RLE multiple healing scabs on ventral aspect of tibia Pertinent Results: CHEST (PORTABLE AP) [2122-11-28] 9:49 AM Comparison is made to previous exams of [2122-11-11] and 10- [3-11]. There is stable mild cardiomegaly. The mediastinal and hilar contours are stable in appearance. There is no significant upper zone redistribution of the pulmonary vasculature. There are no focal consolidations or definite pleural effusions. The visualized soft tissues and osseous structures are stable. Again noted is a nonhealed fracture of the distal right clavicle. IMPRESSION: No evidence of CHF or pneumonia. CT ABDOMEN W/CONTRAST [2122-11-28] 10:04 AM 1. Mild thickening of descending colon compatible with colitis. In the setting of atherosclerotic disease and hypotension, ischemia is a consideration. Infectious and inflammatory causes are also possibilities. 2. Congestive failure with minimal right pleural effusion. [2122-11-28] 07:00AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 RENAL EPI-[7-16] [2122-11-28] 07:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2122-11-28] 07:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.017 [2122-11-28] 07:00AM PT-20.1* PTT-33.8 INR(PT)-2.6 [2122-11-28] 07:00AM PLT COUNT-212 [2122-11-28] 07:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2122-11-28] 07:00AM NEUTS-81* BANDS-12* LYMPHS-5* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2122-11-28] 07:00AM WBC-9.7 RBC-3.95* HGB-11.8* HCT-35.5* MCV-90 MCH-29.9 MCHC-33.2 RDW-15.3 [2122-11-28] 07:00AM TSH-0.25* [2122-11-28] 07:00AM GLUCOSE-112* UREA N-24* CREAT-1.6* SODIUM-135 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2122-11-28] 07:33AM LACTATE-1.9 Brief Hospital Course: The patient is a 70 y.o female with a history of severe diastolic CHF (EF 55%), COPD, DMII, chronic renal insufficiency, and a recent ICU admit x 2 for MRSA aortic valve endocarditis and pseudomonal sepsis (secondary to wound infection), status post intubation x 2 on her prior admits, who presented on [2122-11-28]. On the day prior to presentation she was found to be hypotensive. hTN meds held. On day of presentation with confusion and in ED, found to have UTI with bandemia and hypotension though afebrile. She did not meet sepsis criteria. She was transfered to the ICU where she was peripheral dopamine which was weaned within the first 12 hours and recieved NS overnight. BP increase [Location (un) ] next 12 hours off dopamine and CVP improved. Transferred to the floor on [2122-11-29]. 1) UTI - treated with aztreonam to cover common GNR's, pseudomonas, enterococcus, following urine/blood culture; on Vancomycin as has recent history of MRSA. Urine cultures positive for gram positive cocci suggestive of strep and enterococci. Sensitivities pending. Blood culture still pending. PICC line placed for abx treatment to be a total of 7 days. Will need repeat bld cx once off abx. Please follow up cxs in a few days. 2) CHF - cont lasix, lopressor, statin, aspirin. Spironolactone d/c'd as this may have cont. to hypotension. 3) ARF - ACE inhibitor restarted with improvmeen in Cr over hosptial course. 4) A Fib - resistant to cardioversion, rate controlled with amiodarone and lopressor; INR suprtheraptuic to 5.7, liklely related to abx. Coumadin held for 2 days until INR to 2.0 day prior to d/c. Restarted coumadin at 3 mg qhs and check coags. Will need INR monitoring and readjustment once abx are stopped. 5) Abdominal pain - CT A/P with ?colitis in descending colon. Given patient's history of C. diff with still loose stool, checked stool cultures for C. diff. Lactate 1.1 not suggestive of ischemic colitis in this setting. No further complaints. Given hx and abx now, startd on flagyl empirically for 14 days. 6) Thrush: Nystain oral solution for this. 7)Hypothyroidism: On thyroxine, needs to be monitored in 6 weeks. 8) Depression: Psych saw pt here and suggest increasing ritalin dose to 5 mg in afternoon and 10 mg in am for help with energy level. Psych f/u as oupt. 9) DM: good glycemic control on RI SS. Lantus held for first 3 days and restarted at 18 units 2 days prior to d/c. Continue to monitor FS and adjest as PO intake improves. 10) Code - full. Treat aggressively all reversible illnesses including mech ventilation and cardioversion, no heroic measures if no meaningful recovery possible. D/c back to [Hospital 100] Rehab. Medications on Admission: OP Metoprolol 50 [Hospital1 ] Lisinopril 5 daily Lasix 40 mg daily Lidocaine 5% Lantus 12 u qpm Detrol LA 4 QHs Glyburide 2.5 mg daily Albuterol Q6 prn Amiodarone 200 mg daily ASA 325 Celexa 60 mg Daily Avanesp 40 SQ Ferrous sulfate Neurontin 600 mg TID Insulin Lispro Ipratropium Oxycodone SR 10 [Hospital1 ] Mirapex 0.25 TID Zocor 20 mg QHS Aldactone 25 daily Coumadin 3-4.5 daily Prevacid 30 [Hospital1 ] Synthroid 0.200 daily Ritalin 10 daily oxycodone 10 mg q 4pm Bactrim DS [2040-11-23] Flaygl 500 TID [Date range (1) 105494] IP traZODONE HCl 25 mg PO HS:PRN Aztreonam 1000 mg IV Q12H Vancomycin HCl 1000 mg IV Q24H Oxycodone 5-10 mg PO Q4-6H:PRN Methylphenidate HCl 10 mg PO QAM Levothyroxine Sodium 200 mcg PO QD Lansoprazole 30 mg PO Q12H Warfarin 5 mg PO QD Spironolactone 25 mg PO QD Simvastatin 20 mg PO QD Oxycodone (Sustained Release) 10 mg PO Q12H Gabapentin 600 mg PO TID Ferrous Sulfate 325 mg PO BID Citalopram Hydrobromide 60 mg PO QD Aspirin 325 mg PO QD Amiodarone HCl 200 mg PO QD Ipratropium Bromide MDI 2 PUFF IH QID Albuterol [2-6] PUFF IH Q6H:PRN Furosemide 40 mg PO QD Metoprolol 50 mg PO BID SSI Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: 1. Septicemia 2. Diabetes 3. CHF 4. Atrial fibrillation 5. Coagulopathy 6. Depression Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L. If you have fever/chills, chest pain, shortness of breath, nausea/vomiting, please come to the ED or call you PCP. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2123-4-27] 11:00 Call you PCP for an appointment in [3-10] weeks.	[ "244.0", "V02.59", "041.89", "428.0", "296.20", "272.0", "112.0", "416.8", "496", "300.02", "785.52", "286.9", "038.8", "519.8", "599.0", "995.92", "V09.0", "427.31", "V58.67", "250.00", "V10.87", "428.30", "584.9", "780.57", "285.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	7647, 7732	3759, 6447	331, 354	7862, 7869	1920, 3736	8156, 8428	1490, 1494				7753, 7841		6473, 7624			7893, 8133											1509, 1901																				280, 293								382, 1172														1194, 1391	1407, 1474
64,357	197,694	37531	Discharge summary	report	Admission Date: [2105-1-2] Discharge Date: [2105-1-9] Date of Birth: [2024-7-11] Sex: M Service: SURGERY Allergies: Promethazine Attending:[Last Name (NamePattern1) 4659] Chief Complaint: abdominal pain, pneumotosis, portal vein air Major Surgical or Invasive Procedure: Exploratory laparotomy and small-bowel resection. History of Present Illness: 80yo man with history of ESRD on HD who underwent HD this AM presents from OSH complaining of acute onset severe [11-8] constant diffuse abdominal pain that started a little after returning home from dialysis. Has lunch and felt pain starting. +nausea and vomiting, no fevers or chills. Never has pain like this before. No chest pain or shortness of breath. Per family, they state he has been complaining of abdominal cramping for atelast a week with diarrhea. Last BM yesterday, normal,no blood. At OSH had WBC of 19 and CT scan adbomen showing extensive small bowel pneumotosis and pneumbilia consistent with infarcting small bowel. Received 2L IVF and Unasyn. Uncomfortable on arrival complaining of [11-8] pain, vomiting in ED, NGT placed for only 100cc biliuos return. Received 2L IVF. Past Medical History: ESRD on HD, DM, high cholesterol, COPD Social History: supportive family, lives at home with wife. Family History: na Physical Exam: A and O x 3 v.s.s RRR no m/r/g LSCTA bilat soft, nt, nd, incision d/c/i no c/c/e Pertinent Results: [2105-1-7] 01:20AM BLOOD WBC-7.2 RBC-3.71* Hgb-11.7* Hct-35.7* MCV-96 MCH-31.5 MCHC-32.7 RDW-14.0 Plt Ct-302 [2105-1-2] 01:50AM BLOOD WBC-20.5* RBC-4.97 Hgb-15.6 Hct-48.7 MCV-98 MCH-31.5 MCHC-32.1 RDW-15.0 Plt Ct-318 [2105-1-2] 06:32AM BLOOD Neuts-85* Bands-3 Lymphs-6* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2105-1-2] 01:50AM BLOOD Neuts-92.6* Lymphs-3.2* Monos-4.1 Eos-0.1 Baso-0.1 [2105-1-7] 01:20AM BLOOD Plt Ct-302 [2105-1-7] 01:20AM BLOOD PT-12.2 PTT-34.7 INR(PT)-1.0 [2105-1-2] 01:50AM BLOOD PT-12.1 PTT-25.3 INR(PT)-1.0 [2105-1-9] 05:37AM BLOOD Glucose-463* UreaN-24* Creat-4.0# Na-136 K-4.2 Cl-95 HCO3-21* AnGap-24* [2105-1-7] 06:20AM BLOOD Glucose-98 UreaN-26* Creat-4.5* Na-142 K-3.6 Cl-99 HCO3-29 AnGap-18 [2105-1-7] 01:20AM BLOOD Glucose-55* UreaN-27* Creat-4.1# Na-141 K-3.2 Cl-99 HCO3-32 AnGap-13 [2105-1-6] 05:37AM BLOOD Glucose-184* UreaN-63* Creat-7.5# Na-142 K-5.2 Cl-96 HCO3-21* AnGap-30* [2105-1-5] 12:50AM BLOOD Glucose-46* UreaN-34* Creat-5.5# Na-145 K-4.1 Cl-101 HCO3-29 AnGap-19 [2105-1-4] 02:41AM BLOOD Glucose-170 UreaN-68* Creat-8.1* Na-141 K-5.7* Cl-98 HCO3-22 AnGap-27* [2105-1-3] 04:30PM BLOOD Glucose-144* UreaN-60* Creat-7.4# Na-139 K-5.4 Cl-97 HCO3-20* AnGap-27* [2105-1-3] 04:00AM BLOOD Glucose-83 UreaN-46* Creat-6.3* Na-140 K-5.1 Cl-100 HCO3-24 AnGap-21* [2105-1-2] 12:47PM BLOOD Glucose-153* UreaN-40* Creat-5.4* Na-140 K-4.7 Cl-101 HCO3-25 AnGap-19 [2105-1-2] 06:32AM BLOOD Glucose-160* UreaN-35* Creat-5.3* Na-144 K-4.0 Cl-101 HCO3-23 AnGap-24* [2105-1-7] 01:20AM BLOOD ALT-12 AST-16 AlkPhos-62 Amylase-53 TotBili-0.4 [2105-1-2] 06:32AM BLOOD Amylase-104* [2105-1-9] 05:37AM BLOOD Calcium-8.5 Phos-4.5# Mg-2.2 . Blood Culture, Routine (Final [2105-1-8]): NO GROWTH. MRSA SCREEN (Final [2105-1-6]): No MRSA isolated. Brief Hospital Course: [2105-1-2] Patient was referred from outside hospital with CT scan demonstrating pneumatosis throughout his small bowel, in his portal vein, and in his SMV. It was also seen in the liver. He was hemodynamically stable in the emergency room; however, he had an acute abdomen with diffuse tenderness, rebound and guarding. His lactate level is 3.3. He was taken to the operating room for exploratory laparotomy for presumed ischemic bowel. The patient tolerated the procedure well and was taken to the recovery room stable on 0.3 of Neo-Synephrine for pressor support. [Last Name (un) ] see Dr[Name (NI) 6218] operative report for details. He remained intubated and was transferred to the TICU for continued care. Nephrology was consulted for care of his co-morbid conditions. [2105-1-3] Patient remained stable and was successfully extubated. He remained in the TICU for continuous monitoring. [2105-1-4] Patient remained stable and was out of bed to chair. He remained NPO while awaiting return of bowl function. He was successfully weaned off pressors. Patient received hemodialysis and required Haldol as needed for agitation. [2105-1-5] Patient remained stable and was transferred to the floor. Patient was given ice chips after reported flatus. [2105-1-6] Patient remained stable however required Haldol overnight for agitation. He was OOB and ambulating with assistance. He received hemodialysis today. [2105-1-7] Patient remained stable however he was triggered during the night secondary to psychosis and combative agitation. Full labs were obtained for delirium workup and patient required 4 point restraints to secure his safety. Patient tolerated a clears diet and ambulated throughout the day. Physical therapy evaluated and worked with the patient. [2105-1-8] Patient remained stable and cognitively intact. He received hemodialysis and his diet was advanced. He was screened for rehab services. Physical therapy recommended 24 hour supervision at home. [2105-1-9] The patient remained stable. The patient and staff agreeded that it was safe to discharge patient home with 24 hour care which the family agreed they would be able to provide. Patient was tolerating regular diet and ambulating with a walker and with assistance. He was discharged home in stable condition and will follow up with Dr. [Last Name (STitle) ] next week in clinic. Medications on Admission: Atorvastatin, gabapentin, pantoprazole, lorazepam, lantus, insulin Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO PRN (as needed) as needed for with Hemodialysis. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain for 1 weeks: Not to exceed 4g in 24 hours. . 6. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 7. Lantus 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Ischemic bowel. Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Please keep a log of your blood sugars to bring with you to your MD appt on [2105-1-13]. Followup Instructions: 1. Please call Dr.[Name (NI) 6218] office, [Telephone/Fax (1) 8792], to make a follow up appointment in 1 week. 2. Please follow up with your PCP, [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 74550], on [2105-1-13] at 3:00 pm regarding you blood sugar control. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661] Completed by:[2105-1-9]	[ "557.0", "V58.67", "250.00", "496", "293.0", "V45.11", "285.21", "403.91", "585.6", "307.9" ]	icd9cm	[ [ [] ] ]	[ "39.95", "45.62", "54.11", "96.07" ]	icd9pcs	[ [ [] ] ]	6604, 6610	3363, 5783	323, 375	6672, 6751	1471, 3340	8373, 8841	1351, 1355		5900, 6581		6631, 6651		5809, 5877			6775, 7917								7932, 8350			1370, 1452																				239, 285								403, 1212														1234, 1274	1290, 1335
11,018	186,291	216	Discharge summary	report	Admission Date: [2151-9-21] Discharge Date: [2151-9-24] Date of Birth: [2084-12-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2167] Chief Complaint: nausea/emesis x 2 days Major Surgical or Invasive Procedure: none History of Present Illness: This is a 66 yo M w/h/o HIV(last CD4 307 [2151-9-10], VL 187 [2151-9-15]), HTN, and severe COPD on 3L oxygen at home who presents w/nausea and emesis x 2 days. He notes that he had been feeling generally well but with constipation when he had sudden onset of nausea and emesis 2 nights ago. He does not recall what he was doing. Since then, he has been tolerating some food, but has had several episodes of NBNB emesis. He notes that he has not taken any of his medications x 2 days due to the nausea. He also notes that a few days PTA he took one dose of his new antiretroviral regimen- unsure which pill- and had nausea. He subsequently stopped that regimen and reverted back to his old regimen. He denies subjective fever/chills. Notes mild diffuse, nonfocal abdominal pain which he feels is caused by the nausea and is worse w/eating. He feels that his nausea and abdominal pain is c/w severe constipation, "I know it's my constipation." He denies diarrhea, hematochezia, melena. He notes that he last moved his bowels 2 days ago which is fairly normal for him but has been passing gas. He denies any sick contacts. In the [Name (NI) ], pt was afebrile to 101.5 and hypertensive in 170s-200s/80s-110s. A right femoral line was placed and he received Morphine Sulfate 4mg IV x 1, dilaudid 1mg IV x 3, tylenol, and zofran for nausea. He also received 1 dose of labetalol IV x 1. ROS: The patient endorses mild HA, otherwise denies weight change, chest pain, palpitations, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, rash or skin changes. Past Medical History: - HIV/AIDS: CD4: 307([2151-9-10]) VL: 187 ([2151-9-15])- recently started on Truvada and Ritonavir but d/ced due to nausea. Followed by [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057] outpatient. - h/o SBO s/p Ileocectomy [2136] with lysis of adhesions, ulcer noted at the anastomosis site in 06/[2149]. - COPD: severe, on 2L oxygen at home, followed by Dr. [Last Name (STitle) 2168], last spirometry [7-26] - bronchiectasis - GERD - HTN - h/o internal hemorrhoids, grade I on colonoscopy [2149] - Leukopenia - Iron deficiency Anemia - h/o hiatal hernia - Chronic back pain- laminectomy at L3, L4, L5, and S1 - h/o Granulmatous disease in spleen- seen on ct scan - Esophagitis and gastritis, EGD [2151-4-13] - Schatzki's ring- seen on egd [7-/2143] - H/o substance abuse-cocaine - osteoporosis followed by Dr. [Last Name (STitle) ], on Reclast PAST SURGICAL HISTORY: - Basilar artery clipping [2134] - Status post several lumbar discectomies in the past. - Status post right inguinal hernia repair. - Status post right colectomy for benign disease. Social History: Disabled. Lives in [Location 669] by himself. EtOH: former heavy etoh, quit [2135] Tob: quit tobacco in [2135], 2ppd between [2100]-93. Illicit drugs: smoked crack [2135] Family History: 1. Father: deceased, EtOH 2. Mother: deceased, CVA in 60s 3. Brother: lung cancer 4. Sister: HTN 5. Sister: CVA in 60s Brothers x7 (now only two), Sister x2 (both still alive) Physical Exam: Vitals: T: 98.5 BP: 139/101 HR: 83 RR: 20 O2Sat: 98% 3LNC GEN: thin, elderly, nauseous HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: decreased chest expansion w/decreased air movement throughout, no W/R/R ABD: thin, Soft, diffusely tender, ND, +BS, no HSM, no masses but palpable stool EXT: thin, No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2151-9-21] 12:20PM WBC-4.8 RBC-3.93* HGB-11.3* HCT-35.4* MCV-90 MCH-28.8 MCHC-31.9 RDW-14.6 [2151-9-21] 12:20PM NEUTS-82.4* LYMPHS-12.4* MONOS-3.2 EOS-1.6 BASOS-0.3 [2151-9-21] 12:20PM PLT COUNT-225 . [2151-9-21] 12:20PM PT-13.0 PTT-21.7* INR(PT)-1.1 . [2151-9-21] 12:20PM GLUCOSE-126* UREA N-17 CREAT-1.1 SODIUM-144 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14 [2151-9-21] 12:20PM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-71 TOT BILI-0.4 [2151-9-21] 12:20PM LIPASE-30 [2151-9-21] 12:20PM CALCIUM-9.2 PHOSPHATE-2.3* MAGNESIUM-2.2 . [2151-9-21] 07:15PM TYPE-[Last Name (un) ] PO2-38* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-3 [2151-9-21] 02:18PM LACTATE-1.2 . [2151-9-21] 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . ECG: Sinus rhythm at 98bpm, poor R-wave progression, no acute ST or T-wave changes, relatively unchanged from [2151-5-9]. . Imaging: CT abdomen/pelvis(prelim read): No obstruction or acute abdominal issues to explain abdominal pain. New opacity in the left lung base in a region of scar in which 3 month f/u CT recommended to exclude malignancy. . KUB: Paucity of bowel gas, however, no radiographic evidence for bowel obstruction. No free air. . Admission CXR: Hyperinflated, tortuous aorta w/o evidence of infiltrate Brief Hospital Course: 66 yo M w/h/o HIV, HTN, and severe COPD who presents w/nausea, emesis, diffuse abdominal pain x 2 days and fever in the ED. . Nausea w/emesis: c/b mild, diffuse abdominal pain. Abdominal exam is nonfocal. He does not have lab evidence of pancreatitis, but does have h/o gastritis. CT abdomen w/o evidence of any acute abdominal process and KUB w/o evidence of SBO. Treated with antiemetics and tramadol for pain. His vitals remained stable throughout ICU course. Constipation was likely contributing. He was manually disimpacted with good releif of symptoms. He then developed constipation again on the floor, with a KUB that did not show obstruction. He was given an aggressive bowel regimen, with good relief of his symptoms. . Fever: without a clear source in HIV+ pt. Abdominal pain was concerning, possible pt has diverticulitis, colitis though no CT evidence of bowel inflammation. + relative leukocytosis. Cultures for infectious source were not revealing. He was not started on antibiotics. . HTN: hypertensive urgency in the ED; currently well controlled w/dose of labetalol he received in the ED. EKG w/o acute changes. Doxazosin was restarted. He was also started on HCTZ. . HIV: last CD4 307, VL 187; Per outpatient ID doctor recommendations, he was counseled not to start HAART for now, until he is contact[Name (NI) ] by Dr. [Last Name (STitle) 1057]. . COPD: severe, on 3 L oxygen outpt. Continued on albuterol nebs, tiotropium, and Advair. . Iron deficiency anemia: unclear baseline HCT, appears to be b/w 34-38; guiac (-). He was continued on iron supplements. . FEN: Diet advanced to regular Medications on Admission: ABACAVIR-LAMIVUDINE - 600 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - one Tablet(s) by mouth three times a day as needed for pain do not take more than 3 per day ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2-3 puffs inhaled as needed ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for Nebulization - 1 ml neb three times a day ATAZANAVIR - 400 mg Capsule once a day BENZONATATE - 100 mg Capsule - 1 Capsule(s) by mouth three times a day DOXAZOSIN - 2 mg at bedtime FLUTICASONE-SALMETEROL 500 mcg-50 mcg/Dose 1 puff inhaled twice daily FOLIC ACID - 1 mg once a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually every 5 minutes as needed for chest pain RANITIDINE HCL - 150 mg twice a day TIOTROPIUM BROMIDE - 18 mcg one puff inhaler once a day TIZANIDINE - 2 mg three times a day as needed for spasms TRAMADOL 50 mg Tablet - [11-18] Tablet(s) by mouth every six hours TRAZODONE - 50 mg by mouth at bedtime as needed for insomnia TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg Tablet three times a week ASPIRIN - 325 mg once a day CYANOCOBALAMIN once a day DOCUSATE SODIUM - 200 mg three times a day FERROUS GLUCONATE - 325 mg daily SENNA - 8.6 mg by mouth daily Reclast Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation once a day. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) dose Sublingual once a day as needed for chest pain: one Tablet(s) sublingually every 5 minutes as needed for chest pain . 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for spasms. Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive urgency 2. Constipation 3. HIV 4. Lung nodule on CT scan 5. Pain control 6. Abdominal pain Discharge Condition: Stable Discharge Instructions: You were admitted with abdominal pain from constipation. This improved with a bowel regimen. You have been given a handout on constipation management. If you develop increasing abdominal pain, blood in your stool, fevers, chills, nausea, or vomiting, please call your primary care doctor. . You were also noted to be hypertensive, and you were started on a drug called hydrochlorothiazide for hypertension. . You SHOULD NOT restart your HIV medications until you discuss this with Dr. [Last Name (STitle) 1057]. Followup Instructions: You will need a follow up chest CT for nodule in 3 months. This can be arranged by your PCP. You have an appointment with your PCP. [Name Initial (NameIs) 2169]: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-9-29] 9:10 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1085], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-10-13] 9:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2152-7-31] 9:10	[ "401.9", "780.60", "530.81", "496", "288.60", "530.3", "V46.2", "305.60", "V15.82", "305.00", "V08", "535.50", "787.01", "564.00", "722.83", "530.10", "789.07", "733.00", "518.89", "553.3", "280.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10662, 10668	5777, 7401	339, 345	10819, 10828	4370, 5754	11392, 11939	3428, 3606		8746, 10639		10689, 10798		7427, 8723			10852, 11369									3015, 3203		3621, 4351																				277, 301								373, 2059														2081, 2992	3219, 3412
6,663	164,771	11682+11683	Discharge summary	report+report	Admission Date: [2124-12-25] Discharge Date: [2125-1-11] Date of Birth: [2061-12-4] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old male who presented to an outside hospital [Location (un) ] with complaints of shortness of breath, confusion and right lower back pain. Workup was found to have a right middle lobe infiltrate with a white count of 39,000. Per family Mr. [Known lastname 931] has had lower back pain for about a week and shortness of breath for one day. He did not complain of substernal chest pain, nausea, vomiting or arm pain. On arrival here at [Hospital1 18] laboratories were repeated with a troponin of 3.1 and CPK of 215. Electrocardiogram demonstrated no acute ischemic changes. Bedside echocardiogram was negative. The patient reported to be febrile to 101.8, diaphoretic. Repeat chest x-ray with right middle lobe infiltrate, white count 39.9, repeat electrocardiogram in Intensive Care Unit no evidence of acute ischemia. PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus, hypertension, kidney stones in the past. SOCIAL HISTORY: Positive tobacco one and a half packs per day times many years, although on admission reported negative. The patient denies alcohol, reports he use to drink, although on admission perhaps occasional alcohol. FAMILY HISTORY: Not obtained. PHYSICAL EXAMINATION: Temperature 103. Blood pressure 138/70. Pulse 117. Respiratory rate 24. HEENT intubated. Pupils are equal, round and reactive to light and accommodation. No bruits. No adenopathy. Lungs mild expiratory wheeze left greater then right. Cardiovascular regular rate and rhythm. Normal sinus. Normal S1 and S2. No murmurs. Abdomen soft, nontender, normoactive bowel sounds. Genitourinary Foley. LABORATORIES ON ADMISSION: White count 39.9, hematocrit 34, platelets 352, 82 neutrophils, 3 bands, 4 lymphocytes, sodium 134, potassium 3.6, chloride 95, bicarb 28, BUN 19, creatinine .7, glucose 384, CK 213, MB 5, troponin 3.1. Urinalysis clear 1.015, large blood, negative nitrite, negative leukocyte esterase, 0 to 2 white blood cells, 3 to 5 red blood cells. CT of the abdomen showed no evidence of abscess or free fluid within the abdomen or pelvis, bibasilar dependent air space disease suggestive of aspiration fatty liver, small amount of left perinephric fluid without adjacent parenchymal abnormality, finding nonspecific. Sigmoid diverticulosis, asymmetry in the pelvis, girdle musculature consistent with right side atrophy. Chest x-ray diffuse air space consolidation involving both lungs particularly right lung field and left lower lobe. HOSPITAL COURSE: 1. Infectious disease: The patient was admitted to the Intensive Care Unit and was febrile with an elevated white count. The patient was started on Ceftriaxone, Gentamycin, Vancomycin and Levaquin was later added. The subclavian line was placed for access. Given the complaints of low back pain on the first day of hospitalization an MRI of the back was obtained, which showed extensive epidural abscess most clearly present at L4-5 through L5-S1 along the dorsal aspect of the spinal canal suggestive of a arachnoid inflammatory disease as well and possible ventral component of epidural abscess at the lumbar levels, also extensive abscess involving left psoas muscle and left paraspinal musculature. At this point neurosurgery was consulted as well as Infectious Disease. On [12-27] the patient was taken to the Operating Room for incision and drainage where an enormous multiloculated paraspinous muscle/buttocks abscess on the left was found. There was a large epidural abscess with gross pus extending from L3 to S1. The subarachnoid space was also filled with pus from L4-S1. This was maximally irrigated and debrided and closed over drains and cultures were sent. Prior to going to the Operating Room a surgery consult was obtained and after review of the films it was felt that the buttock abscess was small less then 2 cm, but not loculated. On [12-27] cervical puncture under CT guidance. The CSF in tube one showed 9500 white blood cells, 300 red blood cells, 90 polys, 7 lymphocytes, 1 monocytes. Protein was 192. Glucose 64. Tube four had 7375 white blood cells, 130 red blood cells, 90 polys, 10 lymphocytes, 0 monocytes. Culture of that grew staph coag positive that was Ampicillin sensitive. Additionally blood cultures from the outside hospital came back staph aureus coag positive that was sensitive to Oxacillin. All blood cultures throughout this hospitalization as well as urine cultures were negative at this hospital. Once sensitivities were obtained the Vancomycin was changed to Oxacillin. Additionally Levaquin was eventually stopped as was Ceftriaxone and the patient was maintained on Oxacillin, Gentamycin and with ID consultation Rifampin was added for synergy. White count and fever curve were monitored and surveillance blood cultures were drawn and remained negative. Drains remained in place with neurosurgery follow up. Chest x-ray was also followed and there was continued question of a consolidation, atelectasis and mild congestive heart failure, which never effected oxygenation. On [12-30] the patient was noted to develop some lesions around his mouth that appeared like herpes. In fact, DFA swab was positive for HSV1 and the patient was on Acyclovir intravenous times seven days until these were completely crusted over. The patient was noted to have a tender abdominal examination and on [12-31] a CT of the abdomen was repeated, which showed left psoas and paraspinal low attenuation collections, overall size not increased interval, although a few of these collections appear more hypodense, interval improvement in the amount of left perirenal stranding. On [1-2] spinal tap was repeated under CT guidance. This fluid in tube one showed a white count of 215, red blood cells [Pager number ], polys 67, lymphocytes 24, monocytes 9, protein 166, glucose 71 and in tube four whites 275, red blood cells 15, polys 55, lymphocytes 31, monocytes 4. Gram stain and culture of this fluid was negative. On [1-6] a central line was removed and catheter tip was negative for culture. Several days later the patient had a PICC line placed. On [1-6] chest x-ray PA and lateral showed only hyperinflation probable small effusion and question of small infiltrate seen only posteriorly and on [1-8] chest x-ray showed lungs are clear without focal consolidations or pleural effusions. On [1-5] the drains were removed and the patient felt stable for transfer to the floor. After the 21st, the patient remained afebrile with temperatures under 100. On [1-11] white count was 12.5 with a differential of 70 neutrophils, 22 lymphocytes, 5 monocytes, 2 eosinophils and 1 basophil. On [1-10] Oxacillin was stopped and changed to Clindamycin given concern of AIN see below and on the 27th the Clindamycin was changed to Vancomycin. ESR was checked on [1-6], which was 41. Pathology from the Operating Room on [12-27] epidural tissue showed bone with acute osteomyelitis fibrous and adipost connective tissue with acute and chronic inflammation, fat necrosis and abscess formation. Lumbar spine bone with hematopoietic marrow, fibrocartilage and dense fibrous connective tissue with acute and chronic inflammation. Given the osteomyelitis ID recommended at least six weeks of intravenous antibiotics and the patient to follow up in ID as well as neurosurgery. 2. Cardiovascular: The patient was seen by the cardiology team on admission. There were no acute ischemic changes on the electrocardiogram. Originally the patient was on heparin and ace inhibitor, aspirin, beta blocker and Lipitor. However, aspirin was then held given the patient going to Operating Room. Peak troponin was 3.1 with a CK of 213 and an MB of 5. Echocardiogram on [2124-12-26] was suboptimal image quality due to poor echocardiogram windows, showed left atrium normal size, mild symmetric left ventricular hypertrophy, normal cavity size, resting regional wall motion abnormalities included severe HK of anterior septum and anterior walls, remaining segments mildly hypokinetic. RV chamber size and free wall normal. No significant MR. [Name13 (STitle) ] AR. Moderate pulmonary systolic hypertension. Given that it was thought that this was not an acute event, heparin was stopped. Additionally, it was felt that a TEE was not acutely needed. Given the acute situation cardiology felt that follow up for the cardiac events would be better done when the acute situation was resolved or catheterization or ETT after the patient had recovered. Repeat echocardiogram on [1-8] showed [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] elongated. No ASD, by 2D or color doppler. Left ventricular wall thickness and cavity size normal. Mild regional left ventricular systolic dysfunction with [Doctor First Name ] anterior hypokinesis. Remaining left ventricular segments contract normally. Global systolic function low normal. RV chamber size and free wall normal. Trace AR seen. Trivial MR. Mild pulmonary systolic hypertension. EF 50 to 55%. EF on [12-26], echocardiogram was 35%. In the Intensive Care Unit the patient had marked hypertension requiring a nitroglycerin and Labetalol drip and these were slowly weaned to off as oral medications were titrated up including hydralazine, captopril and then Labetalol was changed to po. Additionally on the floor, Captopril was eventually changed to Zestril. Spironolactone and Hydrochlorothiazide was added and blood pressure was moderately well controlled. 3. Neurological: While in the Intensive Care Unit the patient was sedated and had a waxing and [Doctor Last Name 688] mental status on [12-29]. A neurological consult was obtained due to the patient's continued somnolence. An electroencephalogram was considered to be obtained, but was not obtained. It was thought likely secondary to encephalitis "toxic" in addition to sedation and analgesia. Additionally, an MRI was considered and neurological examination was difficult secondary to mental status and then mental status began to improve and this was not done and the patient's mental status continued to improve. 4. Respiratory: The patient was intubated and there was a question of a possible infiltrate on chest x-ray, which was followed as well as mild congestive heart failure. The patient's oxygenation remained okay. On [12-27] the patient was briefly extubated, but went to surgery and was reintubated and sedated at that point. Over the next several days the patient was intubated and then by [1-3] he was successfully extubated. Chest x-ray on [1-8] showed lungs clear without focal consolidations or pleural effusion on a single view chest x-ray. The patient had no complaints of breathing difficulty. 5. Renal: The patient had microscopic hematuria on admission. On the night of [1-5] he self discontinued his Foley catheter and had some small amount of bleeding around the meatus. On the night of [1-9] the patient noted to have hematuria gross, although he was able to void without difficulty. Urology consult was obtained and of note on [12-31] on CT both drain off and kidneys were noted to be normal, bilateral low attenuation lesions in both kidneys, thick in nature and unchanged from the prior examination. Urology felt the gross hematuria was most likely from the Foley trauma and recommended an outpatient follow up. Coagulations were sent. INR was 1.3, PTT 33.4 and PT was 13.8. Urinalysis was sent, which showed large blood, trace protein, 586 red blood cells, 3 white blood cells, no bacteria, no epi. Repeat on the [1-10] it showed 106 red blood cells, 2 white blood cells, occasional bacteria and no epis. Urine eosinophils were negative, which were sent for concern of AIN, peripheral eosinophils were within normal limits. Urine culture was sent and was negative. Additionally a renal consult was obtained. Urine sediment for renal 5 to 15 red blood cells, 10 to 20 white blood cells, multiple coarse granular white blood cells and tubular epithelial cells cast, _________ pigmented cast with the _________. Differential diagnosis included AIN and DM. E3 and C4 were normal. At this point Oxacillin was discontinued and Clindamycin was started, which was then changed to vancomycin. Hepatitis serologies, [Doctor First Name ] and ANCA were sent and are pending. Urine protein to creatinine were sent as pending. Creatinine and Is and Os were followed. The patient continued to void spontaneously without difficulty. On the 27th the creatinine was stable at .7 with a BUN of 14. 6. Hematology: Hematocrit was monitored. The patient was transfused 2 units of red blood cells on [12-28] and [12-31] as needed. He was guaiac negative at that time. Hematocrit was followed and remained stable. It was 33 on [1-11]. 7. Gastrointestinal: The patient had some loose stools, which were C-diff negative on [12-17], [1-6] and [1-10]. 8. Endocrine: The patient was maintained on a sliding scale regular insulin and finger sticks. As he became able to eat more, Metformin 500 b.i.d. was added back. 9. FEN: The patient was maintained on tube feeds while in the Intensive Care Unit and nutrition consult was obtained. On the floor the patient began taking po without difficulty. Electrolytes were monitored and replaced as needed. 10. Physical therapy: The patient needed rehab placement, but had excellent rehab potential. DISCHARGE DIAGNOSES: 1. Epidural abscess. 2. Meningitis. 3. Buttock abscess. 4. Osteomyelitis. 5. Hematuria. 6. Diabetes. 7. Hypertension. 8. History of nephrolithiasis. MEDICATIONS ON [1-11]: Labetalol 1000 mg b.i.d., Hydralazine 100 mg q.i.d., Rifampin 300 mg q 12 hours, Nystatin powder, Protonix 40 mg q.d., Lipitor 20 mg q.d., aspirin 81 mg q.d., Metformin 500 mg b.i.d., regular insulin sliding scale, Zestril 40 mg q.d., Vancomycin 1 gram q 12, HCTZ 25 mg q day, Spironolactone 25 mg q.d. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 33824] Dictated By:[Last Name (NamePattern1) 4572] MEDQUIST36 D: [2125-1-11] 12:28 T: [2125-1-11] 13:13 JOB#: [Job Number 28040] Admission Date: [2124-12-25] Discharge Date: [2125-1-11] Date of Birth: [2061-12-4] Sex: M Service: ADDENDUM: After discussion with both the renal and infectious disease services and the urinalysis showing only trace protein and trace blood, no eosinophils in urine sediment or peripheral eosinophilia, likely thought that etiology of renal sediment and creatinine rise due to likely postinfectious resolving glomerulonephritis and unlikely to be acute interstitial nephritis. Therefore, it was felt that Oxacillin should be restarted and this was done. The patient did have one more episode of hematuria and urology performed successful cystoscopy which showed urethral trauma at five o'clock in urethrobulbar area. No other bladder or prostate lesions. On [2125-1-12], creatinine bumped from 0.7 to 0.9, and given baseline, the patient was kept one more day to follow this with the plan that if it continued to rise, there would be a consideration of a renal biopsy. However, on the day of discharge, creatinine was 0.8. Hepatitis B surface antigen, hepatitis surface antibody, hepatitis core antibody, ANCA, [Doctor First Name ], hepatitis C antibody were all negative. Norvasc was added and Hydralazine was stopped for blood pressure control. On [2125-1-12], blood pressure was much better controlled, however, it was felt that a slightly higher blood pressure would be good for renal perfusion. Therefore, Norvasc was changed from 10 mg to 5 mg q.d. Renal ultrasound showed stone within the gallbladder, simple cyst of upper pole of left kidney, no renal stones. Repeat magnetic resonance scan showed findings consistent with evolving epidural and perhaps intrathecal infection of lumbosacral spine, laminectomies noted at L4-L5, cell cavity posterior soft tissues measured 3.0 centimeters transversely, enhancement along margins of surgical cavity, and adjacent posterior spinal muscles, there is enhancement extending into the spinal canal within epidural space. Abnormal ventral epidural enhancement visible at level of L3-L4 and extending inferior into sacral canal. Also thick enhancement of the distal thecal fat with some areas of enhancing septation in the sac at L5-S1 level, roots of cauda equina also enhanced and somewhat clumped appearance at the nerve roots and thecal sac is similar to that of [2124-12-26]. Posterior soft tissue enhancement increased in area of abnormal ventral epidural enhancement, more conspicuous on the current study. On the day of discharge, the patient is stable. No new complaints, no back pain, chest pain, no episodes of hematuria, no numbness, tingling, weakness or shooting pains in legs. Back incision was clean, dry and intact, healing well and nontender. After discussion with renal and infectious disease services, the patient discharged to [Hospital3 ]. The patient is to follow-up with primary care physician in one to two weeks, Dr. [Last Name (STitle) 1338] in one to two weeks neurosurgery. The patient is to call for these appointments. Dr. [Last Name (STitle) 36997], infectious disease, on [2124-2-1], at 1:00 p.m. Dr. [Last Name (STitle) ] of renal in one to two weeks. The patient is to have Chem7 drawn three times a week, and potassium replaced as needed, as elevated renal function results to renal clinic. Liver function tests drawn twice a week. Blood pressure taken q.d. Fingerstick done b.i.d. MEDICATIONS ON DISCHARGE: 1. Oxacillin two grams q4hours until [2125-2-8]. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Norvasc 5 mg q.d. 4. Zestril 40 mg q.d. 5 Spironolactone 25 mg q.d. 6. Labetalol 1000 mg b.i.d. 7. Aspirin 81 mg q.d. 8. Sliding scale insulin. 9. Metformin 500 mg b.i.d. 10. Rifampin 300 mg q12hours. 11. Protonix 40 mg q.d. 12. Lipitor 20 mg q.d. The patient with positive troponin on admission, ruled in for myocardial infarction by troponin. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 11283] Dictated By:[Last Name (NamePattern1) 4572] MEDQUIST36 D: [2125-1-13] 14:03 T: [2125-1-13] 14:19 JOB#: [Job Number 36998]	[ "038.19", "599.7", "428.0", "324.1", "997.91", "730.08", "320.3", "054.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "03.4", "03.09", "03.31", "86.22", "99.04" ]	icd9pcs	[ [ [] ] ]							1376, 1391	13731, 17942				17968, 18680		2693, 13619														13638, 13710												1414, 1830															161, 1027							1845, 2675							1050, 1132	1149, 1359
19,212	105,392	11340+11341	Discharge summary	report+report	Admission Date: [2108-8-10] Discharge Date: [2108-8-21] Date of Birth: [2041-8-20] Sex: M Service: HISTORY OF PRESENT ILLNESS: On [8-13], the patient underwent coronary artery bypass grafting times three with LIMA to left anterior descending, saphenous vein graft to OM and right posterior descending artery. The patient's ejection fraction was 50-55%. PAST MEDICAL HISTORY: Chest pain. Vertigo. Claudication. Peripheral vascular disease. Status post bilateral iliac stents. Hypercholesterolemia. HOSPITAL COURSE: Postoperatively the patient's course was complicated by serosanguinous sternal drainage which was treated with Keflex. Upon discharge, the patient's condition was stable. Lungs were clear. Incision was clean with no drainage. The patient's ambulatory status was level [2-23]. DISCHARGE MEDICATIONS: Aspirin 81 mg p.o. q.d., Ranitidine 150 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., Keflex 500 mg p.o. q.i.d. for 7 more days, Lopressor 50 mg p.o. b.i.d., Percocet 5 [11-22] tab p.o. q.3-6 hours p.r.n. DISPOSITION: The patient is arranged to have visiting home nursing care for postoperative wound care and vital sign monitoring. FOLLOW-UP: The patient will follow-up with Dr. [Last Name (STitle) ] in [1-22] weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 186] MEDQUIST36 D: [2108-8-21] 08:35 T: [2108-8-21] 08:24 JOB#: [Job Number ] Admission Date: [2108-8-10] Discharge Date: [2108-8-21] Date of Birth: [2041-8-20] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66 year old male who was admitted on [2108-8-10] for angina and shortness of breath. He was admitted to the medicine service for suspected silent myocardial infarction. The patient underwent cardiac catheterization on the day of admission, which showed trace mitral regurgitation, severe inferior hypokinesis, left ventricular ejection fraction of 40%, 90% left main, distal left anterior descending artery mild lesion, left circumflex mild lesion, right coronary artery 100%. PAST MEDICAL HISTORY: 1. Cerebral palsy. 2. Vertigo. 3. Bilateral claudication. 4. Peripheral vascular disease, status post bilateral iliac stents. 5. Hypercholesterolemia. 6. Asbestos exposure. MEDICATIONS ON ADMISSION: Zestril 10 mg p.o.q.d., Artane 4 mg p.o.t.i.d., Meclizine p.r.n., Prilosec 10 mg p.o.q.d., Lipitor 10 mg p.o.q.d., and propranolol 40 mg p.o.q.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Lungs: Scattered rales at bilateral bases. Cardiovascular: Regular rate and rhythm, S1 and S2 normal. HOSPITAL COURSE: Post cardiac catheterization, the patient was seen by Dr. [Last Name (STitle) ] of cardiothoracic surgery and, on [2108-8-13], the patient underwent coronary artery bypass grafting times three, left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and posterior descending arteries. Postoperatively, the patient did well. The chest tube was discontinued without incident, as well as the Foley, and the patient was able to void on his own. His postoperative course was complicated by serosanguinous sternal drainage and the patient was placed on oral Keflex. CONDITION ON DISCHARGE: The patient was stable. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Incisions: Intact, sternum stable, no drainage. DISCHARGE MEDICATIONS: Aspirin 81 mg p.o.q.d. Ranitidine 150 mg p.o.b.i.d. Keflex 500 mg p.o.q.i.d. times seven days. Lopressor 50 mg p.o.b.i.d. Percocet one to two tablets p.o.q.3-6h.p.r.n. DISCHARGE STATUS: The patient was discharged to home and instructed to follow up with Dr. [Last Name (STitle) ] in three to four weeks and with his primary care physician. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 186] MEDQUIST36 D: [2108-8-21] 09:52 T: [2108-8-21] 10:36 JOB#: [Job Number 36352]	[ "V15.84", "785.0", "343.9", "496", "411.1", "998.12", "414.01", "443.9", "998.89" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56", "39.61", "36.12", "88.53", "36.15" ]	icd9pcs	[ [ [] ] ]									3661, 4272				2479, 2680	2827, 3452																										2703, 2809															1745, 2246														2269, 2452		3477, 3638
10,160	130,583	1511+55290	Discharge summary	report+addendum	Admission Date: [2193-6-26] Discharge Date: Service: GENERAL INTERNAL MEDICINE/[Location (un) 259] CHIEF COMPLAINT: Rash, low grade fevers. HISTORY OF PRESENT ILLNESS: The patient is an 86 year-old man who was hospitalized at [Hospital1 69] in early [2193-6-1] and was found to have MSSA bacteremia. At echocardiogram so the patient was started on Oxacillin intravenous for empiric treatment of SBE. The patient was discharged to rehab with plans for a total six weeks of treatment with intravenous antibiotics. The patient then returned to [Hospital1 1444] on [2193-6-26] feeling itchy with a rash over his extremities. He also complained of a low grade fever, but denied any other symptoms on admission. myocardial infarction in [2168], coronary artery bypass graft in [2192-5-1]. 2. Congestive heart failure with an EF of 30%. 3. History of nonsustained polymorphic ventricular tachycardia status post AICD implantation. 4. Left ventricular aneurysm. 5. History of primary hyperparathyroidism status post resection. 6. Upper respiratory infection. 7. Anemia of unknown etiology presumed secondary to CRI. 8. Hepatitis C. 9. Hypertension. 10. History of urinary tract infection. 11. Paroxysmal atrial fibrillation. 12. Hard of hearing. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Oxacillin 2 grams intravenous q 4 hours. 2. Lisinopril 5 mg q.d. 3. Metoprolol 12.5 mg b.i.d. 4. Calcium carbonate 500 b.i.d. 5. Lasix 40 three to five times a week. 6. Colace 100 mg b.i.d. 7. Vitamin D 400 q.d. 8. Protonix 40 q.d. 9. Zoloft 25 q.d. 10. MVI one tab po q.d. 11. Coumadin 3 q.h.s. 12. Albuterol nebulizers prn. 13. Potassium prn. SOCIAL HISTORY: The patient is a Russian speaking gentleman who lives with his wife in [Name (NI) 86]. Their daughter is a physician at [Hospital6 ]. Both the patient and his wife are retired mathematicians. FAMILY HISTORY: Unknown. PHYSICAL EXAMINATION: On initially physical examination the patient had a temperature of 97.9, blood pressure 136/76, heart rate 76, respiratory rate 24 and oxygen saturation 95% on room air. In general, he was an elderly gentleman appearing his stated age sleeping in no apparent distress. His mucous membranes are moist. He had no lymphadenopathy or JVD. His heart rhythm was irregular. He had a normal S1 and S2. There was a [2-6] holosystolic murmur at the upper sternal border bilaterally and there are no rubs or gallops. He had scattered rhonchi bilaterally and pulmonary auscultation. His abdomen was mildly distended. There was normoactive bowel sounds and there was mild left lower quadrant tenderness. He had 2+ dorsalis pedis and radial pulses bilaterally. His extremities were warm and there was no clubbing, cyanosis or edema. He had petechial lesions on his lower extremities greater in his upper extremities bilaterally. INITIAL LABORATORIES: White blood cell count 5.3, hematocrit 31.9, platelet count 222. The differential demonstrates 60% neutrophils, 27% lymphocytes, 5% monocytes, 6.6% eosinophils and .4% basophils. His PT was 11.7, PTT 31.6, INR 0.9. Initial serum chemistries sodium 139, potassium 4.0, chloride 106, bicarb 16, BUN 60, creatinine 3.1, glucose 116. ALT 28, AST 65, alkaline phosphatase 238, amylase 157, lipase 57, T bili 2.9. Given his mildly elevated liver enzymes an abdominal ultrasound was performed in the Emergency Department. This study demonstrated no intrahepatic ductal dilatation, no hydronephrosis, a cholestic structure of the lateral segment of the left hepatic lobe, gallstones, a small amount of ascites and a small right sided pleural effusion. Chest x-ray demonstrated small bilateral pleural effusions and slight worsening congestive heart failure. IMPRESSION: Given the patient's presentation with the petechial rash, low grade fevers, peripheral eosinophils, elevated serum creatinine and onset of symptoms ten to twelve days after Oxacillin was started the presumptive diagnosis was Oxacillin induced acute interstitial nephritis. Urine eosinophils and a urine sodium were sent. Given the recent increase in the patient's Furosemide dose from 20 to 40 the possibility of prerenal azotemia was considered and urine electrolytes were sent. Given his acute renal failure the patient's Furosemide and Lisinopril were held, Oxacillin was discontinued and Levaquin was started. Although the rash was most likely secondary to Oxacillin induced AIN, given the associated acute renal failure and low grade fever the possibility of vasculitis was considered and serum ANCA and [Doctor First Name ] were sent. Aside from the above the patient was continued on all of his outpatient medications. HOSPITAL COURSE: On the evening of hospital day number two the patient developed chest pain in conjunction with JVD and bilateral crackles. Sublingual nitroglycerin relieved the pain slightly. Chest x-ray showed increased bibasilar haziness. No acute changes were noticed on electrocardiogram. Arterial blood gas was performed, which showed 7.29/37/99 on 3 liters oxygen by nasal cannula. He was assumed to be in acute congestive heart failure and diuresed with good symptomatic relief. He ruled out by cardiac enzymes during this time period as well. On hospital day number three the patient's urinalysis showed eosinophils supporting a diagnosis of AIN. Hemolysis panel came back negative. Serum ANCA and [Doctor First Name ] tests were negative as well. Urine electrolytes showed a sodium of 53, therefore the possibility of prerenal azotemia was felt to be less likely. The night of hospital day number three the patient became tachypneic with respiratory at 38, oxygen saturation 86% on room air. A chest x- ray again showed bilateral pulmonary edema with effusions, which increased a magnitude from a chest x-ray done earlier that afternoon. There were no changes on electrocardiogram. Arterial blood gas showed 7.12/58/107/19. The patient had no urine output to a total of 70 mg intravenous Lasix, and he was subsequently intubated for respiratory distress and hypoxia. He was then transferred to the MICU where he became hypotensive and transiently required pressors to maintain his blood pressure. Serum chemistries done on the morning after transfer to the MICU demonstrated an increase in anion gap metabolic acidosis. He also showed worsening uremia with a BUN of 71 and a creatinine of 3.6. He was therefore started on intravenous steroids for empiric therapy of AIN as well as bicarb to increase his serum pH. Given his hypotension the resulting concern for sepsis the patient's antibiotic coverage was broadened with the addition of Vancomycin to Levofloxacin. By hospital day number five the patient was off pressors. His creatinine was up to four. He was continued on steroids and bicarb and he was started on Furosemide drip with Dyazide diuretics for clinically apparent congestive heart failure exacerbation. He was also started on Hydralazine for after load reduction. By hospital day number six diuretics were held. Serum creatinine increased to 4.8. A trial of weaning the patient off ventilators was not attempted secondary to his metabolic acidosis. Given a hematocrit of 21.9 the patient was transfused 2 units with appropriate increase in hematocrit. An echocardiogram demonstrated no change from the same study done in [Month (only) ] of this year. The patient was also started on tube feeds. On hospital day number seven a right Quinton catheter was placed and the patient was initiated on hemodialysis. Blood cultures were drawn, which came back positive for yeast. He was then started on Fluconazole renally dosed and the PICC line was pulled. Urine sputum and fungal isolates were drawn on [2193-6-29], which came back negative at the time, but the patient had increasing thick oral secretions and therefore an ID consult was obtained. ID Service felt the patient should be started on Vancomycin for a treatment of MMSA bacteremia and that Levaquin should be stopped. He was also continued on Fluconazole, which later speciated and deemed to be a contaminate. At that point Fluconazole was stopped and Prednisone was restated for treatment of AIN. On hospital day number ten sputum culture with gram stain showed gram positive cocci, which was speciated to staph aureus and the patient was continued on Vancomycin. By hospital day number ten the patient's urine creatinine had begun to fall after three rounds of hemodialysis. He was therefore started on a steroid taper and was hydrated with fluids to maintain blood pressure and renal perfusion. Given his continued improvement there appeared to be no indication for further hemodialysis and therefore the patient's Quinton catheter was removed on hospital day number twelve. Given his improving status and resolving acidosis he was successfully extubated on hospital day number twelve. On hospital day number fourteen the patient's serum creatinine had decreased to 2.3, although his BUN increased to 157 most likely secondary to his steroid taper. He also experienced an episode of rapid atrial fibrillation on hospital day number fourteen and was started on Metoprolol. In addition, surveillance blood cultures were drawn on this day. These cultures eventually came back negative. Given this improved medical condition he was transferred out of the MICU to the general medicine floor on hospital day fifteen. On the day he was called out of the MICU the patient complained of chest pain, which resolved spontaneously. Electrocardiogram done at the time demonstrated no changes. By hospital day number sixteen his BUN reached 159, although a creatinine was stable at 2.4. Urine sediment demonstrated muddy brown casts and nondimorphic red blood cells consistent with ATN. Given these findings in concert with the BUN of 169 on hospital day number seventeen he was strongly encouraged to take ample po fluids with a goal of avoiding treatment with intravenous fluids. The patient, however, was taking very poor po and plans were tentatively made to start hemodialysis. Before these plans were implemented, however, the patient's fractional excretion of sodium was calculated to be 0.4%. Given this significant prerenal azotemia, which was attributed to a poor po intake versus congestive heart failure versus renal hyperperfusion versus catabolism versus glucocorticoid therapy, the patient was initiated on IVF with a goal of achieving adequate hydration to decrease his BUN and to clear his sensorium so he would again take adequate po fluids. The patient's BUN had slowly decreased to 141 with intravenous fluid although his mental status was inconsistent and his po intake remained poor. A 24 hour urine collection done demonstrated alarmingly low creatinine clearance of 14 and therefore his collection was repeated for confirmation. In addition, given the patient's poor po intake an nasogastric tube was placed on hospital day number 23 in order to initiate tube feeds. The patient pulled his nasogastric tube within 24 hours and he subsequently pulled out at least five more nasogastric tubes during the next several days. During this time he received a total of only 36 hours of tube feeds. On hospital day number 25 the patient's wife informed the medical team that the patient expressed the desire to harm himself the prior evening. On examination that day, however, the patient's mood was upbeat and he was offering to buy gifts for the staff. A psychiatry consult was therefore deferr. On subsequent examinations the patient refused to answer questions through an interpretor and given the presumptive diagnosis of depression the patient was started on Paxil empirically. The results of repeat 24 hour urine collection obtained on hospital day 26 again demonstrated a very low creatinine clearance of 12 and given this value as well as hisuremia and chronically poor po intake plans were therefore made to initiate hemodialysis. A temporary hemodialysis catheter was placed on hospital day number 27 and hemodialysis was initiated on hospital day number 28. The patient received three straight days of hemodialysis and by hospital day number 33 after four rounds of hemodialysis the patient's BUN had fallen to 41 and his mental status appeared to improve. On hospital day number 29 a psychiatry consult was obtained given the patient's poor po intake and prolonged lack of improvement. The Psychiatry Service did not feel that the patient was depressed, but rather had a component of delirium versus dementia. The SSRI was stopped and psychiatry continued to follow the patient. Given his chronically poor po intake and his multiple episodes of pulling out feeding tubes the patient received a PEG tube, which was placed on hospital day number 31. He was initially scheduled to receive both a Perm-A-Cath and a PEG tube on hospital day 31, but the patient's family refused Perm-A-Cath placement, which was instead tentatively arranged to be done on an outpatient basis. Tube feeds were initiated after the procedure, which the patient tolerated without difficulty. On hospital day number 34 the patient developed an elevated temperature of 99.6 axillary, which was an increase of 3 to 4 degrees above the patient's baseline. Given this elevation, blood cultures, urine cultures and chest x-ray were obtained. By the time of this dictation the patient received a steroid taper for acute interstitial nephritis and he had completed six weeks of antibiotic treatment for MMSA bacteremia and MRSA sputum culture. He was stable on his medication regimen and stable for discharge to rehab. Subsequent discharge summary will be dictated for the remainder of the hospital course. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2193-9-9] 17:34 T: [2193-9-17] 07:00 JOB#: [Job Number 8870] Name: [Known lastname ], [Known firstname 77] Unit No: [Numeric Identifier 1175] Admission Date: [2193-7-30] Discharge Date: Date of Birth: [2107-4-17] Sex: M Service: Internal Medicine - [Location (un) ] Firm TITLE: Discharge Summary Addendum HOSPITAL COURSE [2193-7-30] to [2193-8-18] Hospital course #1 Infectious Disease: Patient completed a pneumonia. He was prepared for discharge to rehab, but had a relative temperature [Name2 (NI) ] on [2193-7-28] from 95 to 99.5. He defervesced over the next few days. He returned to temperature baseline of 96 to 97 during the next few weeks. One of four blood cultures drawn after temperature [Date Range ] grew lactobacillus which was again seen in [1-4] blood culture bottles drawn on [2193-7-30]. Infectious Disease was reconsulted and felt the lactobacillus could be a colonizer of the temporary dialysis catheter. There was subsequently no growth in four bottles of follow up blood cultures drawn on [2193-8-1] from two peripheral sites. The infectious Disease service, however, still recommended that patient finish a 10 day course of clindamycin for the lactobacillus, and he was treated for ten days. Temporary dialysis catheters pulled [2193-8-7], replaced by a Perm-A-Cath by IR (See below for details). Patient had two known events of aspiration pneumonia, the first one [2193-7-30]. This episode resulted from him lying flat during dialysis at which time he desaturated to the 80s before suctioning. He was started on Levaquin and Flagyl for aspiration pneumonia. Antibiotic regimen was changed to Levo and clindamycin to better cover the lactobacillus as discussed previously. He completed a seven day course of antibiotics for pneumonia. A second aspiration event occurred on [2193-8-11] at which time his sputum culture was found to contain methicillin-resistant Staphylococcus aureus and he was started on Vancomycin again. During the first aspiration event, his white count initially increased, then began trending down until he aspirated a second time, and white count increased again to 19,000. Stenotrophomonas maltophilia also grew from the sputum culture, but it was thought by ID to be a contaminant. Renal: He has acute and chronic renal failure most likely due to acute interstitial nephritis secondary to oxacillin use. He was started on scheduled dialysis the last week in [Month (only) 1176] and was continued on his current schedule of hemodialysis 3x a week for chronic renal insufficiency. At baseline, he had a very minimal urine output with a creatinine clearance of 12 in a 24 hour urine collection. On the whole, the patient tolerated dialysis well with dramatic improvement in electrolytes. On a few occasions, some difficulties arouse during dialysis. On [2193-8-3], he had hypotensive episode during dialysis associated with increased heart rate which appeared to be atrial fibrillation. Symptoms resolved with a 200 cc bolus. Also during dialysis [2193-8-6], the patient had chest pain without electrocardiogram changes with stable vital signs. His anasarca improved with dialysis, though lower extremity pitting edema persisted throughout the hospital course. He received one unit of packed red blood cells during dialysis [2193-8-6] with appropriate increase in his hematocrit. His dialysis catheter was switched [2193-8-7] to Perm-A-Cath which had very slow flow through the arterial side during hemodialysis on [2193-8-8] to [2193-8-13]. He was scheduled for replacement of the Perm-A-Cath by IR, but secondary to aspiration event, he was unable to have it replaced immediately. Therefore, he had approximately three runs of hemodialysis with inadequate flow through the catheter. The catheter was finally replaced with a functioning Perm-A-Cath on [2193-8-16]. At that time, a PICC line was placed as well. FEN/GI: PEG tube was placed on [2193-7-25] with tube feeds at 24 hour cycling. Tube feeds temporarily stopped concurrent to the aspiration episodes. The patient failed bedside swallow test [2193-8-1] and was kept on strict NPO. His wife, however, attempted to feed him po on a few occasions. Video swallow study performed [2193-8-8] showed that he was able to tolerate thick liquids/puree, but aspirated thin liquids. Therefore, he was started on a full-liquid honey thickened puree diet for remainder of hospital course. He refused a thickened diet for a number of days and was again made NPO after a second aspiration event. He was continued on tube feeds as tolerated with methylene blue dye added, without evidence of gastric secretion aspiration. Neuro/Psychiatry: Prior to [2193-7-28] patient had been very agitated and vocal, pulling out lines, and screaming most of the day. Psychiatry was consulted and he was started on Haldol 1 mg tid with prn Haldol as needed. However, standing Haldol was discontinued on [2193-7-29] as he was noted to be very somnolent and appeared appreciably less responsive. During the following week, he had a dramatic decrease in phonation and was referred only by his wife to be whispering. ENT was consulted for evaluation of aphonia. On laryngoscopy the patient's vocal cords were noted to be in paramedian position with continued aspiration of fluids even while not coughing consistent with hypoxic event. Video straboscopy was performed [2193-8-5] and was nondiagnostic as the patient could not comply with testing. Given his change in mental status, failed swallow study and findings by ENT, it was felt that the patient may have had a cerebrovascular accident. He was at risk for embolic event due to his atrial fibrillation. His wife refused to acknowledge this possibility and did not consent to proceed with CT scan of head to workup possible cerebrovascular accident. The patient's mental status began to clear on [2193-8-5], and he was more vocal and alert at that time. Pulmonary: He had at least two aspiration events as noted above. Serial chest x-rays showed improvement after treatment with antibiotics. Right lower lobe atelectasis improved with chest physical therapy. Chest x-ray [2193-8-11] was noted to have a loculated right sided pleural effusion which was tapped under ultrasound guidance - 1.2 liters of transparent yellow fluid was removed. Analysis of fluid showed it was transudative with no evidence for infection. It was thought that the fluid collection was secondary to his known cardiac failure and was unrelated to pneumonia. Cardiovascular: He has a history of atrial fibrillation, coronary artery disease, status post coronary artery bypass graft in [Month (only) 412] of 01 with congestive heart failure and an AICD/DDD pacer in place. He remained in atrial fibrillation for majority of the hospital course. The patient's systolic blood pressure ran low for majority of hospitalization with a range of 90-120s. He was given small intravenous boluses 250 cc or less on a few occasions to keep a systolic blood pressure around 100. Coumadin was not administered due to high fall risk as wife has a history of trying to walk patient without assistance. On [2193-8-8] patient had an event of hypotension with systolic blood pressures ranging in high 70s to low 80s. He initially responded to 250 cc boluses x2. However, his extremities remained cool and clammy. On a few occasions his oxygen saturation dropped into the 80s as well, which improved slightly with suctioning. An arterial blood gas was performed that showed a pH of 7.2, pCO2 of 65, pO2 of 84. As the patient was becoming increasingly difficult to oxygenate and blood pressure continued to fall, and overall clinical condition continued to deteriorate with further progression of cold and edematous extremities, he was transferred to the MICU for further hemodynamic monitoring and support. Discharge summary addendum covering MICU course will be dictated at a later date. [Name6 (MD) 1034] [Name8 (MD) 1035], M.D. [MD Number(1) 1036] Dictated By:[Last Name (NamePattern1) 1008] MEDQUIST36 D: [2193-9-9] 17:56 T: [2193-9-16] 07:08 JOB#: [Job Number 1177]	[ "790.7", "427.31", "482.41", "507.0", "584.9", "070.54", "707.0", "428.0", "285.21" ]	icd9cm	[ [ [] ] ]	[ "34.91", "38.93", "96.04", "96.6", "43.11", "38.95", "96.72" ]	icd9pcs	[ [ [] ] ]							1962, 1972							4772, 22355																										1995, 4754							133, 158								187, 1725															1742, 1945
