Split (1)

train · 26.9k rows

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7,884	182,998	12871	Discharge summary	report	Admission Date: [2161-4-10] Discharge Date: [2161-4-16] Date of Birth: [2100-10-31] Sex: M Service: MEDICINE Allergies: Metoprolol / Ibuprofen Attending:[First Name3 (LF) 1042] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 60 year old man with metastatic NSCLC, COPD, CHF, recently hospitalized with pneumonia (discharged [2161-4-3] with levaquin x7d), who presented with worsening respiratory distress. In the ED, patient was placed on NRB and was 100% (no RA sat documented) and he was given Atrovent and Albuterol nebs and his antibiotic coverage was broadened to Vancomycin adn Zosyn. Labs were remarkable for a Hct of 15. Goals of care were discussed given the patient's DNR/DNI status and ultimately, it was decided to transfuse the patient and admit him to the MICU. In the MICU, Zosyn was changed to Cefepime based on culture data that showed that he had fluoroquinolone-resistant Pseudomonas and was thus not treated for previous PNA. He was transfused a total of 4 [Location ] and Hct has remained stable. Etiology of Hct drop remained unclear as there was no clear GI source and hemolysis was not evidenced on labs. Acute on chronic renal failure was another issue that was suspected to be pre-renal in the setting of blood loss and improved with transfusions and fluids. Patient remained in the unit during [4-11] for continued suctioning, which lessened throughout the day and given his overall improvement, on appropriate antibiotics and ability to clear his own secretions, he is now being called out to the floor. Past Medical History: PMHx: Non-small-cell lung cancer, metastatic left femur fx, [11/2160], )had lytic lesion and then fell on [Hospital Ward Name 1826] 7) Arterial embolic disease s/p right SFA stent in [June 2159] CAD s/p 2 vessel CABG at [Hospital1 112] in [Month (only) 205] 97 HTN COPD CHF; EF 35-40% Hypercholesterolemia Primary polydipsia BPH s/p TURP Schizophrenia, Paranoia Nephrotic Syndrome [2-28] membranous GN Social History: He did smoke for 30 years, but quit. He quit drinking alcohol significantly 12 years ago. He previously was in the real estate business with his brother. [Name (NI) ] is Lebanese by heritage. He has two adult children, and he is married and lives [Location (un) 6409], [Location (un) 86]. Family History: Mother died at age 60 of cancer (unknown type) Physical Exam: Physical Exam: T: 96.4 BP: 126/78 P: 84 RR: 18 O2 sats: 94% on RA Gen: Sleeping comfortably, but arousable, NAD HEENT: PERRL, anicteric, MM dry. Neck: Supple, no JVD. CV: S1, S2 nl, no m/r/g appreciated Resp: Coarse BS bilaterally Abd: Soft, NT/ND, + BS Ext: No c/c/e Neuro: Grossly intact Pertinent Results: [2161-4-10] 10:40AM BLOOD WBC-18.1# RBC-1.80# Hgb-5.0# Hct-15.5# MCV-86 MCH-27.7 MCHC-32.2 RDW-17.5* Plt Ct-398# [2161-4-11] 11:48AM BLOOD Hct-28.0* [2161-4-11] 06:29PM BLOOD Hct-30.8* [2161-4-12] 12:28AM BLOOD Hct-26.8* [2161-4-12] 09:52AM BLOOD WBC-20.7# RBC-3.98# Hgb-11.5* Hct-34.2# MCV-86 MCH-29.0 MCHC-33.8 RDW-16.9 Plt Ct-355# [2161-4-12] 11:43AM BLOOD WBC-22.5* RBC-3.95* Hgb-11.4* Hct-34.1* MCV-86 MCH-28.9 MCHC-33.5 RDW-16.7* Plt Ct-295 [2161-4-14] 05:50AM BLOOD WBC-15.2* RBC-3.62* Hgb-10.7* Hct-32.1* MCV-89 MCH-29.6 MCHC-33.4 RDW-16.0* Plt Ct-202 [2161-4-14] 05:48PM BLOOD Hct-25.6* [2161-4-14] 07:13PM BLOOD WBC-16.6* RBC-2.47# Hgb-7.2# Hct-21.8* MCV-88 MCH-29.3 MCHC-33.3 RDW-16.2* Plt Ct-235 [2161-4-15] 07:30AM BLOOD WBC-12.9* RBC-3.60# Hgb-10.4# Hct-31.5# MCV-87 MCH-29.0 MCHC-33.1 RDW-15.9 Plt Ct-176 [2161-4-10] 09:08PM BLOOD PT-12.8 PTT-21.8* INR(PT)-1.1 [2161-4-12] 11:43AM BLOOD Ret Man-4.0* [2161-4-12] 03:04AM BLOOD Glucose-140* UreaN-61* Creat-1.9* Na-133 K-4.5 Cl-100 HCO3-25 AnGap-13 [2161-4-15] 07:30AM BLOOD Glucose-173* UreaN-87* Creat-1.4* Na-138 K-4.6 Cl-106 HCO3-24 AnGap-13 [2161-4-10] 10:40AM BLOOD LD(LDH)-190 CK(CPK)-43 TotBili-0.2 [2161-4-11] 11:48AM BLOOD CK(CPK)-55 [2161-4-12] 11:43AM BLOOD CK(CPK)-164 [2161-4-13] 06:09AM BLOOD CK(CPK)-238* [2161-4-13] 07:10PM BLOOD CK(CPK)-124 [2161-4-14] 05:50AM BLOOD CK(CPK)-130 [2161-4-15] 07:30AM BLOOD LD(LDH)-287* CK(CPK)-99 [2161-4-10] 10:40AM BLOOD CK-MB-4 cTropnT-0.02* [2161-4-11] 11:48AM BLOOD CK-MB-3 cTropnT-<0.01 [2161-4-12] 11:43AM BLOOD CK-MB-12* MB Indx-7.3* cTropnT-0.21* [2161-4-13] 06:09AM BLOOD CK-MB-45* MB Indx-18.9* cTropnT-0.71* [2161-4-13] 07:10PM BLOOD CK-MB-19* MB Indx-15.3* cTropnT-0.48* [2161-4-14] 05:50AM BLOOD CK-MB-14* MB Indx-10.8* cTropnT-0.47* [2161-4-15] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.85* [2161-4-10] 10:40AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.9* [2161-4-15] 07:30AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.3 [2161-4-10] 10:40AM BLOOD Hapto-352* CXR [4-10]: IMPRESSION: No radiographic evidence for pneumonia CT Chest [4-13]: IMPRESSION: 1. New peripheral consolidation within the right upper lobe and adjacent ground glass opacity, concerning for infection. While a bacterial etiology is most likely, fungal infection should be considered depending upon the degree of immune suppression. Post- radiation changes is considered less likely, but correlation with site of radiation port is recommended. Radiation pneumonitis may explain more geographically marginated areas of ground glass attenuation separate from the new area of consolidation. 2. Mild increase in mass-like region of consolidation in the superior segment of the right lower lobe, which may represent indolent infection, organizing pneumonia, or atypical radiation fibrosis. 3. Increased right hilar adenopathy and peribronchial thickening. This is concerning for central tumor encasement and likely lymphangitic spread along bronchovascular bundles. 4. New osseous and soft tissue lesions consistent with progressive metastatic disease. U/S Lower Extremity [4-13]: IMPRESSION: 1. No evidence of DVT in either lower extremity. 2. Two hypoechoic solid structures in the soft tissues of the right calf and medial to the left knee are of uncertain etiology, but may be related to prior vein harvesting. Clinical correlation is recommended. ECG [4-12]: Resting sinus tachycardia. Probable prior inferior wall myocardial infarction. Left atrial abnormality. Slow R wave progression. Cannot exclude prior anteroseptal myocardial infarction. Non-specific ST-T wave changes. Low limb lead voltage. Compared to the previous tracing of [2161-4-10] heart rate is faster. R wave progression is slower. Clinical correlation is suggested ECG [4-13]: Sinus tachycardia Inferior infarct - age undetermined Poor R wave progression Nonspecific T wave changes Low limb lead voltages Since previous tracing of [2161-4-12], T wave flattening noted ECG [4-15]: Possible atrial flutter with 2:1 block Nonspecific ST-T wave changes Low QRS voltages in limb leads Since previous tracing of the same date, atrial flutter, ST changes more pronounced Brief Hospital Course: A/P: This is a 60 year old man with metastatic NSCLC, COPD, and CHF, here with worsening dyspnea. # NSCLC: Mr. [Known lastname 38840] had a second acute HCT drop on [4-14]. The decision by HCP [Name (NI) 25294] was to transfuse 2uPRBC's on [4-14] and that this would be the last attempt at medical intervention for [Known firstname ]. [Known firstname 2979] heart rates became elevated to the 160s overnight on [4-14]. The concern was that with his recent NSTEMI, his heart was now decompensating. ECG showed likely atrial flutter. The overall picture did not look well and this information was relayed to the family in antother meeting on [4-15]. The decision by HCP [Name (NI) 25294] and family was to transition to comfort care. [Known firstname ] was then placed on a Morphine drip and he passed away peacefully at 630am on [2161-4-16] with his family at his side. # NSTEMI: Patient had an NSTEMI during this hospitalization. He expired as above. # Anemia: Mr. [Known lastname 38840] presented with an acute HCT drop to 15 on admission. He was transfused with 4uPRBC and transferred to the Medical ICU. He stabilized and was then transferred to the medical floor. He had a second HCT drop as above. He expired on [2161-4-16]. Medications on Admission: Meds at Home: Levaquin 500 mg once a day for 7 days. Oxycontin 10 mg Q12H Pantoprazole 40 mg Q24H Pravastatin 20 mg DAILY Trimethoprim-Sulfamethoxazole 160-800 mg 3X/WEEK (MO,WE,FR). Tamsulosin 0.8 mg HS Tiotropium Bromide 18 mcg Capsule Inhalation DAILY Oxycodone 2.5-5 mg Q4H as needed Lorazepam 1 mg [Hospital1 ] Olanzapine 10 mg QAM Olanzapine 20 mg HS Fluticasone-Salmeterol 250-50 mcg [Hospital1 ] Mucinex 600 mg twice a day Levothyroxine 25 mcg DAILY Tobramycin 300 mg/5 mL Solution 1 Inhalation [Hospital1 ] Aspirin 81 mg DAILY Diltiazem HCl 480 mg DAILY Fluphenazine HCl 10 mg QAM Fluphenazine HCl 15 mg QHS Prednisone 20 mg DAILY Insulin Lispro 100 unit/mL Solution Senna 8.6 mg 1-2 Tablets PO BID prn constipation Docusate Sodium 100 mg three times a day Tarceva 150 mg once a day Lactulose 10 gram/15 mL prn constipation Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "198.5", "585.3", "276.1", "584.9", "276.52", "427.1", "250.80", "428.0", "482.1", "707.8", "403.90", "583.1", "410.71", "162.8", "428.22", "578.9", "295.32", "491.21", "285.22" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	9332, 9341	7139, 8437	306, 312	9392, 9401	2831, 7116	9457, 9467	2456, 2504				9362, 9371		8463, 9309			9425, 9434										2534, 2812																														245, 268																340, 1667																		1689, 2118	2134, 2440
13,978	125,581	5520	Discharge summary	report	Admission Date: [2186-1-28] Discharge Date: [2186-2-3] Service: ACOVE CHIEF COMPLAINT: Weakness. HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old gentleman with a history of coronary artery disease, status post coronary artery bypass graft on [2186-1-5] admitted to the Intensive Care Unit with an upper gastrointestinal bleed. On the day of admission, the patient felt weak. He denied any chest pain, any shortness of breath, or any palpitations. He fell to the floor. He denies any head trauma or loss of consciousness, and he was brought to the Emergency Department by the family. In the Emergency Department, guaiac was found to be positive, and hematocrit was 23.8 from 31 on [2186-1-20]. Nasogastric lavage was performed and had coffee-ground which did not clear after 2 liters of normal saline. Also in the Emergency Department, the patient was initially transfused with 1 unit of packed red blood cells, and he was administered intravenous fluids. He was then admitted to the Intensive Care Unit for endoscopy and further care. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2186-1-5]. 2. Upper gastrointestinal bleed in [7-/2183] with esophagitis and ulcer in the stomach and duodenum and H. pylori positive. 3. Benign prostatic hypertrophy. 4. Prostate cancer treated with watchful waiting. 5. Status post nephrectomy for renal cancer 40 years ago. 6. Ejection fraction is 40-45% measured before coronary artery bypass graft. MEDICATIONS: 1. Metoprolol 25 po bid. 2. Finasteride 5 mg po q day. 3. Atorvastatin 5 mg po q day. 4. Aspirin 325 mg po q day. 5. Hydrochlorothiazide 25 po q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He was born in [Country 532]. He moved to the US on [2112]. He is a retired rabbi. Smoked tobacco in the Army and quit many years ago. He denies any alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure was 112/46, pulse 87, oxygen saturation is 99% on room air. General appearance: Elderly man pale in no acute distress. HEENT: No jugular venous distention, dry mucous membranes. Lungs with decreased breath sounds in the right. Heart: Regular rate with normal S1, S2, no murmurs, rubs, or gallops and a well-healing sternotomy. Abdomen is soft, nontender, nondistended with decreased bowel sounds. Extremities: 2+ dorsalis pedis pulses bilaterally, no edema. Neurologic is alert and oriented times three. LABORATORIES ON ADMISSION: White blood cells was 7.2, hematocrit 23.8, then dropped to 20.3, MCV of 91. Coags: PTT 31, INR 1.2. Chem-7 was unremarkable except for a potassium of 5.4. Chest x-ray showed bilateral pleural effusions, small on the left side and large on the right side. Electrocardiogram showed sinus rhythm at 68, right axis, right bundle branch block, T-wave depression in leads II, III, aVF, and V2-V6, biphasic similar to the electrocardiogram performed on [2186-1-11]. BRIEF HOSPITAL COURSE: Mr. [Known lastname 22292] is an 82-year-old gentleman with a history of coronary artery disease status post recent coronary artery bypass graft presented with an upper gastrointestinal bleed. Upper gastrointestinal bleed: Mr. [Known lastname 22292] presented to the Emergency Department with a hematocrit of 23.8 from 31.1 on [1-20]. He was guaiac positive and nasogastric lavage showed coffee-grounds which did not clear after 2 liters of normal saline. The patient was admitted to the Intensive Care Unit. He was transfused 4 units of packed red blood cells. An EGD was performed which showed ulcers in the posterior bulb of the duodenum, one of which was actively bleeding and was electrocauterized with successful hemostasis. There was also a single nonbleeding ulcer in the second part of the duodenum which was not treated at this time. His lowest blood pressure was 80/50. He had no chest pain, shortness of breath, or palpitations at this time. His hematocrit then increased to 28 and after that 31.8, and on the second day dropped once again to 26.4. An EGD was repeated which showed a single nonbleeding ulcer. The patient was once again transfused 2 units of packed red blood cells with his hematocrit increasing to 34. The rest of his hospital course was unremarkable. His hematocrit continued to increase spontaneously. The patient was advanced on clear diet and then regular diet without any problems. [Name (NI) ] was started on pantoprazole IV which was then weaned to pantoprazole 40 mg po bid and discharged on pantoprazole 40 mg po q day for eight weeks after which he should be getting omeprazole 20 mg po q day for life. Aspirin was held, and at the time of discharge, it is still held. The plan is for the patient to be started after two weeks. At this time, his discharge hematocrit was 36.6 2. Coronary artery disease: The patient is status post coronary artery bypass graft. His lowest pressure during the upper gastrointestinal bleed with 80/50 and never had any chest pain, shortness of breath, or palpitations. His electrocardiogram had no changes indicating ischemia. Metoprolol and aspirin were initially held because of the low blood pressure and the risk of bleeding. Metoprolol was restarted and his blood pressure improved. Myocardial infarction was ruled out by enzymes. Aspirin at the time of discharge is still held, and as discussed above, should not be restarted within the next two weeks. 3. Pulmonary effusion: The patient was found to have bilateral pleural effusions with the right larger than left. The pleural effusion was tapped and was found to be an exudate with many white blood cells, no organisms, and no PMNs on Gram stain. Cytology was negative for malignant cells. The pleural effusion had a large amount of eosinophils for which PE was considered a possible etiology because of the intermediate risk for PE for this patient who had recent surgery, patient initially underwent a VQ scan which was read as low probability. However, low probability VQ scan in the context of a moderate .................... 20% chance of missing a pulmonary embolus. It was therefore, felt that the patient could benefit from a CT angiogram. The patient initially received intravenous hydration because of his history of nephrectomy and Mucomyst in order to protect his single kidney as much as possible and then underwent a CT angiogram. The CT angiogram showed no pulmonary embolus, but revealed a sclerotic bone lesion at T12. A Pulmonary consult was called, and the pulmonologist felt that the pleural effusion even though had eosinophilia, was most consistent most likely with post-CABG pleural effusion. The patient was started on Lasix 20 mg po q day. It was felt that otherwise felt that since he is asymptomatic, he did not need any further treatment or workup. Plan is for the patient to get a chest x-ray to monitor the progression and hopefully the resolution of pleural effusion within one month, and in discussion with his primary care physician, [Name10 (NameIs) ] is to followup with Pulmonary Clinic here at [Hospital1 69]. 4. Sclerotic bone lesion: A sclerotic bone lesion at T12 was accidentally found on CT scan. Patient and his family were made aware of this finding and because of his history of prostate cancer, at this time, they were recommended to followup with his primary care physician. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Duodenal ulcer. 3. Coronary artery disease. 4. Pleural effusions. 5. Sclerotic bone lesion. 6. Other diagnoses he presented with. FOLLOW-UP PLAN: Referred the patient to followup with his primary care physician and the patient's primary care physician's discretion with the Pulmonary Clinic here and with a the [Hospital ] Clinic also here. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg po q24h for eight weeks after which he should be switched to omeprazole 20 mg po q day for life. 2. Furosemide 20 mg po q day. 3. Metoprolol 25 mg po bid. 4. Bupropion 75 mg po q day. 5. Atorvastatin 10 mg po q day. 6. Hydrochlorothiazide 25 po q day. 7. Finasteride 7 mg po q day. 8. Aspirin is to be held for the next two weeks after which it could be restarted. DISCHARGE STATUS: To home with physical therapy as recommended by the physical therapist, and will see the patient in house. DISCHARGE CONDITION: Good. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) 6071] MEDQUIST36 D: [2186-2-3] 10:16 T: [2186-2-3] 10:17 JOB#: [Job Number 22293]	[ "532.00", "733.90", "V15.82", "600.0", "V45.81", "511.9", "280.9", "V10.46", "414.01" ]	icd9cm	[ [ [] ] ]	[ "54.91", "96.07", "45.13", "44.43" ]	icd9pcs	[ [ [] ] ]		3016, 7431		8396, 8647				7452, 7836	7859, 8374																																															108, 119																148, 1079								2523, 2992										1101, 1737	1754, 2508
26,806	190,977	6136	Discharge summary	report	Admission Date: [2182-10-5] Discharge Date: [2182-10-31] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Hemotysis Major Surgical or Invasive Procedure: Bronchoscopy, [10-7] IR embolization, [10-8] LLL biopsy, [10-14] R thoracentesis, [10-18] bilateral thoracenteses, [10-25] History of Present Illness: Mr [Known lastname 23976] is an 87 year-old Jamaican male with history of mucinous breast cancer (s/p MRM in [2172] and tamoxifen therapy), hypertension, CHF and [Hospital 2182] transferred from an OSH for further evaluation of hemoptysis. The patient had a recent admission to the same OSH from [Date range (1) 23977] for increasing dyspnea and was treated for a CHF and COPD exacerbation, as well as a RLL PNA. The patient was discharged to home in stable condition on a course of Levaquin. On the following day, the patient re-presented with increasing dyspnea and several episodes of gross hemoptysis beginning on the day of discharge. He reported coughing up about 100-200cc of maroon blood. On presentation the patient complained of increased SOB and mild generalized fatigue. He denied frank fever, chills, HA, dizziness, LOC, or chest pain at that time. Admission imaging showed a CXR with a dense infiltrate in the LLL. CT scan reported bilateral patchy infiltrates with small bilateral blebs. Hemoptysis was thought to be secondary to pneumonia (possibly staph) and patient was treated with vancomycin and ceftriaxone. The patient was admitted to the ICU for further monitoring, where he continued to have persistent spoonfuls of gross hemoptysis. The patient subsequently had a bronchoscopy to identify a source of bleeding. Bronchoscopy showed a small amout of blood diffusely but no clear sourc of bleedinge. No frank endobronchial lesions in segmental and subsegmental divisions were identified. The patient tolerated procedure well, but continued to have significant hemoptysis. He was transferred to [Hospital1 18] for further management of hemoptysis and for possible invasive endoscopic therapy. . Upon admission the patient continued to c/o hemoptysis and SOB with minimal exertion (even walking to bathroom is difficult). Otherwise he feels well, denies F/C, weight loss, dizziness/light-headedness, CP/palp, abd pain, n/v/d, weakness/ numbness. He c/o recent fatigue over past few months, but notes that he was walking 3-4miles/day before these events occurred. Past Medical History: Left Mucinous Breast CA ?????? diagnosed in [2172], T2N0, s/p MRM and 5 years of tamoxifen treatment. No heme/onc follow-up. Chronic atrial fibrillation, refuses anticoagulation Congestive heart failure/ diastolic dysfunction COPD HTN BPH History of zoster Social History: Moved from [Country ] 10-15 years ago, last visit 7 years ago. Used to work in construction. Tobacco: smoked up to 2-3 packs per day x ~40years. Quit 25 years ago. Rare alcohol use Patient lives alone in a senior community. Very active, walks [2-17] miles per day. Patient??????s wife currently lives in [Name (NI) 108] Family History: mother with cancer Physical Exam: PHYSICAL EXAM: VS: 98.5 90/56 64 24 99%2L NC GENERAL: WN, WD elderly male sitting in bed in NAD, AAOx3 SKIN: no rashes, no lesions HEENT: NCAT, EOMI, PERRL, b/l cataracts, MMM, OP clear NECK: no LAD, 2+ carotid pulses b/l CHEST: tachypnea; very poor air movement b/l esp. at lung bases, moderate expiratory wheezes anteriorly, no rales. Sputum with nickel- to quarter-sized clots. HEART: irreg reg, I/VI SM LLSB ABDOMEN: +BS, soft, NT/ND, No organomegaly, No masses EXT: 2+ radial pulses b/l, barely palpable DP pulses, 2+ pitting edema to shins NEURO: CN II-XII intact, 2+ reflexes throughout Pertinent Results: LABS: [2182-10-6] 06:14AM BLOOD WBC-20.5# RBC-3.39 Hgb-10.9* Hct-33.3* MCV-98 MCH-32.3* MCHC-32.9 RDW-15.6* Plt Ct-208 [2182-10-6] 06:14AM BLOOD PT-14.2* PTT-30.1 INR(PT)-1.3* [2182-10-6] 06:14AM BLOOD Glucose-72 UreaN-24* Creat-1.1 Na-144 K-4.5 Cl-108 HCO3-26 AnGap-15 [2182-10-12] 09:00AM BLOOD ALT-22 AST-25 LD(LDH)-405* AlkPhos-76 TotBili-1.4 [2182-10-6] 06:14AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.4 [2182-10-8] 07:25AM BLOOD calTIBC-199* Ferritn-179 TRF-153* [2182-10-24] 06:14AM BLOOD VitB12-863 Folate-5.7 [2182-10-23] 08:53AM BLOOD ALT-37 AST-57* LD(LDH)-337* AlkPhos-184* TotBili-1.2 [2182-10-26] 04:59AM BLOOD ALT-42* AST-80* LD(LDH)-325* AlkPhos-203* TotBili-0.7 [2182-10-28] 06:19AM BLOOD ALT-36 AST-60* LD(LDH)-291* AlkPhos-195* TotBili-0.9 [2182-10-28] 06:19AM BLOOD Albumin-2.4* [2182-10-28] 06:19AM BLOOD WBC-8.6 RBC-2.63* Hgb-8.3* Hct-26.7* MCV-101* MCH-31.6 MCHC-31.2 RDW-18.4* Plt Ct-518* [2182-10-20] 05:30AM BLOOD Glucose-110* UreaN-22* Creat-1.6* Na-141 K-4.9 Cl-105 HCO3-30 AnGap-11 [2182-10-28] 06:19AM BLOOD Glucose-88 UreaN-19 Creat-1.4* Na-143 K-4.4 Cl-108 HCO3-30 AnGap-9 . Imaging: [10-6] CT chest w/ contrast: IMPRESSION: 1. Nonoccluding pulmonary thrombosis, left descending pulmonary artery, may be due to vascular stasis from hilar infiltration rather than emboli; see 3. below. 2. Two lung masses at the lung bases are highly concerning for malignancy, especially metastases given the patient's history of breast cancer. 3. Diffuse bronchial wall thickening. More severe occlusive narrowing and obliteration of the encased bronchial and arterial supply to the lingula and left lower lobe could be due to malignant infiltration of the hilus or inflammation such as fibrosing mediastinitis. 4. Bilateral lower lung lobe airspace consolidation could represent aspiration given its distribution, or postobstructive pneumonia. Bilateral, right greater than left pleural effusions, probably secondary. 5. Apical predominant emphysema. Fluid filled left perifissural bulla could be superinfected, not hemorrhagic. 6. Tiny round foci in the left kidney are too small to characterize but may represent small cysts. . [10-6] Echo: The left atrium is moderately dilated. No thrombus/mass is seen in the body of the left atrium. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is mild global right ventricular free wall hypokinesis. There is abnormal septal motion/position. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-18]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: No intracardiac mass/thrombus seen. . [10-7] B/l LE Doppler US: IMPRESSION: No evidence of deep vein thrombosis in either leg. . [10-11] CT chest w/ contrast: IMPRESSION: 1. Worsening lower lobe consolidation with mass-like and lobular components, accompanied by extensive bronchovascular bundle thickening, bronchial narrowing and arterial narrowing, left greater than right. Given the immune- suppressed status of the patient following chemotherapy, atypical organism should be considered including fungal organisms (Aspergillus and mucormycosis), although the appearance is not specific for a particular organism. 2. Slight reduction in size and decrease in the fluid level within large bullae or pneumatocele within left lower lobe, likely due to hemorrhage or infection. New pneumatocele in right lower lobe with fluid/hemorrhage and debris. 3. Left lower lobe pulmonary artery thrombus no longer visualized, but marked narrowing of lower lobe arteries is present, and may be due to adjacent compression by perihilar soft tissue that may be neoplastic, infectious, or fibrotic. 4. Enlarging moderate right and small left pleural effusion. 5. Increasing anasarca. . [2182-10-24] CT chest w/ contrast: IMPRESSION: 1. Overall increase in bilateral pleural effusion with increased fluid component in the cystic structures bilaterally suggesting their relation to the major fissures. 2. Slight improvement in the left lower lobe consolidations with no significant change on the right. 3. Worsening of generalized anasarca. . [10-28] RUE US: IMPRESSION: 1. Nonocclusive thrombus in the right subclavian and axillary veins. 2. Mild soft tissue edema. . [10-31] TTE: The left and right atria are moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is mildly elevatedl. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Trivial pericardial effusion. Symmetric biventricular hypertrophy with low-normal systolic function. Mild mitral regurgitation. Mild pulmonary hypertenion. . Compared with the prior study (images reviewed) of [2182-10-7], pleural effusion has redeveloped. Cardiac findings are similar. . [10-31] CXR (AP port): (preliminary read) UPRIGHT PORTABLE CHEST X-RAY: The patient is status post removal of the right pleural drain and a right PICC. Since four days prior, there is now re-accumulation of a large left pleural effusion. The left cyst appears smaller but this may be due to patient positioning. Small right pleural effusions is present and the left basilar cyst is now fluid-filled. The upper lungs are clear with no pneumothorax. Although the left heart border is obscured by pleural effusion, the heart size is enlarged and likely unchanged. . Procedures: [10-7] IP Bronchoscopy: bleeding source in LLL but no clear causative lesions noted. . [10-8] Pulmonary Artery Embolization: IMPRESSION: 1. Aortogram demonstrated no definite branches supplying the left lower lobe of the lung. 2. Multiple attempts in order to catheterize the left bronchial artery were made unsuccessfully. 3. No collateral supply to the left lower lobe of the lung seen arising from the intercostal arteries or from the right bronchial artery. . Micro/Labs: [10-6] sputum cx: MODERATE OP FLORA [10-6] BCx: neg. AFB neg. x 3 ([10-6], [10-7] x 2, [10-8]), cx pending [10-7] BAL: fungal cx ASPERGILLUS FUMIGATUS, viral cx HERPES SIMPLEX VIRUS TYPE 1 CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY. OP flora, AFB neg, legionella neg, PCP [Name Initial (PRE) ] [10-11]: [Doctor First Name ] neg, CA 27.29 18 (neg); ANCA neg [10-12]: B glucan neg, histoplasmosis antigen neg [10-12]: hcG <5, AFP 2.7, LDH 405 [10-12] fungal cx (sputum): [12-18] aspergillus fumigatis [10-12] BCx: neg. x 2 [10-14] LLL biopsy: POSSIBLE ASPERGILLUS. - G stain: no org, cx neg, no growth - Viral cx neg to date - Fungal cx neg [10-16] galactomannan pending [10-18] pleural fluid: - HSV PCR neg for 1 and 2 - G stain: no polys, no mircoorg, no growth - fungal cx pending - AFB: smear neg, cx pending - viral cx neg [10-19] galactomannan neg. 11/9 L thoracentesis: - G stain: 2+ PMLs, no microorg, cx neg - fungal cx: neg - AFB neg, cx pending [10-25] R thoracentesis: - G stain: 1+ PMLs, no microorg, cx neg - fungal cx: neg - AFB neg, cx pending . [10-14] LLL biopsy: cytology negative for malignant cells Pathology of Lung, left lower lobe, needle core biopsy: Fibrosis, reactive type II pneumocyte hypertrophy, red cell extravasation, hemosiderin deposition, and fibrinous exudate, suggesting organizing pneumonia. No carcinoma seen in this sample. Note: No fungi or bacteria are identified in GMS and Brown-Brenn stained sections. Immunohistochemical stains show cells lining fibrous septae to be positive for cytokeratin MNF116 and negative for calretinin and D2-40, consistent with type II pneumocytes. No keratin-positive cells are present within the fibrinous exudate. . Brief Hospital Course: 87 year-old male w/ history of L breast cancer, COPD, chronic afib, presenting with hemoptysis. Upon admission to [Hospital1 18], the patient was continued on antibiotics and bronchodilators. Admission CT scan showed emphysema with large bullae, small subsegmental PE in LLL, two lesions in LLL suspicious for malignancy, and bibasilar honeycombing (?UIP). The pulmonary service was consulted, and suggested IP bronchoscopy that showed bleeding source to be LLL but no clear causative lesions noted. Bronchial artery embolization was performed on [10-8] and was unsuccessful as no definite arteries to LLL could be identified. In PACU post-proceudre the patient demonstrated increased work of breathing and increased O2 requirement (50% facemask to maintain O2sat > 90%). He was transferred to MICU where he responded to treatment with Lasix diuresis, nebulizers, and IV antibiotics (changed vanc/ ceftriaxone to vanc/ zosyn on [10-8]) for ?PNA and superinfected bulla. He was transferred to the floor in stable condition with O2 sat 99% on 2L NC. . Remainder of hospital course is by problem: # ID: The patient initially presented with labs significant for a leukocytosis to 20 without evidence of fever during admission. The patient presented with evidence of retrocardiac effusions with a possible suprainfected bullae in the LLL. Admission sputum cultures were negative (OP flora), but the patient was continued on vancomycin and zosyn, as above. TB was ruled out with negative AFBs x 3. On [10-11] a repeat CT scan was performed to assess for efficacy of antibiotics. CT showed improvement in LLL cyst with AF level; however interval development of RLL cystic structure with AF level. Septic emboli was felt to be an unlikely etiology, as [10-6] Echo was negative for valvular vegitations. On [10-12] BAL cultures returned as positive for aspergillus fumigatus (sparse growth) HSV-1 (by fluorescent antibody testing) and the patient was started on voriconazole and acyclovir. Zosyn was switched to cefepime so as to not cause false positive results in galactomannan testing. Galactomannan, B-glucan, and histoplasma Ag were sent and returned negative. Fungal sputum cultures were also sent, which returned positive for aspergillus fumigatus in [12-18] samples. HIV Ab testing was also performed, which was negative. On [10-14] a biopsy of the LLL mass was performed by IR in order to further evaluate etiology of symptoms and progression on imaging. Biopsy occurred without complication. Results from this showed cultures consistent with aspergillus, as well. Aspergillus fumigatus was thought to possibly be a contaminent as amount of growth was sparse in all cultures and the fact that presentation and imaging was not consistent with classic picture; however, the family adamantly refused VATS to obtain tissue diagnosis of masses. On [10-18] the patient underwent a right-sided thoracentesis in which 1.3L were removed to attempt to obtain further tissue diagnosis/ culture data with negative results. On [10-25] bilateral thoracenteses were performed to alleviate dyspnea, also with negative culture results at time of discharge. A catheter was left in the R pleural space for an anticipated cyst FNA, but the patient's family declined this. The catheter was removed on [10-31] with no evidence of pneumothorax on CXR. Throughout the admission, the patient complained of dyspnea with minimal exertion, which only improved after bilateral thoracenteses on [10-25]. Lung exam showed minimal improvement on antimicrobial therapy, with significantly decreased breath sounds at lung bases bilaterally. Oxygen saturations have always been good, ranging 95-100% on 2L NC, weaned to room air after thoracenteses were performed. Leukocytosis resolved on antibiotic treatment alone. In consultation with Infectious Disease, the patient was treated with an empiric course of broad-spectrum antimicrobials. He completed a course of 14 days of acyclovir treatment for HSV-1 (completed [10-27]), 30 days of voriconazole for aspergillus, and augmentin (switched from cefepime on [10-21], last day of treatment [10-31]). The patient is to follow up with infectious disease and pulmonary as needed. . # Lung masses: The patient was found to have bilateral lung masses on admission CT concerning for malignancy given patient's previous history of breast cancer and significant smoking history. Bronchial brushings from [10-7] BAL were negative for malignant cells. hcG and AFP were negative with elevated LD, which were interpreted as negative for embryonic tumor. Pathology from CT-guided LLL mass biopsy on [10-14] was negative for malignancy. CA 27.29 levels were sent to evaluate for possible breast cancer. These levels were followed yearly between [2174]-[2177] with results always within normal range, and were again normal upon repeat. CEA was also WNL. [Doctor First Name ] and ANCA levels were sent given concern for hemoptysis and findings of bronchial inflammation on admission CT; results were negative, making vasculitis unlikely. The Hematology/Oncology service was consulted, and they suggested CT abd/ pelvis in future for further assessment of possible metastases. The patient may need outpatient oncologist upon discharge. He may f/u with Dr. [First Name (STitle) ] here (previous oncologist for breast ca, [Name (NI) 653] with patient's info) versus an oncologist in [Hospital1 ] where he receives his care. . # ARF on CRF: The patient's creatinine remained stable within his baseline of 1.2-1.3 for most of his hospitalization. However, the patient's creatinine began to increase after thoracentesis (1.3L removed) and restarting diuretics [10-19]. ARF was felt to be secondary to intravascular depletion given volume losses, as above, and third spacing of fluid given low albumin. LE edema was worsening on exam, yet adequate hydration was needed given administration of acyclovir. Diuretics were initially held in attempt to maintain intravascular volume status, but were later re-introduced as BP allowed. Creatinine upon discharge was stable at 1.4. . # Anasarca: During admission the patient developed anasarca, likely secondary to low albumin from malnutrition. He also developed bilateral pleural effusions, which were improved with thoracenteses, as above. The R pleural catheter was left in place from [10-25] - [10-31] with continued serous drainage. During this time the patient complained of pleuritic chest pain on the right. Serial EKGs were performed and showed lower voltage than on admission. On [10-31] a TTE showed large pleural effusions and trivial pericardial effusion. . # Hemoptysis/anemia - history as above. The patient showed resolving symptoms throughout his hospital course. He had decreasing nickel to dime-sized clots being expectorated by the time of discharge. Hct upon discharge was stable at 25; however, this had been slowly declining throughout his hospitalization most likely secondary to slow ooze of blood. . # Pulmonary thrombosis: The patient was diagnosed with a nonobstructing thrombus in L descending pulmonary artery upon admission, which was not treated with anticoagulation given symptoms of hemoptysis. LENIS were negative, indicating that there was no need for IVC filter. TTE was performed, which showed no intracardiac clot. There was no pulmonary thrombus present on repeat imaging on [10-11]. . # CVS: The patient has a history of diastolic CHF with preserved EF of 50-55% on [10-6] Echo. The patient had recent PMIBI at OSH which was negative. The patient was continued on lopressor for CAD and rate control. ASA was held given hemoptysis and can be re-started upon resolution of hemoptysis. He had increasing peripheral edema on exam in response to holding diuretics to maintain adequate hydration for IV acyclovir. He was given [Male First Name (un) ] stockings during admission, and diuretics were restarted with mild decrease in dependent edema. . # BPH: The patient was continued on his home dose of terazosin. A foley catheter was placed during admission due to concern for obstruction, but was removed prior to admission. . # Access: A PICC line was placed in the RUE for access; however on [10-28] the arm was noted to be erythematous and swollen. A RUE US was performed and showed evidence of a non-occlusive thrombus in the right subclavian and axillary veins. The PICC line was pulled without any anti-coagulation given presentation of hemoptysis and risk for further re-bleeding. The patient refused further IV access. . # Code: code status was confirmed with the patient and his family during admission and was determined to be FULL (but no prolonged resuscitation). . The patient was discharged to rehab on [2182-10-31] in fair condition. Workup has been negative and the patient continues to decline despite broad-spectrum treatment for possible infectious etiologies. The patient's family refused any further diagnostic testing at this time, including aspiration of cyst fluid, and opted for discharge with Infectious Disease and Pulmonology follow-up. Medications on Admission: lopressor 25 [Hospital1 ] Protonix 40 promethazine w/ codeine 5ml q6h terazosin 2mg qhs mg-hydroxide qd albuterol fluticasone prednisone 20 daily on taper ceftriaxone 1g daily [10-2] vancomycin 1g daily [10-2] . Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Primary: pneumonia . Secondary: history of left Mucinous Breast CA Chronic atrial fibrillation Congestive heart failure/ diastolic dysfunction chronic obstuctive pulmonary disease hypertension benign prostatic hypertrophy Discharge Condition: stable, afebrile, VSS, tolerating po well, ambulating with assistance Discharge Instructions: You were admitted with symptoms of coughing up blood, and after extensive workup no definite cause of this was found. It appears that you have a pneumonia, and you have been given broad-spectrum antibiotics for this. You must finish augmentin and voriconazole as prescribed. Please have your labwork checked weekly to measure your liver function tests. Results should be faxed to your PCP @ [Telephone/Fax (1) 23978] or the [Hospital ] clinic @ [Telephone/Fax (1) 23979]. . Please take your medications as prescribed. Please attend all of your follow-up appointments. . If you should experience any fevers > 101, chills, light-headedness, chest pains, worsening of shortness of breath, increased blood in your sputum, abdominal pain, progressive fatigue, or any other concerning symptoms please contact your primary care physician or come to the emergency room for further evaluation. Followup Instructions: Please follow-up with your primary care physician [Name Initial (PRE) 176] 1 week of discharge. Please call for an appointment @ [Telephone/Fax (1) 4475]. . Please follow-up with other physicians, as below: - You may follow-up in [Hospital ] clinic when needed as determined by your PCP. [Name10 (NameIs) 357] call for an appointment @ [Telephone/Fax (1) 457]. - Please follow-up with the pulmonology clinic as follows: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2182-11-25] 3:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2182-11-25] 4:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2182-11-25] 4:00	[ "496", "786.3", "585.9", "997.79", "486", "428.0", "428.30", "600.00", "999.31", "427.31", "511.9", "453.8", "584.9", "403.90" ]	icd9cm	[ [ [] ] ]	[ "38.93", "33.24", "34.04", "34.91", "33.26", "88.49" ]	icd9pcs	[ [ [] ] ]	22239, 22309	12796, 21964	272, 417	22575, 22647	3853, 12773	23592, 24467	3200, 3220				22330, 22554		21990, 22216			22671, 23569										3250, 3834																														223, 234																445, 2549																		2571, 2834	2850, 3184