56,120	110,391	39173	Discharge summary	report	Admission Date: [2118-1-28] Discharge Date: [2118-2-2] Date of Birth: [2056-1-1] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2009] Chief Complaint: transfer for ERCP Major Surgical or Invasive Procedure: ERCP with sphincterotomy and stent History of Present Illness: 62 yo female w/ PMH sig for metastatic ovarian cancer diagnosed 10 years ago, s/p TAH and BSO, adjuvant chemo (last treated [9-24]), and peritoneal stripping in [2110], HTN, hyperlipidemia, who presented initially to [Hospital6 33] with malasie and transferred to [Hospital1 18] for ERCP. History is taken from chart review and sister. She initially presented to [Hospital3 ] beginning of [1-26] and was diagnosed w/ an SBO and chronic cholecystitis discharged home on cipro. She represented [1-25] to the OSH with left flank pain, poor appetite, nausea and emesis. Per sister, + constipation, infrequent on/off emesis one episode bloody, no fevers/chills, ~100lb weight loss over one year. No shortness of breath/chest pain. . An abdominal US was sig for contracted gallbladder w/ wall thickening, sludge concerning for acute cholecystitis superimposed on chronic inflammatory changes, with mildly dilated CBD 9mm, and loculated ascites. MRCP was notable for dilatation of intrahepatic bile ducts and proximal CBD, with midportion of the CMB narrowed by extrinsic mass. She was guaic neg. Labs [1-25] sig for wbc 11, h/h 13.4/40.7, ast 306, alt 144, t bili 3.8, ap 776, lipase 215. Urine cx grew enterococcus faecium (prior urine cx [1-21] sig for enteroccocus R to amp/vanc/macrobid, S linezolid/gent) and she was started on linezolid. She was transferred to [Hospital1 18] for ERCP. Labs on transfer sig for down trending ast/alt 127/94, ap 585, but persistently elevated t bili 3.9. . ERCP was notable stricture at the common hepatic duct and bifurcation of main biliary duct w/ mild post-obstructive dilation compatible w/ extrinsic compression. A sphincterotomy was performed and biliary stent placed. She had brief episode of sbp in 90s, received 100mcg of neo. During procedure, patient had retained food in the stomach and with worry for aspiration in setting of possible SBO, she remained intubated. . Currently, patient is intubated and sedated. . Review of sytems: Unable to assess Past Medical History: -- Metastatic ovarian cancer: s/p TAH/BSO, peritoneal stripping -- Hypertension -- Hyperlipidemia Social History: Lives with her mother, in [Location (un) 686]. Self ambulates. Retired, worked for state in public relations. No ETOH/cig/illicits Family History: No family hx of breast or ovarian cancer. Cousin with lymphoma. Father AMI at 47yo. Sister w/ HTN. Physical Exam: General: Sedated, intubated, no jaundice HEENT: Sclera mildly icteric, dry MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Anterior breath sounds clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, non-tender, non-distended, bowel sounds present, areas of firmness along lower quadrants, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2118-1-28] 09:23PM URINE COMMENT-DUE TO ABNORMAL URINE COLOR INTREPRET DIPSTICK WITH CAUTION [2118-1-28] 09:23PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE EPI-2 [2118-1-28] 09:23PM URINE COLOR-Brown APPEAR-Cloudy SP [Last Name (un) 155]-1.025 [2118-1-28] 11:11PM PT-14.1* PTT-30.8 INR(PT)-1.2* [2118-1-28] 11:11PM PLT COUNT-248 [2118-1-28] 11:11PM WBC-9.4 RBC-4.70 HGB-12.1 HCT-38.7 MCV-82 MCH-25.8* MCHC-31.3 RDW-17.2* [2118-1-28] 11:11PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.4* [2118-1-28] 11:11PM ALT(SGPT)-80* AST(SGOT)-77* LD(LDH)-307* ALK PHOS-592* TOT BILI-2.8* [2118-1-28] 11:11PM estGFR-Using this [2118-1-28] 11:11PM GLUCOSE-165* UREA N-7 CREAT-0.6 SODIUM-137 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-12 . ERCP [2118-1-28]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. Biliary Tree: A single stricture of malignant appearance that was 40 mm long was seen at the common hepatic duct and bifurcation of the main biliary duct. There was mild post-obstructive dilation. These findings are compatible with extrinsic compression.Likely large mass at porta hepatis causing Bismuth III type stricture. Unable to access left system. Right system appears moderately dilated Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was placed successfully. Area of stricture bridged successfully. Distal end of stent within CBD. Impression: Cannulation of the biliary duct was successful. A single stricture of malignant appearance that was 40 mm long was seen at the common hepatic duct and bifurcation of the main biliary duct. There was mild post-obstructive dilation. These findings are compatible with extrinsic compression. Likely large mass at porta hepatis causing Bismuth III type stricture. Unable to access left system. Right system appears moderately dilated A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was placed successfully. Area of stricture bridged successfully. Distal end of stent within CBD. . CXR [2118-1-31] In comparison with study of [1-30], allowing for differences in patient position, there is little change. Left basilar opacification persists, consistent with volume loss and pleural effusion. Diffuse pulmonary metastases are again seen. CT Torso w/contrast: 1. Mid-small bowel obstruction, likely due to omental and anterior abdominal wall mass. 2. Necrotic left pelvic side-wall mass, possibly nodal. 3. Enlarged celiac axis, paraaortic, and right external illiac lymph nodes. 4. Innumerable bilateral pulmonary nodules compatible with metastatic disease. 5. Bilateral pleural effusions, left greater than right with compressive atelectasis on the left side. 6. Stent within the CBD, but the distal tip does not difinitely enter into the duodenum. There is periportal edema and mild biliary ductal dilation. . Microbiolgy: C diff neg X 3, most recent from [1-30]. Sputum culture GRAM STAIN (Final [2118-1-30]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. Blood culture [1-29] NGTD . Discharge labs: [2118-2-2] 04:04AM wBC 6.5 Hgb 9.4* HCt 27.7* MCV 80* Plts 210 INR 1.3 Glucose 132* BUN 5* Cr 0.4 Na 131* K 3.8 Cl 97 CO2 30 Mg 2.0, Ca 7.9, Phos 3.2 ALT 15, AST 15, Alk phos 200, T bili1.0 Brief Hospital Course: Cholecystitis: MRCP notable for extrinsic mass w/ dilatation of CBD and hepatic duct. No evidence for cholangitis. Patient is currently s/p ERCP that was notable for stricture at the common hepatic duct and biliary duct. Sphincterotomy and stenting was performed. Her LFTs continued to improve and she remained hemodynamically stable. . SBO: Suspected SBO, given high grade emesis, abdominal pain and distension and from residual food seen in stomach during procedure. Likely secondary to presumed extensive peritoneal involvement of her ovarian cancer. CT torso was done which confirmed incomplete partial small bowel obstruction of small and large intestines without definite transition point identified. Pt was kept NPO and NG tube was placed to low-intermittent suction with improvement in patient's emesis and pain. Dilaudid and fentanyl patch also improved patient's pain. Pt's emesis resolved completely. Pt developed diarrhea as well, this was C diff negative x3. By discharge, her emesis had stopped, and she was started on clear liquid diet with mild nausea. The NG tube was left in place in the event of recurrent emesis. . Metastatic Ovarian Cancer: Extensive pulmonary mets as well as abdominal disease seen on CT torso, pt and family was made aware of this metastasis. [Month (only) 116] benefit from systemic chemotherapy. She requested transfer back to [Hospital1 34] for management per her primary oncologist. . Aspiration PNA: Concern for aspiration PNA given aspiration event, leukocytosis, and tachycardia. Cefepime and Metronidazole were added to linezolid and pt improved significantly. Sputum cx nondiagnostic and blood cx remained negative. She will need an 8 day course of linezolid, flagyl and cefepime (last dose [2118-2-5]) UTI: per OSH results, sig for 100,000 Vanc resistent enterococcus (VRE). Continued linezolid. Urine culture here was negative. . Diarhea: She developed significant diarrhea, requiring rectal tube. Stool was negative for C diff X 3. . NSVT: Pt developed significant NSVT, probably [1-18] beta blocker withdrawal and hypokalemia [1-18] diarrhea/emesis. Repleted K and started metoprolol 5mg IV Q4H to good effect. She was transitioned to po metoprolol 25 mg po tid on the day of discharge, which can be titrated up as necessary. HTN: Restarted betablocker as above . Hyperlipidemia: Holding statin . FEN: on clear liquid diets as of today, replete electrolytes, regular diet -- If cannot start tolerating POs soon will need nutrition consult for possible TPN . Prophylaxis: Subutaneous heparin . Access: peripherals . Code: Full . Communication: Patient . Disposition: transfer back to [Hospital ] hospital today [2118-2-2] Medications on Admission: Transfer medications: linezolid 600mg [Hospital1 ] lopressor 50mg daily pantoprazole 40mg [Hospital1 ] paxil 20mg daily simethicone 80mg tid simvastatin 40mg daily sucralfate 1gm letrozole 2.5g daily lovenox 40mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Linezolid 600 mg IV Q12H 5. Pantoprazole 40 mg IV Q12H 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Prochlorperazine 10 mg IV Q6H:PRN nausea 8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 9. CefePIME 1 g IV Q12H 10. HYDROmorphone (Dilaudid) 0.5 mg IV Q2H:PRN Pain Hold for sedation or RR<12 11. Potassium Chloride 40 mEq / 100 ml SW IV ONCE Duration: 1 Doses 12. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses 13. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses 14. Metoprolol Tartrate 5 mg IV Q4H hold for SBP <100, HR <55 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Cholecystitis Small Bowel Obstruction Aspiration pneumonia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair. NG tube in place, not to suction. Foley catheter in place. VRE precautions. PICC in place. Discharge Instructions: You were transferred to [Hospital1 18] for ERCP. We found a mass compressing the biliary tree. You had a stent placed to relieve obstruction. You were also vomiting, because of a small bowel obstruction. We treated you for an aspiration pneumonia and placed an nasogastric tube for your obstruction. We are transferring you to [Hospital6 33] for further managment based on your request. Followup Instructions: You are being transfered to [Hospital6 33] for further management. . Follow up with your primary oncologist and primary care doctor after discharge.	[ "789.51", "E878.4", "276.8", "560.89", "507.0", "787.91", "272.4", "197.6", "576.2", "599.0", "575.10", "401.9", "V10.43", "997.39", "197.0", "E849.7" ]	icd9cm	[ [ [] ] ]	[ "51.85", "38.93", "51.87", "00.14" ]	icd9pcs	[ [ [] ] ]	11450, 11465	7362, 10083	308, 344	11577, 11577	3380, 7124	12263, 12419	2709, 2813		10360, 11427		11486, 11556		10109, 10109			11839, 12240			7140, 7339								2828, 3361																				251, 270			2400, 2419			10131, 10337		372, 2382									11591, 11815					2441, 2540	2556, 2693
40,308	163,205	9404	Discharge summary	report	Admission Date: [2106-2-17] Discharge Date: [2106-3-2] Date of Birth: [2046-11-24] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[Doctor First Name 2080] Chief Complaint: transfer for ICD extraction Major Surgical or Invasive Procedure: Removal of ICD/Pacemaker History of Present Illness: Mr. [Known lastname ] is a 59 year-old male with pmh of HTN, HL, CHF w/ EF 30% CAD s/p CABG and stent to left main, s/p pacemaker and [Hospital 3941] transferred from NEBH for ICD extraction after vegetation noted on ICD lead. Patient initially presented to an outside hospital with increasing knee pain over 2-3 weeks time. At the OSH impression was for a septic knee. Aspirate on [2106-2-12] revealed WBC count of 255K in the knee, 8000 rbc's, 100% polys. Treated initially with vancomycin, and later daptomycin. Culture subsequently grew MSSA, and patient subsequently grew MSSA from the blood as well. . Patient taken to the OR for wash out and liner exchange. He was electively intubated for that procedure. Never extubated post-op b/c what was felt to be clinical CHF although partly was to facilitate TEE. Intra-op cultures confirmed MSSA. . In the ICU he was febrile to 103.8. Patient bacteremic at NEBH and on [2106-2-15], and [2106-2-16]. TEE performed and noted veg on AICD wire. Due to Cr 1.9 on presentation to OSH patient was initially treated with CTX/daptomycin given concern for hardware infection and renal failure. Diuresis was attempted with 40mg IV lasix prior to transfer but patient left intubated. . Last VS prior to transfer were HR 80-90 in sinus, 115-120/50, RR 16, on fent/versed 150/12. . On arrival, patient's VS were T102.5, HR 83, BP 152/72, RR 17, O2 100%RA. He was intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: s/p CABG in [2090] with LIMA to LAD, saphenous vein graft to PDA and saphenous vein graft to OM-2. Had known 80% left main, 100% RCA, 90% LAD, and 70% OM on cath. -PERCUTANEOUS CORONARY INTERVENTIONS: Repeat Cardiac Cath in [2095] showed LMCA with an 80% eccentric stenosis in the distal portion (unchanged). The LAD had a 70% lesion in the proximal mid segment just after the S1 origin. The LCX supplied two major OMs, the second of which had an 80 % lesion near the origin. The RCA was totally occluded proximally. Vein graft to OM was occluded proximally, LIMA to LAD open, and RCA filled retrograde from open SVG to mid-RCA/PDA. At that time patient had direct stenting of the protected left main with a 4.5 x 13 mm Bx Velocity stent. Successful PTCA of the OM2 with a 2.5 mm Raptor balloon with 20% residual stenosis. . -PACING/ICD: s/p [Company 1543] [Last Name (un) 24119] single chamber ICD and [Company 1543] Kappa dual chamber pacemaker first placed in [2095] for pauses, ICD functionality added [2098] and single lead ICD placed on the left. . 3. OTHER PAST MEDICAL HISTORY: -CAD s/p CABG as above -Inferior myocardial infarction -Atrial fibrillation -Hypertension -Hyperlipidemia -OSA on CPAP -Chronic kidney disease (history of tubulointersitital disease due to NSAIDS and atherosclerotic renal artery disease) -Gout -Peripheral neuropathy complicated by progressive gait difficulty -Knee arthritis s/p multiple knee surgeries -Depression -Motor vehicle accident in [2074], status post arm tendon transfer -Obesity -Progressive supranuclear palsy -Drop Attacks Social History: Currently unemployed. Lives alone. Drinks occasionally with his son. Family History: Mother died of complications from cancer. Father died at age 75 of natural causes. Physical Exam: General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Wheezes : anteriorly) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: , Obese Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting Skin: Warm, Rash: papular rash over chest/arms Pertinent Results: [2106-2-17] 03:43PM WBC-6.8 RBC-2.92# HGB-9.2# HCT-28.1# MCV-96 MCH-31.5 MCHC-32.8 RDW-15.3 [2106-2-17] 03:43PM NEUTS-74 BANDS-2 LYMPHS-15* MONOS-3 EOS-3 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* [2106-2-17] 03:43PM PLT SMR-NORMAL PLT COUNT-243# [2106-2-17] 03:43PM PT-14.9* PTT-25.8 INR(PT)-1.3* [2106-2-17] 03:43PM GLUCOSE-94 UREA N-25* CREAT-1.3* SODIUM-150* POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-31 ANION GAP-10 [2106-2-17] 03:43PM ALT(SGPT)-45* AST(SGOT)-86* LD(LDH)-255* CK(CPK)-758* ALK PHOS-281* TOT BILI-1.8* [2106-2-17] 03:43PM CK-MB-3 cTropnT-0.04* [2106-2-17] 03:43PM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.5 IRON-20* [2106-2-18] 05:09AM BLOOD WBC-5.8 RBC-2.92* Hgb-8.7* Hct-27.8* MCV-95 MCH-29.8 MCHC-31.3 RDW-15.2 Plt Ct-223 [2106-2-19] 04:29AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.2* Hct-29.7* MCV-96 MCH-29.7 MCHC-31.0 RDW-15.3 Plt Ct-269 [2106-2-20] 02:43AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.2* Hct-26.7* MCV-95 MCH-29.3 MCHC-30.7* RDW-15.3 Plt Ct-260 [2106-2-21] 03:59AM BLOOD WBC-9.6 RBC-3.16* Hgb-9.6* Hct-29.7* MCV-94 MCH-30.3 MCHC-32.3 RDW-15.0 Plt Ct-280 [2106-2-22] 03:44AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.8* Hct-31.0* MCV-93 MCH-29.4 MCHC-31.6 RDW-15.7* Plt Ct-277 [2106-2-23] 06:42AM BLOOD WBC-9.3 RBC-3.04* Hgb-9.7* Hct-28.8* MCV-95 MCH-31.8 MCHC-33.5 RDW-15.8* Plt Ct-343 [2106-2-23] 05:46PM BLOOD WBC-16.4# RBC-3.65 Hgb-11.2* Hct-34.7* MCV-95 MCH-30.6 MCHC-32.2 RDW-15.9* Plt Ct-475* [2106-2-24] 12:10AM BLOOD WBC-14.1* RBC-3.05* Hgb-9.3* Hct-28.6* MCV-94 MCH-30.5 MCHC-32.5 RDW-16.1* Plt Ct-344 [2106-2-24] 06:47AM BLOOD Hct-28.3* [2106-2-25] 03:00AM BLOOD WBC-9.5 RBC-3.14* Hgb-9.8* Hct-29.5* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-395 [2106-2-26] 06:26AM BLOOD WBC-9.8 RBC-3.17* Hgb-10.1* Hct-29.7* MCV-94 MCH-31.7 MCHC-33.8 RDW-16.1* Plt Ct-423 [2106-2-27] 06:13AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.4* Hct-31.4* MCV-94 MCH-31.1 MCHC-33.2 RDW-16.0* Plt Ct-425 [2106-2-28] 06:21AM BLOOD WBC-8.3 RBC-3.61* Hgb-10.7* Hct-32.7* MCV-91 MCH-29.5 MCHC-32.6 RDW-15.9* Plt Ct-416 [2106-3-1] 05:32AM BLOOD WBC-7.9 RBC-3.49* Hgb-10.7* Hct-31.8* MCV-91 MCH-30.6 MCHC-33.6 RDW-16.0* Plt Ct-374 [2106-3-2] 03:32AM BLOOD WBC-7.4 RBC-3.55* Hgb-10.5* Hct-32.1* MCV-90 MCH-29.7 MCHC-32.9 RDW-15.9* Plt Ct-391 [2106-2-17] 03:43PM BLOOD PT-14.9* PTT-25.8 INR(PT)-1.3* [2106-2-19] 04:29AM BLOOD PT-15.6* PTT-25.8 INR(PT)-1.4* [2106-2-22] 03:44AM BLOOD PT-14.2* PTT-28.0 INR(PT)-1.2* [2106-2-23] 05:46PM BLOOD PT-14.2* PTT-28.9 INR(PT)-1.2* [2106-2-24] 06:47AM BLOOD PT-14.6* PTT-27.8 INR(PT)-1.3* [2106-2-26] 06:26AM BLOOD PT-22.3* PTT-34.6 INR(PT)-2.1* [2106-2-27] 06:13AM BLOOD PT-19.7* PTT-33.2 INR(PT)-1.8* [2106-2-28] 06:21AM BLOOD PT-16.2* PTT-29.1 INR(PT)-1.4* [2106-3-1] 05:32AM BLOOD PT-16.1* PTT-78.2* INR(PT)-1.4* [2106-3-2] 03:32AM BLOOD PT-19.2* PTT-62.5* INR(PT)-1.8* [2106-2-18] 05:09AM BLOOD ESR-141* [2106-2-19] 04:29AM BLOOD ESR-137* [2106-2-17] 03:43PM BLOOD Glucose-94 UreaN-25* Creat-1.3* Na-150* K-4.2 Cl-113* HCO3-31 AnGap-10 [2106-2-18] 05:09AM BLOOD Glucose-121* UreaN-28* Creat-1.5* Na-150* K-3.9 Cl-113* HCO3-32 AnGap-9 [2106-3-1] 05:32AM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137 K-3.9 Cl-100 HCO3-24 AnGap-17 [2106-3-2] 03:32AM BLOOD Glucose-123* UreaN-11 Creat-1.1 Na-137 K-3.3 Cl-100 HCO3-27 AnGap-13 [2106-2-17] 03:43PM BLOOD ALT-45* AST-86* LD(LDH)-255* CK(CPK)-758* AlkPhos-281* TotBili-1.8* [2106-2-19] 06:32PM BLOOD ALT-70* AST-104* LD(LDH)-269* AlkPhos-264* TotBili-4.0* [2106-2-21] 03:59AM BLOOD ALT-53* AST-57* AlkPhos-225* TotBili-2.6* [2106-2-23] 05:46PM BLOOD CK(CPK)-115 [2106-2-24] 12:10AM BLOOD CK(CPK)-84 [2106-2-24] 06:47AM BLOOD CK(CPK)-81 [2106-2-27] 06:13AM BLOOD ALT-26 AST-26 AlkPhos-148* TotBili-1.8* [2106-2-28] 06:21AM BLOOD ALT-26 AST-28 AlkPhos-138* TotBili-1.9* [2106-3-1] 05:32AM BLOOD ALT-30 AST-33 AlkPhos-126 TotBili-2.0* DirBili-1.1* IndBili-0.9 [2106-2-19] 06:32PM BLOOD Lipase-57 [2106-2-17] 03:43PM BLOOD CK-MB-3 cTropnT-0.04* [2106-2-23] 05:46PM BLOOD CK-MB-3 cTropnT-<0.01 [2106-2-24] 12:10AM BLOOD CK-MB-NotDone cTropnT-0.02* [2106-2-24] 06:47AM BLOOD CK-MB-NotDone cTropnT-0.03* [2106-2-17] 03:43PM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.5 Mg-2.5 Iron-20* [2106-2-18] 05:09AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.7* [2106-3-1] 05:32AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1 [2106-3-2] 03:32AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 [2106-2-17] 03:43PM BLOOD calTIBC-183* Ferritn-680* TRF-141* [2106-2-24] 12:10AM BLOOD %HbA1c-4.9 eAG-94 [2106-2-24] 12:10AM BLOOD Triglyc-272* HDL-22 CHOL/HD-9.5 LDLcalc-132* [2106-2-25] 03:00AM BLOOD TSH-3.7 [2106-2-17] 03:43PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2106-2-18] 05:09AM BLOOD CRP-156.7* [2106-2-19] 04:29AM BLOOD CRP-121.1* [2106-2-21] 07:13PM BLOOD Vanco-16.8 [2106-2-17] 03:43PM BLOOD Digoxin-0.7* [2106-3-2] 03:32AM BLOOD Digoxin-0.5* [2106-2-17] 03:43PM BLOOD HCV Ab-NEGATIVE EKG ([2106-2-17])- Sinus rhythm with ventricular premature beats. Left atrial abnormality. Right bundle-branch block. Prior inferior myocardial infarction. Consider left anterior fascicular block although is non-diagnostic. ST-T wave abnormalities are primary and are non-specific but cannot exclude myocardial ischemia. Clinical correlation is suggested. Since the previous tracing of [2100-10-12] further intraventricular conduction delay with left axis shift is now present and lateral limb lead ST-T wave changes are more prominent. Knee X-ray ([2-18])- LEFT KNEE: There is a left total knee arthroplasty. There is prominent amount of gas within the joint space. Please correlate with recent intervention. If there has been no instrumentation, then this is highly concerning for infection. No periprosthetic lucency is identified. There are medial surgical skin staples. ECHO ([2-19])- No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. A thin, freely mobile, filamentous mass/thrombus associated with a catheter/pacing wire is seen in the right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Thin, filamentous, freely mobile mass associated with a catheter in the right atrium suggestive of vegetation or thrombus. No valvular vegetations or significant regurgitant valvular disease seen. CT Torso ([2106-2-19])- 1. Dependent opacities in bilateral lung bases are mostly atelectasis; small amount of aspiration or infection cannot be excluded in this case in the lower lobes. Calcified granulomas indicate prior granulomatous disease. 2. Two nodules in the right upper lobe measurting 5 and 8 mm are non-specific and not likely septic emboli. Recommend followup CT in six months. 3. Splenomegaly measuring up to 21 cm. 4. Aneurysmal dilatation of the infrarenal aorta up to 3.7 cm. Aneurysmal dilatation of the proximal right common iliac artery up to 2.3 cm. 5. Cystic lesion in the upper pole of the left kidney incompletely characterized. Comparison to prior is recommended. If not available, follow-up in 6 months with MRI or CT is recommended as ultrasound will not be able to assess. 6. Anterior compression deformity of T11 not acute, but age indeterminate ECHO [2-23]- Compared with the prior study (images reviewed) of [2106-2-19], left ventricular systolic function appears more depressed. ECHO [2-24]- The left atrium is mildly dilated. The left ventricular cavity is moderately dilated with inferior/inferolateral hypokinesis/akinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen in suboptimal views. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2106-2-23], left ventricular systolic function is better visualized with the assistance of contrast [Doctor Last Name 360]. CT Head ([2106-2-25])- IMPRESSION: No definite evidence of intracranial hemorrhage or septic emboli. Previously identified subtle area of hypoattenuation within the left frontal lobe, equivocal for small vessel ischemic disease or possible septic emboli, remain unchanged. No new lesion is identified. EEG ([2106-2-26])- IMPRESSION: This is an abnormal extended routine EEG recording due to diffuse slowing suggestive of a mild to moderate encephalopathy. Infection and metabolic disturbances are among the most common causes. CTA Head ([2106-2-27])- CONCLUSION: No evidence of infarction, hemorrhage, aneurysm formation, or vascular occlusion. ABI ([2106-3-1])- IMPRESSION: 1. No evidence of peripheral arterial disease in the right lower extremity. 2. Mild outflow arterial disease in the left lower extremity. Disease is likely located at the popliteal arterial level or more distal. Brief Hospital Course: Patient is a 59 year old gentleman with history of CAD, s/p CABG with PPM/ICD, prior bilateral total knee replacement surgery, who presented with MSSA bacteremia with seeding of ICD wire and septic arthritis of the left knee. MICU Course- Successfully extubated in MICU to room air within 12 hours of transfer. ID continued to follow and recommended continued Vanc/Nafcillin and ortho consult to remove L knee spacer. Cards with no further recommendations, need not be anticoagulated for Afib. Patient stable overnight and called out to the floor. # MSSA Bacteremia/Vegetation on Pacer wire/Septic Arthritis: Found to have MSSA and coag negative staph in blood cultures at OSH. Cr elevated on admission to NEBH prompting treatment with high dose CTX/daptomycin. Patient was initially persistently febrile and bacteremic. Last positive cultures were [2-16]. Creatinine improved so he was switched to nafcillin and vancomycin. ID held on gentamycin and rifampin at this time and kept the patient on vanc and nafcillin. Nafcillin was briefly discontinued from [Date range (1) 10230] as patient was still being covered with vancomycin. Once cultures had been negative for >7 days, he was switched back to nafcillin with plans for an extended course. Rifampin (300mg PO BID) was added on [2106-2-27]. TEE was done to look for valve vegetations as another nidus of infection; tricuspid valve did not have any vegetations, but a thin fibrin sheath was left in the right atrium from the ICD wire. This was confirmed via chest CT. Cardiology and ID felt there was no need to remove the sheath and to treat through it with antibiotics. CTA head did not show any septic emboli or mycotic aneurysms. Patient will follow-up with ID on [3-24]. While at rehab, he will need weekly CBC w/diff, LFTs, BUN, creatinine faxed to the [Hospital ] clinic at ([Telephone/Fax (1) 1353]. Regarding knee washout, he was followed by orthopedics here- did not feel that left knee was septic. We called NEBH orthopedics. The patient will follow-up with them on discharge ([2106-3-10] at 1:30pm) regarding plans for hardware and sutures in knee. # Respiratory Failure, s/p Intubation: Patient was intubated for three days prior to arrival at [Hospital1 ]. Barriers to extubation included mental status, extreme agitation, and high level of PEEP required. Appears to be ventilating well. He was diuresed to keep even. He was transferred to the MICU for vent weaning. PEEP was quickly weaned and he passed an SBT on the first day in the MICU. He was extubated without difficulty. Although he was briefly confused after extubation, this improved quickly and he was calm and conversant on callout from the MICU to the medical floor. He satted well on room air while on the floor. # Chronic Systolic CHF: EF 30-40%. JVP difficult to assess; CXR showed mild fluid overload on presentation. He was diuresed to keep even. He developed chest pain and shortness of breath on [2-23] and was sent to the CCU. It was determined that he did not have an MI and that its thought that his symptoms were due to his heartfailure. He was diuresed with lasix and responded well. He was sent back to the floor on 20mg IV lasix daily and did well (transitioned to 40mg PO daily on discharge). He was started on lisinopril 10mg daily. # Hx Atrial Fibrillation: On coumadin at home (6mg daily) and OSH ECG's suggest possible A. flutter. PPM was removed on [2-18] due to bacteremia. He was monitored closely on tele. He had some 2 second pauses on tele so his metoprolol was decreased from 200mg daily to 25mg [Hospital1 ]. He remained hemodynamically stable. Patient at high risk for systemic embolization given septic knee, high grade bacteremia. Given concern for transformation, coumadin was initially held. Patient ruled out for embolic phenomenon so coumadin was resumed on [2-28] (with heparin drip bridge). INR on discharge was 1.8. Patient to continue heparin gtt at rehab until INR is therapeutic (2.0-3.0). He will need INR check on [2106-3-3] to determine if dose of coumadin needs to be decreased. Discharged on digoxin .250mg daily. Patient will follow-up with cardiology on discharge. # Altered Mental Status- Patient showed some signs of delerium while here including inattention and occasionally was disoriented (AAO x 2). Neurology consulted. Recommended EEG which showed no signs of seizure. It was thought symptoms were due to toxic or infecttious etiology. CTA did not show any signs of infection, infarct of aneurysm. Patient's symptoms improved while here. He has follow-up with neurology on [2106-3-8]. # Left ankle pain- Patient complained of vague left ankle discomfort on [2-28]. ABI showed mild left arterial outflow disease. # Hypernatremia: Persistent hyponatremia, presented with 8L free water defecit. This was repleted IV and PO per OG tube. Sodium was 137 on discharge # CAD: The patient has a history of CAD s/p CABG and PCI with stent placement. Anatomy as above. Continued on statin, aspirin and beta-blocker. Started on lisinopril 10mg daily. # OSA: Continued on CPAP. # Depression: Home meds initially held. Resumed wellbutrin and amitryptiline on discharge. # Gout: Allopurinol and colchine were continued. # HTN: Beta-blocker continued but decreased to 25mg PO BID given pauses on tele. Hemodynamically stable on discharge. # Hyperlipidemia: Home medications continued. Medications on Admission: MEDICATIONS ON TRANSFER FROM [Hospital1 ]: -Ceftriaxone 2grams q12 -daptomycin 1gram daily IV -Versed gtt -fentanyl gtt -allopurinol 200mg PO daily -zetia 10mg PO daily -welbutrin 75mg PO qhs, 100mg [Hospital1 ] -toprol XL 200mg daily -pepcid 20mg daily -combivent 4 puffs QID -cymbalta 30mg PO daily -Aspirin 81 mg daily -Amitriptyline 75mg daily -Heparin 5000 SQ TID -Digoxin 250ucg daily . Home Medications Lasix 40mg daily digoxin 125 ucg daily coumadin 6mg qPM Prilosec 20mg daily zyloprim 300mg daily EC ASA 81mg daily Zetia 10mg daily Cymbalta 30mg daily Elavil 250mg daily Tramadol 100mg TID Wellbutrin 300mg qAM, 75mg qPM Lyrica 75 TID Toprol 200mg daily . Medications on transfer to [Hospital1 ]: ALLOPURINOL 200 mg po daily AMITRIPTYLINE 75 mg po qhs Aspirin 81mg daily BUPROPION 75 mg po q24, and 75mg qHS colace 100mg [Hospital1 ] DIGOXIN 375 mcg po daily Cymbalta 30mg daily Zetia 10mg daily Pepcid 20mg daily Heparin 5000 SQ TID Toprol XL 200mg daily Lyrica 50mg TID Daptomycin 1gram IV daily Dilaudid 2mg SQ q4-6H PRN Zofran 4mg PO q8H PRN Percocet 1-2 tabs q6H PRN Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for Wheezing. 5. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nafcillin 2 g IV Q4H Start: Stat 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 9. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for Constipation. 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for cramping. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Lyrica 50 mg Capsule Sig: One (1) Capsule PO three times a day. 16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 18. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 23. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 24. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 25. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 27. Wellbutrin 100 mg Tablet Sig: Three (3) Tablet PO qAM. 28. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 29. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 30. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 31. Heparin sliding scale Continue per attached sliding scale. PTT goal- 60-80. Please stop when INR is therapeutic (2.0-3.0) Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary: Septic arthritis, bacteremia Secondary: Atrial fibrillation, hypertension, hyperlipidemia Discharge Condition: Good. Vital signs stable. Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital after a washout procedure for your knee. We found that you had bacteria in your blood so you were treated with IV antibiotics while here. You will need an extended course of these antibiotics on discharge. While here, you experienced an episode of chest pain which required a brief stay in the CCU. They determined that you did NOT have a heart attack. You were transferred back to the floor once you were stabilized and did well. You remained afebrile with no more signs of bacteria in your blood. You are being discharged to a rehab facility to build up your strength. Upon discharge, you were hemodynamically stable. The following changes were made to your medications: 1. Please start taking nafcillin 2g IV daily (Day 1- [2-17]). You will need an extended course of this medication. The infectious disease team will determine the exact duration of the medication. 2. Pleast start taking rifampin 300mg by mouth twice a day (Day 1- [2-27]). You will need an extended course of this medication. The infectious disease team will determine the exact duration of the medication. 3. Please continue your coumadin at 6mg daily. We ask that your rehabilitation facility check an INR on [3-3] and that they adjust your dose as needed. 4. Please continue the heparin drip until your INR is therapeutic (2.0-3.0). 5. Please start taking lisinopril 10mg by mouth daily 6. Please STOP taking your Toprol XL 7. Please start taking metoprolol tartrate 25mg by mouth twice a day 8. Please STOP taking your tramadol Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please remove chest staples on [2106-3-5]. Please follow-up in Sleep Clinic (Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) ] on [2106-3-5] at 7:40am. You can contact them at [Telephone/Fax (1) 612]. Please follow-up with neurology on [2106-3-8] at 3:30pm. You can contact them at [Telephone/Fax (1) 558] Please follow-up with your orthopedic surgeon (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]) on [2106-3-10] at 1:30pm. This will be at [Street Address(2) 32113]- [Location (un) 470], [Location (un) ], MA. You can contact him at [Telephone/Fax (1) 32114]. Please follow-up with infectious disease (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]) on [2106-3-24] at 10:30am. You can contact them at [Telephone/Fax (1) 457]. Please follow-up with the cardiology team in 3 months. You can contact them at [Telephone/Fax (1) 62]. Please follow-up with your primary care physician (Dr. [Last Name (STitle) 9751] within 1 month. You can contact him at [Telephone/Fax (1) 9752]. Completed by:[2106-3-2]	[ "428.23", "414.00", "434.11", "348.31", "996.61", "356.9", "518.81", "333.0", "272.4", "278.00", "995.92", "V58.61", "427.31", "518.0", "311", "711.06", "276.1", "428.0", "441.4", "585.9", "518.89", "403.90", "780.2", "780.09", "584.9", "412", "E878.1", "996.67", "719.47", "274.9", "327.23", "V45.81", "440.1", "038.11", "V43.65", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "37.77", "96.71", "37.89", "88.72", "89.19", "38.93" ]	icd9pcs	[ [ [] ] ]	23787, 23887	14461, 19948	297, 323	24031, 24058	4480, 14438	25924, 27065	3639, 3723		21096, 23764		23908, 24010		19974, 21073			24240, 25901											3738, 4461			1917, 3012																	230, 259								351, 1807									24073, 24216		3043, 3537			1829, 1897	3553, 3623
66,288	192,457	42148	Discharge summary	report	Admission Date: [2118-8-10] Discharge Date: [2118-8-31] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1171] Chief Complaint: right sided weakness, speech difficulty Major Surgical or Invasive Procedure: [2118-8-10] Cerebral angiography with mechanical thrombectomy and intra-arterial tPA administration [2118-8-19] PEG tube placement History of Present Illness: The pt is a 87 year-old M without known medical history who presented with acute onset L-sided hemiparesis, disorientation, garbled speech. the patient was apparently playing golf when at 10:30am he was seen driving his cart into a utility box after which he slumped over the steering wheel. The accident was apparently minor and he was not ejected from the vehicle. He was found to be generally unintelligeable, disoriented with garbled speech and transfered to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital. CT head/neck at that time was negative for fracture or acute hemorrhage. On arrival to [Hospital1 18] ED, he exhibited aphasia without spontaneous movement on the R side of his body. His NIHSS was 19. He underwent CT-A and CTP which showed dense L MCA occlusion with large L-sided perfusion defect on CTP. Given the time course, >4.5 hrs since last known well, tPA was not given however, interventional neuroradiology was contact[Name (NI) ] for possible [Name (NI) ] clot removal after cerebral angio. Past Medical History: CAD (s/p RCA Endeavor DES [3-/2117]), HTN, HL, PPM [5-/2117], CKD, Dyspepsia, Anemia, Prostate CA, Open Angle Glaucoma, Cataracts, OA, Colonic Polyps (removed) Social History: Prior Veteran. Family History: Not known Physical Exam: Physical Exam on admission: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Pacemaker noted L upper chest Neurologic: -Mental Status: Alert, mumbled, garbled speech which sounded stereotyped, could not name or repeat, could follow simple commands, "close your eyes", "lift your leg" with then perseveration. but not complex commands. -Cranial Nerves: II: PERRL 4 to 2mm and brisk. blinks to threat on R but not L visual field. III, IV, VI: EOMI without nystagmus. Did not cross midline, basal R gaze preference VII: Right facial droop VIII: VOR not tested . -Motor: Normal bulk, tone throughout. RUE flaccid. RLE not againt gravity. Left without drift. -Sensory: withdraws to noxious stimuli in all limbs -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor on right. NIH Stroke Scale score was 21: 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 1 2. Best gaze: 1 3. Visual fields: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 4 6a. Motor leg, left: 0 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 2 9. Language: 3 10. Dysarthria: 1 11. Extinction and Neglect: 2 ___________________________________________________ Physical Exam at Discharge: VS: not recorded GENERAL: awake, in bed, nonverbal, appears comfortable HEENT: NCAT. Sclera anicteric. Right facial droop. NECK: Supple with JVP of 5 cm CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were slightly labored, no accessory muscle use. Bibasilar crackles, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [8-10] CTP - IMPRESSION: 1. Complete occlusion of the distal M1 segment of the left MCA with significant prolongation of the mean transit time throughout virtually the entire left MCA territory. A near-complete geographic match in blood volume reduction suggests large "infarct core" with only marginal "ischemic penumbra." 2. No definite correlate of the infarct on the non-enhanced CT, suggesting a relatively hyperacute time course. 3. No evidence of hemorrhage. 4. Extensive atherosclerosis with stensoses involving both the anterior and posterior intracranial circulation and the cervical vessels, as detailed above. [8-10] CT Abd/Pelv IMPRESSION: 1. Mild-to-moderate pulmonary edema with septal thickening and increased interstitial markings. Multiple bilateral pulmonary nodules measuring up to 5 mm. Correlation with prior malignant history is recommended. A repeat chest CT may be obtained after diuresis for further evaluation. 2. No evidence of acute visceral injury in the abdomen or pelvis. 3. Large hiatal hernia with a focal nodularity which may represent a fold but underlying lesion not excluded. Correlation with direct visualization in a non-emergent setting or with any recent endoscopy is suggested. 4. 1.6 x 0.9 cm filling defect in the left posterior portion of the bladder, which may represent a mass versus clot. Urology consultation advised. 5. 1.7 x 1.3 cm focus in the left thyroid lobe. Further evaluation with ultrasound is recommended in a non-emergent setting. [8-10] CT Chest - IMPRESSION: 1. Mild-to-moderate pulmonary edema with septal thickening and increased interstitial markings. Multiple bilateral pulmonary nodules measuring up to 5 mm. Correlation with prior malignant history is recommended. A repeat chest CT may be obtained after diuresis for further evaluation. 2. No evidence of acute visceral injury in the abdomen or pelvis. 3. Large hiatal hernia with a focal nodularity which may represent a fold but underlying lesion not excluded. Correlation with direct visualization in a non-emergent setting or with any recent endoscopy is suggested. 4. 1.6 x 0.9 cm filling defect in the left posterior portion of the bladder, which may represent a mass versus clot. Urology consultation advised. 5. 1.7 x 1.3 cm focus in the left thyroid lobe. Further evaluation with ultrasound is recommended in a non-emergent setting. [8-11] TTE The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([12-26]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No structural cardiac source of embolism seen. The patient appears to be in atrial fibrillation. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. Mild to moderate mitral regurgitation. Moderate tricuspid regurgitation with moderately elevated pulmonary artery systolic pressure. [8-11] NCHCT IMPRESSION: 1. New foci of hemorrhage in the left basal ganglia and scattered subarachnoid hemorrhage- left frontal and parietal and a small focus in the right parietal lobe.Consider close follow up to assess interval change and exclude the possibility of contrast enhancement related to prior contrast studies. 2. New or increasing hypodensities seen in the left caudate, basal ganglia, and periventricular white matter adjacent to the left frontal [Doctor Last Name 534], representing areas of evolving ischemia/ infarct. 3. Mildly increased edema and mass effect in the left hemisphere with mildly increased effacement of the left anterior [Doctor Last Name 534]. There has been no change in the amount of left-to-right shift in normally midline structures. [8-12] NCHCT IMPRESSION: 1. Unchanged subarachnoid hemorrhage overlying the left cerebral hemisphere and right parietal lobe. Unchanged hemorrhage within the left lenticular nucleus and head of the caudate, consistent with hemorrhagic conversion. 2. Hypodensities within the left basal ganglia and frontal lobe are areas of evolving infarction, not significantly changed in size. 3. Persistent compression of the left lateral ventricle without evidence of right ventricular entrapment or central herniation. The degree of slight rightward midline shift is unchanged. [8-13] CTPA IMPRESSION: 1. No evidence of PE or acute aortic syndrome. 2. Small bilateral pleural effusions with associated atelectasis. [8-15] TTE The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferolateral, inferior, distal septal and apical walls. The remaining segments contract normally (LVEF = 30-35 %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2118-8-11], regional left ventricular systolic dysfunction is now present (suggestive of multivessel CAD) and the severity of mitral regurgitation is increased. [8-15] NCHCT: IMPRESSION: 1. Slight increase in edema in the area of infarction, compared to study two days ago; however, no change in mass effect or shift of normally midline structures. 2. Hemorrhage in the left caudate, putamen, and left superior temporal lobe are unchanged. The partial effacement of the frontal [Doctor Last Name 534] of the left lateral ventricle and mild rightward shift is unchanged. 3. Subarachnoid hemorrhage is unchanged. 4. No new areas of hemorrhage. [8-16] Portable CXR: IMPRESSION: Proper Dobbhoff position. Improving mild pulmonary edema. [8-21] 2 view chest Xray: xxxxxxxxxxxxxxxxxxxxxxxxxxxxx URINE CULTURE (Final [2118-8-15]): GRAM POSITIVE BACTERIA. ~3000/ML. SUGGESTING STAPHYLOCOCCI. [2118-8-14] 8:54 am SPUTUM Source: Endotracheal. FINAL REPORT [2118-8-17] GRAM STAIN (Final [2118-8-14]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2118-8-17]): MODERATE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. MODERATE GROWTH. 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. GRAM NEGATIVE ROD(S). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . CXR [2118-8-23]: FINDINGS: As compared to the prior examination, moderate pulmonary edema is little changed. Small pleural effusions and fluid within the right minor fissure are also similar. No pneumothorax is seen. Cardiomegaly is stable. Left-sided pacemaker with three leads and right PICC with tip in SVC are unchanged. . Labs on Discharge: Brief Hospital Course: 87 yo M h/o CAD (s/p RCA DES [3-/2117]), HTN, HL, prostate CA, glaucoma, CKD p/w left sided weakness and speech difficulty with L MCA proximal occlusion s/p mechanical clot retrieval. Hospital course complicated by demand ischemia and pneumonia. #Acute Cerebral Infarction s/p Mechanical Clot Retrieval - The patient developed an extensive L MCA stroke with a L dense MCA sign on CT which was treated with intra-arterial tPA and partial mechanical thrombectomy on [8-10]. He was monitored in the Neuro ICU and had repeat scans which showed interval development of hemorrhagic conversion (PH2 by ECASS criteria) with SAH without clinical changes in his neurologic status. His permanent pacemaker was interrogated and revealed episodes of atrial tachycardia and fibrillation, likely the precipitating event for his stroke. Given the development of this clot in the setting of ASA and Clopidogrel therapy, it was determined that he would likely benefit from anticoagulation. His HgbA1c and FLP were at goal. Normothermia and euglycemia were maintained. He was anticoagulated with a Heparin infusion and started back on Aspirin 81 mg. His exam waxed and waned initially, primarily due to his mental status being variable, but his dysarthria and right-sided weakness lessened and he was able to participate with PT/OT. Due to persistently aspirating during swallow evaluations, a PEG was placed on [2118-8-19]. Patient was started on Coumadin with heparin bridge. Ultimately, it was felt that patient's prognosis for neurologic improvement was poor. After a multidisciplinary meeting, given the patient's prior high level of functioning and previously stated wishes, it was decided to focus or comfort (see below for details). . # Cardiac Ischemia - The patient developed chest pain overnight on [8-11] with new V3-V4 t-wave inversions and V5 t-wave flattening with a troponin of 0.1->1.7->1.85 in the setting of prior CAD with an RCA Endeavor drug-eluting stent. Given his hemorrhagic conversion, he was not a candidate for anticoagulation immediately. He was started back on Metoprolol to reduce cardiac demand. He was started back on Aspirin 81 mg. Again on the night of [8-21] he became tachypneic with a troponin leak peaking at 1.15, then trending down. Cardiology consulted and they recommended medical management. They also recommended starting plavix, but we felt that this would be too much anticoagulation given that pt was already on heparin, coumadin and aspirin in the setting of a recent hemorrhage. He then had tachypnea on morning of [8-23] that improved with 20mg IV lasix. He was transferred to cardiology for a suspected CHF exacerbation. . # Respiratory Difficulty - The patient had intermittent respiratory difficulty over the weekend on [8-5]. He received a CTPA which revealed no pulmonary embolus but did show small pleural effusions and atelectasis. His SaO2 was maintained with supplemental O2. He did grow Staph aureus in his sputum and GNR for which he is receiving broad spectrum antibiotics which managed to improve his respiratory symptoms. On [8-23] in the morning he developed an episode of tachypnea to the 40s and O2 sats to the 80s. On exam, his lungs had diffuse crackles b/l and CXR demonstrated fluid overload. He was given Lasix 20mg IV, put out 2L to this, and O2 sats increased to the mid 90s on room air. Patient was transferred to cardiology for further management of CHF as above. Despite being euvolemic on exam, the patient continued to have episodes of tachypnea while on the cardiology floor. Ultimately, it was felt that the patient's breathing pattern was likely reflective of [Last Name (un) 6055]-[Doctor Last Name ] respirations in the setting of significant CNS pathology. . #Goals of care: Had family meeting with health care proxy, 2 other family members, primary team and neurology. Discussed that prognosis at this time is poor in regards to neurological outcome. Per family, at baseline, patient was very active (played golf, went dancing, went to the gym) and he would not want to have extraordinary measures to continue his life in this state when he is unable to speak, move, return to baseline. Decided to go forth with comfort measures only and hospice. Discontinued all medications that were not associated with comfort. Family also wanted to withhold tube feeds and IV fluids to avoid prolonging patient's suffering. Patient may be given soft PO liquid diet (including ice cream, etc) for pleasure despite aspiration risks. Medications on Admission: ASA 81 Clopidogrel 75 Isosorbide 30 QD Metoprolol 25 QD Lisinopril 10 Simvastastin 40 travaprost 0.004% both eyes Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: Primary: Left middle cerebral artery infarction s/p clot retrieval Atrial fibrillation NSTEMI (Heart attack) Acute on Chronic Systolic heart failure . Secondary: Coronary artery disease s/p CABG, stenting, ICD placement Hypertension Dyslipedemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro exam: Awakens easily to voice, aphasic, follows simple commands. Moves LLE and LUE; no movement of RUE, movement limited to toes on RLE. Discharge Instructions: Dear Mr.[Known lastname 91417], It was a pleasure caring for you during your stay. You were admitted to the hospital for a stroke on the left side of your brain. The interventional team removed a clot from your left middle cerebral artery. The cause of this stroke was due to an embolus associated with your atrial fibrillation, as determined by interrogating your pacemaker. We treated you with blood thinners to preven recurrence of a lot. A feeding tube (aka PEG) was placed during your stay in order for you to receive nutrition and medicines while you continue therapy to improve your swallowing ability. During your stay you were also found to have a pneumonia. We treated you with IV antibiotics Cefepime and Tobramycin for 10 days. . You had chest pain during this hospitalization. Based on blood tests and tracings of your heart, you had a small heart attack. The cardiology team evaluated you and together with the neurology team it was decided that the blood thinners you were on were adequate treatment for the small heart attack. Later, you had an episode of difficulty breathing. Your chest x-ray and lung exam was consistent with fluid overload secondary to decreased cardiac function. We gave you a water pill to help take off the fluid. You responded well to this and your breathing improved. . We had a family meeting with the cardiology and neurology teams. We discussed that unfortunately, your prognosis is poor and it is unlikely that you would gain any more neurological function than you have now. Your family felt that you would not want to exist like this since this is so different from you baseline and did not think you would want extraordinary measures taken to prolong your life. Decision was made to move towards comfort care only and hospice. . We made many changes to your medications. An updated list of your medications is included. Followup Instructions: none Completed by:[2118-8-31]	[ "298.9", "410.71", "342.90", "430", "997.02", "784.51", "365.10", "V10.46", "276.0", "263.9", "427.31", "351.8", "414.01", "427.89", "366.9", "910.0", "553.3", "786.04", "272.4", "V66.7", "428.23", "E823.0", "V45.82", "715.90", "428.0", "403.90", "285.9", "E006.2", "276.4", "585.9", "416.8", "784.3", "434.11", "E934.4", "507.0", "V53.31", "482.41", "424.2", "424.0" ]	icd9cm	[ [ [] ] ]	[ "89.45", "39.74", "43.11", "00.40", "99.55", "99.15", "38.97", "88.41", "99.10" ]	icd9pcs	[ [ [] ] ]	17742, 17816	13040, 17578	299, 439	18106, 18106	4175, 12997	20338, 20374	1763, 1774				17837, 18085		17604, 17719			18429, 20315							2538, 3456				1789, 1803															3470, 4156					220, 261		13017, 13017						467, 1524							1817, 2305		18121, 18405					1546, 1715	1731, 1747
24,116	128,180	1128	Discharge summary	report	Admission Date: [2138-7-21] Discharge Date: [2138-7-25] Date of Birth: [2104-7-24] Sex: M Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is a 33-year-old male, who was on a three-day drinking binge, when he fell out of bed at 3 AM on the day of admission. He had possible loss of consciousness and nausea, no vomiting. This event was not witnessed by anybody. The patient does have a history of seizures. The patient has a head injury requiring subdural hematoma evacuation five months ago. The patient was brought in because of increased confusion in the morning. PAST MEDICAL HISTORY: History revealed the following: Five months ago, which required subdural evacuation of hematoma and subsequent seizure. MEDICATIONS: Dilantin 300 mg q.d., although he is fairly noncompliant. ALLERGIES: The patient has The patient has no known drug allergies.. SOCIAL HISTORY: The patient has a history of alcohol use. LABORATORY DATA: Labs, at the time of admission, revealed the following: White blood cell count 8.5, hematocrit 41, platelet count 104,000. Chem 7: Sodium 140/4.3, chloride 999, bicarbonate 23, BUN 6, creatinine 0.8, Dilantin level 2.2. CT at that time showed a left subdural hematoma with mass effect and some slight subFaustein herniation. PHYSICAL EXAMINATION: Examination revealed the following: Temperature was 100.1, heart rate 88, blood pressure 141/90, respiratory rate 19. The patient was saturating 99% on room air. GENERAL: The patient was groggy. The patient was not fully alert. Pupils were equally round and reactive to light. CHEST: Chest was clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender. NEUROLOGICAL: The patient was lethargic and the examination was significant for focal right sided weakness in both upper extremities, which was greater than the lower extremity. The patient was intubated in the ER in order to secure his airway. He had declining mental status and focal neurological deficits. The patient had a CT finding of left acute subdural hematoma. The patient was taken to the operating room emergently, where left revision temporal craniotomy for evacuation of acute subdural hematoma was performed by Dr. [Last Name (STitle) 6910]. Estimated blood loss was 900 cc. The patient was taken to the PACU, intubated, and in stable condition. Postoperatively, as the patient was weaned off sedation, pupils were 3 to 2 bilaterally reactive to light. He was following commands of the left upper extremity and the left lower extremity, although in the right upper extremity, grip was about 2 out 5 strength. The patient was taken back to the ICU for continued close monitoring. Dilantin was brought to therapeutic levels. He had a repeat head CT on postoperative day #1. The CT showed significant decrease in size of the left subdural hematoma and decreased mass effect and midline shift with post-surgical changes associated with the evacuation of the subdural hematoma. The patient was following commands on postoperative day #1. The patient was extubated with a weakness in the right upper extremity and right lower extremity. The patient was also started on Ativan 1 mg IV q.6. for DVT prophylaxis. The rest of the patient's postoperative course was fairly unremarkable. He was transferred out of the Intensive Care Unit on postoperative day #2. The weakness on the right side has improved. He still has a slight pronator drift on the right, but he is awake, alert, and following commands. He is being discharged to rehabilitation. He will continue on Dilantin and continue on the Ativan DVT prophylaxis. The patient is to follow up with Dr. [Last Name (STitle) 6910] in one month with CT of his head. [Name6 (MD) 6911] [Name8 (MD) ], MD [MD Number(1) 6913] Dictated By:[Last Name (NamePattern1) 7241] MEDQUIST36 D: [2138-7-25] 10:45 T: [2138-7-25] 10:53 JOB#: [Job Number 7242]	[ "E849.0", "852.20", "E884.4", "305.00", "780.39" ]	icd9cm	[ [ [] ] ]	[ "96.71", "01.31", "96.04" ]	icd9pcs	[ [ [] ] ]																																								1342, 4037																													646, 911	928, 1319