26,668	126,775	8590	Discharge summary	report	Admission Date: [2122-4-23] Discharge Date: [2122-6-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2159] Chief Complaint: Elective admission for kidney biopsy and radiofrequency ablation Major Surgical or Invasive Procedure: Kidney biopsy Radiofrequency ablation History of Present Illness: 83 F with a history of dilated cardiomyopathy (EF 15%), dementia, CAD, and PAF recently admitted in [2121-12-28] for pneumonia, and incidentally found to have 4cm L kidney mass concerning for RCC. Patient is here for biopsy and radiofrequency ablation of L kidney mass. . She tolerated the procedure without any immediate periprocedural complications and estimated blood loss during the procedure was minimal. However, in the PACU, she continued to be lethargic and was admitted to medical team. Past Medical History: 1) Dilated CM, EF 15% on [1-2] TTE 2) HTN 3) L kidney mass highly suspicious for RCC 4)Paroxysmal afib 5) Mod to severe MR 6) h/o PNA [1-2] 7). h/o CVA '[02] with residual R weakness 8) Early dementia 9) Transaminitis 10) benign tremor previously misdiagnosed as Parkinsons 11) Ovarian cysts 12) Uterine fibroids, s/p TAH P-MIBI [2122-4-2] fixed small moderate defect distal LAD, fixed medium severe defect PDA territory, increased LV size, EF 45%, inf AK, mild apical HK Echo [1-2]: mild concentric LVH, mild LV dilation, EF 15%, severe global HK Social History: originally from [Country 27587], now lives with son [Name (NI) ]. Denies tob, EtOH. Very limited English Family History: n/c Physical Exam: VS: T: 98.4F (Tm 98.7F) BP: 130/77 (106-144/49-84). HR: 83-101, AFib, RR 16-23, SaO2: 95% RA Gen: Sleepy but arousable HEENT: PERRL, NGT in place CV: Irregularly irregular, no m/r/g Pulm: CTAB, no w/r/r Abd: Soft, NT/ND, +BS all 4 quadrants Ext: No LE edema Neuro: L facial droop, L pronator drift, withdrawing all 4 limbs to noxious stimuli, DTRs 2+ throughout, no clonus. Upgoing toes bilaterally. Pertinent Results: [4-25] Noncontrast Head CT: CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage, hydrocephalus or shift of normally midline structures. When compared to the previous exam, there is an area of hypoattenuation involving the right basal ganglia, which is new concerning for subacute infarction. There is a moderate amount of periventricular white matter hypoattenuation, predominantly seen in the frontal lobes, which appears stable when compared to the previous exam. No new areas of hypoattenuation are seen. Extensive atherosclerotic calcifications are seen within the cavernous portion of the internal carotid arteries bilaterally. There is opacification of the left sphenoid sinus, which is unchanged when compared to the previous exam. The paranasal sinuses are otherwise well aerated. IMPRESSION: New area of hypoattenuation involving the right basal ganglia compared to the previous examination, concerning for acute infarct infarction. MRI with diffusion would help for further evaluation. . [4-25] Brain MRI/A: FINDINGS: BRAIN MRI: The diffusion images demonstrate an area of slow diffusion in the right subinsular region and in the right frontal lobe extending to the corona radiata indicative of an acute right partial middle cerebral artery territorial infarct. There are areas of chronic blood products seen in both cerebral hemispheres including right basal ganglia which are unchanged from previous study. Moderate diffuse periventricular hyperintensities are seen indicative of small vessel disease. There is no midline shift or hydrocephalus seen. IMPRESSION: Acute partial right MCA infarct involving the right frontal lobe and subcortical region. Chronic blood products in both cerebral hemispheres could be due to previous trauma, ischemia or amyloid angiopathy. MRA OF THE HEAD: The head MRA demonstrates tortuous intracranial arteries. Distal right vertebral artery is not visualized which could be secondary to congenitally small vertebral artery. Both middle cerebral arteries demonstrate normal flow signal in the M1 segment with diminished flow signal in the sylvian branches which could be technical in nature. No definite occlusion of the MCA trunk is visualized. IMPRESSION: No evidence of occlusion of the main MCA trunk is identified. Diminished flow signal is seen in sylvian branches of both middle cerebral artery which could be technical in nature. Tortuous intracranial arteries could indicate atherosclerotic disease. . [4-26] CT HEAD WITHOUT IV CONTRAST: There are new, small areas of hyperattenuation in the region of the right basal ganglia compatible with hemorrhage. Surrounding low-attenuation region involving the right basal ganglia, subinsular region and right frontal lobe appears larger and more well- defined when compared to the previous exam. This is consistent with evolution of the partial right middle cerebral artery infarct, demonstrated on the DWI study. No extension of infarction is identified. There is no significant mass effect, hydrocephalus, or shift of normally midline structures. Moderate amount of periventricular white matter hypoattenuation is stable. Also noted is apparent ectasia of the left vertebral and basilar arteries, and extensive intracranial vascular calcification. IMPRESSION: 1. New areas of hyperattenuation within the region of the right basal ganglia concerning for small ("petechial") hemorrhagic conversion in the region of infarction. There is no significant mass effect or midline shift. 2. Findings represent evolution of partial right middle cerebral artery infarction. . [4-26] Abdomen/Pelvis CT: FINDINGS: Left lower lobe atelectasis and left pleural effusion is slightly larger than two days prior. There is also some right basilar atelectasis that is unchanged. Enlarged heart is stable. Liver is unchanged with likely a cyst in the right lobe. Large left retroperitoneal bleed is grossly unchanged from two days prior. No new areas of hemorrhage are identified. The pancreas, spleen, adrenals, right kidney, stomach, and bowel loops are unchanged. CT PELVIS WITH CONTRAST: The bladder and [Month/Year (2) 499] are unchanged. Uterus and adnexa are unchanged. Retroperitoneal bleed in the pelvis is grossly unchanged. BONE WINDOWS: The osseous structures are unchanged. IMPRESSION: Stable appearance of the left retroperitoneal hemorrhage. . [4-27]: Carotid U/S: Duplex evaluation was performed of bilateral carotid arteries. There is no plaque noted in the carotid arteries bilaterally. On the right, peak velocities are 68, 67, and 73 cm per second in the ICA, CCA, and ECA respectively. This is consistent with no stenosis. On the left, peak velocities are 59, 81, and 59 cm per second in the ICA, CCA, and ECA respectively. This is consistent with no stenosis. There is antegrade vertebral artery flow bilaterally. IMPRESSION: Normal carotid study. . [6-2] TTE ECHO: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 4.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.56 Mitral Valve - E Wave Deceleration Time: 317 msec TR Gradient (+ RA = PASP): 31 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [2122-1-21]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Normal LV cavity size. Mild global LV hypokinesis. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Moderately dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: 1. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. 3. The ascending aorta is moderately dilated. 4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. Compared with the prior study (images reviewed) of [1-21]/200, LV function has significantly improved. . [4-24] WBC-6.1 Hct-31.1 MCV-86 Plt Ct-195 PT-13.8* PTT-24.5 INR(PT)-1.2* Glucose-76 UreaN-23 Creat-0.9 Na-142 K-4.1 Cl-105 HCO3-27 Albumin-3.3* Calcium-8.5 Phos-5.0* Mg-1.5* ALT-16 AST-34 LD(LDH)-242 AlkPhos-52 TotBili-0.8 URINE Color-B Appear-CLO Sp [Last Name (un) ]-1.030 Blood-LGE Nitrite-NEG Protein-500 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM RBC-427* WBC-51* Bacteri-MOD Yeast-NONE Epi-<1 . [4-26]: URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.025 Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD RBC-[11-16]* WBC-[3-1] Bacteri-MANY Yeast-NONE Epi-0-2 UCx: PROTEUS MIRABILIS. >100,000 ORGANISMS/ML, pansensitive . [2122-5-4]: URINE CULTURE (Final [2122-5-8]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 207-9197D [2122-5-5]. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. . [4-29] WBC-4.5 Hct-27.3 MCV-87 Plt Ct-175 Glucose-85 UreaN-26* Creat-0.7 Na-137 K-4.0 Cl-102 HCO3-26 Calcium-8.4 Phos-3.0 Mg-2.0 Iron-26* calTIBC-252* Ferritn-166* TRF-194* . Operative Report from Renal Biopsy: TECHNIQUE: Informed consent was obtained from the patient. Pre-procedure timeout was performed to confirm patient identity and indication for examination. Patient has already been examined and marked in the day surgical unit by the attending, Dr. [First Name (STitle) ]. The patient was brought to the CT suite and endotracheal anesthesia was induced. The patient was placed prone. After cleansing and draping in normal sterile fashion, under CT fluoroscopic guidance, 17-gauge outer needle was advanced into the tumor and three biopsies were obtained using an 18-gauge coaxial system. Samples were sent for histological analysis. Further samples were also sent for analysis as part of the renal SPORE project, to which the patient had given independent prior consent. . A cluster electrode was then inserted under CT fluoroscopic guidance and four applications of radiofrequency energy were applied to various parts of the renal tumor under CT fluoroscopic guidance. The energy was ramped to [2115] mA, and individual applications of 10 minutes, 6 minutes, 4 minutes and 2 minutes were applied. Continuous intraprocedural surveillance was performed using CT fluoroscopy. Early in the procedure, due to the close proximity of the adjacent splenic flexure and left [Last Name (LF) 499], [First Name3 (LF) ] 18-gauge [Last Name (un) 11097] catheter was inserted into the retroperitoneal paracolic space and hydrodissection was performed using a total of approximately 100 mL of 5% dextrose. After two applications of radiofrequency energy, an interval contrast-enhanced study was performed which showed 95% tumor necrosis with a clear apparent enhancing rim along the superolateral border of the neoplasm. After this, the cluster electrode was reinserted and further applications of energy were performed. A final unenhanced examination showed no overt evidence of residual tumor, but did reveal some post- ablative gas formation and post-hydrodissection perirenal fluid. The patient was monitored by anesthesiology throughout and remained asymptomatic. The attending, Dr. [First Name (STitle) ], was present and scrubbed throughout the procedure. No complications were apparent. . [4-27] Bedside Speech & Swallow Evaluation: HISTORY: 82 year old Bulgarian speaking woman admitted to [Hospital1 18] on [2122-4-23] with Dilated Cardiomyopathy. She had a biopsy of a L Kidney mass c/b retroperitoneal bleeding. She had a transfusion after dropping her HCT followed by a R CVA w/L weakness on [2122-4-25]. We were consulted to evaluate her oral and pharyngeal swallowing ability to r/o aspiration. . PMH notable for dementia, CAD, dilated cardiomyopathy, old CVA, PAF. She had a recent admission in [1-2] for pneumonia. According to the interpreter, her voice was even weaker during that admission. . EVALUATION: The examination was performed while the patient was seated upright in the bed with the help of the Bulgarian interpreter. Cognition, language, speech, voice: Voice was very high pitched and very weak / soft. According to the interpreter, she does not slur her speech, but she sometimes underarticulates and/or runs out of voice/sound when trying to talk. This makes her speech only about 60% intelligible. Teeth: Full set Secretions: Dry oral cavity . ORAL MOTOR EXAM: Lips with Left droop and some drooling from that side due to weak lip seal Tongue midline w/fair strength Palatal elevation reduced. No gag . SWALLOWING ASSESSMENT: PO assessment was conducted with ice chips, water via tsp & cup sip, nectar thick liquids via tsp and cup sip, custard and one bite of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] cracker. Swallows were delayed. Larngeal elevation felt adequate to palpation. There was a [Last Name (NamePattern4) ] after a cup sip of water, and after a cup sip of nectar following a bite of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] cracker. She continued to [Last Name (LF) ], [First Name3 (LF) ] I gave her one bite of puree and she clearly choked on the custard, spitting it out. She was then suctioned via yankauer. O2 sats remained above 91% the entire time. . SUMMARY / IMPRESSION: Aspiration was seen today at bedside with water, nectar thick liquids, a small bite of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] cracker and after a bite of custard. Therefore, she is not safe to take PO's at this time. She will need an NG tube for a few days and a repeat bedside swallowing evaluation with the Bulgarian interpreter on Thursday. . RECOMMENDATIONS: 1. Remain strictly NPO w/NG tube feeds for now 2. Repeat bedside swallowing evaluation is scheduled for 9:00 Thursday morning with the Bulgarian interpreter. If she passes the bedside, we can also perform a videoswallow next Thursday as well. 3. Suggest PT/OT evaluations These recommendations were shared with the patient, nurse and medical team. . [2122-6-12] CT head FINDINGS: The multiple prior lacunar infarcts, in bilateral cerebellar hemispheres and right frontal lobe, and the right basal ganglia and in right thalamus. There is diffuse low-density in the bilateral white matter, representing chronic microvascular disease. No shift of normally midline structures. There is no acute intracranial hemorrhage. The overall appearance of the brain is unchanged compared to the prior study. Basilar artery is tortuous and calcified. Internal carotid arteries are calcified as well. Soft tissue and osseous structures are unremarkable. . [2122-6-16] CT abdomen and pelvis: CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Views of the lower mediastinum and lung bases demonstrate a previously identified ascending aortic aneurysmal dilatation measuring 51 mm in AP diameter and 52 mm in right left diameter. The thoracic and abdominal aorta is ectatic. The lung parenchyma demonstrates mild bilateral dependent atelectasis. A few right lung blebs are present within the right lower lobe. There is stable cardiomegaly. The liver is unchanged with a small hypodensity within the right lobe likely representing a cyst. The gallbladder, pancreas, spleen, adrenal glands are unchanged and adrenal adenoma is again seen on the right. The right kidney is unremarkable. Again seen within the left kidney is a large exophytic renal lesion measuring 41 x 39 mm, unchanged compared to prior studies. There is interval improvemnet of stranding and hemorrhage. There is no evidence of retroperitoneal bleed. There are no pathologically enlarged nodes within the retroperitoneum or mesentery. The stomach, duodenum, small bowel, and large bowel are normal in caliber and unremarkable. There are multiple diverticuli within the sigmoid [Month/Day/Year 499]. There is ventral diastasis of the abdominal wall, grossly unchanged compared to prior study. CT PELVIS WITH IV CONTRAST: The urinary bladder, uterus, adnexa are within normal limits. The rectum is unremarkable. There are no pathologically enlarged nodes within the inguinal or iliac nodal chains. Aortic and iliac calcifications are noted. BONE WINDOWS: No suspicious lytic or sclerotic bony lesions. Difffusely osteopenic. IMPRESSION: 1) Large unchanged exophytic renal lesion demonstrating minimal enhancement status post RF ablation. Interval improvement of surrounding stranding. 2) No evidence of retroperitoneal bleed. 3) No evidence of residual soft tissue. . WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2122-6-26] 05:50AM 2.4* 3.64* 11.3* 32.9* 91 31.0 34.3 14.9 220 [2122-6-26] INR 2.3 Brief Hospital Course: Ms. [Known lastname 30132] is an 83yo Bulgarian speaking female with a h/o PAF and RCC who was admitted for radioablation and ended up with a retroperitoneal bleed and a subsequent stroke. She remained in house for rehabilitation secondary to insurance issues. She lives with her son who came to take her home and refused any VNA or assistance at home despite our repeated asking. . 1) Retroperitoneal bleed: The morning following admission, the patient was noted to have a drop in her hematocrit from 40 to 31.5; a repeat 6 hours later was 30.5. She was also noted to be hypotensive, with SBP in 90s; her blood pressure responded to 110s after 500mL NS. CT abdomen [4-23] showed moderate amount of left perirenal, retroperitoneal, and pelvic hemorrhage. Surgery evaluated pt, no operative intervention was required. Pt rec'd 2 units PRBC. Repeat CT [4-26] showed that RP bleed was stable. She subsequently remained hemodynamically stable and her hematocrits remained stable. Her anticoagulation was held for a week following this episode. Her antihypertensives were also held in setting of tenuous volume status 2/2 blood loss, but were restarted without complication on [4-27]. Coumadin and aspirin were restarted on [5-4]. A follow up CT on [6-16] showed resolution of the RP bleed. . 2) Stroke: Patient has a history of a CVA in [2102] with residual R-sided weakness. However, on HD #3, she was noted to have a new L sided facial droop. A head CT showed a new area of hypoattenuation involving the right basal ganglia, concerning for acute infarct. She was started on a heparin gtt, and antihypertesives held. A MRI/MRA showed acute partial right MCA infarct involving the right frontal lobe and subcortical region with pooled blood, with no evidence of occlusion of MCA trunk. Her heparin gtt was d/c'ed. She was seen by the stroke service, aspirin and coumadin held, and her neurologic exam followed closely. Surgical intervention was thought to not be necessary, as the hemorrhagic area was small. Carotid U/S demonstrated no stenosis, and a repeat head CT on [4-26] demonstrated new areas of hyperattenuation within the region of the right basal ganglia concerning for small petechial hemorrhagic conversion in the region of infarction, but no significant mass effect or midline shift. Aspirin and coumadin were resumed after one week, on [5-4]. A bedside S&S on [4-27] confirmed absence of gag reflex. Ms. [Known lastname 30132] was kept NPO, and an NGT placed for nutrition and medications. A follow up S&S study demonstrated improvement, and she was started on ground solids and thickened liquids with aspiration precautions. She was discharged with a a followup appointment with Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] in neurology on [2122-7-23] at 2pm. . 3) Renal mass: Pathology consistent with renal cell carcinoma, probably chromophobe type. Dr. [Last Name (STitle) ] in oncology was consulted, who recommended outpatient oncology follow-up 2-3 months after discharge. There was thought to be no role for adjuvant therapy. DR. [First Name (STitle) ] in Radiology confirmed the radioablation was successful and said that the NP will arrange for a follow up MRI. . 4) Respiratory difficulties: After her stroke, Ms. [Known lastname 30132] had a transient O2 requirement, and experienced several episodes of desaturations to the 70s while sitting in a chair. She remained asymptomatic during these episodes, and they resolved spontaneously after lying back in bed. They were thought to represent a shunt physiology from atelectasis secondary to kyphosis and residual weakness post-stroke. A TTE with bubble study on [5-28] did not show any evidence of an anatomical shunt. She was encouraged to use an incentive spirometer, though this was difficult because of language barriers and poor motivation from significant depression. . 5) Afib: HR generally well-controlled while in-house. As above, restarted carvedilol 12.5mg PO bid when hct was stable. Due to transient hypotension, carvedilol dose was decreased to 6.25mg PO bid. Coumadin and aspirin restarted [5-4]. . 6) Hematuria: Pt also noted to have hematuria, rec'd bladder irrigation. Thought to be [1-29] RFA per urology. . 7) UTI: Found to have Proteus UTI on UA. Started Cipro 250mg PO bid for seven days. Switched to Levofloxacin when Ms. [Known lastname 30132] self-d/c'ed her NGT and did not with to have it replaced. After full 7-day course, repeat UA consistent with UTI, urine culture grew MRSA and ESBL Klebsiella. Placed on contact precautions, and completed a course of vancomycin and meropenem. . 8) CAD: Restarted carvedilol 6.25mg PO qD and lisinopril 5mg PO qD. Held ASA for 1 week post-stroke, restarted [5-4]. She occasionally experienced bradycardia during which her carvedilol was held temporarily. Her baseline heart rate was bradycardic in the upper 50's to the 60's. . 9) CHF: Appeared to be clinically euvolemic throughout her stay. Her home regimen of lasix and spironolactone was stopped during this hospitalization. Although her EF was documented as 15% in [2121-12-28], a TTE during this hospitalization showed recovery to >60%. . 10) Aortic aneurysm: Patient has known ascending aortic aneurysmal dilatation. This was stable on scans during this hospitalization, when compared to studies in [2121-12-28], measuring approximately ~5 cm in diameter. . 11) Dementia: Continued aricept. . 12) Depression: Ms. [Known lastname 30132] appeared to be depressed during her stay, and had little motivation to participate with PT or incentive spirometry. She was started on Remeron 7.5mg PO qHS, which was titrated to 15mg PO qHS, with little noticeable effect. This was tapered off and changed to Celexa for concern of causing leukopenia (WBC ~3). Her mood seemed to improve on Celexa 10mg PO daily. . 13) Prophylaxis: She was kept on SC heparin for DVT proph until her warfarin was back on to therapeutic levels. She was placed on a bowel regimen for constipation. SHe is on aspiration precautions and can only eat nector thick liquids and a pureed diet. She will follow up with speech and swallow as an out patient. The phone number is in the discharge paperwork as the clinic is currently close, no appointment was made today. Patient was discharged with a wheelchair to help with home care. Physical therapy has worked with Ms. [Known lastname 30132] throughout her stay and she has done very well with the wheelchair. She still requires help for all transfering. Son has refused any other home services. Medications on Admission: Meds on transfer: Acetaminophen 325-650 mg PO Q4-6H:PRN Ciprofloxacin HCl 500 mg PO Q12H (today: day [1-3]) Docusate Sodium 100 mg PO BID:PRN Donepezil 10 mg PO HS Heparin 5000 UNIT SC TID Senna 1 TAB PO BID:PRN . Meds from home: coumadin (was held since [4-17] pre-procedure) lasix 10mg daily lisinopril 10mg daily metoprolol 50mg tid spironolactone 25mg daily carvedilol 12.5mg [Hospital1 ] fosamax 70mg weekly Aricept 10mg daily calcium + vitamin D Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week. Disp:12 Tablet(s) Refills:2 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 11. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 12. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Disp:45 Tablet(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week: Take while sitting up and remain sitting for at least 30mins. Discharge Disposition: Home Discharge Diagnosis: Acute stroke Retroperitoneal bleed Renal cell carcinoma MRSA urinary tract infection Discharge Condition: Stable Discharge Instructions: You were admitted for a kidney biopsy and radiofrequency ablation. You experienced post-procedural bleeding, as well as an acute stroke. It is important to take all of your medicines as prescribed. . You will need to follow up with the [Hospital 197] clinic to have you coumadin (warfarin) dose checked and your INR level checked which determines your dose. Please see appointments for follow up. . You can not take in any thin liquids because you are aspirating them (swallowing wrong into your lungs). Please only eat thick liquids and nector thick liquids. You will follow up with speech and swallow in clinic to see if your swallowing has improved. Please follow up with all the appointments below for various specialities. . You should return to the ED for worsening abdominal or back pain, confusion, worsening weakness, numbness, or tingling in your arms or legs, headache, fever/chills, or for any other problems that concern you. Followup Instructions: 1) Follow up with Dr. [Last Name (STitle) 6812] ([Company 191] primary care). - Call [Telephone/Fax (1) 250] if you have questions or need to reschedule. You have the appointment with [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 279], RNC ([Company 191] primary care clinic) [2122-7-21] 6pm. . 2) Follow up with Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] (Neurology) [2122-7-23] at 2pm - Call [Telephone/Fax (1) 44] if you have questions or need to reschedule. . 3) Follow up with Dr. [Last Name (STitle) 770] (Urology) - Call ([Telephone/Fax (1) 772] if you have questions or need to reschedule. . 4) Please follow up with Dr. [Last Name (STitle) ] [Name (STitle) ], MD (behavior psychiatrist) Phone:[Telephone/Fax (1) 1690] [2122-7-27] 2pm . 5) Please follow up with Dr. [Last Name (STitle) ] (oncology) in [1-30] months. Phone: [Telephone/Fax (1) 17667] . 6) Please follow up with speech and swallow. Phone: [Telephone/Fax (1) 3731] . 7) [Hospital 197] clinic- please follow up for checking INR and coumadin (warfarin) dose. [Telephone/Fax (1) 2173] please call to make an appointment. Completed by:[2122-6-26]	[ "428.0", "189.0", "285.1", "294.8", "427.31", "997.02", "599.0", "599.7", "799.02", "458.29", "425.4", "998.11" ]	icd9cm	[ [ [] ] ]	[ "99.04", "00.33", "96.6", "55.39", "55.23" ]	icd9pcs	[ [ [] ] ]	26602, 26608	18070, 24700	327, 367	26737, 26746	2075, 2098	27740, 28986	1634, 1639		25215, 26579		26629, 26716		24726, 24726			26770, 27717										1654, 2056																														223, 289																395, 896				2107, 3889	3906, 18047													918, 1488	1504, 1618		24744, 25192
79,272	146,928	34975	Discharge summary	report	Admission Date: [2198-8-28] Discharge Date: [2198-9-5] Date of Birth: [2156-12-3] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 4691] Chief Complaint: s/p Pedestrian struck by auto Major Surgical or Invasive Procedure: [2198-8-28] 1. Irrigation and debridement left iliac [Doctor First Name 362] open fracture down to and inclusive of bone. 2. Open reduction internal fixation left iliac [Doctor First Name 362] fracture with K-wires. History of Present Illness: 41 yo male pedestrian struck by SUV with head strike and no memory of the event (?LOC). He was transported to [Hospital1 18] for further care. Past Medical History: Anxiety Family History: Noncontributory Physical Exam: Upon admission: T:98.4 BP:129/76 HR:89 R26 O2Sats 99% on a 100%NRB mask Gen: WD/WN, multiple injuries with right chest tube, anxious with moderate pain other injuries. HEENT: Pupils:2.5-2.0 EOMs intact Neck: patient in a hard collar. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength bilat hand grip [4-2], bilat plantar flexion [4-2]. Motor exam limited by multiple injuries. Sensation: Intact to light touch. Pertinent Results: [2198-8-28] 07:30PM GLUCOSE-175* UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11 [2198-8-28] 07:30PM CALCIUM-7.2* PHOSPHATE-2.3* MAGNESIUM-1.5* [2198-8-28] 07:30PM WBC-12.0# RBC-3.41 HGB-12.0# HCT-31.9 MCV-94 MCH-35.1* MCHC-37.5* RDW-11.5 [2198-8-28] 07:30PM NEUTS-83* BANDS-8* LYMPHS-3* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2198-8-28] 07:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [2198-8-28] 07:30PM PT-13.2 PTT-23.2 INR(PT)-1.1 [2198-8-28] 05:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2198-8-28] 03:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT head [2198-8-28] IMPRESSION: Small foci of possible subarachnoid hemorrhage within the inferior medial right temporal lobe; continued follow up CT imaging is advised. Known left subgaleal hematoma. CT C-spine [2198-8-28] IMPRESSION: No evidence of acute fracture or malalignment. Arthrodesis involving the C7- T1 vertebral bodies as described above. CT Chest/Abd/Pelvis [2198-8-28] IMPRESSION: 1. Multiple right and left-sided rib fractures as described above, with right sided flail chest. Moderate right and small left pneumothoraces. Appropriately positioned right- sided chest tube. 2. Comminuted fractures involving the left iliac [Doctor First Name 362] and left scapula with associated soft tissue swelling and adjacent subcutaneous emphysema. 3. Hypoattenuating small hepatic lesions, too small to definitively characterize but likely benign cysts. No evidence of solid organ traumatic injury. Shoulder xrays [2198-8-28] IMPRESSION: 1. Fractured scapula. There is likely extension to involve the glenoid fossa. 2. Minimally displaced fractures involving the lateral aspects of the left fourth and fifth ribs. Cardiology Report ECG Study Date of [2198-8-30] 8:23:34 PM Sinus tachycardia. Non-specific inferolateral T wave flattening. Compared to the previous tracing of [2198-8-28] sinus tachycardia and T wave flattening are new. Intervals Axes Rate PR QRS QT/QTc P QRS T 103 130 74 298/373 64 51 63 Brief Hospital Course: He was admitted the Trauma service. Neurosurgery and Orthopedics were consulted. He was taken to the Trauma ICU where his neurologic exam and serial head CT scans were followed and remained stable. He was started on Dilantin for seizure prophylaxis. He was taken to the operating room by Orthopedics for irrigation and debridement left iliac [Doctor First Name 362] open fracture down to and inclusive of bone and open reduction internal fixation left iliac [Doctor First Name 362] fracture with K-wires. There were no intraoperative complications. His scapula fracture was managed non operatively. Postoperatively he was taken back to the Trauma ICU where he remained for several days. He was later transferred to the regular nursing unit where he continued to progress. He did have pain control issues; the Acute Pain Service was consulted for epidural analgesia. An epidural catheter was placed and remained in for a couple of days and he was then changed to a long acting narcotic with shorter acting medications for breakthrough pain. For DVT prophylaxis he was started on Mini-Coumadin and will remain on this until fully ambulatory. Physical therapy evaluation was done and worked with him on a regular basis; he made significant gains and was cleared for discharge to home. Follow up instructions were provided to patient. Medications on Admission: Denies 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. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:1 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p Pedestrian struck by auto Injuries: 1. Right and Left pneumothorax with chest tube on right. 2. Comminuted left scapular fx. 3. Comminuted left iliac [Doctor First Name 362] fx - possibly open. 4. Small right subarachnoid hemorrhage 5. Laceration and subgaleal hematoma on left 6. Right rib fractures [3-9] 7. Left rib fractures [3-5] Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: DO NOT bear any weight on your left arm. Wear the sling for comfort. Perform pin care as directed daily. Take the low dose Coumadin "Mini-Coumadin" (which is a blood thinner use to prevent blood clots) every evening as prescribed until told to stop taking it by Dr. [Last Name (STitle) ], Trauma Surgery. It is important that you continue to cough, deep breathe, use the incentive spirometer at least every hour as instructed while you are at home. You should take short walks around the house or outside at least 3-4 times daily. Return to the emergecny room if you develop any fevers, chills, headache, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation and/or any other symptoms that are concerning to you. It is important that you take your medications as prescribed. Takethe stool softeners and laxatives while you are on narcotics for pain. Followup Instructions: Follow up in [Hospital 5498] clinic in 2 weeks, with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) ], Trauma Surgery in 2 weeks, call [Telephone/Fax (1) 6429] for an appointment. Inform the office that you will need achest xray for this appoinment. Follow up in 4 weeks with Neurosurgery in clinic for a repeat head CT scan; call [Telephone/Fax (1) 1669] for an appointment. Infrom the office that you will need the head CT scan without contrast arranged prior to this appointment. Completed by:[2198-10-9]	[ "807.4", "873.0", "808.51", "338.11", "305.00", "860.4", "E814.7", "852.00", "811.09" ]	icd9cm	[ [ [] ] ]	[ "03.90", "34.09", "79.39", "79.69" ]	icd9pcs	[ [ [] ] ]	6371, 6377	4259, 5603	310, 548	6773, 6853	1981, 4236	7808, 8453	773, 790		5660, 6348		6398, 6752		5629, 5637			6877, 7785										805, 807																														240, 272																576, 726	1288, 1962							821, 1087		1102, 1272								748, 757
77,383	185,889	39256	Discharge summary	report	Admission Date: [2147-6-22] Discharge Date: [2147-7-21] Date of Birth: [2102-5-28] Sex: F Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 943] Chief Complaint: Abdominal bruising Major Surgical or Invasive Procedure: None History of Present Illness: 45 YO F with alcoholic hepatitis and ETOH cirrhosis c/b ascites and ESRD (T/T/Sa) thought [2-14] ATN with multiple hospitalizations over the past several months for complications of alcoholic hepatitis now coming in for expanding abdominal hematoma and fatigue. The patient was last admitted from [Date range (1) 29429] for vomiting blood. She underwent a diagnostic para with a LLQ puncture site by IR on [6-16] to r/o SBP. She was discharged on [6-17] but returned to the ED on [6-19] for persistent bloody leakage from the para site and a small hematoma around it. Derma bond was placed on the site and the bleeding reportedly stopped so the patient was sent home. While at home, the patient had increasing fatigue and noted a spreading hematoma involving the right side of her abdomen and legs. Given worsening hematoma and fatigue such that she was not able to go to HD as scheduled, the patient presented to the ED. . Upon admission to the ED, her initial VS were: 98.4 123 126/54 26 100% RA. Exam was notable for a "well-appearing" female in NAD with a hematoma spreading along her anterior abdominal wall down to her lower extremities. She received 2u pRBCs and 2u FFP and 500ccs NS. She was not given platelets. BPs dropped to 70s systolic on one occasion with improvement by increasing her pRBC infusion rate. Two 18g IVs were placed for access. Transplant surgery was called and recommended transfusing and correcting coagulopathy. Surgery felt there was no indication for CT A/P so no imaging was done. The patient was admitted to medicine with surgery following with consideration of surgical procedure depending on ongoing clinical evaluation. Renal was also consulted to arrange scheduled HD. VS prior to transfer: 98.4 106 103/53 18 97% RA. Although not documented, the patient reports she had a rectal exam in the ED and was guiac negative. . Upon arrival to the floor, she reports feeling ok. She endorses recent orthostasis and fatigue along with some shortness of breath. She has some pain around her hematoma site. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits; she stools approx 4 times per day. No dysuria; she makes a small amount of urine. Denied arthralgias or myalgias. Past Medical History: alcoholic hepatitis in [5-/2147] - hospital course complicated by encephalopathy requiring intuabation for airway protection with likely ETOH cirrhosis; no varices on recent EGD [2147-5-16]; + ascites ESRD on dialysis TTSa at [Location (un) ] [Location (un) ] Alcoholism Pancreatitis DTs Depression (Admissions for SI attempts, atenolol OD [2-22]) Obsessive Compulsive Disorder h/o bariatric surgery in [2138] (Roux en Y) s/p CCY peripheral neuropathy s/p abdominoplasty s/p breast lift Social History: Single, 2 children, lives with boyfriend. Chronic alcoholism with recent history of 1.5 bottles of champagne/day but currently abstinent from EtOH (last drink [2147-4-13]); now involved in AA. Denies smoking or illicits. Family History: Mother and father both had alcoholism, atherosclerosis, and HTN. Mother had thrombotic CVA and lung cancer. Father had DM2. Physical Exam: ADMISSION PE: VS - [Age over 90 ] F, 107/78 BP , 103 HR , 20 R , O2-sat 99% RA GENERAL - well-appearing F in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, scleral icterus, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, 2/6 systolic flow murmur at LUSB, no rubs or gallops ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-17] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: [2147-6-22] 06:20PM PT-23.0* PTT-45.5* INR(PT)-2.2* [2147-6-22] 06:20PM PLT COUNT-113* [2147-6-22] 06:20PM NEUTS-73.8* LYMPHS-18.6 MONOS-4.8 EOS-2.5 BASOS-0.3 [2147-6-22] 06:20PM WBC-10.9 RBC-1.30# HGB-4.7# HCT-14.0# MCV-107 MCH-36.1* MCHC-33.7 RDW-22.0* [2147-6-22] 06:20PM LIPASE-16 [2147-6-22] 06:20PM ALT(SGPT)-24 AST(SGOT)-67* ALK PHOS-131* TOT BILI-10.9* [2147-6-22] 06:20PM GLUCOSE-137* UREA N-25* CREAT-5.0# SODIUM-127 POTASSIUM-3.4 CHLORIDE-89* TOTAL CO2-22 ANION GAP-19 Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 4.9 2.51* 8.0* 24.2* 97 31.8 33.0 21.5* 58* INR 2.1 UreaN Creat Na K Cl HCO3 AnGap 30* PND 136 3.6 97 29 14 ALT AST AlkPhos TotBili 20 40 93 15.5* Albumin Calcium Phos Mg 2.9* 8.8 4.0 2.1 [6-26] blood culture pending . . . . CT a/p: IMPRESSION: 1. New left anterior pelvic wall hematoma. Cannot assess for active extravasation without intravenous contrast. 2. Increased abdominal ascites. 3. Enlarging left pleural effusion. Bibasilar atelectasis or consolidation. 4. Mesenteric, subcutaneous, and bowel wall edema consistent with volume overload. . . Chest Xray: . . [2147-7-1]: -- FINDINGS: Bilateral asymmetrical airspace opacities involving the right lung to a greater degree than the left have worsened, and are concerning for multifocal pneumonia in the appropriate clinical setting. Asymmetrical pulmonary edema is less likely. Otherwise, unchanged appearance of the chest. . . [2147-6-30]: -- FINDINGS: Cardiac size is top normal. Right central catheter tip is in the right atrium. There is no pneumothorax. Diffuse right lung opacities and opacities in the left lower lung are new from [6-16] and partially visualized in the prior CT abdomen from [6-28] consistent with infectious process. . . ([2147-7-3]) Cardiac Echo: -- Normal left ventricular systolic and diastolic function. Mildly dilated right ventricle with normal systolic function. Mild to moderate detected pulmonary artery systolic hypertension. Brief Hospital Course: This is a very complex 45 YO F w alcoholic hepatitis and decompensated cirrhosis w ascites as well as ESRD on HD. She presented to [Hospital1 18] on [2147-6-22] with fatigue, expanding hematoma and approx 10 pt HCT drop following paracentesis. She eventually developed respiratory failure necessitating intubation and severe altered mental status. . . # Acute on Chronic Anemia. Chronic anemia likely [2-14] splenomegaly, ESRD, and possible bone marrow suppression. Acute anemia [2-14] acute blood loss from hematoma. The patient required multiple transfusions to resolve her acute anemia and correct her coagulopathy but remained HD stable and demonstrated return to baseline. The patient received approximately 20 u pRBCs, 18u FFP, 2 u cryo, and 12 u platelets along with one dose of DDAVP over the course of her hospitalization. Surgery was consulted and recommended serial exams and correction of coagulopathy. The patient did undergo CT abd/pelvis which revealed ascites but no evidence of hemoperitoneum or retroperitoneal hematoma. She did require narcotic pain control for pain related to the hematoma. Following transfer from floor to unit, abdominal hematoma expanded in size. Patient received additional packed red blood cells, fresh frozen plasma, platelets, and desmopressin to maintain Hct > 21, INR 1.5 to 2, and platelets > 50,000. Pt also responded well to albumin infusions. IR and surgery were consulted. Albumin and PRBCs were given in the ICU to maintain Hb>8 on transfer to the floor. The patient had a stable Hct>21% and Hb, PLT, and INR. She did require 2 units of PRBC for a hct <21. This was thought to be secondary to her renal failure and nephrology initiated procrit therapy. There was no evidence of acute bleeding on the floor. . . #. Respiratory distress: Pt was intubated because of tenuous respiratory status on the tenth day of her admission. CXR was c/w ARDS, and while ventilated, pt had daily CXRs. ARDS tidal volumes- 6-8cc/kg. She was diagnosed with hospital acquired PNA given CXR and PEx findings, and this was treated with vanc/cipro/zosyn initially, then switched to meropenem when she continued to have fevers and leukocytosis. Vancomycin and Micafungin were added because of continuing febrile episodes and leukocytosis. Cipro continued for SBP prophylaxis. Pt was appropriately weaned from ventilator, and extubated on [2147-7-13] without immediate complications. Prior to extubation, patient's health proxy had changed her code status to DNR/DNI. Antibiotics were discontinued on [7-16]. At time of transfer, pt's leukocytosis was resolving, and patient had been afebrile for >72h. [Name (NI) 5601], pt had PT/OT, speech and swallow, and nutrition consults. Speech/swallow advanced her diet to soft foods and thin liquids. On the floor she developed a low grade fever of 100.1. Cultures were drawn and chest xray showed little change. Vanc was therapeutic and meropenam was hung. She was HD stable at the time and did not appear to be dyspneic. She remained stable and afebrile overnight and the following morning the decision was made to discontinue her antibiotics. She remained afebrile for the rest of her hospitalization. She has been satting in the mid to high 90's on 2L NC at time of discharge. . . # ICU pressor needs: Titrated and weaned from 3 pressor agents to no pressor agents at the time of extubation. Mean arterial pressures post-extubation remained >60. . . #. VRE bacteremia: Blood cultures from 7/5 blood cultures returned positive for gram positive cocci in clusters and pairs and the patient was restated on vancomycin. Her PICC line was removed and the tip sent for culture. On [7-19] the culture speciated out to VRE. Her vancomycin was discontinued and Daptomycin therapy wa initiated. ID was consulted and recommended she complete a 7 day course of 460mg daptomycin dosed every 48 hours. Her last dose was on her day of discharge. She will need another dose on Sunday [2147-7-23] and her final dose will be on Tuesday [2147-7-25]. The long term care facility that she will be transferred to was contact[Name (NI) ] and they are agreeable to this plan. . . #. End Stage Renal Disease: Pt started on CVVH during stay, with CVVH stopped on [7-13]. HD was begun again on [7-15]. Renal following throughout ICU stay. Renal team adjusted dialysate for HCO3 and K, and MICU team repleted Mag and Phos as needed. Goal fluid diuresis >1L/day. Reached dry weight on [7-10]. Patient was continued on HD MWF but had low blood pressures secondary to her ESLD and was given midodrine prior to dialysis to maintain her blood pressures. She was given Procrit per HD protocol. . . # Cirrhosis secondary to alcoholism: Currently not on transplant list, as last alcohol use was 4/[2147]. Patient has had stays complicated by encephalopathy, coagulopathy, and thrombocytopenia, and therefore pt was continued on ciprofloxacin for SBP prophylaxis, rifaximin, Vitamin K, and was continued on lactulose with appropriate stooling of [3-16] bowel movements per day. Her coagulopathy was closely followed and corrected as needed with Platelet and FFP transfusions. Total bilirubin peaked at 22.9 and then trended downward and was 10 at the time of discharge. . . # Abdominal wall hematoma after paracentesis: The patient was followed closely by IR and surgery who did not see any indication for (or feasible) intervention. Imaging on [6-30] demonstrated stable anterior wall hematoma as compared to [6-28]. No signs of active bleeding at this time. Site of hematoma was clinically stable throughout ICU and floor stay. . . # Toxic metabolic encephalopathy: Ms. [Known lastname ] developed AMS after extubation, occasionally with visual hallucinations. Agitation was treated with PRN Zydis 5mg. Patient was frequently re-oriented and supportive treatment given. Lactulose was continued for hepatic encephalopathy. The patient remained altered on the floor, but was noted to be significantly more lucid in the days prior to discharge. . . # Rh + platelets: The patient did receive a batch of Rh positive platelets. Given her Rh negative status and possible need for future solid organ transplant, she was given Rhogam. . # Difficulty swallowing. Followed by speech with a long history of dysphagia that seems to be more pronounced now with her altered mental status due to her hepatic encephalopathy. She would benefit from a video swallow study at your facility. . #. Depression: Pt was continued on her home dose of sertraline. . # Code status: Pt was made DNR/DNI during her stay in the ICU after a discussing with her health care proxy. Before leaving the hospital her code status was rediscussed with the patient and she elected to be full code. Medications on Admission: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 3. Lactulose 10 gram/15 mL Syrup daily 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) ML PO QID (4 times a day) as needed for indigestion. 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) 7. Omeprazole 20 mg Capsule EC [Hospital1 ] 8. Zofran 4 mg Tablet q8H prn Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a day. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to [3-16] BM per day. 4. Folic Acid-B Complex & C No.10 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) ml PO four times a day as needed for indigestion. 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 9. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache, pain. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for Wheezing. 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID:PRN as needed for agitation. 14. Daptomycin 500 mg Recon Soln Sig: Four [Age over 90 881]y (460) mg Intravenous QHD for 14 days: Day one [2147-7-19]. 15. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days: Day 1: [2147-7-19]. 16. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS): please crush and give with meals. 17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO QHD: Please give just prior to dialysis. Discharge Disposition: Extended Care Facility: [Hospital1 ] lower [Doctor Last Name ] Discharge Diagnosis: Primary Diagnosis: -- Decompensated Alcoholic Hepatitis -- Cirrhosis . Secondary Diagnosis: - ESRD - Pancreatitis - Depression - Peripheral neuropathy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with an abdominal hematoma. Your blood count was dangerously low and you received several blood transfusions. You also had acute respiratory distress that necessitated a tube being placed in your throat to help you breathe. This was likely the result of an infection in your lungs. You were transferred to the intensive care unit and put on a machine to help you breathe. You were also were given antibiotics. You recovered from your respiratory needs and were extubated and transferred to the floor. You developed a blood stream infection and were placed back on IV antibiotics. These will be given to you every other day while you are getting dialysis for 2 more weeks. . While you were here the following changes were made to your home medications: -- We started you on 500mg tylenol every 6 hours as needed for pain. You should not take more than 2 grams per day as this could further damage your liver. -- We started you on Ciprofloxacin 500mg once a day. -- Quetiapine fumarate 50mg twice a day as needed for agitation. -- Nephrocaps 1 tablet every day. -- Flagyl 250mg every 8 hours until [7-26] -- Daptomycin 460mg IV every 48 hours to be given on [7-23] and [7-25] to complete a 7 day course -- Midodrine 5mg with dialysis -- Calcium carbonate 500mg three times daily with meals Followup Instructions: The Liver Center will call you to set up a follow-up appointment. If you don't hear from the office by the end of next week, please call them at [Telephone/Fax (1) 2422] to inquire about the status of your appointment.	[ "518.5", "286.7", "356.9", "572.2", "V09.80", "285.1", "303.91", "300.3", "790.7", "285.21", "571.1", "585.6", "486", "998.12", "571.2", "349.82", "V45.11", "311", "V45.86", "041.04", "577.1", "E879.4" ]	icd9cm	[ [ [] ] ]	[ "96.04", "39.95", "38.93", "96.72" ]	icd9pcs	[ [ [] ] ]	15703, 15776	6686, 13484	286, 293	15971, 15971	4584, 5113	17468, 17695	3601, 3727		14008, 15680		15797, 15797		13510, 13985			16110, 17445										3742, 4565																														228, 248										2398, 2809	5133, 6663					321, 2380			15889, 15950				15816, 15868			15986, 16086								2831, 3343	3359, 3585
24,401	181,551	17135	Discharge summary	report	Admission Date: [2115-11-7] Discharge Date: [2115-11-16] Date of Birth: [2045-9-12] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 613] Chief Complaint: hypertensive emergency Major Surgical or Invasive Procedure: esophageal stent placement History of Present Illness: HPI: 70 yoM w/ h/o distal esophageal stricture, colon CA s/p hemicolectomy, CAD, HTN presents with hypertension following esophageal stent placement on [2115-11-6]/ Post-procedure, he was hyptensive 220s/110s and had 150 cc bilious vomitus, umbilical pain ([6-21]), and frontal headache. He received 2.5 mg IV lopressor and 10 mg IV hydralazine prior to admission to the medical service for further evaluation. Overnight, he received an additional 10 mg IV hydralazine. Currently, he reports mild umbilical pain, cramping, with associated nausea (vomited X 3 overnight), no BRBPR, melena. He reports similar pain following prior esophageal dilations. His headache has improved, currently [1-21] frontally located. No chest pain, palpitations, lightheadedness, change in vision. He reports chronic shortness of breath, not significantly changed from baseline Past Medical History: PMHx: 1) Distal esophageal stricture s/p multible balloon dilations 2) colonic adenoCa s/p hemicolectomy 3) ventral hernia 4) s/p CVA 5) CAD s/p MI with stent placement [2112] 6) PVD 7) COPD 8) PUD Social History: SH: lives with wife, [Name (NI) ]: 2 ppd X 50 yrs, past ETOH use, none since MI, no illicits Family History: FH: NC Physical Exam: PE: Tc 98.6, pc 70, bpc 150/70, resp 24, 99% RA Gen: elderly male, breathing rapidly and deeply, A&OX3 HEENT: protuberant eyes bilaterally, PERRL, EOMI, anicteric, nl conjunctiva, OMM slightly dry, OP clear, neck supple, JVP ~ 9 cm, no LAD, no thyromegaly Cardiac: RRR, no M/R/G appreciated Pulm: CTA bilaterally Abd: NABS, soft, minimal umbilical tenderness without R/G. Large, easily reducible ventral hernia. Ext: No cyanosis or edema, warm with good cap refill Neuro: No gross neurological defects Rectal: brown, gauiac (-) stool . Pertinent Results: [2115-11-7] 08:50PM GLUCOSE-162* UREA N-17 CREAT-1.3* SODIUM-138 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-18* ANION GAP-18 [2115-11-7] 08:50PM CK(CPK)-124 [2115-11-7] 08:50PM CK-MB-5 cTropnT-<0.01 [2115-11-7] 08:50PM CALCIUM-9.8 PHOSPHATE-1.9* MAGNESIUM-1.9 [2115-11-7] 03:50PM GLUCOSE-329* UREA N-17 CREAT-1.3* SODIUM-136 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-16* ANION GAP-23* [2115-11-7] 03:50PM CALCIUM-9.5 PHOSPHATE-2.2* MAGNESIUM-2.0 [2115-11-7] 03:50PM ACETONE-MODERATE [2115-11-7] 02:22PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2115-11-7] 02:22PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2115-11-7] 02:22PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2115-11-7] 01:53PM %HbA1c-15.2* [Hgb]-DONE [A1c]-DONE [2115-11-7] 12:45PM ALT(SGPT)-17 AST(SGOT)-21 CK(CPK)-82 ALK PHOS-114 AMYLASE-63 TOT BILI-0.8 [2115-11-7] 12:45PM LIPASE-51 [2115-11-7] 12:45PM CK-MB-4 cTropnT-0.02* [2115-11-7] 12:45PM ALBUMIN-4.3 [2115-11-7] 12:45PM TSH-1.0 [2115-11-7] 11:34AM TYPE-[Last Name (un) ] PH-7.34* [2115-11-7] 07:40AM GLUCOSE-337* UREA N-17 CREAT-1.3* SODIUM-138 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-14* ANION GAP-28* [2115-11-7] 07:40AM CALCIUM-9.8 PHOSPHATE-3.7 MAGNESIUM-1.9 [2115-11-7] 07:40AM WBC-20.4# RBC-4.72# HGB-15.3# HCT-44.9# MCV-95 MCH-32.4 MCHC-34.1 RDW-12.9 [2115-11-7] 07:40AM NEUTS-90.3* BANDS-0 LYMPHS-6.2* MONOS-3.1 EOS-0.1 BASOS-0.3 [2115-11-7] 07:40AM PLT COUNT-224 PLTCLM-1+ KUB [2115-11-12] FINDINGS: There are multiple dilated small bowel loops overlying the mid abdomen. The proximal small bowel loops are not dilated. There may be increased bowel wall of the dilated small bowel loops. This may represent a focal ileus, and partial strangulation of small bowel cannot be excluded. The soft tissue and osseous structures are unremarkable. CT abdomen/pelvis [2115-11-13] IMPRESSION: 1. Large ventral hernia including large and small loops of bowel as well as the anastomotic site. Dilated loops of contrast-filled small bowel with no evidence of transition site. There is no evidence for acute obstruction; however, partial obstruction cannot be excluded and if there is clinical concern, re-scanning of the patient can be performed. 2. Circumferentially thickened esophageal walls with subcentimeter periesophageal lymph nodes. This is consistent with the patients known history of esophagitis. Neoplasm cannot be excluded based on these imaging findings. The previously visualized lower esophageal stent is not seen on this examination. 3. Right kidney stone. 4. The previously seen hypoattenuating contour deformity in the left kidney on a non-contrast CT does not correlate with abnormalities in this region on the current exam. 5. Small ill-defined pulmonary subcentimeter consolidations/nodules to which attention can be paid on any followup exams. [2115-11-7] CT abd/pelvis IMPRESSION: 1. Large ventral hernia including some colon and small bowel, but without evidence of any obstruction. 2. Extensive calcification in the aorta down through the levels of the iliac arteries bilaterally. Extensive calcification also involves the SMA. No bowel wall edema is noted. 3. Hypoattenuating contour deformity noted in the left kidney. This study is slightly limited as no IV contrast was used. Renal ultrasound could be helpful in further evaluating this area if clinically indicated. 4. Esophageal stent seen in place. 5. No evidence of any free air within the abdomen. [2115-11-7] PA and lat IMPRESSION: No acute cardiopulmonary disease. Esophageal stent in the mid- thoracic esophagus. Brief Hospital Course: A: 70 year old male with h/o HTN, CAD presents with hypertension, AG acidosis, hyperglycemia, and leukocytosis following esophageal stent placement . P: 1) Hyperglycemia/DKA: On the night of admission the initial concern was hypertensive urgency following stent placement. However, the pt's blood pressure was shortly brought under control with IV lopressor. Per the pt's wife, he had similar reactions in the past post-procedure, ie, he would become hypertensive with quick resolution. On the night of admission the pt had mild nausea, but this was suspected to be [2-13] to the procedure as well and it was felt that the pt would be discharged shortly after BP and nausea control on the floor. However, blood sugars on the morning after admission were shown to be elevated to the 400s-500s. The pt was also shown to have an AG >20. Initially the pt's AG was suspected to be more likely [2-13] to [Initials (NamePattern4) ] [Last Name (NamePattern4) 12376] perf or some other GI process as opposed to DKA given his lack of DM hx. A chest PA and Lat at the time showed no free air. A CT abd/pelvis also demonstrated no acute abdominal process. A U/A, however, showed positive glucose/ketones/and wbcs. The pt was thus felt to be in DKA, though this was an unusual presentation for type II diabetes or new onset type I diabetes, uncommon in this age group. Initially the pt was managed on the floor with a humalog ISS and q 2hour FS. However, the pt was initially transferred to the [Hospital Unit Name 153] where his AG gap closed and his blood sugar was brought under control. He was transferred from the [Hospital Unit Name 153] back to the floor for further management. . Later on further questioning, the pt's wife reported that his FS was 400 ~ 4 months ago at his nephrologists office, although his PCP told her that he did not have diabetes and did not recommend treatment. The pt's Hb A1C on this admit was found to be 15.2. The pt was discharged on glargine and an ISS protoccol as attached in d/c planning, [First Name8 (NamePattern2) ] [Last Name (un) ]. . 2) abdominal pain--Initially the pt's abdominal pain was felt to be [2-13] to nausea/vomiting related to DKA. However, after returning from the [Hospital Unit Name 153], the pt's abdominal pain persisted. A repeat CT abdomen on [2115-11-13] demonstrated no new process. His abdominal pain resolved by the time of d/c. 3) diminished vision- The pt reported diminished vision after his return to the medical floor. He was seen by optho in the eye clinic. Per optho, his diminshed vision was likely [2-13] to blood sugar associated-fluid shifts in diagnosed cataracts. The pt was set-up for out-pt cataract eval. . 4) Esophageal stricture s/p stent: The pt was continued on his lansoprazole at home dose. Following his return from the [Hospital Unit Name 153], the pt slowly began tolerating po and was tolerating a regular diet on d/c. . 5) COPD: The pt was continued on his combivent (home med) and was placed on advair (added on this admission). . 7) CAD: The pt was continued on his home metoprolol, plavix, lipitor. . 8) F/E/N: Once able to tolerate pos the pt was advanced on a low na/cardiac healthy/ DM diet. His electrolytes were repleted as necessary. . 9) Ppx: The pt was placed on lansoprazole, heparin SC, and a [Last Name (un) 12376] regimen. . 10) Code: Full Code Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: Two (2) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] twice a day. Disp:120 Tablet,Rapid Dissolve, DR(s) Refills:2 2. Finasteride 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 3. Atorvastatin 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 4. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [Last Name (STitle) ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 6. Lisinopril 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 7. Simethicone 80 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:28 Tablet, Chewable(s) Refills:5 8. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Metronidazole 500 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:15 Tablet(s) Refills:0 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [Hospital1 ]: 15-30 MLs PO QID (4 times a day) as needed. Disp:250 ML(s) Refills:0 12. Glargine [Hospital1 ]: Twenty (20) units at bedtime: Inject subcutaneously at the same time every day. Disp:1 1 month supply Refills:2 13. Ultra One Glucometer [Hospital1 ]: One (1) meter before meals and bedtime. Disp:1 meter Refills:2 14. Glucose strips for glucometer [Hospital1 ]: One (1) glucose strips QACHS and QHS. Disp:1 month supply Refills:2 15. Insulin Syringes (Disposable) Syringe [Hospital1 ]: One (1) syringe Miscell. QACHS and QHS. Disp:1 month supply Refills:2 16. Humalog Insulin [Hospital1 ]: One (1) dose QACHS and QHS: Inject Humalog as written in the insulin sliding scale chart. Disp:1 month supply Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 6136] Homecare Discharge Diagnosis: Primary: diabetic ketoacidosis Secondary: chronic obstructive pulmonary disease, colonic adenocarcinoma, distal esophageal stricture, peripheral vascular disease. Discharge Condition: Good Discharge Instructions: Please follow-up with your primary care physician or come to the emergency room if you develop worsening abdominal pain, nausea, vomiting, fevers, chills, or other symptoms that concern you. Please check your fingersticks before each meal and at bedtime and administer insulin as directed. If your FS <70, drink juice and recheck your fingerstick. If FS persistently >250, call your primary care physician Followup Instructions: 1) Primary Care: Please call to schedule an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12832] ([Telephone/Fax (1) 12834]) to be seen within 1 week following discharge. . 2) Ophthalmology Eye clinic: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4853], M.D. Date/Time:[2115-11-19] 3:00 . 3) [2115-11-22] at 2:00pm with Dr.[First Name (STitle) ] and at 3:00pm (on the same day) w/ [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9973] [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "496", "593.9", "414.01", "362.01", "V45.82", "250.11", "276.2", "401.9", "276.50", "530.3", "250.50", "584.9" ]	icd9cm	[ [ [] ] ]	[ "42.81" ]	icd9pcs	[ [ [] ] ]	11680, 11739	5969, 9373	295, 324	11946, 11953	2160, 5946	12408, 13068	1580, 1588		9396, 11657		11760, 11925					11977, 12385										1603, 2141																														233, 257																352, 1223																		1245, 1449	1465, 1564
32,245	113,115	33132	Discharge summary	report	Admission Date: [2146-12-19] Discharge Date: [2146-12-29] Date of Birth: [2093-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: transfer from OSH for respiratory failure Major Surgical or Invasive Procedure: Intubated by EMS History of Present Illness: Mr. [Known lastname 5395] is a 53 yo man with obesity, glucose intolerance and borderline hypertension who was initially taken to an OSH after being found at home by his son nearly unresponsive with vomitus on his shirt. . He was intubated in the field and taken to [Hospital3 ]. On admission, he was febrile to 103, tachycardic to the 140s, tachypneic to the high 30s and sating in the 80s on high FiO2 initially. He underwent LP, CT head and CXR, which revealed bilateral patchy pulmonary infiltrates and evidence of mastoiditis. His initial WBC count was 4.7 and initial BUN/Cr was 28/3.8. A d-dimer was positive, but given the renal failure, he only underwent LENIs that did not demonstrate evidence of thrombosis. He was initially broadly covered with antibx for PNA, both CAP and aspiration, and bacterial meningitis and HSV encephalitis with acyclovir, ceftriaxone, ampicillin, azithromycin, vancomycin, clindamycin. The LP was not suggestive of meningitis or encephalitis. Sputum gram stain demonstrated 4+ GPCs in pairs, chains and clusters, and sputum and blood cultures are pending. His inital CK was ~2400 and rose to ~20,000. Urine was apparently positive for Strep pneumoniae antigen. . On further history from the pt's wife, he had been in his usual state of health until the night prior to admission to [Hospital1 5979]. At that time, he was c/o ear fullness, but he did not mention fever or cough. The next day, the pt's son tried to awaken him in the middle of the day, but he was apprently taking a nap and did not want to be disturbed. Later that evening, the pt's son returned home, and the pt could not be awakened, so EMS was called. . ROS was otherwise unobtainable. . Past Medical History: Obesity ? DM2 ? HTN Social History: No tobacco, social EtOH, no illicits Family History: NC Physical Exam: Vitals: T: 98.8 BP: 153/103 P: 101 R: 35 SaO2: 99% General: opens eyes to voice, squeezes hands to command, wiggles toes to command, intubated HEENT: PERRL, anicteric, no conjunctival injection, bull neck, no LAD Pulmonary: Lungs with bilateral ronchi anteriorly, no wheeze or rales Cardiac: RR, distant S1 S2, no murmurs, rubs or gallops appreciated Abdomen: obese, soft, NT, ND, normoactive bowel sounds Extremities: No edema, 2+ radial, DP pulses b/l Neurologic: Opens eyes to voice, squeezes hands on command, wiggles toes on command Pertinent Results: [2146-12-19] 10:21PM WBC-17.2* RBC-4.21 HGB-11.8* HCT-34.2* MCV-81* MCH-27.9 MCHC-34.4 RDW-13.7 [2146-12-19] 10:21PM NEUTS-82* BANDS-10* LYMPHS-7* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2146-12-19] 10:21PM PLT COUNT-216 [2146-12-19] 10:21PM PT-13.4 PTT-28.1 INR(PT)-1.2* [2146-12-19] 09:53PM GLUCOSE-144* UREA N-36* CREAT-1.5* SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30 ANION GAP-11 [2146-12-19] 09:53PM CK(CPK)-[Numeric Identifier 77019]* [2146-12-19] 09:53PM CALCIUM-8.1* PHOSPHATE-2.0* MAGNESIUM-2.3 . [2146-12-20] Chest CT: 1) Bilateral, multifocal consolidation; CT appearance in correlation with laboratory/clinical history suggestive of multifocal pneumonia, however improvement on subsequent chest radiograph is somewhat atypical. Findings and distribution not typical for aspiration or noncardiogenic pulmonary edema. 2) Fatty liver. . [2146-12-20] Head Ct: 1. Hypodense globus pallidi which may represent carbon monoxide or other toxin exposure. Consider MRI for further evaluation. 2. Fluid-filled mastoid air cells and middle ear cavities. 3. Periodontal disease and/or current or old infection around the roots of multiple teeth. 4. No acute hemorrhage, masses, or mass effect. . [2146-12-21] MRI/MRA Head - T2 hyperintensities and slow diffusion involving the globus pallidi as well as small foci of slow diffusion involving the deep watershed distribution bilaterally and the right anterior watershed distribution. These findings may represent carbon monoxide poisoning or other toxin exposure versus global hypoxia/anoxia. . [2146-12-23] MRI Head - 1) T2 hyperintensities and slow diffusion involving the globus pallidi as well as the subcortical white matter are unchanged since [2146-12-21] and may represent global hypoxia/hypoperfusion event or carbon monoxide poisoning. 2) Bilateral mastoiditis. Brief Hospital Course: A/P: 53 yo man intially found lying on his couch unresponsive covered in vomitus transferred from OSH with multilobar pneumonia, ARDS, acute renal failure and bilateral globus pallidus hypodensity on head CT, doing well since extubated yesterday, some right deltoid weakness on exam. . # PNA/ARDS: possibly [1-21] Strep pneumo (suspected given urine positive for S.pneumo antigen at OSH) complicated by aspiration and ARDS. Also possibly aspiration pneumonia [1-21] vomiting and decreased mental status from unknown precipitant. He was intubated in the field by EMS and transferred to [Hospital1 ]. Nasopharyngeal aspirate at OSH with Strep pneumo and Hemophilus influenza. He was transferred here on [12-20] due to incrasing ventillatory requirements and ARDS. He was maintained on low pressure mechanical ventillation. In addition, antibiotic coverage was broadened to vancomycin, zosyn and ciprofloxacin per ID recommendations to cover for ventillator associated pneumonia given his persistant fevers up to 103. He continued to improve daily and was extubated [2146-12-25] without difficulty. Ciprofloxacin was weaned off on day 7. Vancomycin and Zosyn were continued to complete a 14 day course. . #Bilateral Globus Pallidus Infarct/Unresponsive on Admission - very concerning for anoxic brain insult vs toxic metabolic process. Also classically seen in CO poisoning, although no evidence of other family members affected so less likely. MRI confirmed this finding also with decreased signal in watershed areas of the brain also seen with anoxic insult. Repeat MRI did not show progression. CSF at [Hospital3 ] without growth on culture. Patient had right deltoid weakness which per neurology was likely to right brachial plexus injury from his time down on his right side. This clinically improved during his admission. Otherwise no focal neuro deficits. Patient scheduled to f/u with behavioral neurology. . #Diarrhea - Patient with profuse diarrhea on admission and throughout most of ICU stay. Stool studies negative for C.diff x5. He was treated with brief course of oral flagyl, however this was stopped early as the diarrhea resolved and stool studies were negative. . #Bilateral opacification of middle ear and mastoid air cells- seen on head ct at OSH, pt also had been reporting ear fullness. Currently denies ear pain but state that ears don't feel normal. Seen by ENT, felt that radiographic and clinical signs not c/w mastoiditis. -if necessary pt can f/u with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 77020] . #ARF: Likely combination of volume depletion and mild degree of rhabdomyolysis [1-21] being down vs possible seizure. Resolved. . # Rhabdomyolysis: He had elevated CPK up to 20,000 at OSH possibly due to seizure, but no evidence of seizure activity on EEG at OSH, also possibly from being down for prolonged time. CK's trended down with IVF. . # Prophylaxis: Heparin SC 5000 tid . #Access - PICC . # Code status: FULL CODE Medications on Admission: Home medications: Methylphenidate . Medications on transfer: Ceftriaxone 2 grams q12hrs Esomeprazole Heparin SC tid Methylprednisolone 20 daily Vancomycin 1 g [Hospital1 ] Discharge Medications: 1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) bag Intravenous Q8H (every 8 hours): Give Until [2147-1-2]. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) bag Intravenous Q 8H (Every 8 Hours): Give until [2147-1-2]. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for diarrhea/yeast. 5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: PICC Flush. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO q6 prn as needed for fever or pain. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 ] Discharge Diagnosis: Multilobar Pneumonia Bilateral Globus Pallidus Infarct Rhabdomyolysis Discharge Condition: Vital Signs Stable Discharge Instructions: Return if having fever, chills, shortness of breath, coughing up blood, severe chest pain. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD, PHD Behavioral Neurology Phone:[Telephone/Fax (1) 8645] Date/Time:[2147-2-20] 2:00 [Location (un) ]. [Location (un) ], [Numeric Identifier 4774] (neuropsych testing will be arranged at that time).	[ "250.00", "348.1", "038.2", "278.00", "482.39", "388.8", "276.50", "401.9", "271.3", "507.0", "E849.0", "955.7", "584.9", "571.8", "434.91", "787.91", "995.92", "518.5", "728.88", "E888.8" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.72" ]	icd9pcs	[ [ [] ] ]	8791, 8834	4730, 7742	358, 376	8947, 8967	2803, 3733	9106, 9382	2225, 2229		7969, 8768		8855, 8926		7768, 7768			8991, 9083										2244, 2784					7786, 7804																									277, 320																404, 2111				3742, 4707													7829, 7946	2133, 2155	2171, 2209
4,635	127,939	48466	Discharge summary	report	Admission Date: [2115-11-21] Discharge Date: [2115-11-28] Date of Birth: [2068-1-21] Sex: F Service: Medicine, [Hospital1 139] Firm HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with type 1 diabetes mellitus and end-stage renal disease (on hemodialysis) who presents with critically elevated blood sugar of 863. The patient was to have a fistulogram on the day of admission and was made nothing by mouth. The patient received no insulin on the night prior to admission or on the day of admission. The patient complained of thirst, but otherwise was doing well. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. End-stage renal disease (on hemodialysis). 3. Hypertension. 4. Hypercholesterolemia. 5. History of tobacco abuse. 6. History of anxiety. 7. History of depression. 8. History of alcohol abuse (but quit in [2115-2-9]). ALLERGIES: Allergy to ANTIHISTAMINES (which cause muscle cramps). MEDICATIONS ON ADMISSION: 1. Lipitor 10 mg by mouth once per day. 2. Iron sulfate 325 mg by mouth once per day. 3. Lamictal 75 mg by mouth at hour of sleep. 4. Protonix 40 mg by mouth once per day. 5. Zoloft 200 mg by mouth once per day. 6. Renagel 800 mg by mouth three times per day. 7. Zyprexa 20 mg by mouth once per day. 8. Calcium carbonate 500 mg by mouth three times per day. 9. Insulin 30 units subcutaneously of NPH and 10 units subcutaneously of regular in the morning; 10 units subcutaneously of NPH and 10 units subcutaneously of regular at night. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination was notable for trace lower extremity edema. The patient had an arteriovenous fistula on the left forearm with no palpable thrill. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories were notable for an elevated glucose of 863 and an anion gap of 18. Urinalysis was notable for 1000 glucose and trace ketones. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. DIABETES MELLITUS ISSUES: The patient is a known brittle type 1 diabetic. On admission, the patient was placed on an insulin drip for control of her blood sugars. Eventually, the patient was transitioned to her regular home doses of NPH and regular insulin. The patient's blood sugars were noted to be extremely labile; especially when nothing by mouth. At the time of discharge, the patient had good control of her blood sugars. 2. RENAL ISSUES: The patient has end-stage renal disease (on hemodialysis). The patient underwent a fistulogram which revealed stenosis. Interventional Radiology placed a stent. However, the arteriovenous fistula was not found to be functional during hemodialysis and a temporary femoral line had to be placed. The patient was taken back for a repeat fistulogram. At that time, Interventional Radiology decided to administer t-[MD Number(3) 102035] patient to improve flow in the arteriovenous fistula. The patient was monitored in the Medical Intensive Care Unit during t-PA. She was noted to bleed profusely from the arteriovenous fistula due to t-PA and required 3 units of packed red blood cells. Following t-PA, the arteriovenous fistula was noted to have a palpable thrill which it did not have on admission. Hemodialysis was able to be administered with the arteriovenous fistula prior to discharge. 3. PSYCHIATRIC ISSUES: The patient was continued on her home doses of Zyprexa, Zoloft, and Lamictal for her schizoaffective disorder. CONDITION AT DISCHARGE: Condition on discharge was stable; the patient was ambulating with good control of her blood sugars, and arteriovenous fistula was patent. DISCHARGE STATUS: The patient's discharge status was to home. DISCHARGE DIAGNOSES: 1. Hyperglycemia. 2. Schizoaffective disorder. 3. Type 1 diabetes mellitus. 4. End-stage renal disease (on hemodialysis). 5. Hypertension. 6. Hypercholesterolemia. 7. Tobacco use. 8. Arteriovenous fistula stenosis and clotting. MEDICATIONS ON DISCHARGE: 1. Atorvastatin 10 mg by mouth once per day. 2. Ferrous sulfate 325 mg by mouth once per day. 3. Lamotrigine 75 mg by mouth at hour of sleep 4. Pantoprazole 40 mg by mouth once per day. 5. Sertraline 200 mg by mouth in the morning. 6. Olanzapine 10 mg by mouth at hour of sleep 7. Docusate 100 mg by mouth twice per day. 8. NPH insulin 30 units subcutaneously in the morning and 10 units subcutaneously in the evening. 9. Regular insulin 10 units subcutaneously in the morning and 10 units subcutaneously in the evening. 10. Nephrocaps by mouth every day. 11. Renagel 800-mg tablets three tablets three times per day (with meals). 12. Metoprolol 75 mg by mouth twice per day. 13. Calcium carbonate 500-mg tablets two tablets by mouth three times per day (with meals). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with her primary care physician (Dr. [First Name4 (NamePattern1) 1169] [Last Name (NamePattern1) ]) on [1-21]. 2. The patient was instructed to follow up [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) 805] from Transplant Social Work on [12-3]. 3. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (her psychiatrist) on [12-23]. 4. The patient was instructed to follow up with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 102036] on [2115-12-26]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. Dictated By:[MD Number(1) 102037] MEDQUIST36 D: [2115-11-30] 17:44 T: [2115-12-5] 02:10 JOB#: [Job Number 102038]	[ "V11.3", "295.70", "250.43", "285.1", "996.73", "403.91", "272.0", "305.1", "459.0" ]	icd9cm	[ [ [] ] ]	[ "99.10", "39.95", "38.95", "39.50", "39.90", "88.49" ]	icd9pcs	[ [ [] ] ]								3723, 3960				3987, 4777	995, 1941						4810, 5676																					1975, 3483					3498, 3702																											194, 617																		639, 969
23,808	199,632	27433	Discharge summary	report	Admission Date: [2154-4-11] Discharge Date: [2154-4-17] Date of Birth: [2092-5-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: Transfer from OSH s/p VF arrest and stents to 100% occluded LAD. Major Surgical or Invasive Procedure: Cardiac catheterization where he was found to have a 100% occluded Ostial LAD and 40% RCA and 40% Cx. He was stented to the LAD x 2 with Taxus stents. History of Present Illness: Mr. [Known lastname ] is a 61 year old man who was doing yard work today when he noted chest pressure and asked friend for [Name2 (NI) ]. His friend came back to find Mr. [Name13 (STitle) ] on the ground. He started CPR and 7 minutes later, EMS arrived and found patient cyanotic, pulseless and not breathing. He was intubated and the monitor showed asystole. He was given EPI/Atropine. He was in VFib vs. V Tach. He was shocked x 10, given Amiodarone and Lidocaine and went into sinus tach. He was brought to the ED of [Hospital1 34] and given [Hospital1 ] 325, Plavix, Heparin gtt and taken to cath lab where he was found to have a 100% occluded Ostial LAD and 40% RCA and 40% Cx. He was stented to the LAD x 2 with Taxus stents. He remained hemodynamically stable and intubated. An IABP was placed at the end of the case. Post procedure he was started on Integrillin, but this was stopped due to blood in his NG tube. He was subsequently transferred to [Hospital1 18] for further management. Past Medical History: Hypercholesterolemia ? HTN Social History: Works as service tech for [Company 56315]. Lives with wife. Smoked 1-1.5 PPD and quit 15 years ago. Occasionally drinks. Had 2 beers on day of admission Family History: Father died of MI, brother with MI (both in 50s). No DM. Physical Exam: PE: AF 132/84 95 84 20 100% O2 Sats VENT: AC 600x20 PEEP 5 FiO2 1 GEN: Intubated man RIB in NAD HEENT: Clear OP, MMM, PERRL NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTA, BS BL, No W/R/C (ant) ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. Trace pulses throughout. No cyanosis or clubbing. SKIN: No lesions NEURO: Sedate and intubated Pertinent Results: [2154-4-11] 11:18PM TYPE-ART PO2-207* PCO2-28* PH-7.38 TOTAL CO2-17* BASE XS--6 [2154-4-11] 10:38PM GLUCOSE-145* UREA N-26* CREAT-1.2 SODIUM-140 POTASSIUM-5.1 CHLORIDE-112* TOTAL CO2-15* ANION GAP-18 [2154-4-11] 10:38PM CK(CPK)-3348* [2154-4-11] 10:38PM CK-MB-124* MB INDX-3.7 cTropnT-3.07* [2154-4-11] 10:38PM CALCIUM-7.8* PHOSPHATE-1.5* MAGNESIUM-2.0 [2154-4-11] 10:38PM WBC-15.0* RBC-4.91 HGB-15.4 HCT-42.7 MCV-87 MCH-31.3 MCHC-36.0* RDW-12.7 [2154-4-11] 10:38PM PLT COUNT-252 [2154-4-11] 07:07PM TYPE-ART TEMP-35.0 PO2-345* PCO2-34* PH-7.35 TOTAL CO2-20* BASE XS--5 INTUBATED-INTUBATED [2154-4-11] 07:07PM freeCa-1.08* [2154-4-11] 07:02PM PT-14.8* PTT-89.9* INR(PT)-1.3* [2154-4-12] 10:38AM BLOOD CK(CPK)-8630* [2154-4-12] 06:06PM BLOOD CK(CPK)-[Numeric Identifier 67141]* [2154-4-13] 04:12AM BLOOD CK(CPK)-[Numeric Identifier 67142]* [2154-4-13] 11:43AM BLOOD CK(CPK)-[Numeric Identifier 16501]* [2154-4-14] 04:17AM BLOOD CK(CPK)-8788* [2154-4-17] 06:50AM BLOOD CK(CPK)-2124* [2154-4-17] 06:50AM BLOOD Glucose-109* UreaN-20 Creat-0.8 Na-143 K-3.8 Cl-109* HCO3-23 AnGap-15 . [2154-4-12] 10:38AM BLOOD CK-MB-222* MB Indx-2.6 cTropnT-1.95* [2154-4-12] 06:06PM BLOOD CK-MB-250* MB Indx-2.5 cTropnT-1.63* [2154-4-13] 04:12AM BLOOD CK-MB-165* MB Indx-1.4 cTropnT-1.40* [2154-4-13] 11:43AM BLOOD CK-MB-107* MB Indx-1.0 [2154-4-15] 06:25AM BLOOD CK-MB-10 MB Indx-0.1 cTropnT-0.62* . [2154-4-16] 07:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0 . [2154-4-14] 05:04PM BLOOD Type-ART Temp-38.0 O2 Flow-2 pO2-73* pCO2-37 pH-7.44 calHCO3-26 Base XS-0 . [4-13] ECHO EF 40-45% Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal half of the septum, distal anterior wall, and apex. The remaining left ventricular segments contract normally. No apical aneurysm or thrombus is seen. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD lesion). Mild mitral regurgitation. . [4-14] MRA Brain FINDINGS: This study is of limited quality due to extensive contamination by T1 hyperintense fat. Allowing for this limitation, no definite vascular pathology is seen. . [4-15] CXR The increasing opacification at both lung bases can be explained by atelectasis and dependent edema, though pneumonia cannot be excluded, since there is persistent engorgement of mediastinal veins and upper lobe pulmonary vessels. Small left pleural effusion is present. No pneumothorax. Mild tubulated narrowing of the subglottic and upper trachea has been evident since extubation on [4-14] and could be due to that or previous intubation as well as enlargement of the thyroid gland. . [2154-4-14] 5:08 am URINE Source: Catheter. FINAL REPORT [2154-4-16] URINE CULTURE (Final [2154-4-16]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML __________________ ESCHERICHIA COLI \| PROTEUS MIRABILIS \| \| AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . [2154-4-13] 5:43 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2154-4-13]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM AND PROPIONIBACTERIUM SPECIES. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. HEAVY GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. 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. FURTHER IDENTIFICATION TO FOLLOW. GRAM NEGATIVE ROD #4. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GRAM NEGATIVE ROD(S) \| \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . Brief Hospital Course: ASSESSMENT: The patient is a 61 year old man transferred from OSH for VT/VF arrest and subsequent intubation and transfer s/p cath revealing 100% LAD lesion which was stented. Upon arrival, he was placed on a cooling protocol with Arctic Sun machine with body temp cooled to 94F for 18 hours to preserve long term neurologic functioning. He was subsequently extubated and mental status improved daily. . # CAD: Pt s/p stent to 100% occluded LAD. He has no known history of CAD but does have a hx of hyperlipidemia. We monitored on tele throughout admission. We continued [Month/Day/Year ], Statin, BB (and titrated up as BP tolerated), Plavix and started ACE-i once BP improved. He was temporarily on Integrillin gtt s/p cath for 18 hours. Echocardiogram on HD #1 revealed 40-45% EF with hypokinesis of the distal half of the septum, distal anterior wall, and apex. Regarding his MI, he did quite well post-stent with little ectopy on telemetry. He was extubated on HD #1 and remained CP free. Troponins steadily decreased throughout the admission (from a peak of 3.07). He will follow at [Hospital1 ] cardiology. Since he has two Taxus stents, he will need Plavix with aspirin for at least 6 months. . # VT/VF: His VT and VF was probably secondary to his large MI due to a 100% occluded LAD. He had no residual ectopy since catheterization except for occasional PVCs. We monitored on tele and continued BB. Echo results as per above. He had no further VT after his stents to the LAD. . # Neurologic Status: Pt s/p cooling protocol with Arctic Sun machine to maintain total body temp of 34C for 18 hours upon admission (which was within 4-6 hour window where cooling has been shown to have best effects). This has been demonstrated to improve long term neurologic deficits secondary to hypoxic damage in patients who suffer VF arrest and were subsequently recussitated. Per protocol, we monitored electrolytes q6 hours while on machine. We maintained sedation while paralyzed with Vecuronium Bromide 0.05-0.14 mg/kg/hr IV (used to titrate to no shivering). He tolerated this protocol well and regained some residual neurologic function by HD #1. He was seen by neurology who recommended MRA brain which was unremarkable. His mental status and overall neurologic function improved throughout this hospitalization and he passed a speech and swallow eval and ambulated well, conversed coherently and could follow commands well by time of discharge. Some slugglishness and a resting posture which resembles decerebrate posturing has been noted in the past day. Nonetheless, the patient remains neurologically intact, and has follow up planned with behavioral neurology (Dr. [First Name (STitle) ] at [Hospital1 18]. . # CHF: Pt had interstitial pulmonary edema on CXR on arrival. By [4-15], CXR read "The increasing opacification at both lung bases can be explained by atelectasis and dependent edema, though pneumonia cannot be excluded, since there is persistent engorgement of mediastinal veins and upper lobe pulmonary vessels. Small left pleural effusion is present." He remained afebrile yet sputum cx grew out H. Influenza and S. Aureus. He was started on Vancomycin and Zosyn which was subsequently switched to Levofloxacin when culture data became available. . # Elevated CK: This was presumed to be due to the cooling protocol (see above). CKs trending down at time of discharge to 2124 from peak of 11,444. This should be followed closely at rehab. . # UTI: On HD #2 urine grew pansensitive E.Coli and Proteus and Ciprofloxacin was initiated. When the pt was placed on Levofloxacin for his sputum culture data (see below) on [4-15], this was discontinued. His urine cultures can be repeated at rehab in the coming week. He denies dysuria and his urine appears clear at time of discharge. . # Respiratory: Pt was intubated and sedated upon admission. After the cooling protocol (see above), we weaned ventillation without event and he was extubated on HD #1 and remained off the vent for the duration of the admission. O2 mask was weaned completely by HD #2. . # Hypothyroidism: Levothyroxine continued throughout admission . # Hyperlipidemia: Holding statin until CK is <1000 (2124 and trending down on day of discharge). Recommend 40mg PO Atorvastatin daily and rechecking CK daily once restarting. . # CODE: FULL . # COMM: With sons (and wife in am) . # DISP: To rehab . Medications on Admission: Levoxyl Lipitor Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Until pt ambulating frequently. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: Primary: VT/VF arrest s/p MI due to 100% occluded LAD Anoxic brain injury Secondary: HTN Hyperlipidemia Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. Seek medical attention immediately if you experience new symptoms including shortness of breath, chest pain, loss of sensation, dizziness, fatigue, nausea/vomiting, fainting, palpitations, or any other new symptoms. Follow up as per below. Followup Instructions: Call PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12424], MD to arrange a follow up appointment within the next 2 weeks. [Telephone/Fax (1) 39989] [Hospital1 ] Cardiology Group ([Telephone/Fax (1) 20259]. They will call with an appointment time. Please verify this. Dr. [First Name (STitle) ] (Neurology) [6-27] @ 10:30am [Hospital Ward Name 860] building ([Hospital Ward Name ]) [Apartment Address(1) ]. ([Telephone/Fax (1) 1703]	[ "599.0", "507.0", "V45.82", "482.2", "276.2", "728.88", "482.41", "410.01", "518.81", "272.4", "348.1", "244.9", "428.0", "785.51" ]	icd9cm	[ [ [] ] ]	[ "96.72", "97.44" ]	icd9pcs	[ [ [] ] ]	13819, 13964	8481, 12923	380, 532	14113, 14122	2321, 7291	14455, 14954	1822, 1881		12990, 13796		13985, 14092		12949, 12967			14146, 14432										1896, 2302											7332, 8458																			275, 342																560, 1580																		1602, 1631	1647, 1806
3,242	141,968	1063	Discharge summary	report	Admission Date: [2163-8-11] Discharge Date: [2163-8-15] Service: ORTHOPAEDICS Allergies: Penicillins / Percocet / Heparin Agents Attending:[First Name3 (LF) 64] Chief Complaint: CC: Left hip pain Major Surgical or Invasive Procedure: [2163-8-11] Hip surgery History of Present Illness: HPI: 81 yo woman w/ PMH sig for s/p bovine AVR, periop A.Fib(on coum and amio), HTN, CAD, PTCA X2, PVD, hypercholesterolemia was walking with a cane got stuck in a rug and fell forward and onto her left hip. Denied any dizziness, lightheadedness, CP/palpitations and LOC after fall. Admitted to OSH, reveled a L hip fracture. Preop negative nuclear stress. She was at the OSH x 2d and admitted to ortho for Hip fracture. . Given preoperative FFP, and she underwent an uncomplicated ortho procedure, screw placed. Post op course notable for some hives on thigh and left ear, given 25 benadryl X 1. Pt also noted to be brady to 50s, not symptomatic, no intervention and transferred to medicine this morning. . Now pt states that the pain is controlled with medications. She has not moved her bowels since monday. not passing gas, but pt withholding voluntarily. +burping. Otherwise has no complaints. Denies any n/v. NO Chest pain or palpitations. ADLs: Pt lives at home, able to bathe herself, cook and clean dishes without assistence. Needs assistance with vaccuming. . mobility: After AVR, states walks with a cane. Uses a quad walker when she goes out. Able to drive car and goes to senior care place. Past Medical History: s/p avr [12-11] Afib. HTN CAD (s/p PTCA to D1 in 9/95, repeat PTCA, RCA 40-50%, per Dr. [Name (NI) 6931] note) s/p R CEA [2158] PVD hypercholesterolemia constipation osteoarthritis s/p cataract removal Social History: Lives in [Hospital1 6930] with daughter. Cigs: none ETOH: very rare Family History: non contributory Physical Exam: Admission: PE: T 97.3 BP 130/70 HR 51 RR 18 O2sat 95%2L I/O (8hrs) 600/432 . Genl: Elderly female lying in bed in no acute distress. HEENT: PERRL, EOMI Neck: supple, JVP flat R cea scar. NO carotid bruit. Pulm: CTAB CV: RRR, +SEM. Abd: Soft, nontender, non distended, obese Ext: trace edema bilaterally Neuro: CN II-XII intact. Intact sensation lower ext bilaterally. 5/5 strength bilat. Pertinent Results: [2163-8-11] 02:24AM PT-16.2* PTT-28.2 INR(PT)-1.7 [2163-8-11] 02:24AM PLT COUNT-188# [2163-8-11] 02:24AM NEUTS-88.1* LYMPHS-7.2* MONOS-4.1 EOS-0.4 BASOS-0.2 [2163-8-11] 02:24AM WBC-8.7 RBC-3.54* HGB-10.9* HCT-32.2* MCV-91 MCH-30.9 MCHC-34.0 RDW-14.5 [2163-8-11] 02:24AM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.9 [2163-8-11] 02:24AM GLUCOSE-141* UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-30 ANION GAP-12 . Imaging: [2163-8-11] CXR: Low lung volumes. Continued mild CHF. . persantine nuclear stress test ([2163-8-9]): NO anginal symptoms, no evidence of ischemia on ECG or images. . ECHO ([7-12]): The left atrium is 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 ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate mitral stenosis. Mild to moderate ([1-9]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape unavailable for review) of [2162-4-7], there is now a well-seated aortic bioprosthesis. The transaortic gradients are less. The mitral valve gradients are higher and the calculated mitral valve area is smaller. The pulmonary artery pressures are higher . Discharge labs: [2163-8-15] 06:25AM BLOOD WBC-7.1 RBC-2.99* Hgb-9.0* Hct-27.6* MCV-92 MCH-30.2 MCHC-32.7 RDW-15.0 Plt Ct-245 [2163-8-15] 06:25AM BLOOD Plt Ct-245 [2163-8-14] 05:00PM BLOOD Hct-29.4* [2163-8-14] 06:00AM BLOOD Plt Ct-209 [2163-8-14] 06:00AM BLOOD PT-15.9* PTT-29.2 INR(PT)-1.7 [2163-8-14] 06:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9 Brief Hospital Course: Assessment and plan: Pt is a 81 yof with afib, s/p avr, htn, cad admitted to OSH after a fall and L hip fx. Transferred to [Hospital1 18] for ortho surgery and mgmt. Transferred to medicine after surgery. . 1. Hip Fracture - Ortho service took the patient to OR and placed a screw and stabilized the hip. Postoperatively patient had serous drainage from the wound. The incision remained clean and intact. There were no signs of inction, but started prophylactily on clindamycin per ortho. This should be discontinued when the drainage from the site stops or when she is reevaluated by ortho. Recommend changing dressing TID. Warm soaks to left knee. . Briefly required oxygen 2 L postoperatively via nasal cannula secondary to atelectasis. Incetive spirometer given and pt weaned to room air by discharge. . Patient was able to walk with assistance from physical therapy. Pain was well controlled to allow her to ambulate. . Placed on Lovenox [Hospital1 ] to reduce the risk of hematoma. When INR > 2.0 lovenox should be discontinued. . Hct stable with 1-2 pt fluctuations, likely from blood loss during procedure. No signs of active bleeding and site looks stable without hematoma formation. Please recheck Hct in next 7 days and observe for signs of hematoma formation. . 2. S/p fall - fall likely mechanical given the circumstances. - Geriactics service was consulted who made following recs: - She will need assessment of fall risk, avoiding medications that predispose to falls, use of proper assistive device, regular exercise, proper foot care and footwear. . 3. Risk of delirium post op - Pt received 25mg benadryl for hives, which resolved. There was some concern for confusion on postoperative day one. However this was quickly cleared and patient remained clear for the rest of the admission free of fever and confusion. . 4. Atrial fibrillation - Pt in sinus rhythm on admission to the floor. Continued rate control with BB. Continued amio and AntiCoag with Coumadin (goal INR [2-10]). Will increase dose of coumadin on d/c to 2.5 mg and recheck coagulation studies tomorrow. . 5. HTN - Well controlled. - on atenolol, HCTZ . 6. CAD/hypercholesterolemia - on BB, Statin, Would hold ASA for now given low platelets, lovenox and coumadin. ASA was held in hospital given multiple agents she was on for anticoagulation. . 7. Communication - Was with her daughter [Name (NI) 2411] - [Telephone/Fax (1) 6932] Medications on Admission: atenolol 25mg po qd amiodarone 200mg po qd HCTZ 25mg po qd coumadin 4mg po qd ASA 325mg po qd lipitor 20mg po qd senna MVI Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for FEVER, PAIN. 12. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO once a day: please check INR every 2-3 days to monitor level. 13. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) shot Subcutaneous DAILY (Daily): continue until INR>2.0. 14. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) for 10 days. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: 1. Hip fracture 2. A. Fib 3. s/p AVR 4. HTN Discharge Condition: Stable, ambulatory with assist. Discharge Instructions: If you have fevers, chills, bleeding, shortness of breath, chest pain, please call your PCP or come to the ED. 1. Please continue to take all your medications and followup with all your appointments. 2. You will be on an antibiotic per orthopedics for your wound. 3. Continue to take coumadin and the rehab MD's will monitor and adjust this dose. Physical Therapy: Activity: Out of bed w/ assist wt bearing as tol per ortho Treatments Frequency: Wound care: Site: left incision Type: Surgical Change dressing: [Hospital1 ] Site: left hip Description: surgical site with staples, site well approximated, no s/s infection. Draining moderate amount of serous drainage. Care: dry dressing (abd pads) change [Hospital1 ]. Site: mid back Description: skin tear. pink, moist Care: antibiotic ointment as needed. Please change hip dressing tid-qid. Place warm compresses to knee (left). Monitor left knee abrasion and place dressing on top. [Month (only) 116] need topical neomycin. Monitor INR. Continue PT as outlined. Frequent pain assessment and treatmeent with medications. Followup Instructions: Dr [Last Name (STitle) ] follow up: [2163-8-31]. 11:00 am at [Hospital1 6933]. Ortho: Dr[Name (NI) 4016] office. You will have a f/u appt with Dr [Last Name (STitle) 1005] on [8-23] at 10:20 am, please arrive at 10 am for a pre-appt x-ray. Please call [Telephone/Fax (1) 1228] if you have questions. Where: [Hospital6 29] ORTHOPEDICS Phone:[Telephone/Fax (1) 5499] Date/Time:[2163-8-23] 10:00 Completed by:[2163-8-15]	[ "V58.61", "401.9", "V42.2", "E885.9", "414.01", "285.1", "820.21", "V45.82", "518.0", "427.31", "424.0", "272.0" ]	icd9cm	[ [ [] ] ]	[ "99.07", "79.35" ]	icd9pcs	[ [ [] ] ]	8530, 8607	4628, 7080	268, 297	8695, 8728	2345, 4233	9875, 9904	1893, 1911		7254, 8507		8628, 8674		7106, 7231			8752, 9100				4250, 4605						1926, 2326	9118, 9179	9201, 9201								9915, 10341																				210, 230														9214, 9852		325, 1548																		1570, 1787	1803, 1877