15,547	151,391	5836	Discharge summary	report	Admission Date: [2135-7-23] Discharge Date: [2135-7-27] Date of Birth: [2058-7-9] Sex: F Service: MEDICINE Allergies: Clinoril / Percocet / Oxycontin / Prednisone Attending:[First Name3 (LF) 1055] Chief Complaint: MICU c/o for bleeding < Major Surgical or Invasive Procedure: sp Hickman catheter History of Present Illness: This is a 77 yo female, SICU callout for bleeding s/p tunnel line placement for acute changes in mental status. . Briefly, 77 yo with ESRD on PD now HD, had tunnelled cath placed saturday then HD, then had hematoma around neck and chest and oozing from entry site - was given usual heparin at dialysis but had PTT 150 and INR 3, given protamine and FFP, UF'd on Saturday, next HD scheduled tuesday [7-26]. Called out to medicine for Acute MS changes. . HPI. 77 yo female with MMP including ESRD, PVD, HTN, developed neck and upper chest bleed/hematoma s/p dialysis catheter placement in Left Subclavian area on [2135-7-22] by Transplant Surgery. Patient has bled after recieving anti-coagulation with heparin for dialysis. At SICU, PTT elevated, reversed with protamine and FFP. Called out to medicine for acute mental status changes. . Past Medical History: 1. ESRD: on PD since [1-14], PD at home. ESRD [1-12] longstanding HTN, high grade RAS. 2. h/o CHF: [9-13] Echo--hyperdynamic LV,small LV, EF 70-80%, mild LVH. 1+ aortic regurg, 1+ mitral regurg, 3+ tricuspid regurg 3. HTN 4. PVD: chronic R heel ulcer 5. COPD: FEV1 0.91, decr DLCO, FEV/FVC 90%, 2L home O2 6. Depression 7. Osteoarthritis 8. h/o ETOH abuse 9. s/p TAH and Lysis of adhesions. 10. h/o hematochezia, grade 2 hemorrhoids, colonoscopy [5-14]--diverticulosis, angioectasia 11. s/p small SDH and right orbital fracture in [11-13] Social History: Pt is divorced with two children and 4 grandchildren. 50 pack yr history, quit 5 years ago. She ambulates with walker. History of EtOH abuse. Retired and used to work in [Known firstname ] endoscopy unit doing secretarial work. Lives alone. Family History: HTN in the family. Mother and father with CHF Physical Exam: PHYS EX: ٱ Temp: afebrile ٱ HR: 77 ٱ BP: 173/79 ٱ RR: 18 ٱ Wt.: Ht: BMI: GENERAL: elderly female, acutely agitated. HEENT: PERRL, EOMI MMM, no oral lesions. there is extensive brusing all over neck and upper chest, wrapping around to the posterior surface of neck and down the upper back. catheter at L SC site, tender to palpation. CHEST: Lungs: diffuse wheezing ausculated. no rales or rhonchi CV: non-displaced PMI. Normal S1 and S2. no murmurs, rubs, gallops. No carotid bruits. difficult to assess JVD due to neck hematoma ABD:. +BS. soft, NT, ND, no guarding, no rebound tenderness, no HSM. EXT: cold below the knee. there is [Known firstname ] ulceration of R anterior shin with wet-dry dressing applied. wound is the site of old surgical scar. do purulent drainage noted. multiple missing distal portion of toes on R foot. tender to palpation of L toes and L heel. no ulcers visible. weakly palpable PT and DP both lower extremities. NEURO: agitated. alert and oriented x 2 (person, and time/date) unable to complete neuro exam due to agitated status of the patient Pertinent Results: [2135-7-22] 11:15AM K+-3.4* [2135-7-23] 08:00PM PT-21.3* PTT-150* INR(PT)-3.0 [2135-7-23] 08:00PM PLT COUNT-200 [2135-7-23] 08:00PM HYPOCHROM-2+ ANISOCYT-2+ MACROCYT-1+ [2135-7-23] 08:00PM NEUTS-77.0* LYMPHS-17.9* MONOS-4.1 EOS-0.9 BASOS-0.2 [2135-7-23] 08:00PM WBC-13.2* RBC-3.97* HGB-11.9* HCT-37.4 MCV-94 MCH-29.9 MCHC-31.7 RDW-18.2* [2135-7-23] 08:00PM GLUCOSE-105 UREA N-20 CREAT-4.0# SODIUM-143 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15 [2135-7-23] 09:15PM PT-15.9 PTT-150* INR(PT)-1.7 --------------- CXR AP chest compared to [1381-7-21] hours: Dual channel left jugular line projects over the SVC. No pneumothorax, mediastinal widening or appreciable pleural effusion. Minimal right basal atelectasis is present. Lungs are otherwise clear. Heart size is top normal. . Brief Hospital Course: 77 yo female, SICU callout for bleeding and hematoma into the neck and upper chest s/p tunnel line placement called out to medicine for acute changes in mental status. . #Change MS: differential includes ICH, embolic stroke, infection, e-lyte disturbances, cardiac ischemia, psych causes, i.e. progresson of dementia, sundowning. currenlty infection and acute intra-cerebral process is the highest on the list. CT neg for subdural, mental status improved on discharge. No sign of infection. Routine labs and head CT were within order. Famotidine was stopped as possibleculprit. Patient apparently at baseline by discharge. . # Coagulopathy: elavated PTT, INR of 3 after receiving heparin. drawn off heparinized line. It remains unclear why the patient was so sensitive to this relativley low dose of heparin. . # [Month (only) ] issues: currently has a leg ulcer. [Month (only) 1106] following for s/p R AK-[Doctor Last Name ] [4-14] and s/p L angio and angioplasty of AT [2135-6-10]. Wound care needs addressed. #ESRD: HD on Tue, [Last Name (un) ], Sat. We continued her dialysis as renally dosed meds -Epo during dialysis -cont calcium acetate -cont vitamin D . Anemia: due to blood loss into hematoma and due to chronic inflammation. renal disease. . Medications on Admission: On admission: allopurinol 150 qod ambien 10 qhs ativan 0.5 qd atrovent/albuterol Inh lipitor 40 qd paxil 30 qd calcium acetate protonix 40 qd asa 325 qd EPOgen at dialysis lopressor 25 qd lantanoprost 0.005% doxercalciferol 2.5 qd Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS PRN. Disp:30 Tablet(s) Refills:2 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection 2X/WEEK (2 times a week) as needed for end-stage renal disease: please give 2x/week at dialysis. Disp:8 injection Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 7. Hectorol 0.5 mcg Capsule Sig: One (1) Capsule PO three times a day: please take with meals. Disp:90 Capsule(s) Refills:2 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) INH Inhalation every 4-6 hours: PRN. Disp:1 container Refills:2 12. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) inh Inhalation every 4-6 hours: PRN. Disp:1 container Refills:2 13. Xalatan 0.005 % Drops Sig: 1-2 drops Ophthalmic once a day: per eye. Disp:1 container Refills:2 14. Dialysis Tuesday, Thursday, Friday 15. Cefazolin Please give 1gm IV at each dialysis treatment 16. Outpatient Physical Therapy Please do home PT with patient 17. VNA patient is to have VNA services upon discharge Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: neck hematoma renal failure, ESRD on Hemodyalsis mild dementia Discharge Condition: stable, afebrile, ambulatory Discharge Instructions: -Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet -Fluid Restriction: per nephrology -Call if increasing redness/bruising, shortness of breath, chest pain or any questions/concerns. -please follow call PCP if you have any fevers, chills, pain at catheter site -please follow up at [Location (un) 4265]/[Location (un) ] for dialysis: Tuesday, Thursday, Saturday. You are also to get 1 g Cefazolin IV at each dialysis treatment. Please follow appointment with [First Name8 (NamePattern2) 3122] [Doctor Last Name 1860]. Followup Instructions: Scheduled Appointments : Provider [Doctor Last Name ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2135-8-4] 2:30 Provider [Name9 (PRE) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Where: [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2135-8-4] 3:30--Please address the need for plavix treatment Provider [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Where: LM [Hospital Unit Name 5628] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2135-8-22] 9:20 Completed by:[2135-9-15]	[ "780.09", "790.92", "707.14", "428.0", "458.29", "285.1", "996.73", "567.8", "311", "496", "403.91" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "99.07", "39.95", "88.41" ]	icd9pcs	[ [ [] ] ]	7515, 7572	4149, 5437	329, 351	7679, 7710	3282, 4126	8343, 9014	2090, 2137		5719, 7492		7593, 7658		5463, 5463			7734, 8320											2152, 3263																				265, 291								379, 1228							5477, 5696							1250, 1810	1826, 2074
56,829	191,016	37873	Discharge summary	report	Admission Date: [2138-8-13] Discharge Date: [2138-8-16] Date of Birth: [2073-3-15] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 695] Chief Complaint: abdominal pain and weakness Major Surgical or Invasive Procedure: None History of Present Illness: 65M with history of HCV, HCC s/p left lateral segmentectomy in [2135] who presents now with 1-2 weeks of abdominal pain and overall weakness. He reports that ~10 days ago he had a few days of nausea and emesis; after this passed he began to feel very weak with decreased energy and dyspnea on exertion. Over the same time period he has begun to have sharp right upper quadrant pain, described as under his ribs, worsening with deep breaths in. He has been treating this with advil, he states that he takes three pills (unk strength) once a day. He also endorses involuntary 20lb weight loss over the past month. He denies hematemesis, denies blood in his stool or dark stools, denies changes in urinary frequency/urgency or color. He denies fevers or chills at home. 13 point review of systems is otherwise negative. Past Medical History: PMHx: perforated diverticulitis Hepatitis C, diagnosed in [7-/2135] w/o antiviral therapy h/o alcohol abuse h/o tobacco abuse glaucoma cataracts PSurgHx: sigmoidectomy & diverting loop ileostomy [2136-8-21] Social History: Works as a painter, lives alone, tob 1 ppd x40 years, EtOH one pint/day vodka x 20 years, abstinence since [2136-4-7], remote heroin use, current occasional MJ use. Family History: non-contributory Physical Exam: PHYSICAL EXAM: 98.7 95 100/61 16 100% Gen: AAOx3, comfortable, NAD, cooperative and pleasant HEENT: PERRL, sclera anicteric, oropharynx clear CV: RRR, no m/r/g Pulm: CTAB Abd: BS(+), soft, ND, mild TTP at RUQ. Prior surgical incisions consistent with previous segmentectomy well-healed, non-indurated, non-erythematous, non-tender. G/U: Deferred MSK: No c/c/e Pertinent Results: [2138-8-13] 04:00PM GLUCOSE-122* UREA N-19 CREAT-1.3* SODIUM-132* POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15 [2138-8-13] 04:00PM ALT(SGPT)-34 AST(SGOT)-120* LD(LDH)-537* ALK PHOS-472* TOT BILI-0.9 [2138-8-13] 04:00PM LIPASE-160* [2138-8-13] 04:00PM proBNP-251* [2138-8-13] 04:00PM ALBUMIN-3.5 IRON-19* Brief Hospital Course: Mr. [Known lastname ] was admitted to the Hepatobiliary Surgical Service on [2138-8-13] with abdominal pain and weakness as described above. His initial labs demonstrated a significant anemia, with a hematocrit of 19.7. Further review of his history raised the possibility of an upper GI bleed, as it was determined he had been taking high doses of NSAIDs for his abdominal pain, and had unclear history of melanotic stools and/or blood-tinged emesis. He was initially admitted to the Surgical ICU, where he was stabilized with 2 units of packed red blood cells. His hematocrit then rose to 23.4, at which time he was transfused an additional 2 units. His hematocrit then stabilized at 28.2. A CT of his abdomen performed shortly after admission on [2138-8-13] revealed the following: 1. Extensive hepatic lesions (presumably HCC) with extensive mesenteric root, porta hepatis lymphadenopathy, and mediastinal lymphadenopathy as well as mesenteric/omental implants and possible pancreatic and mesenteric vein invasion as described above. Nonhemorrhagic ascites. No areas of active hemorrhage within the mass lesions or along the course of the bowel are present. 2. Gastroesophageal varices. 3. Nonhemorrhagic right pleural effusion with associated atelectasis. New bilateral pulmonary nodules concerning for metastases. Given the size and distribution of his hepatic lesions, Mr. [Known lastname ] was determined to be not eligible for surgical resection. Mr. [Known lastname ] also received an esophago-gastric endoscopy to evaluate his suspected upper GI bleed, anemia, and abdominal pain. This study revealed the following: - [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] B distal esophagitis, 2 cords of small esophageal varices without red whale signs left undisturbed, irregular GEJ with 2 tongues of salmon like mucosa left undisturbed. - Diffuse mild to modorate erythema with deformed antrum and pyloric area. One small 1cm clean based ulcer with surrounding edema and erythema left undisturbed. Retroflex view revealed a moderate hiatal hernia, hiatus ~3cm. - Duodenitis and one small <1cm superficial clean based ulcer in the duodenal bulb left undisturbed, normal second portion. - Otherwise normal EGD to second part of the duodenum. The etiology of his anemia was determined to be a combination of hepatic lesions/HCC as well as upper GI bleed, possibly secondary to NSAID use. After hemodynamic and cardiovascular stabilization with transfusions as above, Mr. [Known lastname ] was transferred out of the SICU to the surgical floor. His liver lesions and clinical case was discussed during a multi-disciplinary hepatic tumor conference. It was determined he would benefit from biopsy of his lesions, with possible systemic therapy to be determined as an outpatient. Mr. [Known lastname ] future outpatient care was coordinated with the hematology-oncology service, and he was discharged on [8-16], [2137]. Medications on Admission: Occasional NSAID use. Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth q12 hours Disp #60 Tablet Refills:2 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain RX hydromorphone [Dilaudid] 2 mg [12-9] tablet(s) by mouth q 4-6 hours PRN Disp #40 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth [Hospital1 ] PRN Disp #60 Capsule Refills:1 Discharge Disposition: Home Discharge Diagnosis: Extensive liver lesions (presumably recurrent hepatocellular carcinoma) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr.[Name (NI) 1369] office at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications. You will be following up with the oncologist Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852] for possible liver biopsy and treatment discussions. Please continue omeprazole 2 of the 20 mg tablets twice a day due to the stomach and small intestine ulcers that developed most likely due to the amount of advil (ibuprofen) you were taking. This prescription has been called into the [Company 4916] at [Last Name (NamePattern1) 84701] ([Telephone/Fax (1) 84702]) in [Location (un) 669]. It should be covered by your insurance. Please take 2 of the 20 mg tablets twice a day and avoid the use of ibuprofen (advil), aspirin or any aspirin containing products. Please see Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852] ([Telephone/Fax (1) 8770]) as soon as possible for further evaluation and treatment options. No driving if taking narcotic pain medication. Followup Instructions: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852] [Telephone/Fax (1) 8770] Oncologist Call for appointment as soon as possible Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] ([Telephone/Fax (1) 3618] hepatology. Call to schedule an appointment for 2 weeks. Before your appointment, you will go to the lab and get your blood drawn for a lab test. Please bring the lab script that will be provided to you upon discharge so they know what labs to draw. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709*]	[ "305.1", "197.6", "V45.72", "532.90", "070.70", "280.9", "196.1", "535.60", "456.21", "531.90", "530.19", "E935.9", "365.70", "366.9", "578.9", "365.9", "155.0", "197.0", "553.3" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	5851, 5857	2376, 5353	298, 305	5973, 5973	2011, 2353	7261, 7897	1598, 1616		5425, 5828		5878, 5952		5379, 5402			6124, 7238											1646, 1992																				231, 260								333, 1155									5988, 6100					1177, 1395	1411, 1582
59,073	124,950	35811	Discharge summary	report	Admission Date: [2169-1-24] Discharge Date: [2169-1-28] Date of Birth: [2143-6-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chaest pain Major Surgical or Invasive Procedure: s/p coronary artery bypass x4 (LIMA->LAD/RIMA->RCA/SVG->OM1/OM2) History of Present Illness: 25 year old male treated for pericarditis in [June 2167] reports chest pain with activity. Stress test performed indicated ischemia. He was referred for cardiac cath which revealed severe 3 vessel coronary disease. Dr.[Last Name (STitle) ] was consulted for revascularization. Past Medical History: - pericarditis '[67] c/w small effusion managed without drainage. - Mononucleosis at age 14 with subsequent PNA not requiring hospitalization Social History: Pt is a project manager for a construction company. He denies occupational exposures. No hx of drug abuse other than distant rare use of LSD and marijauna. No hx of cocaine. Social history is significant for the absence of current or past tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: GENERAL:NAD VS: 99, 98.5, 114/67, 83SR, 20, 96%RA HEENT: AT/NC, Carotids 2+(B) CVS:RRR Lungs: CTA(B) ABD: benign EXT: no cyanosis/clubbing/edema sternotomy: c/d/i without erythema or drainage Pertinent Results: [2169-1-24] 12:09PM BLOOD WBC-25.2# RBC-3.52# Hgb-11.0# Hct-29.7# MCV-84 MCH-31.1 MCHC-36.9* RDW-13.0 Plt Ct-160 [2169-1-26] 06:20AM BLOOD WBC-15.9* RBC-3.21* Hgb-10.5* Hct-27.9* MCV-87 MCH-32.8* MCHC-37.7* RDW-12.6 Plt Ct-156 [2169-1-24] 06:50AM BLOOD PT-13.1 PTT-26.0 INR(PT)-1.1 [2169-1-24] 01:26PM BLOOD PT-13.8* PTT-28.5 INR(PT)-1.2* [2169-1-27] 05:20AM BLOOD Glucose-110* UreaN-12 Creat-0.8 Na-136 K-4.0 Cl-100 HCO3-27 AnGap-13 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 488] [Hospital1 18] [Numeric Identifier 81450] (Complete) Done [2169-1-24] at 8:55:07 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2143-6-6] Age (years): 25 M Hgt (in): 67 BP (mm Hg): / Wgt (lb): 200 HR (bpm): BSA (m2): 2.02 m2 Indication: Abnormal ECG. Chest pain. Pericarditis. ICD-9 Codes: 786.51, 440.0, 423.9 Test Information Date/Time: [2169-1-24] at 08:55 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 6507], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 1.8 cm <= 2.5 cm Aortic Valve - Peak Velocity: 0.8 m/sec <= 2.0 m/sec Mitral Valve - Pressure Half Time: 48 ms Mitral Valve - MVA (P [1-6] T): 4.6 cm2 Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.2 m/sec Mitral Valve - E/A ratio: 2.50 Findings LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No thrombus in the RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV systolic dysfunction. Low normal LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: The pericardium may be thickened. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). 4. The right ventricular cavity is mildly dilated with normal free wall contractility. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the aortic root. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There are three aortic valve leaflets. No aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. 8. The pericardium may be thickened. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A-pacing . Preserved biventricular systolic function. LVEF = 55%. Trace MR. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2169-1-24] 12:26 ?????? [2163] CareGroup IS. All rights reserved. Brief Hospital Course: [2169-1-24] Mr.[Known lastname ] went to the operating room and underwent coronary artery bypass grafting x 4(LIMA->LAD/RIMA->RCA/SVG->OM1/OM2). Please refer to Dr[Last Name (STitle) ] operative report for further details. He was transferred sedated and intubated to the CVICU. He awoke neurologically intact, weaned off drips and was extubated in a timely fashion. All lines and tubes were discontinued when appropriate criteria was met. POD#1 beta-blocker, statin, aspirin was initiated and he was transferred to the step down unit for further telemetry monitoring. The remainder of his postoperative course was essentially uncomplicated. He continued to progress and was ready for discharge on POD# 4. All follow up appointments were advised. Medications on Admission: SL NTG prn lopressor 25 [Hospital1 ] atorvastatin 80mg [Hospital1 ] lisinopril 2.5mg daily enteric coated aspirin 325mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: s/p CABG x4 (LIMA->LAD/RIMA->RCA/SVG->OM1/OM2) coronary artery disease hyperlipidemia pericarditis tonsillectomy Asthma Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 7047] in 1 week please call for appointment Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 10740] in [1-6] weeks Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2169-1-28]	[ "401.9", "414.01", "272.4", "423.8", "493.90" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.12", "36.16" ]	icd9pcs	[ [ [] ] ]	8878, 8929	6799, 7558	332, 399	9093, 9100	1517, 5054	9612, 10022	1208, 1290		7742, 8855		8950, 9072		7584, 7719			9124, 9589										5103, 6776	1305, 1498																				281, 294								427, 713														735, 884	900, 1192
71,397	123,226	47707	Discharge summary	report	Admission Date: [2131-10-4] Discharge Date: [2131-10-19] Date of Birth: [2073-9-25] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 5569] Chief Complaint: Cirrhosis, abdominal pain Major Surgical or Invasive Procedure: Right Port Line placement [2131-10-9]: Thoracentesis [2131-10-10]: Paracentesis History of Present Illness: 58 year-old gentleman presents 6 hours after discharge from hospital with abdominal pain and vomiting. The patient was recently admitted from [2131-9-27] to [2131-10-3] for bleeding esophageal varices. He is s/p banding, sclerotherapy, and treatment with octreotide and protonix gtt. He was discharged home yesterday and returned to [Location ] a few hours later with severe abdominal pain and vomiting. He said emesis had some blood tinge. He also had an episode of diarrhea with blood in his stool. Abdominal pain was [8-6] in upper abdomen but is now [2-6]. He states his back pain is worse than abdominal pain. NG lavage performed in ED was reportedly negative Past Medical History: Hepatitis C Type 1A cirrhosis since age of 20 c/b gastric and esophageal varices - recently admitted in [8-5] for gastric variceal bleed s/p sclerotherapy Alcohol abuse Cardiac murmur History of IV drug use History of meningitis Anemia Pancytopenia Social History: He is retired post office worker. Lives alone in apt in [Location (un) 3786]. He has parents in their 80s. Estranged from parents who live in [State 108]. Reportedly, stopped drinking 20 years ago. 5 cigarettes / day for last 20 years. History of heroin use, IVDU. Currrently adherent to methadone clinic at [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Clinic - 125 mg methadone daily. Family History: Mom has history of TB, father history of stroke. No known bleeding d/o in family. Physical Exam: VS: T 95.8, HR 88, BP 120/86, RR 18, 98%RA GEN: slightly confused, though answering questions appropriately HEENT: no scleral icterus CV: RRR, nl S1 and S2 LUNGS: decreased BS at bases B/L ABD: soft, distended, +ascites, no rebound, no guarding, no hernias RECTAL: guaiac positive EXT: 1+ edema of LE B/L Labs: WBC 21.9, HCT 46.6, PLT 158 INR 1.8, PTT 38.2 Lactate 3.9, Cr 1.1 Imaging: CT Abd/Pelvis ([10-3]): diffuse colonic wall thickening and small bowel wall thickening. SMA is patent, however, questionnable thrombosis of SMV/portal confluence U/S ([10-3]): minimal to no flow in PV, ascites, gall bladder sludge Pertinent Results: [2131-10-4] 12:12AM BLOOD WBC-21.8# RBC-5.19# Hgb-15.0# Hct-46.6# MCV-90 MCH-28.9 MCHC-32.1 RDW-18.0 Plt Ct-158 [2131-10-4] 06:50AM BLOOD WBC-24.5* RBC-4.19* Hgb-12.2* Hct-38.9* MCV-93 MCH-29.1 MCHC-31.3 RDW-19.1* Plt Ct-132* [2131-10-6] 04:00AM BLOOD WBC-19.4* RBC-3.21* Hgb-9.4* Hct-29.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-19.5* Plt Ct-125* [2131-10-10] 05:00AM BLOOD WBC-5.4# RBC-2.65* Hgb-8.1* Hct-25.4# MCV-96 MCH-30.7 MCHC-32.1 RDW-21.2 Plt Ct-32# [2131-10-13] 06:45AM BLOOD WBC-21.8# RBC-4.34* Hgb-12.6* Hct-40.4 MCV-93 MCH-29.0 MCHC-31.2 RDW-20.7* Plt Ct-157# [2131-10-19] 05:34AM BLOOD WBC-8.5 RBC-3.19* Hgb-9.8* Hct-31.5* MCV-99* MCH-30.9 MCHC-31.3 RDW-23.3* Plt Ct-165 [2131-10-19] 05:34AM BLOOD PT-32.9* PTT-75.7* INR(PT)-3.3* [2131-10-19] 05:34AM BLOOD Glucose-106* UreaN-24* Creat-0.6 Na-135 K-4.5 Cl-99 HCO3-35* AnGap-6* [2131-10-17] 03:56AM BLOOD ALT-10 AST-24 AlkPhos-70 TotBili-3.8* [2131-10-17] 03:56AM BLOOD Albumin-2.0* Calcium-7.4* Phos-3.1 Mg-1.9 [2131-10-19] 05:34AM BLOOD Albumin-2.1* Brief Hospital Course: He was initially admitted to the SICU, intubated and started on iv heparin for portal vein thrombus. Surgery was consulted and followed for PV concern for ischemic colitis. IV Fluid and empiric IV antibiotics (zosyn, flagyl)were started for potential infectious colitis based on CT findings and c.diff. Serial abdominal exams were done notable for distension, but non-tender. He was extubated on [10-4]. He was transferred to the med-[Doctor First Name ] unit and followed by surgery. Abdomen continued to appear distended. He was non-tender, but had intermittent complaints of nausea. He was kept npo and TPN was started. On [10-8], he had worsening abdominal pain with a guaiac positive stool. WBC was 13, hct 34.4. CT demonstrated hyperdense clot noted in the proximal superior mesenteric vein just before the confluence, large ascites, thickened small bowel wall and sigmoid. There was a large right pleural effusion. No free air, mesenteric air or pneumatosis noted. Ex lap was considered and discussed with the patient who declined surgery. IV heparin and antibiotics continued. On [10-9], wbc was improved (18.7) and hct of 34. On [10-10], wbc was done to 5.4 and hct had dropped to 25.6. PTT was 50.7 and inr was 2.3. On exam, pain was improved. Heparin was stopped for drop in hematocrit. Two units of PRBC were given as well as ffp. Paracentesis was performed with removal of 3 liters of dark yellow fluid. Cell count had wbc 120, RBC 9800 and poly 37. Gram stain had 2+ pmn with no organisms. Culture was negative. Thoracentesis was also done removing 2.2 liters. Pleural fluid culture was negative. FFP and PRBC were given for hct of 24. Rifaximin was started per hepatology recommendations. Diuretics were started for edema/ascites. On [10-12], left leg appeared more edematous than the right leg. Lower extremity duplex was positive for a non-occlusive thrombus in the left common femoral vein and a 3.7-cm [Hospital Ward Name 4675] cyst in the right popliteal fossa. INR continued to range between 2.0 and 2.3. On [10-13], platelet count was noted to be trending down 114 from 188. Heparin antibody was sent and returned positive. Serotonin release assay was sent with results negative. Per report: These results argue against, but do not completely rule out a diagnosis of Heparin-Induced Thrombocytopenia (HIT). Anticoagulation with Lepirudin and coumadin continued. Abdominal CT was repeated on [10-13] noting the following: 1)Large volume intra-abdominal and pelvic ascites, unchanged. 2) Progressive dilatation of the proximal small bowel with marked proximal and mid jejunal small bowel thickening and further thickening throughout the colon with no pneumatosis or free air which in the presence of portal venous thrombosis is most likely due to venous congestion/obstruction 3)Large right pleural effusion with right lower lobe atelectasis. 4)Liver cirrhosis. 5)Left sided CFV DVT 6)New splenic infarction. Goal INR was set at 3.0. Coumadin was started on [10-14] at 2mg per day. He received this dose until [10-17] when dose was increased to 5mg daily. INR was 3.3 on [10-19]. Lepirudin was stopped on [10-19]. Nutrition followed him recommending goal of [2121] kcals (~25 kcal/kg, 1.5g protein/kg). TPN was continued as he continued to experienced intermittent nausea, abdominal discomfort and distension. PO kcals were very low and insufficient. PT recommended rehab. [Hospital ] Rehab accepted him and he will transfer to [Hospital1 ] today to continue TPN, coumadin (goal inr 3.0)with daily INRs. Medications on Admission: Albuterol MDI, FeSO4, Klonopin, Lactulose, Lasix 40 mg daily, methadone, Nadolol, Protonix 40 mg [Hospital1 ], Spironolactone 100 mg daily Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Methadone 10 mg Tablet Sig: 12.5 Tablets PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): PT/INR daily until goal 3 is achieved steady state. 11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: hepatitis C PV, splenic vein, smv thrombosis, new since [2131-9-29] ischemic colitis HIT + Malnutrition Discharge Condition: Stable/Fair Discharge Instructions: Please call the Dr.[Name (NI) 8584] office at [Telephone/Fax (1) 673] for fever, chills, increased nausea, vomiting, increased abdominal pain, altered mental status or any bleeding Patient will be continuing TPN via PICC line He has had some degree of nausea and inability to tolerate much PO intake Continue diuresis as ordered TEDS to lower extremities PT/INR daily with results to [Telephone/Fax (1) 673] until stable Followup Instructions: [First Name4 (NamePattern1) 1060] [Last Name (NamePattern1) 8147] RN from the transplant clinic will call with follow up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 100751] for Friday [2131-10-26] ([Telephone/Fax (1) 100752] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2131-11-28] 11:15 (Hepatologist) Completed by:[2131-10-19]	[ "511.9", "453.41", "571.5", "727.51", "456.8", "304.01", "305.1", "305.00", "557.9", "518.0", "263.9", "456.21", "789.59", "070.70", "V58.61", "452", "289.84" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.04", "96.71", "86.07", "54.91", "34.91", "99.15" ]	icd9pcs	[ [ [] ] ]	8441, 8520	3665, 7264	302, 392	8672, 8686	2585, 3642	9168, 9641	1836, 1920		7458, 8418		8541, 8651		7290, 7435			8710, 9145											1935, 2566																				236, 264								420, 1110														1132, 1386	1402, 1820
57,815	186,285	42495	Discharge summary	report	Admission Date: [2122-11-12] Discharge Date: [2122-11-27] Date of Birth: [2060-2-22] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 371] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [2122-11-13] Open Reduction Left Ankle Fracture, Open Reduction Left Hip Fracture with TFN Nail History of Present Illness: 62M transferred from [Hospital6 3105] s/p MVC. Pt was restrained driver involved in head on collision with +LOC and +head strike. He was BIBA boarded and collared to the OSH where trauma series demonstrated multiple rib fractures. He received 1U PRBC and 1U FFP at the OSH. He was then transferred to [Hospital1 18] for further evaluation. At this time, pt endorses pain in his right chest, worse with respirations. He also c/o pain in his left hip and left ankle, exacerbated by motion. He denies numbness/tingling distally, and pain elsewhere in his extremities. Past Medical History: Afib on coumadin, htn. S/p bilateral TKA in [2119], appendectomy. Social History: Lives with wife Family History: Noncontributory Physical Exam: PHYSICAL EXAMINATION: upon admission Temp: 96 HR: 122 BP: 170/p Resp: 23 O(2)Sat: 97 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation, TTP R chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema except LLE with ecchymosis/edema prox femur, distal NVI bilaterally, soft compartments Skin: No rash, Warm and dry Neuro: Speech fluent, MAE, strength/sensation symmetric Psych: Normal mood, Normal mentation Heme/[Last Name (un) ]/[Last Name (un) ]: No petechiae . Physical examination upon discharge: vital signs: t=98.2, bp=116/81, hr=85, resp. rate 18, oxygen sat 96% room air General: NAD, conversant, pleasant CV: irreg, ns1, s2, -s 3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXT: Scab right knee, blesdoe brace left leg, edematous left knee and left ankle, + dp bil., no calf tenderness right knee MENTATION: alert and oriented x 3, speech clear, no tremors. Pertinent Results: [2122-11-12] 11:15PM GLUCOSE-261* UREA N-30* CREAT-1.2 SODIUM-138 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-23 ANION GAP-20 [2122-11-12] 11:15PM LIPASE-103* [2122-11-12] 11:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2122-11-12] 11:15PM WBC-13.9* RBC-4.28* HGB-13.7* HCT-38.4* MCV-90 MCH-32.0 MCHC-35.7* RDW-13.6 [2122-11-12] 11:15PM NEUTS-80* BANDS-2 LYMPHS-5* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-2* [2122-11-12] 11:15PM PLT SMR-NORMAL PLT COUNT-193 [2122-11-12] 11:15PM PT-21.2* PTT-30.6 INR(PT)-2.0* [2122-11-12] 11:15PM FIBRINOGE-284 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2122-11-27] 05:23 13.71 1.3 PITUITARY TSH [2122-11-26] 09:05 3.0 . [11-13] CXR: subcutaneous emphysema, right pneuomthorax [11-15] CXR: no evident pneumothorax. Small-to-mild left pleural effusion is unchanged with unchanged adjacent atelectasis. Right lower lobe opacities have increased, could be due to atelectasis or pneumoni. Pulmonary edema has minimally increased. Subcutaneous emphysema has decreased. Increase in widened mediastinum could be just due to positioning or rotation. [11-16] ECHO: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function (LVEF >55%). Mild mitral regurgitation with normal valve morphology. Mild pulmonary artery hypertension. No effusion. [11-21] CXR As compared to the previous radiograph, there is no relevant change. Bilateral basal parenchymal opacities. Small bilateral pleural effusions, slightly more extensive on the left than on the right. At the right lung bases, in the region of the known displaced rib fractures, there are subtle parenchymal opacities that might represent areas of lung contusion. Minimal fluid overload. Borderline size of the cardiac silhouette. Unchanged position and course of the PICC line [11-22] R Knee film Status post total knee replacement. The prosthetic parts are in correct position. There is no evidence of fracture, luxation or displacement. Periarticular calcifications. No cortical damage. Brief Hospital Course: He was admitted to the Acute Care Surgery team. Patient subsequently admitted to the Trauma SICU. Orthopedics consultation was imediately obtained based on his injuries. . Neuro: Pain control initially with IV narcotics. He was intubated/sedated for ortho procedure [11-13]. Postop manifested clinical instability requiring continued vent dependence. Patient became agitated following SBT [11-17] requiring haldol for sedation. Dilaudid was instituted for longer acting pain control. This was used in conjunction with propofol gtt. Low dose seroquel was added [11-18] with poor effect and prn haldol was continued. [11-19] patient was severely agitated pulling out lines. Haldol required to improve sedation. Extubated [11-20]. Persistently agitated/delirious. Night of [11-21] patient found having gotten out of bed on floor. Given delirium was uncertain as to circumstances of being out of bed. Haldol started on standing basis for continued delirium [11-22]. Delirium improved with floor transfer [11-23] as patient became more oriented though still with intermittent agitation at night. Seroquel at bedtime was ordered. Other causes of his delirium were worked up to include blood cultures, urine and chemistries. Psychiatry consult was placed. Their recommendations were to d/c benzo's, seroquel, and round the clock haldol. After 24 hours, his mental status improved and he did not exhibit signs of delirium. Because of his injuries and to rule out any neurological event, he underwent a head MRI which was normal and did not show signs or hemorrhage. . CV: On arrival, the patient was stable from a cardiovascular standpoint. Following OR w orthopedics [11-13], patient demonstrated elevated lactate up to 5.8, oliguria, hypotension to high 80's SBP. This showed mild to moderate improvement with 4L IVF/albumin. Cardiac enzymes sent which were negative. Left subclavian and Rt A line placed. Patient responded well following this. [11-14] patient manifested afib w/RVR to HR of 160s. Given lopressor IV x 2 and diltiazem IV x 1 push with minimal response. Diltiazem gtt started. Pt had associated hypotension w tachycardia and was started on neo gtt w appropriate BP response. Pressors and dilt gtt weaned [11-15]. TTE [11-16] showed preserved LV fxn. [11-17] afib w RVR returned and dilt gtt was resumed. Diltiazem gtt was again weaned [11-18] in favor of lopressor po. This was up-titrated but with refractory hypertension. Digoxin started for supplemental rate control and tachycardia improved. . Pulmonary: Post-procedure [11-13] patient had shock physiology as above. In this setting, patient developed subcutaneous emphysema, right pneumothorax; right 32F chest tube placed to suction; changed to pulmonary protective vent settings (ARDS). Ventilation continued with minimal improvemetn [2029-11-13]. [11-15] pt found to have thick secretions in setting of likely ARDS on bronchoscopy. BAL was sent with gram stain showing 4+PMNs, no orgs. Started on empiric VAP coverage [11-15] (see ID). Vent was weaned over ensuing days and patient extubated [11-20]. Pulmonary toilet including incentive spirometry and early ambulation were then encouraged. Serial CXRs obtained and showed interval improvement. His oxygen saturations on room air have remained stable. . GI/GU: On admission patient made NPO w IVF hydration. Given persistent intubation following [11-13] OR, enteral access obtained and tube feeds initiated. Advanced to goal and tolerated well. [11-14] patient showed high residuals (300s) and feeds were held initially. Reglan was started for bowel motility [11-15]. Following extubation, his diet was advanced as tolerated which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. . Foley placed at OSH. Patient initially presented with Cr 1.2. Bumped to 1.6 [11-13]. This improved with IV hydration; returned to 1.0 on [11-14]. [11-15] was bolused crystalloid IVF w good effect for oliguria. Patient diuresed prn while in ICU with lasix. Lasix drip started [11-18] to further facilitate diuresis. Drip down-titrated with intermittent bolus for net negative fluid balance [11-22]. Patient stabilized on 40mg daily (home dose 20mg). Foley d/c'd [11-24] and patient voided appropriately. Intake and output were closely monitored. . ID: Patient was covered with ancef periop for ortho procedures. As patient had refractory vent dependence bronchoscopies performed as above (see PULM). [11-15] vancomycin/zosyn started empirically for VAP. BAL cx followed. Aintibiotics were discontinued [11-21] with all cultures negative. The patient's temperature was closely watched for signs of infection. . MSK: Pt sustained orthopedic injuries as above. Underwent ORIF of a left intertrochanteric hip fracture with intramedullary nail, as well as open reduction, internal fixation of a left bimalleolar ankle fracture without complication on [2122-11-13]. Please see operative report for full details. He was made touchdown weight-bearing on his LLE in an unlocked [Doctor Last Name ] with ROM as tolerated. Of note he was found down in room of ICU [11-21] in setting delirium with complaint of right knee pain; knee films were ordered and were negative. . HEME: Trauma labs sent off at admission w admit hct 38 and INR 2.0. Transfused 2 FFP for INR correction [11-13]. Hct trended down over subsequent days likely from combination hemodilution/blood loss secondary to orthopedic injuries. Xfused 2units pRBC w marginal improvement 21->25. Heparin SQ started when hct stable. [11-14] platelets decreased to 68 from [Age over 90 ] yesterday. HIT panel was sent and shown to be negative. Heparin gtt started [11-23] and titrated to goal PTT 60-80. Coumadin resumed [11-23] with INR checked daily. The Heaprin drip was stopped on HD #15 and Lovenox was started as a bridge to Coumadin. Once his INR reaches goal of 2.0-3.0 the Lovenox can be stopped. . OPHTHO: Patient with hisotry of macular degeneration and was noted with "floater" in right eye on [11-23] and ophtho consult obtained. No acute issues were identified. [Month (only) 116] follow up with ophtho as an outpatient after discharge from rehab. . He was transferred to the surgical floor on [11-23]. His vital signs have been stable and he has been afebrile. He is tolerating a regular diet. His white blood cell count is 5 and his hematocrit is stable at 31. He has been started on coumadin with lovenox bridging. His current INR is 1.3. Because of his injuries, he was evaluated by physcial therapy who made recommendations for discharge to an extended care facility where he can regain his strength and mobility. Medications on Admission: - Coumadin 5mg qday - Losartan 100mg QOD - Lasix 20mg qday - Lopressor ER 100mg qday - Amlodipine 2.5mg qday Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day): hold for SBP<100 and HR<60 . 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. losartan 50 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO every four (4) hours as needed for pain. 15. enoxaparin 150 mg/mL Syringe Sig: One [Age over 90 10973]y (130) MG Subcutaneous Q12H (every 12 hours): Indications: Bridge for Coumadin. [Month (only) 116] discontinue once INR reaches goal range b/w 2.0-3.0. 16. haloperidol 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): monitor QTC ( may wean to off when delirium resolved). 17. haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation/hallucinations: may wean to off once delirium resolves. Discharge Disposition: Extended Care Facility: [Hospital 1121] Rehab Skilled Nursing Center - [Location (un) 4047] Discharge Diagnosis: s/p Motor vehicle crash Injuries: Right [12-6] rib fractures Left femur fracture Left bimalleoloar fractures Left femoral condyle fracture Ventilator associated pneumonia Delirium Discharge Condition: Mental Status: Clear and coherent w/ resolving delirium. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after an automobile crash where you sustained multiple injuires which include rib fractures, fractures of the left leg and both ankles. You also developed pneumonia while in the ICU which is resolving with treatment using antibiotics. * Your rib fractures can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: * Department: ORTHOPEDICS When: THURSDAY [2122-12-17] at 10:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: THURSDAY [2122-12-17] at 11:00 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2122-12-17] at 2:00 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Notes: You will need a chest x-ray prior to this appointment. Please go to [Hospital1 7768], [Hospital Ward Name 517] Clinical Center, [Location (un) 3202] Radiology 30 minutes prior to your appointment. Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2122-11-27]	[ "293.0", "512.1", "820.21", "998.81", "V85.41", "958.4", "E812.0", "861.21", "E888.9", "593.9", "V58.61", "854.02", "V43.65", "285.1", "362.50", "518.51", "E879.8", "427.31", "278.01", "997.31", "807.2", "807.08", "276.69", "E878.1", "824.4", "305.00", "821.21", "401.9", "287.5" ]	icd9cm	[ [ [] ] ]	[ "34.04", "33.24", "96.6", "79.36", "96.72", "79.15", "79.35" ]	icd9pcs	[ [ [] ] ]	13383, 13485	4609, 11459	328, 430	13713, 13713	2416, 4586	15597, 16733	1179, 1196		11619, 13360		13506, 13692		11485, 11596			13911, 15574											1211, 1211													1233, 2009							265, 290							2025, 2397	458, 1037									13728, 13887					1059, 1130	1146, 1163
31,216	103,159	44349	Discharge summary	report	Admission Date: [2166-9-9] Discharge Date: [2166-9-17] Service: MEDICINE Allergies: Lithium / Iodine; Iodine Containing Attending:[First Name3 (LF) 358] Chief Complaint: Malaise Major Surgical or Invasive Procedure: None History of Present Illness: This is an 84 yom with history of COPD, Prostate Ca, Schizoaffective disorder, Depression, Hypothyroidism, Gout, +PPD in [2140] s/p treatment who presents from his Nursing Home today for hypoxia and malaise. Per report from PCP, [Name10 (NameIs) ] has been found to be coughing with liquids and food at his nursing home. Patient was found to have increasing weakness and malaise at his nursing home yesterday, O2 sat noted to be 67% which rose to 90% on 3L NC. PCP was notified today and patient was referred to [Hospital1 18] ED. Per ED report, patient also complaining of left knee pain. . Per nursing home report: Patient found sitting on toilet, unable to get himself up. Patient complaining of left leg/left hip pain. V/S Temp 100.4, HR 94, RR 20, BP 103/74. 94% on RA. Patient then had O2 desaturation to 67% as above, with patient to ER> . In the ED: Temp 103.8, HR 128, RR 35 98% on NRB. CXR was done in the ED and was concerning for LLL PNA. Patient was started on Vanco/Zosyn. HR in 130s with Afib. He was given Diltiazem 10mg IV x 2, with HR 100s, also given 2L NS. Patient had increased work of breathing and was placed on BIPAP. Patient was transferred to MICU for further care. . On arrival to MICU, patient was on BIPAP and unable to answer questions. Past Medical History: Atrial fibrillation COPD Hypothyroidism S/P left hip bipolar hemiprosthesis Prostate Ca Schizoaffective disorder Depression Gout thoracic abdominal aortic aneuysm Social History: Lives at [Hospital ] Nursing home Family History: NC Physical Exam: Gen: NAD. HEENT: Anicteric. PERRL 3 to 2 mm bilaterally. Oral mucosa dry. Resp: Mildly increased respiratory effort. On shovel mask 50% O2. Clear at right apex. Slight inspiratory rales left apex. Decreased breath sounds at bases bilaterally. CV: JVP to angle of jaw. Irregular rhythm. S1, S2. No M/G/R. Abd: Bowel sounds present. Soft. Non-tender. Ext: 2+ to 3+ LE edema left, perhaps worsened from yesterday. 1+ LE edema right. Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+), (Right DP pulse: present by doppler), (Left PT pulse: present by doppler) Neurologic: Neurologic exam limited by mental status. Responds to simple commands. Keeps repeating ??????at 5:38??????. Speech limited to short phrases. Not oriented. PERRL 3 mm to 2 mm bilaterally. EOMI. Symmetric smile. Elevates palate in midline. Protrudes tongue min midline. Moves all 4 extremities. Brief Hospital Course: 84 yo M with COPD, Afib, prostate cancer, thoracic aortic aneurysm, s/p hip partial replacement, presented on [2166-9-9] with altered mental status, tachycardia, hypoxemia, LLE edema, and left hip/knee pain. Imaging studies revealed pneumonia, large thoracic aortic aneurysm, and multiple blastic bone lesions. The patient initially required non-invasive respiratory support but his respiratory status improved, and he has been off of respiratory support since last night [2166-9-10]. healt care acquired pneumonia/respiratory distress: The patient presented with desaturation and increased work of breathing, for which he was started on BIPAP in the ED. The patient continued to require non-invasive ventilatory support (CPAP with pressure support) until the evening of [2166-9-10], after which time, oxygenation was maintained with a face tent mask. Chest radiography was consistent with pneumonia, which was treated as healthcare associated pneumonia, given the patient's residence in a nursing home. The patient was treated with Zosyn, vancomycin, and azithromycin. At the time of transfer out of the MICU, the plan was to continue azithromycin for a 5-day course, which will be complete in the early morning of [2166-9-14], and to continue Zosyn and vancomycin for a 10-day course, which will be complete on [2166-9-17]. Legionella urinary antigen was negative. At the time of transfer out of the MICU, blood cultures x 2 were pending and were found to be negative. Altered mental status: Per nursing home, patient A&Ox3 without dementia at baseline. Mental status has fluctuated from hour to hour and tends to be better in the afternoon. At his best, the patient was able to respond to simple commands and answer simple questions. The patient's mental status changes were felt to be due todelirium in the setting of acute infection. However, CVA was considered in the differential diagnosis. The patient had a negative head CT. Neurology was consulted and felt that the patient's exam was non-focal and not consistent with CVA. The patients electrolytes remained stable during the duration of his hospital course. A repeat head CT showed no interval change. Atrial fibrillation with RVR: On presentation, the patient was tachycardic to 128. In the ED, he received diltiazem 10 mg IV x 2 and bolused with 2L NS, with improvement of the tachycardia. In the MICU, the tachycardia recurred and responded only transiently to diltiazam boluses. The patient was started on a diltiazem drip, on which he remained until the early morning of [2166-9-11]. At that time, digoxin was initiated to provide rate control while enhancing blood pressure, cardiac output, and renal perfusion. Rate control and BP were good on digoxin. The patient is not on anticoagulation. The MICU team contact[Name (NI) ] the patient's PCP, [Last Name (NamePattern4) ]. [First Name (STitle) ], who did not believe that anticoagulation was in the patient's interest given his fall risk. At the time of transfer out of the MICU, the plan was to continue digoxin for rate control, monitoring the patient's ECG and checking a digoxin level in the a.m. of [2166-9-13]. The patient's digoxin level remained therapeutic and he his EKG was unchanged. COPD ?????? Baseline COPD likely contributed to intiail poor respiratory status. Started on 60 mg q8 solumedrol bolus. Tapered methylprednisolone to 20 mg IV and then transitioned to PO, where he was tapered off. Blastic bone lesions ?????? Likely metastasis given history of prostate cancer and PSA 279.9. Consulted PCP regarding management of patient??????s prostate cancer, likely would not want medical interventions. AFter discussion with guardian, the conclusion was to not pursue aggressive intervention, including escalating the patients status to an ICU. She will consider a Do not hospitalize order during the upcoming days after discussion with Dr. [First Name (STitle) ], as well as referral to hospice. She preferred the patient be transported back to his nursing facility where he was comfortable, rather than spend additional time in the hospital. Externally rotated hip. LLE shortened and externally rotated. No evidence of fracture of dislocation on CT. External rotation likely chronic per ortho. MRI of spine ordered to rule out metastatic lesion. MRI positive for lesions in the thoracic and cervical spine, no lesions in lumbar spine or evidence of stenosis. LLE edema ?????? No clot. DDx includes venous insufficiency, CHF (although worse on left). Elevated CK ?????? [Month (only) 116] be due to traumatic muscle injury in the setting of a fall. Continuing to trend down. Schizoaffective disorder Home meds were held while NPO, then restarted Medications on Admission: Levothyroxine 100mcg daily Prilosec 20mg daily Diltiazem 120mg daily Acetaminophen 1000mg [Hospital1 ] Docusate 200mg [Hospital1 ] Depakote 750mg [Hospital1 ] Milk of Magnesia 30mg M/W/F Zyprexa 10mg qHS Doxazosin 2mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Acetaminophen 500 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Levothyroxine 100 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-8] Drops Ophthalmic PRN (as needed). 6. Olanzapine 2.5 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO HS (at bedtime). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Valproate Sodium 250 mg/5 mL Syrup [Last Name (STitle) ]: One (1) 750 mg syrup PO Q12H (every 12 hours). 9. Digoxin 125 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Last Name (STitle) ]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Location (un) 16662] - [Street Address(1) ] Discharge Diagnosis: 1. Pneumonia 2. Hypotension 3. Respiratory distress 4. Urinary retention s/p foley placement 5. Atrial fibrillation with rapid ventricular response 6. Weakness 7. L arm swelling Secondary 1. Schizoaffective disorder 2. Hypothyroidism 3. Metastatic prostate cancer 4. Thoracic aortic anneurysm Discharge Condition: Hemodynamically stable, tolerating PO intake Discharge Instructions: You have been diagnosed with altered mental status, respiratory distress and hypotension during your hospital stay. You should return to the hospital as needed for changes in mental status, difficulty breathing, fever, or other symptoms concerning to you, but during your hospital stay it was discussed with your guardian the possibility of do not hospitalize in the future. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in [1-8] weeks. You can call [Telephone/Fax (1) 608] to schedule an appointment. Completed by:[2166-9-17]	[ "441.2", "274.9", "518.81", "496", "295.72", "788.20", "427.31", "427.1", "428.0", "198.5", "V10.46", "507.0", "244.9", "311", "276.52", "293.0", "V43.64" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9239, 9318	2785, 4293	249, 256	9656, 9703		10127, 10301	1834, 1838		7844, 9216		9339, 9635		7583, 7821			9727, 10104											1853, 2762																				202, 211								284, 1577									4308, 7557					1599, 1763	1779, 1818
31,048	166,879	33844	Discharge summary	report	Admission Date: [2107-6-23] Discharge Date: [2107-7-1] Date of Birth: [2068-3-16] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 21193] Chief Complaint: hemiparesis, confusion, dysarthria followed by headache Major Surgical or Invasive Procedure: Lumbar Puncture Conventional Cerebral Angiogram Endotracheal Intubation History of Present Illness: Patient is a 39 yo man with PMH of hypercholesterolemia and recent diagnosis of complex migraines who presents with his third episode in 3 days of hemiparesis/confusion/dysarthria followed by a throbbing headache. He has never had migraines or similar symptoms prior to this and generally does not suffer from headaches very much. Was in his baseline state of health until monday night at 10 PM when he noted right foot numbness/weakness which advanced up to his right arm and face over a period of minutes. 2-3 hours later he had confusion and dysarthria. He went to [Hospital ] Hospital where he was worked up for stroke. He had a negative MRI and MRA, negative cardiac echo, and his symptoms had all resolved after about 4 hours. As his deficits resolved a bitemporal throbbing headache set in for a period of hours. He has never had these types of headaches in the past. He was discharged from [Hospital1 ] yesterday AM with a diagnosis of complex migraines and instructions to start ASA and Zocor. After being home a few hours he was cleaning and around 6pm noted onset of right foot numbness and weakness again in the right foot. The numbness and weakness advanced up to the right hand over 5 minutes. He became confused and dysarthic at some point after that but cannot say exactly when. Deficits lastted 1.5-2 hours and throbbing headache recurred as his deficits abated. Was taken to [Hospital6 ] where he was given compazine and ASA but did not have any imaging. They reviewed his old records and told him again complex migraine and sent him home last night. His throbbing headache never actually resolved and continued until today. This morning around 0930 he noted numbness and weakness in his left foot (prior 2 episodes were right) which spread up to the back of his head and arm over period of minutes. Again followed by confusion and dysarthria. Deficits lasted period of hours and HA has continued since yesterday. The headache is throbbing pressure bitemporally without lateralizing predominance. The throbbing sensation is accompanied by a "whooshing" sound in each ear. Has moderate photophobia and phonophobia as well as N/V. No neck stiffness or pain. His wife describes the hemiparesis as he was unable to use that side and could not move the foot to get his sock on it. She also said that the weak side of the body correlated with a droop on that side ((on both occasions she was witness to). His confusion manifested as not being able to recall the names of co-workers who visited at the OSH [Name (NI) ] although he said he recognized them. He was also dysarthric and would often just say "um...um....um.....". He could not name any animals on timed test at OSH. ROS: no fevers, but some chills. No sweats. No neck symptoms. Has N/V and photo/phonophobia. No dysuria or incontinence. Past Medical History: prior to 4 days ago had no PMH. Social History: Works as a corrections officer. Drinks occasional alchohol. Occasional cigars and remote cigarrettes. No drugs. Drinks 1 cup coffee a day. Started drinking "red Bulls" about 2 months ago, but not the last few days. No dietary supplements. Family History: Mother had migraines from age 15-20, but never with symptoms such as this. Father and brother do not have migraines. No strokes, DVT or PE. Mother has some CAD. GF had MI and stroke at 47. GM had stroke at 62. Physical Exam: T- 99.0 BP- 130/79 HR- 89 RR- 16 O2Sat 100 RA Gen: Lying in bed, NAD, sleeping HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Wakes up easily, and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [Doctor Last Name 1841] backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [Location (un) ] intact. Registers [3-21], recalls [3-21] in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Disc margins slightly blurrred left but intact right. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift. No asterixis. [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, heel to shin normal, RAMs normal. Gait: Narrow based, steady. tandems well. Romberg: Negative Pertinent Results: Labs: 139 101 19 AGap=17 ------------< 110 3.9 25 1.1 14.4 9.9 >< 263 41.2 N:88.3 L:9.3 M:2.1 E:0.1 Bas:0.2 UA negative. UTOX negative. STOX negative. Imaging: OSH MRI/A report negative. MR HEAD W/O CONTRAST [2107-6-23] 7:34 PM FINDINGS: The study is normal. There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are normal in caliber and configuration. The MRA examination appears normal. CONCLUSION: Normal study. EEG [2107-6-25]: abnormal routine EEG in the waking and sleeping states due to several brief bursts of moderate amplitude theta frequency slowing in the left fronto-temporal region suggestive of an underlying area of subcortical dysfunction. The tracing cannot specify the etiology. There are no clearly epileptiform features and no electrographic seizure activity was noted. CTA HEAD W&W/O C & RECONS [2107-6-27] 12:34 PM CT HEAD: The study is limited by patient motion, however, the exam appears grossly unchanged from the CT head of [2107-6-24], without evidence of acute intracranial hemorrhage, edema, mass, mass effect, hydrocephalus, or of acute large vascular territory infarction. Fluid in the nasopharynx and mucosal thickening in the maxillary sinuses likely relate to ET tube, which is in place. Mucous retention cyst in the left maxillary sinus is unchanged. Otherwise, the soft tissues, orbits and osseous structures are unremarkable. CT PERFUSION: Again, the study is limited by patient motion; no region of definite perfusion abnormality is seen in the visualized portions of the brain. CTA HEAD: The internal carotid and vertebral arteries and their major branches appear patent. Slightly hypoplastic appearance to the right A1 is unchanged in appearance, with patent anterior communicating artery. There is no evidence of focal stenosis or occlusion. No aneurysm is seen. IMPRESSIONS: 1. CT head and CT perfusion is limited by patient motion, however, no definite evidence of acute intracranial process. No definite region of abnormal perfusion is seen in the visualized portions of the brain on CT perfusion. If there is continued concern for acute infarct, MRI may be performed for more sensitive evaluation. 2. CTA head shows patent vessels, without evidence of stenosis or occlusion. CONVENTIONAL CEREBRAL ANGIOGRAM [2107-6-27] Four vessel study was normal. No evidence of aneurysm, vasculitis, or vasospasm. Brief Hospital Course: Mr. [Known lastname 78226] is a 39 yo man with PMH of hypercholesterolemia and admitted with his third episode in 3 days of hemiparesis/confusion/dysarthria followed by a throbbing headache. 1) Meningoencephalitis, vasospasm- The pt was admitted to the neurology service and monitored without event. He had a normal neurologic examination. MRI was performed (priors at outside hospitals were also normal) without evidence of infarct. LP was performed revealing 195 WBC, 0 RBC, Protein 162, Glucose 61. The pt was started on ceftriaxone, vanco, acyclovir. Gram Stain and bacterial cultures were negative. He was continued on acyclovir until HSV PCR on the CSF also returned negative. He was continued on aspirin and started initially on topiramate, then changed to verapamil. A CTA of the head was without evidence of vasospasm. The pt then went for conventional four vessel cerebral angiogram where he recalls being on the table in the IR suite and having a sudden onset of his prior symptoms of throbbing HA, but remembers nothing further. The pt was returned to the floor and was noted to have a global aphasia without other focal neurologic deficits. Code purple was called due to extreme agitation and inability to lay flat following the angiogram, he was given haldol and ativan without effect. Code blue was then called for elective intubation in order to obtain STAT head CT and CT perfusion studies to rule out a new infarction induced by likely cerebral vasospasm. He was transferred to the neurology ICU where he was extubated 24 hrs later without event. His neurologic exam was normal. Repeat LP in the ICU revealed WBC 90, Protein 73. Cytologic exam revealed increased, normal appearing lymphocytes in the CSF. ID was consulted. Serum HIV Ab was negative. CSF for CMV was negative. EBV IgG postive, but EBV IgM was negative. Cryptococcal antigen negative. RPR and Lyme were negative. Hepatitis B and C negative. [Doctor First Name ] negative. ESR, CRP, C3 and C4 levels were normal. Serum ACE level negative. EEE, West [Doctor First Name ], Anti Ro, La, MS profile, cryoglobilins were pending at time of discharge. He was continued on verapamil, aspirin and intravenous fluids and transferred to the neurology floor where the pt was stable for 48hrs. A third LP, which was traumatic due to multiple prior LP's, was performed prior to discharge revealing WBC 177, RBC 62, protein 191, glucose 55. Given the persistent CSF lymphocytic pleocytosis the pt was offered a brain biopsy for further evaluation of possible primary CNS angiitis. The pt declined brain biopsy at this time. He had a normal neurologic examination. He was discharged to home on verapamil and aspirin daily. He will return to the ED with any further symptoms. He should refrain from driving, swimming, tub bathing for one week. If there are recurrent symptoms of speech arrest and hemiplegia he will likely require brain biopsy for further evaluation. Diagnosis at time of discharge is meningoencephalitis inducing transient cerebral vasospasm with migraine like symptoms (referred by some as [Last Name (un) 78227] syndrome) Etiology is likely an occult viral infection, but the inciting inflammatory process or infectious organism remains unclear. The patient was scheduled to follow up in one month with Drs. [First Name8 (NamePattern2) 2530] [Name (STitle) ] and [First Name8 (NamePattern2) 10378] [Last Name (NamePattern1) 14440] in [Hospital 878] Clinic. He was ordered a repeat routine EEG to be performed one week prior to his follow up appointment as a prior study during this hospitalization revealed left hemisphere slowing. Based on clinical and diagnostic testing in one month, further studies such as repeat MRI/A, repeat LP, will be considered at that time. Medications on Admission: None Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:5 3. Simvastatin (zocor) Please start taking this medication under the guidance of your primary care physician. Discharge Disposition: Home Discharge Diagnosis: [Last Name (un) 78227] Syndrome Meningoencephalitis Complicated Migraine secondary to cerebral vasospasm Discharge Condition: Normal Neurologic Exam Discharge Instructions: You were admitted for episodes of difficulty speaking and weakness. These were likely caused by spasm of vessels in your brain in the setting of a viral meningoencephalitis. Please call your doctor or 911 if you experience any further difficulty producing or understanding speech, tingling, numbness, weakness, difficulty urinating or any other concerning symptoms. Followup Instructions: You have an appointment to see: DRS. [Name5 (PTitle) 162] & [Doctor Last Name ] Date/Time:[2107-8-8] 2:30 Office Phone:[Telephone/Fax (1) 44] Please have an EEG performed one week prior to your return visit. [Name6 (MD) 3523] [Name8 (MD) 3524] MD [MD Number(2) 21196]	[ "346.80", "435.9", "048", "272.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "88.41", "03.31", "96.71" ]	icd9pcs	[ [ [] ] ]	12498, 12504	8258, 12054	373, 447	12657, 12682	5771, 6711	13097, 13425	3661, 3878		12109, 12475		12525, 12636		12080, 12086			12706, 13074											3893, 4263																				277, 335								475, 3327	4714, 5752	6720, 8235							4302, 4698			4287, 4287		3349, 3383	3399, 3645