47,790	103,674	53657	Discharge summary	report	Admission Date: [2121-4-26] Discharge Date: [2121-5-2] Date of Birth: [2048-5-29] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 633] Chief Complaint: weakness, abdominal pain Major Surgical or Invasive Procedure: [First Name3 (LF) ] with stent placement History of Present Illness: Pt is a 72 y.o female with h.o metastatic [First Name3 (LF) 499] cancer to the liver s/p colostomy and urostomy ~6 years ago, no longer on chemo, who presented from home with 3 days of generalized weakness, fatigue, anorexia and [8-1] throbbing RUQ abdominal pain. Pt reports she has not eaten for 3 days due to fear of nausea and abdominal pain. Denies change in stool in ostomy (increase or decrease or blood/black), constipation, dysuria, but does report urine has appeared darker than usual. Otherwise, denies fever, chills, weight gain/loss, ST, URI, cough, cp, palpitations, rash, joint pain, paresthesias, weakness, headaches, dizziness. . Pt's daugther reports that pt has had recurrent choledocholithiasis with [Month/Year (2) ] and stent at [Last Name (un) 1724]. Last [Last Name (un) ] 1 month ago with stent extraction per pt's dtr. Pt was told she would need a CCY to prevent future recurrences. . In the ED, INnitial vitals T98.2, BP 114/79, HR 80, RR 16, sat 97% on RA recent T 99, BP 132/68, HR 110-113, RR 18-20 sat 96-100% Pt underwent an u/s that showed biliary dilation. Pt was given IV vanco and flagyl and PO keppra. Past Medical History: -metastatic [Last Name (un) 499] cancer with metastatis to the liver, off chemo for at least 6 months. S/p surgery resection colostomy and urostomy -recurrent choledocholithiasis -seizure disorder -depression/anxiety -recurrent UTI Social History: Pt lives alone. Dtrs nearby and helpful to pt. Denies ever smoking. Denies ETOH, drug use Family History: [Name (NI) 1094] mother with [Name2 (NI) 499] and breast ca pt's dtr with breast ca Physical Exam: GEN: NAD, lying in bed, appears nervous vitals: T98.8, Bp 114/68, HR 110, RR 20 sat 99% on RA HEENT: ncat +icterus, MMM neck: supple, no LAD, no JVD chest: b/l ae no w/c/r heart: s1s2 rr no m/r/g abd: +bs, soft, NT, ND, no guarding or rebound, +ostomy with brown stool. Urostomy with [Location (un) 2452] urine back: non tender ext: no c/c/e 2+pulses neuro: AAOx3, CN2-12 intact, motor [4-26] x4, sensation intact to LT, slight oral and L.hand pill rolling tremor psych: slightly anxious, cooperative skin: jaundiced Pertinent Results: Labs at [Last Name (un) 1724] [1-/2121] tbilo 0.6, alt 25, ast 15, CEA 7.6 . [2121-4-26] 12:16PM GLUCOSE-130* UREA N-18 CREAT-0.9 SODIUM-130* POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-17* ANION GAP-17 [2121-4-26] 12:16PM estGFR-Using this [2121-4-26] 12:16PM ALT(SGPT)-148* AST(SGOT)-116* ALK PHOS-892* TOT BILI-7.4* [2121-4-26] 12:16PM LIPASE-14 [2121-4-26] 12:16PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-1.7* MAGNESIUM-1.8 [2121-4-26] 12:16PM WBC-13.4* RBC-3.76* HGB-10.3* HCT-34.5* MCV-92 MCH-27.4 MCHC-29.9* RDW-14.0 [2121-4-26] 12:16PM NEUTS-91.8* LYMPHS-4.4* MONOS-3.5 EOS-0.3 BASOS-0.1 [2121-4-26] 12:16PM PLT COUNT-307 [2121-4-26] 12:16PM PT-17.0* PTT-74.4* INR(PT)-1.6* [2121-4-26] 12:14PM LACTATE-1.7 [2121-4-26] 12:10PM URINE HOURS-RANDOM [2121-4-26] 12:10PM URINE UHOLD-HOLD [2121-4-26] 12:10PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.007 [2121-4-26] 12:10PM URINE BLOOD-TR NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-6.5 LEUK-SM [2121-4-26] 12:10PM URINE RBC-2 WBC-24* BACTERIA-MOD YEAST-NONE EPI-0 [2121-4-26] 12:10PM URINE AMORPH-FEW . RUQ u/s: IMPRESSION: 1. Intra- and extra-hepatic biliary ductal dilatation and some gallbladder wall sludge. The biliary stent is visualized in the distal duct. Based on this patient's clinical symptoms consistent with cholangitis and prior history of cholelithiasis, [Year/Month/Day ] would be most beneficial for further evaluation. 2. Multiple hepatic masses consistent with known metastatic [Year/Month/Day 499] cancer. . [Year/Month/Day ] [3-27]: Impression: 1. Successful balloon sweep of the extrahepatic biliary ducts. 2. Removal of the double pigtail biliary stent and a calculus from the common bile duct. . CXR-There are new bilateral consolidations and bilateral pleural effusions, not seen on the limited view of the CT abdomen. In addition, there is potentially present left mid lung consolidation and right apical consolidation. Patient has azygos lobe, anatomical variant. Heart size is normal. Mediastinal contours are unremarkable. Port-A-Cath catheter tip is at the level of mid SVC. Overall, the findings might be consistent with bilateral effusions and bibasal consolidations reflecting pneumonia, although atelectasis is another possibility. Port-A-Cath placement is unremarkable with the tip in the appropriate location. Biliary stent is projecting over the right upper abdomen. . Echo: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: No endocarditis, abscess or significant valvular regurgitation seen. Normal regional and global biventricular systolic function. . MRCP IMPRESSION: 1. Examination is severely limited and had to be terminated due to combination of factors including multiple artifacts noted in the upper abdomen related to prior surgery and metallic hardware in the lower abdomen, inability of patient to breath-hold and lack of peripheral IV line. 2. There are new bilateral pleural effusions and atelectasis in the lower lobes bilaterally. 3. Extensive metastatic disease within the left lobe of the liver with complex cystic lesion also noted within segment II, which is more impressive when compared to outside hospital CT from [Month (only) 958] [2120].Overall, the size of both the right and left lobes of the liver have increased by 1 cm (measured craniocaudially) 4. There has been interval decompression of the right intrahepatic biliary tree when compared to prior outside hospital imaging. A pigtail stent is noted in the distal common bile duct with marked decompression compared to prior CT. Sludge and gallstones are noted dependently within the gallbladder without evidence for acute cholecystitis. The common bile duct cannot be assessed in full due to due to artifacts in the upper abdomen and presence of a double-pigtail stent. However, 3 stones are noted in the distal CBD. 5.The left-sided bile ducts are filled with likely sludge or even tumor de ris. Tumor is seen surrounding the left intra-hepatic biliary tree. : . [2121-4-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-27] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2121-4-27] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2121-4-27] 7:15 pm BLOOD CULTURE Source: Line-POC. Blood Culture, Routine (Preliminary): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. SENSITIVE TO Daptomycin MIC = 3.0MCG/ML, Sensitivity testing performed by Etest. HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S [Year/Month/Day ]------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R [2121-4-27] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-27] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2121-4-26] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] [2121-4-26] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {VIRIDANS STREPTOCOCCI}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2121-4-26] BLOOD CULTURE Blood Culture, Routine-PENDING [2121-5-2] 05:45AM BLOOD WBC-6.4 RBC-2.65* Hgb-7.4* Hct-24.3* MCV-91 MCH-27.9 MCHC-30.5* RDW-15.0 Plt Ct-295 [2121-5-1] 05:30AM BLOOD WBC-6.0 RBC-2.75* Hgb-7.4* Hct-24.9* MCV-90 MCH-27.0 MCHC-29.8* RDW-14.3 Plt Ct-291 [2121-4-30] 06:11AM BLOOD WBC-4.5 RBC-2.68* Hgb-7.3* Hct-24.0* MCV-90 MCH-27.2 MCHC-30.3* RDW-14.2 Plt Ct-292 [2121-4-29] 03:04PM BLOOD Hct-26.6* [2121-4-29] 12:50AM BLOOD WBC-6.2 RBC-2.63* Hgb-7.2* Hct-23.6* MCV-90 MCH-27.4 MCHC-30.5* RDW-14.2 Plt Ct-230 [2121-4-28] 02:06PM BLOOD WBC-7.4 RBC-2.77* Hgb-7.6* Hct-25.1* MCV-91 MCH-27.4 MCHC-30.2* RDW-14.3 Plt Ct-252 [2121-4-28] 03:30AM BLOOD WBC-7.2 RBC-2.63* Hgb-7.3* Hct-24.1* MCV-92 MCH-27.7 MCHC-30.2* RDW-14.0 Plt Ct-224 [2121-4-27] 10:39PM BLOOD WBC-7.9 RBC-2.57* Hgb-7.2* Hct-23.5* MCV-92 MCH-28.0 MCHC-30.5* RDW-14.9 Plt Ct-184 [2121-4-27] 07:15PM BLOOD Hct-24.5* [2121-4-27] 03:00PM BLOOD Hct-24.6* [2121-4-27] 05:33AM BLOOD WBC-12.9* RBC-3.03* Hgb-8.5* Hct-27.2* MCV-90 MCH-28.0 MCHC-31.2 RDW-13.9 Plt Ct-246 [2121-4-26] 12:16PM BLOOD WBC-13.4* RBC-3.76* Hgb-10.3* Hct-34.5* MCV-92 MCH-27.4 MCHC-29.9* RDW-14.0 Plt Ct-307 [2121-4-28] 03:30AM BLOOD Neuts-81* Bands-5 Lymphs-7* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-1* [2121-4-28] 03:30AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2121-4-28] 03:30AM BLOOD PT-13.8* PTT-29.5 INR(PT)-1.3* [2121-5-2] 05:45AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-137 K-4.4 Cl-111* HCO3-23 AnGap-7* [2121-5-1] 05:30AM BLOOD Glucose-89 UreaN-3* Creat-0.6 Na-139 K-3.7 Cl-110* HCO3-23 AnGap-10 [2121-4-30] 06:11AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-139 K-3.9 Cl-111* HCO3-23 AnGap-9 [2121-4-29] 12:50AM BLOOD Glucose-119* UreaN-6 Creat-0.7 Na-135 K-3.6 Cl-111* HCO3-21* AnGap-7* [2121-4-28] 02:06PM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-138 K-4.1 Cl-112* HCO3-20* AnGap-10 [2121-4-28] 03:30AM BLOOD Glucose-66* UreaN-9 Creat-0.6 Na-141 K-4.1 Cl-116* HCO3-19* AnGap-10 [2121-4-27] 07:15PM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-142 K-4.4 Cl-117* HCO3-19* AnGap-10 [2121-4-27] 05:33AM BLOOD Glucose-113* UreaN-10 Creat-0.8 Na-135 K-3.0* Cl-108 HCO3-19* AnGap-11 [2121-4-26] 12:16PM BLOOD Glucose-130* UreaN-18 Creat-0.9 Na-130* K-3.6 Cl-100 HCO3-17* AnGap-17 [2121-5-2] 05:45AM BLOOD ALT-25 AST-23 AlkPhos-556* TotBili-1.7* [2121-5-1] 05:30AM BLOOD ALT-31 AST-25 AlkPhos-530* TotBili-1.9* [2121-4-30] 06:11AM BLOOD ALT-37 AST-25 AlkPhos-482* TotBili-2.1* [2121-4-29] 12:50AM BLOOD ALT-46* AST-28 CK(CPK)-33 AlkPhos-440* TotBili-2.2* [2121-4-28] 03:30AM BLOOD ALT-55* AST-32 LD(LDH)-179 AlkPhos-437* TotBili-3.1* [2121-4-27] 05:33AM BLOOD ALT-99* AST-63* AlkPhos-657* TotBili-6.0* [2121-4-26] 12:16PM BLOOD ALT-148* AST-116* AlkPhos-892* TotBili-7.4* [2121-4-26] 12:16PM BLOOD Lipase-14 [2121-5-2] 05:45AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8 [2121-5-1] 05:30AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0 [2121-4-30] 06:11AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.3 [2121-4-29] 12:50AM BLOOD Calcium-7.0* Phos-2.6* Mg-1.9 [2121-4-28] 02:06PM BLOOD Calcium-7.8* Phos-2.5* Mg-2.3 [2121-4-27] 07:15PM BLOOD Calcium-7.9* Phos-2.8 Mg-1.5* [2121-4-27] 05:33AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.6 [2121-4-26] 12:16PM BLOOD Albumin-3.4* Calcium-9.1 Phos-1.7* Mg-1.8 [2121-4-30] 06:11AM BLOOD CEA-7.3* AFP-2.0 [2121-4-27] 07:20PM BLOOD Lactate-0.8 [2121-4-26] 12:14PM BLOOD Lactate-1.7 [2121-4-30] 06:33AM BLOOD CA [27]-9 -PND Brief Hospital Course: Assessment/Plan: Pt is a 72 y.o female with h.o metastatic [Year (2 digits) 499] cancer with known metastasis to the liver, depression, who presented with weakness and was found to have cholangitis and enterococcal and strep viridans sepsis. . #Sepsis-due to polymicrobial bacteremia (VRE, strep viridans) and due to cholangitis/biliary obstruction. Pt was found to have fever, RUQ pain, transaminitis and bile duct obstruction. She was started on cipro and flagyl upon admission as well as IV vanco given her recent instrumentation/[Year (2 digits) ] at OSH 1 month ago with stent pull. Pt underwent an [Year (2 digits) ] on [4-27] finding biliary pus and a large obstructing stone that could not be removed. A plastic stent was placed. Pt will need a repeat [Month/Day (4) ] in 1 month at [Hospital6 1597] for stent extraction. The day of pt's [Hospital6 ], she developed severe sepsis and required many liters of IVF. She was transferred to the ICU after the [Hospital6 ] for further monitoring. In the ICU, pt received continued aggressive IVFs. Her BP improved and she was then transferred back to the medical floor. Initial BCX from the periphery grew strep viridans and another BCX in the setting of hypotension grew VRE from the port sample. AFter this, the ID service was consulted. The final ID recommendation was to place pt on IV daptomycin during admission and switch to [Hospital6 11958] to complete a 2 week total course for bacteremia (600mg [Hospital6 11958] [Hospital1 ]), 11 more days after discharge. Port/line infection was considered. However, only 1 blood culture from the line was positive with subsequent cultures negative and prior cx's negative. It was not recommended that the patient have her line/port removed at this time unless subsequent cultures return positive. Pt will be treated with cipro/flagyl for 10 days for cholangitis. TTE did not show endocarditis. LFTs improved as did jaundice. -would recommend weekly cbc, lfts, chem 7 while on [Hospital1 11958] and given recent cholangits. MONITOR CLOSELY FOR SEROTONIN SYNDROME WHILE PT IS ON [Name (NI) ] AND SSRI . #biliary obstruction/obstructive jaundice/transaminitis-Pt with known liver mets and history of cholangitis/cholelithiasis. Pt presented this admission with sepsis and cholangitis. The physicians at [Last Name (un) 1724] had been recommending that the patient undergo consultation with Dr. [Last Name (STitle) 7504] at [Hospital1 18] for consideration of CCY and ?hepatic metastasis resection. MRCP was performed showing progression of hepatic metastasis as well as cholelithiasis and biliary sludge. The patient was discussed at hepatobiliary surgical conference. The team will likely be performing a CCY in the outpatient setting after treatment for cholangitis/bacteremia. The appointment has been set up with Dr. [MD Number(4) 110191] below. Pt will need a repeat [MD Number(4) ] in 1 month's time for stent extraction at [Hospital6 2561]. . #metastatic [Hospital6 499] cancer-s/p resection, urostomy, ileostomy-Pt is no longer on chemo x 6 months. MRCP and U/S revealed the presence of hepatic metastasis. Pt should follow up with her outpatient oncologist for further care. . #Urinary tract infection-Pt treated with ciprofloxacin. . #non-gap metabolic acidosis-resolved . #anemia, normocytic-no current suggestion of active bleeding. Anemia worsened after agressive IVF. HCT upon discharge 24.3. No signs of active bleeding during admission. . #seizure d/o-continued keppra. . #depression/anxiety-continued venlafaxine/clonazepam. Social work was consulted. PLEASE MONITOR FOR SEROTONIN SYNDROME WHILE PT IS ON AN SSRI . #FEN-regular low fat . #ppx-hep SC TID . #access-PIV . #communication-letter sent to PCP, [Name10 (NameIs) ] Team HCP [Name (NI) ] [Telephone/Fax (1) 110192] . #code-full, discussed with pt and HCP Medications on Admission: clonazepam 0.5mg [Hospital1 ] ciprofloxacin 500mg [Hospital1 ] levetiracetam 500mg [Hospital1 ] venlafaxine ER 75mg daily cyanocobalamin 500mcg, 2 tabs daily ferrous sulfate 325mg daily prochlorperazine 10mg suppository daily Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. [Hospital1 11958] 600 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days: MONITOR FOR SEROTONIN SYNDROME. 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:8 Tablet(s) Refills:0 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. Disp:12 Tablet(s) Refills:0 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port. 13. Outpatient Lab Work WEEKLY CBC, LFTS, CHEM 7 WHILE ON [Hospital1 ] THERAPY Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [First Name4 (NamePattern1) 6107] [Last Name (NamePattern1) ] - [Location (un) 3786] Discharge Diagnosis: -sepsis due to cholangitis and Strep viridans, enteroccal bacteremia -bile duct obstruction/obstructive jaundice -urinary tract infection . Chronic -metastatic [Location (un) 499] cancer with hepatic metastasis, s/p urostomy, ileostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a severe infection in your bile ducts and blood stream. For this, you were given antibiotics, aggressive IV fluids and underwent an [Location (un) ]. The [Location (un) ] confirmed infection in your bile ducts and also found a large stone. You had a stent placed and will need to have a repeat [Location (un) ] done in 1 month's time for stent removal at [Hospital3 ]. . You will need to continue your antibiotics upon discharge. . medication changes: 1.start PO [Hospital3 ] 600mg twice a day for 11 more days 2.cipro/flagyl for 4 more days . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: PCP-[Name10 (NameIs) ] have your rehab facility call to make an appointment with your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6099] at [Telephone/Fax (1) 56399] upon discharge. . GI-please be sure to follow up with Dr. [Last Name (STitle) 73382] at [Hospital3 ] for a repeat [Hospital3 ] within 1 month for stent removal. . Department: TRANSPLANT CENTER-surgery When: THURSDAY [2121-5-15] at 3:45 PM With: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Please also be sure to follow up with your primary oncologist upon discharge.	[ "311", "785.52", "574.51", "V87.41", "V44.3", "427.89", "300.00", "038.0", "293.0", "V10.05", "275.3", "276.2", "345.90", "276.1", "V16.0", "995.92", "292.81", "599.0", "V16.3", "576.1", "V13.02", "197.7", "V44.6", "E939.4", "285.9" ]	icd9cm	[ [ [] ] ]	[ "51.87", "51.88" ]	icd9pcs	[ [ [] ] ]	18394, 18548	12896, 16817	295, 342	18832, 18832	2566, 7939	19712, 20555	1913, 2006		17105, 18371		18569, 18811		16843, 17082			19008, 19479										2021, 2547						7983, 12873																			19499, 19689					231, 257																370, 1531										18847, 18984								1553, 1790	1806, 1897
64,182	158,495	38837	Discharge summary	report	Admission Date: [2167-11-4] Discharge Date: [2167-11-11] Date of Birth: [2126-12-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: Hypoxia/altered Mental Status Major Surgical or Invasive Procedure: Intubation History of Present Illness: 40M w/ recent onset cirrhosis, recent w/u for transplant likely NASH. Went back to [State 1727] to sort out insurance, and was having chronic diarrhea when he presented to [Hospital6 ] in early [Month (only) ] for diarrhea/nausea and was d/c'd [10-19]. He represented on [10-25] with chills, diarrhea, vomitting and 2 syncopal episodes after standing from seated position. He was noted to have waxing and [Doctor Last Name 688] mental status and had paracentesis [10-26] which showed 140 wbcs w/ 51% polys. There is no culture data available. His mental status continued to wax and wane over the next few days but he was ambulatory and A/Ox2. Over night [Date range (1) 17948] he became acutely non-responsive after vomiting large amounts of feculent material. His WBC increased to 16.5 and he was intubated for airway protection. After intubation he required norepinephrine and got a CVL. He was started empirically on vanc/zosyn. CT abd did not show obstruction. . In ICU [Hospital6 8432] BP 107/61 map 77, HR 74, 16, 36.4 [Telephone/Fax (1) 86204] . In Flight, patient was given some ativan for agitation, and his FiO2 was increased to 60% for transport, up from 30% while on the floor. . On the floor, the patient was stable, and his FiO2 was initially decreased to 50%. CVP was 14 w/ PEEP 5. Past Medical History: -Child-[Doctor Last Name 14477] Score 11/ class C cirrhosis/NASH -Crohn's Disease since age 13, s/p ex lap, no history of bowel resection -H. pylori -Primary Biliary cirrhosis (diagnosed at St.[Hospital 11042] hosp?) -R. Hydrothorax ([2167-4-6]) transudative effusion -Morbid obesity/OSA -Anemia of Chronic Dz. episode with Hgb 7.5(Hospt with transfusions [2167-10-2]) - [Hospital 1725] Hospital. -Hyperkalemia/Hypoalbuminemia -Depression/Adjustment Disorder -?Inguinal Hernia on the Right side Social History: Reports being an active in martial arts prior to recent decompensation. Denies tobacco, reports occ. EtOH use. No IVDU. Previously lived in [State 8780], recently moved back to [State 1727] (lives in/near [Location (un) ], [State 1727]). Currently not working. Married and divorced twice with last divorce 2 years ago. Has grandmother who is involved in his care. Family History: No family history of cardiac disease, liver disease, cancer or renal failure. Mother bipolar d/o. Father emphysema, CAD. Physical Exam: On transfer to [Hospital1 18] MICU: Vitals: T:96.5 Oral BP:107/78 P: 92 on Vent FiO2:51% O2Sat 99% General: NCAT, intubated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral air entry with decreased breath sounds over Lower Right lung field. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, obese, no organomegaly, some ascites noted. GU: Foley in place Ext: warm, well perfused, 2+ pulses, +2 pitting edema bilaterally, +1 edema in upper extremities. Pertinent Results: [2167-11-4] 07:34PM O2 SAT-76 [2167-11-4] 07:34PM TYPE-CENTRAL VE TEMP-35.6 RATES-/15 TIDAL VOL-550 PEEP-5 O2-50 PO2-45* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED VENT-SPONTANEOU [2167-11-4] 07:43PM O2 SAT-93 [2167-11-4] 07:43PM TYPE-CENTRAL VE PO2-109* PCO2-36 PH-7.44 TOTAL CO2-25 BASE XS-0 [2167-11-4] 08:30PM PLT COUNT-191 [2167-11-4] 08:30PM NEUTS-81.0* LYMPHS-12.6* MONOS-3.3 EOS-2.6 BASOS-0.5 [2167-11-4] 08:30PM WBC-8.2 RBC-2.53* HGB-7.8* HCT-24.7* MCV-98 MCH-30.8 MCHC-31.6 RDW-17.4* [2167-11-4] 08:30PM TRIGLYCER-56 [2167-11-4] 08:30PM ALBUMIN-2.2* CALCIUM-7.3* PHOSPHATE-3.1 MAGNESIUM-2.0 [2167-11-4] 08:30PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-81* ALK PHOS-86 TOT BILI-1.6* [2167-11-4] 08:30PM estGFR-Using this [2167-11-4] 08:30PM GLUCOSE-82 UREA N-14 CREAT-0.9 SODIUM-143 POTASSIUM-3.8 CHLORIDE-115* TOTAL CO2-24 ANION GAP-8 [2167-11-4] 09:19PM URINE GRANULAR-0-2 [2167-11-4] 09:19PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2167-11-4] 09:19PM URINE BLOOD-TR NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2167-11-4] 09:19PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.044* [2167-11-4] 09:19PM URINE OSMOLAL-704 [2167-11-4] 09:19PM URINE HOURS-RANDOM UREA N-554 CREAT-355 SODIUM-14 POTASSIUM-GREATER TH CHLORIDE-25 [2167-11-4] 09:24PM TYPE-ART TEMP-35.8 RATES-/14 TIDAL VOL-550 PEEP-5 O2-50 PO2-118* PCO2-36 PH-7.45 TOTAL CO2-26 BASE XS-2 INTUBATED-INTUBATED VENT-SPONTANEOU . CT abd: 1. No suspicious hepatic lesions identified. Known underlying fatty infiltration of the liver with sequelae of portal hypertension noted including recanalized paraumbilical vein. Third spacing involving the gallbladder wall with mild amount of intra-abdominal ascites and mesenteric induration and mild cecal/ascending colonic edema, all likely secondary to underlying portal hypertension. 2. Scattered enlarged mesenteric lymph nodes, presumably reactive. Mild dilatation and air-fluid levels of the small bowel suggestive of mild ileus. 3. Moderate right simple pleural effusion. New infectious or inflammatory centrilobular and tree-in-[Male First Name (un) 239] opacities within the left lower lobe with mild bronchiectasis and bronchial wall thickening. 4. Conventional arterial anatomy. Accessory right hepatic vein draining into the IVC. . Echo: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are most consistent with normal left ventricular diastolic function. 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 appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2167-5-7], the detected pulmonary artery systolic pressure is lower. . Left upper ext U/s: No DVT in left upper extremity. . CXR: As compared to the previous radiograph, there is unchanged position of a left PICC line and a nasogastric tube. Unchanged presence of a right pleural effusion. However, the extent of the effusion has decreased in the interval. . RUQ U/S: 1. Limited study due to large amount of bowel gas obscuring portions of the left hepatic lobe and the pancreas. 2. Where visualized, no focal liver lesion is seen. 3. Left portal vein not visualized due to bowel gas, otherwise hepatic vasculature is patent. In particular, main and right portal veins are patent with normal hepatopetal flow. 4. Evidence of portal hypertension, with splenomegaly and small ascites. 5. Right pleural effusion. . CT head: No evidence of acute intracranial process. Brief Hospital Course: Mr. [Known lastname 1182] is a 40 year old man with a history of ESLD [3-10] NASH, transferred here for acutely decompensated encephalopathy with intubation for airway protection. . # Encephalopathy - likely [3-10] decreased bowel movements from ileus. CT head negative for bleed at OSH. Ileus likely caused by electrolyte abnormalities from 2 months of preceding diarrhea and pt had bowel surgeries in the past for Crohn's disease with small bowel/colonic anastomoses. CT scan showed bowel edema which may be [3-10] ascites and can cause malabsorption. Pt has been oriented and non-encephalopathic since extubation. Having several bowel movements on lactulose. Rifaximin was started as well. Will continue these as outpt. . # Ileus - as above, likely from electrolyte abnormalities from chronic diarrhea. No evidence of complete SBO at OSH, erythromycin was started then discontinued to help move bowels. Lactulose and rifaximin will be continued as outpt. Diet was successfully advanced and pt was able to tolerate full diet prior to discharge. . #ESLD/Cirrhosis - cirrhosis [3-10] NASH diagnosed on biopsy in [4-15], c/b ascites, recurrent R hydrothorax and encephalopathy. Unable to do diagnostic para because there was not enough fluid. Pt began to undergo liver transplant work-up on this admission. We continued Lactulose, rifaximin. Ultrasound of liver showed no signs of thrombosis or flow impedance. CT scan did not show suspicious liver lesions. Echo and PFTs were done as part of transplant work-up. Increased lasix dose and spirinolactone to manage peripheral edema. Has recurrent R side hydrothorax which was drained once on initial presentation in [4-15]. Stable on CXR and not drained on this admission given pt's good respiratory status. Will follow up with Dr. [Last Name (STitle) ] for the remained of pre-transplant evaluation. . # Aspiration - intubated at OSH for aspiration [3-10] vomiting feculent material from ileus. CXR showed signs of aspiration pneumonitis, pt completed a 7-day course of vanc/zosyn. Prior to discharge had no oxygen requirement and was afebrile. All cultures were negative (of note, pt had one culture at OSH that grew Propionobacterium, which was likely a contaminant). . # Anemia - HCT around 23-24 throughout admission. Received 2U RBCs on [11-9]. No evidence of active bleeding, no blood in stool, likely chronic. No evidence of hemolysis. Will follow this up as outpt. Encouraged pt to take home iron supplement. Medications on Admission: Medications: 1. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:0 2. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). . OUTPATIENT meds: 1. Melatonin 6 at bedtime 2. Vitamin D3 1000 daily 3. Iron chews 3 times daily 4. Vit C 500 D 5. Spironolactone 100 dialy 6. Zofran q6h PRN nausea 7. Lasix 40 daily 8. Oxycodone 5/500 two tabs q6hrs prn pain. . MEDICATIONS ON TRANSFER: 1. Versed 5mg q 5 minutes as needed for agitation/anxiety 2. Lactulose Enema 200g/L Twice Daily 3. Pantoprazole IV 40 daily 4. Rifaximin 200mg via NG Q8hrs 5. Spironolactone 50mg NG Daily 6. Vancomycin 1000 IV Q8 7. Zosyn 4.5Gm q6hrs [11-3] 8. Norepinephrine 4mg -8mg Continuous infusion 9. Propofol (as needed for sedation) 10.Vitamin D 1000 daily 11. Vitamin C 500 daily 12. Zofran IV 4mg q8hrs 13. Lasix 80mg NG daily 14. Albuterol Nebs 15. Potassium 20mEq NG [Hospital1 ] 16. Oxycodone as needed 10mg q2hrs for pain Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day: Please take one 50mg tablet and one 100mg tablet, for a total of 150mg of spironolactone every day. Disp:30 Tablet(s) Refills:2 3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please take a total of 150mg spironolactone a day. Disp:30 Tablet(s) Refills:2 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). Disp:1800 ML(s) Refills:2 5. furosemide 40 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)): Please take 60mg (1 1/2 tablets) of lasix in the morning and 40mg (1 tablet) of lasix in the evening. Disp:90 Tablet(s) Refills:2 6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. iron Oral 8. Zofran Oral 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-7] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Aspiration Pneumonia 2. Hepatic encephalopathy 3. Cirrhosis 4. Hydrothorax Discharge Condition: Alert, oriented x3 Self ambulating Discharge Instructions: You were transferred to [Hospital1 18] because of your breathing, confusion, and swelling in your extremities. You were intubated in the ICU and treated with antibiotics for a pneumonia. You were extubated successfully. Your confusion and swelling is due to your cirrhosis, liver disease. We started you on two medications called lactulose and rifaximin. These medications will help prevent confusion. Lactulose will cause you to have increased stools, you should have at least 3 bowel movements per day. We also started you spironolactone and increased your lasix dose, these are water pills that should help reduce the amount of swelling you have. While you were here we also started a transplant work up. You have an appointment to follow up with Dr. [Last Name (STitle) ] (see below) in the [Hospital 1326] clinic. . We have made the following changes to your medications: 1. Start lactulose, titrate to at least 3 bowel movements per day 2. Start rifaximin 3. Start sprinolactone 4. Increase lasix from 40mg daily to 60mg in the morning and 40mg in the afternoon 5. Stop oxycodone, because of your liver disease this will make you sleepy and confused 6. Albuterol as needed for wheezing . You can continue the rest of your medications. Followup Instructions: Please follow up with: . PCP [Name Initial (PRE) 648]: Wednesday, [11-18] at 1:30pm With: Dr. [First Name8 (NamePattern2) 3065] [Last Name (NamePattern1) 406] Phone: [Telephone/Fax (1) 86205] Where: [Hospital1 86206]. [Location (un) ], [State 1727] . Department: TRANSPLANT When: THURSDAY [2167-11-19] at 2:20 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2167-11-11]	[ "560.1", "572.2", "511.89", "276.51", "285.9", "211.3", "518.81", "787.91", "327.23", "571.5", "278.01", "507.0", "V12.79" ]	icd9cm	[ [ [] ] ]	[ "45.23", "38.91", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	12168, 12174	7485, 9992	348, 360	12296, 12333	3389, 7409	13643, 14277	2678, 2800		11006, 12145		12195, 12275		10018, 10428			12357, 13226										2815, 3370																						13255, 13620								279, 310																388, 1727		7418, 7462															10453, 10983	1749, 2265	2281, 2662
20,624	150,078	43931	Discharge summary	report	Admission Date: [2132-12-7] Discharge Date: [2132-12-14] Date of Birth: [2063-10-15] Sex: M Service: MEDICINE Allergies: Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base / Ciprofloxacin Attending:[First Name3 (LF) 3043] Chief Complaint: Weakness. Major Surgical or Invasive Procedure: none History of Present Illness: This a 69 yo man recently d/c'd from [Hospital1 ] [11-16] who presents [12-7] with weakness. Of note, this is his 16th admission of [2132]. He c/o one week history of total body aches, chills, cough (productive of black sputum, no blood), and sore throat. He previously was c/o left sided chest pain, but denies this currently. He does acknowledge poor po intake of food for the last week, unclear why, denies nausea, vomitting, diarrhea, constipation, abdominal pain. He denies arthralgias, rash. He notes everyone is sick at the shelter he has been staying at. He c/o sore throat. He denies HA, photophobia, neck stiffness. In the ED VS: 99.8 102 139/78 16 89% on RA -> 93% on 3L NC. He was given 1L NS, 1gm vancomycin, gentamycin 660mg gentamycin, and tamiflu 75mg po. ROS: 10 point review of systems negative except as noted above. Past Medical History: 1. Seizure history - describes as "[Doctor Last Name 11332] mal" but was previously described as "tonic-clonic" with bilateral arm shaking, no LOC. Was on Trileptal in the past, but was weaned off due to associated hyponatremia, now on Keppra. Followed by Dr. [First Name (STitle) 3322] [Name (STitle) ] (EEG negative 2/[2132]). Apparently seen at [Hospital1 336] in early [Name (NI) ], unclear of admission details, but no apparent change to seizure meds. 2. Headaches - taken multiple narcotics in the past to treat this, in addition to advil and tylenol. It was described in prior notes as starting on the left side of his head and radiating anteriorly and down his back. He also has had documented left face pain. 3. Type II DM 4. Peripheral neuropathy 5. Hypertension 6. Hypercholesterolemia 7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH) 8. GERD 9. Depression/Anxiety 10. Lumbar spinal stenosis w/ history C3/C7 fractures 11. Degenerative joint disease 12. Neurogenic bladder 13. s/p left cataract surgery [37]. Vitamin B12 deficiency 15. Atypical CP (last MIBI negative [3-10]) 16. Hyponatremia (baseline 128-131) 17. h/o multiple falls due to multifactorial gait ataxia, also followed by Dr. [First Name (STitle) 3322] [Name (STitle) ] 18. 8-mm thecal mass, stable over several years, consistent with nerve sheath tumor. 19. Likely prior left temporal infarct (per atrophy on head MRI) Social History: Homeless since [2131], stays at various shelters- most recently in [Location (un) 538]. Retired OR nurse, Buddhist monk. Sister with severe CAD living in [Name (NI) ] as only family. Tobacco: former smoker, ~45 pack year history (quit 30 years ago). Denies any current alcohol use since college. Denies any illegal substance use at any point. Also, per records: Pt has been living on the street for 3-4 months. Was engaged to a woman many years ago but broke it off. He states he had many relationships, and used to be bisexual. Now he is "celibate" since becoming a priest and is not in any relationship. Graduated from high school. College graduate. Worked on Masters. Attended nursing school. Buddhist priest x 25 years. Was working to counsel AIDS patients prior to becoming homeless. No social supports in [Location (un) 86]. All of his friends have passed away. Pt has a history of sexual abuse by his father's brother at age [6-8]. Never told anybody, no treatment. Was also physically abused by his father growing up. Currently patient reports he was left his nursing home a few days ago and has been staying in a hotel Family History: Mother died of esophageal cancer, ?EtOH abuse and depression. Father died suddenly of heart attack. Multiple family members with CAD including father, sister [Name (NI) ] at 58 yo), all 4 grandparents Type 2 DM (paternal grandfather) Physical Exam: VS: T 98.8 HR 90 BP 118/62 RR 24 Sat 93% 3L NC->88% RA->93% on 1L NC Gen: Chronically ill appearing man in NAD Eye: extra-occular movements intact, left pupil surgical, pupils reactive, [Name (NI) 3899] without nystagmus, 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: Transmitted upper airway sounds, refuses to cough to try to clear them, otherwise 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: Oriented x3 when pressed, CN II-XII intact, sensation normal, asterixis present, speech fluent but slow to answer questions, nods off in conversation, DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis, motor [5-6] UE, refuses to participate with motor in LE but withdraws to pain bilaterally, moves legs when rolling to the side for respiratory exam Integument: Warm, moist, no rash or ulceration Hematologic: no cervical or supraclavicular LAD Pertinent Results: Admit labs: CBC: WBC-11.7# RBC-4.78 HGB-12.4 HCT-38.6* MCV-81* MCH-25.8* MCHC-32.0 RDW-14.2 PLT COUNT-254; NEUTS-90.2* LYMPHS-6.3* MONOS-2.8 EOS-0.5 BASOS-0.2 BMP: GLUCOSE-215* UREA N-21* CREAT-1.3* SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 CK(CPK)-186* cTropnT-<0.01 LACTATE-1.8 CXR pa/lat [12-7]: wet read: rotated, underpenetrated, low lung volumes, bibasilar opacification, ? right base increased opacification, no definite volume overload, likely atelectasis. Micro: blood cx pending. ECG: ST (101), nl axis, intervals, QWIII (old), ? ST depressions in I but may be due to baseline artifact. on repeat NSR (88), improved ST segments in I. CT Chest [2132-12-11]: 1. Resolution of the left lower lobe consolidation with residual left lower lobe atelectasis and mild bronchiectasis. 2. New multifocal ground-glass opacities with mild bronchiolectasis and bronchiectasis, bronchial wall thickening and centrilobular nodules are likely due to a combination of recurrent aspiration--the patient has a moderate-to-large hiatal hernia--and concurrent atypical infection, probably viral. 3. Minimal increase in right lower lobe well-circumscribed nodule could be accounted for by differences in technique; follow up in one year would be prudent. 4. Diffuse triple vessel coronary artery and aortic valve calcification. KUB [2132-12-13]: Three views. Positioning is suboptimal. The bowel gas pattern is unremarkable. No free air is identified. There are no significant air-fluid levels on what appears to be a lateral decubitus view. Soft tissues and bony structures are unremarkable in appearance. IMPRESSION: Unremarkable, limited examination. Brief Hospital Course: Mr. [Known lastname 13469] is a 69 yo male who frequently presents with weakness, hypotension, hypoxia, often poorly responsive, and always with subsequent quick recovery. His course almost always includes aspiration pneumonitis, and to some degree renal failure due to hypotension. On this admission patient presented with to ED with complaints of weakness. Given that he was somnolent and had minimal O2 requirement, he was admitted for further evaluation and treatment. In the hospital he was ruled out for flu. His somnolence was best described as medication side effect. He did not respond to shaking or loud voice. To sternal rub, however he awoke, and threatened with violence if the staff would not let him sleep. His symptoms improved initially on the first day, and he became more alert and was weaned of supplemental oxygen. However the next day patient became somnolent again and poorly responsive. His oxygen desaturated and he had one time fever spike. Due to concern for aspiration and his hypoxia 85% RA, he was transferred to the ICU where he received broad spectrum antibiotics for possible nosocomial pneumonia (Meropenem, Vancomycin, Levofloxacin). Again he recovered within 24 hours, and was called out the ICU, alert and off oxygen. The episode was thought to be due to aspiration pneumonitis. His somnolence was thought to be due to hoarding his medication with intentional overdose. His antibiotics were discontinued. The MRSA colonies in his sputum were thought to represent colonization rather true MRSA pneumonia. This was supported by the sparse growth, rapid recovery, improved CT finding compared to past. The benign clinical presentation was most consistent with simple pneumonitis rather than any infection. It is recommended that he be observed taking his medications when in the hospital to prevent hoarding of medications. He complained of diffuse body pain throughout the admission, which was noted during multiple previous admissions. He has known L4-L5 spinal stenosis, for which he has seen neurosurgery in the past but failed to follow up. He had no objective findings for his pain. The remainder of his hospital course is significant for his poor cooperation with medical, nursing, and physical therapy staff. He refused to ambulate with assistance on multiple occasions due to pain and weakness, however when he felt unattended, he ambulated freely without support in his room from bed to bathroom. On the day of his discharge he refused to accept the discharge plan, reasoning that his crutches were stolen from him in this hospital. Of note this was at his bed side, but patient expressed the wish to have a different kind (Canadian Crutch), which unfortunately could not be accommodated as these were not available, furthermore he was provided many pairs of crutches in the past. We recommended him continue using his old ones. All his other chronic medical conditions were stable, and no change was made to his outpatient treatment plan. Medications on Admission: Amlodipine 10 mg PO DAILY Metoprolol Tartrate 25 mg PO BID Lisinopril 20 mg PO DAILY Simvastatin 80 mg PO DAILY Isosorbide Mononitrate 30 mg PO DAILY Levetiracetam 1000 mg PO BID Oxycodone 20 mg PO BID Duloxetine 60 mg PO DAILY Pantoprazole 40 mg PO Q24H Trazodone 100 mg PO HS (at bedtime) as needed for insomnia. Gabapentin 1200 mg PO Q12H Aspirin 81 mg PO once a day Docusate Sodium 100 mg PO BID Nitroglycerin 0.4 mg every six (6) hours as needed for chest pain. Ditropan XL 5 mg SR PO twice a day Humulin N 10 units Subcut qAM, 6 units Subcut qPM Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Ditropan XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO twice a day. 15. Humulin N 100 unit/mL Suspension Sig: One (1) injection Subcutaneous twice a day: 10 units s.c. qAM, 6 units s.c. qPM . Discharge Disposition: Home Discharge Diagnosis: Primary Aspiration pneumonia Narcotic overdose Secondary 1. Seizure disorder 2. Headaches 3. Type II DM 4. Peripheral neuropathy 5. Hypertension 6. Hypercholesterolemia 7. GERD 8. Depression/Anxiety Discharge Condition: oxygen saturation 100% Discharge Instructions: You wewre admitted with shortness of breath and fever. You were found to have mild lung infection from aspiration in the setting of somnolence by abusing your narcoics. . You can abbulate without difficulty and assistance. . Please stop abusing your narcotis. Please follow up with your primary care docotor for perscribtions and any other health concern. Followup Instructions: Please follow with your primary care docotor within 2 weeks	[ "596.54", "788.39", "327.13", "724.02", "356.9", "401.9", "V02.54", "305.50", "345.90", "E980.0", "965.8", "272.4", "V58.61", "785.0", "507.0", "E935.9", "250.00", "530.81", "338.29", "V60.0", "266.2", "799.02" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12091, 12097	7096, 10093	351, 358	12340, 12365	5389, 7073	12770, 12833	3898, 4138		10695, 12068		12118, 12319		10119, 10672			12389, 12747										4153, 5370																														302, 313																386, 1241																		1263, 2714	2730, 3882