13,023	189,947	13174	Discharge summary	report	Admission Date: [2165-11-18] Discharge Date: [2165-11-24] Date of Birth: [2114-11-22] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Very rare throat tightness with occ. palpitations. Major Surgical or Invasive Procedure: Aortic valve replacement with 21 mm St. Jude valve. History of Present Illness: 50 y/o male with very rare throat tightness with occ. palpitations. s/p PTCA [73] yrs ago. Past Medical History: AS CAD s/p PTCA [73] yrs ago HTN ^Chol s/p Tonsillectomy Social History: Lawyer. Lives with wife and 3 children. Tob: 2ppd until 10 yrs ago, now [3-6] cigs/day. ETOH: [2-1]/wk. -IVDU Family History: Mother with PPM, Father +CAD(died at 90) Physical Exam: HR 68 RR 20 BPR 130/94 Ht: 5'3" Wt: 220# Gen: well appearing male in NAD Skin: -rashes/lesions HEENT: EOMI/PERRLA Neck: supple, -JVD, bruits Chest: CTAB Heart: RRR +S1S2, 3/6 SEM with radiation to carotids Abd: soft NT/ND, +BS Ext: warm, trace edema bilat., r. great toe with black nail Neuro: A & O x 3, grossly intact Pertinent Results: Pre-op Labs: WBC/RBC/Hgb/Hct 9.8 5.12 15.9 44.9 PT/PTT/INR 11.7 23.5 0.9 Gluc/BUN/Creat/NA/K/Cl/HCO3 83 16 0.9 139 4.3 103 25 Pre-op UA negative Pre-op CXR: No active lung disease. Pre-op EKG 59 sinus brady Cardiac Cath: 1. Coronary arteries are normal. 2. Moderate aortic stenosis. 3. Normal ventricular function. [2165-11-18] 02:44PM BLOOD WBC-19.5# RBC-4.13 Hgb-12.8# Hct-35.9 MCV-87 MCH-31.1 MCHC-35.8* RDW-13.4 Plt Ct-97# [2165-11-23] 10:50AM BLOOD WBC-12.1 RBC-3.15* Hgb-9.7* Hct-27.5* MCV-87 MCH-30.9 MCHC-35.5* RDW-14.8 Plt Ct-255 [2165-11-18] 02:44PM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.3 [2165-11-24] 05:30AM BLOOD PT-18.2* INR(PT)-2.1 [2165-11-18] 02:44PM BLOOD Glucose-124* UreaN-15 Creat-0.8 Na-141 K-4.0 Cl-110* HCO3-25 AnGap-10 [2165-11-21] 04:02AM BLOOD Glucose-110* UreaN-26* Creat-0.8 Na-133 K-4.4 Cl-97 HCO3-27 AnGap-13 [2165-11-21] 09:46AM BLOOD ALT-19 AST-40 LD(LDH)-432* AlkPhos-55 TotBili-2.3* Brief Hospital Course: Pt brought to the operating room on [2166-11-18]. After pt. was induced [Initials (NamePattern4) ] [Last Name (Prefixes) ] performed a AVR. See OP summary for full details. Pt. tolerated the procedure well. CPB time was 131, XCT 103. Pt. transferred to CSRU in stable condition with a MAP of 77, CVP 14, PAD 19, [Doctor First Name 1052] 25, HR 88 NSR. And he was being titrated on a Propofol gtt. Later this day propofol was weaned and pt was extubated. POD #1 - Pt. doing well and was transferred to telemetry floor. POD #2 - Chest tubes and foley removed. Pt. encouraged to ambulate. Hct 23.7, pt. rec.'d 1 UPRBC's. POD #3 - Hct 22.8., pt. transfused another unit of PRBC. L pleural effusion, IV lasix increased. Pacing wires removed. POD #4 - Hct is up to 27.8. Pt. cont. to improve, c/o sore throat. Coumadin started with a goal INR of [3-4].5. POD #6 - Pt. doing well, level 5. D/C home today with VNA services. Medications on Admission: Lopressor 50 [Hospital1 ] Lipitor 10 [Hospital1 ] ASA 325 [Hospital1 ] Vit C/Vit E 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. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by physician for an INR goal of [4-3].5. Disp:30 Tablet(s) Refills:2 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:120 Tablet(s) Refills:0 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO QD (once a day) for 10 days. Disp:20 Capsule, Sustained Release(s) Refills:0 11. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [5-7] hours as needed. Disp:50 Tablet(s) Refills:0 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Aortic stenosis s/p AVR w/ 21 mm St. Jude Valve Coronary artery disease s/p PTCA [73] yrs ago HTN ^chol. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 13248] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 13175] for 2-3 weeks. Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks. Completed by:[2166-3-21]	[ "V45.82", "401.9", "424.1", "272.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "99.04", "35.22" ]	icd9pcs	[ [ [] ] ]	4845, 4916	2159, 3097	375, 429	5069, 5076	1185, 2136	5319, 5572	788, 830		3243, 4822		4937, 5048		3123, 3220			5100, 5296											845, 1166																				285, 337								457, 553														575, 637	653, 772
12,089	185,999	52680+59453	Discharge summary	report+addendum	Admission Date: [2178-5-27] Discharge Date: [2178-6-6] Date of Birth: [2108-9-16] Sex: M Service: Medical Intensive Care Unit CHIEF COMPLAINT: Three day history of progressive dyspnea and lower extremity edema. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with a history of aortic valve replacement and atrial fibrillation on Coumadin, recently diagnosed with cryptogenic cirrhosis, pancytopenia, and splenomegaly, who presents with a three day history of increasing fatigue, lower extremity edema, and dyspnea. The patient is status post a three week hospitalization at [Hospital6 1129] following a three month history of anorexia, weight loss, weakness, and increasing abdominal girth. The patient was found with pancytopenia, hepatosplenomegaly, with increasing liver function tests. The patient underwent an extensive workup at [Hospital6 2121] including right heart catheterization, bone marrow aspirate, and biopsy, and transjugular liver biopsy with the diagnosis of pancytopenia with myelodiplasia, cryptogenic cirrhosis, splenomegaly, congestive heart failure, and mitral stenosis. A course of amiodarone (200 mg [Hospital1 ] from [2177-6-11] to [2178-1-11]) is the suspected culprit for cirrhosis. The patient was discharged on prednisone and Procrit as well as his prior medications including Lasix, Coumadin, Flomax, and thyroxine. Since discharge from [Hospital6 1129] on [5-23], the patient reports progressive shortness of breath with dyspnea at rest, orthopnea, increased malaise, increasing abdominal distention, and increasing lower extremity edema. The patient reports compliance with his medications, however, reports minimal oral intake with confinement to his bed secondary to weakness. The patient denies fevers, chills, nausea, vomiting, diarrhea, chest pain, confusion, as well as spontaneous bleeding. In the Emergency Department, the patient was found afebrile with a heart rate of 85, atrial fibrillation, blood pressure 108/58, respiratory rate 20, with an oxygen saturation of 95% on room air. The patient's chest x-ray revealed a new large right pleural effusion. Patient's initial laboratories were notable for an INR of 8.7. The patient was admitted to the Medicine [Hospital1 ] for a planned thoracentesis with correction of the INR. However, on the floor, the patient became hypoxic with an oxygen saturation of 90% on 2 liters nasal cannula, tachycardic with a heart rate in the 120s, and acutely short of breath. The initial arterial blood gas was 7.45/28/78 with a lactate of 7.3. A repeat chest x-ray with lateral decubitus demonstrated progressive increasing pleural effusion with complete whiteout. Repeat laboratories demonstrated a drop in hematocrit from 38.5 to 30.9, and increased INR to 21.4. The patient was transferred to the Medical Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Aortic stenosis status post aortic valve replacement in [2158]. 2. Type 2 diabetes mellitus (diet controlled). 3. Atrial fibrillation complicated by congestive heart failure. 4. Benign prostatic hypertrophy. 5. Osteoarthritis. 6. Left vocal cord trauma status post left vocal cord silicone implants. 7. Recurrent laryngeal nerve paralysis. 8. Cryptogenic cirrhosis status post transjugular biopsy, liver biopsy on [2178-5-15]. 9. History of pancytopenia status post bone marrow biopsy [2178-5-14]. 10. Splenomegaly. 11. Hypothyroidism secondary to amiodarone toxicity. 12. Congestive heart failure status post right heart catheterization with restrictive heart physiology on [2178-5-11]. 13. Status post cholecystectomy ([2155]). ALLERGIES: Heparin with a reaction of HITT. MEDICATIONS ON ADMISSION: 1. Flomax 0.4 mg po q day. 2. Lasix 20 mg po q day. 3. Ativan 0.25 mg po q hs. 4. Procrit 20,000 units subQ q week. 5. Thyroxine 25 mcg po q day. 6. Prednisone 20 mg po tid. 7. Zantac 150 mg po bid. 8. Coumadin 2.5 mg po q hs. SOCIAL HISTORY: The patient is a retired chief of Plastic Surgery at [Hospital1 69]. The patient is married with three grown children. The patient reports occasional alcohol, however, denies tobacco as well as illicit drug use. The patient reports progressive weakness and anorexia with approximate 50 pound weight loss over several months. The patient also reports postural instability times several months with several falls (denies head trauma, syncope, as well as loss of consciousness). The patient reports chronic cough productive of yellow sputum. Denies hemoptysis. The patient reports nocturia x2-3 without incontinence or hesitancy. The patient reports bilateral hand tremors. PHYSICAL EXAM ON TRANSFER TO THE MEDICAL INTENSIVE CARE UNIT: Temperature 97.4, heart rate 92, sinus, blood pressure 114/52, respiratory rate 24, and oxygen saturation of 98% on 15 liters of facemask. In general, the patient is a tired appearing, thin male in mild distress. HEENT examination: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation, no scleral icterus, dry mucous membranes, clear oropharynx, no oral bleeding. Neck supple, with 8-9 cm jugular venous distention, midline trachea, no lymphadenopathy with 2+ carotid pulses bilaterally. Pulmonary examination: Decreased breath sounds on the right approximately [4-14] of the way up with egophony with dullness to percussion. Left lung clear to auscultation. Cardiovascular examination: Regular, rate, and rhythm with a 3/6 systolic murmur at the left upper sternal border, no S3, S4 appreciated. Abdominal examination is notable for hepatosplenomegaly, nontender, and nondistended, with normoactive bowel sounds. Extremities: Warm and well perfused with trace lower extremity edema bilaterally to the knees, 2+ dorsalis pedis and posterior tibial pulses bilaterally. LABORATORIES AND STUDIES ON ADMISSION: Complete blood count with a white blood cell count of 5.8 with 87% polys, 0 bands, 5% monocytes, hematocrit 38.5, platelets 72. Chem-7 with a sodium of 145, potassium 3.9, chloride 99, bicarb 24, BUN 27, creatinine 1.1, and glucose of 197. Admission coags with a PT of 36.2, INR 8.7, and PTT of 55.1. Admission LFTs with a total bilirubin of 3.9, ALT of 100, AST 80, alkaline phosphatase 190, albumin 2.8, amylase 48, calcium 8.3, magnesium 2.0, and phosphate 2.6. CHEST X-RAY: New large right pleural effusion, stable cardiomegaly, status post aortic valve replacement and left lung without acute cardiopulmonary process. HOSPITAL COURSE: DR.[Last Name (STitle) ],[First Name3 (LF) ] 11-933 Dictated By:[Name8 (MD) 4935] MEDQUIST36 D: [2178-6-7] 14:11 T: [2178-6-11] 09:26 JOB#: [Job Number ] Name: [Known lastname 17796], [Known firstname 422] Unit No: [Numeric Identifier 17797] Admission Date: [2178-5-27] Discharge Date: [2178-6-6] Date of Birth: [2108-9-16] Sex: M Service: MICU ADDENDUM: This is a continuation of prior Dictation Summary that was inadvertently interrupted by phone disconnection. Continuing with the [Hospital 1325] hospital course: The patient was transferred to the Medical Intensive Care Unit in acute respiratory distress with progressively enlarging right pleural effusion. The patient underwent a right thoracentesis with 1.5 liter bloody drainage with significant symptomatic improvement. However, after approximately 30 minutes, the patient again developed acute respiratory distress with tachypnea, tachycardia, hypotension, and oxygen desaturation. A repeat chest x-ray demonstrated pleural effusion reaccummulation and CT Surgery was called for emergent chest tube placement. On chest tube placement, another 2 liters of blood was drained from the right lung. Two central lines (right groin and right subclavian) were placed emergently, packed red blood cells, intravenous fluids, and FFP were infused, and the patient was taken emergently to the Operating Room. The patient underwent right VATS with evacuation of the right hemothorax and therapeutic epinephrine injection of a pleural tear at the junction of the IVC to the inferior pulmonary vein. In the Operating Room, the patient received a total of 11 units of packed red blood cells, 18 units of FFP, 15 units of platelets, and 1 unit of cryoprecipitate as well as 3 grams calcium chloride, 100 mEq of sodium bicarbonate, and sedatives. The patient's initial ABG postintubation was 7.22/47/213 with a lactate of 6.0. The patient returned to the Medical Intensive Care Unit, intubated and sedated with two chest tubes in place. The patient remained intubated overnight given his large volume load in the Operating Room with concern for recurrent bleed. The patient remained hemodynamically stable overnight with a stable oxygen requirement. No anticoagulation was started given the concern for recurrent bleed. On the morning of hospital day number two, the patient's pleural fluid culture returned with E. coli growth, pan sensitive. Blood cultures and urine cultures were obtained and the patient was subsequently started on levofloxacin. Later on hospital day number two, prior to extubation, the patient acutely decompensated with hypotension, increase oxygen requirement, and decreased urine output. The patient also developed atrial fibrillation with rapid ventricular rate and underwent failed DC cardioversion times two. A bedside echocardiogram demonstrated a hyperdynamic underfilled heart with no evidence of wall motion abnormality or pericardial effusion. The patient was given a fluid challenge with minimal blood pressure response and was subsequently started on blood pressure support including Neo-Synephrine and dopamine to maintain mean arterial pressures greater than 65. The remainder of the [Hospital 1325] hospital course was notable for E. coli sepsis with multiorgan system failure including liver failure with increasing total bilirubin (maximum 33 on [2178-6-6]) and coagulopathy requiring frequent FFP transfusion, progressive anuric renal failure with persistent lactic acidosis, hypoxic respiratory failure requiring continuous ventilatory support with MRSA pneumonia, and continuous requirement for blood pressure support. The patient remained in atrial fibrillation, rate controlled on digoxin. The patient remained anuric throughout the remainder of the hospitalization with total body overload, however, relative intravascular volume depletion requiring frequent fluid boluses to facilitate organ perfusion. The patient was initially started on broad spectrum antibiotics given the overwhelming sepsis. However, antibiotics were eventually tailored to cover known pathogens including E. coli and methicillin-resistant Staphylococcus aureus (blood and sputum). Despite negative culture data from [2178-6-1] on, the patient's white blood cell count continued to rise without known source for recurrent infection. The patient was evaluated by the Renal Service for CVVH, however, given the patient's unstable blood pressure and multiorgan failure, CVVH was deemed potentially detrimental to the patient's current health situation. On [2178-6-4], the patient underwent repeat cardiac echocardiogram with evidence of an echodense lesion in the right atrium consistent with right atrial thrombus. The patient was already coagulopathic and there was minimal therapeutic options at this point. On [2178-6-6], with progressive decline including persistent elevated lactate and electrolyte abnormalities, the patient developed a junctional rhythm with progressive hypotension on maximal supportive therapy. No CPR was performed and the patient subsequently expired. DISCHARGE DIAGNOSIS: 1. Right hemothorax. 2. Atrial fibrillation with rapid ventricular rate. 3. Aortic valve replacement. 4. E. coli sepsis. 5. Hypotension requiring pressors. 6. Hypoxic respiratory failure requiring ventilatory support. 7. Anuric renal failure secondary to acute tubular necrosis. 8. Methicillin-resistant Staphylococcus aureus bacteremia. 9. Methicillin-resistant Staphylococcus aureus pneumonia. 10. Liver failure secondary to septic shock. 11. Cirrhosis. 12. Coagulopathy. 13. Upper gastrointestinal bleed. 14. Pancytopenia. 15. Ileus. 16. Hypothyroidism. 17. Diabetes mellitus. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 36], M.D. Dictated By:[Name8 (MD) 2285] MEDQUIST36 D: [2178-6-7] 02:32 T: [2178-6-7] 15:19 JOB#: [Job Number 17798]	[ "518.81", "998.2", "998.11", "427.31", "584.5", "511.1", "038.42", "482.41", "276.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.09", "34.91", "99.15", "34.04" ]	icd9pcs	[ [ [] ] ]											11809, 12638		3774, 4002	7215, 11788																																	173, 242								271, 2926							5928, 6557							2948, 3748	4019, 5913
21,004	171,714	24158+24159+57390	Discharge summary	report+report+addendum	Admission Date: [2179-4-5] Discharge Date: Date of Birth: [2113-3-1] Sex: F Service: VSU CHIEF COMPLAINT: Bilateral ankle ulcerations. HISTORY OF PRESENT ILLNESS: This is a 66-year old female with a history of congestive heart failure, diabetes, and peripheral vascular disease who presents with 6 weeks of bilateral medial malleolar ulcerations and bilateral lower extremity cellulitis (right greater than left). This has been complicated by a recent (4.5 weeks ago) medial malleolar fracture. The patient also complains of bilateral foot pain which is worse with a.m. ambulation. Ulcer healing has waxed and waned. The patient was referred here for further evaluation and treatment. She denies any shortness of breath, chest pain, weakness, numbness, amaurosis, fevers, chills. Does admit to nausea. Denies vomiting. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Include Lipitor 10 mg daily, Avandia 4 mg b.i.d., aspirin 81 mg daily, Zantac 150 mg b.i.d., Colace 100 mg b.i.d., Senokot tablets 1 b.i.d., allopurinol 100 mg b.i.d., Vicodin tablets 1 q.12h. p.r.n., Lasix 80 mg daily, Compazine 10 mg q.6h. p.r.n., Procrit 40,000 units subcutaneously weekly, Diovan, hydrochlorothiazide daily. PHYSICAL EXAMINATION: Vital signs of 98.5, 96, 22, blood pressure of 146/82, oxygen saturation of 95%. General appearance is a very pleasant white female in no acute distress. Neurological exam is remarkable for left facial drooping. Chest exam reveals lungs are with crackles bilaterally at the bases. Heart has a regular rate and rhythm without murmur. HEENT exam shows bilateral carotid bruits and JVD. Abdominal exam is unremarkable. Extremity exam with 2+ edema bilaterally with shallow ulcerations on the medial aspect of both ulcerations. Pulse exam shows palpable radial's and femoral's bilaterally. DP's are triphasic signals only. PT's are monophasic Dopplerable signals on the right and triphasic on the left. HOSPITAL COURSE: The patient was admitted to the vascular service. Wound cultures were obtained. Cardiology medicine was requested to see the patient because of her congestive heart failure on admission chest x-ray. The patient was transferred to the medicine service for further evaluation and treatment of congestive heart failure. The patient an echocardiogram done which showed symmetrical left ventricular hypertrophy with global and regional systolic dysfunction, consistent with multivessel coronary artery disease or other diffuse process. In the absence of systolic hypertension and infiltrative process should be considered. There is moderate pulmonary systolic hypertension, moderate tricuspid regurgitation, right ventricular cavity is enlarged, free wall is hypokinetic. The patient underwent a myocardial perfusion stress which demonstrated a transient dilatation of the left ventricle with stress. The stress perfusion images showed a moderate reduction in tracer distribution involving the mid and distal inferolateral wall. He rest perfusion images demonstrated this defect to be reversible. Stress perfusion images additionally demonstrate a moderate defect in the tracer uptake of the apex, and this defect was partially reversible. The stress also demonstrated moderately reversible defects in the mid and distal anteroseptal wall. Calculated ejection fraction was 29%. Once the patient was compensated for her congestive heart failure and her renal function stabilized, she underwent a cardiac catheterization on [2179-4-13] with documented 3- vessel disease with markedly elevated and right and left- sided filling pressures. She underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ]/diagonal and an angioplasty to the LAD with partially successful PTCA of the right coronary. This was transected by catheter during the catheterization. The patient was transferred to the CCU for continued monitoring and rule out. Troponin levels were 0.59, 0.19, 0.08. The patient remained on the cardiology service. Aspirin, Plavix, and Lopressor were continued. She required a transfusion for a low hematocrit. This was related to her chronic myelodysplasia disorder. A transesophageal echocardiogram was obtained immediately post cardiac catheterization. There was a small pericardial effusion. There was no echocardiographic sign of tamponade. The patient did experience contrast renal failure post cardiac catheterization and required aggressive treatment for hyperkalemia. The peak creatinine was 3.0. The patient finally returned to baseline renal function with a creatinine of 1.9 on [2179-4-21]. The patient was transferred to the vascular service that same day. The patient was pre hydrated with Mucomyst and sodium bicarbonate infusion and underwent a peripheral arteriogram on [2179-4-22]. The patient tolerated the procedure. She was without hematoma, and her creatinine remained stable. The patient was seen by the orthopaedic service for her ankle fracture. Recommendations were bivalved cast with nonweightbearing and that further surgical orthopaedic intervention would be done after her cardiac and peripheral vascular problems were addressed. The patient requested on [2179-4-23] a desire to be discharged to home during the [Holiday ] holiday. Dr. [Last Name (STitle) 1391] was agreeable. The patient has discussed this with family and made arrangements for discharge over the weekend. The patient will return on [4-26] to be readmitted for elective revascularization of the right lower extremity on [2179-4-27]. MEDICATIONS ON DISCHARGE: 1. Atorvastatin 80 mg daily. 2. Enteric coated aspirin 325 mg daily. 3. Plavix 75 mg daily. 4. Metoprolol sustained release 50 mg daily. 5. Isosorbide mononitrate 30 mg daily. 6. Colace 100 mg b.i.d. 7. Protonix 40 mg daily. 8. Hydrocodone/acetaminophen 5/500-mg tablets 1 to 2 tablets q.6h. p.r.n. (for pain). 9. Hydralazine 50 mg q.6h. 10. Calcium carbonate 500 mg daily. 11. Vitamin D3 400-unit tablet daily. 12. Glargine insulin 15 units at bedtime. 13. Regular insulin sliding scale before meals and at bedtime as follows: Glucose less than 150 use 1 unit, glucose of 151 to 200 use 3 units, glucose of 201 to 250 use 5 units, glucose of 251 to 300 use 7 units, glucose of 301 to 350 use 9 units, glucose of 351 to 400 use 11 patient will be instructed regarding insulin usage and administration prior to discharge. DISCHARGE DIAGNOSES: 1. Bilateral medial malleolar ischemic ulcerations. 2. Type 2 diabetes; uncontrolled. 3. New insulin-dependent diabetic. 4. Myelodysplastic anemia; refractory - transfused. 5. Congestive heart failure; compensated. 6. Chronic renal insufficiency exacerbated by contrast- induced acute tubular necrosis. 7. Coronary artery disease with a positive stress test; status post arteriogram with stenting of the left anterior descending/diagonal and angioplasty of the left anterior descending with attempted angioplasty of the right coronary artery with catheter transection resulting in a myocardial infarction. RECOMMENDED FOLLOWUP: The patient is recommended to be readmitted on [2179-4-26] for elective revascularization on [2179-4-27]. MAJOR SURGICAL-INVASIVE PROCEDURES: 1. Arteriogram of pelvic vessels and right leg runoff on [2179-4-22]. 2. Cardiac catheterization with intervention on [2179-4-13]. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2179-4-23] 16:46:20 T: [2179-4-23] 18:11:36 Job#: [Job Number 61381] Admission Date: [2179-4-5] Discharge Date: [2179-5-6] Date of Birth: [2113-3-1] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 4748] Chief Complaint: B/L ankle ulcers Major Surgical or Invasive Procedure: angiogram with pelvic vessels and rt. leg runoff [2179-4-22] cardiac cath with [Month/Day/Year ] of lad/Dg1, PTCA of lad, attempted PTCA of RCA with catheter transection [2179-4-13] rt. CFA-akpop-at w NRSVG,angioscopy and valve lysis [2179-4-27] History of Present Illness: This is a 66yo F with history of congestive heart failure, diabetes mellitus, peripheral vascular disease who presents with 6 weeks history of bilateral medial malleoulus ulcers (complicated by recent PTA fracture) and bilateral lower extremities cellulitis(R>L). She was admitted under vascular surgery. In pre-op assessment by medicine, she noted to have abnormal pMIBI Past Medical History: 1.CHF 2.myelodysplasia with refractory anemiarequiring transfusion and procrit 3.hypercholesterolemia 4.diabetes on oral hypoglycemics 5.s/p CVA 14years ago(no residual weakness) 6.peripheral vascular disease 7.CAD 8.gout 9.partial thyroidectomy 10.HITT Social History: retired medical transciptionistlives alone lives alone neg etoh neg ivda neg tob Family History: deferred Physical Exam: Vital signs of 98.5, 96, 22, blood pressure of 146/82, oxygen saturation of 95%. General appearance is a very pleasant white female in no acutedistress. Neurological exam is remarkable for left facial drooping. Chest exam reveals lungs are with crackles bilaterally at the bases. Heart has a regular rate and rhythm without murmur. HEENT exam shows bilateral carotid bruits and JVD. Abdominal exam is unremarkable. Extremity exam with 2+ edema bilaterally with shallow ulcerations on the medial aspect of both ulcerations. Pulse exam shows palpableradial's and femoral's bilaterally. DP's are triphasic signals only. PT's are monophasic Dopplerable signals on the right and triphasic on the left. Pertinent Results: echo [4-7] The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis with regional akinesis of the distal half of the septum, severe hypokinesis of the inferior wall, and mild apical dyskinesis. No intracavitary thrombus is seen. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion. MIBI3/10: 1. Moderate, reversible defect involving the mid and distal inferolateral wall. 2. Moderate, partially reversible defect involving the apex. 3. Moderate, reversible defect involving the mid and distal anteroseptal wall. 4. Transient left ventricular dilatation with stress. Global hypokinesis with ejection fraction of 29%. IMPRESSION: Symmetric left ventricular hypertrophy with global and regional systolic dysfunction c/w multivessel CAD (or other diffuse process; in the absence of a history of systolic hypertension, an infiltrative process should be considered). Moderate pulmonary artery systolic hypertension. Moderate tricuspid regurgitation. Right ventricular cavity enlargement/free wall hypokinesis. arterial study [2179-4-6] Moderate diffuse calcified plaque with bilateral less than 40% carotid stenosis. Significant aorto-right iliac and bilateral superficial femoral artery occlusive disease.ABI right 0.83, left 0.66 cath [4-13]: CO/CI 4.37/2.73 PCWP 36 CVP 19 PAP 67/32 LMCA-OK LAD-mid 99%, distal TO, D1 70% prox LCX-30% prox, 50% before OM1 RCA-90% after AM 3VD with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]/D1 and PCA LAD, partially successful PTCA RCA Vein mapping [4-26] TECHNIQUE AND FINDINGS: [Doctor Last Name ] scale examination was performed at the level of the superficial veins of the bilateral upper extremities with compression maneuvers. In the upper extremities, the bilateral cephalic and basilic veins are patent and fully compressible. Their caliber varies between 2.8 mm and 4.2 mm for the right cephalic vein, between 1.5 and 3.9 mm for the right basilic vein, between 2.3 and 3.0 mm for the left cephalic vein, and between 2.6 and 4.7 mm for the left basilic vein. CONCLUSION: Pre-operative vein mapping with patency of the bilateral cephalic and basilic veins and dimensions as stated above. [2179-5-5] WBC-6.7 RBC-2.71* Hgb-8.3* Hct-24.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-15.7* Plt Ct-119* [2179-5-5] PT-14.2* PTT-28.4 INR(PT)-1.3 [2179-5-5] Glucose-120* UreaN-61* Creat-1.1 Na-141 K-4.9 Cl-105 HCO3-30* AnGap-11 [2179-5-5] Calcium-8.4 Phos-2.7 Mg-2.1 Brief Hospital Course: The patient was admitted to the vascular service. Wound cultures were obtained. Cardiology medicine was requested to see the patient because of her congestive heart failure on admission chest x-ray. The patient was transferred to the medicine service for further evaluation and treatment of congestive heart failure. The patient an echocardiogram done which showed symmetrical left ventricular hypertrophy with global and regional systolic dysfunction, consistent with multivessel coronary artery disease or other diffuse process. In the absence of systolic hypertension and infiltrative process should be considered. There is moderate pulmonary systolic hypertension, moderate tricuspid regurgitation, right ventricular cavity is enlarged, free wall is hypokinetic. The patient underwent a myocardial perfusion stress which demonstrated a transient dilatation of the left ventricle with stress. The stress perfusion images showed a moderate reduction in tracer distribution involving the mid and distal inferolateral wall. He rest perfusion images demonstrated this defect to be reversible. Stress perfusion images additionally demonstrate a moderate defect in the tracer uptake of the apex, and this defect was partially reversible. The stress also demonstrated moderately reversible defects in the mid and distal anteroseptal wall. Calculated ejection fraction was 29%. Once the patient was compensated for her congestive heart failure and her renal function stabilized, she underwent a cardiac catheterization on [2179-4-13] with documented 3- vessel disease with markedly elevated and right and left- sided filling pressures. She underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ]/diagonal and an angioplasty to the LAD with partially successful PTCA of the right coronary. This was transected by catheter during the catheterization. The patient was transferred to the CCU for continued monitoring and rule out. Troponin levels were 0.59, 0.19, 0.08. The patient remained on the cardiology service. Aspirin, Plavix, and Lopressor were continued. She required a transfusion for a low hematocrit. This was related to her chronic myelodysplasia disorder. A transesophageal echocardiogram was obtained immediately post cardiac catheterization. There was a small pericardial effusion. There was no echocardiographic sign of tamponade. The patient did experience contrast renal failure post cardiac catheterization and required aggressive treatment for hyperkalemia. The peak creatinine was 3.0. The patient finally returned to baseline renal function with a creatinine of 1.9 on [2179-4-21]. The patient was transferred to the vascular service that same day. The patient was pre hydrated with Mucomyst and sodium bicarbonate infusion and underwent a peripheral arteriogram on [2179-4-22]. The patient tolerated the procedure. She was without hematoma, and her creatinine remained stable. The patient was seen by the orthopaedic service for her ankle fracture. Recommendations were bivalved cast with nonweightbearing and that further surgical orthopaedic intervention would be done after her cardiac and peripheral vascular problems were addressed. The patient requested on [2179-4-23] a desire to be discharged to home during the [Holiday ] holiday. Dr. [Last Name (STitle) 1391] was agreeable. The patient has discussed this with family and made arrangements for discharge over the weekend. The patient will return on [4-26] to be readmitted for elective revascularization of the right lower extremity on [2179-4-27]. Pt readmitted to vascular surgery for elective revascularization of the right lower extremity. On [4-27] patient underwent a Right femoral to anterior tibialis bypass graft with composite PTFE and vein graft. Transfered to the PACU in stable condition. Pt was transfused with 2 units PRBC post procedure. With the following drop in HCT a Heme/Onc consult was put in. They diagnosed the person with HITT, All heparin was DC'd. Pt' HCT and PLT improved after heparin items were Dc'd. On [2179-5-3] pt foley was DC'd, she was allowed OOB to chair, A PT / Case management consult was put in. On discharge pt is stable, able to urinate taking PO, and ambulating with asst. Medications on Admission: lipitor 10, vandia 4", asa 81', zantac 150", colace 100", senna 1", allopurinol 100", vicodin 1"", lasix 80', compazine 10, recently d/c'd metformin, toprol 200', diovan, procrit 40,000 Discharge Medications: 1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:2 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). [Date Range ]:30 Tablet Sustained Release 24HR(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). [Date Range ]:120 Tablet(s) Refills:2 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). [Date Range ]:100 Tablet, Chewable(s) Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Glargine 100 unit/mL Cartridge Sig: Fifteen (15) units Subcutaneous at bedtime. [Date Range ]:qs 2 Refills:2 12. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day: AC/HS sliding scale: glucoses <150/1 units insulin glucoses 151-200/3u glucoses 201-250/5u glucoses 251-300/7u glucoses 301-350/9u glucoses 351-400/11u glucoses >400 [Name8 (MD) 138] Md. [Last Name (Titles) ]:qs Refills:2 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: bilateral ankle ulcers diabetes type 2,uncontrolled, new insulin dependant myleodysplastic anemia, refractory,transfused CHF,compensated [4-3] chronic renal insuffiency with contrast incude ATN,resolved CAD w + stress [4-3],s/p angiio with stenting of LAD,Dg1,Ptca of Lad, PTCA-rca with catheter transection, MI Discharge Condition: stable Discharge Instructions: Look at wound care and PT instructions Followup Instructions: 2 weeks w Dr. [Last Name (STitle) 1391]. call for appointment [Telephone/Fax (1) 1393]. He will take staples out when he see her in the office. Completed by:[2179-5-6] Name: [Known lastname ],[Known firstname 1940] Unit No: [Numeric Identifier 11123] Admission Date: [2179-4-5] Discharge Date: [2179-5-6] Date of Birth: [2113-3-1] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 231] Addendum: planned discharge to home for [Holiday ] weekend was cancelled because family was not avaible to care for patinet. Discharge Disposition: Extended Care Facility: [Hospital6 2876] - [Location (un) 4415] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2179-5-6]	[ "428.0", "E928.9", "824.8", "238.7", "584.5", "287.4", "707.13", "414.01", "998.2", "423.9", "V58.67", "285.9", "440.23", "250.02", "997.5", "E870.6", "682.6", "E934.2" ]	icd9cm	[ [ [] ] ]	[ "93.53", "36.05", "88.42", "36.07", "39.29", "99.04", "88.48", "88.56", "37.23", "00.13", "99.20" ]	icd9pcs	[ [ [] ] ]	20700, 20930	13003, 17292	8045, 8309	19935, 19943	9846, 12980	20030, 20677	9104, 9114	6507, 7451	17528, 19478		19592, 19914	5622, 6486	17318, 17505	1988, 5596		19967, 20007											9129, 9827													1270, 1970							7989, 8007								8337, 8711														8733, 8989	9005, 9088	7476, 7972
69,660	101,858	4476	Discharge summary	report	Admission Date: [2199-4-23] Discharge Date: [2199-4-24] Service: SURGERY Allergies: Keflex / Bactrim Attending:[First Name3 (LF) 148] Chief Complaint: Hemodynamic instability with right retroperitoneal bleed. Major Surgical or Invasive Procedure: Arteriogram of right kidney. Coil embolization of right lower pole renal artery branch bleed. History of Present Illness: 93-y.o. male h/o CAD, COPD, and worsening renal insufficiency, recently admitted to [Hospital1 18] [Date range (1) 19174] for worsening renal insufficiency leading to volume overload. He underwent a R renal biopsy on [2199-4-10]. His renal failure was managed with steroids, the volume overload with diuretics, and a UTI with meropenem from [Date range (1) 19175]. His aspirin was held for 5days pre- and post- renal biopsy. He has been doing well at rehab until last evening when began to experience R flank and abdominal pain. Brought to [Location (un) 620] ED where hemodynamically borderline, Hct 26.5 (prior 28.5 on [4-18]), and CT non-contrast showed R retroperitoneal hematoma. Bolused 2L [Hospital 19176] transferred to [Hospital1 18] ED, received 2u PRBC en route. On arrival initial BP 70/40 and emergent surgical consult requested. Pt currently reports notable R-flank pain, denies abd pain, and has mild dyspnea. Denies chest pain. Remaining interview truncated for placement of CVL. Past Medical History: CAD s/p velocity stent x2 to RCA [2190] Diastolic CHF (EF 55% [2-/2199]) Hypertension Hypercholesterolemia COPD on 2L home O2 Chronic renal insufficiency (recent exacerbation s/p R renal bx) L parotid cancer BPH Obesity PAST SURGICAL HISTORY: EVAR [4-/2193] Debridement and closure of R3 toe [2-/2199] Bilateral cataracts [5-/2189] and [4-/2190] Social History: Retired. The patient is widowed, two children, 4 grandchildren, 7 great-grandchildren. -Tobacco history: 40+ pack year history, quit in [2148], smoke a pipe until [2181] -ETOH: none currently, whiskey daily for many years, stopped two months ago -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Sister and brother had strokes. Father had CAD. Mother had an "enlarged heart." Physical Exam: On admission: Dopamine gtt 15 T 96.5 P 124 BP 122/68 RR 22 O2sat 100 on NRB A&Ox3, uncomfortable and moaning Lungs CTAB Heart RRR / tachy Abdomen soft, NT, ND, ecchymoses across lower abdomen bilaterally (c/w subcutaneous injections) R flank diffusely tender No L CVA tenderness Pertinent Results: [2199-4-23] 05:23AM WBC-20.0# RBC-2.99 HGB-8.7* HCT-26.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.8 [2199-4-23] 05:23AM NEUTS-88.0* LYMPHS-8.9* MONOS-3.0 EOS-0 BASOS-0 [2199-4-23] 05:23AM PLT COUNT-78# [2199-4-23] 05:23AM PT-13.7 PTT-31.2 INR(PT)-1.2* [2199-4-23] 05:23AM GLUCOSE-184* UREA N-132* CREAT-2.5* SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 [2199-4-23] 05:23AM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-38* TOT BILI-0.4 [2199-4-23] 05:23AM LIPASE-51 [2199-4-23] 05:23AM ALBUMIN-2.1* [2199-4-23] 05:23AM cTropnT-0.08* [2199-4-23] 06:55AM HCT-33.7# [2199-4-23] 11:54AM TYPE-ART PO2-78 PCO2-43 PH-7.38 TOTAL CO2-26 BASE XS-0 [2199-4-23] 11:54AM LACTATE-5.1* [2199-4-23] 12:10PM WBC-31.1# RBC-3.25 HGB-9.5* HCT-27.6* MCV-85 MCH-29.1 MCHC-34.4 RDW-15.6* [2199-4-23] 12:10PM PLT COUNT-123# [2199-4-23] 01:44PM TYPE-ART PO2-78 PCO2-45 PH-7.35 TOTAL CO2-26 BASE XS-0 [2199-4-23] 01:44PM LACTATE-4.8* [2199-4-23] 04:16PM WBC-27.9* RBC-3.30* HGB-9.5* HCT-27.4* MCV-83 MCH-28.8 MCHC-34.7 RDW-15.7* [2199-4-23] 04:16PM PLT SMR-LOW PLT COUNT-83* [2199-4-23] 04:52PM TYPE-ART PO2-185* PCO2-47* PH-7.39 TOTAL CO2-30 BASE XS-3 [2199-4-23] 04:52PM LACTATE-4.7* [2199-4-23] 08:40PM WBC-30.9* RBC-3.63* HGB-10.5* HCT-29.3* MCV-81* MCH-28.9 MCHC-35.9* RDW-15.9* [2199-4-23] 08:40PM PLT COUNT-85* [2199-4-23] 08:54PM TYPE-ART PO2-111* PCO2-50* PH-7.38 TOTAL CO2-31* BASE XS-3 [2199-4-23] 08:54PM LACTATE-4.3* Brief Hospital Course: On [2199-4-23] morning, the patient was admitted to the SICU for retroperitoneal bleed and started on norepinephrine gtt for hemodynamic instability. Family was [Name (NI) 653], and the surgical team discussed and confirmed DNR/DNI status and treatment wishes with patient and family. According to patient's wishes, he underwent endovascular arteriographic coil embolization by interventional radiology. Throughout the day, the patient received a total of 11 units PRBC, 6 units FFP, and 2 units platelets to maintain hemodynamic stability. He remained stable on norepinephrine gtt after the procedure. On [2199-4-24] early morning, he suffered respiratory distress with increased oxygen requirement, and CXR showed near complete opacification of the right lung, likely secondary to mucous plug. Bronchoscopy was offered, which would have required intubation with low likelihood of successful extubation, and patient and family understood and declined in accordance to DNR/DNI wishes. Over the subsequent few hours, the patient suffered respiratory failure and expired at 0715. The family declined autopsy. Medications on Admission: prednisone 60 mg daily ASA 81 mg daily metoprolol 50 mg [Hospital1 ] lisinopril 2.5 mg daily, isosorbide dinitrate 40 mg TID doxazosin 2 mg daily lasix 120 mg daily simvastatin 20 mg dailiy nitro SL PRN spiriva 18 mcg daily atrovent PRN albuterol PRN omeprazole 20 mg dailyi lidocaine 5% patch colace 100 mg [Hospital1 ] vit D2 50,000 units Qweek cyanocobalamin 1000 mcg daily calcium carbonate 500 mg TID acetaminophen PRN senna PRN trazadone 50 mg QHS PRN Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Retroperitoneal bleed. Respiratory failure. Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None needed. Completed by:[2199-4-24]	[ "902.41", "428.32", "V66.7", "441.4", "414.01", "272.4", "998.11", "V10.02", "428.0", "785.59", "403.90", "585.9", "V45.82", "440.20", "600.00", "V15.82", "V46.2", "278.00", "496", "584.5", "518.81", "E879.8" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.42", "39.79", "88.45" ]	icd9pcs	[ [ [] ] ]	5917, 5926	4243, 5371	280, 375	6013, 6023	2660, 4220	6118, 6161	2145, 2342		5887, 5894		5947, 5992		5397, 5864			6047, 6095									1715, 1835		2357, 2357																				183, 242								403, 1441							2371, 2641							1463, 1692	1851, 2129
62,543	150,489	53944	Discharge summary	report	Admission Date: [2113-4-19] Discharge Date: [2113-5-9] Date of Birth: [2077-9-28] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1185] Chief Complaint: cardiac arrest, seizure Major Surgical or Invasive Procedure: - none History of Present Illness: 35 y/o female with hx of HCV s/p recent bowel perforation 1 month ago surrounding a complicated ERCP presents s/p report of cardiac arrest and seizures. Per report, patient was at home with her sister when she sufferred a seizure. The patient has been feeling lethargic for the last several days, and today was found by her sister to be "shaking" on the couch with seizure like activity, clenching her jaw with staring and rigid posturing. Her sister called the neighbor over who is an MA, and no pulse could be palpated so CPR was intiated and 911 was called. Emergency responders arrived, the patient was placed on an AED and had reportedly two shocks with return of spontaneous circulation. During this time, patient started to have seizues with bladder incontinence. She was taken to [Hospital3 ] where vitals were BP 132/72, HR 131, satting 100% on RA with no recroded RR. Patient was intubated and given fosphenytoin, phenobarbital, diazepam, and propfol without resolution of her seizures. EKG at the OSH showed sinus tachycardia to 133, normal axis, normal intervals, flattened TW in AvL and V1 with good R wave progression in the anterior leads. Labs were significant for an EtOH <10, WBC of 37.4 with 28.9 absolute PMN count, HCT of 39.5, plts of 502. . In the ED, nursing notes document patient seizing on arrival. She was given 2 mg of midazolam Initial VS were: temp 102.6, Labs showed WBC of 24.5, H/H 10.7/33.7, K 2.6, lactate 2.4. ABG showed 7.38/31/139. Blood cultures were sent. Given continued sizure activity given another 2 mg of midazolam 10 minutes after inital dose. Neurology, surgery, and the Post-Arrest team were consulted. A propofol gtt was titrated to sedation to control seizure activity. Surgery rec'd a CT A/P which showed stable positioning of patient's perc drain with minimal resolution of prior fluid collection and no evidence of new collections or abscesses. Neuro rec'd to continue the cooling protocol with EEG, check dilantin level and continue 100mg q8hrs, obtain LP to eval for infectious source of fevers and seizure, and to consider loading with Keppra or start midazolam drip if continued seizures. LP was done which showed no evidence of infection. Given fevers, she was given vancomycin 1gm, zosyn 4.5gm, acetaminophen 650mg PR, and IV potassium repletion and sedated with fentanyl and versed. EKG showed shivering artifact but evidence was ventricular bigeminy and sinus waves. No troponins were present at time of ICU admission. Cooling protocal initaited at 0350 hrs with temperature prob in foley and rectum. Patient was started on fentanyl and midazolam at this time prior to transfer to the floor. At 4:10 AM pt was noted to be awake, pulling at lines and tubing with noted seizure activity, moving extremities but not collowing commands. Midazolam gtt was uptitrated. . On arrival to the MICU, patient is intubated on the vent shaking with Arctic Sun cooling being underway. Rectal and bladder temperature probes were affirmed by patient's nurse. Past Medical History: Perforated bowel Heroin Abuse ERCP on [2113-3-10] HCV migraines Chronic LBP Anxiety/Depression CBD stones Cholilithiasis History of sphincterotmy complicated by duodenal perforation Social History: Unemployed and currently homeless, though she stays frequently with her ex-husband/sister. Two children ages 3 and 5. +Tobacco use, 1PPD currently. Denies ETOH. Uses heroin, marijuana regularly. Family History: Mother and sister with symptomatic cholelithiasis requiring CCY. Father died in [2107] from MI, mother, alive, with alcoholic cirrhoisis. Physical Exam: On admission to ICU: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Coarse to auscultation bilaterally. No wheezes Abdomen: Abdominal scar located midline. Abdominal distention with respiratory effort. Bowel sounds present, no organomegaly appreciated. Purulent drainage from grenade drain on right. GU: clear urine Ext: cold to touch with mottled appearance. 2+ pulses. Prior IV site on dorsum of left hand. PIVs in antecubital vv bilaterally. Neuro: Unconscious sedated on vent. Gag reflex. Pupils from 6 to 2-3 mm with light. Right corneal reflex intact, left not brisk to corneal irritation. Decerabrate posturing. Down going babinski's b/l with 2+ patellar/bicipital reflexes b/l. Discharge Exam: General: pt awake, NAD Skin: PICC site no erythema, mild crusting, last changed on [5-1]. HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended. Surgical incision site intact, no erythema, no drainage. mild tenderness to palpation over incision site, tenderness over drain site improved. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: no focal deficits Pertinent Results: [2113-4-19] 02:25AM BLOOD WBC-24.5* RBC-3.69* Hgb-10.7* Hct-33.7* MCV-92 MCH-28.9 MCHC-31.6 RDW-14.1 Plt Ct-386 [2113-4-19] 02:25AM BLOOD Neuts-81.0* Lymphs-13.3* Monos-5.3 Eos-0.2 Baso-0.2 [2113-4-19] 02:25AM BLOOD Plt Ct-386 [2113-4-19] 02:25AM BLOOD Fibrino-338 [2113-4-19] 06:28AM BLOOD Glucose-124* UreaN-3* Creat-0.7 Na-145 K-4.1 Cl-112* HCO3-17* AnGap-20 [2113-4-19] 02:25AM BLOOD ALT-17 AST-31 AlkPhos-107* TotBili-0.4 [2113-4-19] 02:25AM BLOOD Lipase-76* [2113-4-19] 02:25AM BLOOD cTropnT-0.06* [2113-4-19] 06:28AM BLOOD CK-MB-4 cTropnT-<0.01 [2113-4-19] 01:20PM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-<0.01 [2113-4-19] 03:35PM BLOOD CK-MB-14* MB Indx-1.5 cTropnT-<0.01 [2113-4-20] 09:02AM BLOOD CK-MB-13* MB Indx-1.9 cTropnT-<0.01 [2113-4-19] 06:28AM BLOOD Calcium-7.1* Phos-3.8 Mg-1.1* [2113-4-20] 07:37AM BLOOD HCG-<5 [2113-4-20] 06:00AM BLOOD Vanco-35.2* [2113-4-21] 07:00AM BLOOD Vanco-8.5* [2113-4-22] 06:48PM BLOOD Vanco-7.3* [2113-4-27] 05:14AM BLOOD Vanco-46.1* [2113-4-27] 01:07PM BLOOD Vanco-14.1 [2113-5-1] 07:45AM BLOOD Vanco-24.3* [2113-4-20] 06:00AM BLOOD Phenyto-11.7 [2113-4-30] 10:20PM BLOOD Phenyto-11.5 [2113-4-19] 02:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-POS Tricycl-NEG [2113-4-19] 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-POS Tricycl-NEG [2113-4-19] 02:32AM BLOOD pO2-139* pCO2-31* pH-7.38 calTCO2-19* Base XS--5 [2113-4-19] 02:32AM BLOOD Glucose-134* Lactate-2.4* Na-143 K-2.6* Cl-117* [2113-4-19] 02:32AM BLOOD Hgb-10.7* calcHCT-32 O2 Sat-98 COHgb-1 MetHgb-0 [2113-4-19] 02:25AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 [2113-4-19] 02:25AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [2113-4-19] 02:25AM URINE RBC-13* WBC-8* Bacteri-FEW Yeast-NONE Epi-<1 [2113-4-19] 03:30AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-25 Monos-75 [2113-4-19] 03:30AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-83 [2113-5-9] 04:41AM BLOOD WBC-10.4 RBC-3.44* Hgb-9.9* Hct-31.1* MCV-90 MCH-28.9 MCHC-31.9 RDW-15.6* Plt Ct-389 [2113-5-9] 04:41AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-138 K-4.0 Cl-102 HCO3-28 AnGap-12 [2113-5-9] 04:41AM BLOOD ALT-46* AST-37 AlkPhos-212* TotBili-0.2 [2113-5-9] 04:41AM BLOOD Calcium-8.4 Phos-5.1* Mg-1.7 . MICROBIOLOGY [2113-5-1] STOOL C. difficile DNA amplification assay-NEGATIVE [2113-4-30] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-30] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-22] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-21] STOOL C. difficile DNA amplification assay-NEGATIVE [2113-4-21] STOOL C. difficile DNA amplification assay-NEGATIVE [2113-4-21] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-21] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-20] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [2113-4-19] BILE GRAM STAIN-FINAL; FLUID CULTURE-{PSEUDOMONAS AERUGINOSA, PSEUDOMONAS AERUGINOSA}; ANAEROBIC CULTURE-NO GROWH [2113-4-19] URINE URINE CULTURE-NEGATIVE [2113-4-19] MRSA SCREEN MRSA SCREEN-NEGATIVE [2113-4-19] CSF;SPINAL FLUID GRAM STAIN-NO ORGANISM; FLUID CULTURE-NO GROWTH [2113-4-19] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-NO ORGANISM; Anaerobic Bottle Gram Stain-NO GROWTH [2113-4-19] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-NO ORGANISM; Anaerobic Bottle Gram Stain-NO GROWTH . IMAGING: [2113-4-26] Radiology MR HEAD W & W/O CONTRAST: No evidence of intracranial mass, infarction, or infectious process. Acute-on-chronic inflammatory disease in the left sphenoid air cell; correlate clinically. [2113-4-25] Cardiovascular ECHO [2113-4-25]: The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2113-4-21] Neurophysiology EEG [2113-4-21]: This is an abnormal continuous ICU monitoring study because of the presence of a few isolated paroxysmal potential epileptiform transients in the left central region. Compared to the prior day's recording, this record shows improvement in background rhythms. [2113-4-20] Cardiovascular ECHO [2113-4-20]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and the inferolateral wall. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2113-4-20] Neurophysiology EEG [2113-4-20]: This is an abnormal continuous ICU monitoring study because of the presence of a diffuse severe encephalopathy. While the frequencies are in a range that would suggest reasonable brain activity there continues to be a reverse anterior posterior gradient. This may still be the effect of medication and the cooling protocol itself. It is necessary to monitor this to see if it evolves into and alpha coma pattern. There also exists multifocal and independent appearing interictal sharp transients. These also should be monitored for detection of seizures. In comparison to the previous today's recording, there does appear to be some improvement in this record. There is more evident background activity in the occipital poles. Near the end of the record there appeared to be some variability to the background suggesting some cyclic behavior. [2113-4-19] Radiology CT HEAD W/O CONTRAST: No acute intracranial pathology. Mucus-retention cyst with aerosolized secretions within the left sphenoid air cell, with inflammatory changes in the anterior ethmoidal air cells; correlate clinically. [2113-4-19] Radiology CT ABD & PELVIS WITH CO:Residual rim-enhancing fluid collection in the right posterior perirenal and pararenal spaces, slightly smaller since [2113-4-6]. Percutaneous pigtail drainage catheter is appropriately positioned within this cavity. No new fluid collections. [2113-4-19] Neurophysiology EEG [2113-4-19]:This is an abnormal continuous ICU monitoring study because of a severe diffuse encephalopathy with some multifocal interictal epileptic features. Additionally, there were short runs of semi- rhythmic activity which may represent brief abortive seizure discharges. None of them had clinical accompaniments. Brief Hospital Course: 35 y/o female with Hep C and recent bowel/biliary perforation s/p ERCP with drain in place who presents s/p reported cardiac arrest with ROSC after 2 shocks in addition to seizure activity and clinical pararamaters consistent with sepsis. . # Possible VF/VT arrest: Pt was initially brought to OSH s/p reported cardiac arrest. Events surrounding the event was unclear. [Name2 (NI) ] report, she had seizures prior to the arrest and was found with loss of pulse with shockable rhythm. She was shocked twice. EMS and police were contact[Name (NI) ] to attempt to discern her heart rhythm at the time but AED could not be interrogated. She was intubated at OSH. Post-cardiac arrest team was consulted. She was started on cooling protocol upon arriving to [Hospital1 18] MICU and then re-warmed. She was also on neuromuscular blockade during this time. Trop was initially 0.06 but then downtrended to <0.01. CKs were elevated by MB was largely unremarkable. Initial TTE showed EF 35-40% with moderate regional LV systolic dysfunction in a non-coronary distribution. However, this had been performed while pt was on cooling protocol was likely unreliable. TTE was later repeated which showed normal functions in both ventricles. Patient has been stable since hospitalization. . #Sepsis: On admission to MICU, pt met SIRS criteria with fever, leukocytosis, and tachycardia and also had elevated lactate. Concern was high for GI source of infection given recent history of bowel perforation. She had recently completed course of augmentin/fluconazole prior to admission. She was broadly covered with vancomycin/zosyn initially. Four sets of blood cultures from [2113-4-19] grew staph epi and coag neg staph (not sensitive to oxacillin). Ob/gyn was also curbsided regarding possible removal of IUD but did not feel IUD was source of infection. Her JP drain was sent for culture and grew pseudomonas sensitive to ciprofloxacin. She was transitioned to vancomycin and ciprofloxacin PO. She was followed by surgery for her JP drain. JP drain fell out prior to transfer to medicine floor; surgery recommended no replacement of drain or reimaging unless patient was febrile. Patient was seen by ID while on the floor who recommended her to be switched to IV ceftazidime for 2 weeks. Patient had mild increase in WBC and transaminitis during day 11 of hospitalization while on vancomycin and ceftazidime. Repeat blood cultures and c.diff assay were sent which returned negative. Patient was asymptomatic during this period and remained afebrile. Patient completed a 14 day course of vancomycin on [5-3] and 2 weeks of IV ceftazidime on [5-9] with appropriate decreased in WBC and LFTs. See below for abdominal abcess. . # Seizure - No history of seizures in the past. Urine tox was positive for barbs and benzos which she had received at OSH. There was no evidence of IC mass/process on stat head CT. Lumbar puncture showed no growth in CSF fluid. She was kept on continuous EEG monitoring initially. This did not show seizures. She was followed by neurology who recommended initiation of dilantin 100mg q8H. On week 2 of hospitalization, patient??????s dilantin level was found to be subtherapeutic and she was loaded with 1000mg of Dilantin to therapeutic level. Patient was maintained on 100mg q8H. She will need to follow up with neurology in 4 weeks. . # Bowel perforation - Etiology was due to duodenal perforation after ERCP. She had been treated with Perc drain in perinephric space and abx course recently completed. CT A/P in the ED showed drain in appropriate place and no new evidence for abdominal catastrophe. Surgery consulted in ED and followed pt on floor. She was kept on vanc/zosyn initially and switched to vanc/cipro when JP drain culture grew pseudomonas sensitive to cipro. JP Drain fell out on [2113-4-23]; surgery recommended no replacement of drain unless patient is febrile. Patient finished a 2-week course of IV ceftazidime on [5-9]. Repeat CT of the abdomen showed only slight decrease in the size of the abdominal fluid collection. Given this ID and surgery were reconsulted and recommended drainage. The patient refused to stay in the hospital for this procedure even after explaining her the high risk for spreading of the infection, her becoming septic again and potentially dying from this. She refused to stay as she was very upset she had to be here for so long and this was not found earlier. Prior to discharge she was given a prescription for ciprofloxacin 500 mg [Hospital1 ] until she is instructed otherwise by her PCP or Dr. [Last Name (STitle) 468]. Appointments were made with these doctors. . # Hep C - last month VL at 72,762 IU/mL. Stable, with LFT's WNL. . # Diarrhea: After extubation, pt developed diarrhea associated with profound electrolyte abnormalities that required frequent monitoring and repletion. C.diff was negative. She was treated with loperamide. Diarrhea may have been due to narcotic withdrawal. She was continued on her home dilaudid for chronic abdominal pain. Patient??????s diarrhea resolved on its own 4 days after being on the floor and patient remained asymptomatic off of loperamide. . # Psych: Addictions/social work consult was obtained for polysubstance abuse, including active IVDU. She appeared quite depressed with flat affect, had issues with polydipsia (drinking liters of water daily), and had anorexia. Psych was consulted who did not think she was at acute risk of harming herself and her anorexia in the ICU was most likely appetite related. Patient was initially maintained on a 1.5L fluid restriction but given well-compensated kidneys and normonatremia, the fluid restriction was lifted with no issues. Patient??????s appetite improved progressively during her hospitalization. She was seen by nutrition who initially recommended ensure puddings then multivitamins. . # IV Access: Pt had difficult IV access. She was maintained on peripheral IVs while at ICU and ordered for IR guided PICC placement while on the floor for the completion of her antibiotic course. The PICC line was taken out prior to discharge. Medications on Admission: lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID prn acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID prn gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain amoxicillin-pot clavulanate 500-125 mg Tablet 1 po q12 (just completed with this admission) fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day for 10 days (just completed with this admission) ZOFRAN ODT 4 mg Tablet 1 po q8hrs prn Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:16 Tablet(s) Refills:0 2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:0 3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: - Cardiac Arrest - Seizure - Intra-abdominal abscess - Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to be involved in your care. You were admitted because your heart stopped and had a seizure. . You were initially intubated in the intensive care unit where you were given medication and cooled to stop your seizures. You did not have any further seizures during your hospitalization. You will need to follow up with neurologist (brain doctors) 4 weeks after discharge. . Initial image of your heart showed slowing of activities but that was in the setting of you going through cooling for your seizures. You had a repeat image after you left the intensive care unit which showed normal function of your heart. . You also had blood cultures which showed a bacteria in your blood. You were given antibiotics to treat that for 14 days. You completed your course on [2113-5-3]. . You were also found to have an infection in your stomach from your prior intestine performation. You were given antibiotics for the infection and you finished that course on [5-9]. You had a repeat CAT scan of your stomach which showed that the infection was not completely gone. We recommended you stay in the hospital for a procedure to drain this infection but you decided you wanted to be discharged against our advice. We explained that in doing so this infection might worsen and it can be catastrophic for your health. Please take the antibiotics prescribed, see your PCP and Dr. [Last Name (STitle) 468] from general surgery to have this draining procedure arranged soon. Medication Changes: Start: ciprofloxacin 500 mg [Hospital1 ] until told to stop by your PCP or Dr. [Last Name (STitle) 468]. Start: phenytoin 100 mg three times a day Followup Instructions: Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital 22163] MEDICAL PRIMARY CARE Address: [Street Address(2) 66034]. STE #200, [Location (un) ],[Numeric Identifier 66035] Phone: [Telephone/Fax (1) 66036] Appt: [5-15] at 6pm *The Neurology Department is working on an appointment for you within the month and they will call you at home with the appt. If you dont hear back from them by Wednesday, please call the office directly to book at [Telephone/Fax (1) 110633] Department: SURGICAL SPECIALTIES When: MONDAY [2113-5-22] at 9:00 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 [Name6 (MD) ] [Name8 (MD) ] MD [Doctor Last Name 1189**]	[ "041.7", "567.22", "787.91", "998.59", "038.19", "070.54", "785.52", "305.20", "311", "V60.0", "304.00", "995.92", "305.1", "427.1", "292.0", "427.41", "345.3", "788.30", "427.5" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.97", "03.31" ]	icd9pcs	[ [ [] ] ]	20349, 20355	12884, 19073	315, 324	20465, 20465	5423, 12861	22310, 23286	3828, 3973		19753, 20326		20376, 20444		19099, 19730			20616, 22108											3988, 4858							4874, 5404												22128, 22287	251, 277								352, 3388									20480, 20592					3410, 3598	3614, 3812
45,598	109,727	16087	Discharge summary	report	Admission Date: [2191-4-19] Discharge Date: [2191-4-21] Date of Birth: [2147-10-24] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 1936] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Mechanical Ventillation Lumbar Puncture History of Present Illness: Limited history as patient intubated and sedated. History obtained from medical records and ED course. 43 yo F presented to [Hospital3 ] with complaint of CP and agitation. Woke up [4-18] shaking, complaining of pressure on her chest. Concerned for anxiety attack at home and took her to OSH. Apparently patient usually takes cymbalata. Ran out of cymbalta 48 hours prior to presentation. Found to be restless, short of breath, with chest pain, delerious with hallucinations. She also developed strange movements, concern for dystonic reaction. She was given Ativan 1mg, Toradol 30mg, Cymbalta 60mg, Ativan 1mg, Valium 10mg, thorazine, benadryl, and haldol at OSH. Then propofol and versed gtt and was intubated. She was transferred for concern for ?medication reaction vs. overdose. Head CT from OSH was negative. . History of multiple suicide attempts -most recently 2 years ago Overdosed on sleeping pills. Has had inpatient psych admissions. Severe depression. Intermittent extreme agitation. This situation has occurred before, in the setting of drug use. Daughter is concerned that she may be taking opiates. She has been physically restrained before. . In the ED, initial vs were: T 98.4 P 71 BP 132/87 R 18 O2 sat 100% -intubated, unknown FiO2. A+Ox 0. Pupils 2-3mm. Intubated and sedated. Gaze downward bilaterally. No clonus or hyperreflexia. Guaiac negative. No petichiae. Neck supple. LP was performed. Given Ceftriaxone 2g IV x1, Acyclovir 700mg IV x1, Vancomycin 1g IV x1. Consulted Toxicology, but they were not reached. . On the floor, . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: h/o multiple suicide attempts -most recently 2 years ago OD'd on sleeping pills. Has had inpatient psych admissions. Severe depression. Intermittent extreme agitation. This situation has occurred before, in the setting of drug use. Daughter is concerned that she may be taking opiates. She has been physically restrained before. Cholecystectomy Ulcerative colitis s/p ileostomy takedown anal stenosis s/p dilatation [4-/2186] Social History: Works as a teacher at Southeastern. No alcohol use. Occasional Tobacco. Family History: Non-Contributory Physical Exam: Vitals: T: 96.6 BP:113/75 P: 70 R: 15 O2: 100% on FiO2 50%. Vt 450mL. PEEP 5. General: Intubated and sedated HEENT: Sclera anicteric, downward gaze bilaterally, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2191-4-19] 11:16AM CK(CPK)-302* [2191-4-19] 11:16AM CK-MB-6 cTropnT-<0.01 [2191-4-19] 04:56AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.050* [2191-4-19] 04:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2191-4-19] 03:19AM URINE HOURS-RANDOM [2191-4-19] 03:19AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2191-4-19] 02:41AM GLUCOSE-190* UREA N-6 CREAT-0.6 SODIUM-141 POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14 [2191-4-19] 02:41AM ALT(SGPT)-11 AST(SGOT)-18 LD(LDH)-211 ALK PHOS-73 AMYLASE-49 TOT BILI-0.3 [2191-4-19] 02:41AM LIPASE-16 [2191-4-19] 02:41AM ALBUMIN-3.4 CALCIUM-7.7* PHOSPHATE-1.8* MAGNESIUM-2.0 [2191-4-19] 02:41AM VIT B12-942* FOLATE-GREATER TH [2191-4-19] 02:41AM TSH-0.68 [2191-4-19] 02:41AM WBC-17.9* RBC-3.90* HGB-10.9* HCT-33.2* MCV-85 MCH-27.8 MCHC-32.7 RDW-14.7 [2191-4-19] 02:41AM PLT COUNT-447* [2191-4-18] 11:45PM estGFR-Using this [2191-4-19] 02:41AM PT-14.2* PTT-29.2 INR(PT)-1.2* [2191-4-18] 11:55PM LACTATE-1.0 [2191-4-18] 11:45PM GLUCOSE-111* UREA N-6 CREAT-0.6 SODIUM-144 POTASSIUM-3.1* CHLORIDE-115* TOTAL CO2-20* ANION GAP-12 [2191-4-18] 11:45PM estGFR-Using this [2191-4-18] 11:45PM CK(CPK)-312* [2191-4-18] 11:45PM CK-MB-8 cTropnT-<0.01 [2191-4-18] 11:45PM VIT B12-893 FOLATE-GREATER TH [2191-4-18] 11:45PM TSH-0.72 [2191-4-18] 11:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2191-4-18] 11:45PM WBC-14.7* RBC-3.91* HGB-10.7* HCT-31.6* MCV-81* MCH-27.4 MCHC-33.9 RDW-14.3 [2191-4-18] 11:45PM NEUTS-76.7* LYMPHS-19.6 MONOS-2.9 EOS-0.4 BASOS-0.3 [2191-4-18] 11:45PM PLT COUNT-471* [2191-4-18] 11:35PM CEREBROSPINAL FLUID (CSF) PROTEIN-32 GLUCOSE-77 [2191-4-18] 11:35PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-3* POLYS-5 LYMPHS-85 MONOS-10 [2191-4-18] 11:29PM TYPE-ART PEEP-5 PO2-427* PCO2-32* PH-7.46* TOTAL CO2-23 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED . Head CT-IMPRESSION: No evidence of acute hemorrhage. . CT abd/pelvis:Preliminary Report !! WET READ !! No intra-abdominal abscess. Free fluid around the gallbladder, in the right flank and in the pelvis. No evidence of acute cholecystitis, although HIDA scan would be more specific if clinical suspicion becomes high. . Discharge Labs [2191-4-21] 05:30AM BLOOD WBC-11.6* RBC-4.10* Hgb-11.5* Hct-34.0* MCV-83 MCH-28.2 MCHC-33.9 RDW-14.7 Plt Ct-515* [2191-4-21] 05:30AM BLOOD Plt Ct-515* [2191-4-21] 05:30AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-140 K-3.7 Cl-107 HCO3-24 AnGap-13 Brief Hospital Course: Assessment and Plan: This is a 43 yo F with a history of a suicide attempt who presented to OSH with chest pain, SOB, and with altered mental status. . # Altered Mental Status: The pt presented intubated from an OSH. Initial differentiel included withdrawal from Cymbalta vs reemergence of underlying psychosis. It was thought that a toxidrom from cymbalta was less likely. Given concern for infectious etiologies including HSV encephalitis, meningitis the pt underwent an LP which was found to be negataive, as the pt was briefly placed on empiric abx and acyclovir. Head CT negative for acute intracranial process. Electrolytes did not support metabolic abnormality. The pt was subsequently extubated and was calm and AOX3, only complaining of chronic back pain. Following consultations with both psych and toxicology, the patients most likely etiology for change in MS [First Name (Titles) ] [Last Name (Titles) ] from cymbalta, followed by complications [1-24] to polypharmcy at the OSH in the setting of a potential panic attack. Infectious etiologies for change in MS less likely consider exam, cultures and imaging non-focal. Pt did have leukocytosis and fever in the last 24hrs of her ICU course, but these resolved prior to arrival to the floor. The pt was restarted on Cymbalta 30mg Daily and instructed to increase to her home dose of 60mg the following day once at home. The pt was given a 1 week supply of Percocet to bridge her to her next pain clinic appointment. Medications on Admission: (Of note per patient, Could not confirm with PCP or [Name9 (PRE) 1194] Doc) Cymbalta 60mg po qd "Oxycodone 20mg TID:PRN" Tylenol Discharge Medications: 1. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: Two (2) Tablet PO twice a day for 5 days: Please do not drive or operate heavy machinery while taking this medication. Disp:20 Tablet(s) Refills:0 4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. Disp:7 Tablet(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Acute Respirtory Failure Discharge Condition: Good. Patient ambulating. At her physical and mental baseline. Pain controlled. Discharge Instructions: You were admitted from an outside hospital intubated following a change in your mental status. This was likely secondary to a combination of medications. You were seen by both our toxicology and psychiatry departments that made no further recommendations to your medication regimen. . Please continue to take all of your medications as listed below. We have made no changes to your regimen. . Please keep all of your appointments and follow-up with your PCP within the next 1-2 weeks. . Please return to hospital if you experience chest pain, shortness of breath, fainting, loss of consciousness, fevers or chills. Followup Instructions: Please follow-up with your PCP and [Name9 (PRE) 1194] Management Physicians within 1-2 weeks of discharge.	[ "786.50", "786.05", "780.97", "518.89", "300.01", "285.9", "301.9", "333.94", "296.20", "556.9" ]	icd9cm	[ [ [] ] ]	[ "03.31", "96.71" ]	icd9pcs	[ [ [] ] ]	8532, 8538	6223, 6385	290, 332	8627, 8709	3477, 6200	9372, 9486	2878, 2896		7900, 8509		8559, 8606		7743, 7877			8733, 9349											2911, 3458																				230, 252			1940, 2320					360, 1922									6400, 7717					2342, 2773	2789, 2862
83,527	156,131	39636	Discharge summary	report	Admission Date: [2156-6-27] Discharge Date: [2156-7-14] Date of Birth: [2108-7-11] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Trauma Major Surgical or Invasive Procedure: Posterior Cervical Fusion C2-4 ACDF C3-4 History of Present Illness: HPI: 47 year old male who presented to an OSH after a diving accident. he was diving into a pool and collided with someone else striking his neck. Per family reports he was immediately flaccid and unable to breathe. EMS was called and he was intubated for lack of ability to attempt to breathe on his own. he was transported to an OSH in [Location (un) ] where plain c-spine films were obtained which showed subluxation in his cervical spine and as a result he was transferred to [Hospital1 18] via helicopter for further evaluation. Upon arrival he is sedated on propofol and it is reported that he had been overbreathing the vent and was chewing on the endotracheal tube. After receiving his CT scans his sedation was lightened and he was awake alert and interactive. Past Medical History: [Doctor Last Name 79] Parkinson White syndrome s/p ablation [2153] Social History: married Family History: non-contributory Physical Exam: Gen: intubated, not sedated HEENT: NCAT Pupils: PERRL bilaterally EOMs full without nystagmus Neck: c-collar in place, trachea appears deviated to left Neuro: Mental status: Awake and alert, cooperative with exam, intubated Orientation: Oriented to self, hospital, and date when given choices via blinking to answer Motor: D B T WE WF IP Q H AT [Last Name (un) 938] G Sensation: Intact to light touch consistent with C3 sensory level Reflexes: absent No proprioception Toes mute Rectal exam : zero rectal tone PHYSICAL EXAM ON DISCHARGE ***** Pertinent Results: [6-26] Head CT: IMPRESSION: No acute intracranial injury seen. [6-26] C-spine CT: IMPRESSIONS: 1. Multiple fractures and ligamentous injuries result in disruption of all three columns at C3-4 as delineated above, with severe canal narrowing at this level, down to 6 mm in the AP dimension and anterior displacement and clockwise rotation of the C3 vertebral body and bilateral facets with respect to C4. For assessment of extent of cord injury, MRI is recommended. 2. Transverse fracture extends through the right C4 transverse foramen. CT or MR angiographic study would be recommended to evaluate for injury to the right vertebral artery. [6-26] C-spine CTA: **** [6-26] C-spine MRI: MPRESSION: 1. Disruption of all three columns of the cervical spine at C3-4, with fractures, an anterolisthesis and epidural hematoma, resulting in severe spinal canal narrowing. Spinal cord contusion at the levels of C3 and C4. 2. Intramural hematoma involving the visualized cervical course of the right vertebral artery, indicative of a dissection. Concurrent neck CTA indicates complete occlusion of the true lumen from C2-3 through C4-5. [7-2] CT CSPINE FINDINGS: Interval placement of endotracheal tube as well as surgical repair of previously described fracture dislocation of C3-C4 with anterolisthesis and bilateral locked facet. Note interval C3-C4 laminectomy and bilateral C3-C4 facetectomy with fusion of C3-C4 with anterior plate and screws fixing C3-C4 with intermediate bone allograft. The surgical hardware is intact. There continues to be C3 on C4 anterolisthesis however improved from grade 4 to grade 1 on this study. Again note is made of the left C3 pedicle fracture line. The prominence of the epidural soft tissue is improved compared to prior study and likely related to a combination of venous plexus and resolving traumatic edema. There is opacification of the bilateral mastoid air cells and middle ear spaces (right greater than left) as well as the sphenoid and bilateral maxillary sinuses. IMPRESSION: Status post C3-C4 laminectomy and bilateral facetectomy with fusion of C3-C4 with placement of bone strut. Hardware intact, improved anterolisthesis of C3 on C4, from grade 4 to grade 1. Prominence of epidural soft tissue from C2-C4 is improved. Brief Hospital Course: The patient was admitted to the [Last Name (un) ] ICU under the Neurosurgery Service for close monitoring. He was loaded with Decadron and kept on sedation while intubated. An MRI was obtained which demonstrated subluxation at C3 with severe cord damage. He was initially placed on pressors for blood pressure support, but on HD #3 he no longer reauired this. He was thoroughly pre-op screened for surgery to undergo C2-5 posterior fusion and laminectomies. [6-30]: Pt underwent C2-5 laminectomies and fusion on this day. He tolerated this procedure very well with minimal blood loss. A jp drain was placed post operatively and the pt was transfered back to the ICU for continued care. Pt was started on antiobiotics on [6-29] for presumed pneumonia. Upon post op exam the pt remained unchanged. He was awake and alert and following commands with shrugging shoulders. He had no motor movement in his four extremities and he remained intubated though he was breathing over the ventilator. [7-1]: The patient was taken to the operating room for a C3-4 ACDF on this day. He tolerated this procedure well with minimal blood loss and no complications. He did undergo an IVC filter after his ACDF and did tolerate this very well. Post operatively pt continued his cervical collar and was again transfered back to the ICU for continued management. His JP drain had minimal output overnight and it was removed on [7-2]. On [7-2], a CXR demosntrated a new L lobe consolidation. He underwent brochoscopy and thick secretions were found. Infectious disease team was consulted for proper Abx coverage recommendations and he was started on vancomycin, ciprofloxacin and meropenem for ventilator aquired pneumonia. Additionally and he was continued on IV fluids. Blood cultures were obtained and were negative as of this date. [7-6] Pt continued on triple antibiotic coverage for PNA and vancomycin levels were followed prior to every fourth dose. His current level is 16.1 and within the therapeutic range. He is planned for tracheostomy and PEG today. He will continue his VAP protocol for a total of ten days. 8/4-5 Pt started on tubefeeds and advanced to goal without difficulty. Sedation was weaned and he was noted to be more awake and alert. His physical exam remained stable and still showed a T5 sensory level and full trapezius strength. He underwent another bronchoscopy and continued on his antibiotic regimen for ventilator aquired pneumonia. His serum sodium was noted to increase to 150 and he was started on free water boluses of 200cc every 8 hours and serum Na levels were checked every 12 hours. [7-9] Pt required bronchoscopy again for desaturations and bradycardia. Tube feeds on hold for severe dilatation of bowels. Sutures and Staples removed from posterior cervical incision site. exam remained neurologically stable. [7-11] Pt has remained afebrile and has finished a 10 day course for pneumonia. His antibiotics have been discontinued and he has been doing well. Pt will be discharged to rehab facility in stable condition. Medications on Admission: none Discharge Medications: . 1. Magnesium Hydroxide 400 mg/5 mL Suspension [Month/Day (4) ]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 2. Chlorhexidine Gluconate 0.12 % Mouthwash [Month/Day (4) ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. Phenol 1.4 % Aerosol, Spray [Hospital1 ]: One (1) Spray Mucous membrane PRN (as needed) as needed for sore throat. 7. Oxycodone 5 mg/5 mL Solution [Hospital1 ]: [4-12] Ml PO Q3H (every 3 hours) as needed for pain. 8. Acetaminophen 650 mg/20.3 mL Solution [Month/Year (2) ]: 650-1000mg mg PO Q6H (every 6 hours) as needed for fever/pain. 9. Heparin (Porcine) 5,000 unit/mL Solution [Month/Year (2) ]: 5000 (5000) units Injection TID (3 times a day). 10. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment [Month/Year (2) ]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 11. Polyvinyl Alcohol 1.4 % Drops [Month/Year (2) ]: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 13. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 14. Citalopram 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Ondansetron 4 mg IV Q8H:PRN nausea 16. Metoclopramide 10 mg IV Q8H 17. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: C3-C4 Displaced fractures with resulting spinal cord injury Discharge Condition: Activity Status: [Month (only) 116] get OOB to cardiac chair as tolerated. Cervical collar at all times. Discharge Instructions: CERVICAL SPINE SURGERY Wound Care: ?????? You may shower, however try not to let the water run directly over the incision. You [Month (only) ] NOT soak the incision in a bathtub or pool for 4 weeks. If your wound gets wet, gently [Last Name (LF) ], [First Name3 (LF) *] NOT RUB the wound dry. ?????? Your incision was closed with dissolvable sutures under the skin. There are steri-strips in place, and these should stay on until the fall off on their own. The edges may begin to curl, and these may be trimmed. ?????? You may remove the dressing after 2 days after surgery. If there is still a small amount of bloody drainage, you can place a new sterile gauze dressing, otherwise you can leave the wound open to air. Pain: ?????? Hoarseness, sore throat, or difficulty swallowing may occur in some patients and should not be cause for alarm. These symptoms usually resolve in 1 to 4 weeks. ?????? Take your pain medication as prescribed. You will likely only require narcotic pain medication for 2-3 days. After that timeframe, over the counter Tylenol or Acetaminophen will be sufficient. Medications: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and be comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: ?????? Narcotic pain medication such as Dilaudid, Percocet or Vicodin ?????? Muscle relaxant such as Robaxin, Flexeril or Valium. Take these as needed for muscle spasm. They will make you sleepy, so do not drive while taking these medications ?????? An over the counter stool softener for constipation (try Dulcolax, Milk of Magnesia or ?????? Correctal at first and Magnesium Citrate or Fleets enema if needed). Miscellaneous: You have had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing. * Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ] to be seen in 4 weeks. You will need AP and lateral Cervical spine x rays in your collar at follow up appointment Completed by:[2156-7-12]	[ "560.1", "E883.0", "E849.7", "518.0", "997.31", "458.9", "041.11", "E912", "433.20", "584.9", "518.81", "934.8", "276.0", "806.00", "344.00" ]	icd9cm	[ [ [] ] ]	[ "80.51", "03.09", "38.7", "96.72", "31.1", "43.11", "81.62", "88.51", "81.02", "96.05", "96.6", "03.53", "33.24" ]	icd9pcs	[ [ [] ] ]	9249, 9319	4290, 7373	326, 368	9423, 9534	1968, 1979	11836, 12127	1320, 1338		7428, 9226		9340, 9402		7399, 7405			9558, 9582											1353, 1519																				280, 288					9594, 11813			396, 1180				1988, 4267					1534, 1949					1202, 1279	1295, 1304
74,535	104,886	6813	Discharge summary	report	Admission Date: [2171-12-29] Discharge Date: [2172-1-1] Date of Birth: [2093-10-10] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2387] Chief Complaint: Throat and arm pain Major Surgical or Invasive Procedure: cardiac catheterization with thrombectomy of stent and promus drug eluting stent to the mid right coronary artery History of Present Illness: 78 year old female with history of NIDDM, MI x 3, and COPD who presents who presents with chest pain found to have EKG changes concerning for STEMI. . The patient was in her usual state of health until about two weeks ago when she developed intermittent throat and arm pain. This happened a few times but has increased in frequency over the last three days, which is when she noted the developed of chest pain as well. At around 1300 today, the pain became constant, rated at an [2170-9-11], which was very concerning to the patient so she called EMS at 1800 and was brought to [Hospital1 18] ED for further evaluation. Of note, the patient reports poor compliance with her home medications of late, which include PO antihyperglycemics, aspirin, and plavix. . She received ASA 325mg in the ambulance and rated her pain at [2170-3-7] on arrival to the ED. She denied any SOB and reports the pain was different than the pain she experienced with her prior MI. In the ED, EKG was concerning for STEMI and cardiology was notified. She received heparin gtt, plavix 600mg, and integrillin and was sent for urgent cardiac catheterization. During the cath, she was found to have a in-stent thrombosis in the RCA, which was suctioned and angioplastied. Per report, "successful primary angioplasty for inferior STEMI with 80% thrombotic stenosis in the mid portion of previously placed stent; this was treated with PCI and stenting utilizing 3.5x23mm Promus DES, post-dilated to 3.75mm with excellent result." The patient tolerated the procedure well and is being admitted to the CCU for further monitoring. . On arrival to the CCU, vital signs were T- 97.6, HR- 90, BP- 103/77, RR- 19, SaO2- 88% on RA. The patient denies chest pain, shortness of breath or headache. She remains hemodynamically stable. . 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, at this time, is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: . CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: - CABG: n/a - PERCUTANEOUS CORONARY INTERVENTIONS: AMI in [2159]- tPA followed by PTCA/PCI of RCA and LCx. She has had two other interventions with a total of four stents placed - PACING/ICD: n/a 3. OTHER PAST MEDICAL HISTORY: 1. Coronary artery disease status post multiple PCIs. 2. Diabetes mellitus- non-insulin dependant, with peripheral neuropathy 3. Hyperlipidemia. 4. COPD from smoking 5. Status post hysterectomy. 6. Status post right common femoral arterial thrombectomy in [2164-11-2]. Social History: #SOCIAL HISTORY: Patients husband died at age 41, she has worked as a waitress all of her life. Until recently worked as a cashier at CVS. Lives at home with her Daughter [Name (NI) ] [Telephone/Fax (1) 25793], son-in-law and grand children. Able to complete all ADLs/IADLS. No etoh or IV drugs Family History: #FAMILY HISTORY: Mom MI [35] Son died mi [97] Brother died MI Aunt MI [01] DAD bone cancer died 92 Physical Exam: ON admission: VS: T- 97.6, HR- 90, BP- 103/77, RR- 19, SaO2- 88% on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with normal JVP. CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Bibasilar crackles with no wheezes or rhonchi. no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . On discharge: Vitals - Tm/Tc: 97.8/97.1 HR: 73-76 BP:102-123/48-51 RR:20 02 sat: 96% RA In/Out: Last 24H: [Telephone/Fax (1) 25794] Last 8H: Weight: 66.2 (68.5) . Tele: SR, few PVC's . FS: 273/211/191 . GENERAL: 78 yo F in no acute distress, lying flat in bed HEENT: no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: crackles right base, [Month (only) ] BS on left CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, obese, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs 2+. NEURO: A/O, pleasant and conversant, MAE, good memory of recent events SKIN: no rash Pertinent Results: ON admission: [2171-12-29] 07:10PM BLOOD WBC-6.1 RBC-4.21 Hgb-12.4 Hct-40.0 MCV-95 MCH-29.5 MCHC-31.1 RDW-12.4 Plt Ct-242 [2171-12-30] 04:03AM BLOOD Glucose-284* UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-31 AnGap-9 [2171-12-30] 04:03AM BLOOD CK(CPK)-213* [2171-12-30] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17* [2171-12-30] 12:02PM BLOOD CK(CPK)-187 [2171-12-30] 06:20PM BLOOD CK(CPK)-129 [2171-12-30] 04:03AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0 . On discharge: [2172-1-1] 06:55AM BLOOD WBC-6.1 RBC-3.92* Hgb-11.8* Hct-36.6 MCV-93 MCH-30.0 MCHC-32.1 RDW-12.7 Plt Ct-225 [2172-1-1] 06:55AM BLOOD Glucose-222* UreaN-20 Creat-0.7 Na-138 K-4.2 Cl-101 HCO3-32 AnGap-9 [2171-12-30] 04:03AM BLOOD CK-MB-22* MB Indx-10.3* cTropnT-0.39* [2171-12-30] 12:02PM BLOOD CK-MB-16* MB Indx-8.6* cTropnT-0.25* [2171-12-30] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17* . Cardiac catheterization: [12-29] 1. Selected coronary angiography in this right dominant system demonstrated 2 vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a 30-40% mid vessel stenosis slightly worsened from [2164]. The LCX in known to have a total flush occlusion. The mid RCA is diffulsely disease with an 80% in stent restenosis and possible thrombus suggestive of very late ISRS. There is a focal 50% lesion at the distal RCA bifurcation worsened from [2164]. THE RPLV (very substantive vessel) stent placed in [2164] is widely patient. 2. Limited resting hemodynamics revealed a normotensive central systemic arterial pressure of 124/71 mm Hg. 3. Successful thrombectomy and PCI to the mRCA using 3.5x23mm Promus DES. 4. No complications. FINAL DIAGNOSIS: 1. 2 vessel coronary artery disease with in stent restenosis of RCA. 2. Successful PCI to the mRCA with Promus DES. 3. No complications. . ECHO [12-30]: preliminary only Brief Hospital Course: # Right coronary artery ST elevation myocardial infarction: S/P RCA STEMI with succesful DES to site of in-stent thrombosis and early resolution of EKG abnormalities. NO further chest pain, CK's have downtrended. On BB, ACEi, statin, plavix and ASA. ECHO with poor windows and no WMA, preserved EF on first read, reviewed by Dr. [Last Name (STitle) ] who felt there was an inferior wall motion abnormality with EF 45%. Appears euvolemic. Plan to continue clopidogrel for 1 year/month for DES and likely forever. NP and SW saw pt for her history of medicaton non-complience. She is able to afford her medicines, just stated she was "stubborn" and didn't feel that she needed the medicine anymore. Her diabetes regimen is also onerous to her and she wishes it could be simplified. She states she now realizes that she needs to take her medications daily. . # RHYTHM: SR, no VEA . # Hyperlipidemia- high dose atorvastatin for now, change back to rosuvastatin at discharge because of her history of myalgias on high dose statin. She has [Last Name (un) ] tolerating 20 mg of rosuvastatin so far. . # Diabetes mellitus- on glypizide and onglyza at home, struggling to do fingersticks 4 times per day and take her meds. Last A1c in [11/2171] was 10.5. Followed by Dr. [Last Name (STitle) ] from [Last Name (un) ] in [Location (un) 620]. Her home PO meds were restarted at discharge and she has a f/u appt with Dr. [Last Name (STitle) ] at the end of the week. . Transitional issues: 1. VNA at home to monitor for medication compliance and to do diabetic teaching 2. ASA and plavix for one year at least 3. F/U with Dr. [Last Name (STitle) ] in 2 weeks. 4. VNA to check BP and HR on new lisinopril and metoprolol Medications on Admission: HOME MEDICATIONS: confirmed with [Company 25795] 1. Glipizide XL 10 mg daily 2. Onglyza 5 mg daily 3. Crestor 20 mg daily 4. Aspirin 81mg daily 5. Plavix 75mg daily (did not fill for one month) 6. Amytripiline- 25mg qHS 7. Omeprazole 20 mg daily 8. Hydrocodone/acetaminophen 7.5/750mg TID as needed Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. Onglyza 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 9. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: ST elevation myocardial infarction Diabetes Mellitus type 2 Coronary artery disease Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [Hospital1 18]. You had a heart attack that was caused by a clot in an earlier stent from being off your plavix. The clot was removed and another drug eluting stent was placed over the previous stent. You will need to take a full aspirin (325mg) and Plavix 75 mg every day for the next year and likely longer. Do not stop taking Plavix or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you to. This is very important to prevent another heart attack or possibly death. An echocardiogram showed that your heart function is good. . We made the following changes to your medicines: 1. Increase aspirin to 325 mg for the next year 2. Continue Crestor at 20 mg daily 3. STOP taking omeprazole (prilosec), take ranitidine instead for your heartburn 4. START lisinopril to lower your blood pressure 5. START metoprolol to lower your heart rate and help your heart recover from the heart attack. Followup Instructions: Dr. [Last Name (STitle) ] on Monday [1-13], the office will call you at home with an appt. Dr. [Last Name (STitle) ] on Friday [1-3] as previously scheduled.	[ "414.01", "272.4", "250.60", "496", "410.41", "305.1", "V45.82", "357.2" ]	icd9cm	[ [ [] ] ]	[ "00.40", "00.45", "00.66", "37.22", "88.56", "36.07" ]	icd9pcs	[ [ [] ] ]	10108, 10166	7123, 8607	325, 441	10307, 10307	5178, 5178	11470, 11647	3796, 3892		9216, 10085		10187, 10286		8888, 8888		6924, 7100	10458, 11447											3907, 3907			2936, 3136	8906, 9193												5677, 6907	8628, 8862			266, 287								469, 2824							5192, 5662		10322, 10434		3167, 3442			2846, 2916	3475, 3763
60,164	163,089	55083	Discharge summary	report	Admission Date: [2104-8-11] Discharge Date: [2104-8-22] Date of Birth: [2076-1-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4095] Chief Complaint: [Last Name (un) ] Major Surgical or Invasive Procedure: Tunneled catheter line placement History of Present Illness: This is a 28 year old female with no significant past medical history who was admitted to [Hospital6 3105] yesterday with nausea, vomiting, diarrhea and shortness of breath, found to be in acute renal failure with severe anemia, and is now being transferred to [Hospital1 18] for further management. . Her symmptoms began on Thursday with diarrhea, nausea and vomiting (non-bloody) as well as some chest tightness and mild shortness of breath. No cough, no fevers or chills. No blood in her stools. Her symptoms got worse so she presented to LGH yesterday. . Her labs on presentation were notable for a creatinine of 20.24 (!) a BUN of 132 and a hematocrit of 20.4. Platelets were normal. An ABG was 7.29/18/73/8.4 on a FiO2 28%. Cardiac enzymes were elevated with a troponin of 1.26, CPK of 398, CKMB of 11.6. A non-con CT torso was notable primarily for small bilateral pleural effusions, trace pericardial effusion, and pulmonary nodules of unclear relevance. A D-dimer was positive however this was not further worked up as it was felt that a PE was a less likely explanation for her dyspnea. . She was admitted to the LGH ICU for severe acute renal failure, severe anemia, and respiratory distress. She was given 80mg of IV lasix with minimal urine output (~100 cc) overnight. Oxygen saturations overnight were mid 90s on [1-11] L nasal canula and slightly improved to mid-90s on room air at the time of transfer. She was seen by nephrology and cardiology. Nephrology felt that she required urgent but non-emergent HD which could be started after transfer to a larger medical center. She remained afebrile throughout her brief course at LGH. Blood, urine and stool cultures were drawn and were all without any growth at the time of transfer. . On arrival to the MICU she appeared comfortable and in NAD with nonlabored breathing on 6L NC. . She explains that over the last month she has felt anxious and has been having trouble sleeping. She has also noticed she has lost weight although she is not sure how much. This past weekend she drank an entire bottle of [Doctor Last Name ] (at baseline she only drinks on the weekend). . Review of systems: (+) Per HPI + headache + diarrhea (nonbloody) + lethargy + anxiety + weight loss + abdominal pain w/axiety . (-) Denies fever, chills, night sweats. Denies sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies palpitations or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Anemia (she just knows she was told to take iron supplements) Depression w/prior history of SI and self-mutilation (superficial cutting) Social History: Lives with three daughters (ages 5, 6 and 11). She is not currently working. No current boyfriend. Occasional cocaine use with last use 1 week prior to admission. Drinks alcohol on weekends mostly with last EtOH use this past weekend (a whole bottle of [Last Name (un) 46373]). Smokes [2-10] cigarettes per day. Presumed history of depression with prior attempts at hurting herself (cutting herself with glass) most recently 2 years ago. Family History: Mother and brother with seizure disorder. Sister with brain cancer (unclear what type, sounds like a benign meningioma which was resected). No known family history of kidney disease. Physical Exam: Admission: Vitals: afebrile HR 113 BP 150/94 RR 22 97/6L General: Alert, oriented, mild discomfort HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, +JVD to close to jaw, no LAD CV: tachycardic, faint SEM, no rubs, gallops Lungs: rales bilaterally at bases, no wheeze Abdomen: soft, mild epigastric tenderness, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: 1+ edema bilaterally, red nonblanching macules across calves bilaterally, otherwise warm, well perfused, 2+ pulses, no clubbing, cyanosis Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, no asterixes Discharge: Vitals: 98.5, 117/79, 89, 18, 97% RA General: Alert, oriented, mild discomfort HEENT:Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD, no JVD Chest wall: R tunneled catheter site mildly tender to palpation, non-indurated, non erythematous CV: regular rate and rhythm, faint SEM, no rubs, gallops Lungs: CTAB, no rales or wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: no edema b/l, red nonblanching macules across calves bilaterally, otherwise warm, well perfused, 2+ pulses, no clubbing, cyanosis Pertinent Results: Labs on Admission: [2104-8-11] 01:03PM TYPE-[Last Name (un) ] PH-7.45 [2104-8-11] 01:03PM freeCa-0.80* [2104-8-11] 12:35PM GLUCOSE-89 UREA N-121* CREAT-18.2* [2104-8-11] 12:35PM GLUCOSE-89 UREA N-121* CREAT-18.2* [2104-8-11] 12:35PM ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-461* CK(CPK)-422* ALK PHOS-53 AMYLASE-107* TOT BILI-0.3 [2104-8-11] 12:35PM ALBUMIN-3.3* CALCIUM-6.5* PHOSPHATE-8.8* MAGNESIUM-1.8 [2104-8-11] 12:35PM WBC-7.2 RBC-2.60* HGB-7.9* HCT-22.5* MCV-87 MCH-30.5 MCHC-35.2* RDW-14.3 [2104-8-11] 12:35PM PLT COUNT-260 [2104-8-11] 12:35PM PT-11.2 PTT-26.7 INR(PT)-1.0 [2104-8-11] 12:35PM FIBRINOGE-443* [Hospital3 ]: [2104-8-11] 05:55PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE [2104-8-11] 05:55PM HCV Ab-NEGATIVE [2104-8-11] 04:06PM PTH-590* [2104-8-11] 04:05PM ANCA-NEGATIVE B [2104-8-11] 04:05PM [Known firstname ]-NEGATIVE [2104-8-11] 01:45PM URINE HOURS-RANDOM UREA N-232 CREAT-45 SODIUM-104 POTASSIUM-14 CHLORIDE-87 albumin-193.8 alb/CREA-4306.7* [2104-8-11] 01:45PM URINE UCG-NEGATIVE [2104-8-11] 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2104-8-11] 01:45PM URINE COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.007 [2104-8-11] 01:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2104-8-11] 01:45PM URINE RBC-11* WBC-19* BACTERIA-FEW YEAST-NONE EPI-9 [2104-8-11] 01:45PM URINE MUCOUS-RARE [2104-8-11] 01:03PM TYPE-[Last Name (un) ] PH-7.45 [2104-8-11] 01:03PM freeCa-0.80* [2104-8-11] 12:35PM LIPASE-88* Discharge Labs: [2104-8-22] 07:25AM BLOOD WBC-4.7 RBC-2.32* Hgb-7.1* Hct-21.8* MCV-94 MCH-30.4 MCHC-32.4 RDW-13.6 Plt Ct-219 [2104-8-22] 07:25AM BLOOD Glucose-95 UreaN-36* Creat-7.3# Na-134 K-4.2 Cl-100 HCO3-23 AnGap-15 [2104-8-22] 07:25AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 Imaging: ECG Study Date of [2104-8-11] Sinus tachycardia. Anterolateral T wave inversion. Accelerated A-V conduction. No previous tracing available for comparison. ECHO [2104-8-12] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. There is moderate global left ventricular hypokinesis (LVEF = 35%). 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. The aortic valve is not well seen. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-10]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. CHEST (PORTABLE AP) Study Date of [2104-8-11] There is mild cardiomegaly. Large bibasilar opacities are worrisome for aspiration/pneumonia. There is mild vascular congestion. There is no pneumothorax. Bilateral pleural effusions are small, larger on the right side. CHEST (PORTABLE AP) Study Date of [2104-8-12] As compared to the previous radiograph, there are increasing bilateral perihilar pulmonary parenchymal opacities with multiple air bronchograms. In addition, there is mildly increasing retrocardiac atelectasis, moderate cardiomegaly as well as presence of minimal pleural effusions. The diameter of the apical vessels are slightly increased. Overall, the changes are consistent with acute pulmonary edema. RENAL U.S. PORT Study Date of [2104-8-12] FINDINGS: The renal cortex is markedly echogenic bilaterally, with preservation of normal appearing hypoechoic pyramids, consistent with medical renal disease. There is no focal renal mass, hydronephrosis, or renal calculus. The right kidney measures 8.7 cm, and the left kidney measures 8.1 cm. The bladder is normal in appearance. IMPRESSION: 1. Markedly echogenic kidneys, consistent with medical renal disease. 2. No hydronephrosis CHEST (PORTABLE AP) Study Date of [2104-8-13] FINDINGS: As compared to the previous radiograph, the parenchymal opacities in the perihilar areas and at the lung bases have substantially improved. Borderline size of the cardiac silhouette. Unchanged moderate retrocardiac atelectasis. No new parenchymal opacities. No larger pleural effusions. DUPLEX DOPP ABD/PEL Study Date of [2104-8-14] IMPRESSION: 1. Markedly echogenic contracted kidneys, consistent with medical renal disease. 2. Echogenic material in the left perinephric space, concerning for hematoma. A CT of the abdomen and pelvis is recommended for further assessment. RENAL U.S. Study Date of [2104-8-14] FINDINGS: The right and left kidneys measure 8.7 and 8.1 cm respectively. Again seen are markedly echogenic shrunken kidneys, consistent with medical renal disease. No hydronephrosis, stones or renal masses are seen. Surrounding the left kidney, there is a heterogeneously echogenic soft tissue, highly concerning for a perinephric hematoma in the setting of recent renal biopsy. Trace abdominal free fluid is seen. The urinary bladder is normal. Color doppler and spectral assessment of both renal arteries were performed. The segmental arteries of the right kidney demonstrate normal arterial waveforms with a sharp systolic upstroke(Resistive indices-0.6-0.8) and left kidney (RI-0.57-0.76). The main renal veins are patent. [2104-8-15] Cardiovascular ECHO [2104-8-15] There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. Mild to moderate ([12-10]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Symmetric left ventricular hypertrophy with normal global biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. [2104-8-19] Radiology VENOUS DUP UPPER EXT [Hospital1 ] FINDINGS: Duplex was performed of bilateral upper extremity veins. A catheter is in place in the right neck and subclavian vein could not be imaged. The left subclavian vein has phasic flow. The right cephalic and basilic veins are patent. Diameters are noted on the scanned report. The left basilic vein is patent with diameters as noted. The left cephalic vein is thrombosed at the site of prior intravenous line. Brachial and radial arteries are patent with triphasic waveforms bilaterally and diameters are noted on the scanned worksheet. IMPRESSION: Patent right cephalic and basilic veins and left basilic vein with diameters as noted. [2104-8-19] Radiology ART DUP EXT UP BILAT CO FINDINGS: Duplex was performed of bilateral upper extremity veins. A catheter is in place in the right neck and subclavian vein could not be imaged. The left subclavian vein has phasic flow. The right cephalic and basilic veins are patent. Diameters are noted on the scanned report. The left basilic vein is patent with diameters as noted. The left cephalic vein is thrombosed at the site of prior intravenous line. Brachial and radial arteries are patent with triphasic waveforms bilaterally and diameters are noted on the scanned worksheet. IMPRESSION: Patent right cephalic and basilic veins and left basilic vein with diameters as noted. Brief Hospital Course: 28F no prior PMH who presented to an OSH with nausea, vomiting, diarrhea; found to be in severe acute renal insufficiency with severe anemia and respiratory distress. Transferred to [Hospital1 18] for further management. # [Last Name (un) ]: Patient admitted with creatinine of 20; found to be likely subacute, given elevated PTH and creatinine of 1.1 one year prior to admission. The patient was evaulated by renal and rheumatology for a source of her renal failure with differential diagnosis including malignant hypertension secondary to cocaine use, secondary hypertension causes. vasculitis, glomerular nephropathy other autoimmune etiologies. HIC, Hep Serologies, dsDNA, anti-[Doctor Last Name ], UPEP, SPEP, anti-RNP [Known firstname ], ANCA, anti-GBM studies all negative. Differential also included levamisole induced kidney injury given history of cocaine use. While this may explain renal failure, ANCA was negative and rash was not characteristic. The patient had a temporary femoral dialysis line placed and underwent several dialysis sessions. A renal biopsy was ultimately performed showing ESRD with diffuse glomerular destruction, difficult to determine underlying etiology but clearly chronic. A tunnelled HD line was placed for permanent dialysis as a bridge to possible transplantation. Family expressed interest in learning about donor process. Renal biopsy was complicated by retroperitoneal/subcapsular bleed with patient endorsing acute worsening of left flank pain with concommittent HCT drop, with CT identifying retroperitoneal/ sucapsular bleed. Managed with blood transfusion and tight BP control <140 with initially hydralazine, the nitroprusside drip, then esmolol, and finally labetalol p.o. Metanephrines and 2nd Anti-GBM negative. Renal biopsy showed diffuse scaring. A PPD was placed and result negative. Patient was seen by nutrition who provided eduation for proper renal diet. Patient discharged with tunneled HD line and schedule to have HD on M,W,F. She will follow up with transplant surgery for evaluation for renal transplant. . # Hypertension: Patient had elevated blood pressures in the setting of [Last Name (un) ] with fluid overload. No prior history of hypertension. Treated with nitro drip for afterload reduction. Seen by cardiology, recomended hydralazine for afterload reduction, had some headaches/dizziness. Given her persistent hypertension here, work-up for secondary causes of hypertension was done. Ultimately ended up on esmolol drip, transitioned to labetolol with good BP control. Work up of secondary causes of HTN negative for evidence of renal artery stenosis or fibromuscular dysplasia. Metanephrines negative, TSH wnl. Elevated pressure likely secondary to fluid overload- improved with hemodialysis. Patient discharged on labetolol. . #SOB- Patient with shortness of breath and chest tightness on admission with 02 requirement. CXR revealed some evidence of volume overload, with Echo showing EF of 20 to 30%. She received several dialysis sessions for afterload reduction, with repeat echo showing recovery of EF to 55-60%. She was able to wean off oxygen to room air. # Anemia: Normocytic anemia of unclear etiology. She reports a history of mild iron deficiency anemia in the past. No signs of active bleeding. Patient likely has significant erythropoietin deficiency secondary to likely chronic renal failure. Concern for hemolysis with haptoglobin 5, though normal T. bili The patient may have marrow suppressive effects related to process driving renal failure. However, other cell lines ok. Hematology consulted, ? levamisole induced hemolysis,thrombocytopenia. Planned to check levamisole in urine but not on lab menu so send out lab supervisor could not send out. G6PD testing negative for deficiency. Anemia improved with 1UPRBC. # Rash on Legs: Patient has red macules scattered across her legs which she believes are from recent bed bug manifestation at her home. They do not appear infected. She reports having them for the past month and that her daughters had bed bugs until a month ago when she took them to the doctor. Dermatology consult did not believe these were likely scabies and skin scrapings were negative. Felt to be consistent with uremic folliculitis. Infection control involved regarding bed bugs with clearing of room of patient clothing/bedclothing. Rash was not consistent with lavamisole induced vasculitis. # Lung Nodules: Lung nodules on chest x-ray. Unclear if related to acute presentation or not. Needs outpatient follow up. Smoker. # Depression: Concerning with history of self-mutilation. Patient denied active suicidal or homicidal ideation. Social work followed patient and provided input. Transitional Issues: - follow up lung nodules - Hemodialysis M,W,F - Primary care follow up scheduled - Cardiology follow up scheduled - Renal follow up at HD - follow up scheduled with transplant surgery Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Labetalol 400 mg PO TID hold for BP<110 or HR<60 RX labetalol 200 mg 2 tablet(s) by mouth three times a day Disp #180 Tablet Refills:3 2. Nephrocaps 1 CAP PO DAILY RX B complex-vitamin C-folic acid 400 mcg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 3. Ferrous Sulfate 325 mg PO DAILY 4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth QID:PRN Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Renal Failure Secondary: Substance abuse, cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for kidney failure that required dialysis. You also had respiratory difficulty and depressed heart function. Your heart function and respiratory function improved with dialysis. Followup Instructions: Name: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD When: Tuesday [8-26] at 11:40am Location: GREATER [Hospital1 ] FAMILY HEALTH CENTER Address: [Location (un) ], [Hospital1 ],[Numeric Identifier 66038] Phone: [Telephone/Fax (1) 82128] Department: CARDIAC SERVICES When: TUESDAY [2104-9-2] at 1:30 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 6738], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: TRANSPLANT CENTER When: MONDAY [2104-9-8] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 14955], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "276.2", "311", "305.00", "V45.11", "275.3", "305.1", "998.12", "275.41", "285.1", "585.6", "793.11", "305.60", "584.9", "E879.8", "782.1", "403.01" ]	icd9cm	[ [ [] ] ]	[ "55.23", "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	18627, 18633	13047, 17791	326, 361	18743, 18743	5081, 5086	19206, 20173	3583, 3767		18180, 18604		18654, 18722		18023, 18157			18894, 19183			6798, 13024								3782, 5062																	17812, 17997	2559, 2943		265, 288								389, 2540							5100, 6782		18758, 18870					2965, 3104	3120, 3567
13,309	199,382	52774	Discharge summary	report	Admission Date: [2132-7-28] Discharge Date: [2132-8-11] Date of Birth: [2074-2-21] Sex: M Service: NEUROLOGY Allergies: Mevacor Attending:[First Name3 (LF) 5018] Chief Complaint: code stroke; transfer from OSH aftyer iv tPA Major Surgical or Invasive Procedure: TPA at outside hospital Right Hemi-craniectomy and partial right temporal lobecomy History of Present Illness: The patient is a 58yo R-handed man with CAD, s/p MI, hypercholestreolemia, hypothyroidism, who is transferred to [Hospital1 18] after he received iv tPA at OSH. . The patient was driving in his truck this pm. He was well until about 15.00. At that thime, he pulled over to look at a map. He opened the door of his truck, bent over to look for his phone under his seat, and then fell out of the truck. When on the ground he noted that his L-side was weak. He hit his head, causing a laceration on his head. He was awake and alert and did not lose consciousness. . He was taken to an OSH, where his NIHSS was 18. A CT head was negative for hemorrhage, but showed a hyperdense R-MCA. At 16.45, iv tPA was given after consent. He was then transferred to [Hospital1 18] at 17.20 and arrived at 18.20. His exam had only minimally improved, and he remained awake, alert and oriented. He had some bilateral wheezing, but we were able to hold off on intubation. His bloodpressure had been managed with extra boluses of labetolol. . NIHSS at OSH: 18 1a. Level of consciousness: 0 1b. LOC questions: 0 (age and month) 1c. LOC commands: 0 2. Best gaze: 2 3. Visual: 2 4. Facial Palsy: 3 5. Motor Arm: 0/4 6. Motor Leg: 0/4 7. Limb ataxia: 0 8. Sensory: 1 9. Best Language: 0 10. Dysarthria: 1 11. Extinction: 1 Past Medical History: -CAD, s/p MI ('[16] and '[30]) and cardiac stents -hypercholesterolemia -s/p splenectomy -s/p Hodgkins '[12] -hypothyroidism Social History: Smoking: not currently; in the past; EthOH: no; Family History: unknown Physical Exam: VITALS: T98.1 HR94 BP140/73 180/96 RR20 sO2 98% on high flow O2 . GEN: NAD HEENT: mmm, scalp laceration NECK: neck in collar, unable to assess for bruits LUNGS: wheezing bilaterally HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema . MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date, person; able to tell what happened today. Attention: MOYbw. Memory: Registration: [2-22] items; Recall [2-22] at 5 min. Language: fluent; repetition: intact; Naming intact; Able to follow simple commands; clear dysarthria, no paraphasic errors. Prosody: normal. Apraxia not tested. L-sided neglect. . CRANIAL NERVES: II: Blinks to threat on the R, not on the left. Pupils equally round and reactive to light both directly and consensually, 3-->2 mm bilaterally. Disc margins sharp, no papilledema. III, IV, VI: Extraocular movements without nystagmus, decreased L-gaze. No ptosis. V: Facial sensation intact to light touch and pinprick on the R, decreased on the L. VII: Left facial droop. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. . MOTOR SYSTEM: Normal bulk bilaterally. Tone of left extremities is decreased. Strength on the R intact throughout. Does withdraw L-leg to noxious. No clear movement after noxious in L-arm. . SENSORY SYSTEM: Sensation intact to light touch and temperature (cold) on the R. No sensation on the L. . REFLEXES: B T Br Pa Pl Right unable due to lines 1 0 Left unable due to lines 1 0 Toes: upgoing on the L, down on the R. . COORDINATION: Normal [Last Name (LF) 11140], [First Name3 (LF) ], HTS on the R. . GAIT: deferred Pertinent Results: [2132-7-28] 06:31PM FIBRINOGE-172 [2132-7-28] 06:31PM PT-15.7* PTT-50.8* INR(PT)-1.4* [2132-7-28] 06:31PM PLT SMR-NORMAL PLT COUNT-306 [2132-7-28] 06:31PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-OCCASIONAL [2132-7-28] 06:31PM NEUTS-93.9* BANDS-0 LYMPHS-4.0* MONOS-1.4* EOS-0.2 BASOS-0.3 [2132-7-28] 06:31PM WBC-29.1# RBC-4.60 HGB-13.8 HCT-40.5 MCV-88 MCH-29.9 MCHC-34.0 RDW-13.7 [2132-7-28] 06:31PM GLUCOSE-180* UREA N-13 CREAT-1.0 SODIUM-142 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 [2132-7-28] 09:54PM CK-MB-10 MB INDX-3.6 cTropnT-<0.01 [2132-7-28] 09:54PM CK(CPK)-280* . [2132-7-28] CTA Head: Dense right middle cerebral artery consistent with occlusion. Left scalp hematoma. Occluded right middle cerebral artery. No evidence of significant internal carotid artery stenosis. See above comment regarding the appearance of the cervical spinal canal. . [2132-7-28] MRI C/L/T spine: No definite signs for epidural or subdural spinal hematoma. Clearly, the hyperdensity noted on the recent CT scan could raise the question of subarachnoid hemorrhage. . [2132-7-29] CT Head: There are findings consistent with an evolving large right middle cerebral artery territory infarct, with focus of intraparenchymal hemorrhage, as described above. There is associated mass effect, with a suggestion of right hippocampal herniation. . [2132-7-30] CT Head: Evolving large right middle cerebral artery territory infarct with a focus of intraparenchymal hemorrhage, demonstrating greater mass effect with a new subfalcine herniation and greater right hippocampal herniation as compared to the day before. . [2132-7-31] CT Head: Examination compared to prior study of [2132-7-30]. Again is noted the extensive abnormality in the right hemisphere consistent with infarction and hemorrhage. There is increased prominence of left lateral ventricle, especially the temporal [Doctor Last Name 534], consistent with some obstruction of the foramen of [Last Name (un) 2044]. There is increased subfalcial right to left herniation, which now measures 22 mm at the level of the foramen of [Last Name (un) 2044]. There is a small extra-axial hematoma in the region of the craniectomy site Increased mass effect with increased subfalcial herniation and some developing dilatation of the left lateral ventricle. Small extra-axial hematoma in the region of the prior craniectomy. . [2132-8-1] Head CT: [2132-7-31] Echo: The left atrium is elongated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears mildly depressed. Resting regional wall motion abnormalities include inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets (3) 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . No intracardiac mass/thrombus identified. Brief Hospital Course: ICU Course: . Neurologically: Arrived within 1-2 hours of receiving IV TPA at outside hospital. Repeat CT at [Hospital1 18] showed persistent hyperdense MCA suggesting clot. Decision for Intra-arterial TPA was strongly considered but family eventually decided against as [Hospital 228] [Hospital ] medical status was tenuous (became hypotensive). He was intubated for respiratory distress. On exam, he was able to follow some commands with the right side (moving RUE and RLE), and could weakly withdraw the LUE (extension mostly . Follow up CTs showed evidence of infarct and devolopment of edema which became worrisome at 36 hours. On [7-30] he was taken to the OR for right craniectomy and temporal lobectomy. Post operative CTs initially showed right frontal hemorrhage (3 x 3.5cm) and some increasing edema with significant midline shift. The edema was managed medically with Mannitol 50mg IV Q6 and Dexamethasone 4mg IV Q6 as well as keeping the head of bed at < 30 and PcO2 less than 35. His exam in the first 48 hours post-op declined with some dilation and fixing of the right pupil as well as inability to follow commands. He was still withdrawing purposefully on the right and weakly on the left. . On [8-4] improvement was noted on patient's exam. He was following commands by showing thumbs up and two fingers on right and could move the right toes on command. He was not able to follow any commands left and could not track with eyes. Repeat CT was performed [8-4] and showed evolution of the right MCA stroke and hemorrhage as well as slight decrease in midline shift and sub-falcine herniation. Mannitol was weaned slowly from [Date range (1) 108853] with caution for rebound edema. Dexamethasone also weaned slowly. Exam improved only slightly more over the next 48 hours in that his ability to follow commands with right hand was more crisp. Also began to develop some aggitation with trach care and required prn doses of propofol to keep him comfortable during nursing care. on [8-5], family began to mention desire to maintain patient's wishes and make him CMO. On [8-6] they met with Dr [First Name (STitle) ] and decided on CMO status to start at midnight. After extubation, vitals remained stable and he was kept comfortable with morphine drip and prn fentanyl. . CVS: Cardiac enzymes negative on admission. Had some wide complex abnormal rythems (not V-tach) around [Date range (1) 3563]. Was ruled out again with cardiac enzymes and had an echo which showed EF 35%. Please see results section for further detail. Was noted to have bradycardia down to 30s when put on CPAP on [8-5]. Otherwise has been in NSR while on Tele. . Resp: Had wheezes/ronchi bilaterally suggesting aspiration on admission. Intubated on admission for poor oxygenation. Thought to have aspiration pneumonia and given antibiotics but then d/c'd after 24 hours. CXR on [8-2] suggested question of aspiration pna in lower lobes but [8-4] showed clearing. . GI: Received IV protonix for prophylaxis. Tube feeds started with Doboff on [7-31] with Promote full fiber. Started at 10cc and eventually titrated up to 95cc/hour. Vomitted [8-5] and tube feeds held for 24 hours. Restarted [8-6] . Renal: Some mild increase in BUN after several days of Mannitol, but corrected quickly as mannitol was weaned off. Peaked at 34. Creatinine never elevated. . ID: Started on antibiotics at admission for presumed aspiration pneumonia but d/c'd after 24 hours. Sporadic low grade fevers but no spikes. Persistently elevated white count but no shift. Blood cultures x 3 and urine culture from admission negative. Sputum culture multi-flora. . Heme: Persistently elevated white count but no shift. WBC around 18-23 mostly. . Endocrine: continued on levoxyl alternatin doses of 100mcg QD and 200mcg QD. Covered with RISS. . Floor Course: Palliative care was consulted and recommended Levsin and a Scopalamine patch to control secretions, Ativan PRN anxiety or agitation, and Morphine PRN pain. Pt. appeared comfortable on the floor. There was no improvement in his Neuro exam, and over the next several days his respiratory status became more tenuous. On [8-11] at 2:15 he stopped breathing. His pupils were fixed and dilated, had had no heart sounds or breath sounds, and no palpable carotid or radial pulse. His family was notified and declined autopsy. Medications on Admission: -lipitor 20mg daily PO -toprol XL 25mg daily PO -synthroid 200mcg alternated with 100mcg daily PO -Ticlid ? -diltiazem 30mg daily PO -omeprazole 20mg daily -vit E -MVI Discharge Disposition: Expired Discharge Diagnosis: R MCA Ischemic Stroke with cerebral edema and herniation Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2132-8-11]	[ "V10.72", "285.9", "V45.82", "507.0", "244.9", "272.0", "412", "E884.9", "V66.7", "348.5", "873.0", "434.11", "348.4", "414.01", "787.03", "440.0", "342.90" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.72", "01.53", "96.6", "96.04", "96.07" ]	icd9pcs	[ [ [] ] ]	12051, 12060	7384, 11832	315, 399	12160, 12169	3965, 5177	12222, 12372	1980, 1990				12081, 12139		11858, 12028			12193, 12199											2005, 2388																				230, 277								427, 1737	2826, 3946	5734, 6505		6515, 7361					2403, 2810					1759, 1898	1914, 1964