82,038	189,923	40839	Discharge summary	report	Admission Date: [2197-7-23] Discharge Date: [2197-8-8] Date of Birth: [2172-8-20] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 371] Chief Complaint: Pedestrian struck by car Major Surgical or Invasive Procedure: [2197-7-23] D.L. PICC [2197-8-5] PEG History of Present Illness: This is a 24 year old female pedestrian struck at approximately 40mph, per EMS report "obliterated" windshield. Trauma STAT called to ED for altered mental status, on arrival GCS 3 with roving eye movements. Intubated immediately on arrival. Found to have a subdural and occipital condyle fracture as well as rib fractures and pneumothorax. Neurosurgery and orthopedics consult were placed. INJURIES: L SDH subtle parafalcine SAH bilateral posterior temporal bone fracture fracture through carotid canal, sella, sphenoid sinus L occipital condyle fracture R 1st, 4th, 5th rib fractures R small pneumothorax R scapular spine fracture L scapular fracture L clavicle fracture L superior ramus fracture L sacral fracture Past Medical History: None Social History: Supportive parents at bedside. Law student. Family History: Non-contributory. Physical Exam: On Admission: HR: 120 BP: 80 systolic Resp: 4 O(2)Sat: 93% Low Constitutional: The patient is brought in by the paramedics being bagged in boarded and collared. Her GCS is 4. HEENT: She has roving eye movements going to either side of the midline. Pupils are 3 mm and both reactive 2 mm. there is some blood in both nares but appears it may be from external source. No obvious step-off Chest: Bilateral breath sounds Cardiovascular: Normal first and second heart sounds Abdominal: Soft Extr/Back: No long bone findings. She has bilateral knee abrasions. The great toe on the right side is bleeding. Bilateral scapular and left hip abrasions but no step-off on the spine. Neuro: Her neurological evaluation is very limited. She is not speaking. She is not moving anything. Upon Discharge: T99.8 HR 106 BP 142/82 Resp 18 O2sat 98%onRA HEENT: She has appropriate movements. Pupils are equal and reactive. No obvious step-off Chest: Bilateral breath sounds Cardiovascular: Normal first and second heart sounds Abdominal: Soft, PEG site is clean and minimally tender Extr/Back: No long bone findings. She has bilateral knee abrasions. Bilateral scapular and left hip abrasions but no step-off on the spine. Neuro: She is speaking coherently with some word salad. Still some confusion Moving all four extremities with limited motion of R upper extremity. Follows commands. Pertinent Results: CT head ([2197-7-23]) - bilateral scapula fractures, fx of right posterolateral first, 4th and 5th rib, right pneumothorax, bilateral opacifications likely aspiration, however hemorrhage/contusion can't be excluded in setting of trauma CT [Month/Day/Year ] ([2197-7-23]) - No evidence of a fracture or malalignment in the cervical spine. Nondisplaced left occipital condyle fracture. The left occipital condyle articulates normally with the left lateral mass of C1. Temporal bone and skull base fractures are described in the concurrent head CT report. Nondisplaced fractures of the right first, second, and third ribs, with a small right apical pneumothorax. Biapical pulmonary contusions versus atelectasis. Enlarged and heterogeneous thyroid gland with a 1-cm nodule in the left lobe. This may be evaluated by son[Name (NI) 867] when the patient is stable. CT torso ([2197-7-23]) - Right pneumothorax. Bilateral opacifications, likely aspiration, however, hemorrhage or contusion cannot be excluded in the setting of trauma. Comminuted right scapular fracture, left lateral [Doctor First Name 362] scapular fracture. Left sacral fracture and superior ramus fracture. Left clavicular fracture. Bilateral lower extremity XR ([2197-7-23]) - There is no evidence of acute fracture or traumatic dislocation. There is no knee joint effusion bilaterally. No soft tissue calcifications or radiopaque foreign bodies are identified. Repeat CT head ([2197-7-23]) - Stable subdural hemorrhage along the left convexity, right tentorium, and posterior falx. Increased conspicuity of bihemispheric subarachnoid hemorrhage. Increased nodular hemorrhage in left temporal region, which could represent an evolving hemorrhagic contusion or nodular subarachnoid hemorrhage. Multiple skull base and bilateral temporal bone fractures are again noted. MR [Last Name (Titles) ] ([2197-7-23]) - Bone marrow edema in the left occipital condyle at the site of known fracture. No abnormalities in the cervical spine. MRA brain/neck ([2197-7-23]) - Technically limited neck MRA without evidence of obvious abnormalities. While evaluation for dissection or intramural hematoma is limited in the absence of axial T1-weighted fat-suppressed images, there is no irregularity in the carotid siphons to suggest an injury related to the bilateral sphenoid fractures. CT head ([2197-7-24]) - Stable subdural hemorrhage along the left cerebral convexity and right tentorium with minimally decreased hemorrhage along the posterior falx. Redistribution of subarachnoid hemorrhage with less conspicuity of bihemispheric subarachnoid hemorrhage. Nodular hemorrhagic focus in left temporal region is relatively stable in appearance and size compared with most recent prior examination. Multiple skull base fractures and bilateral temporal bone fractures are again noted. CT head ([2197-7-25]) - Stable small subdural hemorrhage and few residual small foci of subarachnoid hemorrhage. Stable left temporal hemorrhagic contusion with more prominent edema. CTA head/neck ([2197-7-25]) - Questionable small dissection flap in the right cavernous carotid artery near the known sphenoid fracture, versus artifact. Aberrant right subclavian artery. EEG ([2197-7-26]) - This is an abnormal routine EEG due to the presence of a slow background which represents a moderate encephalopathy. It is also abnormal due to the presence of bursts of generalized delta frequency slowing which may represent deep midline dysfunction. There was left hemisphere delta frequency slowing which represents focal subcortical dysfunction. There were no epileptiform discharges or electrographic seizures. MR head ([2197-7-27]) - Hemorrhagic contusion in the left temporal lobe. Several small foci of hemorrhage and diffusion abnormalities in the white matter suggest diffusion axonal injury. Shallow left-sided subdural fluid collection is slightly increased since the recent CT study. Fluid and blood in the bilateral mastoid air cells, sphenoid sinuses and the ethmoid air cells from recent trauma. [2197-8-3] CT sinus' : There are soft tissue changes in the left sphenoid sinus, likely related to trauma with blood products and small bony ossicles in the floor of the sinus, which have slightly changed, but better visualized on the initial head CT of [2197-7-23]. The right sphenoid sinus changes are new, could be related to intubation. Mucosal thickening is seen in the left maxillary sinus. No fluid levels are visualized in the sphenoid sinus and in the maxillary sinuses. [2197-7-23] 01:30AM WBC-9.8 RBC-3.82* HGB-11.2* HCT-32.4* MCV-85 MCH-29.3 MCHC-34.6 RDW-12.9 [2197-7-23] 01:30AM PT-14.5* PTT-29.4 INR(PT)-1.3* [2197-7-23] 01:30AM FIBRINOGE-229 [2197-7-23] 01:30AM ASA-NEG ETHANOL-236* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2197-7-23] 01:30AM UREA N-11 CREAT-0.7 [2197-7-23] 01:44AM HGB-11.2* calcHCT-34 O2 SAT-92 CARBOXYHB-6* MET HGB-0 [2197-7-23] 01:53AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Brief Hospital Course: [7-23]: The patient was initially admitted to the trauma ICU. On admission she was evaluated by Ortho Spine, Ortho Trauma and Neurosurgery. CSF leakage was initially draining from her right ear but slowed down and per Neurosurgery required no treatment. Per Ortho Spine was she was kept in a hard collar. Per Ortho Trauma her fractures were nonoperative and required slings. [7-24]: Her propofol was weaned to off. Her SBP was maintained at less than 160 per Neurosurgery. [7-25]: Her head CT and CTA's of her head and neck were repeated and were normal. Prophylactic heparin was started. [7-26]: She was noted to have thick secretions and was bronched, and a BAL was sent. Neurology was asked to see her for her failure to wake up off sedation. An EEG was obtained. [7-27] - [7-30]: An MRI was obtained which showed [Doctor First Name ]. Her mental status slowly improved and was noted to wax and wane. Precedex was utilized for agitation and her dilantin was discontinued. [7-31]: Ortho spine recommended c-collar for another 6-8 weeks. Neurology recommended a repeat EEG. She remains on minimal ventilator settings but is unable to extubate secondary to mental status. [8-1]: Her WBC was noted to be rising so cultures were repeated and a c.diff was ordered. Following transfer to the Surgical floor her WBC peaked at 23K and all cultures were negative except for some sparse growth of SA in a sputum culture without chest xray findings or symptoms. She remained afebrile off antibiotics and her WBC continued to trend down. It was 15K at the time of discharge. She was tolerating her tube feedings at goal rate and was seen by the Speech and Swallow therapist as her mental status improved. She was inconsistent in her ability to follow commands and as she was at such a high risk for silent aspiration she underwent a video swallow on [2197-8-8] which indicated she was ready for trials by mouth of thick liquids like honey given by teaspoon. Both the Physical Therapy and Occupational Therapy services evaluated her on a daily basis and noted modest progression. Her attention span was gradually longer and she was beginning to say a few words. The Physical Therapist was limited in increasing her mobilization as she was non weight bearing to both upper extremities, required a hard cervical collar and she was impulsive. Nevertheless she was out of bed and attempting gait training. Her speech has improved immensely and she can give coherent responses. She is moving all her extremeties with limited movement of her R upper extremity. After an unfortunate accident she was transferred to rehab on [2197-8-8] for vigorous physical and cognitive therapy in the hopes that she will get back to her baseline in time. Medications on Admission: OCP Discharge Medications: 1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO Q6H (every 6 hours). 5. oxycodone 5 mg/5 mL Solution Sig: 5-10 mls PO Q4H (every 4 hours) as needed for pain. 6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation . Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: S/P Pedestrian struck 1. Right SAH 2. Left SDH and right tentorium 3. Bilateral scapular fractures 4. Bilateral temporal bone fractures 5. Left occipital condyle fracture 6. Comminuted fractures of both sphenoid sinus walls 7. Left sacral fracture and superior ramus fracture 8. Right rib fractures 1, [5-16] 9. TBI 10.Right pneumothorax 11.Tracheobronchitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable and sometimes agitated and impulsive Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital after being hit by a car. You sustained multiple injuries including head injuries and broken bones. Currently you are making slow progress and you are being transferred to rehab so that you can get vigorous therapy for your head injury. You will need to work hard with the Occupational Therapists and Physical Therapists so that you can get back to your baseline. * Even though you are going to rehab you will still need to come back to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] so that you can follow up with your doctors [Name5 (PTitle) ]. * Currently you are getting all of your nutrition thru a feeding tube in your stomach but that is only temporary until you can safely swallow. Therapists at the rehab will be testing your swallowing when they see fit. * You have bilateral scapula fractures which means that you cannot bear weight thru your upper extremities. You should have gentle range of motion to both shoulders to prevent frozen shoulder. * You will need to wear the hard cervical collar at all times for 8 weeks. Followup Instructions: Please follow up with Neurosurgery Dr. [First Name (STitle) ] on [8-31] at 2pm in theLowry Building [Hospital Unit Name 12193]. You will also need a CT scan of the brain at that time.... the CT is scheduled at 1pm (west, clinical ctr. 3rd fl). Please call our office at [Telephone/Fax (1) ] should any questions come up. Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [3-16] weeks. Call the [Hospital ] Clinic at [Telephone/Fax (1) 1228] for a follow up appointment in 4 weeks. Call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from Cognitive Neurology at [Telephone/Fax (1) 1690] for a follow up appointment in 4 weeks.	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62,641	188,485	3499+55480	Discharge summary	report+addendum	Admission Date: [2154-11-23] Discharge Date: [2154-12-2] Date of Birth: [2079-10-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 16063] is a 75M with history of atrial fibrillation on aspirin, non-small cell lung cancer status post neoadjuvant chemotherapy/radiation and excision, ulcerative colitis, and bladder cancer status post radical cystectomy and neobladder who presents from an outside hospital with atrial fibrillation with rapid ventricular response. At the outside hospital, he received IV diltiazem, and his rate decreased to 110s with blood pressure to the high 80s systolic. Of note, he was admitted recently to [Hospital1 69] from [Date range (1) 16065], during which time he developed rapid atrial fibrillation to 140s-150s in the setting of community-acquired pneumonia. On that admission, he was transferred to the medical ICU after he became hypotensive following 5mg IV metoprolol x3 for attempted rate control. Given a CHADS score of 1 at that time, the decision was made to anticoagulate with aspirin only in discussion with the patient's son. Through his son, the patient, who is primarily Russian-speaking, reports that he was in his usual state of health until the day prior to admission, when he developed palpitations. Upon awakening on the morning of admission, he felt lightheaded and dizzy and later developed an intermittent dull ache in his left chest, radiating to the ipsilateral shoulder, [5-21] in intensity and not reliably associated with activity. He endorses chills without documented fever, as well as mild shortness of breath at rest unchanged from baseline and without cough. He denies weight gain, paroxysmal nocturnal dyspnea/orthopnea, or peripheral edema. He has been exposed to relatives with upper respiratory symptoms, but has not himself experienced upper respiratory symptoms and denies dysuria/hematuria; chronic diarrhea in the setting of ulcerative colitis has been consistent with baseline. His son notes that his father typically develops atrial fibrillation in the setting of infection, however. In the ED, initial vital signs were as follows: 97.2, 102, 104/66, 16, 98% RA. Admission labs were notable for lactate of 2.4 (down to 0.8 with 4L IV fluids), Ca of 7.1, Hct of 29.9, and TnT <0.01. CTA demonstrated no pulmonary embolism or acute aortic pathology, but did reveal post-treatment changes to the left lung with trace bilateral pleural effusions and bibasilar opacities, which may reflect aspiration or atelectasis/scarring. He received diltiazem 10mg IV x2 and diltiazem 30mg PO x1. He also was given calcium gluconate 1g IV x1. Vital signs at transfer were as follows: 98.1, 115, 105/50, 18, 98% RA. 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: -Ulcerative proctitis with evidence of ulcerative colitis -Bladder cancer status post radical cystectomy and neobladder -Non-small cell lung cancer status post neoadjuvant chemotherapy/radiation and left thoracotomy, left upper lobectomy, left chest wall resection, ribs one through four -Small bowel obstruction -Pneumonia in [1-21] complicated by rapid atrial fibrillation and medical ICU admission Social History: He is a former welder who was born in Leningrad and moved to the United States in [2137]. He is married and has a son and a daughter, who is a physician. [Name10 (NameIs) ] smoked one pack per day over an uncertain period, but quit 12 years ago. He denies alcohol use. Family History: Son with atrial fibrillation, necessitating ablations. Physical Exam: On admission: VS: Afebrile, 110/64, 115, 94% 1L Telemetry: Atrial fibrillation, largely to 110s, occasionally to 140s GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctivae pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Left upper chest without sensation in the setting of past operative interventions. LUNGS: Respirations were unlabored, no accessory muscle use. CTAB, LUL quiet in the setting of past lobectomy, RLL crackles. ABDOMEN: Soft, NT/ND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. At discharge: Afebrile GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctivae pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Left upper chest without sensation in the setting of past operative interventions. LUNGS: Respirations were unlabored, no accessory muscle use. CTAB, LUL quiet in the setting of past lobectomy, RLL crackles. ABDOMEN: Soft, NT/ND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: CBC: 6.8 (76.4P,15.1L,7.5M)/29.9/473 Coags: 10.9/1/31.4 Lytes: 137/4.1/107/20/13/0.9/95 7.1/2.1/2.9 Cardiac enzymes: TnT <0.01 -> 0.01 Other: Lactate 2.4 -> 0.8 UA: Small blood, negative nitrite/leuks, 31 Rbc, 9 Wbc, no bacteria At discharge: Microbiology: UCx ([2154-11-23]): NG BCx x2 ([2154-11-23]): NG BCx ([2154-11-24]): NG BCx ([2154-11-25]): NG . EKG ([2154-11-23]): Atrial fibrillation with rapid ventricular response. Right axis deviation. Low limb lead voltage. Compared to the previous tracing of [2154-2-7] atrial fibrillation with rapid ventricular response has appeared and the axis is more rightward. Intervals Axes Rate PR QRS QT/QTc P QRS T 112 0 86 322/413 0 95 3 EKG ([2154-11-24]): Atrial fibrillation with rapid ventricular response. Low limb lead voltage and right axis deviation. Compared to the previous tracing of [2154-11-23] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 118 0 90 288/389 0 90 -9 . CXR PA/lateral ([2154-11-23]): Stable background chronic lung changes. Stable top normal heart size with evidence of volume overload consistent with provided diagnosis of right ventricular regurgitation. CTA chest with/without contrast ([2154-11-23]): 1. No pulmonary embolism or acute aortic pathology. 2. Changes of prior left upper lung and chest wall resection due to non-small cell lung cancer with multiple enlarged mediastinal and hilar lymph nodes concerning for recurrence with bibasilar septal thickening potentially related to pulmonary edema, with lymphangitic tumor infiltration is a less likely consideration. 3. Trace bilateral pleural effusions with bibasilar and lingular opacities, which could reflect aspiration or an infectious process. Due to nodular nature of the lingular opacity, short term interval follow up (6-8 weeks) is recommended, to assess for resolution. Portable CXR ([2154-11-25]): As compared to the previous radiograph, the post-surgical left lung is unchanged. In the right lung, there is an increase in interstitial markings, notably at the lung bases and in the right lower lung. In addition, there is blunting of the right costophrenic sinus, suggesting the presence of a small right pleural effusion. The size of the cardiac silhouette is unchanged. The findings in the right lung might represent a combination of pulmonary edema and pneumonia. CXR [2154-11-27] Patient has had left upper thoracoplasty, usually for tuberculosis or lung cancer. Heterogeneous opacification in the right lung has worsened since [11-23], probably pulmonary edema, accompanied by increasing small right pleural effusion. Predominant abnormality in the axillary region of the right upper lobe could be concurrent pneumonia, but I am not surprised by asymmetric distribution of edema in this patient with moderate-to-severe emphysema and scarring at the right lung apex. Heart size is normal, in the leftward shifted mediastinum. No pneumothorax. Labs at discharge [2154-12-2] 06:10AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.6* Hct-30.2* MCV-93 MCH-29.5 MCHC-31.8 RDW-15.8* Plt Ct-616* [2154-12-2] 06:10AM BLOOD Glucose-85 UreaN-16 Creat-0.9 Na-134 K-4.1 Cl-98 HCO3-29 AnGap-11 Brief Hospital Course: Mr. [Known lastname 16063] is a 75M with history of atrial fibrillation on aspirin, non-small cell lung cancer status post neoadjuvant chemotherapy/radiation and excision, ulcerative colitis, and bladder cancer status post radical cystectomy and neobladder who presents from an outside hospital with atrial fibrillation with rapid ventricular response. << Active Issues # Atrial fibrillation: On admission, patient was found to be in rapid atrial fibrillation, largely to 110s and transiently to 140s-160s with activity, but remained hemodynamically stable on short-acting diltiazem 60mg qid in place of home diltiazem ER 240mg daily, with blood pressures in the 100s-110s systolic. Although no clear reversible cause was initially apparent, he later developed signs of a possible community-acquired pneumonia, for which he was treated with antibiotics as below. On the morning of hospital day 2, he became transiently hypotensive (SBP mid-80s) and hypoxic (mid-80s% on room air), with improvement in blood pressure to the high-90s systolic and oxygen saturation to the low 90s% on room air on recheck. He received limited gentle hydration, with subsequent pressures of 90s to 120s throughout the remainder of admission. Following conversion to sinus rhythm on hospital day 2 without dedicated intervention, amiodarone load 400mg tid was initiated along with dabigatran 150mg [Hospital1 ]; use of dabigatran was discussed with gastroenterologist Dr. [First Name (STitle) 679], given known ongoing refractory ulcerative colitis. He was discharged on home ER diltiazem, amiodarone (400mg tid x1 week, 400mg [Hospital1 ] x1 week, 400mg daily x1 week, 200mg daily x1 week), and dabigatran, with close cardiology follow-up. # Community-acquired pneumonia: Although admission CTA chest demonstrated bibasilar and lingular opacities possibly reflective of aspiration or infection, antibiotics were held initially in the absence of clinical signs clearly attributable to pneumonia, including lack of fever, leukocytosis, or productive cough. When patient developed low-grade fever to 100.3, increased Wbc (6.8-6.9 to 10.5), and nonproductive cough in association with possible right lower lobe infiltrate on CXR, empiric treatment for community-acquired pneumonia with ceftriaxone/azithromycin was initiated. Unfortunately the patient became progressively more hypoxic despite adequate rate control for his atrial fibrillation and on [2154-11-26] was broadened to vancomycin/cefepime/azithromycin for HCAP coverage. He required a non-rebreather on the floor to keep O2 sats in the mid90s and as such was transferred to the MICU. He was given gentle diuresis as well at this time, his respiratory status improved and his was weaned to NC and called back to the floor on [2154-11-28]. Transient supplemental oxygen requirement was weaned by the time of discharge. He remained afebrile/hemodynamically stable without leukocytosis for the remainder of admission and was discharged on cefpodoxime and azithromycin, for a total 10 day antibiotic course. # Chest ache: In this patient with no known history of coronary artery disease, acute coronary syndrome in the setting of dull left chest ache was excluded on the basis of serial EKGs without acute ischemic changes and absence of troponinemia. Chest ache resolved without dedicated intervention. # History of non-small cell lung cancer: In this patient with history of non-small cell lung cancer status post chemotherapy/radiation and multiple operative interventions, CTA chest on admission revealed multiple enlarged mediastinal and hilar lymph nodes concerning for recurrence of malignancy, with bibasilar septal thickening potentially related to pulmonary edema, with lymphangitic tumor infiltration a less likely consideration. << Inactive Issues # Ulcerative colitis: Home prednisone 10mg daily and Cortifoam enemas were continued throughout admission while weekly methotrexate was held, given limited duration of stay. # Normocytic anemia: Hct remained 29-32 throughout admission, consistent with recent baseline. He remained largely hemodynamically stable, with the exception of transient hypotension as above, without active signs of bleeding throughout admission. << Transitional Issues # Atrial fibrillation: He was discharged on home ER diltiazem, amiodarone (400mg tid x1 week, 400mg [Hospital1 ] x1 week, 400mg daily x1 week, 200mg daily x1 week), and dabigatran, with close cardiology follow-up arranged. # Community-acquired pneumonia: He was discharged on cefpodoxime and azithromycin, for a total 10-day antibiotic course. BCx x4 ([Date range (1) 16066]) were pending at the time of discharge. # History of non-small cell lung cancer: CTA chest on admission revealed findings concerning for possible recurrence of malignancy, which were shared with the patient and family members. Close oncology follow-up was arranged. CT also demonstrated a nodular lingular opacity, with short-term interval follow-up (6-8 weeks) advised to assess for resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO HS 2. Diltiazem Extended-Release 240 mg PO DAILY 3. FoLIC Acid 1 mg PO QFRI 4. Hydrocortisone Acetate 10% Foam 1 Appl PR DAILY 5. Methotrexate 2.5 mg PO QFRI 6. Omeprazole 20 mg PO DAILY 7. Sodium Bicarbonate 650 mg PO QID 8. Aspirin 325 mg PO DAILY 9. PredniSONE 10 mg PO DAILY 10. Ascorbic Acid 1000 mg PO DAILY 11. Vitamin B Complex 1 CAP PO DAILY Discharge Medications: 1. home O2 Sig: Continuous home oxygen 2 L Disp: QS Diagnosis: COPD Oxygen saturation 85% on room air. 2. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 3 Days RX cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #24 Tablet Refills:0 3. Amitriptyline 10 mg PO HS 4. Ascorbic Acid 1000 mg PO DAILY 5. Hydrocortisone Acetate 10% Foam 1 Appl PR DAILY 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 10 mg PO DAILY 8. Vitamin B Complex 1 CAP PO DAILY 9. Dabigatran Etexilate 150 mg PO BID RX dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 10. Diltiazem Extended-Release 240 mg PO DAILY 11. FoLIC Acid 1 mg PO QFRI 12. Methotrexate 2.5 mg PO QFRI 13. Sodium Bicarbonate 650 mg PO QID 14. Azithromycin 250 mg PO DAILY RX azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #6 Tablet Refills:0 Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: Primary diagnoses: Atrial fibrillation with rapid ventricular response Healthcare-associated pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 16063], It was a pleasure taking part in your care during your admission to [Hospital1 69]. As you know, you were admitted for atrial fibrillation in the setting of pneumonia. Yout atrial fibrillation initially was treated with amiodarone, which was later discontinued in the setting of breathing difficulty. You also were started on dabigatran for stroke prevention. You were found to have pneumonia during this admission and treated with intravenous antibiotics, including vancomycin, cefepime, and azithromycin. You were admitted briefly to the intensive care unit in the setting of breathing difficulty, but made good progress and subsequently returned to the floor for further recovery. You did well and is currently off all intravenous medication and off O2 as well. The following changes have been made to your medications: -Please START cefpodoxime and take through [2154-12-7]. -Please CONTINUE azithromycin, which was started in the hospital, and take through [2154-12-7]. -Please STOP aspirin. -Please CONTINUE dabigatran, which was started in the hospital, until directed to discontinue by your cardiologist. -Please discuss with your primary care physician regarding appropriate vaccination You will go home with a heart monitor. The results of the monitoring will be sent to his cardiologist during the next appointment. We also arranged home VNA, Physical therapy services. You have appointments arranged as outlined below. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2154-12-9] at 1:40 PM With: Dr. [Last Name (STitle) ] [Name (STitle) ] Location: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2154-12-25] at 11:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: Gastroenterology Name: Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] When: Please call Dr. [Last Name (STitle) 16067] office to make a hospital follow up appointment for 4-8 days after your hospital discharge. Address: [Doctor First Name ],STE 8A, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 682] Name: [Known lastname 2536],[Known firstname 2537] Unit No: [Numeric Identifier 2538] Admission Date: [2154-11-23] Discharge Date: [2154-12-2] Date of Birth: [2079-10-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 2539] Addendum: This note is to rectify that Mr. [Known lastname 2540] amiodarone use. Mr. [Known lastname ] was started on amiodarone in the setting of atrial fibrillation. The amiodarone was discontinued after he converted back to sinus rhythm, and he was not discharged on amiodarone. We made this decision because 1) his atrial fibrillation only occurred in the setting of pneumonia, and 2) we did not want to continue a medication with potential pulmonary complications given his already significantly compromised pulmonary reserve. Discharge Disposition: Home With Service Facility: Multicultural VNA [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD [MD Number(1) 2541] Completed by:[2154-12-13*]	[ "V10.11", "427.31", "V45.74", "799.02", "275.41", "796.3", "794.2", "285.9", "785.6", "V10.51", "V12.54", "556.9", "486", "V15.3", "786.59", "496", "427.69" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	19034, 19252	8738, 13792	327, 333	15356, 15356	5474, 5474	17051, 19011	3875, 3931		14280, 15138		15230, 15335		13818, 14257			15539, 17028										3946, 3946				3053, 3126															5734, 8715					5606, 5719						275, 289																361, 2940								5488, 5589		15371, 15515		3157, 3564						2962, 3033	3580, 3859
74,337	158,343	39659	Discharge summary	report	Admission Date: [2134-7-18] Discharge Date: [2134-7-27] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 598] Chief Complaint: free air on CT abdomen, transfer from OSH Major Surgical or Invasive Procedure: 1. Diagnostic laparoscopy. 2. Exploratory laparotomy. 3. Sigmoid resection with an end left colostomy. History of Present Illness: 87 M admitted to OSH [7-15] s/p fall from chair incidentally found to have free air on imaging, now transferred for further management. The patient suffered a mechanical fall from his rocking chair and in the OSH ED was found to have an elevated CPK and he was admitted for IV hydration. The patient had a decreased O2 saturation and increased respiratory rate in the AM [7-17] and a CT chest was performed which incidentally revealed a large amount of intraabdominal air. CT abd PO/IV contrast was then performed and demonstrated large free air with sigmoid perforation likely due to diverticulitis. He has hemodynamically stable. He did have a fever to 102 F prior to being transferred to [Hospital1 18], however before this he had been afebrile without chills/nausea/emesis. He also denies any abnormality in the frequency, consistency or color of his stools. He was noted to have abdominal distention and he received levofloxacin and Flagyl. He was then transferred to [Hospital1 18]. Past Medical History: DM-2, elevated cholesterol, BPH, COPD, A. fib on Coumadin, arthritis, nephrolithiasis Social History: ETOH none Tobacco remote devoted family Family History: unknown Physical Exam: VS: AFVSS Gen: NAD, AOx3 CVS: irregularly irregular Pulm: no respiratory distress Abd: Soft but distended. TTP LLQ without rebound or guarding. +tympanitic LE: no LLE Pertinent Results: [2134-7-18] 12:46AM WBC-8.6 RBC-3.45* HGB-11.0* HCT-32.4* MCV-94 MCH-31.8 MCHC-33.8 RDW-13.6 [2134-7-18] 12:46AM PLT COUNT-150 [2134-7-18] 12:46AM PT-21.0* PTT-30.9 INR(PT)-1.9* [2134-7-18] 12:46AM GLUCOSE-64* UREA N-25* CREAT-1.0 SODIUM-131* POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-24 ANION GAP-12 [2134-7-18] 04:45AM GLUCOSE-199* UREA N-22* CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-24 ANION GAP-23* [2134-7-18] 12:30PM WBC-4.4 RBC-3.70* HGB-11.7* HCT-35.3* MCV-95 MCH-31.6 MCHC-33.2 RDW-13.8 [2134-7-18] 12:30PM CALCIUM-8.1* PHOSPHATE-3.4 MAGNESIUM-1.7 [2134-7-21] CXR : Mild pulmonary edema with bilateral pleural effusions are similar to that seen one day prior. The new major abnormality consists of left lower lobe collapse, with leftward shift of the heart and mediastinal contents. No pneumothorax is seen. [2134-7-23] CXR : The ET tube tip is 6 cm above the carina. Cardiomediastinal silhouette is unchanged compared to the prior study. The NG tube passes below the diaphragm. There is interval worsening of pulmonary edema and increase in bilateral pleural effusions as well as no change in the left retrocardiac opacity consistent with atelectasis. RESPIRATORY CULTURE (Final [2134-7-24]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S URINE CULTURE (Final [2134-7-23]): STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- 32 S OXACILLIN------------- =>4 R TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Brief Hospital Course: Pt admitted to ACS service on [2134-7-18]. After extensive discussion with the patient and his four daughters, decision was made to proceed to the operating room emergently for exploration. While in the OR, the pt underwent a sigmoid resection with an end left colostomy. He tolerated the surgery well and was brought to the PACU for recovery. He maintained stable hemodynamics and had adequate pain control. CVS - pt with known history of a.fib, was persistently tachycardic to low 100's/110's while on the surgical unit. His pre op Lopressor was resumed and adjusted for rate control. Currentlt on 25 mg of Lopressor TID his heart rate is in the 80's. His preop Coumadin was restarted at 3 mg daily on [2134-7-26] but his INR is only 1.1. He will receive Coumadin 5 mg tonight and have his Coumadin dosed daily based on his INR to achieve a goal between 2.0 and 2.5. Pulm - On [7-21], pt triggered for decreased O2 saturation and increased O2 requirement. Sats dropped to low 80's on 3LNC, while HR was in the 140's; pt was placed on NRB mask and transferred to the ICU for further management. He underwent vigorous pulmonary toilet and nebulizer treatments but eventually required intubation. He had copious secretions and underwent a bronchoscopy on [2134-7-22]. Multiple plugs were suctioned out and BAL was positive for MRSA He was extubated on [2134-7-23] without difficulty. Currently he is on 2L oxygen with saturations in the 94-96 range and is continuing with bronchodilator therapy as well as the incentive spirometer. GI/GU - On [7-20], pt noted to have grossly edematous penis and scrotum. On [7-21], pt only able to void x2 throughout the day; bladder scanned for >850cc in the early afternoon. Urology consulted to place catheter due to difficult anatomy with significant swelling. Catheter placed successfully and he failed another voiding trial on [2134-7-26]. His urine culture is also positive for MRSA. He will follow up with the [Hospital 159] Clinic for a voiding trial next week. ID : Vancomycin was started on [2134-7-22] for a 2 week course thru [2134-8-4] for MRSA in 2 areas. His dose has been adjusted and his last trough was [2134-7-26] at 18.6. Currently he is on 1000 mg IV BID and his creatinine is 0.8. A left basilic PICC line was placed on [2134-7-27] for long term antibiotics. Mr. [Known lastname 7716] did remarkably well after his transfer to the Surgical floor. His diet was gradually advanced to regular and his ostomy was active. His blood sugars were in good control and he was on blood sugar checks QID. He was seen by the ostomy nurse daily for ostomy care, teaching and management and he was gradually learning as were his daughters. His surgical incision was healing well and he was actively working with Physical therapy to regain mobility and return home soon. He was discharged to rehab on [2134-7-27] and will follow up in the [Hospital 2536] Clinic in [1-27] weeks. Medications on Admission: [Last Name (un) 1724]: Actos 45', Glipizide ER 10', Lopressor 25', Zetia 10', Zocor 20', Coumadin 3', MVI' Meds on transfer: Advair 1 puff'', Duoneb'''', Nexium 40'', Glipizide 10'', Metoprolol 25'', Actos 45', Spiriva 18', Zetia 10', RISS, Levo 750', Flagyl 500', Vit K 5 mg SQ' Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain,temp. 3. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 5. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr 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. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once: for [2134-7-27] Adjust to keep INR >2.0 <2.5. 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours). 16. 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. Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: 1. Perforated sigmoid diverticulitis with feculent gross contamination. 2. MRSA pneumonia 3. MRSA UTI 4. Atrial fibrillation 5. Urinary retention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital with diverticulitis requiring surgery to remove part of your colon. You have a colostomy now and will pass air and stool thru it. * Over time you will learn how to manage the colostomy when you get home. The VNA will also help you. * You developed pneumonia after surgery and will need to continue antibiotics intravenously which will be given through your PICC line. You will also need to continue to cough, deep breath and use your incentive spirometer to keep your lungs inflated. * You also have a urinary tract infection which will be taken care of with the antibiotic. Your catheter will probably be removed next week at the urology clinic. * Your Coumadin will be regulated at rehab. Followup Instructions: Call the [Hospital 2536] Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [1-27] weeks. Call the [Hospital 159] Clinic at [Telephone/Fax (1) 164] for a voiding trial next week. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2134-7-27]	[ "519.19", "V15.88", "600.01", "567.21", "518.81", "272.0", "562.11", "788.20", "716.90", "V58.61", "250.00", "427.31", "482.42", "599.0" ]	icd9cm	[ [ [] ] ]	[ "33.24", "46.11", "96.04", "38.93", "45.76", "33.23", "96.71" ]	icd9pcs	[ [ [] ] ]	9727, 9804	4727, 7743	260, 365	9994, 9994	1802, 4704	10930, 11282	1590, 1599		8079, 9704		9825, 9973		7769, 7881			10177, 10907										1614, 1783																														178, 222																393, 1408										10009, 10153								1430, 1517	1533, 1574		7899, 8056