32,371	147,318	48254	Discharge summary	report	Admission Date: [2111-2-23] Discharge Date: [2111-3-5] Date of Birth: [2052-1-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 663] Chief Complaint: Syncope Major Surgical or Invasive Procedure: upper endoscopy x2 History of Present Illness: Ms. [Known lastname 1057] is a 59 year-old woman with a history of diabetes and hypertension who presents with nausea/vomiting and syncope, found to have a new anemia and likely GI bleed. . One week prior to admission, she reports a mild cough and runny nose; similar to an infection her husband had had earlier. She was taking NSAIDS for these symptoms . One day prior to admission, patient felt week and dizzy at work. She also had an upset stomach. She rested some but didn't feel significantly better so her boss sent her home. . At home, while trying to get water, she syncopized. She felt dizzy and lightheaded beforehand with mild shortness of breath and chest discomfort. She does not know how long she was out but did not feel that she hit her head. Later in the morning, she felt extremely week and did not feel that she was strong enough to go to work. She later syncopized again. . In addition to the above, she reports two episodes of emesis with possible blood (reports seeing what she felt was a spicy sauce she had eaten). She is unsure of the amount of emesis produced. . When asked about bloody stools, she is unsure, reporting that does not usually look at her stools. She does recall one episode of very dark watery stool one month ago. She denies any abdominal discomfort or dyspepsia now or in the past. Reports one episode of diarrhea the day prior to admission. ROS otherwise negative for fevers, though she has had some mild chills. . Regarding her insulin, she reports not taking any yesterday evening or this morning as she has had poor PO intake. . In the ED, her initial temperature was 97.5, BP 102/75, HR 56. While getting the second unit of blood, she spiked a temp to 101.1 She also recieved 3 liters of NS. An NG was placed which showed dark blood which cleared after 500cc. Her finger stick was >400 and she was started on an insulin gtt. . She was initially admitted to the ICU where she had an EGD, approximately 5units of PRBCs were transfused (one stopped early due to fever and ?transfusion reaction). She had a significant cough which required narcotics for cough suppression. She felt that her pulmonary symptoms started to resolve by hospital day 4. She continued to be febrile, however. MICU team consulted ID who felt that this was most likely chemical pneumonitis and recommended adding flagyl if she continues to be febrile for aspiration pneumonia. They did not feel she was likely to have pertussis. Radiologist did not feel CT had the appearance of aspiration pneumonia however. Flagyl not added given improving condition. She also had a positive urine culture with e.coli sensitive to ceftriaxone. Past Medical History: 1. Diabetes: A1c 8.9% ([5-25]) 2. Hypertriglyceridemia - Complicated by severe pancreatitis requiring hospitalization and surgery at [Location (un) 511] [Hospital ] Hospital - TG 1523 ([5-25]) 3. Abdominal surgery (ex-lap) 23 years ago in [State ] for abdominal pain. Reports this is how her diabetes diagnosis was made. Social History: Has a real estate business but is also working as a restaurant manager. Lives with her husband. Denies smoking/drinking for over 30 years. Family History: Mother died of pancreatic cancer in her 60s; father died of cancer (?liver vs. lung) in his 80s. Physical Exam: VITALS - T 100.9, BP 102/39, HR 54, RR 15, 97% on 3 liters GEN - Lying flat in bed. Able to provide HPI. HEENT - Mild conjunctival palor. Right cheek with very mild echymosis and swelling. Mildly tender. CV - Regular. No murmurs. PULM - Clear. No rales/wheeze. ABD - Soft and non-tender. Midline scar noted. EXT - Warm. No edema. NEURO - Alert and oriented. Moving all extremeties. No focal deficits. Pertinent Results: [2111-2-23] 05:10PM BLOOD WBC-10.9# RBC-2.29# Hgb-6.3# Hct-19.6# MCV-86 MCH-27.6# MCHC-32.3 RDW-14.8 Plt Ct-128 [2111-2-24] 01:49AM BLOOD WBC-9.8 RBC-2.65* Hgb-7.7* Hct-22.0* MCV-83 MCH-28.9 MCHC-34.8 RDW-14.7 Plt Ct-119* [2111-2-24] 02:37PM BLOOD WBC-8.9 RBC-2.91* Hgb-8.6* Hct-24.4* MCV-84 MCH-29.5 MCHC-35.3* RDW-14.4 Plt Ct-115* [2111-2-25] 03:44AM BLOOD Hct-19.9* [2111-2-26] 02:59AM BLOOD WBC-9.6 RBC-3.39# Hgb-9.9# Hct-28.9* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.7 Plt Ct-142* [2111-3-2] 05:40AM BLOOD WBC-7.8 RBC-3.13* Hgb-9.1* Hct-27.3* MCV-87 MCH-29.2 MCHC-33.5 RDW-14.2 Plt Ct-293# [2111-3-3] 05:30AM BLOOD WBC-6.7 RBC-2.77* Hgb-8.2* Hct-23.5* MCV-85 MCH-29.5 MCHC-34.7 RDW-14.3 Plt Ct-237 [2111-3-3] 01:05PM BLOOD Hct-24.6* [2111-3-4] 05:45AM BLOOD WBC-5.9 RBC-3.22* Hgb-9.3* Hct-27.2* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.5 Plt Ct-259 [2111-3-5] 05:55AM BLOOD WBC-5.0 RBC-3.02* Hgb-9.0* Hct-25.8* MCV-85 MCH-29.9 MCHC-35.1* RDW-15.6* Plt Ct-248 [2111-2-23] 05:10PM BLOOD Glucose-408* UreaN-74* Creat-1.5* Na-132* K-3.6 Cl-94* HCO3-18* AnGap-24* [2111-3-3] 05:30AM BLOOD Glucose-147* UreaN-30* Creat-0.6 Na-136 K-4.3 Cl-104 HCO3-25 AnGap-11 [2111-2-23] 05:41PM BLOOD PT-15.6* PTT-30.1 INR(PT)-1.4* [2111-2-26] 02:59AM BLOOD PT-12.5 PTT-29.4 INR(PT)-1.1 [2111-3-2] 05:40AM BLOOD Triglyc-272* . Endoscopy [2111-2-24] Impression: Normal mucosa in the whole esophagus Ulcer in the angularis (injection, thermal therapy) Normal mucosa in the first part of the duodenum and second part of the duodenum Otherwise normal EGD to second part of the duodenum Recommendations: 1. Continue IV PPI drip for 72 hours and then IV BID as long as she is in hospital.After that she needs po PPI [Hospital1 ] for 6 weeks and repeat endoscopy in 6 weeks to document healing of ulcer 2. Check H. pylori serology and treat if positive 3. Serial HCT and transfuse PRN . Chest CT [2111-2-26] 1. Extensive right lower lobe pneumonia. 2. Additional multifocal areas of consolidation with peribronchovascular distribution (right lung greater than left). Considering rapid development in 24 hours, this could potentially represent asymmetrical pulmonary edema especially considering the new septal thickening and history of treatment for GI bleed. However, rapidly progressive multifocal pneumonia is also possible. 3. Incompletely imaged marked splenomegaly with large wedge-shaped defect suspicious for an infarct. Dedicated abdominal imaging with ultrasound or CT would be helpful for more complete assessment, as communicated by phone to Dr. [First Name (STitle) ] on [2111-2-26]. 4. Mediastinal and hilar lymphadenopathy, probably reactive in the setting of pneumonia. 5. Probable fatty infiltration of the liver. . Echocardiogram [2111-2-26] The left atrium is mildly dilated. The right atrial pressure is indeterminate. There is moderate symmetric left ventricular hypertrophy. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . ? Transfusion Reaction - Report DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [Known lastname 1057] experienced fever during the transfusion of packed red blood cells. The laboratory workup did not reveal any evidence of hemolysis. Of note, her fevers continued after stopping the transfusion and new pulmonary infiltrate was detected on the chest X-ray the following day. In addition, there was also evidence of UTI. Septic reactions are very rare with red blood cell products and such a reaction would be extremely unlikely explanation to this patient's symptoms. Febrile non-hemolytic transfusion reactions are in the differential for transfusion-associated fever, but are extremely unlikely with leukoreduced products and would not explain continued fevers. Thus the patient's fever was most likely due to her underlying illness and not the transfusion. No change in transfusion practice is recommended at this time in this patient. . Brief Hospital Course: #. Acute blood loss anemia due to GI Bleed: stabilized after injection/cautery large bleeding 1.5 cm ulcer at the angularis. H.pylori antibody serology was equivocal. [Month (only) 116] have been due to NSAID use. Transitioned from PPI drip to PPI [Hospital1 ] PO. She was hemodynamically stable once transferred to the floor. Prior to discharge her HCT trended down again. It was unclear if this was due to recurrent bleeding or slow erythropoeisis. Ferritin was elevated suggesting adequate iron stores. On repeat endoscopy on [3-4] the ulcer was injected and clipped (report not available at present). She was discharged with PCP followup and plans for followup endoscopy in ~2 months to document healing. She was discharged with empiric treatment for H.pylori after which she was to continue PO bid PPI for a total of 6 weeks. . #. Respiratory illness: on admission CXR lungs appeared clear; however with increased hydration a clear RLL infiltrate declared itself. She was febrile into the 102 range and continued to be febrile despite coverage with Ceftriaxone/azithromycin for CAP. Flu negative but she had been having symptoms for several days prior to DFA so this could have been a false negative. Although ID felt this might be aspiration, it did not appear so radiographically. Overall, on transfer to the floor, she seemed to be improving clinically with improving cough and stable O2 sats on room air. She was continued on ceftriaxone and azithromcyin initially and then changed to levofloxacin on [3-2]. She did continue to have fevers however. Blood and urine cultures showed no growth, and sputum samples were all contaminated by upper respiratory secretions. She briefly received metronidazole for her fevers but this was not continued as she was felt to be doing well clinically. She had significant volume resuscitation so some of respiratory distress could have been to volume overload - she seemed to respond to one dose of lasix and subsequently had significant autodiuresis. . #. DKA: Presented with blood fingerstick >400 with a postive anion gap. Was started on an insulin gtt in ED. Gap closed; continued on dextrose containing IV fluids plus insulin gtt while NPO. Electrolytes repleted. Transitioned to home dosing. Had some low-normal blood sugars prior to discharge so given 60u 70/30 [Hospital1 ] instead of home dose of 70u [Hospital1 ] with instructions to incurease dosing if needed once she resumes her outpatient diet. (outpatient diet likely higher in carbohydrates - patient works in a restaurant and reports somewhat irregular eating habits) . # UTI: E.coli. treated with ceftriaxone and then levofloxacin. . #. Thrombocytopenia: Appears chronic with a platelet count ranging in the 90-120 range since [2099]. No history of liver disease, though the elevated INR has no explanation. Did have an enlarged spleen on Chest CT. platelets had improved by time of discharge. . # splenic infarct on CT unclear etiology, likely chronic. She is having some chest wall pain which is most likely due to coughing as it is reproducible on palpation of ribs. . # hypertriglyceridemia gemfibrozil held in ICU, restarted on floor for elevated triglycerides . #. Acute renal failure: On admission, serum creatinine elevated at 1.5 from baseline of 0.5 in [5-25]. This was likely a result of volume depletion. Normalized during hospital course and patient restarted on HCTZ and ACE-inhibitor . #. Anion gap acidosis: Likely from DKA. Lactate 1.5. Resolved. . #. Syncope: Likely related to her anemia. Appears that she did hit her head/face with one of her falls. CT head negative. Medications on Admission: 1. Atenolol 25 mg daily 2. Hydrochlorothiazide 12.5 mg daily 3. Lisinopril 40 mg daily 4. Gemfibrozil 600 mg [Hospital1 ] 5. Metformin - 1,000 mg [Hospital1 ] 6. Humulin 70/30 70 units [Hospital1 ] Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): for cough. Disp:21 Capsule(s) Refills:0 2. Prevpac 500-500-30 mg Combo Pack Sig: One (1) tablet PO twice a day for 14 days. Disp:28 tablets Refills:0 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. insulin 60units 70/30 insulin twice daily, can increase to previous dose of 70 units 70/30 insulin twice daily if blood sugars >200 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 4 weeks: start after prevpak is finished in 14 days. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 9. Outpatient Lab Work Please check hematocrit on [3-10] Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Aspiration Pneumonia Diabetes Mellitus type II Hypertriglyceridemia Urinary tract infection Discharge Condition: Good, ambulatory without lightheadedness. HCT has dropped slightly to 25 but EGD [3-4] injected and clipped bleeding from ulcer site. Stable for discharge with close followup. Discharge Instructions: You were admitted to the hospital for a bleed from your stomach and you also had a respiratory infection as well. The bleeding may have been contributed to by the use of ibuprofen and it also may have been due to an infection with a bacteria called helicobacter pylori (although a test for this was negative but we still feel it is prudent to treat for it). . We have decreased your dose of lisinopril to 20mg and your blood pressure was well-controlled on this dose. . you need to take omeprazole for four weeks after the prevpak is finished and then have a repeat endoscopy (see below) . Please return to the emergency room if you have lightheadedness, more vomiting of blood, large dark or tarry bowel movements, or any other new or concerning symptoms. Followup Instructions: Please followup with Dr. [First Name (STitle) ] on Tuesday [3-10] at 3:30pm to check in post-hospitalization and to have your blood level (hematocrit) checked (Rx for lab draw attached) . You will need to have another endoscopy in 6 weeks to make sure the ulcer in your stomach has healed. The number for the GI unit is ([Telephone/Fax (1) 2233]. Dr.[Name (NI) 17410] office can also help arrange this.	[ "041.4", "250.13", "584.9", "789.2", "286.9", "E935.9", "285.1", "401.9", "531.40", "486", "276.1", "599.0", "287.5" ]	icd9cm	[ [ [] ] ]	[ "44.43", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	13574, 13580	8679, 12329	320, 341	13740, 13923	4099, 8656	14729, 15152	3565, 3663		12589, 13551		13601, 13719		12355, 12566			13947, 14706											3678, 4080																				273, 282								369, 3029														3051, 3393	3409, 3549
4,292	196,125	1387	Discharge summary	report	Admission Date: [2116-7-21] Discharge Date: [2116-8-1] Date of Birth: [2054-1-23] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 62 year-old gentelman patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2201] was referred for outpatient cardiac catheterization. He had symptoms of chest pain that typically occurred after eating. He had been treating this as a GI symptom, but was referred to his doctor and on [7-17] he underwent an exercise tolerance test, which showed electrocardiogram changes. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Question of arthritis. 4. Status post vagotomy in the [2084]. 5. Status post cholecystectomy in the [2094] with two follow up surgeries for abdominal adhesions in the [2094]. He had a cardiac catheterization done on [7-21]. MEDICATIONS ON ADMISSION: Atenolol 25 mg po q.d., Lipitor 40 mg po q.d., Hydrochlorothiazide 25 mg po q.d., Celebrex 200 mg po b.i.d., Diovan 80 mg po q.d., Zantac 150 mg po b.i.d., Percocet prn and Valium prn. ALLERGIES: No known drug allergies. ADMISSION LABORATORIES: Day prior to catheterization were white count 7.4, hematocrit 35.2, platelet count 274,000 with an INR of 1.1. His catheterization showed 70% less main lesion, proximal right coronary artery lesion of 90%, right posterolateral ventricular branch 100% lesion, circumflex 80% lesion and mild luminal irregularities of the left anterior descending coronary artery. It also showed an ejection fraction of 51%. Please refer to the cardiac catheterization report on [7-21]. He was referred to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of cardiac surgery who examined him on the 21st. He also had no history of claudication. PHYSICAL EXAMINATION: He was alert and oriented. His lungs were clear. His heart was regular rate and rhythm. Preop his BUN was 28 with a creatinine of 1.3 and his hematocrit was 35%. HOSPITAL COURSE: On [7-23], he underwent coronary artery bypass graft times four with a left internal mammary coronary artery to the left anterior descending coronary artery, vein graft to the posterior descending coronary artery, vein graft to the PLV and a vein graft to diagonal one by Dr. [Last Name (STitle) ]. He was transferred to the Coronary Care Unit in stable condition on propofol and nitroglycerin. On postoperative day one he had no events overnight. He remained on a Nipride drip at 0.5 mcg per kilo per minute. He was extubated and sating 96% on 4 liters. He had a cardiac index of 3.2. He was in sinus rhythm in the80s with a good blood pressure. His white count was 9.4, hematocrit 22.3, platelet count 207,000, sodium 134, K 4.7, chloride 101, CO2 23, BUN 18, creatinine 1.3 with a blood sugar of 149. His examination was unremarkable. He started his Lopressor and aspirin. He began his Lasix diuresis. His chest tubes were discontinued as was his Swan-Ganz catheter and he was transferred out to the floor. He was seen by physical therapy there and began his ambulation. On postoperative day two he was sating 94% on 3 liters with a blood pressure of 150/78. He had a temperature max of 102.1. His heart was regular rate and rhythm. His incisions were clean, dry and intact with mild bilateral lower extremity edema. His Foley was removed. His Lopressor was increased for better blood pressure control. His hematocrit remained 22.2. On postoperative day three he remained in sinus rhythm. He was readmitted to the Intensive Care Unit for transfusion reaction. His lactic acid was 2.0. Additional laboratories were drawn. He was awake and alert. He had no wheezing. His heart was regular rate and rhythm. He had some minimal swelling of his extremities. His abdominal examination was benign. He continued with his rule out protocol. He was on Dopamine at 3 micrograms for improving his urine output. He got D5W with three amps of bicarb, which had been started overnight and a renal consult was requested and complete urinalysis was done. On postoperative day four he had a temperature max of 100.6 with a good blood pressure. He was sating 94% on 6 liters nasal cannula. He remained on Dopamine, Lasix. His hematocrit rose to 25.4. His white count rose to 17.8. K was 3.4 with a BUN of 48 and a creatinine of 2.5. He had decreased breath sounds at bilateral bases of his lungs, but his heart was regular rate and rhythm. The dopamine was to be weaned off and he was transferred back out to the floor. He was seen again by physical therapy. He had good clinical improvement from his transfusion reaction. On postoperative day five his blood pressure was slightly elevated at 157/96. His sternum was stable. His abdominal examination was benign. His incisions were clean, dry and intact. His Foley remained in place as did his pacing wires. His central line was removed. His hematocrit remained 25.4, which was to be monitored. The patient became agitated in the middle of the night and he took off his O2 and telemetry and gown and the nurses tried to reorient him. Eventually the intern convinced the patient to take some Valium and it was arranged for a sitter to stay with the patient and monitor him closely through the night. He again then wandered from his room and left his room again at 5:30 in the morning on the 29th. Security found him downstairs in the cafeteria drinking coffee. He was reoriented again back to the floor by psychiatry staff who responded to the code purple. His blood pressure was 190/80 when they returned him to his room. He received another dose of Lopressor to help bring his blood pressure down. He was started on Haldol and was again accompanied by a sitter. His hematocrit rose to 26.1 on postoperative day six with a BUN of 52 and a creatinine of 2.4. His K was 5.0 with a magnesium of 2.3. His sternum was stable and his examination was again unimpressive. It was determined that he should have a sitter until his mental status showed clear improvement. He was again combative at 9:00 a.m. He was placed in four point restraints. A full set of laboratories was drawn again. A chest x-ray was done. He was also to be followed by security for a 24 hour period while he continued Haldol therapy on Far Six. His chest x-ray showed a decreased effusion. No localized infection was noted. At 8:00 in the evening on postoperative day six the patient's blood pressure rose to 265/130. He had a temperature max of 103 and was in sinus tachycardiac, tachypneic in the 30s and was with rigors. Neurologically he was seen again by the CT Surgery fellow that evening. He was neurologically intact with normal speech and following commands. His chest wall sternum were stable. His lungs were clear. His heart was regular rate and rhythm. He had no erythema or signs of infection in his wounds. His chest x-ray early in the day had showed no infiltrates. His white count was 12.1 with a hematocrit of 26. He received Demerol. Blood cultures were obtained. His electrocardiogram showed no signs of ischemia. He was given Hydralazine intravenous to manage his acute hypertension and he was transferred back to the Intensive Care Unit. He was seen by psychiatry who recommended again that this was probably delirium and to keep him in restraints with possibly some deep venous thrombosis prophylaxis. The asked that his Serax and Valium be minimized. He was seen by case management. He remained with a security sitter. His transfer to the Intensive Care Unit was canceled after his rigors resolved and his blood pressure responded to the intravenous Hydralazine. On postoperative day seven he remained in a Posey belt for his agitative episodes over the night. He was started on Ciprofloxacin for empiric coverage. His BUN was 42. The creatinine of 1.7 with a K of 3.5. His alkaline phosphatase was elevated at 456, otherwise his laboratories were unremarkable. His white count was 12.1 with a hematocrit of 26.2. His incisions were clean, dry and intact. Urine culture was reordered. His physical examination was unremarkable. He continued to be followed by psychiatry and rehab services with physical therapy. On postoperative day eight his BUN came down to 31 with a creatinine of 1.5. His hematocrit remained stable in the mid 20s. He was down one kilogram of weight. He remained on Hydralazine, Lopresor, Lasix, Valium, Haldol and Ciprofloxacin. Blood cultures were still pending. His incisions were intact. His Serax was discontinued His Haldol was switched to prn. He remained on a one week course of Ciprofloxacin. His sitter was discontinued as he became more oriented and stated that he did feel much better. He continued to make steady progress with good activity levels and endurance. His pulmonary status was good. He was followed by case management in planning for his discharge and he continued to make dramatic improvement. On postoperative day nine his blood pressure was 164/92, sating 93% on room air. He was neurologically intact. His wounds were clean, dry and intact. The plan was to check his culture and sensitivities before discharge and plan for VNA Services at home and to continue his Ciprofloxacin for a total of seven days. On [2116-8-1] he was discharged to home with instructions for follow up in one week for staple removal and to follow up with his primary care physician in one to two weeks as well as following up with Dr. [Last Name (STitle) ] in three to four weeks. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times four. 2. Coronary artery disease. 3. Hypertension. 4. Hypercholesterolemia. 5. Question of arthritis. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg po b.i.d. times seven days, Lopressor 75 mg po b.i.d., Hydralazine 15 mg po q.i.d., Zantac 150 mg po b.i.d., Colace 100 mg po b.i.d., Lipitor 40 mg po q.h.s., Valium as needed. Motrin as needed. Percocet also as needed. Lasix 20 mg po b.i.d. times fourteen days and K-Ciel replacement 20 milliequivalents po q.d. times fourteen days. PHYSICAL EXAMINATION ON DISCHARGE: His heart was regular rate and rhythm. His vital signs were stable. His wounds were clean, dry and intact. His sternum was stable. His lungs were clear. His final chest x-ray did show a left lower lobe pneumonia for which he was receiving his antibiotics and again he was discharged on [2116-8-1] in stable condition to home with VNA Services. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2116-10-20] 11:29 T: [2116-10-20] 09:39 JOB#: [Job Number 8376]	[ "401.9", "V15.82", "413.9", "414.01", "293.0", "272.4", "999.8", "486", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.53", "36.15", "39.61", "36.13", "37.22" ]	icd9pcs	[ [ [] ] ]								9621, 9779	9803, 10182				934, 1838	2045, 9600																										1861, 2027			10197, 10831												175, 589														612, 907
32,707	173,679	7334	Discharge summary	report	Admission Date: [2126-5-16] Discharge Date: [2126-5-21] Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 19836] Chief Complaint: DOE, lightheadedness Major Surgical or Invasive Procedure: Colonoscopy Capsule study History of Present Illness: This is a 83 year-old female with a h/o ischemic colitis, MGUS, HTN, AS who presents with SOB, lightheaded, found to have Hct of 19 down from 26. She developed a transfusion reaction vs flash pulmonary edema in the ED and was admitted to MICU for further monitoring. She was briefly on Bipap and her dyspnea/hypoxia resolved. She was diursed 1.2 L (but her breathing improved prior to this). Her hct has been stable after 2U pRBCs. Please see below for more details of her presentation and course. Ms. [Known lastname ] feels well currently, no dyspnea, orthopnea, PND, fevers, chills, cough, LE swelling. . Pt recently had an episode of nonbloody vomiting, felt also more tired, lightheaded and had DOE. Denied any CP, syncope, diaphoresis. She is being closely followed by her PCP, [Name10 (NameIs) ] found to have worsened anemia with Hct from baseline of 30s down to 24 on [2126-5-6]. Her valsartan was held and her PPI was increased to [Hospital1 ]. She underwent EGD on [2126-5-8]. EGD was unremarkable but pt had a granulomatous mass on colonoscopy in [9-/2125] which was initially suspicious for plasma cell neoplasm and led eventually to the diagnosis of MGUS (per last Heme/Onc note from [2126-3-27]). Of note, she has known ischemic colitis with LGIB in [2121] and [7-/2125], treated conservatively. . On day of admission, she was more lightheaded, became diaphoretic while trying to have a BM in the bathroom. Her relatives called 911 and she was brought to the ED. . In the ED, her VS were T97.1, 84, 116/50, 12, 99%RA. She was guaiac positive but takes iron. An EKG was unremarkable. CXR with no acute process. Labs notable for Hct of 19 down from 26 just three days ago. Pt was given 2L IVF and was ordered for 2U PRBC. However, after 60cc of blood, she developed facial redness, diaphoresis, was cool and pale, and was sob with diffuse crackles on exam. She says that she was not at all dyspneic until getting blood. Her BP went down to 83/41 transiently. RR up to high 30s and tachy to 122. She was given IV benadryl, solumderol, and zantac. Repeat CXR showed fluid overload. She was started on BiPAP with improvement of symptoms. She was weaned to NC (satting 100% on 3L) but her admission bed was changed to ICU for closer monitoring. . On arrival in the MICU, she was less SOB, satting well on 2.5L NC. In the MICU she was briefly on BIPAP, SOB resolved with before diuresis. She recieved 2U pRBCs without event, but was diuresed 1.2L with 10mg IV lasix. Transfusion medicine feels that she did not have a blood reaction, but likely flash pulmonary edema. . ROS: The patient denies any fevers, chills, nightsweats, abdominal pain, chest pain, or lower extremity edema. She c/o occasional urinary frequency, dysuria, and constipation. Past Medical History: 1. Hypertension. 2. Hypercholesterolemia. 3. Moderate aortic stenosis. Last echo in [2122] with AoVA 0.8-1.19cm2 4. Gout. 5. Ischemic colitis with LGIB in [2121] and [7-/2125], treated conservatively. 6. Diverticulosis. 7. MGUS (Oncologist Dr. [Last Name (STitle) 410] Social History: Used to drink one cocktail drink a day. Denies any tobacco use. Lives at home with sister. Is functional, does all ADLs herself. Not married. Physical Exam: Vitals: T: 97.6 BP: 100/43 HR: 81 RR: 20 O2Sat: 99% on RA. -1.2L GEN: WDWN elderly female in no acute distress HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear NECK: No JVD COR: RRR, 3/6 SEM at USB radiating to both carotids, no G/R, normal S1 S2. pulsus parvus/tardus PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, 2+ DP pulses NEURO: alert, oriented. Moves all 4 extremities. SKIN: No jaundice, cyanosis. No ecchymoses. Brief Hospital Course: Anemia: Black, guaiac positive stools suggestive of UGI source. Baseline Hct in 30s, on admission with hct of 19 ([5-16]) s/p 2 units pRBC in the MICU. Hct stable throughout hospital course at 26-27. On [5-20] colonoscopy with polyps in the descending colon s/p biopsy. She was discharged with capsule endoscopy on [5-21]. She was restarted on her regimen of iron. . Hypoxia: Was thought to be secondary to TRALI versus pulmonary edema from acute blood-transfusion-related volume overload. In the end a diagnosis of TRALI was preferred given the right timing of onset, hypotension and facial flushing. Hypoxia completely resolved since being on the floor. . AS: Moderate AS (AoVA 0.8-1.19cm2) on last echo in [2122]. Repeat ECHO here was unchaged. At baseline she is asymptomatic with AS, though this may have contributed to her SOB/hypoxia here as noted above. She remained stable throughout the rest of her hospitalization. . HTN: She was restarted on her BB and [Last Name (un) ] at discharge and tolerated these well. Medications on Admission: 1. Atenolol 25 mg once a day. 2. Protonix 40 mg [Hospital1 ]. 3. Simvastatin 20 daily. 4. Allopurinol 300 daily. 5. Psyllium daily 6. Iron 160 [Hospital1 ]. 7. (Valsartan 160 daily held for last few days by PCP) Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Allopurinol Oral 5. Psyllium Oral 6. Iron 160 mg (50 mg Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Anemia Secondary Hypertension Hyperlipidemia Aortic stenosis Gout Diverticulosis Discharge Condition: hemodynamically stable, stable hct Discharge Instructions: You were admitted with lightheadedness. You were found to have a very low blood count. You had a blood transfusion during this hospitalization. You had an adverse to the blood transfusion and were admitted to the intensive care unit. Your blood counts stabilized following these transfusions. You also had a colonoscopy. You are being discharged with instructions for a capsule endoscopy. You should return the capsule as instructed by the gastroenterologist tomorrow [5-22]. The following medications were changed during this hospitalization: Iron was restarted for your low blood count. Please start the iron following your capsule study. If you have any of the following symptoms, you should call your PCP or return to the emergency room: Chest pain, shortness of breath, lightheadedness, loss of Followup Instructions: We have scheduled an appointment for you with Dr. [Last Name (STitle) 9006] for tomorrow [5-22] at 12:20 PM. Please attend this appointment. You will likely have your blood count monitored then. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4853], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2126-6-5] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3749], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2126-6-12] 11:00 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2126-6-17] 11:00 [First Name8 (NamePattern2) ] [Name8 (MD) ] MD, [MD Number(3) 19838] Completed by:[2126-6-5]	[ "272.0", "274.9", "285.1", "426.3", "424.1", "562.10", "514", "401.9", "429.9", "276.0", "211.3", "578.9" ]	icd9cm	[ [ [] ] ]	[ "45.42", "93.90", "45.25" ]	icd9pcs	[ [ [] ] ]	5844, 5850	4059, 5108	240, 268	5983, 6020		6883, 7701			5379, 5821		5871, 5962		5134, 5356			6044, 6860											3571, 4036																				180, 202								296, 3088														3110, 3397	3413, 3556
652	100,262	27608	Discharge summary	report	Admission Date: [2142-4-28] Discharge Date: [2142-6-11] Date of Birth: [2120-10-16] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish Attending:[First Name3 (LF) 30] Chief Complaint: Purpura, fever, "flu-like" symptoms Major Surgical or Invasive Procedure: Oral Intubation Central Line Placement [2142-5-14]: Placement of 8.0 Portex tracheostomy tube, placement of #19 French Ponsky percutaneous endoscopic gastrostomy tube, flexible bronchoscopy. [2142-5-23]: PICC Line Placement [2142-5-28]: Right foot incision and drainage. [2142-5-30]: Bilateral incision and drainage with debridement of both feet. History of Present Illness: The patient is a 21 year old African-American male with no significant past medical history who presented to the ED on [2142-4-28] after being transferred from [Hospital 1474] Hospital. The patient had presented to [Hospital1 1474] via his family on [2142-4-27] at 5:30 pm with the chief complaint of generalized body aches. He complained of left knee pain after recently suffered an injury to his left knee (scraped) while playing basketball for which he was evaluated for at an OSH. He also complained of nausea, vomiting, diarrhea, and headache. . At [Hospital1 1474], the patient was noted to have a temperature of 103, P 122, BP 128/69. He was sat'ing 99% on RA. The patient was found to have a left swollen knee and purpura fulminans. He was given Ceftriaxone 2 gm IV (split dose), doxycycline 100 mg PO, vancomycin 1 gm IV. He also received an estimated 3.5 liters. . The patient's ABG at [Hospital1 1474] at 12:40 am was as follows: . 7.33/27/103/13.6 . His Chem7 at [Hospital1 1474] was notable for a K of 3.2, gap of 15, Cr 2.4. . At [Hospital1 1474], the left knee was tapped. He was then transferred to [Hospital1 18] for further evaluation. . On arrival, the CXR concerning for ARDS with: . Diffuse faint opacity bilaterally with increased interstitial markings, worrisome for atypical diffuse infection such as virus or PCP. . His ABG at [Hospital1 18] was as follows: . 7.11/47/116/16 with a lactate of 9.6 at 5:15 am on [2142-4-28]. . He was subsequently intubated. His SBP dropped to the 80s and he was thus started on levophed now at 0.458. Solumedrol and later decadron were given. Central line with continuous Svo2 monitor placed. . ROS: as per HPI, unable to get further info as pt int/sed Past Medical History: PMH: Asthma . Past Surgical History: None Social History: The patient works at [Company 2486]. He is married but separated and currently sexually active (unprotected) with a female partner. The patient had travelled to [State 2748] three weeks ago. No animal/rodent contact. Physical Exam: On admission to the ED: Tc=97.7 P=97->136 BP=102/49 RR=23 92% on RA . On arrival to MICU . Tc= P=136 BP=115/63 RR=28 Gen - int/sed HEENT - PERRLA Heart - tachy, nl s1s2, no mrg Lungs - clear Abdomen - soft nt nd nabs Ext - wwp Skin - diffuse purpura over arms/legs, including soles and palms Neuro - mae, sedated on meds Pertinent Results: [2142-4-28] 03:00AM FIBRINOGE-142* D-DIMER->[Numeric Identifier 961]* [2142-4-28] 03:00AM PT-27.7* PTT-80.6* INR(PT)-2.9* [2142-4-28] 03:00AM PLT SMR-LOW PLT COUNT-81* [2142-4-28] 03:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+ [2142-4-28] 03:00AM NEUTS-73* BANDS-10* LYMPHS-4* MONOS-1* EOS-1 BASOS-0 ATYPS-1* METAS-10* MYELOS-0 [2142-4-28] 03:00AM WBC-11.0 RBC-5.19 HGB-14.4 HCT-44.4 MCV-86 MCH-27.8 MCHC-32.5 RDW-13.6 [2142-4-28] 03:00AM CORTISOL-42.0* [2142-4-28] 03:00AM TOT PROT-4.8* CALCIUM-6.9* PHOSPHATE-3.8 MAGNESIUM-1.1* [2142-4-28] 03:00AM CK-MB-9 [2142-4-28] 03:00AM ALT(SGPT)-14 AST(SGOT)-36 CK(CPK)-1401* ALK PHOS-108 AMYLASE-92 TOT BILI-0.6 [2142-4-28] 03:00AM GLUCOSE-86 UREA N-20 CREAT-3.1* SODIUM-141 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-11* ANION GAP-26* [2142-4-28] 03:01AM LACTATE-9.6* [2142-4-28] 04:45AM URINE RBC-[1-28]* WBC-[5-5]* BACTERIA-MANY YEAST-NONE EPI-0 [2142-4-28] 04:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [2142-4-28] 04:45AM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.023 [2142-4-28] 05:15AM PO2-116* PCO2-47* PH-7.11* TOTAL CO2-16* BASE XS--14 [2142-4-28] 06:30AM JOINT FLUID NUMBER-NONE [2142-4-28] 06:30AM JOINT FLUID NUMBER-NONE [2142-4-28] 06:30AM JOINT FLUID WBC-4100* HCT-14.0* POLYS-89* LYMPHS-9 MONOS-2 . CXR [2142-4-28] - The heart is normal in size. The mediastinal contours are within normal limits. Note is made of increased interstitial markings bilaterally, worrisome for atypical infection such as virus or PCP. [Name10 (NameIs) 67451] arch is somewhat prominent. . CT HEAD [2142-4-28] - No evidence of hemorrhage, shift of normally midline structures, or hydrocephalus. [Doctor Last Name ]-white differentiation appears grossly preserved. Air- fluid levels are noted within the frontal, maxillary and sphenoid sinuses. There is also opacification of the ethmoid airspaces. . MRI HEAD/CSPINE ([2142-5-12])- No evidence of intracranial enhancement, mass effect, or hydrocephalus. No focal signal abnormalities or acute infarcts. Extensive soft tissue changes in the mastoid air cells and the paranasal sinuses could be related to intubation. No evidence of epidural abscess or hematoma. No spinal cord compression seen. Clinical correlation recommended. . CT TORSO ([2142-5-13]) - CT OF THE CHEST WITHOUT IV CONTRAST: The endotracheal tube is above the level of the carina. The NG tube is in satisfactory position. There are multiple sub 5-mm pulmonary nodules diffusely throughout the lung fields. There are small bilateral pleural effusions as well as bibasilar atelectasis. There is diffuse anasarca. There is evidence of pulmonary edema. There are no visualized lymph nodes meeting CT criteria for pathology on this unenhanced scan. The pleural effusions measures simple fluid in Hounsfield units. . CT OF THE ABDOMEN WITHOUT IV CONTRAST: On this unenhanced scan, the liver, adrenal glands, gallbladder, spleen, pancreas, kidneys, and ureters are normal. The small bowel is normal. The large bowel is distended and fluid- filled, and featureless. Again there is diffuse anasarca. There is no visualized lymphadenopathy or free fluid, given the limitations of this unenhanced scan. The aorta is of normal caliber. There is no evidence of retroperitoneal hematoma. . CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum is fluid-filled and distended. The bladder contains a Foley catheter. There is diffuse anasarca. No free fluid. No inguinal lymphadenopathy. . PORTABLE CHEST OF [2142-5-29] Tracheostomy tube and right PICC line remain in standard position. Cardiac silhouette appears prominent but stable in size. Pulmonary vascularity is within normal limits. Previously reported basilar areas of consolidation are no longer evident. There are no new areas of consolidation, but the extreme periphery of the right lung base laterally has been excluded, precluding assessment of this region. . ECHOCARDIOGRAM [2142-5-25]: The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. There is a trivial/physiologic pericardial effusion. . TEE [2142-6-1] (under general anesthesia): No thrombus/mass is seen in the body of the left or right atrium. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). A Chiari network is present in the right atrium (normal finding). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. No masses or vegetations are seen on the aortic, mitral, tricuspid or pulmonic valves. There is a trivial pericardial effusion or pericardial fat present. . CXR [2142-6-6]: Portable chest radiograph reviewed. The PICC tip is unchanged in position overlying the mid SVC. The heart and mediastinal contours are stable. The lungs are suboptimally evaluated given exposure, but appear clear. The pleura appear clear. Pulmonary vasculature appear normal. IMPRESSION: No evidence for PICC migration. . Culture Data: [2142-4-28]: Blood Cx x 2. No growth. [2142-4-28]: Urine. No growth. [2142-4-28]: Synovial fluid from left knee. 1+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [2142-4-28]: Stool. No growth. [2142-4-28]: BAL. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [2142-4-28]: Sputum culture. Rare oropharyngeal flora. No microorganisms seen. [2142-4-29]: Blood Cx x 2. No growth. [2142-4-30]: Blood Cx x 2. No growth. [2142-4-30]: Urine. No growth. [2142-5-1]: Blood Cx x 2. No growth. No fungus, no mycobacteria. [2142-5-1]: Stool. C. diff negative. [2142-5-1]: Urine x 2. No growth. [2142-5-2]: Sputum. [9-19] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2142-5-4]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. [2142-5-2]: Sputum. No growth. [2142-5-3]: Blood x 2. No growth. [2142-5-3]: Urine. No growth. [2142-5-3]: BAL. No growth. No Legionella. No PCP. [Name10 (NameIs) ] PMN's. [2142-5-3]: Urine. No growth. [2142-5-4]: Blood x 2. No growth. [2142-5-4]: Sputum. No growth. No PMN's. [2142-5-4]: Blood x 2. No growth. [2142-5-5]: Stool. Negative for C. diff. [2142-5-5]: Blood. No growth. [2142-5-5]: Urine. No growth. [2142-5-6]: Stool. Negative for C. diff. [2142-5-6]: Blood. No growth. No fungus, no mycobacteria. [2142-5-6]: Catheter tip. No significant growth. [2142-5-7]: Stool. Negative for C. diff. [2142-5-8]: Blood x 2. No growth. [2142-5-8]: Urine. No growth. [2142-5-8]: Sputum. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. OROPHARYNGEAL FLORA ABSENT. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH. 2ND MORPHOLOGY [2142-5-9]: Sputum. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2142-5-11]): OROPHARYNGEAL FLORA ABSENT. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH. 2ND MORPHOLOGY. [2142-5-10]: Blood x 2. No growth. [2142-5-10]: Urine. No growth. [2142-5-12]: Blood x 2. No growth. [2142-5-12]: Urine. No growth. [2142-5-12]: Sputum. No growth. [2142-5-13]: Blood x 2. No growth. [2142-5-13]: Urine. No growth. [2142-5-13]: Sputum. OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. [2142-5-15]: Blood x 2. No growth. [2142-5-15]: Urine. No growth. [2142-5-15]: Sputum. No growth. [2142-5-17]: Blood x 2. No growth. [2142-5-17]: Urine. No growth. [2142-5-17]: Right foot wound culture. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. No bacterial growth. [2142-5-17]: Left foot wound culture. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. No bacterial growth. [2142-5-22]: Blood Culture (1 set). No growth. [2142-5-22]: Blood Culture (1 set). Coag negative staph, oxacillin resistant. [2142-5-23]: Catheter tip. No significant growth. [2142-5-24]: Blood Culture x 3. No growth. [2142-5-25]: Blood Culture x 2. No growth. [2142-5-26]: Blood Culture. No growth. [2142-5-27]: Stool. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [2142-5-27]: Blood Culture. No growth. [2142-5-27]: Wound, right foot. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. YEAST. RARE GROWTH. [2142-5-28]: Blood Culture. No growth. [2142-5-28]: Wound, right foot. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. YEAST. SPARSE GROWTH. [2142-5-28]: Wound, right foot. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. YEAST. RARE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. [2142-5-30]: Wound, left foot. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. [2142-5-30]: Wound, left foot. SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH SKIN FLORA. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. OF THREE COLONIAL MORPHOLOGIES. [2142-6-5]: Urine. No growth. [2142-6-5]: Blood. STILL PENDING. [2142-6-5]: Sputum. OROPHARYNGEAL FLORA ABSENT. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Brief Hospital Course: ADMISSION IN INTENSIVE CARE UNIT: 21 year old male with no known significant PMH p/w menongococcemia, purpura fulminans, ARDS and DIC. His hospital course, by problem list is as follows. . 1) SEPTIC SHOCK/PURPURA FULMINANS: [11-28] Blood culture bottles at [Hospital 1474] hospital were positive for N. meningitidis, although near-daily cultures of blood, sputum, and urine throughout the patient's ICU stay remained negative. On admission to the ICU, the patient recieved a 4 day course of Xigris and a 7 day course of empiric stress dose steroids (Hydrocortisone/fludricortisone). To treat his infection, he had an 8d course of cephalosporin (for meningococcemia; recieved ceftriaxone x 6d then cefepime), vancomycin, and flagyl. He persistently spiked nightly fevers to 103, and he had a profound leukocytosis up to 98.6K, with L shift. Culture data remained negative, and his only source was a questionable LLL pneumonia on CXR. Bedside flexible bronchoscopy and a BAL were pristine, so antibiotics were discontinued on hospital day 9. He briefly defervesced after changing of his central venous catheter, but then continued to have nightly fevers. He recieved another 10d course of vancomycin, cefepime, and flagyl empirically. When these antibiotics were discontinued, his white count had normalized, although he continued to have low grade fevers. Infectious disease was consulted upon admission, and followed the patient throughout his hospital stay. . The patient also was noted to have progressive acral necrosis of his fingers and toes. This was followed daily by the ICU team, and plastic/hand surgery and podiatry were consulted. There was no evidence of wet gangrene/progressive infection, and the necrosis was allowed to demarcate. By discharge from the ICU, this had been stable for one week, and the patient's necrosis remained limited to the distal 1.5 phalanxes of bilateral hands (largely sparing the thumbs), as well as the distal phalanx of bilateral feet. Occupational therapy was consulted to help the patient with this, and the patient will be followed as an outpatient or at rehab by OT. He also will follow up weekly with hand surgery and podiatry to assess need for amputation (versus allowing auto-amputation). . The patient also had diffuse lower extremity bullae and purpura, which were cared for supportively with [Hospital1 ] bacitracin as well as xeroform dressings. . #) PERSISTENT FEVERS: Intravenous access was difficult to obtain, and access was maintain via L subclavian central venous catheter. This was removed in the setting of persistent fevers and IR placed a PICC line. Blood cultures revealed Methicillin Resistant Staph Epidermidis and pt was started on Vancomycin for 14 day course. C. diff toxin assay were also positive and the patient was started on metronidazole. Pt. was sent to OR for surgical wound debridement with podiatry of the R foot, wound cultures revealed pseudomonas and ceftazidime was started for full Gram negative coverage. . 2) ACUTE RENAL FAILURE: Upon admission, the patient was noted to have a Cr 3.1, BUN 20 from presumed normal baseline. This trended up to a maximum Cr of 7.3 on HD#6. The renal team was following the patient throughout his stay, and thought the renal failure was likely Acute Tubular Necrosis from his sepsis. Dialysis was considered, but the patient never met acute indications for dialysis. He was treated prn with high dose diuretics (Lasix 200mg IV and Diuril 500mg IV up to [Hospital1 ]) for decreased urine output in the context of anasarca. However, predominately, he was treated supportively, and from HD#7, his creatine began to trend down and he autodiuresed significantly. By discharge from the ICU, his creatinine had normalized to 0.8. . 3) RESPIRATORY FAILURE: The patient was intubated on arrival due to respiratory distress/fatigue with profound metabolic acidosis. Initial chest xrays were consisted with ARDS, and the patient was maintained on lung protective ventilation. As mentioned above, daily chest xrays showed questionable pneumonia versus pulmonary edema. The patient was on vancomycin, cefepime and flagyl; and was also diuresed. His chest xrays continued to show significant edema, however, his vent settings were able to be weaned over his stay. He was not able to pass a spontaneous breathing trial, and extubation was also deferred because the patient had significant oral lesions and glossal edema, raising the concern for difficulty in reintubation. The patient therefore recieved a tracheostomy tube and PEG tube with thoracic surgery. He tolerated the procedure well, and postoperatively was quickly able to be transitioned to a trach mask, then a passamuir valve over the course of 2 days. His respiratory status remained stable throughout the remainder of his ICU stay. . 4) CARDIOVASCULAR SYSTEM - The patient had several different cardiovascular issues during his stay. On HD#1 an ECHO showed severely depressed LV function, with estimated EF < 15%. Repeat ECHO on HD#4 showed improved, but still severly depressed LV function, EF 30%. This was not repeated during his ICU stay. He also had one episode of non-sustained (~30 BEATS) ventricular tachycardia. His hemodynamics were stable and his electrolytes were normal at this time, however, and he had no further episodes of similar tachycardias. He was maintained on telemetry throughout this stay. He did have elevation of his cardiac biomarkers, which peaked on hospital day #7 with a Troponin T of 4.21. His CKs had been elevated (thought due to his acral necrosis), and his EKGs were unchanged. The troponinemia was ascribed to his renal failure and systolic heart failure (as opposed to an NSTEMI), and indeed, the rise and fall improved with resolution of his renal function. He should have a repeat ECHO as an outpatient, in [3-1] weeks after hospital discharge. . Additionally, after resolution of his initial sepsis, the patient was persistently tachycardic (HR usually 120s-130s, up to 150s, always sinus rhythm), and hypertensive (SBPs up to 180s-190s). The etiology was thought to be due to a combination of pain, anxiety, and fevers, and a generalized state of sympathetic excess. The patient was started on amlodipine, hydralizine, and metoprolol. . 5) NEUROLOGIC - As the patient's sedation was weaned in advance of possible extubation, he was noted to have questionable neurologic deficits. Specifically, he was not moving his upper extremities spontaneously, and while he was able to follow commands by eye blinking, he did not appear to demonstrate any tracking movements with his eyes. As he had been on Xigris, and also had significant microvascular pathology in other organ systems, an MRI HEAD/CSPINE was obtained to rule out intracerebral or spinal hematoma, bleeds, or infection. This examination was normal. An ophthamologic consult was also obtained to perform a dilated pupil retinal exam. This showed diffuse bilateral retinal hemorrhages, and outpatient follow up was reccomended. His tracking gaze, and upper extremity movement continued to improve as sedation was weaned. . 6) FLUIDS/NUTRITION - The patient was maintained on tube feeds throughout his admission. Initially, he had high residuals, and therefore, was supplemented with parenteral nutrition. Nutrition service provided useful reccomendations. By discharge, the patient had passed a speech and swallow examination, and was tolerating po intake with his PM valve in place. From a fluids standpoint, the patient required initial aggressive fluid rescuscitation for his sepsis and insensible volume losses, and was significantly volume overloaded throughout his stay, although this improved dramatically with forced- and auto-diuresis, and improvement of his renal function. . . . . . . . . . . . . . . . . . ................................................................ TRANSFER TO FLOOR. The patient's renal failure normalized; his creatinine returned to normal. The patient was breathing room air through a tracheostomy tube; the trach tube was removed on [2142-6-6]. Soon afterward, he was tolerating PO food; the G-tube was removed on [2142-6-10]. The patient spiked low-grade temperatures until [2142-5-27], when his temperature remained below 100.4F. Cultures were positive for the following: - MRSE in blood and wound culture ([5-22] in blood, [5-28] in wound) - + C. diff ([2142-5-27]) - + Yeast in wound cultures ([5-30] in wound culture) - Pseudomonas in wound cultures ([5-28] in wound culture) For these organisms, the patient was continued on vancomycin (started [5-22]), cefepime to ciprofloxacin (started [5-29]), and metronidazole (started [2142-5-28]). He will continue to get a full six week course of these antibiotics. . His foot wounds were dressed daily by podiatry, using Duoderm gel on dry sterile dressings and xenoform on leg wounds, bacitracin on leg bullae. His fingers were dressed with dry sterile dressing between the fingers to minimize maceration. . The patient is discharged to a rehab facility in stable condition for continued physical therapy, daily dressing changes, and IV antibiotic treatment (vancomycin). He requires substantial pain control especially for his dressing changes, and he has developed a tolerance to morphine; his pain is controlled with 2-4mg morphine EVERY MORNING before dressing changes, and he has tolerated a sliding scale of morphine (1-8mg) for physical therapy and any additional dressing changes or examinations of the wounds. He is discharged in stable condition, tolerating PO fluids/regular diet, breathing room air, and afebrile. Medications on Admission: Albuterol inhaler Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 30 days. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 30 days. 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 30 days. 7. Vancomycin 500 mg Recon Soln Sig: 1750 (1750) mg Intravenous Q 12H (Every 12 Hours) for 30 days. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for break through pain: Please hold for sedation or RR<8. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 12. Morphine 10 mg/mL Solution Sig: 1-8 mg Intravenous every twelve (12) hours as needed for pain: Please give prior to dressing changes. 13. Metoprolol Tartrate 100 mg Tablet Sig: One [Age over 90 1230]y (150) mg PO DAILY (Daily). 14. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain: for breakthrough pain. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Primary: Meningococcemia Respiratory Failure Disseminated intravascular coagulation Acute respirator distress syndrome Clostridium difficile infection MRSE bacteremia Wound infections Discharge Condition: Stable, afebrile, tolerating PO, oxygenating 100% on room air, tracheostomy tube and G-tube removed. Discharge Instructions: You were admitted for meningococcemia; your hospital course was complicated by disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and hypotension. You also have been diagnosed with MRSE bacteremia (bacteria in the blood), for which you are taking vancomycin; C. difficile colitis (a diarrheal illness), for which you are taking Flagyl; and several different bacteria and yeast that have infected the wounds, for which you are taking ciprofloxacin and fluconazole. These antibiotics will continue for four and a half more weeks. Please take all of your medications as directed. If you develop a fever, shortness of breath, new pain, or other concerning symptoms, please seek medical advice immediately. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] (Infectious Disease), Phone: [Telephone/Fax (1) 457] Date/Time: [2142-7-31] 10:00AM Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (Internal Medicine), Phone: [Telephone/Fax (1) 250] Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2142-6-14] 10:30 Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2142-6-19] 9:30 Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM (Podiatry) Phone:[Telephone/Fax (1) 543] Date/Time:[2142-6-20**] 1:30	[ "728.88", "036.0", "288.8", "428.21", "785.52", "362.81", "359.81", "041.10", "041.7", "401.9", "286.6", "518.5", "785.4", "427.89", "112.3", "682.7", "036.2", "276.2", "528.9", "730.07", "995.92", "493.90", "584.5", "008.45" ]	icd9cm	[ [ [] ] ]	[ "43.11", "88.72", "33.22", "99.15", "00.17", "33.24", "96.72", "96.04", "86.28", "31.1", "99.04", "86.22", "96.6", "83.39", "86.04", "00.11", "38.93", "81.91" ]	icd9pcs	[ [ [] ] ]	24809, 24891	13532, 23182	328, 693	25119, 25222	3144, 13509	26011, 26850			23250, 24786		24912, 25098		23208, 23227			25246, 25988									2537, 2544		2801, 3125																				253, 290								721, 2478														2500, 2514	2560, 2786
30,177	180,920	23709	Discharge summary	report	Admission Date: [2103-5-3] Discharge Date: [2103-5-8] Date of Birth: [2077-11-21] Sex: F Service: MEDICINE Allergies: Bactrim Ds Attending:[First Name3 (LF) 1990] Chief Complaint: responsible for her care only for the last two days of hospitalization. The following is a review of the history as obtained on review of her written medical record only Headache and altered mental status Major Surgical or Invasive Procedure: Intubation and mechanical ventilation. History of Present Illness: 25 yo F with mixed connective tissue disease and intersitial pulmonary fibrosis on chronic steroids, presented to the ED with HA, agitation, abnormal behavior. . Roommate states she heard moaning at 4 AM, then again a little while later. Found patient on couch c/o headache - called EMS. Before EMS arrived, [Known firstname 60587] MS changed - agitated, not answering questions, combative. In ED, screaming, combative, febrile 105, tachy to 150s, HTN to 180s, rectally, HTN, tachycardic. not hypoxic; intubated, imaging studies done, LP done, broad spectrum abx. started emperically for bacterial meningitis, including steroids. Past Medical History: # Mixed connective tissue disease - dx [2102-8-9], followed by Dr. [Last Name (STitle) 1667] of rheumatology (U1 RNP antibodies) - presented with digital swelling and recurrent wrist pains - positive [Doctor First Name ], polyclonal hypergammaglobinemia, low-positive anticardiolipin, [Doctor Last Name 1968] RNP positive, SCL-70 negative, SSA positive, ESR elevated # Seborrheic Dermatitis # Allergic Rhinitis # Benign fibrous tumor # MCTD with severe lung involvement and pulmonary fibrosis presents for followup # Elevated LFTs - thought to be due to atovaquone # Interstitial pneumonitis Social History: exercise - walks to the T, nothing formal no tobacco social EtOH - [2-11]/week no IVDU single bank auditor Family History: Mother - breast lump removed (? benign or malignant) M Aunt - breast Ca at age 40 * MGGM - breast Ca Father - died when patient was young (PNA) Siblings - 35 yo brother, A/W Children - none Physical Exam: I was not the examining physician at the time of admission: At discharge: Pt. afebrile, VSS. Fully alert and oriented, speech fluent, gait and station intact. No complaints. EOMI, PERRL, anicteric No JVD or LAD CTA throughout RRR no MRG Soft, NT, abdomen, no HSM, BS present No peripheral edema or rash. PICC line present lt. UE. Pertinent Results: [2103-5-3] 05:10AM PLT COUNT-371 [2103-5-3] 05:10AM NEUTS-47.1* LYMPHS-50.2* MONOS-2.4 EOS-0 BASOS-0.2 [2103-5-3] 05:10AM WBC-12.0# RBC-4.45 HGB-12.7 HCT-39.8 MCV-89 MCH-28.5 MCHC-31.8 RDW-13.6 [2103-5-3] 05:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2103-5-3] 05:10AM LIPASE-27 [2103-5-3] 05:10AM ALT(SGPT)-39 AST(SGOT)-35 LD(LDH)-212 ALK PHOS-47 TOT BILI-0.6 [2103-5-3] 05:10AM GLUCOSE-169 UREA N-18 CREAT-1.2* SODIUM-142 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-15* ANION GAP-34* [2103-5-3] 05:24AM K+-3.8 [2103-5-3] 05:24AM COMMENTS-GREEN TOP [2103-5-3] 05:30AM URINE HYALINE-0-2 [2103-5-3] 05:30AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-0-2 [2103-5-3] 05:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2103-5-3] 05:30AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2103-5-3] 05:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2103-5-3] 05:30AM URINE HOURS-RANDOM [2103-5-3] 06:11AM LACTATE-5.6* [2103-5-3] 06:11AM TYPE-ART PO2-512* PCO2-34* PH-7.42 TOTAL CO2-23 BASE XS--1 [2103-5-3] 06:45AM CEREBROSPINAL FLUID (CSF) WBC-260 RBC-10* POLYS-3 LYMPHS-94 MONOS-1 ATYPS-2 [2103-5-3] 06:45AM CEREBROSPINAL FLUID (CSF) PROTEIN-127* GLUCOSE-50 [2103-5-3] 06:46AM CEREBROSPINAL FLUID (CSF) WBC-325 RBC-25* POLYS-4 LYMPHS-94 MONOS-2 [2103-5-3] 01:04PM CALCIUM-7.8* PHOSPHATE-2.7 MAGNESIUM-1.8 [2103-5-3] 01:04PM GLUCOSE-186* UREA N-7 CREAT-0.8 SODIUM-141 POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17 [2103-5-3] 01:49PM C3-128 C4-29 [2103-5-3] 01:49PM OSMOLAL-298 [2103-5-3] 01:50PM LACTATE-4.8* [2103-5-3] 01:50PM TYPE-[Last Name (un) ] TEMP-37.3 COMMENTS-GREEN TOP CT head: IMPRESSION: Normal head CT. MR head: CONCLUSION: MR findings consistent with the clinical diagnosis of meningitis. These findings were discussed directly during a consultation with the infectious disease team caring for the patient. [2103-5-3] 6:45 am CSF;SPINAL FLUID GRAM STAIN (Final [2103-5-3]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. CRYPTOCOCCAL ANTIGEN (Final [2103-5-3]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. Blood cultures: NGTD. Brief Hospital Course: 1. AMS/Meningitis. Pt. was intubated for airway protection. Broad spectrum abx. administered for bacterial meningitis as well as ACV emperically for HSV. Decadron given emperically for pneumococcal meningitis. ID was consulted and followed throughout admission. Abx. were slowly removed (vanc stopped, then acv stopped) as cx. remained negative and pt. clinically improved. Ultimately pt. was sent home to complete 3 weeks of Ampicillin alone over concern for listeriosis, with a picc line. Safety labs will be faxed to the [Hospital ] clinic (Dr. [First Name (STitle) 1075] and she will follow up with PCP. 2. MCTD/ILD, on outpatient [Last Name (LF) 60588], [First Name3 (LF) ]-term. - was initially on decadron as above. After 4 days of empiric rx. with this was converted back to her home dose of 10 mg daily of prednisone. Medications on Admission: oral contraceptive prednisone, 10 mg. daily. Discharge Medications: No changes to above - the following added: 1. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) Grams Recon Soln Injection Q4H (every 4 hours) for 17 days: stop date [2103-5-24]. Disp:204 Grams Recon Soln(s) Refills:0 2. Picc line care Sig: One (1) line care each bag change and prn for 17 days: Picc line care per CCS protocol. Disp:QS picc line care Refills:0 3. Saline Flush 0.9 % Syringe Sig: One (1) flush, 10 cc Injection Q bag change and prn for 17 days. 4. Heparin Flush 10 unit/mL Kit Sig: [3-14] mL Intravenous as needed per CCS pic line care protocol for 17 days. Disp:QS kit Refills:0 5. Lab draws Sig: One (1) Lab draw once a week for 2 weeks: Draw: CBC, Chem 7, LFTs (ALT and AST) on [2103-5-14] and on [2103-5-21] and fax results to: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] at [Telephone/Fax (1) 432]. Disp:2 lab draws Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Meningoencephalitis and respiratory failure requiring intubation and mechanical ventilation Discharge Condition: Stable. Discharge Instructions: Resume you home medications as you were taking them prior to coming to the hospital. You have stated that you do not need refills on these (there are only two - prednisone and your oral contraceptive). You have been provided a prescription only for the antibiotic prescribed here. If you are sexually active while taking the antibiotic, you should use a second form of birth control in addition to your oral contraceptive (barrier protection such as a condom), as the antibiotic can diminish the efficacy of the pill. You should do this for at least one month following stopping the antibiotic. Return to the [Hospital1 18] Emergency Department for: Fevers Headache Nausea and vomiting Neck stiffness Visual changes Followup Instructions: Call you primary doctor for a follow up appointment for within two weeks of leaving the hospital. [Last Name (LF) ],[First Name3 (LF) ]: ([Telephone/Fax (1) 60589]. When you see doctor [Last Name (Titles) ], you will need to have a pneumonia vaccination if you are not already up to date on this given you interstitial lung disease. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 14200], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2103-5-17] 8:20 Provider: [Name10 (NameIs) 3712] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2103-6-8] 4:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2103-7-20] 3:00	[ "515", "518.81", "710.8", "323.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71", "03.31" ]	icd9pcs	[ [ [] ] ]	7357, 7409	5465, 6318	480, 521	7545, 7555	2524, 4429	8329, 9101	1961, 2155		6413, 7334		7430, 7524		6344, 6390			7579, 8306											2170, 2231								5335, 5442							2246, 2505					231, 442								549, 1184		4439, 4991												1206, 1816	1832, 1945		5023, 5302
65,654	141,453	37451	Discharge summary	report	Admission Date: [2161-3-13] Discharge Date: [2161-3-18] Date of Birth: [2093-10-10] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2161-3-13] Mitral Valve Repair (28mm [Company 1543] 3D profile ring) History of Present Illness: This 67 year old male has worsening shortness of breath and has had pleural effusions tapped in [10-17]. At that time the echo showed mitral stenosis with moderate pulmonary hypertension, both increasing since prior echo in [12-16]. Catheterization showed mild left main disease. She was referred for surgical evaluation and is now admitted for same. Past Medical History: Mitral Regurgitation mild coronary artery disease Chronic diastolic heart failure Pneumonia [10-17] ADHD osteoartritis s/p bilateral hip replacements s/p bilateral shoulder surgery s/p right wrist surgery bacteremia [11-17] ( undetermined source and bacteria) Social History: Race: Caucasian Last Dental Exam: 2 months ago Lives with: wife Occupation: works at [Company 7546] Tobacco: never ETOH: 1-2 drinks per day Family History: non-contributory Physical Exam: Admission: Pulse:67 Resp:16 O2 sat: 99% RA B/P Right: 108/65 Left: 100/64 Height: 70" Weight:165 # General:thin, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs with bibasilar rales Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiates throughout precordium into carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema-none;mult. healed scars Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit :murmur radiate to bil.carotids Pertinent Results: [2161-3-16] 05:35AM BLOOD WBC-5.9 RBC-2.87* Hgb-9.2* Hct-27.4* MCV-96 MCH-32.0 MCHC-33.5 RDW-13.0 Plt Ct-121* [2161-3-15] 03:00AM BLOOD WBC-8.9 RBC-2.92* Hgb-9.4* Hct-27.4* MCV-94 MCH-32.2* MCHC-34.3 RDW-13.0 Plt Ct-123* [2161-3-13] 12:57PM BLOOD WBC-12.9# RBC-2.77# Hgb-9.2# Hct-25.9# MCV-94 MCH-33.0* MCHC-35.3* RDW-13.0 Plt Ct-193 [2161-3-16] 05:35AM BLOOD Glucose-152* UreaN-23* Creat-1.0 Na-136 K-4.7 Cl-105 HCO3-29 AnGap-7* [2161-3-16] 03:15PM BLOOD K-4.4 [2161-3-13] 02:45PM BLOOD UreaN-19 Creat-0.9 Cl-113* HCO3-25 [2161-3-18] 06:05AM BLOOD Hct-30.5* [2161-3-18] 06:05AM BLOOD K-4.9 [2161-3-18] 06:05AM BLOOD Hct-30.5* Brief Hospital Course: The patient was a same day admit after undergoing pre-operative work-up as an outpatient. On [3-13] he was brought to the Operating Room where he underwent a mitral valve repair. Please see operative report for surgical details. He weaned from bypass on Epinephrine and Propofol infusions. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, pressors and awoke neurologically intact and extubated. CTs and temporary pacemaker wires were removed according to protocols. He remained stable, beta blockers were begun and diuresis towards his preoperative weight begun. Physical Therapy was consulted for strength and mobility. He had brief atrial fibrillation which converted to sinus rhythm quickly. He maintained sinus rhythm and was independently ambulatory at discharge. Discharge medication, restrictions and follow up were discussed with him prior to discharge. Medications on Admission: ritalin 5 mg daily B complex daily lasix 20 mg daily KCl 20 mEq daily lisinopril 2.5 mg daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Disp:50 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Ritalin 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] VNA Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repair mild coronary artery disease Chronic diastolic heart failure Pneumonia [10-17] ADHD osteoartritis bilateral hip replacements bilateral shoulder surgs.(right shoulder has screw) right wrist [Doctor First Name ] (c/b infection) bacteremia [11-17] ( undetermined source and bacteria) Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon: Dr. [Last Name (STitle) ] in 4 weeks on [4-30] at 1pm ([Telephone/Fax (1) 170]) Primary: Care Dr. [First Name11 (Name Pattern1) 2174] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] in [1-10] weeks ([Telephone/Fax (1) 84157]) Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 83788] in [1-10] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2161-3-18]	[ "414.01", "V43.64", "394.0", "429.5", "428.32", "428.0", "416.8" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.12" ]	icd9pcs	[ [ [] ] ]	4946, 5001	2738, 3700	296, 375	5382, 5478	2047, 2715	6018, 6583	1232, 1250		3844, 4923		5022, 5361		3726, 3821			5502, 5995											1265, 2028																				237, 258								403, 764														786, 1055	1071, 1216