31,746	185,109	31191	Discharge summary	report	Admission Date: [2199-8-12] Discharge Date: [2199-8-23] Date of Birth: [2153-7-20] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2518] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: None History of Present Illness: 46 yo M PMH L wrist injury and PVD presents as CODE STROKE. Called at 10:48am. Stroke fellow at bedside within minutes. Last seen well @6am. Onset of symptoms @7am. Girlfriend saw patient well at 6am when she was helping him get dressed. Patient had a f/u appt in [Location (un) 86] for his recent arm lac and needed to drop off keys for his 18 [Doctor Last Name ] at the shop. He left for the shop located in [Location (un) ] where he was found at 7am by coworkers on the ground by the car which was still parked outside the shop. Apparently, keys were still hanging out of the garage door to the shop. Per EMS reports, he was diaphoretic VSS 97.3 193/95 67 20 95%RA. Taken to OSH ED were upon arrival @7:30am, he was groggy, sleepy, L hemiparesis (face, arm> leg). OSH Head CT showed dense R MCA sign. No bleed. ASA 325mg given. Ambulance called to transfer pt to [Hospital1 18] ED. Per ambulance exam, awake to voice, answer questions appropriately. Upon arrival in [Hospital1 18] ED @10:30am, VS 74 105/58 18 91% 2L. Per ED nurse note, "pt seen this am prior to 7am by wife (later clarified as 6am). Pt states getting into his truck this am, fell to ground, denies prior HA. Pt found by friend at 7am slumped on floor and was taken to OSH." NIHSS 1a. alert 1 1b. LOC questions 0 1c. LOC commands 0 2. Gaze 1 3. Visual 1 4. Facial palsy 2 5. Motor L arm 0 5. Motor R arm 4 6. Motor L leg 0 6. Motor R leg 2 7. Limb ataxia 0 8. Sensory 1 9. Best language 0 10. Dysarthria 1 11. Extinction 1 NIHSS Total 14 Head CTA head & neck performed at 10:56am without obvious signs of bleed and again R ICA clot just distal to bifurcation. Labs INR 1.0, Cr 0.8 and FS 210. Past Medical History: 1) Left arm lac: Per pt's girlfriend. Pt sustained a left forearm laceration when a metal shop machine part (grinding disc) exploded. He went to OSH ED where stitches were placed and he was referred emergently up to [Location (un) 86] [Hospital1 2177] for further eval. At [Hospital1 2177], wound was re-irrigated and 11 stitches were placed. He was given Keflex and Percocet PRN. He only took one Percocet two days ago and hasn't taken any since then. 2) HTN: Has been on a low dose of anti-htn med GF doesn't remember the name. It had run out 3 days ago and pt hadn't gotten around to filling it. 3) PVD 4) Lasix to eyes b/l Social History: Smokes 1 PPDx12 yrs. Weekend Etoh 1-2 drinks. No drugs. Screened regularly since he is an 18 wheel truck driver. Lives with girlfriend [Name (NI) ] [Name (NI) 73625] in [Name (NI) 9101] [Telephone/Fax (1) 73626]. Family History: unable to obtain Physical Exam: T- 97.7 BP- 141/74 HR- 87 RR- 14 97 O2Sat 2LNC Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema, left arm in bandages clean dry intact Neurologic examination: Mental status: Awake and fluctutating alertness, easily arousable to voice or tactile stim, cooperative with exam. Oriented to person, place, and date. Speech is fluent with normal comprehension with mild dysarthria. [Location (un) ] intact. ?L-neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Decreased blink to threat from left. Gaze deviated to the right but able to cross midline with pursuit. Sensation intact V1- V3. Left UMN facial. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Decreased tone left side arm>leg. No observed myoclonus or tremor. Left arm - no movement. Left leg antigravity but drifts down to stretcher within 5 seconds. Right side full [5-25]. Sensation: Decreased on L-arm>leg to noxious stim. Reflexes: +2 and symmetric throughout. Toe left toe upgoing and right toe downgoing. Coordination: finger-nose-finger normal on the right. Gait: unsteady Romberg: unsteady Pertinent Results: [2199-8-12] 10:50AM WBC-7.7 RBC-4.93 HGB-16.5 HCT-46.1 MCV-93 MCH-33.4* MCHC-35.8* RDW-13.2 [2199-8-12] 10:50AM PLT COUNT-146* [2199-8-12] 10:50AM PT-12.0 PTT-24.2 INR(PT)-1.0 [2199-8-12] 10:50AM AST(SGOT)-35 CK(CPK)-145 ALK PHOS-78 AMYLASE-33 TOT BILI-0.7 [2199-8-12] 10:50AM GLUCOSE-210* UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 STUDIES: CT Head [8-12]: Dense right MCA consistent with thrombo-embolism. Evolving right MCA territory infarction with new low attenuation in the right caudate head, which raises the possibility that the right proximal ACA is now involved. No intraparenchymal hemorrhage identified. MERCI Clot retrieval: 1. Complete occlusion of the right internal carotid artery just distal to the common carotid bifurcation with faint opacification of the cavernous portion. Three attempts were made with minimal success with a 9-French Merci clot retrieval system. Procedure was subsequently terminated per discussion and recommendation of the neurology stroke attending, Dr. [Last Name (STitle) ]. CTA Head and Neck [8-12]: 1. Complete occlusion of the right internal carotid artery shortly after the carotid artery bifurcation with minimal reconstitution of the right supraclinoid portion. 2. Minimal if any enhancement of the proximal portion of the right middle cerebral artery with a hyperdense MCA sign seen on the non-CT scan consistent with acute thromboembolism. Diminished number and caliber of distal right MCA branches. 3. Nonvisualization of the right lentiform nuclei consistent with acute infarct. 4. Penetrating ulcer of the atherosclerotic plaque involving the left ICA bulb. CT Chest: 1. No evidence of mediastinal mass. The abnormal contour is most likely explained by excessive mediastinal fat deposition. 2. Nodular ground-glass opacity in left upper lobe is non-specific in appearance and might be of infectious or neoplastic etiology. Evaluation in a year is recommended for documentation of stability or resolution of this finding to exclude bronchioloalveolar cell carcinoma. 3. Marked fatty infiltration of the liver. A large liver cyst. Gallbladder sludge with no evidence of cholecystitis. CT Head [8-14]: 1. Further evolution of right MCA infarct with minimal worsening of right to left subfalcine herniation measuring approximately 3 mm. No intracranial hemorrhages. CT Head [8-15]: Since the previous CT of [2199-8-14], the CT extent of the infarct has increased involving the right middle cerebral territory. There is mild mass effect indenting the right lateral ventricle which is slightly increased. No acute hemorrhage is identified. EEG [8-15]: This is an abnormal portable EEG due to the presence of frequent prolonged mixed theta and delta frequency slowing over the right hemisphere, most prominently over the right centrotemporal region, suggestive of underlying cortical and subcortical dysfunction in this region. Also noted were intermittent bursts of generalized slowing in the setting of a slowed background rhythm consistent with a moderate global encephalopathy. No clearly epileptiform features were seen. ECHO [8-19]: Mild symmetric left ventricular hypertrophy with normal systolic function, no significant valvular abnormality, and no evidence of atrial septal defect. CT Head [8-20]: There is redemonstration of the large right middle cerebral artery territory infarction, which likely involves primarily the superior division. There is extensive mass effect exerted upon the right lateral ventricle, with a few millimeters leftward subfalcine herniation identified. No definite signs for hemorrhagic conversion are apparent. No other new areas of infarction are identified. No new extracranial abnormalities are discerned. Brief Hospital Course: Mr. [Known lastname ] is a 46-year-old man with a history of peripheral vascular disease and hypertension who presented with right hemiplegia. His hospital course was as follows: 1. STROKE. He was transferred to [Hospital1 18] from [Hospital3 ] Hospital as a Code Stroke. He was outside the window for intra-arterial tPA. MERCI clot retrieval was attempted, but was unsuccessful. He was initially admitted to the ICU for close monitoring. He was extubated on the morning after admission. He had significant edema on CT, and so was given mannitol, which was later tapered off. After several days, his head CT was stable, as was his clinical exam, and so he was transferred to the floor. Evaluation included an echocardiogram that was normal. CTA showed complete occlusion of the right ICA. The mechanism of the occlusion, which caused his infarct, was thought to be due to atherosclerosis as his LDL was markedly elevated (449). Lipitor and Zetia were started. Hypercoagulability labs showed a normal homocysteine. He did have an elevated ESR and CRP. He was initially treated with aspirin for secondary prophylaxis but switched to Plavix given his history of peripheral vascular disease. * His A1c was 6.8; his fasting glucose should be monitored by his PCP, [Name10 (NameIs) ] no medications other than an insulin sliding scale were indicated at this time. * 2. Chest mass. This was seen on CXR, and was thought on CT to be fat deposition. However, he did have small lung nodules for which he will need a follow-up scan in [4-26] weeks. 3. Arm abrasion: he finished a course of Keflex with no fevers or WBC elevation. 5. FEN/GI: He had repeated swallow evaluations. He needs a ground diet with thin liquids and purees. 6. Dispo: He was discharged to rehab and will follow-up with Dr. [Last Name (STitle) ] in [Hospital 878] clinic. Medications on Admission: Cephalexin 500mg (started 2 days ago for left wrist) Percocet PRN Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection every eight (8) hours. 10. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR Injection four times a day: Sliding scale. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary: 1. Stroke Secondary: 1. Hypertriglyceridemia 2. Elevated blood glucose Discharge Condition: Fair condition; neuro exam is notable for a left facial droop, left hemiplegia, extinction to double simultaneous stimuli on the left. Discharge Instructions: You have been treated for a stroke. You have been started on several medications to prevent future strokes, including Plavix, Lipitor, Zetia, Lisinopril, and metoprolol. Please take all medications as directed and keep all follow-up appointments. If you should develop further weakness, numbness, facial droop, difficulty speaking, or any other symptom that is concerning to you, please call your PCP or your neurologist or go to the nearest hospital emergency department. Followup Instructions: You have the following appointment scheduled: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2199-9-16] 1:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2533] Completed by:[2199-8-23]	[ "327.23", "518.89", "433.11", "401.9", "305.1", "443.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "88.41" ]	icd9pcs	[ [ [] ] ]	11113, 11186	8290, 10163	329, 336	11310, 11446	4451, 8267	11968, 12262	3010, 3028		10280, 11090		11207, 11289		10189, 10257			11470, 11945										3043, 3342																														277, 291																364, 2074	3644, 4432									3381, 3628					3366, 3366			2096, 2743	2759, 2993
4,273	158,748	24994	Discharge summary	report	Admission Date: [2187-7-21] Discharge Date: [2187-8-2] Date of Birth: [2126-9-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 10493] Chief Complaint: Painful Left foot Major Surgical or Invasive Procedure: Lower extremity angiogram History of Present Illness: Briefly, this is a 60 y/o female w/ h/o nausea and wt loss of 40 lbs in [1-26] months who also developed a painful left foot over last week w/ discoloration. Saw PCP 1 week ago and was told that pain was [12-27] neuropathy and started on Neurontin. No claudication sxs. Left foot with sharp pains localized to distal foot increasing over last week with bluish discoloration, with decreased ability to walk, saw Dr. [Last Name (STitle) 1007] yesterday who told pt to come to the ED. +cough, clear productive for years, +constipation. States that she has not had much of an appeptite, no night sweats, no abd distention. No urinary sxs. Vital on arrival in the ED were afebrile, 106, 80/52, guaic negative. In the ED, initally BP was 80's, breifly, improved with IVFs. BP remained in the mid 90's to mid 110's. Given morphine for pain control in the ED and 2 L NS. Started on heparin after vasc consult. Past Medical History: PMH: 1. RA 2. HTN 3. Arthritis 4. DM2 5. Hypercholesterolemia 6. s/p CCY 7. s/p TAH Social: 1 ppd smoking/54 pack yr hx, no etoh, former maid at hotel, 3 children/3 grandchildren, lives with husband [Name (NI) 62773]: father died of lung cancer at 61 yo mother alive 81 years old Social History: Social: 1 ppd smoking/54 pack yr hx, no etoh, former maid at hotel, 3 children/3 grandchildren, lives with husband Family History: [Name (NI) 62773]: father died of lung cancer at 61 yo mother alive 81 years old Physical Exam: Temp 98, Bp 95/47 Pulse 98 Resp 16 sats 94% RA Gen alert, no acute distress, lying in bed HEENT: PEERL extraocular motions intact, anicteric, mucouus membranes dry, dentures Neck No JVD, no cervical lymphadenopathy. Chest distant Breath sounds, no wheezing CV: Nomral s1/s2 Regular rhytm no murmurs, no rubs or gallops Abd Soft, non tender non distended with normoactive bowel sounds Ext right foot with trace edema. Left foot with blue toes to MT joint, cool until mid foot, dopplerable pulses. Neuro alert, oriened, non focal. Pertinent Results: [2187-7-20] 02:45PM BLOOD WBC-19.1* RBC-4.44 Hgb-12.3 Hct-38.1 MCV-86 MCH-27.6 MCHC-32.2 RDW-14.7 Plt Ct-515* [2187-8-2] 06:11AM BLOOD WBC-12.1* RBC-3.82* Hgb-10.3* Hct-32.7* MCV-86 MCH-27.1 MCHC-31.6 RDW-15.7* Plt Ct-447* [2187-7-20] 02:45PM BLOOD Neuts-82.7* Lymphs-12.5* Monos-3.7 Eos-0.8 Baso-0.2 [2187-8-2] 06:11AM BLOOD Neuts-79.0* Lymphs-14.1* Monos-6.1 Eos-0.7 Baso-0.1 [2187-7-20] 02:45PM BLOOD Hypochr-1+ [2187-8-2] 06:11AM BLOOD Hypochr-2+ [2187-7-20] 02:45PM BLOOD PT-13.2 PTT-27.5 INR(PT)-1.2 [2187-8-2] 06:11AM BLOOD Plt Ct-447* [2187-8-2] 06:11AM BLOOD PTT-81.1* [2187-7-20] 02:45PM BLOOD Glucose-179* UreaN-17 Creat-0.5 Na-136 K-5.3* Cl-97 HCO3-27 AnGap-17 [2187-8-2] 06:11AM BLOOD Glucose-135* UreaN-19 Creat-0.9 Na-142 K-3.9 Cl-103 HCO3-27 AnGap-16 [2187-7-20] 02:45PM BLOOD ALT-16 AST-21 CK(CPK)-27 Amylase-73 TotBili-0.5 [2187-7-28] 05:54AM BLOOD CK(CPK)-101 [2187-7-21] 10:15AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.3* [2187-8-1] 05:40AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-1.9 [2187-7-27] 10:30PM BLOOD Cortsol-24.1* [2187-7-28] 02:44PM BLOOD Cortsol-71.2* CT ABD--Extensive omental and peritoneal fluid and nodularity concerning for metastatic disease. The lack of oral or IV contrast limits further diagnostic evaluation. No abdominal aortic aneurysm. CXR--No acute cardiopulmonary abnormality including infiltrate, effusion, or mediastinal widening. Hyperinflation. CT HEAD--No intracranial hemorrhage or mass effect. MRI would be more sensitive for evaluation of early metastases Brief Hospital Course: In the ED, initally BP was 80's, breifly, improved with IVFs. BP remained in the mid 90's to mid 110's. Given morphine for pain control in the ED and 2 L NS. Started on heparin after vasc consult. On vascular exam, a pulsatile abdominal mass was appreciated, which prompted a CT scan of the abd/pelvis. The CT w/o contrast showed omental caking, mesenteric LAD, no obvious masses. Pt was informed of results by Dr. [Last Name (STitle) 1007]. Pt subsequently had CT abd/pelvis with IV which raised suspicion of mass in the tail of the pancreas along with carcinomatosis. An MRI/MRA of the abdomen was done the next day which also demonstarted a 1.5 X2.5 cm mass in the tail of the pancreas with omental caking and carcinomatosis. Pt had an angiogram [7-25] with 50% L CIA stenosis, distal AT/PT and peroneal occlusions with no foot vessels patent. Pt foot became progressive necrotic. Her WBC count raised from 14K tro 24K but she remained afebrile and HD stable. Morphine was given for both abdominal pain and foot pain control. Her ascitic fluid drained via us-guided paracentesis by IR and cytology returned preliminarily on [7-27] as + for malignant adenocarcinoma. CEA returned elevated at 115, CA-125 326 while CA19-9 remains pending (later on positive). Hem/onc consultation recommended obtaining a definitive tissue diagnosis and discussion was had about possible CT guided biopsy of omental caking. Pt was seen by palliative care and her swift return to home with pain control was emphasized by the patient. Pt was started on SR MS contin and MS04 elixir for pain control. On [7-27] in the evening PM labs showed elevated potassium to 6.4 (with hemolysis) and her SBP<80 around this time. Given worsening appearance of necrotic toe, concern for sepsis she was started on A/B. Pt was also treated for hyperkalemia and had aggressive IV fluids but had refractory hypotension requiring continues IV bolus to maintain her Blood pressure. Her O2 Sats were 93% on 3L. She was transfer to the MICU for hypotension r/o sepsis an medical managment and possible invasive lines. Patients blood pressure was maintained with IV fluid boluses and did not requiered pressors. She was always afebrile on the floor and in the MICU. After adding up the Morphine dosis she had received on the floor about 37mg MSO4 and it was thought to play a key role on her hypotension episode. Over her stay in the MICU she had low urinary output, complained of nausea and pain. Patient came out to the floor and underwent a CT scan guided biopsy. Final tissue diagnosis reported pancreatic cancer. Final result was discussed with the family and patient. Patient decided that she would rather be at home as soon as possible. Patient was discharged home with hospice. Medications on Admission: neurontin glipizide lipitor metformin lexapro DM folic acid lisinopril Discharge Medications: 1. Escitalopram Oxalate 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 7. Morphine 10 mg/5 mL Solution Sig: Five (5) mL PO q2-3 h as needed for pain. Disp:120 mL Refills:0 8. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a day). 9. Lactulose 10 g/15 mL Solution Sig: Two (2) PO twice a day. Disp:120 cc Refills:0 10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:120 Tablet(s) Refills:0 11. Oxygen 2-3 L oxygen by nasal cannula 12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] hosp. Hospice Discharge Diagnosis: 1. Right Toe Gangrene 2. Pancreatic Cancer Discharge Condition: Stable to be discharged to home with hospice care. Discharge Instructions: Please continue all medications as prescribed. Please continue all pain medications as needed. If you have fevers, chills, sweats, nausea, vomiting, worsening pain, please call the Hospice nurses or Dr.[Name (NI) 19421] office. Followup Instructions: Please call Dr.[Name (NI) 19421] Office with any concerns. [Telephone/Fax (1) 10492] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495] Completed by:[2187-10-26]	[ "250.00", "440.22", "305.1", "444.22", "401.9", "197.6", "157.8", "444.89", "714.0" ]	icd9cm	[ [ [] ] ]	[ "99.07", "88.47", "88.48", "54.91", "54.24" ]	icd9pcs	[ [ [] ] ]	8115, 8175	4019, 6784	333, 360	8262, 8315	2415, 3996	8597, 8853	1763, 1850		6906, 8092		8196, 8241		6810, 6883			8339, 8574										1865, 2396																														276, 295																388, 1306																		1328, 1614	1630, 1747
26,751	133,185	34704	Discharge summary	report	Admission Date: [2140-6-29] Discharge Date: [2140-7-8] Date of Birth: [2083-6-21] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Sudden onset headache after blowing nose Major Surgical or Invasive Procedure: 1. Embolization of basilar artery aneurysm 2. Embolization of acomm aneurysm History of Present Illness: Patient is a 57F who reports blowing her nose this morning with a subsequent "worst HA of life" that was in a "helmet-like" cranial distribution. She also reports having vomited once, and associated near syncope event. She was then taken to OSH where a CT was performed that revealed a SAH. Past Medical History: 1. Depression 2. s/p Spinal Surgery 3. s/p Deviated Septum repair 4. Bilateral tubal ligation Social History: Resides at home with family Family History: non-contributory Physical Exam: On Admission: O: T: 99.3 BP:107/58 HR:84 RR:16 O2Sats: 100% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Pupils: PERRL EOMs: intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [2-22] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm 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 [4-25] throughout. No pronator drift. Mild Kernig's sign. Sensation: Intact to light touch, proprioception. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger. Pertinent Results: Head CT/CTA([6-29]) IMPRESSION: 1. 7 mm aneurysm at the apex of the basilar artery. 4 mm aneurysm of the anterior communicating artery. 4 mm aneurysm at the origin of the left posterior communicating artery. Small infundibula at the origins of the right posterior communicating artery and the right lateral lenticulostriate artery. 2. Small amount of intraventricular hemorrhage within the fourth ventricle and tiny layering intraventricular hemorrhage within the occipital horns of the lateral ventricles. A small amount of subarachnoid blood in the right sylvian fissure and prepontine cistern. Head CT [7-1]: 1. Diffuse subarachnoid high density material; likely a combination of extravasated contrast material from the vascular coiling procedure of three hours earlier, as well as subarachnoid hemorrhage. No evidence of mass effect. Followup examination recommended. Head CT [7-2]: Considerable reolution of SAH. No hydrocephalus or new hemorrhage. Changes from previous coiling. CT Brain Perfusion [7-4]: Residual diffuse subarachnoid hemorrhage with layering of hemorrhage in the dependent region of the lateral ventricles bilaterally. There is no evidence of new hemorrhagic areas. The CTA demonstrates mild narrowing of the caliber of the vessels in the circle of [Location (un) 431] suggesting mild vasospasm as described in detail above. Focal outpouching is identified at the origin of the right posterior communicating artery, likely consistent with a prominent infundibulum. Labs: [2140-6-29] 12:34PM BLOOD WBC-11.1* RBC-3.90* Hgb-12.6 Hct-36.9 MCV-95 MCH-32.4* MCHC-34.3 RDW-13.3 Plt Ct-227 [2140-6-29] 12:34PM BLOOD PT-12.4 PTT-21.5* INR(PT)-1.0 [2140-6-29] 12:34PM BLOOD Glucose-134* UreaN-14 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-27 AnGap-12 [2140-6-29] 12:34PM BLOOD cTropnT-<0.01 Brief Hospital Course: Patient was admitted to neurosurgery for a subarachnoid hemorrhage. Angiography revealed the presence of both a basilar and anterior communicating artery (ACOMM) aneurysms. She was preoped and consented for embolization of the basilar and anterior communicating artery anyeurysms. Patient went to to the angio suite on [2140-6-28] for coiling of the basilar artery aneurysm. She tolerated the procedure well, was extubated, and returned the SICU for Q1hour neurochecks. She underwent coiling for the ACOMM aneurysm on [2140-7-1]. She again tolerated the procedure well, was extubated, and returned to the SICU for Q1hr neuro checks. She was placed on nimodipine 60mg Q4 hours for vasospasm prophylaxis. Her neuro exam was stable during her entire SICU stay. On [7-4] she underwent a CT perfusion study of the brain, which showed minimal cerebral vasospasm and a resolving SAH. On [2140-7-6] she was transferred to the neuro step down unit for Q2 hour neuro checks. She continued to do well wihout signs or symptoms of cerebral vasospasm. She did continue to have a headache with photophobia, but was well-controlled with IV dilaudid and oxycodone. Neuro exam prior to discharge: she had no focal neurodeficits continued with persistent headache. Her angio site was well healed. She was tolerating a regular diet and voiding without difficultly a UA was sent prior to discharge which was negative. She was ambulating without difficulty. Medications on Admission: 1. Buspar prn HS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed: No more than 4GMs per day. 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use with oxycodone. Disp:60 Capsule(s) Refills:0 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Buspirone 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day) for 30 days. Disp:180 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. SAH/Intraventricular hemorrhage 2. Basilar aneurysm 3. acomm aneurysm Discharge Condition: Neurologically stable Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? 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: Follow up Appointments/Imaging -Please call [Telephone/Fax (1) 1669] to schedule a follow-up appointment with Dr. [First Name (STitle) ] for 4 weeks post-op. -You will need a CTA scheduled prior to this appointment and can be arranged by our office. Completed by:[2140-7-8*]	[ "599.0", "430", "998.11", "041.04", "E878.8", "311", "564.09" ]	icd9cm	[ [ [] ] ]	[ "39.72", "88.41" ]	icd9pcs	[ [ [] ] ]	6350, 6356	4158, 5623	357, 436	6473, 6497	2296, 4135	8476, 8764	937, 955		5690, 6327		6377, 6452		5649, 5667			6521, 7535	7561, 8453									970, 970																														277, 319																464, 758	1472, 2277							984, 1179		1194, 1456								780, 876	892, 921
51,992	109,221	35065	Discharge summary	report	Admission Date: [2180-5-24] Discharge Date: [2180-6-6] Date of Birth: [2114-8-25] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 348] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Rigid Bronchoscope History of Present Illness: 65 yo F COPD, recurrent PNA, non small cell lung cancer s/p chemo and radiation in [2175], OSA, worsening pulmonary function, increasing O2 requirement leading to intubation today at OSH, sputum growing aspergillosis, and on flex bronchoscopy a fungal ball was visualized in left main stem bronchus. At OSH she was admitted on [2180-5-10] for acute onset of respiratory distress. She was treated for bilateral lower lobe pneumonia with ceftriaxone and azithyromycin later changed to intravenous vancomycin and ceftazidime as well for a COPD exacerbation with IV steriods and combivent nebs. She worsened and was put on high flow O2, she coughed a whitish mass that was shown to be Aspergillus by histopathology. She was placed on PO voriconazole. She then had worsening respiratory function and was switched to IV voriconazole. She continued wheezing and was intubated on [5-23] and a felxible bronchoscopy was performed that showed extensive endobroncial whitish mass obsturcting mainly the Left main stem bronchus aparently biopsies of this were consistent with the specimen that was coughed up. She also had a CT Angio in order to determine if a PE was contributing to her symptoms. That scan showed no PE and extensive bilateral lower lobe infiltrates. She was transferred to [Hospital1 18] where she had been previously treated in the MICU for MRSA PNA with bilateral infiltrates and COPD in [2180-4-10]. Past Medical History: - Stage IIIb lung cancer diagnosed 3 years ago now s/p chemo & XRT - Asthma/COPD - [Doctor Last Name 933] disease s/p RAI - GERD s/p Nissen fundoplication - Hypertension - Sinusitis - type 2 diabetes - Depression - Anal fissure - Tonsillectomy - Hemorrhoidectomy - Pilonidal cyst excision - Ear plastic surgery - Appendectomy Social History: - Retired - 30 pack year smoker, quit in [2157] - No EtOH use - She is single and lives with her sister Family History: - Mother: HTN, TTP, goiter - Father: [Name (NI) 3495] disease, CVA, lung cancer - Sister: MS - Brother: Psychiatric illness Physical Exam: Physical exam on admission to MICU: Intial Vital Signs: T: 97.6 BP:119/91 P:57 R:15 O2:99% General: Intubated, sedated and paralyzed HEENT: Sclera anicteric, ET tube in place, pupils 1mm Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Scatterred Wheezes, diminished at bases. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, mild edema in legs Neuro: Intubated, sedated, and paralyzed DISCHARGE PHYSICAL: Vital Signs: T98.4 BP 137/75 P88 R22 O2 95 on 3L General: obese female in NAD HEENT: Sclera anicteric, no conjunctival pallor, MMM Neck: supple, no LAD CV: distant heart sounds, however no murmurs appreciated this AM, regular rate Lungs: prominent inspiratory wheezes worse at the base with improved end-expiratory wheezes bilaterally. Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, minimal edema in Lower extremities; upper extremities with 2+ edema. Neuro: A+O x 3 Pertinent Results: [2180-5-24] 01:30AM WBC-26.2# RBC-4.45 HGB-11.1 HCT-35.2* MCV-79* MCH-24.9* MCHC-31.5 RDW-18.3* [2180-5-24] 01:30AM NEUTS-87* BANDS-2 LYMPHS-2* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [2180-5-24] 01:30AM CORTISOL-16.0 [2180-5-24] 01:30AM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-4.6* MAGNESIUM-2.0 [2180-5-24] 01:30AM GLUCOSE-205* UREA N-44* CREAT-1.1 SODIUM-133 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14 [2180-5-24] 01:37AM LACTATE-1.4 IMAGING: CT chest [2180-6-2] IMPRESSION: 1. Interval improvement in bibasilar consolidation, and multifocal solid and ground-glass nodules from [5-22]. There is redemonstration of mild bronchiectasis, and marked irregular tracheal and bronchial wall thickening, with a large amount of inspissated debris within the left main stem bronchus and its tributaries. Soft tissue situated in the subcarinal location is unchanged and may represent lymph node. 2. Small airways disease with airtrapping. Post-radiation changes to the left upper lobe are constant. LABS ON DISCHARGE: [2180-6-6] 11:00AM BLOOD WBC-8.0 RBC-3.77* Hgb-9.7* Hct-30.4* MCV-81* MCH-25.7* MCHC-31.9 RDW-19.8* Plt Ct-140* [2180-6-6] 11:00AM BLOOD Glucose-188* UreaN-34* Creat-1.2* Na-135 K-3.4 Cl-98 HCO3-26 AnGap-14 [2180-6-6] 11:00AM BLOOD ALT-111* AST-44* AlkPhos-176* TotBili-0.4 [2180-6-6] 11:00AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.7 [2180-5-29] 06:34AM BLOOD TSH-6.1* B-GLUCAN Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- 100 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL Brief Hospital Course: 65 yo F COPD, recurrent PNA, non small cell lung cancer s/p chemo and radiation in [2175], OSA was found to have invasive aspergilloma complicated by respiratory failure requiring intubation. Active Diagnoses #Respiratory failure-improved. Multifactorial etiologies of respiratory failure requiring intubation including COPD, PNA, and Invasive Aspergilloma. Patient required bronchoscopy for removal of obstruction as well as respiratory support with mechanical ventilation. After being successfully extubated, patient was gradually weaned to 3L supplemental O2. #Invasive Aspergilloma: Rigid bronchoscopy with debridment showed large fungus ball obstructing left mainstem bronchus. Pathology proven aspergillus along with positive B-glucan indicative of invasive aspergilloma. Started on Voriconazole IV and switched to po form to avoid nephroxoticity. Pt. then developed worsening LFTs and was switched to Ambisome IV, with subsequent improvement of her LFTs. She is to continue ambisome until [2180-7-7]. #COPD exacerbation: PT with chronic COPD, requiring high dose steroids for nearly 2 months. Patient has been tapered to steroid dose of 15mg PO daily. Will continue at 15mg PO daily for 5 total days, then 10mg for 5 days, then 5mg for 5 days, then discontinue. Patient was switched from albuterol and ipratropium nebulizers to MDIs, with good control. #HCAP: Pt found to have PNA at OSH, completed 14 days of antibiotic therapy in house for suspected HCAP. #Venous acccess: Non-occlusive thrombosis noted in left upper extremity after difficulty using left PICC line. Right PICC was attempted, however was only able to get midline, which subsequently did not draw and then did not allow pushing fluids. At discharge, a midline was placed. #Depression: Patient had flat affect and psychomotor retardation throughout stay in hospital. It is highly advised that patient be followed up for depression -continue citalopram. #Anxiety: patient was anxious daily during her hospital stay, sometimes causing tachycardia. Patient responded well to ativan 0.5mg IV. Would benefit from outpatient management of anxiety. Chronic Diagnoses #HTN -Pt was hypotensive during the course of her MICU stay likely [12-30] effects of sedation from propofol during intubation. Levophed was required. Cortisol levels normal. Anti hypertensives were not required in house. Patient should be re-evaluate for hypertension as an outpatient. #Stage IIIb Non small cell lung cancer -Pt diagnosed 3 years ago now s/p chemo & XRT. NO acute relapse noted in this admission. #OSA: -After extubation, pt continued to use CPAP nightly as she does at home. #Diabetes Mellitus: -Pt's po meds were held, she was managed on SSI. She was stabilized on 35 units lantus with sliding scale on top. #HLD -continued on simvastatin. #Hypothyroid Pt remained stable, continued on outpatient Levothyroxine. #GERD Pt continued omeprazole. TRANSITIONAL ISSUES -Pulmonologist should follow up on IgE levels pending in hospital for possible allergic bronchopulmonary aspergillosis. Medications on Admission: Medications from OSH: citalopram 20mg PO doxycycline 100mg iv lovenox 80mg combivent propofol for vent nystatin [Numeric Identifier 78144] units oral pantoprazole iv 40mg iv mom[Name (NI) 6474] 1 [Name2 (NI) ] lorazepam 1-3mg for vent levothyroxine 150mcg daily po insulin detemir 20 units daily subq methylprednisone 40mg daily iv Voriconazole 500mg [Hospital1 ] iv trimethoprim/sulfamethox- iv 500mg Q8Hr amlodipine 5mg daily po Valsartan 80 daily po Simvastatin 20 daily po Medications from MICU [4-20] 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Xopenex Inhalation 6. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. (takes 2 tabs on sunday) 7. mom[Name (NI) 6474] 50 mcg/Actuation [Name (NI) 37062], Non-Aerosol Sig: [11-29] Nasal once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: as directed Inhalation as directed. 11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. fluticasone 50 mcg/Actuation [Month/Day (2) 37062], Suspension Sig: One (1) 15. Januvia 50 mg qd 16. Diovan 80 mg qd 17 levemir 38 units qpm Discharge Medications: 1. Albuterol Inhaler 3 PUFF IH Q4H:PRN wheezing please use spacer with MDI. 2. Citalopram 20 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Ambisome 450 mg IV Q24H Please space by 2 hours from platelet transfusions. 8. Guaifenesin [4-6] mL PO Q6H:PRN cough 9. Lorazepam 0.5 mg PO Q8H:PRN anxiety/ dyspnea hold for sedation, RR<10 10. GlipiZIDE 10 mg PO BID 11. Simvastatin 20 mg PO DAILY 12. traZODONE 200 mg PO HS:PRN insomnia 13. PredniSONE 15 mg PO daily Duration: 4 Days 14. PredniSONE 10 mg pO DAILY Duration: 5 Days Start: After 15 mg tapered dose. 15. PredniSONE 5 mg po daily Duration: 5 Days Start: After 10 mg tapered dose. 16. Glargine 35 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Primary diagnosis: respiratory failure, aspergillosis Secondary diagnosis: acute kidney injury, anxiety, COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 29425], You were treated at [Hospital1 18] for respiratory distress and invasive aspergillosis. While here, you required having a tube to breath, and having a procedure where we were able to take out things that were blocking the airway of your lung. We started you on a medication to kill the infection, however it made your liver numbers worse. We then stopped that medication and started a different one, and your liver numbers improved. As you recovered, you have required less oxygen over time. You should continue to take the medications we prescribed you, and follow up with your primary care doctor in [1-31] days and your pulmonologist within 1 week. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 1730] P. Location: [Hospital 46644] MEDICAL ASSOCIATES Address: [Location (un) 46645], [Hospital1 ],[Numeric Identifier 59250] Phone: [Telephone/Fax (1) 34574] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [Last Name (LF) ],[Name8 (MD) ] MD Department: Pulmonary Address: [Location (un) 80096], [Apartment Address(1) 31103], [Location (un) ],[Numeric Identifier 39854] Phone: [Telephone/Fax (1) 80097] Appointment: Tuesday [2180-6-13] 2:45pm Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2180-6-22] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6543], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2180-6-23] at 3:30 PM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: THURSDAY [2180-7-20] at 11:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2180-6-6]	[ "934.1", "519.19", "486", "244.9", "453.81", "530.81", "V58.65", "300.00", "E879.8", "996.74", "584.9", "518.81", "272.4", "V15.3", "117.9", "117.3", "278.00", "250.00", "493.22", "401.9", "E915", "V87.41", "V15.82", "327.23", "V10.11", "794.8", "287.5", "311", "E930.1" ]	icd9cm	[ [ [] ] ]	[ "33.23", "38.97", "96.71", "98.15" ]	icd9pcs	[ [ [] ] ]	11041, 11088	5458, 8537	323, 344	11243, 11243	3507, 4566	12146, 13731	2298, 2428		10161, 11018		11109, 11109		8563, 10138			11419, 12123										2443, 3488																														263, 285								4585, 5435								372, 1803			11185, 11222				11128, 11164			11258, 11395								1825, 2156	2172, 2282
25,683	161,645	11979	Discharge summary	report	Admission Date: [2116-11-30] Discharge Date: [2116-12-7] Date of Birth: [2048-12-10] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: This is a 67 year old male who presented to [Hospital3 417] Hospital with chest pain and left arm pain. This was relieved with Nitroglycerin. He ruled in for myocardial infarction by enzymes with a negative EKG. A cardiac catheterization at the outside hospital revealed disease of obtuse marginal, left anterior descending, right coronary artery. An ejection fraction was 35%. PAST MEDICAL HISTORY: Noncontributory. PAST SURGICAL HISTORY: Noncontributory. ALLERGIES: Allergies to penicillin. MEDICATIONS UPON TRANSFER: 1. Zestril 2.5 mg q. day. 2. Heparin drip. 3. Lopressor 25 mg twice a day. 4. Aspirin. PHYSICAL EXAMINATION: Afebrile, vital signs stable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm. Abdomen soft, nontender, nondistended. Prominent aorta. Extremities with no previous scars, no edema. ADMISSION LABORATORY: Hematocrit 44.6, sodium 140, potassium 3.6, chloride 104, bicarbonate 27, BUN 13, creatinine 0.9, glucose 128, CK 248, MB 12. Chest x-ray was clear. HOSPITAL COURSE: The patient was admitted to [Hospital1 346] and brought to the Operating Room on [2116-12-2]. A coronary artery bypass graft times three was performed with left internal mammary artery to the left anterior descending, SVG to the PO and SVG to obtuse marginal. The pericardium was left open. An arterial line and CVP was placed. Two atrial wires were left along with two mediastinal tubes and one portal tube. The patient was brought to the Intensive Care Unit where he was rapidly extubated. A Neo-Synephrine drip was also weaned when tolerated upon transfer to the Intensive Care Unit. He received four doses of Vancomycin postoperatively. The patient was transferred to the Floor on [2116-12-4]. His chest tubes were removed as well as mediastinal tubes. On [12-5], his wires and Foley catheter were removed. Physical Therapy was working with the patient and he achieved Level 5 activity. His CT scan obtained on [2116-12-6], of the abdomen revealed an approximately 8 cm abdominal aortic aneurysm. The patient was seen by Dr. [Last Name (STitle) ] from Vascular Surgery on [2116-12-7]. It was decided that he would have an outpatient follow-up with Dr. [Last Name (STitle) ]. The patient, on discharge, was stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q. day. 2. Colace 100 mg twice a day. 3. Percocet, one to two tablets p.o. q. four to six hours p.r.n. 4. Lopressor 26 mg p.o. twice a day. 5. Iron Sulfate 325 mg p.o. twice a day. 6. Lasix 20 mg q. day times seven days. 7. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mEq q. day times seven days. 8. Prilosec 20 mg p.o. q. day. DISCHARGE LABORATORY: Hematocrit 24.4, white count 7,500, sodium 137, potassium 4.0, chloride 102, bicarbonate 25, BUN 16, creatinine 1.0, glucose 105. DI[Last Name (STitle) 408]E STATUS: The patient will go home. He will follow-up with his primary care physician or Cardiologist in three weeks, Dr. [Last Name (STitle) ] in two weeks and Dr. [Last Name (Prefixes) ] in four weeks. DIAGNOSES: 1. Status post coronary artery bypass graft times three. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 1308] MEDQUIST36 D: [2116-12-7] 08:52 T: [2116-12-7] 10:22 JOB#: [Job Number 37685]	[ "414.01", "410.71", "401.9", "305.1", "496", "429.9", "441.4" ]	icd9cm	[ [ [] ] ]	[ "36.12", "37.23", "88.56", "88.53", "36.15", "39.61", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]									2516, 3625					1231, 2493											626, 801																		824, 1213																													174, 561																		584, 602
2,664	119,966	20805	Discharge summary	report	Admission Date: [2191-9-7] Discharge Date: [2191-9-23] Date of Birth: [2126-6-23] Sex: F Service: MED Allergies: Mellaril / Lithium / Thorazine Attending:[First Name3 (LF) 6114] Chief Complaint: 65 year-old female with multiple medical problems status-post open cholecystectomy on [2191-7-12], transferred from outside hospital with wound infection. Major Surgical or Invasive Procedure: Right internal jugular line placement ([2191-9-8]) Endotracheal intubation ([2191-9-8]) History of Present Illness: Ms. [Known lastname ] is a 65 year-old female with extensive past medical history including right mastectomy, CAD, CHF, COPD, stroke with residual left hemiparesis, schizoaffective disorder, mental retardation, AAA and arthritis. She had an open cholecystectomy for gallstone pancreatitis on [2191-7-12]. She was discharged to a nursing home. She is being readmitted with a wound infection, transferred from [Hospital1 55475] Hospital. Past Medical History: S/p Open cholecystectomy on [2191-7-12] 1.Gallstone pancreatitis 2.Mechanical aortic valve 3.Chronic obstructive pulmonary disease 4.Abdominal aortic aneurysm 5.Schizoaffective disorder 6.Non insulin dependend diabetes mellitus 7.Congestive heart failure: LVEF 63% with normal wall motion on [6-/2191] nuclear test. 8.s/p R masectomy 9.Known MRSA colonisation by nasal swab s/p CVA with L hemiparesis Social History: Lives at [Hospital ] Healthcare Center. Family History: Non contributory Physical Exam: On [2191-9-7] per surgery note: Vitals: Temperature 97.2; BP:112/50; P:84; RR: 20. Baseline confused. Dyskinetic movements. Regular rhythm Lung with decreased air entry bilaterally--- difficult to examine Abdomen: Erythema, wound fluctuance. Periwound tenderness. On [2191-9-16], per medical intern note: General: Elderly female, short stature, sitting up in chair, tachypneic, screaming for swabs and juice. HEENT: MMM. NCAT. Sclera anicteric Neck: Supple, R IJ line in place. No pain on palpation. No LAD. CV: RRR Mechanical S2. ? mumur at LUSB. Lungs: Uncooperative. Poor air movement. Abdomen: +BS. Soft, NT, ND. Dressing removal revealed open wound ~ 7 cm in length. Mildly erythematous on edges. Ext: Pneumoboots in place. DP 2+. Pitting in form of pneumoboots so hard to access. 1+ b/l. Neuro: Alert and oriented: Hospital, though did not know which one. Knew it was [2191-8-21] though not exact date. Pertinent Results: Laboratory data on admission ([2191-9-7]): WBC-10.2# HGB-8.5* HCT-26.7* MCV 96 PLT COUNT-190# (Differential NEUTS-74.7* LYMPHS-16.8* MONOS-7.4 EOS-1.0 BASOS-0.2) GLUCOSE-92 UREA N-18 CREAT-0.7 SODIUM-141 POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-30* ANION GAP-13 PT-20.7* PTT-33.9 INR(PT)-2.7 LACTATE-0.5 Pertinent results in hospital Microbiology: [9-15]-UCx-yeast [9-14] UA - [6-30] WBC, <1 epi, occ bacteria [9-13] Ucx - 10-100,000 yeast [9-10] Ucx - neg [9-12] C-diff - neg [9-11] C-diff - neg [9-10] Endotrach - >25PMNs, yeast [9-7] Wound cx - MRSA [9-7] Bld cx - neg [9-8] Bld cx - neg Radiology: [9-9] CT chest/abdomen/pelvis: - No pulmonary embolism identified. - Atelectasis and/or consolidation seen in the superior segment of the right lower lobe. Atelectasis is noted in the right middle lobe and left lower lobe. - No focal fluid collections are seen. - Enhancing inflammatory tissue at the site of the patient's known wound infection which involves the abdominal wall fascia and musculature extending from the subcutaneous soft tissues and minimally into the intra-abdominal space. No involvement with intra-abdominal organs. - Aneurysmal dilatation of the thoracoabdominal aorta - Sigmoid diverticulosis without diverticulitis. - Mild common duct and intrahepatic dilatation. [9-15] CXR: Worsening opacities in the lingula and left lower lobe, suspicious for aspiration or aspiration pneumonia. [9-16] CXR: No pneumothorax. Bilateral pleural effusions with bibasilar infiltration. [9-17] CXR: There is no pneumothorax. The patient is status post median sternotomy. Again noted are small bilateral pleural effusion with patchy increased opacity at the lung bases. Feeding tube tip terminates in the proximal stomach and is too high to be used for feeding. This is also unchanged compared to the prior film. [9-21] CXR: No interval change from previous exam [9-20] Shoulder X-ray: There are marked degenerative of the glenohumeral joint, with marked joint space narrowing, subchondral sclerosis and large osteophytes. There is slight superior subluxation of the humeral head. AC joint shows mild degenerative changes. I doubt the presence of glenohumeral dislocation, but the absence of an axillary or Y view cannot entirely exclude it. Brief Hospital Course: Ms. [Known lastname ] was initally admitted to [Hospital Ward Name 121] 5. She was started on Levofloxacin and Vancomycin for her wound infection. Per report, on hospital day #2, her blood pressure began to drop and her respiratory status deteriorated, with decreasing oxygen saturation. The patient was transferred to the SICU for close hemodynamic monitoring and pressure support in a setting of likely sepsis. Her hospital course will be reviewed by problems. 1) Cardiovascular: As per report, in the SICU, she was started on norepinephrine to maintain her blood pressure. On [2191-9-11], a vasopressin drip was added for pressure support. Levophed was weaned off on [2191-9-12], while vasopressin was stopped on [2191-9-13]. However, her blood pressure remained low (SBP in 80s) and an ACTH stmulation test was performed on [2191-9-14]. Cortisol failed to rise appropriately (12.4 to 15.5), and Hydrocortisone was started for probable adrenal insufficiency, with a notable improvement in her blood pressure the following day. She was transferred to the medicine floor on [2191-9-16]. Her blood pressure remained fairly stable while on the floor, with occasional boluses given. At discharge, her SBP is in 120s and DBP in 70s-80s. Steroids were slowly tapered, from Hydrocortisone to Prednisone 10 mg PO daily on [2191-9-15], decreased to 5 mg daily on [2191-9-22]. She should be tapered off steroids in 4 days. Of note, while in the SICU, whe was noted to have occasional PVCs and PACs. No other rhythm disturbances were noted. 2) Respiratory: In the SICU, Ms. [Known lastname ] was initially on non-rebreather with adequate oxygenation but CO2 retention. Poor management of oral secretions was noted. She was intubated for airway protection and progressive hypercarbic respiratory failure (pCO2 79). The ventilatory settings were adjusted with a higher target PCO2 in this known CO2 retainer. A CTA was performed on [2191-9-9] which was negative for pulmonary embolism. She was extubated on [2191-9-12] and placed on a shovel mask, then nasal cannula. However, on [9-15], she had persistent respiratory acidosis with hypercarbia (ABG 7.26/87/146 on 4L N/C) and she was transferred to the MICU for further management of her respiratory issues. In the MICU, a CXR was suspicious for aspiration pneumonia in this patient with impaired mental status and history of failed swallowing assessment on [2191-9-13] (see below). Levofloxacin and Flagyl were started. Repeat CXRs in the ensuying days revealed persistent small bilateral pleural effusions and fairly stable patchy bibasilar infiltrates. While on the medicine floor, she was stable from a respiratory standpoint. Her oxygen requirements declined from 4 L/min to 2L/min on the day of discharge, with a goal oxygen saturation of 89-92 %. She remains on Flagyl and Levofloxacin for the treatment of her aspiration pneumonia, to be completed on [2191-9-25] (total 10 days of antibiotherapy). 3) MRSA wound infection: The wound was opened on admission and allowed to heal by secondary intention. Ms. [Known lastname ] was initially started on Levofloxacin and Vancomycin on [2191-9-7]. Levofloxacin was changed to Zosyn on [2191-9-9]. A wound culture eventually grew MRSA, and Zosyn was stopped. She had a CT abdomen performed on [2191-9-9], which showed no focal fluid collection in the abdomen. There was inflammatory tissue at the site of the patient's known wound infection involving the abdominal wall fascia and musculature without involvement of the intra-abdominal organs. Aneurysmal dilatation of the thoracoabdominal aorta (4.5 cm diameter), sigmoid diverticulosis without diverticulitis and mild common duct and intrahepatic dilatation were also seen. She completed a 14-day course of Vancomycin, with her last dose on [2191-9-21]. Her wound improved clinically, with fibrinous exudate and granulating base evident on examination. Surgery followed the patient throughout her hospital stay. 4) Heme: The patient received a total of 4 units of PRBCs while in hospital for a low hematocrit. Iron studies were normal (iron 74, ferritin 583), along with normal folic acid in previous admission (>20) and B12 (777). Question anemia of chronic disease. Ferrous sulfate was stopped given above results. The patient was also given FFP (1 unit) on [2191-9-16] for persistent bleeding from a central line site after the line was pulled back. Coumadin was held on admission (elevated INR) and she was kept on a heparin drip while in the SICU. Coumadin was restarted, but held in the setting of the bleeding described above. It was restarted on [2191-9-19], with 5 mg PO times 3 days, then 4 mg PO on [9-22]. Her usual dose is 4 mg PO once daily. Of note, flagyl may increase the INR and cautious has been taken with dosage. Please monitor the INR closely. 5) FEN: An NJ tube was inserted on [2191-9-9] and tube feeds were begun. Ms. [Known lastname ] failed an initial swallowing evaluation on [2191-9-13] because of inability to handle secretions and desaturation without her shovel mask. She was kept NPO, and a Dobhoff NGT was placed on [2191-9-14]. A second swallowing assessment was limited secondary to poor cooperation. Risk of aspiration has been a chronic issue in Ms. [Known lastname 55476] care, and the option of long-term tube feeding via a PEG was adressed with the patient's daughter, who refused. A trial of nectar-thick liquids diet was initiated on [2191-9-22]. Of note, the patient was on nectar-consistency fluids at the nursing home. 6) DM type 2: The patient was maintained on a regular insulin slinding scale while in hospital, with fair control of her blood sugars. 7) AAA: 4.5 cm in diameter on CT abdomen. 8) Neuro: Patient with known schizoaffective disorder. She was maintained on her outpatient dose of Valproic acid and trazodone, along with Risperidone. The dose of the latter was reduced on [2191-9-22] with improvement in sensorium noted afterwards. Medications on Admission: Ferrous sulfate 325 mg PO daily Folic acid 1 mg PO daily Risperdal 2 mg PO qAM, 3 mg PO qpm Albuterol 90 mcg 2 puffs q 6 hours prn Tylenol 2 tabs PO q 4 hours prn Kayexalate 15 mg/60ml PO 5x/week Coumadin 4 mg PO qday Valproic acid 750 mg PO qam, 100 mg PO at 1400 and qhs Cogentin 0.5 mg PO BID Flovent 110mcg 2 puffs [Hospital1 ] Traxodone 50 mg PO TID Atrovent inhaler 2puffs QID Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). Tablet(s) 2. Valproate Sodium 250 mg/5 mL Syrup Sig: 1000 (1000) mg PO AT 2 PM AND HS (). 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Valproate Sodium 250 mg/5 mL Syrup Sig: Seven [Age over 90 1230]y (750) mg PO QAM (once a day (in the morning)). 7. Colace 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO twice a day. 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane ASDIR (AS DIRECTED). 10. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days: Last dose on [2191-9-24] to complete 10 days of treatment. Tablet(s) 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: Last doses on [2191-9-24] to complete 10 days of treatment. 13. Risperidone 1 mg/mL Solution Sig: Two (2) mg PO HS (at bedtime). mg 14. Risperidone 1 mg/mL Solution Sig: One (1) mg PO QAM (once a day (in the morning)). 15. Warfarin Sodium 2 mg Tablet Sig: Four (4) mg PO once a day: Please monitor daily INR. 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 17. Regular insulin sliding scale 18. Heparin IV per weight-based dosing guidelines Please monitor PTT carefully and adjust Heparin drip accordingly per nomogram. Continue Heparin until INR therapeutic for aortic valve replacement. Discharge Disposition: Extended Care Discharge Diagnosis: MRSA wound infection Aspiration pneumonia Chronic obstructive pulmonary disease with CO2 retention Congestivee heart failure Mechanical aortic valve Schizoaffective disorder Non insulin dependend diabetes mellitus Discharge Condition: Patient transferred to [Hospital1 55475] Hospital in stable condition. Minimal oxygen requirements via nasal cannula 1L/min. NG tube still in place for tube feeding. Diet advanced to nectar-thick fluids with aspiration precautions on [2191-9-22]. Hct 30.5, INR 1.9 at discharge. Discharge Instructions: Transfer to [Hospital1 55475] Hospital for final management of anticoagulation, dietary advancement with aspiration precautions, and wound care. Followup Instructions: Transfer to [Hospital1 55475] Hospital (Dr. [Last Name (STitle) 55477]. Completed by:[2191-9-23]	[ "996.74", "507.0", "038.11", "518.81", "255.4", "428.0", "998.59", "496", "295.70" ]	icd9cm	[ [ [] ] ]	[ "99.07", "96.04", "96.71", "96.6", "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	13172, 13187	4854, 10927	444, 541	13445, 13733	2502, 4831	13931, 14042	1527, 1545		11364, 13149		13208, 13424		10953, 11341			13757, 13908										1560, 2483																														246, 406																569, 1018																		1040, 1450	1466, 1511