79,813	126,763	38904+58241	Discharge summary	report+addendum	Admission Date: [2123-4-5] Discharge Date: [2123-4-9] Date of Birth: [2068-11-6] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2123-4-5] Mitral Valve Repair (28mm St. [First Name4 (NamePattern1) 923] [Last Name (NamePattern1) ]) History of Present Illness: 54 year old female with history of mitral regurgitation with recent echo revealing worsening cardiac parameters and 4+ MR. She is experiencing dyspnea on exertion currently and presents for surgical evaluation. Past Medical History: Mitral Regurgitation Chronic obstructive pulmonary disease Obesity Hypertension Past Surgical History: s/p Open Cholecystectomy s/p Appendectomy s/p Tubal ligation Social History: Lives with: Husband Occupation: Accountant Tobacco: Quit 12 yrs ago after 25 yrs of 2ppd ETOH: Several per week Family History: grandmother died from MI at 55 Physical Exam: Pulse: 90 Resp: 16 O2 sat: 97% B/P Right: 147/77 Left: 157/115 Height: 5'3" Weight: 214 lbs General: Well-developed, well-nourished obese female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: Regular-Irregular Rhythm with 2/6 holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [2123-4-8] 05:11AM BLOOD WBC-11.9* RBC-3.73* Hgb-10.7* Hct-32.6* MCV-87 MCH-28.8 MCHC-33.0 RDW-14.4 Plt Ct-166 [2123-4-5] 10:38AM BLOOD WBC-17.8# RBC-2.99# Hgb-8.7# Hct-26.0# MCV-87 MCH-29.0 MCHC-33.4 RDW-13.3 Plt Ct-193 [2123-4-8] 05:11AM BLOOD Plt Ct-166 [2123-4-5] 10:38AM BLOOD PT-13.8* PTT-27.9 INR(PT)-1.2* [2123-4-5] 10:38AM BLOOD Fibrino-277 [2123-4-8] 05:11AM BLOOD Glucose-101* UreaN-35* Creat-0.9 Na-139 K-4.7 Cl-106 HCO3-26 AnGap-12 [2123-4-5] 12:15PM BLOOD UreaN-20 Creat-0.9 Cl-117* HCO3-24 [2123-4-5] 09:38PM BLOOD ALT-20 AST-47* LD(LDH)-314* AlkPhos-53 Amylase-21 TotBili-0.2 [2123-4-8] 05:11AM BLOOD Mg-2.7* PA AND LATERAL CHEST RADIOGRAPH: New mild pulmonary edema. The mild cardiomegaly is unchanged. The sternal wires are intact. A right IJ terminates in the distal SVC in appropriate position. Linear atelectasis in the left lower lobe is unchanged. No pleural effusions are present. IMPRESSION: New mild pulmonary edema. Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild mitral annular calcification. Moderate thickening of mitral valve chordae. No MS. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB: 1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. 4. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 5. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. There is a central jet. The annulus measures 3.8-3.9 cm. 6. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of epi briefly, phenylephrine. Sinus rhythm. Well-seated annuloplasty ring in the mitral position. MR is 1+. MS is 5 cm H2O. Preserved biventricular systolic function with LVEF now 50%. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2123-4-5] 10:56 Brief Hospital Course: Same day admit after undergoing all pre-operative work-up as an outpatient. On [4-5] she was brought directly to the operating room where she underwent a mitral valve repair. Please see operative report for surgical details. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. She did have frequent ventricular ectopy and was placed on a lidocaine drip intraoperatively. This was stopped due to a junctional rhythm on postoperative night. She was started on oral amiodarone on postoperative day 1 once she was in sinus rhythm due to continued ventricular ectopy. She was weaned from all vasoactive medications on her postoperative night. Swan-Ganz catheter was removed with good cardiac output/index on postoperative day 1. A nasogastric tube was placed postoperative night due to nausea and vomiting. This was removed on post operative day 1 and Reglan was started for hypoactive bowel sounds. She was changed from Percocet to Ultram due to nausea, which resolved. She was transferred to the step down unit on postoperative day 2 in stable condition. Pacing wires and chest tubes were removed per cardiac surgery protocol. She continued to work with physical therapy to improve strength and endurance. She continued to progress, amiodarone was discontinued as ventricular ectopy resolved. She was ready for discharge home with services post operative day 4. Medications on Admission: Actonel 35mg qwk Aerobid 250mcg 2 puffs daily Aspirin 81mg daily Diltiazem 180mg daily Diovan 80mg daily Omeprazole 20mg daily Serevent diskus 50mcg twice a day Albuterol MDI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Aerobid 250 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation [Hospital1 ] (2 times a day). Disp:120 puff Refills:0 4. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 5. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 6. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Disp:qs qs Refills:0 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: please take 40 mg twice a day for seven days then decrease to 400 mg daily for 7 days - please follow up with cardiologist prior to completion . Disp:21 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): take 20 meq twice a day for 7 days, then decrease to 20 meq once a day for 7 days. Disp:21 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repair Chronic obstructive pulmonary disease Obesity Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with ultram prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2123-5-13] 1:15 Please call to schedule appointments Primary Care Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 72458] in [1-23] weeks [Telephone/Fax (1) 74012] Cardiologist Dr. [First Name4 (NamePattern1) 4597] [Last Name (NamePattern1) 5017] in [1-23] weeks Completed by:[2123-4-9] Name: [Known lastname 13656],[Known firstname 2660] M. Unit No: [Numeric Identifier 13657] Admission Date: [2123-4-5] Discharge Date: [2123-4-9] Date of Birth: [2068-11-6] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 741] Addendum: Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: please take 40 mg twice a day for seven days then decrease to 400 mg daily for 7 days - please follow up with cardiologist prior to completion . Disp:21 Tablet(s) Refills:0 correction for above prescription - spoke with [Location (un) 11941] [4-9] at 1715 - lasix 40 mg twice a day for 2 weeks then decrease to 40 mg once a day Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) 102] [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2123-4-9]	[ "424.0", "427.1", "511.9", "V15.82", "787.01", "E935.2", "530.81", "278.00", "401.9", "496" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.12", "35.32" ]	icd9pcs	[ [ [] ] ]	11835, 12035	6358, 7770	339, 455	9872, 9966	1800, 4502	10590, 11812	1027, 1059		7995, 9626		9745, 9851		7796, 7972			9990, 10567									820, 882	4551, 6335	1074, 1781																				280, 301								483, 695														717, 797	898, 1011
25,405	194,136	17472	Discharge summary	report	Admission Date: [2133-2-7] Discharge Date: [2133-2-18] Date of Birth: [2088-12-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 562] Chief Complaint: overdose (found down) suicide attempt Major Surgical or Invasive Procedure: Debriedment of R leg and L arm closure of R leg split thickness graft of L arm History of Present Illness: The patient is a 44 yo Brazilian male with HIV on HAART found down at 7 am [2-7] accompanied by a suicide note. EMS found him unresponsive, pale, and cool. His male partner had last seen the patient at midnight the night before. His BP on admission was 62/40 HR 78 RR 8 100% on 15L FS 90 in ambulance. He was given 2 mg narcan as EMS had found an empty bottle of Percocet and ativan. His SBP increased to 100s with little effect on his responsiveness. In the ER, he was moving all extremities. There, he was given activated charcoal and an additional 2 mg narcan with no increased responsiveness. He was also noted to have a diffuse rash and thus given 50 mg IV Benadryl. In the ED, his serum tox was notable for + cocaine with no benzos or opiates. ETOH 89. No tylenol. His Partner states the patient has access to percocet, ketamine, bottle of clonazepam 0.5 mg, ultracet, ativan, bupropion. He had a negative head CT on admission. Past Medical History: HIV since [2121] on HAART Social History: Born in [Country 4194], immigrated to US in [2114]. Famils in [Country 4194]. Currently in long-term stable relationship with male partner. [Name (NI) ] high school education. Works in condominium management at Four Seasons Hotel. Has used ketamine and ecstasy in past and has current access to ketamine. Denies tobacco or IV drug use. Family History: Father - leukemia [Name2 (NI) ] family history of depression, suicidal attempts. Physical Exam: on admit to ICU from ED: general: unresponsive except to sternal run and rectal probe HEENT: PERRL; ngt in place CV: RRR Abd: active BS, soft Resp: coarse bs at left lung base Neuro: toes downgoing b/l Day 2 ICU: gen: alert and oriented middle age M HEENT:PERRL. MMM moist. + charcoal in mouth CV:RRR, NlS1, S2. no m/r/g. Resp: CTAB Abd: active BS. soft NT, ND. no HSM L arm: c/o tenderness to elbow, swelling, no erythema, no pitting edema, good radial pulse and capillary refill Right leg: swelling lateral of tibia; no erythema. good DP bilaterally On transfer to Floor [2133-2-10] Tc=97.9 P=84 BP=122/68 RR=20 97% O2 Gen - NAD, AOX3 HEENT - PERLA, EOMI, small aphthous ulcers on uvula otherwise no lesions/thrush, no oropharyngeal exudate. No LAD. Heart - RRR, Grade II/VI systolic holosystolic murmur at apex. Lungs - CTAB with decreased breath sounds at right base Abdomen - Soft, NT, ND + BS, no hepatomegaly Ext - LUE with brace and RLE with brace s/p fasciotomoy, all four extremities warm to touch Skin - No rashes/lesions Neuro - CN II-XII intact, 5/5 strength x 4 Pertinent Results: EKG: NSR U/A: 1.017, 6.5, trace ketones, large blood, 0-2 RBCs--? rhabdo CK 2513 Lactate 1.0 Serum tox neg, Serum ETOH 89 Urine tox cocaine + CT HEAD W/O CONTRAST [2133-2-7] 9:37 AM 1. Examination limited by motion artifact during image acquisition. Allowing for this, no definite evidence of acute intracranial hemorrhage or mass effect. 2. No fracture. [2133-2-7] 05:18PM TYPE-[Last Name (un) ] PO2-60* PCO2-49* PH-7.34* TOTAL CO2-28 [2133-2-7] 05:18PM LACTATE-1.5 [2133-2-7] 05:01PM ACETONE-NEGATIVE OSMOLAL-298 [2133-2-7] 05:01PM ETHANOL-NEG [2133-2-7] 03:21PM URINE HOURS-RANDOM CREAT-118 SODIUM-23 [2133-2-7] 02:43PM TYPE-ART PO2-71* PCO2-46* PH-7.34* TOTAL CO2-26 [2133-2-7] 12:14PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2133-2-7] 12:14PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2133-2-7] 07:50AM GLUCOSE-90 UREA N-25* CREAT-1.3* SODIUM-139 POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-19* ANION GAP-23* [2133-2-7] 07:50AM ALT(SGPT)-70* AST(SGOT)-100* LD(LDH)-271* CK(CPK)-2513* ALK PHOS-115 AMYLASE-106* TOT BILI-0.5 [2133-2-7] 07:50AM LIPASE-23 [2133-2-7] 07:50AM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-5.2* MAGNESIUM-2.3 [2133-2-7] 07:50AM TSH-3.3 [2133-2-7] 07:50AM ASA-NEG ETHANOL-89* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2133-2-7] 07:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2133-2-7] 07:50AM WBC-13.3* RBC-4.38* HGB-15.1 HCT-42.9 MCV-98 MCH-34.3* MCHC-35.1* RDW-12.3 [2133-2-7] 07:50AM NEUTS-81* BANDS-6* LYMPHS-9* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2133-2-7] 07:50AM PLT COUNT-282 [2133-2-7] 07:50AM PT-12.8 PTT-23.3 INR(PT)-1.0 Brief Hospital Course: A: 44 year old male with drug overdose in suicide attempt with positive cocaine and EtOH in urine complicated by compartment syndrome of left forearm and right leg which resulted in rhabdomyolysis s/p LUE and RLE fasciotomy now with down-[Hospital1 ] trending CKs, improved mental status: 1. Drug Overdose/Depression: - Patient quickly resolved his decreased mental status. While the history was consistant with benzo or opiate od, he has found to only be cocaine + on tox screen. He has been hemodynamically stable since he was stabalized in the ED. Furthemore, his metabolic acidosis also quickly resolved. He was seen by psych who placed him on lexapro 10mg qday. He has not been expressing SI since clinically improved. Psych has set him up with an a partial hospital program which will start the day after discharge. 2. Acute Renal Failure: Presented with a creatinine of 1.3 (baseline 0.7). He also developed rhabdo likely while he was passed out. His CK peaked at 67,000. The CK decreased to the 500's by discharge. His renal function also returned to baseline with IVF likely secondary to rhabdomyolysis and dehydration. 3. Compartment Syndrome: Patient presented with compartment syndrome of L arm and R leg. This likely occured [2-18] to him passing out for a significant amount of time. He was debrieded by trauma (leg) and plastics (arm). The Leg wound was closed by trauma on [2-12]. His arm was closed with a split thickness skin graft harvested from the thigh by plastics on [2-16]. Patient was treated with IV cefazolin from [Date range (1) 48802]. The dressings on the arm and thigh should not be changed until f/u in surgery clinic on [2-20]. 4. Transaminitis - patient had increase LFT. Likely [2-18] rhabdo or drug od. RUQ US was normal. His labs trended down after admission. HAART was stopped [2-18] this deviation. . 5. HIV: HIV regimen stopped [2-18] abnormal LFT. Will restart once liver function returns to normal. . 6. PPX: bowel regimen, PPI, SC Heparin . Full Code Medications on Admission: Outpatient Medications: Meds: Norvir, Epivir, Reyataz, Viread, Bupropion, Percocet Discharge Medications: 1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 3. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:30 Tablet Sustained Release(s) Refills:0 4. Morphine Sulfate 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:30 Tablet Sustained Release(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 1 months: please take while you are still requiring large doses of pain medications. Disp:90 Capsule(s) Refills:0 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please take as needed to have at least 1 bowel movement evry 2 days. Disp:60 Tablet(s) Refills:0 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: please take as needed to have 1 bowel movement per every 2 days. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: overdose rhabdomyolisis acute renal failure compartment syndrome Discharge Condition: stable Discharge Instructions: Please take all medications and make all appointments as listed below. Please do not change the dressing on your left thigh or left hand. Please keep both of these areas dry until your appointment with the surgeons. Please change the dressing on your lower right leg once a day with dry sterile gauze. If the pain increases severly in any of the areas operated on please seek medical attention. If you have fevers or chills please seek medical attention. Please hold off on your HIV medications until you see Dr. [Last Name (STitle) 571]. If you feel at all depressed to the point where you may hurt yourself please contact either Dr. [Last Name (STitle) 571] or the Triangle program. Followup Instructions: Provider: [Name10 (NameIs) ] Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 274] Date/Time:[2133-2-20] 1:00 Triangle Program, Partial Program Thursday [2133-2-19] at 9 am [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 48803] [Telephone/Fax (1) 48804] [Street Address(2) ]. [Location (un) ], MA [Hospital6 ] Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 571] [Telephone/Fax (1) 5723] [2133-3-6] 2pm	[ "305.60", "309.28", "729.9", "275.41", "305.00", "790.4", "E950.0", "276.5", "584.9", "965.09", "276.2", "V08", "728.88" ]	icd9cm	[ [ [] ] ]	[ "86.69", "83.45", "83.65", "83.09" ]	icd9pcs	[ [ [] ] ]	8439, 8445	4890, 5168	352, 433	8554, 8562	3048, 4867	9310, 9818	1841, 1927		7079, 8416		8466, 8533		6972, 6972			8586, 9287											1942, 3029											6996, 7056									275, 314								461, 1403									5184, 6946					1425, 1456	1472, 1825
19,173	199,251	29175	Discharge summary	report	Admission Date: [2153-11-21] Discharge Date: [2153-11-26] Date of Birth: [2072-4-13] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1267] Chief Complaint: Hemoptysis s/p CABG Major Surgical or Invasive Procedure: Bronch Chest CT History of Present Illness: This 80 y/[Initials (NamePattern4) ] [Last Name (NamePattern4) 4746] underwent CABGx3(LIMA->LAD, SVG->PDA, OM) on [2153-11-20] at [Hospital3 45967]. Post op he developed severe hemoptysis and bronch revealed a large mass in the distal trachea. He was transferred to the IP service @ [Hospital1 18] for further management. Past Medical History: HTN CAD-s/p MI, s/p CABGx3 [2153-11-20] s/p PPM IDDM GERD mild PVD peripheral neuropathy gait ataxia Social History: Lives with his wife. Cigs: none ETOH: none Family History: Unremarkable Physical Exam: Elderly [Male First Name (un) 4746], intubated in stable condition. VS: T: 99.1 HR: 120 AF BP: 102/78 HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 1+= bilat. without bruits Lungs: Coarse bilat. BS CV: IRRR without R/G/M Abd: soft, nontender, without masses or hepatosplenomegaly Ext: 2+ edema bilat. Neuro: sedated, intubated Pertinent Results: [2153-11-26] 02:14AM BLOOD WBC-10.7 RBC-3.87# Hgb-12.4# Hct-35.8# MCV-93 MCH-32.0 MCHC-34.6 RDW-14.3 Plt Ct-240 [2153-11-26] 02:14AM BLOOD PT-13.9 PTT-30.3 INR(PT)-1.2* [2153-11-26] 02:14AM BLOOD Glucose-75 UreaN-21* Creat-1.1 Na-136 K-3.8 Cl-98 HCO3-30 AnGap-12 [2153-11-26] 02:14AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.2 RADIOLOGY Final Report CHEST (PORTABLE AP) [2153-11-25] 11:49 AM Reason: ? pneumothorax [Hospital 93] MEDICAL CONDITION: 81 year old man with CAD/CHF/HTN s/p bronch s/p chest tube removal REASON FOR THIS EXAMINATION: ? pneumothorax CHEST, SINGLE VIEW ON [11-25] HISTORY: Status post chest tube removal. FINDINGS: The endotracheal tube and left chest tube have been removed. There is a right IJ Cordis with a kink in it at the soft tissues of the neck. Right-sided pacemaker leads are unchanged. There continues to be a right pleural effusion and right lower lobe volume loss/infiltrate. There is no pneumothorax. DR. [First Name (STitle) ] [Doctor Last Name ] OPERATIVE REPORT [Last Name (LF) ],[First Name3 (LF) ] NOT REVIEWED BY ATTENDING Name: [Known lastname ], [Known firstname ] M Unit No: [Numeric Identifier 70200] Service: [Last Name (un) 7081] Date: [2153-11-23] Date of Birth: [2072-4-13] Sex: M Surgeon: [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 17274] ASSISTANT: Dr. [Last Name (STitle) 70201]. PREOPERATIVE DIAGNOSIS: Massive hemoptysis. POSTOPERATIVE DIAGNOSIS: Massive hemoptysis. PROCEDURE: Flexible bronchoscopy. INDICATION FOR PROCEDURE: Assessment of airway patency and therapeutic aspiration of secretions. DESCRIPTION OF PROCEDURE: After informed consent was obtained, Mr. [Known lastname 28755] was prepped with 1% lidocaine applied through the endotracheal tube. The flexible bronchoscope was introduced through the endotracheal tube and into the airways where we could appreciate several residual clots in the trachea, right and main bronchial tree. These were suctioned. There was no evidence of endobronchial lesions to the subsegmental level. IMPRESSION: Multiple clots throughout the airway. No endobronchial lesions seen. A cervical examination was performed and there was no evidence of airway lesion at that level as well. COMPLICATIONS: None. [Name6 (MD) ] [Name8 (MD) ], MD [MD Number(2) 286] Brief Hospital Course: The patient was admitted on [2153-11-21] and was intubated and sedated. he underwent bronch which revealed multiple clots without endobronchial lesions. He was bronched again the following day and this also showed multiple clots. He remained stable and was extubated on [11-23]. His chest tubes d/c'd and his wires were left in. He had is pacer checked by EP and it is functioning well. He remained stable and occasionally coughs up small amounts of dark blood. He had a chest CT prior to d/c, results pending, and needs to follow up with Dr. [Last Name (STitle) ] of IP for a bronch in 1 month. He was transferred back to [Hospital3 ] for further management. Medications on Admission: Protonix 40 mg IV BID Propofol IV Neo IV Insulin IV Amiodorone IV Kefzol IV Lasix IV Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Furosemide 10 mg/mL Solution Sig: Two (2) Injection [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Tracheal clot s/p CABG Discharge Condition: Good Discharge Instructions: [First Name8 (NamePattern2) ] [Hospital1 ] team. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] for bronch in 1 month. [Telephone/Fax (1) ] Transfer to [Hospital3 45967]. Completed by:[2153-11-26]	[ "443.9", "V58.67", "V45.81", "998.11", "781.2", "530.81", "250.00", "356.9", "427.31", "786.3", "428.0", "V58.61", "V53.31", "401.9" ]	icd9cm	[ [ [] ] ]	[ "33.24", "33.22", "96.05", "96.71" ]	icd9pcs	[ [ [] ] ]	5212, 5227	3826, 4507	303, 321	5294, 5301	1343, 1778	5406, 5576	898, 912		4642, 5189	1815, 1882	5248, 5273		4533, 4619			5325, 5383											927, 1324																				244, 265	1911, 3803							349, 694														716, 822	838, 882
14,629	187,473	13686	Discharge summary	report	Admission Date: [2163-7-7] Discharge Date: [2163-7-14] Date of Birth: [2095-1-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1234] Chief Complaint: B/L life threatning leg ischemia Major Surgical or Invasive Procedure: [2163-7-8] 1. Left axillobifemoral bypass graft using 6 mm ringed polytetrafluoroethylene. 2. Re-do/revision. [2163-7-9] 1. Right femoral thromboembolectomy. 2. Intraoperative angiogram, performance and S and I. History of Present Illness: The patient is a 68 year old male with end stage lung cancer who has undergone a previous axillobifemoral bypass graft for lung ischemia. He presented with an occlusion several months ago but could not have surgery due to his chemotherapy regimen. He now presents with limb threatening ischemia of both legs, right greater than left. After intravenous heparin therapy and repeat angiogram, he was taken to the Operating Room. The family and patient were aware of his critical medical condition as well as the possibility that even with a revision of his bypass graft, he may still have the potential for limb loss. Past Medical History: Past medical history is significant for lung cancer that is metastatic to the neck and hilum that is being treated with chemotherapy and is being monitored by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] from The Cancer Center of [Location (un) 86]. Also past medical history is significant for pancytopenia with anemia, neutropenia, and thrombocytopenia He also has a history of pericardial infusion with approximately 1200 cc of bloody fluid removed from the pericardial sac in [Month (only) 1096] without recurrence. Patient's primary care doctor is Dr. [First Name8 (NamePattern2) 41246] [Last Name (NamePattern1) ], who is part of [Hospital6 ] Medical Associates, phone number is [Telephone/Fax (1) 30837]. Past surgical history is significant for laparoscopic cholecystectomy, exploratory laparotomy for cancer, and questionable partial colectomy for diverticulitis. Social History: pos alcohol remote tobacco abuse remote Family History: non contributary Physical Exam: Physical examination upon admit revealed a well-developed and well-nourished, ill appearing. His neck was supple without evidence of jugular venous distention or carotid bruits. The heart was sinus tachycardia without murmer without evidence of murmur. Lungs scattered rhonchi Abdomen was soft, nontender, and nondistended with a well-healed midline scar. His extremity examination revealed the right lower extremity to be somewhat cool and paler from the left with decreased sensation. non - palpable femoral pulse b/l non - palpable [Doctor Last Name ] puls b/l left le - dopplerable signals in the dorsalis pedis and posterior tibial arteries. right le - non dopplerable dorsalis pedis and posterior tibial arteries Pertinent Results: [2163-7-13] WBC-3.8# RBC-3.41 Hgb-8.9* Hct-28.6* MCV-84 MCH-26.0* MCHC-31.0 RDW-18.5* Plt Ct-54* [2163-7-13] Neuts-20* Bands-32* Lymphs-17* Monos-15* Eos-1 Baso-0 Atyps-7* Metas-3* Myelos-0 NRBC-15* Other-5* [2163-7-13] Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-2+ Ovalocy-1+ Burr-1+ [2163-7-13] PT-19.1* PTT-73.8* INR(PT)-2.4 [2163-7-13] Glucose-57* UreaN-28* Creat-1.3* Na-142 K-4.3 Cl-107 HCO3-12* AnGap-27* [2163-7-13] ALT-14 AST-22 CK(CPK)-53 AlkPhos-147* TotBili-1.6* [2163-7-13] CK-MB-NotDone cTropnT-0.03* [2163-7-13] Albumin-1.8* Calcium-7.5* Phos-4.6# Mg-2.2 [2163-7-14] echo PATIENT/TEST INFORMATION: Indication: Pericardial effusion. BP (mm Hg): 70/40 HR (bpm): 113 Status: Inpatient Date/Time: [2163-7-14] at 03:21 Test: TTE(Focused views) Doppler: No Doppler Contrast: None Tape Number: 2003W275-0:0 Test Location: West Echo Lab Technical Quality: Suboptimal INTERPRETATION: Findings: GENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Emergency study performed by the cardiology fellow on call. Conclusions: Large somewhat echo dense region around the heart (particularly the apex) consistent with an organized pericardial effusion/mass. The right ventricle appears compressed. No atrial collapse is seen (pericardial effusion/mass smaller around the right atrium). [2163-7-13] INDICATION FOR CONSULT: INVESTIGATION OF TRANSFUSION REACTION INDICATIONS FOR CONSULT: Investigation of transfusion reaction CLINICAL/LAB DATA: Mr. [Known lastname ] is a 68-year-old man, s/p left axillobifemoral bypass for bilateral lower extremity ischemia. He developed fever and respiratory distres during the transfusion of a unit of RBC on [2163-7-13]. His temperatoure was elevated from 99.3F to 101.0F. The transfusion was stopped after about 200 ml of RBC was transfused. According to the note from nurse and on-call resident, before tranfusion, the patient had two episodes of fever (>101.4) over the previous 48 hours, and a few hours before transfusion, he was noted to have shortness of breath and tachycardia. He was coded and expired in the early morning of [2163-7-14]. Laboratoy data: Patient ABO/Rh: O/neg Unit ABO/Rh: O/pos Pre-transfusion Hct: 26.7 Post-transfusion Hct: 28.2 WBC: 12.6 K (20% bands) PT/PTT/Plt: 19.1/73.8/93 Blood culture ([7-12]): Serratia Marcescens Post-transfusion DAT: negative Date Time Temp Pulse Resp BP Started [7-13] 6 pm 99.3 126 28 95/52 Stopped [7-13] 6:40 pm 101.0 N/A N/A N/A . [2163-7-13] 4:03 AM CHEST (PORTABLE AP) Reason: f/u CHF CHEST AP PORTABLE: Comparison is made to the prior study obtained on [2163-7-12]. The heart is again noted to be mildly enlarged. The Swan-Ganz catheter is again noted, with tip in the right main pulmonary artery. There is no significant change in overall pulmonary vasculature pattern. There is residual bilateral lower lobe infiltrate/atelectasis. Again noted is a bilateral pleural effusion, right greater than left. IMPRESSION: Persistent CHF, with bilateral pleural effusion, right greater than left. There is no significant change from the prior study. [2163-7-12]\ ECG Study Sinus tachycardia Low voltage Incomplete right bundle branch block pattern Early precordial QRS transition with prominent R wave in lead V2 - consider posterior myocardial infarct of indeterminate age Diffuse ST-T wave abnormalities with slight ST elevation - cannot exclude in part injury/ischemia. Clinical correlation is suggested Since previous tracing of [2163-7-10]: sinus tachycardia rate has increased. Intervals Axes Rate PR QRS QT/QTc P QRS T 146 0 74 [Telephone/Fax (2) 41247]0 58 [2163-7-7] INTRO AORTA FEM/AXIL Reason: assess RLE circulation [Hospital 93] MEDICAL CONDITION: 68 year old man with cold right foot acutely REASON FOR THIS EXAMINATION: assess RLE circulation HISTORY: 68-year-old male presents with right cold foot. The patient is status post right axillary-bifemoral bypass which is now occluded as seen by duplex ultrasound. RADIOLOGISTS: The procedure was performed by Drs. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and [Name5 (PTitle) ] [Doctor Last Name ] [Doctor Last Name ] with the attending radiologist Dr. [Last Name (STitle) ] [Name (STitle) ] being present in the entire procedure. FINDINGS: The angiograms showed occlusion of the abdominal aorta just below the takeoff of the inferior mesenteric artery ([Female First Name (un) 899]). The celiac trunk, superior mesenteric artery and single right and double left renal arteries are opacified. The [Female First Name (un) 899] is prominent. There are also some lumbar arteries visualized giving collateral circulation. On the right, the iliac vessels and common femoral artery are not opacified. The superficial femoral artery and profunda femoris are reconstituted just below their takeoff and patent. The right popliteal artery is faintly opacified but appears patent up to its bifurcation in the anterior tibial artery and the tibioperoneal trunk, both of which are faintly opacified in their proximal portions. On the left, the iliac arteries and proximal common femoral artery are not opacified. The distal common femoral, profunda femoris, superficial femoral and popliteal arteries are patent with no severe stenosis, and their opacification appears earlier than on the left side. The tibioperoneal trunk and posterior tibial arteries are faintly opacified. Below the level of the knees, contrast is too diluted to allow good diagnostic image quality. CONTRAST: A total of approximately 160 cc of Conray 30% were given intraarterially for the angiograms. IMPRESSION: 1. Occlusion of the distal abdominal aorta just below the [Female First Name (un) 899] takeoff. 2. The bilateral iliac arteries, the right common femoral and proximal left common femoral arteries are not patent. 3. No graft was visualized. 4. Patency of the bilateral SFAs and popliteal arteries, with slower flow in the right than the left side. Brief Hospital Course: pt admitted [2163-7-7] for acute rle ischemia Heparin started stat [2163-7-7] Pt underwent a: 1. Left axillobifemoral bypass graft using 6 mm ringed polytetrafluoroethylene. 2. Re-do/revision. After the procedure, the patient remained in somewhat critical condition on pressors and ventilator. He was taken to the Intensive Care Unit. His right foot was still blue and somewhat mottled,but the grafts were clearly patent. Decision was made to observe the patient, stabilize his blood pressure, and get him off pressors. [2163-7-8] Pt remained in the SICU. He was sedated on a variety of drips for blood presssure control. [2163-7-9] One day after left axillobifemoral bypass for bilateral lower extremity ischemia, right greater than left. Mr [Known lastname ] required a significant amount of pressors to maintain a blood pressure. Over the course of the day, his requirement of pressors diminished. Mr [Known lastname ] right foot still was fairly mottled and there was concern of distal thrombus. In addition, there was a clear difference between the left and right foot, indicating potential for a unilateral problem. Because of this the patient was brought semi-urgently to the operating room. He was already sedated. This was added to by the anesthesia staff during the procedure. Mr [Known lastname ] then underwent a second procedure for his ischemic limb. 1. Right femoral thromboembolectomy. 2. Intraoperative angiogram, performance and S and I. During the procedure it was thought that there was nothing technically that could be fixed, this was either related to spasm of the distal vessels from chronic ischemia and the pressors, or related to thrombus in the distal vessels. At this point, the decision was made to do nothing further, since there was no bypass situation that could be expected to be successful. Plan was to continue to resuscitate the patient, and get the patient off pressors and hopefully this would solve the problem. Also of note, since there was concern about a white platelet plug, decision was made to stop all heparin and switch the patient eventually to Hirudin. After the procedue there was a strongly palpable graft pulse, and a palpable pulse in the femoral artery. In addition, the superficial femoral artery Doppler signal sounded more triphasic and not as obstructive. The patient was taken to the Intensive Care Unit in critical condition. [2165-7-10] - [2165-7-11] Pt was weaned of pressors for blood pressure control. Pt was also extubated. [2163-7-12] Seemed like pt improved, remained in sicu, extubated. Pt was gently diuresed with lasix. PT HIT panel came back negative. Hirudin was dc'd. Pt medication was changed back to heparin. To note, pt remained slighty tachycardic. Pt was beta blocked. At about 1230 pt experienced decrease sats, with an increase in breathing. His heart rate was in the 140's, with low BP SBP 90's. It was thought the pt was experiencing resp distress. He was given lasix. There was a low threshold for reintubation (bi-pap). His heparin was increased to 1000 units hr. Thinking that this could be a PE. [2165-7-13] PA catheter changed to triple lumen. Pt was transfused 1 unit PRBC's for decrease BP, still was tachy (140), after blood transfusion pt remained in sinus tach. with SBP 80 - 90. His levo was weaned off. [2165-7-14] Pt spiked temperature to 102, became more tachycardic with SBP in the 70's. Levophed was restarted. Also to note. pt had an increase in resp to the 30's. A stat ABG was done. 7.43 / 29 / 71 / 120 / -3 / 95%. CXR showed r plueral effussion. Pt started on esnolol to decrease his HR. Lephofed was changed to neo and titrated for a MAP of 70. Pt resp status continued to worsen. Pt intubated by anesthesia. Pt developed PEA - ACLS protocol was initiated. pt recieved several rounds of epi / bicarb / ca ( BP / HR would return for short periods of time. ) Right chest tube placed. two liters of transudate recoverd. F/U CXR showed no effussion or pnuemothorax. Pericardial centesis performed ( 10 cc non pulsatile blood ) Cardiology consulted - echo rechecked. pericardial effussion with ? tamponade. Bedsidetap performed. Pt developed and maintained PEA dispite continual ACLS protocols. Pt expired. Pronounced dead. Medications on Admission: dexamethasone 4 mg qd deltasone 20 mg qod Discharge Medications: Pt deceased Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: none Followup Instructions: n/a Completed by:[2165-8-13*]	[ "162.9", "197.2", "E878.2", "423.8", "996.74", "444.22", "518.81", "285.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "34.04", "96.04", "37.0", "39.29", "89.64", "88.48", "38.08" ]	icd9pcs	[ [ [] ] ]	13727, 13736	9221, 13599	346, 583	13783, 13788	3066, 3732	13841, 13875	2283, 2301		13691, 13704	6908, 6953	13757, 13762		13625, 13668			13812, 13818						3758, 6871					2316, 3047																				274, 308	6982, 9198							611, 1269														1291, 2210	2226, 2267
48,254	177,121	29534	Discharge summary	report	Admission Date: [2187-12-5] Discharge Date: [2187-12-15] Date of Birth: [2117-9-29] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional Angina Major Surgical or Invasive Procedure: [2187-12-10] - CABGx2 (Left internal mammary->Left anterior descending, Saphenous vein graft-> [2187-12-5] - Cardiac Catheterization History of Present Illness: 70 yo F with CAD s/p mulitple PCIs between [2174]-[2184] with eight coronary stents, DM type I, HTN, HL and medullary sponge kidney s/p RA who presents for cardiac catheterization for CABG evaluation. She presented to her cardiologist, with recurrent exertional angina and he reccomended cath. She states that for the past 6 mo her chest discomfort has become more frequent and severe. She states that she gets CP when she walks on an incline or walks fast, substernal, radiating to arms bilateral, sometimes to the jaw as well, relieved by rest and accompanied by SOB, diaphoresis. She presented today for a diagnostic cath. On cath she was found to have The LAD had a 90% proximal in-stent restenosis and an 80% mid-vessel stenosis. The LCX had a patent Ramus stent and no significant stenoses. The RCA had a 70% proximal stenosis and a 70% distal stenosis. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: Multiple PCIs at [Hospital 12017] Hospital and [Hospital3 17921] Center in [Location (un) 3844] between [2174] and [2184] with a total of 8 prior stents. Most recent stent procedure was on [2184-2-18] at which time long Taxus stents were placed in the LAD and a long Taxus stent was placed in the RCA and the left renal artery was also stented. OTHER: Renal artery stent Medullary sponge kidney without known sequelae Endometriosis Type I IDDM diagnosed at age 52 Hypertension Hyperlipidemia Benign breast lumpectomy Tonsillectomy Social History: -Tobacco history: -ETOH: -Illicit drugs: Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T 97.8, BP 124/48, HR 68, RR 18, Sat 97% RA GENERAL: Well appearing in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without JVP elevation. CARDIAC: PMI not felt. 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. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Cath site c/d/i, no bruits or hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ 2+ DP 2+ PT 2+ Left: Carotid 2+ 2+ DP 2+ PT 2+ Pertinent Results: [2187-12-5] Cardiac Catheterization 1. Selective coronary angiography of this right-dominant system demonstrated two-vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had a 90% proximal in-stent restenosis and an 80% mid-vessel stenosis. The LCX had a patent Ramus stent and no significant stenoses. The RCA had a 70% proximal stenosis and a 70% distal stenosis. 2. Limited resting hemodynamics demonstrated mildly elevated left ventricular filling pressures with an LVEDP of 21 mmHg. There was no gradient seen on left-heart pullback. Systemic arterial hypertension was noted with a central aortic pressure of 165/61 mmHg. 3. Left ventriculography revealed normal global and regional systolic function and no significant mitral regurgitation. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Left ventricular diastolic dysfunction. 3. Systemic arterial hypertension. [2187-12-10] ECHO PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Thoracic aorta is intact. No significant change from pre-bypass study. [2187-12-6] carotid USThere is less than 40% stenosis within the internal carotid arteries bilaterally. Preop [2187-12-5] 09:40AM PT-12.6 PTT-31.6 INR(PT)-1.1 [2187-12-5] 09:40AM PLT COUNT-273 [2187-12-5] 09:40AM WBC-6.9 RBC-3.84* HGB-10.9* HCT-32.6* MCV-85 MCH-28.4 MCHC-33.4 RDW-14.3 [2187-12-5] 09:40AM %HbA1c-8.0* [2187-12-5] 09:40AM ALBUMIN-3.9 [2187-12-5] 09:40AM ALT(SGPT)-12 AST(SGOT)-13 ALK PHOS-47 TOT BILI-0.3 [2187-12-5] 09:40AM GLUCOSE-145* UREA N-17 CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13 post-op [2187-12-14] 09:00AM BLOOD WBC-10.1 RBC-3.87* Hgb-11.2* Hct-32.7* MCV-85 MCH-29.0 MCHC-34.3 RDW-14.7 Plt Ct-290 [2187-12-14] 09:00AM BLOOD Plt Ct-290 [2187-12-10] 03:22PM BLOOD PT-13.5* PTT-41.1* INR(PT)-1.2* [2187-12-14] 09:00AM BLOOD Glucose-188* UreaN-12 Creat-1.0 Na-137 K-4.8 Cl-97 HCO3-33* AnGap-12 [2187-12-13] 05:35AM BLOOD ALT-31 AST-26 LD(LDH)-218 AlkPhos-51 Amylase-15 TotBili-0.5 Radiology Report CHEST (PORTABLE AP) Study Date of [2187-12-12] 3:57 PM [Hospital 93] MEDICAL CONDITION: 70 year old woman with small ap. PTX post CT pull Final Report HISTORY: Chest tube removal, to evaluate for pneumothorax. FINDINGS: In comparison with the study of [12-11], the chest tube has been removed and there is no evidence of pneumothorax. There has also been removal of the right central catheter. Bibasilar atelectatic change persists. Small pleural effusions are again noted. DR. [First Name11 (Name Pattern1) 1569] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11006] Approved: WED [2187-12-12] 9:44 PM Imaging Lab Brief Hospital Course: Mrs. [Known lastname 6160] was admitted to the [Hospital1 18] on [2187-12-5] for a cardiac catheterization given the progression of her chest pain. This revealed severe two vessel disease with patent stents in her left circumflex system. Given the severity of her disease, the cardiac surgical service was consulted. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed a less than 40% stenosis within the internal carotid arteries bilaterally. As she had been on plavix, her surgery was delayed several days to allow the medication to clear. On [2187-12-10], Mrs. [Known lastname 6160] was taken to th eoperating room where she underwent coronary artery bypass grafting to two vessels. Please see operative note for details. In summary she had coronary bypass graft with left internal mamary to left anterior descending artery and reverse saphenous vein graft to right coronary artery. Her bypass time was 48 minutes with a crossclamp time of 38 minutes. She tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. In the immediate post operative period she was hemodynamically stable, she woke neurologically intact, was weaned from the ventilator and extubated. On POD1 she was transferred to the stepdown floor for continued care and recovery from surgery. Beta blockade, aspirin and a statin were resumed. Plavix was reastarted given her multiple circumflex system stents. [Hospital ] clinic was consulted for assistance with her diabetes control. The remainder of her post operative course was uneventful and on POD 5 she was discharged home with visiting nurses. Medications on Admission: Plavix 75mg po daily Lantus 12 units q HS Humalog Pen Sliding Scale 3x/day NPH 4 units q am Lisinopril 10mg po daily Ranexa 500mg po daily (prescribed for [Hospital1 ], but pt only takes once daily d/t hair loss side effect) Crestor 20mg po daily ASA 81 mg po daily Centrum Silver 1 tab po daily Omeprazole 20mg po BID SL Nitro PRN Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): 20mg [Hospital1 ] x10 days then 20mg QD x10 days. Disp:30 Tablet(s) Refills:0 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day: 20 mEq [Hospital1 ] x10 days then 20 mEQ QD x10 days. Disp:60 Tablet Sustained Release(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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: resume preop schedule. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous QHS. 11. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Four (4) units Subcutaneous QAM. 12. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous three times a day. Discharge Disposition: Home With Service Facility: [Location (un) 15739] District Visiting Nurse Assoc. Discharge Diagnosis: CAD s/p CABGx2 (LIMA-LAD, SVG-RCA) Hypertension Hyperlipidemia CAD s/p multiple(8)PCIs from [2174]-[2184] Renal artery stent Type I DM diagnosed age 52 Medullary sponge kidney without known sequelae x40 yrs Endometriosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Wound: healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr. [Last Name (STitle) ] on [First Name9 (NamePattern2) 5929] [1-10] @1:15PM [Telephone/Fax (1) 170] Primary Care Dr. [Last Name (STitle) 70843] in [1-5] weeks call to schedule appointments Cardiologist Dr. [Last Name (STitle) ] in [1-5] weeks call to schedule appointments Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2187-12-15]	[ "401.9", "V58.67", "996.72", "V17.3", "411.1", "753.17", "433.10", "272.4", "250.01", "V15.82", "433.30", "458.29", "E878.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.11", "37.22", "39.61", "88.53", "36.15" ]	icd9pcs	[ [ [] ] ]	10343, 10430	6748, 8459	345, 487	10703, 10844	3088, 3873	11468, 11930	2160, 2275		8846, 10320	6167, 6725	10451, 10682		8485, 8823		3890, 6127	10868, 11445											2290, 3069			1490, 2085																	288, 307								515, 1386														1408, 1470	2101, 2144
66,492	112,615	52473	Discharge summary	report	Admission Date: [2185-5-23] Discharge Date: [2185-6-8] Service: MEDICINE Allergies: Flagyl Attending:[First Name3 (LF) 1253] Chief Complaint: pneumonia, tachycardia Major Surgical or Invasive Procedure: PICC placement History of Present Illness: Ms. [Known lastname 7756] is a [Age over 90 ] year-old woman with dementia and benign meningioma, presenting from [Hospital3 2558] with increased productive cough, SOB and tachycardia. Patient has had one week of increasing productive cough. She denies any chest pain, nausea, vomiting. She is unable to provide further history about her symptoms. . Of note, she was admitted from [Date range (1) 108390] for sinus tachycardia and chronic cough. She was again admitted from [Date range (1) 33900] for a rash that was determined to be from metronidazole, which she was taking for Clostridium difficile colitis, upon which she was placed on PO vancomycin, which she was to take until [2185-5-7]. . In the ED, initial vs were: T 100 P 150 BP 140/84 R 20 Sat 98% 2L. Patient was noted to have wheezing on exam with crackles at bases R>L. She was also noted to have diffuse rash on torso, legs, and arms, documented to be from Flagyl at [Hospital3 2558]. CXR was concerning for RLL pneumonia, so she was given a dose of Vancomycin and levofloxacin IV. She was also noted to have UTI. She was given 1g of tylenol for fever. HRs improved briefly to 90s with brief conversion to NSR after IVF bolus, then converted back to Afib with rates in 150s. She received a total of 1.5L of IVFs in the ED. For ventricular rates intermittently in 150s, she was then given 5mg IV lopressor which decreased HR to 110s-130s. Patient has a signed DNR form in her [Hospital3 2558] records. She had also complained of some abdominal discomfort in the ED, but on exam, she was easily distracted with no signs of tenderness. Vitals in ED prior to transfer were as follows: HR 98 BP 115/61 RR 28 O2sat 99% 2L. . On arrival to the MICU, patient appears comfortable and states that her cough is much better. She complains of no chest pain or dyspnea. She has no noted pain. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: -HTN -CKD III/IV -Dementia baseline A&O X 1 -h/o SVT (usually post op or during stress) -h/o UTI (pansensitive E.Coli) -Dysphagia -Benign cerebellopontine angle meningioma. -History of diverticulitis. -Osteoporosis, s/p L hip fx s/p ORIF [8-22], vertebral compression fractures (L2/L3) -Depression w/ psychosis -Colonic polyps, s/p partial colorectal resection [2167], for sessile polyp. Postoperative course c/b SVT -s/p thyroid surgery - details unknown -EGD [11/2174], with gastritis, (+) H. pylori. -Colonoscopy [11/2174], adenomatous polyp resection. -Status post C3 through C7 laminectomy. -Glaucoma - recent admission for pancreatitis [4-25] - recent episode of Cdiff [4-25] Social History: She lives at [Hospital3 2558]. Has no surviving family. HCP is friend, [Name (NI) ] [Name (NI) 108388] [Telephone/Fax (1) 108389]. At baseline is not that ambulatory (not at all per pt, minimally so with assistance per [Location (un) ]) since hip fracture. Family History: Not relevant to current presentation. Patient also not able to provide. Physical Exam: Vitals: T: 96.6 BP: 114/64 P: 69 R: 27 O2: 97%RA General: Alert, oriented x 3, no acute distress, cooperative HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rhonchorous sounds present at the right base > left base, presence of upper airway sounds, no accessory muscle use, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: exfoliative, erythematous rash on arms, legs and torso Pertinent Results: CT Chest w/o Contrast: [2185-5-31] 1. Bilateral nonhemorrhagic pleural effusions, with associated dependent atelectasis, including left lower lobe collapse, with additional atelectasis seen dependently in the right middle lobe. There is associated opacification of the left lower lobe bronchi, which may reflect mucus plugging or aspiration. In the aerated lung parenchyma, there are no focal opacities to suggest pneumonia. 2. Redemonstration of left apical lung mass, suboptimally evaluated due to respiratory motion, though little change from [2184-5-21]. 3. Aortic valvular calcifications, with mild ectasia of the ascending aorta. 4. Atrophy of the left kidney, with configuration suggesting chronic left UPJ obstruction. 5. Moderately severe biapical pleural scarring. . CT Abdomen/Pelvis: [2185-5-30] 1. Bibasilar and right middle lobe atelectasis with small bilateral pleural effusions, new since prior imaging. 2. Resolution of the previously described pancreatitis of the tail with a stable 16-mm hypodense lesion which may represent either a pseudocyst or other pancreatic cystic lesion, for example IPMN. This could be further evaluated with MRCP. 3. Unchanged multiple fat-containing anterior abdominal wall hernias. One midline hernia now contains a loop of transverse colon but no evidence for proximal obstruction. 4. No intra-abdominal collection to account for elevated white cell count. . [2185-5-30] RUE U/S: No evidence of right upper extremity DVT. . Microbiology: UCx [2185-5-23] with E.coli; all blood cultures negative; repeat urine culture negative; C.difficile negative x 2 . PENDING C-diff PCR remains pending at this time. [Month (only) 116] discontinue oral vancomycin if returns negative. Note that pt has allergy to flagyl. . [2185-5-23] 07:00PM BLOOD WBC-7.8 RBC-3.58* Hgb-11.8* Hct-33.8* MCV-95 MCH-33.1* MCHC-35.0# RDW-15.0 Plt Ct-163 [2185-5-25] 01:00PM BLOOD WBC-20.4# RBC-3.42 Hgb-10.7* Hct-33.5* MCV-98 MCH-31.2 MCHC-31.8 RDW-15.2 Plt Ct-198 [2185-6-6] 08:00AM BLOOD WBC-10.3 RBC-3.33* Hgb-10.4* Hct-32.2* MCV-97 MCH-31.2 MCHC-32.2 RDW-15.7* Plt Ct-115* [2185-5-24] 03:44AM BLOOD Glucose-159* UreaN-26* Creat-1.4* Na-142 K-4.6 Cl-109* HCO3-19* AnGap-19 [2185-5-27] 06:00AM BLOOD Glucose-101* UreaN-46* Creat-2.4* Na-143 K-4.7 Cl-109* HCO3-22 AnGap-17 [2185-6-6] 08:00AM BLOOD Glucose-83 UreaN-19 Creat-1.9* Na-142 K-3.8 Cl-109* HCO3-21* AnGap-16 [2185-5-30] 04:47AM BLOOD ALT-11 AST-13 AlkPhos-96 TotBili-0.4 [2185-6-6] 08:00AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.5* [2185-5-23] 07:00PM BLOOD cTropnT-0.02* [2185-5-24] 03:44AM BLOOD TSH-1.5 Brief Hospital Course: HEALTH CARE ASSOCIATED PNEUMONIA: Treated with vancomycin and cefepime x 8 day total course. ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RATE: Treated with dilatiazem and metoprolol. Discharge regimen was metoprolol 12.5mg po bid and diltiazem 60 mg po QID. Diltiazem may be converted to Diltiazem XR 240 mg po q day as an outpatient. Heart rates well-controlled when patient takes medications as scheduled. ACUTE ON CHRONIC KIDNEY FAILURE: Treated with IVF and improved to 2.1-2.2 at time of discharge. C DIFF COLITIS: Recent c diff 1 month ago. The patient was treated in the last month with flagyl and developed a rash, at which time she was transitioned to PO vancomycin, which she completed prior to this admission. While on broad spectrum antibiotics for HCAP above she developed a leukocytosis of 20 from 5 so she was started empirically on vancomycin oral 125mg po q6hrs and should continue this for after she is finished with her antibiotics for aspiration pneumonia (See below). Aspiration: Patient noted to be frankly aspirating on [2185-5-28]. She was made NPO and was seen in evaluation by speech and swallow. She had evidence of continued aspiration on three subsequent evaluations, attributed to delirium and weakness from prolonged hospitalization and multiple infections. In the setting of her aspiration, elevated WBC, and findings on chest CT she was started on an eight day course of Piperacillin/Tazobactam for presumed aspiration pneumonia. In discussion with her health care proxy it was decided that parenteral nutrition or placement of a G-tube would not be in keeping with her goals of care, and she was allowed to eat to her comfort and desire. She was followed closely by both Speech and Swallow and Nutrition. Hypernatremia: While NPO for aspiration as above patient became hypernatremic. She was treated for two days with D5W and her sodium normalized. Medications on Admission: brimonidine Dosage uncertain [2184-11-12] clobetasol 0.05 % Ointment apply [Hospital1 ] x 5 days then QOD x 1 wk [2185-5-6] latanoprost [Xalatan] Dosage uncertain [2184-11-12] levothyroxine Dosage uncertain [2184-11-12] metoprolol tartrate Dosage uncertain [2184-11-12] mirtazapine Dosage uncertain [2184-11-12] mupirocin 2 % Ointment Apply to wound daily [2185-1-4] omeprazole Dosage uncertain [2184-11-12] timolol maleate Dosage uncertain [2184-11-12] triamcinolone acetonide 0.1% Oint apply [Hospital1 ] on days not using clobetasol [2185-5-6] * OTCs * acetaminophen Dosage uncertain alum-mag hydroxide-simeth [Mylanta] Dosage uncertain aspirin Dosage uncertain bisacodyl [Dulcolax] Dosage uncertain calcium carbonate-vitamin D3 [Calcium with Vitamin D] Dosage uncertain carbamide peroxide [Debrox] Dosage uncertain cranberry ext-C-L. sporogenes [Azo Cranberry] Dosage uncertain docusate sodium [Colace] Dosage uncertain magnesium hydroxide [Milk of Magnesia] Dosage uncertain sennosides [Senokot] Dosage uncertain sodium phosphates [Fleet Enema] Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): take until [2185-6-16]. 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H (every 12 hours). 3. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical once a day for 5 days: to affected areas (rash) - do not use on face, armpit, or groin. . 8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours): [Month (only) 116] wean off or switch to MDI as tolerated. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 14. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 tabs PO Q8H (every 8 hours) as needed for pain. 17. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Health care associated bacterial pneumonia Aspiration pneumonia Possible C diff colitis Atrial fibrillation with rapid ventricular rate Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a fever and found to have pneumonia. You also may have had a recurrance of your C diff (colon infection), although this is uncertain. Please take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 2 weeks of your discharge from the hospital: [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 608]	[ "787.20", "293.0", "585.4", "294.10", "695.0", "482.9", "599.0", "365.9", "507.0", "331.0", "276.0", "693.0", "288.60", "349.82", "V85.1", "V12.72", "225.2", "V49.86", "244.9", "428.0", "427.31", "428.32", "584.9", "733.00", "564.09", "V45.72", "263.1", "E930.8", "008.45", "403.90", "041.4" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.97" ]	icd9pcs	[ [ [] ] ]	11678, 11748	6952, 8847	236, 252	11947, 11947	4279, 6929	12405, 12606	3512, 3585		10001, 11655		11769, 11769		8873, 9978			12125, 12382											3600, 4260																				174, 198			2176, 2469					280, 2158						11788, 11926			11962, 12101					2491, 3200	3216, 3496
32,078	158,867	45683	Discharge summary	report	Admission Date: [2183-8-6] Discharge Date: [2183-8-13] Date of Birth: [2110-3-18] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Hia wife reports Mr [Name (NI) 9955] had three generalized clonic - tonic seizures Major Surgical or Invasive Procedure: ETT History of Present Illness: The patient is a 73 year old man with a history of TIA in [5-17], left temporo-occipital stroke in [2-15] with severe left inferior MCA stenosis on Coumadin, hypertension, and hyperlipidemia who presents with 3 GTC seizures. This history is taken from the [Hospital 228] medical record. Per his wife, he was in his usual state of health when they went for a walk together, when he fell to the ground, became stiff, and had a GTC that lasted less than 5 minutes. This resolved, and the patient was taken to [Hospital1 18]. In the ED, vitals were temp 100, HR 140, bp 222/106, RR 20, SaO2 100% on NRB, FSBG 95. He was reportedly incontinent of urine, responded to name but was not following commands. Head CT showed no evidence of hemorrhage or acute edema, there was evolution of left temporal and parietal/occipital infarction, and sinus disease. At approximately 17:15 he had seizure activity and rigid body movements, and was given Ativan 2 mg IV x1. He was intubated with Etomidate 20 mg IV x1 and Succs 120 mg x1, but there was no color change, so the ET tube was removed and he was bagged. They attempted to place nasal tube for intubation, but there was trauma with insertion. Anesthesia was called to intubate, and he was given Etomidate 20 mg x1 and Succs 150 mg x1. He was started on a Propofol gtt. He had possible seizure activity after the intubation with his head moving side to side, and was given Ativan 1 mg IV x1. Neurology was consulted, and an LP was performed. He was started on Ceftriaxone 2 gm IV and transferred to the MICU. In the MICU, he was also started on Vancomycin 1 gm IV q12 hr, Ampicillin 2 gm IV q6 hr, Acyclovir 800 mg IV q8hr. All but the Acyclovir were subsequently discontinued when his LP came back with 0 WBC. Past Medical History: - L inferior division MCA stroke here in [3-18], found to have soft clot in vertebral arteries, as well as L MCA intracranial stenosis of the inferior division. TEE was negative. He was discharged with residual Wernicke-type aphasia on coumadin after being admitted on aggrenox for a prior TIA in [5-17] - HTN - hyperlipidemia - Pernicious anemia/B12 deficiency - Hx prostate ca [2169] s/p radical prostatectomy - Hx L orbit lymphoma (malt-[Female First Name (un) ]) [3-15] yrs ago, s/p XRT; had intracerebral lesion discovered on MRI, had further w/u including PET scan at Farber or [Hospital1 112] - felt to be small avm that bled - Hx tremor at rest x 3 mo, due to see Dr. [Last Name (STitle) ] - PNA [3-17] - L5-S1 disc herniation - s/p ccy [2167] - s/p L inguinal repair Social History: Lives with wife, formerly worked as ophthalmologist at [Hospital1 18]; no tob, rare etoh, drugs. Family History: Father had MI age 58 yo; His mother reportedly had multiple TIAs and then had stroke or MI at age 75 years Physical Exam: VS: temp 101.7, bp 137/71, HR 90, RR 11, SaO2 100% on CPAP + PS Genl: Intubated, Propofol weaned off for exam. Opens eyes on command, does not squeeze bilateral hands on command HEENT: Sclerae anicteric, no conjunctival injection, nasal packing in right nare CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen Neurologic examination: Mental status: Opens eyes on command, does not squeeze bilateral hands on command. Cranial Nerves: PERRL 3mm->2mm bilaterally. Corneal reflexes intact bilaterally. Does not blink to threat. Normal OCRs Motor: Normal bulk bilaterally, increased tone in the bilateral upper extremities. Right side appears weaker than the left. Withdraws all 4 extremities to noxious stimulus. Localizes pain with the LUE. No observed myoclonus or tremor. Reflexes: 2+ and symmetric in biceps, brachioradialis, knees. 1+ an symmetric in triceps. 2 beats of clonus in the left ankle, no clonus on the right. Toes upgoing bilaterally. Pertinent Results: CT head 08/ 27/ 08: 1. No evidence of hemorrhage or acute edema. 2. Evolution of left temporal and parietal/occipital infarction. 3. Sinus disease. CTA head and neck: 08/ 27/ 08: 1. No areas of acute intracranial hemorrhage or acute infarction identified. 2. Unchanged moderte-severe stenosis of the inferior division of left M2 branch with some flow noted and decreased caliber distally. 3. Atheroslcerotic disease invovling the common carotid arteries at bifurcation causing moderate stenoses and mild at proximal cervical itnernalc arotid arteries, not significantly changed compared to CTA of [2183-3-8]. 4. Heterogeneous thyroid with multiple areas of low density and we would recommend ultrasound for further evaluation. 09/ 02/ 08 CT scan: No changes. [2183-8-6] 10:20PM GLUCOSE-131* UREA N-18 CREAT-1.3* SODIUM-134 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12 [2183-8-6] 10:20PM WBC-11.0 RBC-4.37* HGB-12.6* HCT-35.5* MCV-81* MCH-28.9 MCHC-35.6* RDW-15.7* [2183-8-6] 10:11PM CEREBROSPINAL FLUID (CSF) PROTEIN-57* GLUCOSE-86 [2183-8-6] 10:11PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* POLYS-2 LYMPHS-56 MONOS-42 [2183-8-6] 08:17PM URINE HOURS-RANDOM [2183-8-6] 08:17PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2183-8-6] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2183-8-6] 05:40PM PT-15.0* PTT-31.1 INR(PT)-1.3* Brief Hospital Course: The patient improved once intubated and treated with PHT. He was bridged to Keppra with good control of his seizures. A CNS infection was ruled out and antibiotics were withdrawn, including acyclovir. He has remained normothermic with stable normal WBC values. He had no recurrent seizures. On 09 02 08 he fell down and hit his head without LOC. A CT scan ruled out new hemorrhage. Medications on Admission: Outpatient Medications (per OMR): -Cyanocobalamin 100 mcg PO DAILY -Folic Acid 1 mg PO DAILY -Hexavitamin 1 Cap PO DAILY -Simvastatin 20 mg PO DAILY -Latanoprost 0.005 % Drops 1 Drop Ophthalmic HS -Timolol Maleate 0.5 % Drops 1 Drop Ophthalmic DAILY -Aspirin 81 mg PO DAILY -Irbesartan 150 mg qPM -Coumadin 6 mg alternating with 7.5 mg every other day Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:30 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: [12-11] Inhalation Q6H (every 6 hours) as needed. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:60 Tablet(s) Refills:0 9. Warfarin 4 mg Tablet Sig: One (1) Tablet PO at bedtime: On Monday, Wednesday and Friday. Disp:30 Tablet(s) Refills:0 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: On Tuesday, Thursday, Saturday and Sunday. Disp:30 Tablet(s) Refills:0 11. Outpatient Lab Work INR follow up 12. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Generalized tonic clonic seizure (status epilepticus) in the context of previous RIGHT parieto-occipital hemorrhagic stroke Discharge Condition: The patient is back to his baseline. Remarkable findings at discharge are: His attention spam is impaired: digit spam forward and backward are abnormal. He also has a RIGHT pronator drift. Discharge Instructions: You have had three episodes of generalized convulsions. You will be discharged on Keppra 750 mg q12h. If you experienced mood changes or vomiting or pharyngitis, please contact your primary care doctor. Followup Instructions: You should follow up with Dr. [Last Name (STitle) 1693]: Please call [Telephone/Fax (1) 1694] to arrange for an appointment.	[ "345.3", "722.10", "272.4", "266.2", "V10.46", "V10.79", "V58.61", "401.9", "V15.3", "438.89" ]	icd9cm	[ [ [] ] ]	[ "03.31", "96.04" ]	icd9pcs	[ [ [] ] ]	7927, 8012	5870, 6253	410, 416	8180, 8371	4394, 5847	8622, 8758	3185, 3294		6656, 7904		8033, 8159		6279, 6633			8395, 8599											3309, 3732																				284, 372								444, 2214	3856, 4375								3771, 3840			3756, 3756		2236, 3050	3066, 3169
31,563	159,549	34373+57918	Discharge summary	report+addendum	Admission Date: [2138-9-21] Discharge Date: [2138-9-30] Date of Birth: [2064-4-29] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2836] Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: OPERATION: Total abdominal colectomy and end ileostomy. History of Present Illness: This is a 74 yof with history of CAD s/p 2 stents on Plavix, HTN, hyperlipidemia, hypothyroidism who presented to an OSH today with BRBPR. Patient states she was visiting her husband at his nursing home when she had 1 episode of BRBPR. Patient states she had the urge to go to the bathroom and noticed a large amount of bright red blood in the toilet. She presented to an OSH and had [3-2] more episodes of BRBPR. She denies any recent nausea, vomiting, melena, abdominal pain, chest pain, fevers, or chills. She does report some lightheadedness today. She received 2uPRBCs at the OSH. HCT at 30.1. GI was consulted and performe endoscopy which was reportedly normal, ?colonoscopy. Patient states she had both an upper and a lower endoscopy, results not known. Per OSH notes, patient has history of two failed colonoscopies [3-1] to "kink" in the colon. Also with history of colon polyps. She denies any recent weight loss, decreased appetite or fatigue. In the ED: HR 90, BP 85/61, RR 23, 99% 3LNC. She received 4uPRBC. Initial HCT here at 30. GI and surgery were consulted. Patient continued with BRBPR, with at least 500cc output. Left femoral cordis placed along with 3 18G PIV. Patient was transferred to MICU for further stabilization and workup Past Medical History: CAD s/p MI s/p 2 stents in [11-4] HTN Hyperlipidemia Hypothyroidism TAH Social History: Occupation: Retired. Patient has been married for 13 years, her husband lives at [Location (un) 169] Nursing home in [Location (un) ]. She used to work as a computer data entry technician and is currently retired. Patient has smoked 1 ppd for 58 years. Drugs: none Alcohol: none Other: Lives by herself, married. Husband lives in a nursing home Family History: No history of cancer Physical Exam: Vitals- T 96.9, HR 95, BP 132/p, RR 26, O2sat 100% Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no rhonchi, no crackles Abd- soft, NT, ND, +BS, RLQ and lower midline scar Rectal- copious blood per rectum, no masses Ext- warm, well-perfused, no edema Pertinent Results: [2138-9-21] 09:55PM BLOOD WBC-9.4 RBC-3.51* Hgb-11.1* Hct-30.9* MCV-88 MCH-31.7 MCHC-36.1* RDW-14.5 Plt Ct-193 [2138-9-22] 04:39AM BLOOD WBC-11.2* RBC-4.48# Hgb-14.3# Hct-38.1 MCV-85 MCH-31.9 MCHC-37.5* RDW-15.0 Plt Ct-138* [2138-9-23] 02:01AM BLOOD WBC-12.9* RBC-3.92* Hgb-11.7* Hct-33.4* MCV-85 MCH-30.0 MCHC-35.2* RDW-15.8* Plt Ct-187 [2138-9-24] 09:05AM BLOOD WBC-7.3 RBC-2.89* Hgb-8.9* Hct-25.2* MCV-87 MCH-30.9 MCHC-35.5* RDW-15.2 Plt Ct-175 [2138-9-25] 05:55AM BLOOD Hct-24.7* [2138-9-21] 09:55PM BLOOD Glucose-164* UreaN-19 Creat-0.6 Na-141 K-3.9 Cl-114* HCO3-20* AnGap-11 [2138-9-23] 02:01AM BLOOD Glucose-168* UreaN-10 Creat-0.6 Na-146* K-3.5 Cl-117* HCO3-22 AnGap-11 [2138-9-25] 05:55AM BLOOD K-3.9 [2138-9-24] 09:05AM BLOOD Calcium-7.7* Phos-1.8* Mg-2.1 . SPECIMEN SUBMITTED: Transverse and Right Colon. Procedure date Tissue received Report Date Diagnosed by [2138-9-22] [2138-9-23] [2138-9-25] DR. [Last Name (STitle) ]. [Doctor Last Name ]/axg DIAGNOSIS: Ileocolectomy and distal segment of colon: 1. Diverticular disease of the colon. a. Ruptured diverticula in the distal colon with intramucosal and pericolic abscesses. b. Other diverticula in the proximal segment without perforation. 2. Area of mucosal hemorrhage in the distal part of the proximal segment, consistent with acute ischemic lesion. 3 Ileal segment: Within normal limits. 4. No neoplasm. Clinical: Low gastrointestinal bleed. . [2138-9-22] GI Bleeding study IMPRESSION: No active GI bleeding AMENDMENT: The patient returned to the department 6 hours after injection. Dynamic images demonstrate activity throughout the colon. There is a suggestion that new activity appears in the hepatic flexure during the dynamic study at 6 hours. . [2138-9-22] Angio Preliminary Report !! PFI !! Mesenteric arteriogram demonstrating active bleeding at a distal branch of the middle colic artery. Attempts to selectively catheterize this vessel were unsuccessful. By the end of the procedure active extravasation of contrast material could not be noted. . Brief Hospital Course: This is a 74 year old female admitted to [Hospital1 18] with an Acute LGIB. Upon arrival, she had a large blood per rectum, and was acutely hypotensive with SBP 70's. She underwent a tagged RBC scan which was initially negative, and was found to be positive the next morning. Patient went to IR where the bleeding was found to be from the middle colic artery, however attempts at embolization were unsuccessful. She received at least 12 units PRBCs in ordered to maintain her HCT. Surgery was consulted and if the patient continues to bleed and if her Hct continues to trend down, she'll go to the OR. The patient went to the OR on [2138-9-22] for: Total abdominal colectomy and end ileostomy Pain: She had a PCA for pain control and was using it appropriately. She had good pain control and was transitioned to PO pain meds once tolerating a diet. Abd/GI: She was NPO with IVF. Her ostomy was pink and began functioning on POD 3. She had post-op emesis on POD 4 and complained on chest pain. She was ordered for cardiac enzymes which were negative. She was having high ostomy output and was started on Immodium QID to decrease ostomy output. She was tolerating a diet at time of discharge. Prior to discharge the staples were removed and steri strips were applied. Anticoag: She was restarted on her ASA/Plavix on POD 5. Medications on Admission: Plavix/ASA, lisinopril 5', metoprolol xl 25', simvastatin 80', prilosec, calcium Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool. Disp:120 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Lower GI Bleed at the hepatic flexure and sigmoid and proximal rectal mass. 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. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[11-12] lbs) for 6 weeks. * You may shower and wash. No tub baths or swimming. * Monitor your incision for signs of infections Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 3 weeks. Call ([Telephone/Fax (1) 6347] to schedule an appointment. Completed by:[2138-9-30] Name: [Known lastname 1715],[Known firstname ] Unit No: [Numeric Identifier 12725] Admission Date: [2138-9-21] Discharge Date: [2138-9-30] Date of Birth: [2064-4-29] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3149] Addendum: To clarify, on admission the patient was in hypovolemic shock. She also suffered from acute blood loss anemia on admission. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2000] MD [MD Number(2) 3151] Completed by:[2138-10-20]	[ "285.1", "401.9", "562.12", "272.4", "414.01", "244.9", "V45.82", "785.59" ]	icd9cm	[ [ [] ] ]	[ "88.47", "99.04", "46.23", "45.8", "99.07" ]	icd9pcs	[ [ [] ] ]	9566, 9775	4686, 6026	327, 386	7354, 7361	2553, 4663	8871, 9543	2190, 2213		6157, 7160		7255, 7333		6052, 6134			7385, 8848											2228, 2534																				275, 289								414, 1696														1718, 1800	1816, 2174
17,122	185,618	6464+6494+55759	Discharge summary	report+report+addendum	Admission Date: [2134-6-17] Discharge Date: [2134-6-20] Service: MEDICINE Allergies: Ciprofloxacin / Ambien Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 82 year-old female with CAD s/p stent to LAD in [2-23] and instent restenosis s/p PTCA [2134-4-26], multiple admissions in the last few months for congestive heart failure secondary to diastolic dysfunction. She was recently admitted 6/7-9 for acute renal failure secondary to overdiuresis and supratherapeutic INR. She now presents with left-sided, substernal chest pain of 12 hours duration. She reports that the pain started yesterday at 10 pm. She described it as "heaviness" without radiation associated with SOB and mild nausea. She went to bed and awoke with the same degree and quality of pain. Nothing seemed to make it worse or better. The pain was not associated with eating or exertion. Denies dizziness, sweating or vomiting. She is not sure if it feels like the chest pain that she has in the past but does not think it feels like her CHF pain. She took her medications as usual and called her PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] because she was concerned and he told her to call 911. EMT found her to have stable vital signs (BP 118/60, HR 60) and gave her O2, NTG, aspirin 324mg PO, morphine 2mg IV. On arrival to ED, still with 2/10 CP which eventually resolved with NTG. She was given another full dose aspirin, heparin bolus, started on heparin gtt. She was also given Tylenol for headache. Patient became transiently and asymptomatically hypotensive to 73/36 and bradycardic in the ED, attributed to the nitroglycerin, which resolved with IV fluid bolus to SBP's in 110's. She received a total of 900cc of NS. Currently she is chest pain free with SBP's in 110's. EKG with <0.5mm questionable ST depression in V4-V6. and negative cardiac enzymesx1(9 am ). Past Medical History: 1. Atrial fibrillation status post DCCV on [2133-3-18] and again on [2134-3-23] (still in AF) - chronically on coumadin. Successfully cardioverted [4-18]. Being bridged with hep and coumadin at [Hospital 100] Rehab. 2. Hypercholesterolemia/HTN 3. UTI: Klebsiella in past (pansensitive) 4. Diastolic congestive heart failure. Hemodynamic evaluation revealed moderately to severely elevated right-sided pressures (mean RA was 17 and RVEDP was 22 mmHg), severely elevated left-sided pressures (mean PCW was 29 and LVEDP was 31), and severely elevated pulmonary pressures (PA was 67/33 mmHg). There were prominent V waves on the PA tracing up to 50 mmHg, 2+MR. 5. CAD: s/p PCI of the proximal LAD on [2130-2-23], then had NSTEMI and in-stent restenosis treated with PTCA [2134-4-26] and PTCA of mid-LAD 70% lesion (cypher stents x2) 6. Gout. 7. Obesity. 8. Obstructive sleep apnea on CPAP (setting of 12). 9. Status post cholecystectomy. 10. History of spinal stenosis Social History: Very functional, lives alone. Just discharged from [Hospital 100] Rehab last Friday. She is able to shop, drive, all ADLS. Widowed 24 years ago. Has three children. Denies tobacco, alcohol, or recreational drug use. Her daughter is her health care proxy. Family History: F - MI at 60y/o no strokes Physical Exam: VS: T 98.1 BP 110/54 P 53 R 20 O2 Sats 99% on 3L NC General: pt lying supine with bed at 45 degree angle, NAD, no respiratory distress breathing with nasal cannula HEENT: PERRL, MM moderately dry with thick white secretions on oral mucosa Neck: no carotid bruits appreciated, no lymphadenopathy, JVP ~12 cm CV: RRR, S1/S2 appreciated, [2-28] murmur loudest at RUSB, no radiation to carotids, PMI not displaced Pulm: diffuse crackles at the bases bilaterally Abd: obese, + BS, soft, NT/ND, no masses appreciated Ext: LE warm and well perfused with 2+ distal pulses, 1+ pitting edema up to knees Rectal: guaiac negative per ED Pertinent Results: [2134-6-18] 05:30AM BLOOD WBC-14.0# RBC-3.68 Hgb-10.9* Hct-31.3* MCV-85 MCH-29.7 MCHC-34.9 RDW-13.6 Plt Ct-153 [2134-6-17] 09:15AM BLOOD WBC-7.4 RBC-3.38* Hgb-9.4* Hct-29.1* MCV-86 MCH-27.9 MCHC-32.4 RDW-18.1* Plt Ct-236 [2134-6-18] 05:30AM BLOOD Neuts-80* Bands-0 Lymphs-7* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2134-6-17] 09:15AM BLOOD Neuts-71.9* Lymphs-18.7 Monos-6.4 Eos-2.1 Baso-0.9 [2134-6-18] 05:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2134-6-17] 09:15AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Microcy-1+ [2134-6-18] 05:30AM BLOOD Plt Smr-NORMAL Plt Ct-153 [2134-6-18] 05:30AM BLOOD PT-14.8* PTT-23.9 INR(PT)-1.5 [2134-6-17] 10:50PM BLOOD PTT-42.4* [2134-6-17] 03:30PM BLOOD PT-17.1* PTT-71.8* INR(PT)-1.9 [2134-6-17] 09:15AM BLOOD Plt Ct-236 [2134-6-17] 09:15AM BLOOD PT-15.7* PTT-25.5 INR(PT)-1.6 [2134-6-18] 05:30AM BLOOD Glucose-113* UreaN-44* Creat-1.5* Na-142 K-4.0 Cl-103 HCO3-27 AnGap-16 [2134-6-17] 09:15AM BLOOD Glucose-107* UreaN-45* Creat-1.3* Na-141 K-4.1 Cl-103 HCO3-26 AnGap-16 [2134-6-17] 10:50PM BLOOD CK(CPK)-77 [2134-6-17] 03:30PM BLOOD CK(CPK)-64 [2134-6-17] 09:15AM BLOOD CK(CPK)-108 [2134-6-17] 10:50PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2134-6-17] 03:30PM BLOOD CK-MB-NotDone cTropnT-0.01 [2134-6-17] 09:15AM BLOOD cTropnT-<0.01 [2134-6-17] 09:15AM BLOOD CK-MB-3 proBNP-[2154]* [2134-6-18] 05:30AM BLOOD Mg-2.0 [2134-6-17] 03:30PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0 [2134-6-18] 10:00AM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.015 [2134-6-18] 10:00AM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2134-6-18] 10:00AM URINE RBC-21-50* WBC->50 Bacteri-MOD Yeast-NONE Epi-<1 [2134-6-20] 05:10AM BLOOD PT-15.0* PTT-23.6 INR(PT)-1.5 [2134-6-20] 05:10AM BLOOD WBC-7.4 RBC-3.40* Hgb-9.6* Hct-30.0* MCV-89 MCH-28.2 MCHC-31.9 RDW-18.0* Plt Ct-214 [2134-6-18] 10:00AM URINE RBC-21-50* WBC->50 Bacteri-MOD Yeast-NONE Epi-<1 Brief Hospital Course: 1. Chest Pain/CHF: Patient r/o for MI. She had no significant ECG changes. Was found to be in decompensated congestive heart failure and was diuresed. Spironolactone 25 mg PO once daily was added to her heart faliure regimen and her lasix dose was changed to 60mg po once daily. Her beta blocker was changed to toprol XL 25mg once daily because of several episodes of asymptomatic bradycardia in the 50s during her hospital course. The rest of her medications including ASA, plavix, simvastain, Imdur and valsartan on admission were continued at the same dose as on admission. 2. Rhythm: She did not have any episodes on atrial fibrillation while an inpatient. She was continued on amiodarone 200mg PO daily and coumadin 5mg po QHS which was restarted ([6-18]) after discontinuing heparin. Her INR will resume being monitored as before admission. 3.UTI: Urine culture showed >100,000 E.coli s/p foley catheter. The foley was removed and she received one dose of ceftriaxone 1 g IV. She was discharged on Bactrim DS x 6 days pending sensitivities. She has a follow-up appointment with her NP [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 3817] tomorrow and an e-mail was sent informing her of the medication changes and pending culture to be followed up. Medications on Admission: allopurinol 100mg qd amiodarone 200mg qd asa 325mg qd plavix 75mg qd colace 100mg qd lasix 40mg PO daily Imdur 30mg qd prevacid 30mg qd lopressor 50mg [Hospital1 ] mvi qd zocor 80mg qhs diovan 40mg qd coumadin combivent 1-2 puffs q 4 hrs prn wheeze Senna as needed Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-27] Puffs Inhalation Q4H (every 4 hours) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 16. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 17. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: congestive heart failure Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5liter per day Please take all medications as prescribed: you will need to complete your antibiotic course with Bactrim for a urinary tract infection. You should stop taking lopressor because of slow heart rate - you are now taking toprol 25mg po qd. We have also added aldactone to your regimen. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name12 (NameIs) 17452] Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2134-6-21] 10:20 Provider: [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM Where: BA [Hospital Unit Name ] ([Hospital Ward Name ] COMPLEX) [Hospital Ward Name 1947] Phone:[Telephone/Fax (1) 543] Date/Time:[2134-6-21] 1:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Where: [Hospital6 29] ORTHOPEDICS Phone:[Telephone/Fax (1) 1228] Date/Time:[2134-6-24] 9:00 Admission Date: [2134-6-20] Discharge Date: [2134-6-29] Service: MEDICINE Allergies: Ciprofloxacin / Ambien Attending:[First Name3 (LF) 2704] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Endotracheal Intubation DC Cardioversion Arterial Line Placement Central Venous Line Placement History of Present Illness: 84F with hx CAD, CHF (DD) who was discharged from the CHF/[Hospital Unit Name 196] service on [2134-6-20], called EMS the evening of discharge with SOB and DOE and was found to be in VTach, BP was stable, she was started on IV Amio, spontaneously converted to afib, then dropped BP. Pt was intubated en route to hospital. Intermittently in and out of VTach/afib. In [Name (NI) ], pt BP dropped during afib with rate 150bpm, DCCV with conversion to sinus at 70 bpm. BP remained at 80 systolic, Levophed started. Post-cardioversion EKG showed [Street Address(2) 1766] depressions in I, II, III, F, V4, 5, and 6, believed to be result of cardioversion and not representing new ischemia. Pt received 100 mg IV lasix en route to hospital. CXR showed florid pulmonary edema. . Transferred to CCU. Pt was reintubated on arrival to CCU because of air leak around ET tube, and anesthesiology noted difficult intubation. TLC placed in RIJ, and A-line placed in L radial artery. Was sent to CCU on integrillin gtt, which was d/c'ed due to low suspicion of AMI. Past Medical History: 1. Atrial fibrillation status post DCCV on [2133-3-18] and again on [2134-3-23] (still in AF) - chronically on coumadin. Successfully cardioverted [4-18]. Being bridged with hep and coumadin at [Hospital 100] Rehab. 2. Hypercholesterolemia/HTN 3. UTI: Klebsiella in past (pansensitive) 4. Diastolic congestive heart failure. Hemodynamic evaluation revealed moderately to severely elevated right-sided pressures (mean RA was 17 and RVEDP was 22 mmHg), severely elevated left-sided pressures (mean PCW was 29 and LVEDP was 31), and severely elevated pulmonary pressures (PA was 67/33 mmHg). There were prominent V waves on the PA tracing up to 50 mmHg, 2+MR. 5. CAD: s/p PCI of the proximal LAD on [2130-2-23], then had NSTEMI and in-stent restenosis treated with PTCA [2134-4-26] and PTCA of mid-LAD 70% lesion (cypher stents x2) 6. Gout. 7. Obesity. 8. Obstructive sleep apnea on CPAP (setting of 12). 9. Status post cholecystectomy. 10. History of spinal stenosis Social History: Very functional, lives alone. Just discharged from [Hospital 100] Rehab last Friday. She is able to shop, drive, all ADLS. Widowed 24 years ago. Has three children. Denies tobacco, alcohol, or recreational drug use. Her daughter is her health care proxy. Family History: F - MI at 60y/o no strokes Physical Exam: PE: T 99.5 HR 75 BP 97/63 R 18 99% on AC 18 X 500 FiO2 100%, PEEP 5 Gen: intubated and sedated HEENT: EOMI, PERRL Neck: brawny, unable to assess JVD Chest: crackles throughout CV: RRR, S1 s2 Abd: obese, soft + BS Ext: no edema, dopplerable pulsed at DP bilaterally Neuro: moves all four Pertinent Results: [2134-6-20] 10:15PM GLUCOSE-398* UREA N-35* CREAT-1.5* SODIUM-137 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-24 ANION GAP-19 [2134-6-20] 10:15PM ALT(SGPT)-23 AST(SGOT)-24 LD(LDH)-263* CK(CPK)-110 ALK PHOS-93 AMYLASE-67 TOT BILI-0.4 [2134-6-20] 10:15PM LIPASE-26 [2134-6-20] 10:15PM cTropnT-0.01 [2134-6-20] 10:15PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-1.9 [2134-6-20] 10:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2134-6-20] 10:15PM NEUTS-76.0* LYMPHS-19.1 MONOS-2.1 EOS-2.2 BASOS-0.5 [2134-6-20] 10:15PM PT-15.2* PTT-23.1 INR(PT)-1.5 [2134-6-20] 05:10AM MAGNESIUM-2.0 [2134-6-20] 05:10AM PLT COUNT-214 [2134-6-20] 05:10AM PT-15.0* PTT-23.6 INR(PT)-1.5 [2134-6-19] 06:10AM GLUCOSE-126* UREA N-32* CREAT-1.1 SODIUM-141 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14 [2134-6-19] 06:10AM WBC-7.6 RBC-3.37* HGB-9.6* HCT-29.3* MCV-87 MCH-28.6 MCHC-32.9 RDW-17.9* [2134-6-19] 06:10AM PT-14.3* PTT-23.3 INR(PT)-1.4 ECHO Study Date of [2134-6-22] EF 70-80% Mild to moderate ([12-27]+) MR. Prolonged (>250ms) transmitral E-wave decel time. Mild AS. 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. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-27]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Labs at discharge: [2134-6-28] 05:15PM BLOOD Hct-34.6* [2134-6-28] 05:15PM BLOOD Glucose-165* UreaN-59* Creat-1.4* Na-138 K-3.8 Cl-95* HCO3-32 AnGap-15 [2134-6-29] 12:30PM BLOOD PT-21.9* PTT-27.8 INR(PT)-3.2 Brief Hospital Course: 82F with CAD, CHF (DD) and afib, admitted after developing "flash" pulmonary edema due to VT/Afib. Afib/VT: Pt had been on PO amio 200mg PO bid at admission, but reloaded with IV amio. Was changed to 400mg PO bid on [6-22]. Remained in NSR throughout admission. [Month/Year (2) 5937] intervals were monitored. On discharge patient was given 400 mg amiodarone PO for a two week period, which is to be followed by 200 mg PO amiodarone qd. EP followed the patient and did not recommend pacer/ICD therapy. CHF: Secondary to diastolic dysfxn. Pulmonary edema on admission was a consequence of Afib/Vtach, not due to volume overloaded state. Levophed was quickly weaned after arrival to CCU. Echo done on [2134-6-22] showed: EF 70-80%, mild symmetric LVH, abnormal systolic flow contour at rest, but not LVOT obstruction. Mild AS (AV valve area 1.7cm2, pk gradient 46, mean gradient 27), [12-27]+ MR, mild PA systolic HTN. No significant changes from previous [4-29] echo. BPs initially labile, with most readings in 160s/100s, but with unexpected drops down to 90s/50s, always asymptomatic during these episodes. Upon discharge, metoprolol was titrated up to 50mg PO TID, and patient started on valsartan 80mg PO BID for afterload reduction. Anxiety likley played a huge component of patient symptoms, with panic attacks associated with tachycardia and acute pulmonary edema due to severe diastolic dysfucntion. Patient does not tolerate benzodizepines per report. Started Celexa low dose near end of hospitalization. CAD: Initial CK: 110 and trended down. Troponin rose to 0.31 morning after admission. Continued ASA, Plavix, lipitor, and metoprolol, and restarted valsartan on [6-24]. No evidence of ischemia during this hospitalization. Dyspnea: Patient admitted with dyspnea and was likely from "flash" pulmonary edema secondary to vtach/afib. Episodic dyspnea continued during stay. Etiology thought to be multifactorial. Has h/o OSA on home BiPap. Pulmonary edema from admission resolved over first two days of admission. Initial CXR showed retrocardiac infiltrate suggesting of PNA, and pt spiked occasional fevers to 101.5 F during admission. Also had an element of reactive airway disease responsive to albuterol/ipratropium nebs. Added vancomycin 1gm q48 to Ceftriaxone being given for UTI due to h/o MRSA. Sputum and blood cx's NGTD. UTI: Pansensitive E. Coli from [6-20] UCx. Patient had reported allergy to fluoroquinolones & concerned about [Last Name (LF) 5937], [First Name3 (LF) ] started 7-day course CTX. New UCx and BCx sent, brief course of Zosyn which was completed at time of discharge. ARF: Cr 1.5 on admission, possible effective prerenal state secondary to hypotension. Cr slowly dropped to 1.2, which is her baseline. FEN: Patient had good PO intake. Her electrolytes were monitored and repleted prn. Patient was discharged on [2134-6-29] to [Hospital 100] [Hospital 24920] rehabilitation facility. The patient will need followup of her guaiac positive stool, possible outpatient colonoscopy in future. Hematocrit stable during hospital stay. She will also need monitoring of INR on coumadin. Medications on Admission: 1. Allopurinol 100 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Isosorbide Mononitrate 30 mg PO DAILY 4. Amiodarone 200 mg PO DAILY 5. Simvastatin 80 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Multivitamin Capsule (1) Cap PO DAILY 8. Albuterol-Ipratropium MDI q 4 prn 9. Docusate Sodium 100 mg PO QD 10. Lansoprazole 30 mg PO DAILY 11. Senna 8.6 mg PO BID prn 12. Valsartan 40 mg PO qD 13. Warfarin 5 mg PO HS 14. Toprol XL 25 mg PO once a day. 15. Furosemide 60 mg PO DAILY 16. Aldactone 25 mg PO qD 17. Bactrim DS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 5. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:qs one month Refills:0 9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: Please take 400 mg qd for two weeks followed by 200 mg qd. Disp:14 Tablet(s) Refills:0 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start taking 200 qd after finishing 2 weeks of 400 mg qd. Disp:30 Tablet(s) Refills:2 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 13. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 14. Warfarin Sodium 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 15. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:qs one month Refills:1 16. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: 1. Atrial Fibrillation 2. Diastolic Congestive Heart Failure 3. Pneumonia Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call your doctor or go the ER if you have symptoms of increased shortness of breath, chest pain, palpitations or dizziness. Followup Instructions: 1. Please schedule a follow-up appointment with your cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 7179] withing the next month. 2. Your INR was 3.2 today. Please have your INR re-checked on Thursday or Friday. The number to the coumadin clinic is ([Telephone/Fax (1) 2834]. 3. Please follow-up with [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Where: [Hospital 4054] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2134-7-26] 11:00 4.Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Where: [Hospital6 29] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2134-7-26] 9:30 5. Provider: [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM Where: BA [Hospital Unit Name ] ([Hospital Ward Name ] COMPLEX) PODIATRY Phone:[Telephone/Fax (1) 543] Date/Time:[2134-8-25] 10:10 Name: [Known lastname 4229],[Known firstname 1194] Unit No: [Numeric Identifier 4230] Admission Date: [2134-6-20] Discharge Date: [2134-6-29] Date of Birth: [2052-1-7] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Ambien Attending:[First Name3 (LF) 2129] Addendum: Addendum to Discharge diagnosis: 4. Acute Respiratory Failure Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - Acute Rehab [First Name11 (Name Pattern1) 448] [Last Name (NamePattern4) 2130] MD [MD Number(1) 2131] Completed by:[2134-7-16]	[ "278.00", "493.90", "272.0", "518.81", "780.57", "792.1", "285.9", "428.30", "458.9", "427.32", "427.31", "274.9", "478.29", "412", "584.9", "V58.61", "599.0", "V45.82", "996.74", "300.01", "041.4", "428.0", "486", "414.01", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93", "99.62", "96.04", "99.04", "96.71" ]	icd9pcs	[ [ [] ] ]	23460, 23693	16036, 19226	10803, 10899	21662, 21670	13659, 15792	21949, 23385	13308, 13336		19792, 21448		23406, 23437		19252, 19769			21694, 21926											13351, 13640																				10744, 10765				15811, 16013				10927, 11995														12017, 13011	13027, 13292
14,245	160,978	7992+55901	Discharge summary	report+addendum	Admission Date: [2147-7-23] Discharge Date: [2147-7-29] Date of Birth: [2068-2-6] Sex: M Service: SURGERY Allergies: Ambien Attending:[First Name3 (LF) 4748] Chief Complaint: Bilateral foot ulcerations, he was admitted in anticipation of angiography under general anesthesia. Major Surgical or Invasive Procedure: Right lower extremity angiography History of Present Illness: The patient is a 79 year old man with a history of CHF (EF 20-30%), s/p CABG w/ subsequent stent to LAD and RCA, COPD on home O2, and history of L SFA-peroneal bypass with non-reversed saphenous vein graft in [2137] who is seen in vascular surgery consultation with bilateral foot ulceration. He previously underwent non-invasvive arterial studies demonstrating severe bilateral tibial disease R>L with flat waveforms distal to his calf. He underwent diagnostic angio on [2147-7-13] with the following conclusions: Extensive atherosclerotic changes of the right femoral and popliteal segments. There is a significant common femoral stenosis. Abrupt occlusion of the below-knee popliteal artery with reconstitution of the proximal peroneal. This tibioperoneal trunk occlusion may be amenable to endovascular recanalization but would require general anesthetic to prevent the patient motion. He is admitted today in anticipation of angio under general anesthesia tomorrow. Past Medical History: 1. CARDIAC RISK FACTORS: -Coronary Artery Disease (s/p MI x2) -Diabetes (Type 2 insulin-dependant) -Dyslipidemia -Hypertension 2. CARDIAC HISTORY: -CABG: -s/p CABG in [2139] (LIMA->diag, SVG->OM1, SVG->LAD) -PERCUTANEOUS CORONARY INTERVENTIONS: -s/p prior LAD stent and PTCA of diag -s/p [Year (4 digits) ] to RCA in [2146] -PPM/ICD: - Ischemic cardiomyopathy, s/p ICD implantation [2141-7-14] - PPM (unclear when placed) -OTHER CARDIAC HISTORY: - Paroxysmal atrial fibrillation - Nonsustained ventricular tachycardia - Chronic systolic CHF [2-14] ischemic cardiomyopathy(last EF 20%) - Mitral regurgitation - Pulmonary Hypertension 3. OTHER PAST MEDICAL HISTORY: -Chronic Obstructive Pulmonary Disease on 3L home O2 since [2146] -Chronic Renal Insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -Severe Peripheral Vascular Disease, s/p left fem-[Doctor Last Name ] bypass [2137] -Obstructive sleep apnea intolerant to CPAP -GERD -Anxiety -Depression -Post Traumatic Stress Disorder Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [Hospital ] [Hospital6 28623]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: Physical exam on admission: 98.0 101 97/58 20 100% RA - NAD - RRR - lungs clear - abdomen soft/NT/ND - R foot with scattered small ulcers in distal toes; 1X1cm heel ulcer; all with dry eschar without purulence or evidence of infection; - L foot with scattered distal ulcers with dry eschar present; Pulses: R femoral palpable, R DP and PT dopplerable L femoral palpable, L DP and PT dopplerable No interval change in exam at discharge Pertinent Results: . Laboratory values on admission: [2147-7-23] 09:30PM GLUCOSE-367* UREA N-52* CREAT-2.5* SODIUM-131* POTASSIUM-3.3 CHLORIDE-88* TOTAL CO2-35* ANION GAP-11 [2147-7-23] 09:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.1 [2147-7-23] 09:30PM WBC-9.2 RBC-4.60 HGB-13.4* HCT-39.6* MCV-86 MCH-29.1 MCHC-33.7 RDW-16.5* [2147-7-23] 09:30PM PLT COUNT-348 [2147-7-23] 09:30PM PT-16.9* PTT-27.4 INR(PT)-1.5* . Laboratory values on discharge: [2147-7-29] 05:43AM GLUCOSE-115* UREA N-26* CREAT-1.1* SODIUM-135* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-33* ANION GAP-10 [2147-7-29] 05:43AM WBC-9.4 RBC-4.21 HGB-12.3* HCT-36.5* MCV-87 MCH-29.4 [2147-7-29] 05:43AM PLT COUNT-271 [2147-7-27] 09:30PM PT-13.9* PTT-25.4 INR(PT)-1.2* . Echo [2147-7-27] The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is moderate to severe regional left ventricular systolic dysfunction with septal akinesis, and inferior and anterior hypokinesis. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The right ventricular cavity is dilated with depressed free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2147-6-13], the detected pulmonary artery hypertension is lower; the image quality is better with better delineation of wall motion abnormalities. The overall ejection fraction is similar. Venous Duplex [2147-7-28] Duplex and color Doppler demonstrate patency of the greater saphenous veins bilaterally. Please note that the right greater saphenous vein is diminutive below the knee. The basilic and cephalic veins are patent bilaterally. Note that there is thrombus within the left basilic vein in the antecubital fossa. Angio [2151-7-24] Patent right common femoral artery. Patent right profunda. Patent SFA. Patent above-knee [Doctor Last Name ]. Patent below-knee [Doctor Last Name ]. With all the aforementioned, there were multiple heavy calcifications throughout but this was not flow-limiting. The AT was totally occluded. The tibioperoneal trunk was occluded to the upper one third of the peroneal artery. The peroneal artery was fed by collaterals from above from the upper one third to the foot. It was widely patent. The proximal portion of the PT to about the level of the calf was occluded. Again collaterals from blood filled the distal PT. Vessels into the foot: The PT was patent. It did fill the medial and lateral plantars. The tibial peroneal trunk did reconstitute to fill the dorsalis pedis. The dorsalis pedis did fill the medial and lateral plantar tarsals. The foot vessels were very small in caliber. Brief Hospital Course: Admitted [7-23], v/c/f, mucomyst and bicarb [7-24] angio cancelled [7-26] went for angio, unable to pass tibioperoneal trunk on right hypotensive to SBP 70s after angio, landed up in the ICU briefly but no pressors required, only fluid boluses [7-28] venous duplex (vein mapping) shows basilic and cephalic veins are patent bilaterally, thrombus within the left basilic vein in the antecubital fossa Medications on Admission: Amiodarone 100 mg po qd Aspirin 325 mg po qd Vitamin C Colace Advair 250/50 Lasix 60 mg IV BID Insulin SS Levothyroxine 25 mcg po qd Lopressor 12.5 mg po bid Ranitidine 150 mg po qd Simvastatin 10 mg po qd Tramadol 50 mg po q6hrs Valsartan 40 mg po qd Effexor 37.5 mg po qd Coumadin 5mg po qd Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 8. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Non-infected bilateral foot ulcers Severe peripheral vascular disease Coronary artery disease Ischemic cardiomyopathy with systolic congestive heart failure- NSVT Diabetes mellitus Hypertension Hyperlipidemia Paroxysmal atrial fibrillation Mitral regurgitation Pulmonary hypertension COPD Obstructive sleep apnea GERD Anxiety Depression Post-traumatic stress disorder 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: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please call Dr.[Name (NI) 1392] office in 2 weeks. Call to schedule an appointment. With: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391] Department: Vascular Surgery Location: [Last Name (NamePattern1) 439] [Hospital Unit Name ] [Location (un) ] Suite C, [Location (un) 86] [Numeric Identifier 718] Phone: [Telephone/Fax (1) 1393] Please be sure to keep all follow-up appointments with your PCP and heart doctor. Name: [Known lastname 5022],[Known firstname 389] T Unit No: [Numeric Identifier 5023] Admission Date: [2147-7-23] Discharge Date: [2147-7-29] Date of Birth: [2068-2-6] Sex: M Service: SURGERY Allergies: Ambien Attending:[First Name3 (LF) 231] Addendum: The following serves as an addendum to the discharge summary completed on [2147-7-29]. The following diagnosis should be included under the list of diagnoses during this admission: Acute renal failure (on admission) Chronic renal failure [Doctor Last Name ] [Doctor Last Name 5024] PGY-1 Discharge Disposition: Extended Care Facility: [Hospital6 5025] & Rehab Center - [Location (un) ] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2147-9-20]	[ "440.23", "414.01", "V45.02", "272.4", "300.4", "530.81", "412", "496", "403.90", "584.9", "707.14", "458.29", "707.15", "428.22", "585.9", "414.8", "V45.81", "V45.82", "309.81", "428.0", "416.8", "327.23" ]	icd9cm	[ [ [] ] ]	[ "88.48" ]	icd9pcs	[ [ [] ] ]	10199, 10441	6785, 7206	366, 402	8766, 8766	3322, 3342	9062, 10176	2780, 2848		7550, 8245		8375, 8745		7232, 7527			8949, 9039											2863, 2877			1590, 2117													3779, 6762				226, 328								430, 1417							3356, 3765		8781, 8925		2148, 2503			1439, 1570	2519, 2764
69,398	195,318	45463	Discharge summary	report	Admission Date: [2150-11-20] Discharge Date: [2150-11-23] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1936] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: R IJ placement and removal History of Present Illness: 86 year old female with DM presenting with nausea, vomiting, LLQ pain and high fever for one day. On the night prior to admission she called her daughter and reported nausea, vomiting, chills and LLQ pain. Her daughter found her slightly delirious and brought her to the ED. Her symptoms were only present for one day. In the ED, she had a temp of 104.8, HR 120, SBP to 80s, 88% RA with RR of 30. She received quick resuscitation with 1 L IVF over 20 minutes with improvement in her BP to SBP 130s. She received Zosyn, Vancomycin, Tylenol and fluids. She initially improved after 1.5 liters of fluid, but after 3-4 liters had intermittent hypotension (total of 5 L NS). LLQ pain improved and mental status improved after IVF resuscitation. She had a CVL placed for pressors and levophed started. Patient denies any mental status changes though does note that she felt quite badly at home. Reports a decreased appetite for the last week, but denies any urinary complaints. Over the course of the last 24 hours, she reports vomiting twice at home with one episode of diarrhea. Also, reports chills. Denies any fevers, nightsweats, chest pain, palpitations, shortness of breath, currently abdominal pain other than as noted above, weakness, paresthesias, headaches, vision changes, or other. Since arrival to the ICU, she reports feeling fatigued. Otherwise, feels much improved. Past Medical History: Diabetes mellitus, type 2 Hypothyroidism dyslipidemia depression Arthritis Urinary incontinence and prolapse s/p sling suspension surgery Spinal stenosis s/p decompression/laminectomy/fusion [2147] s/p hysterectomy [2109] Total hip replacement -left Social History: Lives independently at home. No alcohol, no tobacco Family History: +DM, HTN Physical Exam: on discharge Vitals: Tm 99.1 Tc 98.6 143/84 73 16 95%RA Pain: 0/10 Access: RIJ removed, PIV Gen: nad, pleasant elderly female HEENT: o/p clear, mmm, adentulous CV: RRR, [12-25] SM at LSB Resp: CTAB, +R >L basilar crackles, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, nonfocal Skin: no changes psych: appropriate Pertinent Results: White count 2.9->10->5.9 hgb 10s stable BUN/creat 34/1.4-->14/1.0 INR 1.1 cortisol 41.9 Ca [60]-9 pending lactate 4.5->1.0 LFTs unremarkable . UA [11-20] large blood 10-14rbc, neg LE, 6-10wbc, mod bacteria, +nitrite UCx: >100K Ecoli Blood cx [11-20] NTD X2 . Imaging: CT Abdomen/Pelvis [2150-11-20]: 1. Edema in the left inferior retroperitoneum, around the ureter and pelvic side-wall. Mild left uretral enhancement with surrounding inflammatory change, which could represent ureteritis. Recommend followup ureteroscopy after appropriate treatement. There is no hydroureteronephrosis. 2. Sigmoid diverticulosis without evidence of diverticulitis. 3. Multiseptated cystic lesion in the tail of the pancreas, given appearance without associated duct dilation would favor serous cystic pancreatic tumor or IPMN. Recommend comparison with priors if available or endoscopic ultrasound. 4. Diffuse low attenuation of the liver consistent with fatty infiltration. . HEAD CT [2150-11-20]: No hemorrhage or other acute changes. Brief Hospital Course: Briefly 86year old female with DM, HTN, urinary incontinence admitted [11-20] with one day of fever, nausea/vomiting, MS changes, LLQ pain. In ER, hypotensive, s/p 5L IVF and levophed, lactate 4.5, transfered to MICU. Started on vanc/zosyn, UA dirty and no other source. CT a/p w/o diverticulitis (LLQ pain) but did show inflammation L inferior ureter c/w ureteritis, possible [12-21] passed stone. Story also suggestive of possible passed stone given intense pain that spontaneously resolved. Last temp [11-20] on admission, afebrile since and sepsis resolved and transfered to Gen Med [11-22]. Urine with ecoli and antiobiotic changed to cipro PO, plan for 10days. Did require O2 for couple days [12-21] massive IVFs, no infiltrate or cough to suggest PNA, O2 weaned down. Tolerating PO and MS back to normal. Renal function back to normal. On day of discharge, reported a couple watery stools, but no abdominal pain, no fevers or leukocytosis. Had been getting scheduled stool softners and diet recently resumed. Understands to call PCP if persists or fevers/pain since at risk for c-diff. Empiric flagyl not given, did not have another BM prior to d/c so did not send stool while here. Incidental CT finding of multiseptate lesion pancreas tail without associated duct dilation suggestive of serous cystic pancreatic tumor or IPMN. No prior CT a/p to compare, she needs outpt workup (GI or surgery), Dr. [Last Name (STitle) ] notified by email. Ca19-9 sent by MICU and pending at time of discharge As for CT finding of ureteritis on L side, may be [12-21] passed stone, can f/u with CT in 2months, if still persists, then pt can f/u with her urologist for possible ureteroscopy. Medications on Admission: synthroid 75 lisinopril 10 metformin 500/250 paxil 20 simva 20 Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day: take 1 tablet in morning and 0.5tablet in evening. Discharge Disposition: Home Discharge Diagnosis: Urosepsis Possible nephrolithisis->ureteritis abnormal Pancreatic tail cyst Discharge Condition: GOOD Discharge Instructions: You were admitted for severe urinary tract infection that made you very ill requiring admission to the intensive care unit. From your history of severe adominal pain and CT scan findings of inflammation of the ureter, it is possible that you passed a stone. You will be on Cipro for 10days (until [11-29]). Please monitor your diarrhea (dont take stool softners) and if it persists or you have fevers/abdominal pain, talk to your doctor, who can order some stool tests and start you on medications (you are at risk for the antibiotic causing diarrhea called C-diff). You can resume all of your other medications at same doses Your CT scan showed a cyst in your pancreas, please ask Dr. [Last Name (STitle) ] to refer you to surgery or GI for biopsy/work up. Your CT scan showed the inflammation around the L ureter as mentioned above, you can have your urologist follow this up and if it persists, he can consider a ureteroscopy Followup Instructions: Please make an appointment to see Dr. [Last Name (STitle) ] in 2weeks. Please f/u with urology and surgery in next month Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Phone:[Telephone/Fax (1) 11262] Date/Time:[2152-5-3] 2:15	[ "287.5", "250.00", "593.89", "788.30", "724.02", "599.0", "995.92", "577.2", "311", "244.9", "272.4", "592.0", "V43.64", "584.9", "716.90", "401.9", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	5890, 5896	3528, 5248	271, 300	6015, 6021	2464, 3505	7006, 7361	2076, 2086		5361, 5867		5917, 5994		5274, 5338			6045, 6983											2101, 2445																				225, 233								328, 1709														1731, 1991	2007, 2060
7,204	103,040	21939	Discharge summary	report	Admission Date: [2193-11-28] Discharge Date: [2193-12-10] Service: MEDICINE Allergies: Calcium Channel Blocking Agents-Benzothiazepines / Beta-Adrenergic Blocking Agents / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 30] Chief Complaint: Left main stem stent obstruction Major Surgical or Invasive Procedure: Bronchoscopy and left main stem stent removal History of Present Illness: 80 yo female with COPD, tracheobonchomalacia, CAD s/p MI (12yrs ago), seizure d/o, HTN, Type II DM s/p left mainstem stent [10-11] who presented to [Hospital 1562] hosp [11-24] with SOB and respiratory failure [1-14] LLL mucus plugging and L mainstem 90% occlusion. Also had seizure with sub-therapeutic dilantin level. Transferred to [Hospital1 18] for w/u of L mainstem stent obstruction. Dr.[Last Name (STitle) 57475] took patient to bronch, which revealed granulation tissue obstruction, then entire stent removed [11-29]. Since the patient did not feel better when the stent was placed, she was not considered to be a good candidate for tracheoplasty. Ms.[Known lastname 17562] could not be extubated after stent removal because of laryngeal edema/spasm, finally extubated [12-4] with no plans for further intubation if necessary (i.e. DNI). Vanc (started at OSH on [11-24])/levo (started [11-30]) to complete 10 day course for LLL opacities suspicious for PNA. Initially started on Nipride for tight BP control, weanded off on [11-30]. Started on captopril on [12-2] with good response to borderline hypotension. Past Medical History: Tracheobronchomalacia Respiratory distress COPD Depression Hypothyroid Hypertension Diabetes Hyperlipidemia Seizure disorder s/p MI (~12 years ago) Social History: Smoker since [2132], 1pack/week, quit ~12 years agoDenies alcohol and IDU useLives in nursing home, [Location (un) 6598] Manor, [Hospital3 ] Family History: Father with COPD Brother with stomach cancer Brief Hospital Course: 1. Stent Obstruction: Pt presented with shortness of breath and fever to [Hospital 1562] hospital [11-24] with SOB and LL mucus plugging. Bronch revealed left mainstem occlusion and pt transferred to [Hospital1 18] for care. Bronchoscopy at [Hospital1 18] also revealed nearly totally occluded L main stem stent, which was removed. No tracheostomy was placed since pt had no subjective improvement when stent initially went in, late [9-16]. Ms.[Known lastname 17562] was unable to be extubated second to lack of air-leak, and presumed laryngeal edema/spasm. Finally, she was extubated [12-4] and tolerated the extubation well. Currently, denies shortness of breath, cough, sputum production or chest pain. Interventional pulmonary no longer feels Ms.[Known lastname 17562] to be an interventional candidate for her tracheobronchiomalacia. 2. Seizure D/O: Pt experienced a seizure at OSH, by report. She was placed on dilantin and dosed by level. No further seizure activity. 3. DMII: Kept on insulin sliding scale and diabetic diet. No episodes of hyperglycemic coma or hypoglycemia. 4. ID: Vanc (started at OSH [11-24]) and levoquin (started [11-30]) to complete a 10 day course of possible post-obstructive PNA (will finish [12-10]). Now without features of pneuomonia by physical. No septic hemodynamics. Lactate normal. 5. HTN: Transiently required nipride gtt for BP control, easily transitioned to PO ACE-inhibitor, with good control. 6. Mental Status Change: Pt noted to have a decreased sensorium and behaving inappropriately. This was attributed to sedatives (while intubated), possible hypoxia, ICU psychosis and sundowning. She was at baseline by time of discharge. Medications on Admission: [Last Name (un) ] prn phenobarbital 120 po qhs dilantin 200 IV q8h levothyroxine 75 mic/d hep 5000 sq tid protonix 40 IV qD solumedrol 125 mg IV q8h levaquin 500 IV qd vanc 1g q12h propofol gtt atrovent nebs q6h albuterol nebs prn Discharge Medications: 1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:qs Refills:0 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). Disp:180 neb Refills:2 6. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day). Disp:270 Tablet, Chewable(s) Refills:2 7. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) ] mannor Discharge Diagnosis: Primary: 1. Tracheo-bronchomalacia. 2. Post-Obstructive Left Lower Lobe Pneumonia. 3. Delirium. 4. Larnygeal Edema. Secondary: 1. Hypertension. 2. Seizure D/O NOS. 3. Diabetes Mellitis. Discharge Condition: Good Discharge Instructions: If you have these symptoms, call your doctor or go to the ER: - fever/chills - shortness of breath (slowly worsening or sudden) - cough with blood/sputum - weakness - Headache - visual changes Followup Instructions: Pulmonary. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7631], MD [Hospital1 57476], [Numeric Identifier 19665] ([Telephone/Fax (1) 57477] Completed by:[2193-12-10]	[ "496", "478.6", "486", "401.9", "519.1", "780.39", "518.82", "250.00", "996.59", "293.0" ]	icd9cm	[ [ [] ] ]	[ "33.22", "98.15", "38.91", "96.6", "96.72" ]	icd9pcs	[ [ [] ] ]	4950, 5004	2022, 3774	346, 393	5234, 5240		5483, 5685	1953, 1999		4059, 4927		5025, 5213		3800, 4036			5264, 5460																															274, 308								421, 1596														1618, 1767	1783, 1937
15,639	190,575	52459+59426	Discharge summary	report+addendum	Admission Date: [2110-12-18] Discharge Date:[2111-1-1] Service: A-C0VE NOTE: Day of discharge to be included in Addendum by incoming intern. HISTORY OF PRESENT ILLNESS: This is an 81-year-old female admitted to the A-Cove Service overnight on [2110-12-18] with a past medical history of chronic renal insufficiency, multiple prior urinary tract infections, acolasia, ulcerative colitis (status post colonic resection and ileostomy) who was admitted from nursing home for one week of "general decline" and increasing lethargy. On admission on [2110-12-18], the patient complained of being cold, having thoracic back pain at the site of her multiple decubitus ulcers but denied chest pain, shortness of breath, nausea, vomiting, diarrhea, fevers, chills, abdominal pain, and cough. The patient did have frequency and dysuria. In the Emergency Department, the patient was noted to be volume depleted with an increased creatinine, pyuria, and a decreased bicarbonate. The patient was admitted and given 150 mEq of bicarbonate in D-5 water, and oral Levaquin, and cefpodoxime after a head computed tomography showed no bleed, a subtle patchy opacity in the right lung base may be related to pneumonia, and the abdomen noted possibly bowel gas, and no obstruction. The patient was also admitted for a gastrojejunostomy tube revision. On the floor on the night of admission, the patient became progressively hypotensive to a systolic blood pressure in the 70s/50s. The patient was emergently brought to the Intensive Care Unit to establish access and treat for septic syndrome. A left subclavian line was placed with a subsequent iatrogenic pneumothorax. A left chest tube was placed at that time. PAST MEDICAL HISTORY: 1. Acolasia; status post multiple attempts at balloon dilation. Status post gastrojejunostomy tube placement for nutrition. 2. Ulcerative colitis; status post ileostomy with colonic resection for high-grade dyspepsia in [2097]. 3. Neurogenic bladder. 4. History of stroke in [2094] and [2096] with right-sided upper and lower extremity deficits. [Hospital 108373]campus was also effected. 5. Iron deficiency anemia; chronic. 6. History of spinal subarachnoid hemorrhage while on anticoagulation. 7. Depression. 8. Chronic renal insufficiency with a baseline creatinine of 1.6. 9. Status post left hip fracture; status post open reduction/internal fixation. Also status post right hip fracture and open reduction/internal fixation. 10. Osteoporosis and osteoarthritis. 11. Recurrent urinary tract infections with Klebsiella and methicillin-resistant Staphylococcus aureus. 12. History of ethanol. ALLERGIES: CIPROFLOXACIN (which causes hand swelling). MEDICATIONS ON ADMISSION: 1. Sodium bicarbonate 150 mEq. 2. Prevacid 30 mg p.o. q.d. 3. M.V.I. with minerals 30 cc p.o. q.d. 4. Vitamin C 500 mg p.o. b.i.d. 5. Florinef 0.1 mg p.o. q.d. 6. Effexor 75 mg p.o. q.d. 7. Imodium 2 mg p.o. q.i.d. 8. Atarax 25 mg p.o. q.8h. p.r.n. 9. Morphine 2 mg/mL q.4h. as needed (for pain). 10. Tylenol p.o. b.i.d. 11. Tums p.o. b.i.d. SOCIAL HISTORY: The patient is a nursing home resident. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed blood pressure was 90/42, heart rate was 60, respiratory rate was 14, oxygen saturation was 89% on room air and 100% on nonrebreather. The patient was afebrile. Head, eyes, ears, nose, and throat examination pupils were equal, round, and reactive to light. Sclerae were anicteric. The neck revealed jugular venous distention flat. No lymphadenopathy. Chest revealed crackles over the right base; otherwise, clear to auscultation. Heart revealed a regular rate and rhythm. No murmurs, gallops, or rubs were appreciated. The abdomen was soft, nontender, and nondistended. Ileostomy without erythema. Gastrojejunostomy tube with erythema and leakage around the tube. The back showed multiple decubitus ulcers in the thoracic area with surrounding erythema. Extremities were modeled with 3+ pitting edema bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories and studies on [2110-12-28], the patient's white blood cell count was 36.9, hemoglobin was 12.2, hematocrit was 38.7, mean cell volume was 91, and platelets were 199. PT was 15, PTT was 35.8, INR was 1.5. Fibrinogen was 332. D-dimer was 1000 to [2108]. The rest of the disseminated intravascular coagulation panel was pending. Reptilase level was pending. Urinalysis showed greater than 1000 white blood cells on admission and subsequently dropped to 227 white blood cells on [2110-12-23]. On [2110-12-28], creatinine had dropped from the high 3s to 2.4. Sodium was 146, potassium was 3.9, chloride was 120. LD was 267, amylase was 220, ALT was 13, AST was 15, alkaline phosphatase was 163, total bilirubin was 0.5, lipase was 1. Albumin was 1.8, calcium was 7.7, phosphate was 3.3, magnesium was 2.1. Thyroid-stimulating hormone was 2.7, T4 was 1.2, free T4 was less than 0.4, cortisol was 16. Lactate on [12-28] was 2.1. Clostridium difficile screen was negative times one. Blood cultures were no growth to date from [12-27] and [12-23], and no growth from blood cultures on [12-22] and [12-19]. Rectal swab to rule out methicillin-resistant Staphylococcus aureus showed the patient was oxacillin resistant on rectal swab and oxacillin sensitive on the nasale swab. The wound swab revealed no Staphylococcus aureus isolated. Urine culture on [2110-12-23] grew yeast (speciation pending). Wound cultures from the decubitus ulcers grew Pseudomonas aeruginosa sensitive to every antibiotic tested. RADIOLOGY/IMAGING: The patient has received multiple chest x-rays to follow the evolution of her left pneumothorax and has also received chest computed tomographies for the same purpose, as many of the chest x-rays were not very helpful. One ultrasound of the abdomen showed no abscess around the gastrojejunostomy tube on [2110-12-19]. A computed tomography of the chest, abdomen, and pelvis on [2110-12-22] showed small atrophic native kidneys without hydronephrosis, large left pneumothorax, and extensive subcutaneous emphysema on the left with minimal pneumomediastinum, a filling defect in the proximal esophagus with a distended gallbladder; likely food bolus, and ascites. HOSPITAL COURSE: The patient had a complicated hospital course. The family was divided on how to treat the patient. The official health care proxy was her daughter ([Name (NI) 2127]); however, her daughter ([Name (NI) 5969]) was the one who was referred to when making many of the decisions, and this was agreed upon by the siblings. Throughout the admission, the patient often was complaining of pain and asking to stop treatment; however, the children felt that she did not understand the consequences of these requests and also that she had always been this way her entire life. Ethics consultation was involved, and the situation was generally resolved. As for the [Hospital 228] hospital course: 1. INCREASED WHITE BLOOD CELL COUNT: This white blood cell count remained persistently elevated throughout the admission. The white count was up as high as 37 and decreased to 19; however, it continued to rise again. The patient was placed on empiric vancomycin, Levaquin, clindamycin, and eventually Flagyl and fluconazole. Infectious Disease Service was consulted, and there was some question as to whether the patient had a urosepsis, and could this have been from a fungal etiology. It was unlikely; however, it could not be ruled out that the patient did have fungal sepsis. The patient was placed on the fluconazole for this. The clindamycin was stopped due to its propensity to cause Clostridium difficile, and Flagyl was started after Infectious Disease Service was consulted when the patient came out of the Medical Intensive Care Unit. The patient continued to have a right pleural effusion which Infectious Disease recommended tapping, but as the patient concurrently had a pneumothorax on the left this right effusion has not been tapped as of [2110-12-28]. 2. HYPOTENSION: Hypotension was the reason the patient was transferred to the Cardiothoracic Intensive Care Unit. The access was achieved with a subclavian line, and the patient remained stable after fluid resuscitation with systolic blood pressures in the high 80s to low 90s. The patient's blood pressure remained in the 90s to 100s throughout the hospital admission. The patient remained extremely difficult to intravascularly replete due to her very low albumin. This may have been contributing to her hypotension. The patient remained in the Medical Intensive Care Unit for two days only. She was never intubated and did well throughout her Intensive Care Unit stay. 3. GASTROINTESTINAL SYSTEM: The patient has acolasia and is status post gastrojejunostomy tube placement. There was leakage around the gastrojejunostomy tube throughout the entire hospital stay. By [2110-12-28], the patient was actually leaking succulent material around the gastrojejunostomy tube. It was hypothesized that there was some fistula within the tract. The gastrojejunostomy tube was left in place and never changed as the plastic of the gastrojejunostomy tube was not deteriorating a previously thought; and, also, this provided a drainage for any succulent material. The patient remained on tube feeds throughout most of the admission and received tube feeds at a goal rate. However, on [2110-12-24] the patient had been gastrointestinal bleeding overnight, and the tube feeds were stopped at that point. They were never restarted again because the patient continued to have gastrointestinal bleeds, and subsequently the gastrojejunostomy tube leakage significantly increased and the tube feeds could not be given. The patient also had what appeared to be a food mass in the esophagus. The eventual plan was to do an esophagogastroduodenoscopy and remove this as well as to attempt another dilation in the esophagus. These procedures were never performed as the patient was not stable enough to undergo this. 4. PULMONARY SYSTEM: The patient received an iatrogenic pneumothorax from the left subclavian line. This pneumothorax did not resolve, and on [2110-12-24] there was some question of a possible bronchopleural fistula. Cardiothoracic Surgery was consulted, and the patient went for placement of a pigtail catheter in the left lung apex to determine if the pneumothorax would resolve. On a chest computed tomography on [2110-12-26], it appeared as though the left pneumothorax was resolving; however, there was still an air leak. On [2110-12-28], there continued to be an air leak out of the pigtail catheter and Cardiothoracic Surgery determined that the pigtail catheter was not in the right place, and the pigtail catheter subsequently fell out. For increased creatinine, the Renal Service was consulted to address the patient's low bicarbonate and increased creatinine. The patient was likely very hypovolemic partially due to her poor nutritional status. Renal suggested given the patient albumin and increasing doses of bicarbonate as the patient was most likely losing bicarbonate from the gastrointestinal tract. These interventions were done, and the patient's creatinine dropped to 2.4 on [2110-12-28] and her blood pressure remained stable. 5. WOUNDS: The patient had multiple decubitus ulcers on her back. Plastic Surgery followed these, and many suggestions were made for addressing these. These suggestions were followed throughout the admission. 6. HEMATOLOGY: The patient was transfused 2 units of packed red blood cells at one point when her hematocrit dropped to 25. The patient also had an elevated INR to 2.3 and was given vitamin K. It was likely that these elevated coagulation indices were due to her malnutrition. A disseminated intravascular coagulation panel was also sent, and Hematology was consulted. Hematology agreed with the administration of vitamin K. 7. NUTRITIONAL STATUS: Nutrition was consulted, and the patient's situation was discussed with Dr. [Last Name (STitle) 519]. It was decided not to begin total parenteral nutrition at this time as the patient would be more susceptible to yeast infections. For the most part, the patient was on her tube feeds at goal with the exception of the dates described when she was gastrointestinal bleeding, and subsequently the gastrojejunostomy tube did not function. 8. MENTAL STATUS: The patient's mental status was, for the most part, interactive. The patient was at times able to converse in a [Known lastname ] conversation. However, it was unclear exactly how much the patient was understanding of her illness. The children were making the patient's decisions. On [2110-12-28], the patient began to acutely desaturate in the afternoon. At this point, the patient was a full code, as her code status had been reversed in the midst of the hospital course. The family felt that they had wanted to reverse the code status at the time she was having the pigtail catheter placed. The patient may possibly have had a pulmonary embolism; however, this suspicion was not pursued because the family decided to do no further interventions. The patient was kept comfortable on morphine; however, there was some confusion as to the patient's status as to whether the family would like her to be comfort measures only or to be treated. The patient is still receiving her intravenous antibiotics. The patient remained very edematous with her blood pressure hovering around a systolic of 90 and continues to have gastrointestinal bleed, leaking around the gastrojejunostomy tube site, a right pleural effusion, a food mass in her esophagus, and a pneumothorax on the left which has never resolved. MEDICATIONS ON DISCHARGE: (Medications as of [2110-12-28] were) 1. Vancomycin 1 g intravenously q.48h. 2. Morphine 2 mg to 4 mg intravenously q.1-4h. (holding for sedation). 3. Bicarbonate 50 mEq intravenously q.d. 4. Protonix 40 mg intravenously q.12h. 5. Nystatin oral suspension 5 mL p.o. q.i.d. 6. Fluconazole 200 mg intravenously q.48h. 7. Metronidazole 500 mg intravenously q.12h. 8. Levofloxacin 250 mg intravenously q.48h. 9. Miconazole 2% cream applied to the decubitus ulcers and 2% powder applied to the gastrojejunostomy tube site. NOTE: This Discharge Summary to have addendum by the incoming intern. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 33176], M.D. [MD Number(1) 33177] Dictated By:[Last Name (NamePattern1) 4525] MEDQUIST36 D: [2110-12-29] 03:17 T: [2111-1-1] 08:00 JOB#: [Job Number ] Name: [Known lastname ], [Known firstname ] Unit No: [Numeric Identifier 17712] Admission Date: [2110-12-18] Discharge Date: [2111-1-1] Date of Birth: [2029-6-26] Sex: F Service: Patient was made CMO only by the family. She was started on a Morphine drip. The patient remained comfortable and nonresponsive, so on [2111-1-1], at 10:10 pm, when she was found unresponsive without pulse or respiratory effort. I examined the patient, the patient had no pupillary reflexes, no pulse, no pressure, no respiratory effort, no breath sounds. Patient was pronounced dead at 10:10 pm. Family was called. Dr. [First Name (STitle) ] was called. Family previously refused an autopsy. [First Name11 (Name Pattern1) 1194] [Last Name (NamePattern1) 17713], M.D. [MD Number(1) 17714] Dictated By:[Last Name (NamePattern1) 17715] MEDQUIST36 D: [2111-1-2] 14:54 T: [2111-1-15] 12:23 JOB#: [Job Number 17716]	[ "276.5", "578.9", "512.1", "707.0", "041.7", "038.9", "511.9", "584.9", "263.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.15", "99.10", "34.04" ]	icd9pcs	[ [ [] ] ]												13978, 15897	2771, 3133	7111, 12614																																									189, 1728									12630, 13951					1751, 2744	3150, 6392

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