69,176	128,091	3899	Discharge summary	report	Admission Date: [2183-6-5] Discharge Date: [2183-6-23] Date of Birth: [2099-12-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Transesophageal Echocardiography History of Present Illness: Mr. [Known lastname ] is an 83 y/oM with diabetes and reportedly labile sugars recently, also recently s/p ORIF after fall in [3-24] and recent admission from [Date range (3) 17395] for urosepsis at [Hospital3 ], who was transferred from his nursing unit at Life Care Center of [Location (un) 5165] to the [Hospital1 18] ED today for weakness and fatigue. His family felt that he had been doing poorly over the last several days with labile blood sugars ranging by report from 60s to over 400 on his regimen of NPH and novolog sliding scale. He had also increasing confusion over the last several days as well. He was scheduled for TURP today for his BPH (has indwelling foley) but this was cancelled and he was transferred at family request to [Hospital1 18]. His recent hospitalization sepsis in the above dates was notable per discharge summary for ??????Urosepsis with methicillin-reisistant staphylococcus aureus bacteremia?????? and r/o endocarditis and seeding of right hip. He was found to have MRSA in his urine culture, and then [2-19] blood culture bottles were MRSA as well. He underwent TEE which had a question of an old aortic anterior leaflet vegetation, and subsequently underwent TEE which showed no evidence of valvular lesions. The treating team noted in their d/c summary that they believed he had a MRSA UTI with blood seeding secondary to urinary retention. He was treated with vancomycin. His creatinine prior discharge was 1.7, and was started on linezolid IV for ten days, completing a course of antibiotics on [2183-5-13]. He was on lovenox previously, but this had been discontinued at the rehab. He presented to the [Hospital1 18] ED where his vitals at triage were T 97.8 HR 72 BP 132/78 RR 18 O2 Sat 98% on Room Air. He was found to be in DKA/HONK, and after cultures was started on vanc/ceftriaxone empirically. He was found to have a melanotic bowel movement in the ED (confirmed guaiac positive). GI was consulted to see him, but as he remained hemodynically stable, an immediate scope was not planned. NG lavage was attempted but unsuccessful in the ED. Past Medical History: Hip Fracture s/p ORIF [2183-4-11] with intramedullary rod h/o T 12 compression fracture and C6-C7 disk protrusion ANEMIA DIABETES MELLITUS HYPOTHYROIDISM HYPERCHOLESTEROLEMIA XEROROSIS LUNG NODULE HYPERTENSION Needs outpt cysto, TURP Social History: Tobacco: Former smoker Alcohol: none per d/c Was living in [Hospital 5165] Living Center prior to admission WWII Veteran-was gunner onboard merchant vessels from [2117] to [2120] Family History: noncontributory Physical Exam: Admission Exam General Appearance: No(t) Well nourished, Thin Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : ) Abdominal: Soft Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Unable to stand Skin: Dry. Left clavicular head has superficial redness/tenderness. Neurologic: Attentive, Responds to: Not assessed, Oriented (to): person initially (hospital vs. shopping center, knew day was thursday but not year). This improved after 1 hr, Movement: Not assessed, Tone: Not assessed Discharge Exam afebrile, VSS Gen -- very thin, frail eldelry male HEENT -- anicteric, op clear, edentulous, dentures present Heart -- regular Lungs -- clear Abd - soft, benign, +BS Ext -- no edema, right antecubital PICC in place without erethyma or exudate Skin -- stage II sacral decubitus ulcer Pertinent Results: [2183-6-5] 11:35AM GLUCOSE-641* UREA N-28* CREAT-1.1 SODIUM-134 POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-16* ANION GAP-27* [2183-6-5] 11:35AM CK(CPK)-17* [2183-6-5] 11:35AM CK-MB-NotDone cTropnT-<0.01 [2183-6-5] 11:35AM CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-1.9 [2183-6-5] 11:35AM WBC-13.1# RBC-3.17# HGB-9.1# HCT-28.7# MCV-90 MCH-28.7 MCHC-31.7 RDW-16.2* [2183-6-5] 11:35AM NEUTS-93.6* LYMPHS-4.0* MONOS-2.1 EOS-0.1 BASOS-0.2 [2183-6-5] 11:35AM PLT COUNT-408 [2183-6-5] 11:35AM PT-17.0* PTT-52.0* INR(PT)-1.5* [2183-6-5] 11:35AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.029 [2183-6-5] 11:35AM URINE BLOOD-MOD NITRITE-POS PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2183-6-5] 11:35AM URINE RBC-[3-20]* WBC-[12-5]* BACTERIA-MOD YEAST-NONE EPI-0 Neck, soft tissue ultrasound [6-6]: 1.5 x 0.8 x 0.5 cm echopenic lesion over the left clavicular head most likely represent a synovial fluid pocket/cyst, less likely a lymph node. Followup imaging can be performed as clinically indicated. LENIs [6-6]: No evidence of DVT in the bilateral lower extremities. Hip films [6-6]: The patient is status post ORIF of an intratrochanteric fracture of the left femur. The fracture is comminuted. The hardware is intact. There is no evidence for loosening or fracture of the hardware. Left knee [6-6]: A portable lateral film is provided of the left knee. This demonstrates hardware in adequate position. There is no evidence of loosening. No osteolytic changes are seen. -------- [2183-6-8] CT Left shoulder: IMPRESSION: 1. No obvious left shoulder effusion or bony abnormality involving the left shoulder, aside from minor degenerative change. 2. Relatively large pulmonary artery embolus involving the left main pulmonary artery and branches to the left upper lobe and lingula and left lower lobe. 3. Minimal fluid in the left sternoclavicular joint. Nearby soft tissue calcification could represent chondrocalcinosis. Finding described on recent ultrasound is not definitively identified, but might not be appreciated on this exam due to resolution and artifact from nearby bone. ------- MRI Cervical and Thoracic Spine: IMPRESSION: Study somewhat limited by lack of contrast. Possible discitis osteomyelitis at T12 and the adjacent endplates. There is epidural soft tissue at T11-T12 contiguous with the disc , which may represent a focal disc herniation, although the possibility of a tiny epidural abscess cannot be excluded. There is mild focal kyphotic angulation at this level. However, evaluation is limited due to lack of gadolinium and motion degradation on the axial images through this region. There is abnormal signal within the C3 and adjacent C4 vertebral bodies. Findings most likely related to DJD but possibility of infection cannot be entirely excluded. Moderate cervical spondylosis as detailed above. ------ TEE: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There are filamentous strands on the tip of the right coronary cusp measuring 0.6cm x 0.2cm most consistent with Lambl's excresences (normal variant), but cannot exclude endocarditis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve.. No masses or vegetations are seen on the pulmonic valve. There is no pericardial effusion. Impression: Filamentous strand on the aortic valve most consistent with Lambl's excresence (normal variant), but cannot exclude endocarditis. --------- CT Scan Pelvis and Abdomen: CT ABDOMEN WITH CONTRAST: Moderate right and small left pleural effusions are new since [2181] with associated bibasilar atelectasis. A 2-mm right lower lobe nodule (2:3) is stable since [2181]. Pleural calcifications are seen bilaterally. The cardiac apex is unremarkable. The stomach, proximal small bowel, spleen, adrenal glands, and kidneys, are unremarkable. Clips in the gallbladder fossa are likely related to previous cholecystectomy. The pancreas is thin and atrophic and otherwise unremarkable. The distal common bile duct is slightly prominent given the patient's age, measuring 10 mm (2:25). The liver contains a focal hypodensity in segment 4A measuring 7 mm thickness and too small to characterize. There is no free gas or fluid in the abdomen, though note is made of edema suggesting third-spacing of fluid. There is no retroperitoneal or mesenteric lymphadenopathy. CT PELVIS WITH CONTRAST: The rectum contains a large amount of stool and otherwise the rectum and colon are unremarkable. The urinary bladder contains a moderate amount of gas related to the Foley catheter which is in place. Debris is seen settling dependently in the bladder. The prostate is enlarged and measures 63 x 52 x 63mm. There is no inguinal or pelvic lymphadenopathy. There is no free gas or fluid in the pelvis. OSSEOUS FINDINGS: Left hip fracture and hardware are similar to that cataloged on [2183-6-6]. Otherwise, there is no suspicious sclerotic or lytic lesion. Multilevel degenerative changes noted, including anterior wedge compression deformity of the T12 vertebral body with approximately 50% of loss of height anteriorly. IMPRESSION: 1. Right greater than left, small bilateral pleural effusions. 2. Enlarged prostate. 3. Debris seen dependently in the bladder. Non-specific on imaging and may represent small amount of blood. Recommend correlation to urinalysis. 4. Left hip hardware and fractures as detailed on the dedicated CT from [2183-6-6]. 5. Compression deformity of T12 of unknown chronicity. ------ [2183-6-19] CT chest, for eval of L SC joint FINDINGS: The airways are patent to the segmental levels. There is marked loss of volume in the right middle lobe. In the right middle lobe, there are bronchiectasis and calcified granulomas. Two 2-mm lung nodules in the RML are stable since in [2180]. In the right middle lobe, surrounding the largest calcified granuloma, soft tissue abnormality measures 12 mm, was 9 mm. I believe the increase in size is given the increase in loss of volume in the right middle lobe compared to prior studies, but followup in six months is recommended to assess stability. Bronchiectasis and bronchial wall thickening is also present in the lower lobes bilaterally. Small bilateral pleural effusions are layering and non-hemorrhagic. Calcified pleural plaques are noted bilaterally. Bibasilar atelectases are greater in the left base in the dependent portions. Elongated nodular opacity in the left lower lobe, series 4, image 168, is likely an area of small atelectasis. There is mild centrilobular emphysema, predominating in the upper lobes. 3-mm nodule in the left upper lobe (4:135), is stable since [2180]. 2-mm nodule in the upper lobe, (4:124), is stable since [2180]. 7 x 4 mm nodule, left upper lobe superior segment, series 4, image 168, is unchanged from prior. Consolidation is in the lingula. 2-mm subpleural nodule is in the right lower lobe, is unchanged, (4:197). There are no new lung nodules. Mild aortic calcification is of unknown hemodynamic significance. Coronary calcification is in the LAD. Cardiac size is normal. There are no enlarged mediastinal, hilar, or axillary lymph nodes. There is no pericardial effusion. This examination is not tailored for subdiaphragmatic evaluation. The upper abdomen is unremarkable. Right PICC tip is in the lower SVC. There is no abscess or osseous erosion. Very mild soft tissue swelling overlying the left sternoclavicular joint. There is minimal asymmetry with slight increased bony sclerosis about the left sternoclavicular joint compared to the right, best seen on sagittal images (401b:18). Compression fracture is at T12. IMPRESSION: No definite abscess or osseous erosion around the left sternoclavicular joint. Given uptake on indium-111 scan in the region of the left sternoclavicular joint, query septic joint or osteomyelitis. This should be correlated clinically. ---- [2183-6-18] tagged WBC nuclear scan INTERPRETATION: Following the injection of autologous white blood cells labeled with Tc-[Age over 90 ]m/In-111, an image of the whole body was obtained, demonstrating increased asymmetric activity at the left sternoclavicular junction, corresponding to the known supraclavicular fluid collection, now concerning for an abscess. The mild activity in the liver and the high activity in the spleen are normal. Non-specific, mild, asymmetric increased activities are noted in the right hemipelvis, in the anterior view. SPECT-CT images in the pelvis were obtained for further evaluation. SPECT-CT images from the lower abdomen to the pelvic symphysis were obtained, but revealed no abnormal activities. Borderline enlarged inguinal nodes are identified, but none demonstrate abnormal tracer activities. IMPRESSION: Abnormal increased focal tracer activity projected onto the left sternoclavicular junction, corresponding to the known left supraclavicular fluid collection. Findings consistent with an abscess. ------ [2183-6-5] 11:35 am URINE Site: CATHETER FINAL REPORT [2183-6-8] URINE CULTURE (Final [2183-6-8]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 16 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R ------ Blood cultures from [6-5] thru [6-13] all grew coag positive staph aureus with following sensitivites: STAPH AUREUS COAG + \| DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 4 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S Blood cultures from [6-14] thru current have been no growth to date. Brief Hospital Course: Mr. [Known lastname ] is a n 83M w/ DM2, HTN, BPH w/ chronic indwelling Foley, left hip ORIF in [3-24], recent urosepsis/MRSA bacteremia presents from rehab with DKA and now w/ MRSA bacteremia who was treated initially treated in the ICU for his DKA which resolved fairly quickly and was subsequently transferred in stable condition to the floor. His prolonged course and treatment are as follows. # Diabetic Ketoacidosis: After insulin/glucose overnight the patient was no longer in DKA. His anion gap resolved, blood sugars fell into the normal range. His NPH and HISS were continued, and although initially poorly controlled, have stabilized on the current regimen. # GIB: In the ICU had melanotic stool. GI consulted and given stable hematocrit did not intervene. He is recommended to follow up for possible EGD/[Last Name (un) ] as an outpatient when stable, finished treatment for bacteremia. # MRSA Bacteremia: Etiology uncertain, although endocarditis was initially suspected. He had recent MRSA bacteremia in [4-24], treated at OSH. TTE showed possible old vegetation on aortic valve and a mass on the mitral valve, but subsequent TEE was negative and he was treated with a 10 day course of antibiotics. After admission here, repeat TTE and TEE were negative for vegetation. Given his persistent, high grade bacteremia, a site of seeding was suspected. He does have left hip hardware, but imaging did not show evidence of infection. On exam, he had a very erythematous, tender left sternoclavicular joint. Imaging by ultrasound initially was suspicious for fluid collection, however CT scan of the area did not show a drainable collection. Thoracic surgery was consulted to discuss aspiration and/or debridement, as this was felt to be the source of his persistent bacteremia. Given his frail state, treatment with IV vancomycin without debridement was felt to be the best conservative course. His bacteremia cleared, last positive culture [6-13], and the L SC joint appearance (erythema and tenderness) improved as well. In additional workup, a tagged WBC scan showed increased uptake at the left sternoclavicular joint concerning for an abscess. Repeat CT of the area failed to demonstrate a clear abscess, but had no bony destruction. No intervention was recomended by thoracic surgery and interventional radiology. He was started on Vancomycin and should be continued on this antibiotic for 6 WEEK course from [2183-6-14]. End date [2183-7-25]. Follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 18] recommended, they will call for follow up date/time. # Incidental PE: Found on CT of left shoulder. Lovenox bridging to warfarin goal INR [2-18]. # UTI versus colonization, pseudomonas: Foley was changed on admission. He was treated with ciprofloxacin until cultures showed pseudomonas, so this was changed to Zosyn, but senstivities revealed multi-drug resistance, sensitive only to amikacin. Given that it was unclear if this organism was causing symptoms and may have been a colonizer in his indwelling Foley, Zosyn was stopped and a repeat urine culture was sent from the new Foley that continued to grow Pseudomonas. He had improved clinically, however, so this was considered chronic colonization. His Foley was changed a second time two weeks later and repeat urine culture showed persistant pseudomonas. ID recommended a one week course of tetracycline. . #. Decubitus Ulcer ?????? stage II ulcer on admission. Received daily wound care, will need continued precautions and wound care on discharge. Medications on Admission: iron 325mg po daily sliding scale novolog QID 200-300 1 unit [Unit Number ]-400 2 units >400 3 units NPH 5 units at 9pm, 10 units at 8:30am oyster calcium 500mg [Hospital1 ] flomax 0.4mg PO qHS synthroid 50mcg qAM colace 100mg PO BID MVI with minerals qAM Vitamin c 500mg daily zinc 220mg daily prilosec 20mg po daily Cozaar 100mg qd Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for left shoulder pain. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for prevent constipation. 8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO PRN: prior to PT/OT. 9. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 10. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO PRN as needed for constipation. 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. Tetracycline 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Capsule(s) 14. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln Intravenous Q 24H (Every 24 Hours) for 5 weeks: end date [2183-7-25]. 15. Sodium Chloride 0.9 % 0.9 % Syringe Sig: 1-2 MLs Injection twice a day as needed for line flush. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous qAM. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous qPM. 18. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) units Subcutaneous qAC and qHS: by sliding scale attached. 19. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. 20. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 21. Lovenox 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous every twelve (12) hours for 2 days: until INR theraputic at 2-3. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: 1. MRSA Bacteremia, left sternoclavicular joint infection 2. pulmonary embolus 3. DMII 4. HTN 5. BPH, chronic foley 6. UTI, pseudomonas Discharge Condition: Stable to extended care facility for ongoing treatment of bacteremia, chronic left shoulder pain, left rib pain, right PICC in place. Discharge Instructions: You were admitted to the hospital for complications related to your diabetes and were found to have an infection of your blood. You are currently being treated with IV vancomycin for an infection in your blood stream, and will need 6 weeks of this medicine. You are being discharged to extended care facility ([Hospital1 ]) so that you may continue to receive IV antibiotics, physical therapy, and close observation of your condition. If you have fever, chills, altered mental status, oozing or redness from your PICC line, chest pain, shortness of breath, or any other concers, please call your primary physician or return to the emergency department. Followup Instructions: Please keep the following appointments. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15048], MD Phone:[Telephone/Fax (1) 9347] Date/Time:[2183-7-28] 9:15	[ "272.0", "578.9", "401.9", "707.22", "600.00", "415.19", "790.7", "244.9", "285.9", "250.12", "711.98", "041.12", "707.03", "041.7", "599.0" ]	icd9cm	[ [ [] ] ]	[ "88.72", "38.93" ]	icd9pcs	[ [ [] ] ]	21111, 21193	15031, 18666	322, 357	21375, 21511	4124, 15008	22219, 22416	3011, 3028		19058, 21088		21214, 21352		18692, 19035			21535, 22196										3043, 4105																														274, 284																385, 2523																		2545, 2786	2802, 2995
77,131	120,073	40698	Discharge summary	report	Admission Date: [2128-4-24] Discharge Date: [2128-5-4] Date of Birth: [2073-4-18] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 99] Chief Complaint: L SDH Major Surgical or Invasive Procedure: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. History of Present Illness: 55 y/o M with history of liver cirrhosis presents s/p 1 day of headache and unsteady gait per friend presents to OSH. Per OSH reports, patient was seen in ED where he seized 3 times and was found to have L SDH on CT scan of head. He was loaded with dilantin and intubated, then transferred to [Hospital1 18] for further evaluation and management. Patient is sedated on propofol with a platelet count of 48 upon arrival to [Hospital1 ]. Past Medical History: liver cirrhosis, bipolar, hepatitis C Social History: ETOH, drink beer daily Lives with friend Family History: NC Physical Exam: O: BP:125/73 HR:73 R:18 O2Sats: 100%CMV Gen: patient is intubated on propofol HEENT: atraumatic, normocephalic Pupils:4-3mm bilaterally Neuro: Minimal EO to stimuli Pupils 4-3 mm bilaterally BUE purposeful BLE w/d to noxious L>R Pertinent Results: CT HEAD W/O CONTRAST [2128-4-24] 1. Bilateral subdural hematomas, as above, left greater than right, with stable rightward shift and subfalcine and mild/early uncal herniation. 2. Possible retained foreign body in left frontotemporal soft tissues, please correlate clinically. 3. Comminuted nasal fractures, likely chronic. CT HEAD W/O CONTRAST [2128-4-25] 1. Post-left subdural evacuation changes, with improved moderate left pneumocephalus and overlying subcutaneous emphysema. 2. Unchanged blood layering along the tentorial leaflets. 3. Improved rightward subfalcine herniation. 4. No new hemorrhage or mass effect. Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Brief Hospital Course: 55 y/o M with hepatitis C andl iver cirrhosis presents to OSH after 1 day of headachae and unsteadiness. Head CT revealed L SDH with midline shift. He was transferred to [Hospital1 18] for further neurosurgical intervention. His platelet count at the OSH was 48, repeat head CT showed no increase in hemorrhage, he was taken emergently to the OR for a L craniotomy for evacuation of L SDH. OR was uncomplicated and patient was transferred to the ICU for monitoring overnight. Post op head CT showed pneumocephalus with good evacuation of blood. On post op examination, he localized bilateral upper extremities and moved BLE spontaneously. On [4-26], patient was slightly lethargic, but alert and moving all extremities to commands. He was transferred to step down unit. He remained stable overnight but he also remained hyponatremic. A repeat sodium was 135 after being started on salt tabs. A repeat urinalysis was also checked to evaluate the UTI that was treated in the emergency room which was essentially negative. On the evening of [2128-4-27], patient bacame hypotensive and required aggressive crystalloid resuscitation. He responded reasonably but continued to have hypotension in the AM [4-28]. He required several boluses of IVFs. NGT was placed in routine fashion and a CXR confirmed placement in the bowel. Cardiac enzymes and ECG was obtained to rule out cardiac etiology for persistent hypotension. In addition, medicine was consulted for further recommendations and assistance in management of hypotension. CK was elevated at 1028. ECG showed low voltage and thus TTE was recommended by medicine as well as urine studies to rule out rhabdomyolysis. Required ventilation support for hypoxia. Continued to become progressively more hypotensive despite multiple vasopressors. Decision made by HCP to withdraw treatment and make patient CMO. Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Medications on Admission: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Discharge Medications: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Discharge Disposition: Expired Discharge Diagnosis: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Discharge Condition: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Discharge Instructions: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO. Followup Instructions: Patient Passed Away on [2128-5-4] at 5:31 PM after being made CMO.	[ "997.5", "349.82", "070.70", "785.59", "507.0", "296.80", "V49.86", "608.86", "287.49", "785.52", "599.0", "286.9", "E878.8", "728.88", "557.9", "432.1", "997.1", "276.4", "276.1", "345.90", "305.01", "293.0", "428.0", "305.1", "E944.5", "584.5", "E947.8", "038.9", "789.59", "998.59", "V85.0", "995.92", "303.91", "518.5", "348.4", "571.2", "572.3", "787.91" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "38.93", "96.6", "38.91", "96.72", "01.31", "02.12" ]	icd9pcs	[ [ [] ] ]	4164, 4173	1993, 3948	308, 380	4287, 4359	1268, 1970	4478, 4551	990, 994		4069, 4141		4194, 4266		3974, 4046			4383, 4455										1009, 1249																														262, 270																408, 854																		876, 916	932, 974
11,818	104,457	23837	Discharge summary	report	Admission Date: [2184-9-30] Discharge Date: [2184-10-4] Date of Birth: [2143-1-25] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 2009] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 41 yo male with a PMH of a fall off a ladder [2179] with multiple MSK injuries requiring T10-L3 fusion, iliac crest bone graft, ORIF of right femur, and eventual total left hip replacement [5-11] with multiple infectious complications of his left hip replacement (including MRSA septic arthritis) which was finally removed with spacer placed. He presented on [2184-9-30] with asymptomatic hypotension and ? sepsis. Please see MICU [Location (un) ] H&P for full HPI, PMH, home meds, SH, FH. Briefly, after his septic arthritis, he required a prolonged course of vanc, but unfortunately became [Last Name (LF) 60810], [First Name3 (LF) ] it was changed to dapto in [Month (only) ]. He was subsequently doing well up until this admission. . Because of hypotension and tachycardia, he was sent to MICU 6. He had a nl lactate, and he was on transient pressors while awaiting fluid management, but was ultimately fluid responsive. His VS have since been stable. He was initially placed on dapto/zosyn. His BCx have grown out enterococcus and his urine is growing GNRs. Despite joint fluid from his left hip showing WBC of 1800, ortho felt this was not a septic joint. ID was consulted bc they are following him as an outpatient. Their latest recs were to stop dapto bc they felt enteroccus would respond to ampicillin (not VRE). A TTE was negative, but a TEE is recommended. His PICC was removed and cultured (no signficant growth). He has one PIV, refusing another. . In addition to the above, he has had bradycardia with HRs in 40s-50s, thought to be related to vagal tone. His PR has been wnl and the bradycardia has been asymptaomtic. He has a hx of svt, on dilt, which is being held for the bradycardia. . He has also had ARF to 2.8, bl 0.9. This is felt likely ATN after hypoperfusion [1-5] to hypotension. He is making urine and has gotten roughly 6L of IVF, + 2.5L LOS. . Finally, he has been disruptive in the ICU. He has a hx of depression and polysubstance abuse. Today, upon talking with psychiatry, he was verbally abusive to him. He apparently was nearing code purple, but he calmed down spontaneously. Psych felt he is compitent to make dnr/dni and to make medical decisions, including AMA. Past Medical History: 1) L THR [2184-5-20] (due to traumatic osteoarthritis [2179] - fell off ladder), L hip MRSA prosthetic joint infection with bacteremia, s/p explant [6-9], multiple washouts, spacer placement, 2) ex-lap with resection of his small bowel, 3) ORIF R femur, 4) T10-L3 fusion, transpedicular decompression, at T12, multiple laminotomies, 5) right Iliac Crest Bone Graft, 6) h/o polysubstance abuse, etoh, cocaine 7) depression, s/p multiple suicide attempts: cocaine binge, radial artery laceration/percocet overdose 8) SVT after washouts, responded to dilt 9) h/o GI bleed in the setting of thrombocytopenia from Vancomycin, improved with stopping Vanco, refused colonoscopy Social History: Mom died while pt hospitalized for initial fall. h/o incarceration Disability. Tobacco 1.5 ppd. ETOH, crack cocaine, opiate use in past. Denies IVDU. Last EtOH and drug use in [1-12]. Family History: NC Physical Exam: Tm/c 96.8 HR 65, 56-83 114/72, 87-120/45-75 RR 20 93-99%RA PHYSICAL EXAM GENERAL: NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP=12cm on left LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No c/c/e SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Grossly nonfocal Pertinent Results: [2184-9-29] 11:50PM BLOOD WBC-14.7# RBC-3.33 Hgb-9.3* Hct-27.3* MCV-82 MCH-28.1 MCHC-34.2 RDW-16.3* Plt Ct-186 [2184-9-30] 06:34AM BLOOD WBC-9.6 RBC-2.99* Hgb-8.1* Hct-25.2* MCV-85 MCH-27.1 MCHC-32.0 RDW-15.9* Plt Ct-164 [2184-9-30] 02:38PM BLOOD WBC-6.0 RBC-2.90* Hgb-8.0* Hct-24.4* MCV-84 MCH-27.7 MCHC-32.8 RDW-16.3* Plt Ct-169 [2184-10-1] 03:25AM BLOOD WBC-6.5 RBC-3.17* Hgb-8.9* Hct-26.8* MCV-85 MCH-28.0 MCHC-33.1 RDW-16.3* Plt Ct-217 [2184-10-2] 05:40AM BLOOD WBC-6.2 RBC-3.35* Hgb-9.1* Hct-28.4* MCV-85 MCH-27.1 MCHC-31.9 RDW-16.0* Plt Ct-257 [2184-10-3] 06:45AM BLOOD WBC-6.7 RBC-3.15* Hgb-9.0* Hct-26.6* MCV-85 MCH-28.6 MCHC-33.8 RDW-16.3* Plt Ct-286 [2184-10-4] 07:10AM BLOOD WBC-8.9 RBC-3.42* Hgb-9.6* Hct-28.4* MCV-83 MCH-28.0 MCHC-33.7 RDW-16.3* Plt Ct-333 [2184-9-29] 11:50PM BLOOD Neuts-86* Bands-2 Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2184-10-1] 03:25AM BLOOD Neuts-51 Bands-2 Lymphs-32 Monos-8 Eos-6* Baso-1 Atyps-0 Metas-0 Myelos-0 [2184-9-29] 11:50PM BLOOD PT-13.5* PTT-24.2 INR(PT)-1.2* [2184-9-30] 06:34AM BLOOD PT-13.3 PTT-27.3 INR(PT)-1.1 [2184-10-4] 07:10AM BLOOD Plt Ct-333 [2184-9-29] 11:50PM BLOOD ESR-99* [2184-9-29] 11:50PM BLOOD UreaN-33* Creat-2.9# [2184-9-30] 06:34AM BLOOD Glucose-136 UreaN-31* Creat-2.7* Na-137 K-3.2* Cl-103 HCO3-23 AnGap-14 [2184-9-30] 02:38PM BLOOD UreaN-30* Creat-2.7* Na-142 K-3.4 Cl-109* HCO3-23 AnGap-13 [2184-10-1] 03:25AM BLOOD Glucose-108* UreaN-31* Creat-2.8* Na-144 K-4.0 Cl-110* HCO3-24 AnGap-14 [2184-10-2] 05:40AM BLOOD Glucose-85 UreaN-24* Creat-2.5* Na-145 K-3.6 Cl-111* HCO3-23 AnGap-15 [2184-10-3] 06:45AM BLOOD Glucose-93 UreaN-18 Creat-2.2* Na-144 K-3.4 Cl-109* HCO3-24 AnGap-14 [2184-10-4] 07:10AM BLOOD Glucose-93 UreaN-13 Creat-2.0* Na-145 K-3.3 Cl-110* HCO3-26 AnGap-12 [2184-9-30] 06:34AM BLOOD ALT-9 AST-17 LD(LDH)-201 AlkPhos-86 TotBili-0.5 [2184-9-30] 02:38PM BLOOD LD(LDH)-199 TotBili-0.3 [2184-9-30] 06:34AM BLOOD Albumin-2.8* Calcium-7.5* Phos-3.9 Mg-1.6 [2184-10-4] 07:10AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.7 [2184-9-30] 02:38PM BLOOD calTIBC-195* Hapto-285* Ferritn-380 TRF-150* [2184-9-29] 11:50PM BLOOD CRP-235.2* [2184-9-30] 06:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2184-9-29] 11:55PM BLOOD Glucose-129* Lactate-1.3 Na-133* K-3.3* Cl-93* calHCO3-24 [2184-9-30] 04:53AM BLOOD Lactate-1.0 [2184-9-30] 04:53AM BLOOD Hgb-9.1* calcHCT-27 ECHO ([2184-9-30])- The left atrium is mildly dilated. 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 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) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Chest X-ray ([2184-9-30])- IMPRESSION: No acute intrathoracic process. CT Pelvis ([2184-9-30])- IMPRESSION: 1. Redemonstration of methyl methacrylate beads, wire and spacing device in the left acetabulum/proximal femur with proximal migration of the femur. 2. No frank joint effusion identified. High density soft tissue in region of hip joint, may represent granulation tissue. 3. Bilateral fat-containing inguinal hernias. ECG ([2184-9-30])- Sinus bradycardia. Incomplete right bundle-branch block. Prolonged Q-T interval. Compared to the previous tracing of [2184-7-6] an RSR' pattern is now present in lead V1 with a slight increase in the QRS duration. The sinus rate is slower. Premature atrial beats are no longer present. Chest X-ray for line placement ([2184-10-4])- FINDINGS: Radiodense wire of left PICC terminates in the lower superior vena cava just above the junction with the right atrium. Heart size is normal, and lungs are grossly clear. Brief Hospital Course: #. Septic shock - Patient was hypotensive on admission and was admitted to the MICU. It was determined this was most likely SIRS/sepsis that was fluid responsive (received 2L NS in MICU). He was transferred to the floor on [2184-10-1]. Hypotension has since resolved. BP on discharge was 144/80. Patient treated for bacteremia, initially with ampicillin and zosyn. Zosyn was discontinued after urine cultures returned (showed GNRs). He was switched to PO cipro 500mg PO q12hr. Ampicillin continued at 2gm IV q4hr. Patient had PICC line placed on [10-4]- chest x-ray showed tip in lower SVC. Please apply heat to LUE 4 times a day for 2-3 days. #. Bacteremia: Patient currently on ampicillin and cipro for enterococcus and GNR coverage. Joint fluid, PICC culture and blood cultures have not grown anything to date. Joint fluid thought not septic by ortho. TTE was negative for endocarditis. ID team did not feel like patient needed a TEE also given negative TEE. Urine culture grew pan-sensitive klebsiella (MIC <.25 for cipro). Patient remained afebrile with normal WBC. ID followed patient- regarding discharge planning, they recommended ampicillin 2gm q 4hr for total of 14 days (day 1- [10-1]). They said if IV access is lost again, then to give PO linezolid. Patient is to also continue cipro 500mg PO BID x 7 days (day 1- [10-2]). #. Anemia - Patient has a history of normocytic anemia secondary to chronic inflammation with negative DIC/TTP labs on previous hospitalization. Hct trended up while here (24.4 on admission and 28.4 on discharge). He did not require any blood transfusions while in the hospital. No signs of active bleed or hematoma at surgical site. #. Acute Renal Failure - Admissions creatinine up to 2.8 from baseline of 0.9. An FENA was 0.5 suggesting prerenal etiology. Patient maintained excellent UOP while in the hospital. Creatinine trended down daily (was 2.0 on discharge). #. Bradycardia - HR was down to high 30s in ED. Patient was on CCB at home- his diltiazem was held while here. Patient had normal PR interval. It was felt bradycardia was secondary to vagal tone. Diltiazem was held on discharge. HR upon discharge was 60. Patient denied any headache, dizziness, or syncope. #. Depression- Patient on fluoxetine 40mg daily. Currently has no outpatient psychiatrist at this time. He had no suicidal ideation while here. Patient was seen by psych in the ICU and felt he had capacity for code status and AMA decisions. Patient did nearly code purple on [10-1] but he calmed down on his own. However, he was code purpled on [10-2] after altercation with IV nurse. Patient threatened to leave AMA but decided to stay after it was explained to him that he needed antibiotics. IV was placed later on that evening. After that he remained calm and appropriate. #. S/p left hip arthroplasty- Orthopaedics saw patient while here. They aspirated the joint fluid and determined it was not septic. They recommended patient be NWB LLE. #. Polysubstance abuse - Last use of cocaine/EtOH was [1-12]. #. CODE STATUS: DNR/DNI confirmed in ICU . # Follow up: Will need ID, ortho and pcp follow up, as well as BMP this week. Medications on Admission: Heparin 5000 UNIT SC TID Ampicillin 1 g IV Q6H Calcium Carbonate 500 mg PO/NG QID:PRN Nicotine Patch 21 mg TD DAILY Docusate Sodium 100 mg PO/NG [Hospital1 ] Piperacillin-Tazobactam 2.25 g IV Q8H Fluoxetine 40 mg PO/NG DAILY Simethicone 40-80 mg PO QID:PRN indigestion Gabapentin 300 mg PO/NG TID HYDROmorphone (Dilaudid) 8 mg PO/NG Q4H:PRN pain Discharge Medications: 1. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion/GERD. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 8. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: Rosscommons Discharge Diagnosis: Primary: Bacteremia Secondary: S/p left hip replacement Discharge Condition: Good, vital signs stable Discharge Instructions: You were admitted to the hospital with an infection in your blood. While here, you were treated with antibiotics and did well. You remained afebrile with normal white blood cell count. Tests showed that you did not have any infection on your heart valves. Upon discharge, you were afebrile and stable. The following changes were made to your medications: 1. Please continue ampicillin 2mg IV every 4 hrs for a 14 day course (day 1- [10-1]) 2. Please continue ciprofloxacin 500mg by mouth every 12hrs for a 7 day course (day 1- [10-2]) 3. Please discontinue your diltiazem If you experience any fevers, chills, chest pain, shortness of breath, headaches, or any other medically concerning symptoms, please contact your primary care physician or go to the emergency department immediately Followup Instructions: Please follow-up with infectious disease ([First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD- [Telephone/Fax (1) 457]) on [2184-10-15] at 9:00am Please follow-up with your [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN on [2184-10-20] at 2:40pm. Completed by:[2184-10-5]	[ "304.00", "303.91", "041.3", "599.0", "995.92", "304.22", "999.31", "038.0", "V43.64", "584.5", "785.52", "285.9", "427.89", "038.19" ]	icd9cm	[ [ [] ] ]	[ "81.91", "38.93" ]	icd9pcs	[ [ [] ] ]	13012, 13050	8436, 11573	283, 290	13152, 13179	4127, 8413	14031, 14368	3532, 3536		12053, 12989		13071, 13131		11677, 12028			13203, 14008										3551, 4108										11585, 11651																				232, 245																318, 2602																		2624, 3309	3325, 3516
5,096	162,020	27057	Discharge summary	report	Admission Date: [2139-7-31] Discharge Date: [2139-8-9] Service: MEDICINE Allergies: Levofloxacin Attending:[First Name3 (LF) 348] Chief Complaint: OSH transfer w/ abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: (History confirmed by sign-out from PCP and OSH notes) . [Age over 90 ]M anesthesiologist h/o CAD s/p CABG, CHF (EF 45%), pAF s/p pacemaker for tachy-brady syndrome, AS and MR, CRI, esophageal stricture s/p PEG, and recent PNA c/b C diff, transferred from [Hospital3 3583] with abdominal pain [1-9] known CDiff colitis. Three weeks prior to admission, pt had been diagnosed with PNA and treated with amoxicillin/clavulanate at OSH, after which he developed C. diff colitis, for which he was treated with vancomycin/metronidazole and then transferred to rehab. Three days prior to admission, pt developed T 103.9, vomiting and was admitted to OSH, where CXR showed RLL PNA (recurrent vs persistent) with positive C. diff toxin. Per PCP, [Name10 (NameIs) ] underwent a CT scan chest/abd/pelvis w/o contrast today which showed new ascites, cholelithiasis, B renal cysts, subcutaneous edema, an IM lipoma, and no obvious source of abdominal pain. Pt also had a negative HIDA scan. . Because pt had been "yelling in agony for up to 6 hours" at the OSH, pt was transferred to [Hospital1 18] for further w/u. Of note, pt had been transfused 2 units PRBC given decreased hematocrit of 27 from baseline 32, in the setting of chronically guaiac-positive stools. . In the MICU, patient reported an intermittent [8-17] "sensation" in his abdomen which was best characterized as colicky pain. . ROS: Positive for intermittent [9-16] abdominal pain. Negative for SOB, cough, fever, nausea, myalgia/arthralgia. Past Medical History: GI # Esophageal dysfunction --Dysmotility: Treated with Botox injections --PEG placement (5 years ago) # Esophageal stricture - unable to pass pediatric endoscopy tube without dilation . CV # Paroxismal atrial fibrillation s/p pacemaker placement for tachy brady syndrome # Ischemic heart disease s/p CABG '[18] # Aortic stenosis # Mitral regurgitation # HTN # CHF (EF 45%) . GU # CRI: Cr baseline mid-1's # Bladder tumor Social History: # Employment: Retired anesthesiologist who worked for 40 years at [Hospital3 3583]. # Tobacco: Never # Alcohol: Never # Recreational drugs: Never Family History: # Parents, d80s: Heart disease not otherwise specified Physical Exam: VS: T 98.4, BP 141/74, HR 74, RR 19, O2 sat 98% 5LNC Gen: Alert, oriented, cachectic male, NAD HEENT: MM dry, OP clear, PERRL, poor dentition CV: [2-10] holosystolic SEM at BUSB, apex; no radiation to carotids Chest: Bibasilar rales (to mid-lung on L); overall decreased BS at R Abd: Concave, thin, tender to palpation periumbilically and at L lateral side, ND, hypoactive BS Ext: No c/c/e BLE Neuro: Grossly intact Pertinent Results: Admission labs: . [2139-7-31] 10:27PM PT-14.2* PTT-35.1* INR(PT)-1.3* [2139-7-31] 10:27PM PLT COUNT-192# [2139-7-31] 10:27PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [2139-7-31] 10:27PM NEUTS-74.5* BANDS-0 LYMPHS-19.1 MONOS-4.8 EOS-0.8 BASOS-0.8 [2139-7-31] 10:27PM WBC-8.5 RBC-4.00* HGB-11.9* HCT-35.7* MCV-89 MCH-29.8 MCHC-33.4 RDW-17.4* [2139-7-31] 10:27PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-2.7* [2139-7-31] 10:27PM CK-MB-NotDone cTropnT-0.43* [2139-7-31] 10:27PM LIPASE-22 GGT-266* [2139-7-31] 10:27PM ALT(SGPT)-75* AST(SGOT)-86* LD(LDH)-277* CK(CPK)-48 ALK PHOS-262* AMYLASE-48 TOT BILI-0.7 [2139-7-31] 10:27PM GLUCOSE-97 UREA N-55* CREAT-2.0* SODIUM-135 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16 =========================================== Studies: . # CHEST PORT. LINE PLACEMENT [2139-8-1] 3:20 PM The patient is status post sternotomy, with moderately severe cardiomegaly and a calcified aorta. The hila appear prominent, suggesting pulmonary hypertension. A left-sided pacemaker is present, lead tips over right atrium and right ventricle. There is a focal opacity adjacent to the left hilum, of uncertain etiology or significance. There is patchy opacity diffusely throughout the right lung -- at least some of this is thought to represent CHF, with superimposed more consolidative process. There are bilateral right greater than left effusions. No pneumothorax is detected. A right subclavian PICC line is present, tip in the region of the cavoatrial junction. There is probably fluid in the minor fissure, accounting for some of the opacity seen in the right lung. A rounded loop linear density is seen adjacent to the right main stem bronchus. This lies near, but is not clearly related to the PICC line. Attention to this area on followup films is recommended. This may also lie outside the patient. . IMPRESSION: 1. PICC line at cavoatrial junction. Unusual loop-like structure near it, but not clearly arising from it. Attention to this area on followup films is recommended. No pneumothorax. 2. Doubt CHF. Bilateral pleural effusions. Question underlying pneumonia. . # LIVER OR GALLBLADDER US (SINGLE ORGAN) [2139-8-1] 8:55 AM RIGHT UPPER QUADRANT ULTRASOUND: There are multiple layering gallstones. The gallbladder is not distended and there is no wall edema or pericholecystic fluid. A [Doctor Last Name 515] sign was not elicited. The common bile duct is not dilated. The liver demonstrates no echotextural or focal abnormalities. The main portal vein is patent with appropriate hepatopetal flow. Increased pulsatility likely reflects right heart failure. There are multiple cysts in the right kidney, the largest within the lower pole measuring 3.4 x 3.2 x 3.7 cm with a single thin septation. There is a moderate-sized right-sided pleural effusion and trace perihepatic ascites. . IMPRESSION: 1. Cholelithiasis without cholecystitis. 2. Moderate right-sided pleural effusion. 3. 3.7-cm renal cyst with single septation. . # CT PELVIS W/O CONTRAST, CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST [2139-8-1] 1:13 AM CT OF THE CHEST WITHOUT CONTRAST: There is no axillary adenopathy. AP window lymph nodes measure up to 1.3 cm in size. No other mediastinal or hilar adenopathy is appreciated. Examination of soft tissue windows also demonstrates marked vascular calcifications involving the aortic arch as well as the descending thoracic aorta. Impressive coronary artery calcifications are also present. Marked cardiomegaly is present. A dual-chamber cardiac pacemaker is present. A moderate-large right-sided pleural effusion is present, as well as a small left-sided pleural effusion with some fluid loculated within the major fissure. . Examination of lung windows demonstrates a patency of the central airways in the segmental bronchi bilaterally. However, in conjunction with compressive atelectasis of the right lower lobe, there are also some regions of air bronchograms, and narrowing of the more distal bronchi, suggesting superimposed infection/consolidation within these regions. . CT OF THE ABDOMEN WITHOUT CONTRAST: Allowing for non-contrast technique, the liver is unremarkable. Calcified stones are seen dependently within the gallbladder. No evidence of cholecystitis. Coarse calcifications are also seen within the spleen, consistent with granulomata. Marked vascular calcifications of the splenic artery as well as the abdominal aorta are appreciated, without aneurysmal aortic change. Multiple low-density lesions are seen arising from both kidneys, many of which have attenuation characteristics consistent with simple cysts, but others which are too small to accurately characterize. It is unclear whether several punctate calcifications seen within the kidneys represent vascular calcifications or calcifications within the collecting systems. Right adrenal gland appears unremarkable. The left adrenal gland is not well visualized. The pancreas appears atrophic, but again is not well visualized without IV contrast. Note is made of a gastrostomy tube. A trace of ascites is present. No abdominal adenopathy is appreciated. . CT OF THE PELVIS WITHOUT CONTRAST: Bowel and bladder appear unremarkable, with a Foley catheter draining the bladder. No pelvic adenopathy or free fluid is appreciated. . Examination of osseous structures does not show lytic or sclerotic lesions suspicious for malignancy. Old right-sided posterior T9 rib fracture is seen. Diffuse subcutaneous edema is present throughout the entire body. . Coronally and sagittally reformatted images support these findings. . IMPRESSION: 1. Large right-sided pleural effusion, with a combination of atelectasis and consolidation involving the right lower lobe. Small left-sided pleural effusion, with loculated component within the major fissure. 2. Vasculopathy, with pronounced vascular calcifications. 3. Small amount of abdominal free fluid is present. 4. No evidence of overt bowel pathology. 5. Cholelithiasis. . # ABDOMEN (SUPINE & ERECT) [2139-8-3] 9:18 AM FINDINGS: Previews of the abdomen demonstrate nondilated small bowel loops. Contrast administered for a recent CAT scan is seen through the large bowel into the sigmoid colon. There is no evidence of free intraperitoneal air. The heart is enlarged. There is a right-sided pleural effusion. . IMPRESSION: 1. No evidence of small-bowel obstruction or free intraperitoneal air. 2. Cardiomegaly, right pleural effusion. . # CHEST (PORTABLE AP) [2139-8-4] 2:54 PM The examination on this [Age over 90 ]-year-old man was performed to evaluate chest and exclude recurrent pneumonia. The Bipolar pacemaker leads are noted in appropriate position. The mediastinum is midline. The airspace consolidation on the left as well as right with atelectatic changes. Bilateral pleural effusions are noted. The position of the PICC line has not changed. There is extensive calcification in the aorta. . CONCLUSION: The findings are largely those of congestive failure with pulmonary edema and pleural effusion. However, an underlying pneumonitis cannot be excluded. There has been essentially no change in the appearance of the chest from the [2139-8-1] examination. . # RENAL U.S. [2139-8-4] 3:34 PM FINDINGS: Comparison is made to upper quadrant ultrasound [8-1], [2138] and CT torso [2139-8-1]. Redemonstrated is a large right pleural effusion. There is trace fluid about the liver. The right kidney measures 10.8 cm and contains multiple simple cysts of varying sizes, unchanged. The left kidney measures 9.6 cm and also contains a 1.8 cm simple cyst. There is no hydronephrosis, but both renal cortices are diffusely echnogenic. . Doppler examination is limited given patient's inability to hold his breath. There are abnormal intraparenchymal arterial waveforms bilaterally with decreased diastolic flow and slow time to peak systolic waveforms. The velocity in the right main renal artery measures 30 cm/sec with similar waveform. The left renal artery velocity measures 21 cm/sec. Foley is in situ. . IMPRESSION: 1. No evidence of hydronephrosis. 2. Multiple bilateral simple renal cysts. 3. Echogenic kidneys with bilateral abnormal renal artery waveforms secondary to chronic medical renal disease and atherosclerosis. . # PORTABLE ABDOMEN [2139-8-4] 2:54 PM FINDINGS: There are no dilated small bowel loops. There is no supine evidence of pneumoperitoneum. Contrast from the previous CT scan is still present in the large bowel, not appreciably advanced compared to the prior study. The small bowel is featureless. Again seen is a right-sided pleural effusion. IMPRESSION: Non-obstructive bowel gas pattern. . # CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [2139-8-5] 2:39 PM FINDINGS: Cardiac size remains enlarged with extensive coronary artery calcifications in three vessels as well as aortic calcifications. Again seen is a large right pleural effusion, and small partially loculated left pleural effusion. Adjacent consolidations are present, and may represent atelectasis versus infiltrates. . Non-contrast evaluation of the liver is unremarkable. There is a gallstone present in the gallbladder. Again noted are coarse calcifications in the spleen. Extensive vascular calcifications are present. Pancreas is somewhat atrophic. Adrenal glands are unremarkable. There are numerous hypodensities in the kidneys bilaterally, some are consistent with appearance of simple cysts, some are too small to definitely characterize, and are better evaluated on the recent renal son[Name (NI) ]. [Name2 (NI) ] calculi are present in the renal collecting systems or along the course of the ureters. A G-tube is in place. There is no small bowel loop dilation. Contrast is seen in the loops of small and large bowel. Normal appendix is seen. . There is small amount of free fluid in the abdomen. There is no free air in the abdomen. . CT PELVIS WITHOUT INTRAVENOUS CONTRAST: Non-contrast enhanced evaluation of the rectum, sigmoid colon, seminal vesicles is unremarkable. Calcifications are noted in the prostate. There is small amount of free fluid in the pelvis. A Foley catheter is draining the bladder. . BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic lesions. . Diffuse edema is again present in the soft tissues. . IMPRESSION: 1. No definite evidence of bowel pathology in this limited non-IV contrast enhanced study. 2. Cholelithiasis. 3. Bilateral pleural effusions with atelectasis; underlying infection is a possibility. 4. Cardiomegaly and extensive coronary and other arterial atherosclerosis. 5. Anasarca. . # CHEST (PORTABLE AP) [2139-8-5] 12:19 AM FINDINGS: Comparison to [2139-8-4] at 3:24 p.m. There is a pacemaker seen overlying the left anterior chest wall with intact leads leading to the right atrium and right ventricle. The patient is status post median sternotomy. There is a right-sided PICC line with tip terminating at the RA/SVC junction. Cardiomediastinal silhouette is unchanged. There is a small left-sided pleural effusion. There is opacification of the right lower lung, essentially unchanged compared to the previous exam, with pleural fluid tracking along the fissure and seen at the right lung base. Underlying opacity of the lung reflects atelectasis and/or consolidation. Trace atherosclerotic vascular calcification is seen. Osseous structures are unremarkable. . IMPRESSION: 1. No evidence of pneumoperitoneum. 2. Persistent opacification of the right lung compatible with a large right- sided pleural effusion with associated atelectasis and/or consolidation. 3. Patchy retrocardiac opacity is slightly worse compared to the previous study and reflects underlying atelectasis and/or consolidation. . # CHEST (PORTABLE AP) [2139-8-6] 1:44 PM PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST AT 1:30 P.M.: There is no interval change from prior exams, after accounting for change in patient positioning. There has been no change in pleural effusions bilaterally. The right lower lobe consolidation is unchanged. Marked cardiomegaly is unchanged. Dual- chamber pacemaker is in unchanged position with intact leads. The aorta is heavily calcified. . IMPRESSION: No interval change in right lower lobe pneumonia and bilateral pleural effusions. . # PATIENT/TEST INFORMATION: MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 6.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.7 cm Left Ventricle - Fractional Shortening: 0.16 (nl >= 0.29) Left Ventricle - Ejection Fraction: 30% (nl >=55%) Aorta - Ascending: 3.8 cm (nl <= 3.4 cm) Aortic [Month/Day/Year ] - Peak Velocity: 3.2 m/sec (nl <= 2.0 m/sec) Aortic [Month/Day/Year ] - Peak Gradient: 33 mm Hg Aortic [Month/Day/Year ] - Mean Gradient: 17 mm Hg Aortic [Month/Day/Year ] - LVOT Peak Vel: 0.59 m/sec Aortic [Month/Day/Year ] - LVOT Diam: 2.0 cm Aortic [Month/Day/Year ] - Pressure Half Time: 520 ms Mitral [Month/Day/Year ] - E Wave: 1.2 m/sec Mitral [Month/Day/Year ] - A Wave: 0.4 m/sec Mitral [Month/Day/Year ] - E/A Ratio: 3.00 Mitral [Month/Day/Year ] - E Wave Deceleration Time: 168 msec TR Gradient (+ RA = PASP): 40 to 50 mm Hg (nl <= 25 mm Hg) . INTERPRETATION: Findings: This study was compared to the prior study of [2138-1-13]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Moderate symmetric LVH. Top normal/borderline dilated LV cavity size. Moderate-severe global left ventricular hypokinesis. No LV mass/thrombus. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. AORTIC [Year (4 digits) ]: Three aortic [Year (4 digits) ] leaflets. Moderately thickened aortic [Year (4 digits) ] leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL [Year (4 digits) ]: Mildly thickened mitral [Year (4 digits) ] leaflets. No MVP. Severe mitral annular calcification. Mild thickening of mitral [Year (4 digits) ] chordae. Calcified tips of papillary muscles. Severe (4+) MR. [First Name (Titles) 24998] [Last Name (Titles) ]: Mildly thickened [Last Name (Titles) ] [Last Name (Titles) ] leaflets. Thickened/fibrotic [Last Name (Titles) ] [Last Name (Titles) ] supporting structures. No TS. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC [Last Name (Titles) ]/PULMONARY ARTERY: Normal pulmonic [Last Name (Titles) ] leaflets. No vegetation/mass on pulmonic [Last Name (Titles) ]. Significant PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. . Conclusions: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are seen in the left ventricle. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. There are three aortic [Last Name (Titles) ] leaflets. The aortic [Last Name (Titles) ] leaflets are moderately thickened. There is severe aortic [Last Name (Titles) ] stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral [Last Name (Titles) ] leaflets are mildly thickened. There is no mitral [Last Name (Titles) ] prolapse. There is severe mitral annular calcification. Severe (4+) mitral regurgitation is seen. The [Last Name (Titles) ] [Last Name (Titles) ] leaflets are mildly thickened. The supporting structures of the [Last Name (Titles) ] [Last Name (Titles) ] are thickened/fibrotic. Moderate to severe [3+] [Last Name (Titles) ] regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic [Last Name (Titles) ]. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2138-1-13], the left ventricular ejection fraction is reduced, the aortic [Year (4 digits) ] orifice area is further reduced; the mitral and [Year (4 digits) ] regurgitation are significantly increased. Brief Hospital Course: [Age over 90 ] M anesthesiologist w/ PMh s/f CAD, GIB, CRI, esophageal stricture, moderate AS, and recent PNA c/b C diff transferred from [Hospital3 3583] with abdominal pain, expired [2139-8-9]. . # Abdominal pain: Pt's abdominal pain was considered likely secondary to C. diff colitis, given postive stool cultures and recent treatment with antibiotics, although CT abdomen and pelvis did not show evidence of overt bowel pathology. Pt was continued on metronidazole IV with vancomycin PO. Tube feeds were held for bowel rest, and pt was given TPN for nutrition. DDx also included possible mesenteric ischemia given known low EF, but lactate levels were within normal limits. Pt was initially given hydromorphone PCA without a basal rate, which was inadequate for pain control. After pt decided to transition to [Name (NI) 3225], pt was provided with morphine drip, and antibiotics were removed. . # ARF: Pt developed acute-on-chronic renal failure, given recent Cr baseline ~1.6. Furosemide was held and pt initially was aggressively hydrated with NS boluses and a basal rate, with some improvement of Cr but no improvement of urine output. Urine lytes demonstrated prerenal etiology, renal ultrasound demonstrated poor diastolic flow in bilateral renal arteries. Echo demonstrated end-stage heart failure with significant mitral regurgitation, [Name (NI) ] regurgitation, aortic stenosis, and L ventricular hypomobility, likely a significant factor in his low urine output. . # UTI: Pt's repeat urine culture was positive for yeast, and pt was started on fluconazole for treatment, until he was made [Name (NI) 3225], after which it was removed. . # R pleural effusion: Pt maintained O2sats in the mid-90s on 2L O2. As pt had completed 14-day course of piperacillin-tazobactam, and was afebrile throughout this admission, pt's initial recurrent pneumonia was considered likely inactive. . # Esophageal stricture s/p PEG placement: Pt was given meds through his PEG, although tube feeds were held for bowel rest. . # Hypothyroid: Pt continued on home regimen of levothyroxine until he was made [Name (NI) 3225], after which it was removed. . # Paroxismal atrial fibrillation: Pt was monitored on telemetry given his h/o pacemaker placement for tachy-brady syndrome, until he was made [Name (NI) 3225], after which it was removed. . # Ischemic heart disease s/p CABG '[18]: Pt was continued on home regimen of carvedilol, until he was made [Year (2 digits) 3225], after which it was removed. . # Aortic stenosis: Echo demonstrated end-stage heart failure, with significant MR, TR, and AS, as well as LV hypomobility. . # DNR/DNI Medications on Admission: Acetaminophen 650mg Q6H PRN Fentanyl patch 50mcg Fluconazole 100mg daily Furosemide 20mg daily Heparin SC 5000mcg TID Levothyroxine 25mg daily Metoclopramide 10mg daily Morphine 2-4mg Q4H PRN MVI Percocet-5 Q6H PRN Pantoprazole 40mg [Hospital1 ] Simethicone 80mg QID NaCl nasal spray Vancomycin 125mg PO Q6H Water 250ml NGT TID Zolpidem 10mg QHS PRN Atrovent 0.5mg Q4H PRN Albuterol nebs PRN TID Piperacillin-tazobactam 2.25g Q6H Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2139-8-10]	[ "788.20", "263.9", "511.9", "530.3", "008.45", "428.0", "574.20", "599.0", "427.31", "244.9", "414.00", "584.9", "396.0", "401.9", "486", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	23548, 23557	20353, 23032	250, 256	23609, 23619	2957, 2957	23675, 23713	2445, 2501		23516, 23525		23578, 23588		23058, 23493			23643, 23652						15390, 20330				2516, 2938																														179, 212																284, 1813						2973, 15364												1835, 2262	2278, 2429
11,288	167,790	54265	Discharge summary	report	Admission Date: [2182-4-12] Discharge Date: [2182-4-26] Date of Birth: [2105-1-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: fall, productive coughs Major Surgical or Invasive Procedure: none History of Present Illness: This is a 77 y/o F with primary papillary serous carcinoma with brain metastasis presented after fall at home. Recently discharge from [Hospital1 18] [2182-3-25] for an admission after fall. . Patient states that after going to the bathroom, she could not stop "shaking" and she fell on the floor. Denied hiting her head, chest pain, shortness of breath, lightheadeness, palpitations or any other symptoms associated with it. Per her repot, her husband found her. On the other hand, she states that she had been doing ok after re-starting her chemotherapy. Her baseline status, she walks with a walker since most recent admission. she denied nausea, vomit, diarrhea or urinary symptoms. She reports taking all her medications as prescribed. . Of note yhe patient has a history of frequent mechanical falls from steroid-induced myopathy. . In the ED, Vs 98.3 Hr 81, Bp 104/59, RR 20 Sats 90% RA. Given history of ? syncope and low o2 sats, CTA was performed to r/u PE which was negative. she received Levofloxacine and Vancomycin given initial concern of low BP per ED report. She also received 10 mg decadron IV x1. Unclear how much fluid she receivd from ED records. Past Medical History: Oncologic: * Ovarian cancer: - diagnosed of stage IIIC primary peritoneal papillary serous carcinoma in [2174] - optimal debulking surgery on [2175-2-9] - underwent six cycles of DoCaGem chemotherapy, which completed in [2175-7-22]. - in [2180-3-20], her CA125 was measured at 42 and subsequent CT scanning on [4-29] showed an anterior chest wall mass, 4 cm x 4 cm, just to the left of the sternum. - On [2180-8-1], she underwent a radical resection of the chest wall mass en bloc, which involved resection of the left hemisternum, ribs one through three, left supraclavicular joint, left lobe of the thymus, and a left upper lobe wedge resection. Surgical margins were absent of tumor, and thus she had a successful optimal debulking procedure. - completed 6 cycles of Taxol/[Doctor Last Name ] in [2180-12-21] - found to have innumerable metastatic brain lesions in [Month (only) 359] [2180] and completed a course of whole brain XRT on [2182-9-18]. - was doing well in [State 108] for the [5-28] winter, however began noting subtle, increased problems with balance over the her last 4-6 weeks there. She had a repeat MRI of the brain performed which showed progressive disease and commenced irinotecan and bevacizumab on [2182-2-28]; bevacizumab on [2182-3-14], most irinotecan on [2182-2-28]. - had grade 2 diarrhea after one dose of irinotecan as well as an ANC of [Telephone/Fax (1) 111183] cGy given tothe C-spine --> completed on [2182-4-5]. -[2182-4-9] C2D1 Irinotecan and Avastin for treatment of her met ovarian cancer. Non-oncologic: * hypothyroidism Social History: drinks wine daily.has 15 pr yr smoking history-quit 40 yrs ago. lives with his husband who has severe dementia. Family History: non-contributory Physical Exam: Vitals: T: 97.2 P: 77 R: 18 BP: 132/70 SaO293% 3L: General: Awake, alert, NAD, speaking full sentences.cachectic HEENT: oropharinx clear, Neck: supple, no JVD Pulmonary: Crackles on the left side anteriorly. otherwise clear. Cardiac: RRR, nl. S1S2, no murmurs Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema Neurologic: alert, oriented x3, able to count backwards, fluent speech. CN Ii-Xii nbormal. coordination preserved. Heel to shin coordination ok. Strength 4+ proximal LE, 4+ proximal upper extremity extension. no babinsky Pertinent Results: [2182-4-11] 06:43PM WBC-5.7 RBC-3.62* HGB-11.0* HCT-31.9* MCV-88 MCH-30.5 MCHC-34.6 RDW-16.1* [2182-4-11] 06:43PM NEUTS-91.1* BANDS-0 LYMPHS-7.6* MONOS-0.6* EOS-0.4 BASOS-0.3 [2182-4-11] 06:43PM PLT SMR-LOW PLT COUNT-126* [2182-4-11] 06:43PM PT-12.9 PTT-25.5 INR(PT)-1.1 [2182-4-11] 06:43PM GLUCOSE-107* UREA N-19 CREAT-0.6 SODIUM-134 POTASSIUM-7.3* CHLORIDE-99 TOTAL CO2-27 ANION GAP-15 [2182-4-11] 06:43PM CALCIUM-8.4 PHOSPHATE-4.8# MAGNESIUM-2.1 Brief Hospital Course: 77-year-old woman with primary papillary serous carcinoma with brain and cervical spine metastases, status post XRT and recent irinotecan/bevacizumab presented after fall at home. . # PCP: [Name10 (NameIs) ] also presented with productive coughs and was found to be hypoxic. Chest CTA was negative for pulmonary embolism but was notable for bilateral airspace opacities. She underwent a bronchoscopy with bronchoalveolar lavage positive for Pneumocystis jirovecii. Before culture came back, she had already been started on TMP/SMX DS 2 tablets q8h and her dexamethasone was increased from 4 mg qam/ 2 mg qpm to 4 mg IV q8h. Dexamethasone was used because of CNS metastases. She had initially been started on levofloxacin, which was discontinued when the diagnosis of PCP was made. After 30 hours of treatment the patient required increased oxygen supplementation, from 2L to 4L. She became more somnolent. ABG was 7.54/26/66. CXR revealed worsened bilateral infiltrates. Due to her clinical deterioration she was transferred to the ICU. The patient continued to deteriorate rapidly and expired on [2182-4-26]. . # Ovarian cancer with CNS mets: stable brain and cervical spine metastases on MRI during this admission. She most recently received irinotecan and bevacizumab on [2182-4-9] (cycle 2 day 1). Medications on Admission: 1. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO once a day (). 3. Dexamethasone mg Tablet 1 (One) Tablet(s) by mouth As follows: [Date range (1) 15222] 4 mg in am / 2mg in pm. [Date range (1) 22229] 2 mg every am and pm. [Date range (1) 73206] 2 mg in am 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Modafinil 100 daily 7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 10 Bactrim Ds daily Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292*]	[ "V10.43", "458.9", "253.6", "288.00", "584.9", "136.3", "359.4", "518.81", "287.5", "484.1", "198.3", "078.5", "E932.0", "244.9", "276.2", "518.1" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "96.6", "33.24" ]	icd9pcs	[ [ [] ] ]	6666, 6675	4518, 5833	346, 352	6726, 6735	4008, 4495	6791, 6937	3370, 3388				6696, 6705		5859, 6643			6759, 6768										3403, 3989																														283, 308																380, 1557																		1579, 3225	3241, 3354
22,810	123,890	44794	Discharge summary	report	Admission Date: [2119-4-29] Discharge Date: [2119-5-11] Date of Birth: [2041-2-10] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 78-year-old woman with a history non-small-cell lung cancer status post chemotherapy and radiation therapy who presented now with a large right parietal occipital lesions and question of brain metastases. PAST MEDICAL HISTORY: The patient has a past medical history of breast cancer, status post lumpectomy in [2111] with six weeks of radiation therapy. Status post coronary artery bypass graft times three in [2105]. Non-small-cell lung cancer with rib and bone metastases. PHYSICAL EXAMINATION ON PRESENTATION: Her vital signs revealed blood pressure was 164/75 and heart rate was 65. She was awake, alert and oriented times three. She was moving all extremities with good strength. Her chest was clear to auscultation. Her cardiac status was within normal limits. HOSPITAL COURSE: She was admitted status post a right occipital craniotomy. Preoperative diagnosis was metastatic lesion. At the time of surgery it was discovered that the patient had a dural arteriovenous malformation with large varices. Postoperatively, was monitored in the Recovery Room overnight. Her vital signs were stable. She was awake, alert and oriented times three. Extraocular movements were full. Her smile was symmetric. She had no drift. Her iliopsoas were [4-10]. She did continue to have a left field cut that she had preoperatively; more left inferior quadrant than superior quadrant. Her vital signs remained stable, and she was transferred to the regular floor on postoperative day one. She was referred to Dr. [Last Name (STitle) 1132] for an arteriogram to assess for residual arteriovenous malformation or arteriovenous fistula. The patient was taken to the angiogram suite on [2119-5-10] where she underwent a diagnostic arteriogram which did not show evidence of remaining arteriovenous fistula but an aneurysm was detected that was not diagnosed prior to this arteriogram. The patient's right groin site was clean, dry, and intact status post procedure. She had strong pedal pulses with a warm foot. Her vital signs were stable. She was afebrile. She was alert, awake, and oriented times three with some intermittent periods of confusion; most likely related to sedation for angiogram and slight dehydration. The smile was full. No drift. Iliopsoas were [4-10]. The patient was evaluated by Physical Therapy and Occupational Therapy and found to require rehabilitation prior to discharge to home. MEDICATIONS ON DISCHARGE: (Her medications at the time of discharge included) 1. Decadron 2 mg p.o. q.12h. for one day; then 1 mg p.o. twice per day for one day; then 1 mg p.o. once per day for one day; then discontinue. 2. Paroxetine 40 mg p.o. once per day. 3. Fentanyl patch 75 mcg topically q.72h. 4. Famotidine 20 mg p.o. twice per day. 5. Percocet one to two tablets p.o. q.4h. as needed. 6. Heparin 5000 units subcutaneously q.12h. 7. Colace 100 mg p.o. twice per day. 8. Dulcolax 10 mg p.o./p.r. once per day as needed. CONDITION AT DISCHARGE: The patient's condition was stable at the time of discharge. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 1132] in two weeks' time. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2119-5-11] 14:38 T: [2119-5-11] 15:24 JOB#: [Job Number 95848]	[ "V10.11", "V45.81", "V10.3", "276.5", "437.3", "198.5" ]	icd9cm	[ [ [] ] ]	[ "01.59", "88.41" ]	icd9pcs	[ [ [] ] ]												2647, 3168		974, 2620					3279, 3649																										3183, 3245																											160, 376																		399, 955
14,337	127,290	14200+56510+56511+56512	Discharge summary	report+addendum+addendum+addendum	Admission Date: [2122-5-19] Discharge Date: [2122-5-22] Service: Cardiac Care Unit CHIEF COMPLAINT: Syncope, new onset, rapid atrial fibrillation. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 19276] is an 81 year old man with a past medical history significant for coronary artery disease, status post coronary artery bypass graft in [2116], hypertension, cerebrovascular accident, peripheral vascular disease, abdominal aortic aneurysm repair in [2116], pulmonary fibrosis who was transferred from an outside hospital for transesophageal echocardiogram cardioversion secondary to new onset atrial fibrillation. The patient initially presented to [Hospital ] Hospital on [5-16] after a syncopal episode. The patient denied presyncopal symptoms, no prior history, occurred a few minutes post micturition, positive loss of consciousness, positive ................., no chest pain, no shortness of breath, no palpitations, no dizziness, no incontinence, no tremors and no postictal confusion. The patient woke up in a pool of blood, called for help at the outside hospital and was noted to be in new atrial fibrillation with RVR to the 150s. He was given Diltiazem and Lasix with good response. Head computerized tomography scan was negative for bleed. He was started on intravenous heparin and transferred to [Hospital6 2018] for transesophageal echocardiogram cardioversion. The patient underwent cardioversion on the day of admission. Transesophageal echocardiogram demonstrated no clot, cardioversion required 360 joules with resulting bradycardia with bursts of paroxysmal atrial fibrillation. A ten minute presentation to initial Cardiac Care Medicine Team the patient felt great and was without complaints. REVIEW OF SYSTEMS: Unremarkable, stable urinary hesitancy, no paroxysmal nocturnal dyspnea, no lower extremity edema, no orthopnea, some increased shortness of breath. He is minimally active at baseline. PAST MEDICAL HISTORY: Cerebrovascular accident. Coronary artery disease status post coronary artery bypass graft in [2116] with saphenous vein graft to posterior descending artery, left internal mammary artery to left anterior descending, saphenous vein graft to ramus and saphenous vein graft to obtuse marginal. Abdominal aortic aneurysm repair in [2116]. Chronic pulmonary fibrosis on 2 liters home oxygen. Cholecystectomy. Peripheral vascular disease. Hypertension. Ejection fraction 40 to 45% while in atrial fibrillation as noted by echocardiogram. Benign prostatic hypertrophy. MEDICATIONS ON ADMISSION: Lasix 20 mg p.o. q. day; Enteric coated Aspirin; Prazosin 2 mg q. day; Vitamin E 400 IU b.i.d.; Vitamin C 500 mg q. day; Multivitamin. ALLERGIES: None. FAMILY HISTORY: Brother died of myocardial infarction in his 70s, mom deceased of breast cancer. SOCIAL HISTORY: Positive heavy tobacco, quit in [2081], occasional alcohol, no drugs. Lives alone. Never married. Independent in activities of daily living. PHYSICAL EXAMINATION: Afebrile, blood pressure 126/79, heartrate 79, respiratory rate 20. Oxygen 84% on 4 liters of nasal cannula. In general, frail elderly man, rather poor historian, talkative, in no acute distress. Head, eyes, ears, nose and throat, bilateral periorbital ecchymosis with thrombotic thrombocytopenic purpura, bilateral cataracts, not reactive, poor dentition, oropharynx clear. Mucosal membranes slightly dry. Neck, supple, no jugulovenous pressure. Lungs, diffuse dry crackles bilaterally. Cardiovascular, regularly irregular, loud S2. No murmurs, rubs or gallops. Abdomen, soft, positive, mid epigastric hernia reproducible and nontender, nondistended, normoactive bowel sounds. No hepatosplenomegaly. Extremities, no edema, warm feet bilaterally. Positive venous stasis changes. LABORATORY DATA: On transfer from outside hospital, hematocrit 36, platelets 189, INR 1.5, PTT 69.8, sodium 141, potassium 3.7, chloride 97, bicarbonate 38, BUN 24, creatinine 1.0, glucose 125, TSH 0.79, CPKs 94, troponin 0.2 to 0.8. Chest x-ray, interstitial fibrosis with superimposed congestive heart failure. Electrocardiogram, atrial fibrillation at 115, right bundle branch block old, normal limb at axis, low voltage T wave inversions, V1 through V3, no ST changes. HOSPITAL COURSE: Cardiovascular - The patient was admitted to the Cardiac Medicine Service after his cardioversion. He was loaded on Amiodarone with dose of 400 mg p.o. b.i.d. Liver function test and thyroid function test at the time of starting medications were normal. The patient with known interstitial lung disease and will need close follow up on his pulmonary function as he is starting on this anti-arrhythmic. For his coronary artery disease, the patient was started on a beta blocker with Metoprolol 25 mg b.i.d. and Lisinopril 5 mg q. day as well as a daily Aspirin. The patient was also started on anticoagulation including heparin GGT and Coumadin 5 mg q. day. The patient was maintained on standing Lasix 20 mg q. day dose. On the second hospital day the patient began developing respiratory distress on the floor with oxygen saturations in the mid 80s on 4 liters and briefly required a nonrebreather mask to maintain his oxygenation. Given these findings as well as his crackles on examination, he was diuresed with approximately 140 mg intravenous Lasix. The patient had poor urine output and continued respiratory distress as well as eventual progression to anuria on [2122-5-21]. The patient was then transferred to the Cardiac Care Unit for Swan-Ganz catheter placement to evaluate his volume status to determine if congestive heart failure was indeed the cause of his hypoxia as well as answer to the question as to his anuric renal failure, particularly if he may in fact be hypovolemic with prerenal failure. Swan-Ganz catheter was attempted times two on [5-21], first in the right groin with inability to pass the catheter secondary to venous blockage. Later attempts were made in the right internal jugular, however, venous access could not be obtained. The patient's volume status was determined to be hypovolemic and the decision was made to proceed with fluid resuscitation. The patient received approximately 1.5 to 2 liters of fluid and urine output improved to approximately 40 cc q. hour. Cardiovascular plan at the time of discharge includes continuing him no Aspirin, addition of beta blocker if the patient's blood pressure and pulmonary disease tolerates. The patient's LDL was determined to be 74 and no statin therapy was initiated. Pump function, the patient was felt to be hypovolemic at the time of discharge. Plans were made to continue his home Lasix dose of 20 mg p.o. q. day as well as lift his salt and fluid restructions. Initiation of the ACE inhibitor was delayed given his acute renal failure. Rhythm, the patient has maintained normal sinus rhythm since the time of DC cardioversion. He will receive Amiodarone 400 mg b.i.d. while hospitalized with decreased dose to 400 mg p.o. q. day for three months followed by 200 mg q. day thereafter. The patient will need follow up pulmonary function tests at the time of discharge as well as in six weeks time to evaluate for any progression of his interstitial lung disease. He will also need follow up liver function and thyroid function tests. Anticoagultaion, the patient was continued on Coumadin, decreased dose of 2.5 mg p.o. q.h.s. and his heparin drip was discontinued once his INR was therapeutic. Endocrine - The patient was noted to have elevated glucose values while hospitalized. He was started on a sliding scale insulin regimen. He will need confirmatory fasting glucose levels as well as hemoglobin A1C evaluation. He will need continued outpatient follow up for his hyperglycemia. Infectious disease - The patient diagnosed as a urinary tract infection, started on a course of Levofloxacin on [2122-5-21], should plan to complete a full ten day course. Renal - The patient with severe prerenal azotemia, diagnosed by phenol, less than 1% as well as diuria of 5% which was improving with fluids at the time of discharge from the Cardiac Care Unit. Creatinine was 2.1 from high of 2.3. MEDICATIONS ON TRANSFER: 1. Warfarin 2.5 mg p.o. q. day 2. Enteric coated Aspirin 3. Amiodarone 400 mg p.o. q. day 4. Cimethicone 5. Levofloxacin 500 mg p.o. q. day through [2122-5-29] 6. Multivitamin 7. Docusate 8. Tylenol 9. Continue his previous medications at home including Vitamins E and C CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Atrial fibrillation with rapid ventricular response 2. Interstitial pulmonary disease 3. Prerenal azotemia 4. Urinary tract infection [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 7485] MEDQUIST36 D: [2122-5-22] 13:43 T: [2122-5-22] 15:44 JOB#: [Job Number 42245] Name: [Known lastname 3141], [Known firstname ] Unit No: [Numeric Identifier 7612] Admission Date: [2122-5-19] Discharge Date: [2122-5-22] Date of Birth: [2040-9-4] Sex: M Service: HOSPITAL COURSE: Cardiovascular - The patient was admitted to the Cardiac Medicine Service after his cardioversion. He was loaded on Amiodarone with dose of 400 mg p.o. b.i.d. Liver function test and thyroid function test at the time of starting medications were normal. The patient with known interstitial lung disease and will need close follow up on his pulmonary function as he is starting on this anti-arrhythmic. For his coronary artery disease, the patient was started on a beta blocker with Metoprolol 25 mg b.i.d. and Lisinopril 5 mg q. day as well as a daily Aspirin. The patient was also started on anticoagulation including heparin GGT and Coumadin 5 mg q. day. The patient was maintained on standing Lasix 20 mg q. day dose. On the second hospital day the patient began developing respiratory distress on the floor with oxygen saturations in the mid 80s on 4 liters and briefly required a nonrebreather mask to maintain his oxygenation. Given these findings as well as his crackles on examination, he was diuresed with approximately 140 mg intravenous Lasix. The patient had poor urine output and continued respiratory distress as well as eventual progression to anuria on [2122-5-21]. The patient was then transferred to the Cardiac Care Unit for Swan-Ganz catheter placement to evaluate his volume status to determine if congestive heart failure was indeed the cause of his hypoxia as well as answer to the question as to his anuric renal failure, particularly if he may in fact be hypovolemic with prerenal failure. Swan-Ganz catheter was attempted times two on [5-21], first in the right groin with inability to pass the catheter secondary to venous blockage. Later attempts were made in the right internal jugular, however, venous access could not be obtained. The patient's volume status was determined to be hypovolemic and the decision was made to proceed with fluid resuscitation. The patient received approximately 1.5 to 2 liters of fluid and urine output improved to approximately 40 cc q. hour. Cardiovascular plan at the time of discharge includes continuing him no Aspirin, addition of beta blocker if the patient's blood pressure and pulmonary disease tolerates. The patient's LDL was determined to be 74 and no statin therapy was initiated. Pump function, the patient was felt to be hypovolemic at the time of discharge. Plans were made to continue his home Lasix dose of 20 mg p.o. q. day as well as lift his salt and fluid restrictions. Initiation of the ACE inhibitor was delayed given his acute renal failure. Rhythm, the patient has maintained normal sinus rhythm since the time of DC cardioversion. He will receive Amiodarone 400 mg b.i.d. while hospitalized with decreased dose to 400 mg p.o. q. day for three months followed by 200 mg q. day thereafter. The patient will need follow up pulmonary function tests at the time of discharge as well as in six weeks time to evaluate for any progression of his interstitial lung disease. He will also need follow up liver function and thyroid function tests. Anticoagulation, the patient was continued on Coumadin, decreased dose of 2.5 mg p.o. q.h.s. and his heparin drip was discontinued once his INR was therapeutic. Endocrine - The patient was noted to have elevated glucose values while hospitalized. He was started on a sliding scale insulin regimen. He will need confirmatory fasting glucose levels as well as hemoglobin A1C evaluation. He will need continued outpatient follow up for his hyperglycemia. Infectious disease - The patient diagnosed as a urinary tract infection, started on a course of Levofloxacin on [2122-5-21], should plan to complete a full ten day course. Renal - The patient with severe prerenal azotemia, diagnosed by phenol, less than 1% as well as diuria of 5% which was improving with fluids at the time of discharge from the Cardiac Care Unit. Creatinine was 2.1 from high of 2.3. MEDICATIONS ON TRANSFER: 1. Warfarin 2.5 mg p.o. q. day 2. Enteric coated Aspirin 3. Amiodarone 400 mg p.o. q. day 4. Simethicone 5. Levofloxacin 500 mg p.o. q. day through [2122-5-29] 6. Multivitamin 7. Docusate 8. Tylenol 9. Continue his previous medications at home including Vitamins E and C CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Atrial fibrillation with rapid ventricular response 2. Interstitial pulmonary disease 3. Prerenal azotemia 4. Urinary tract infection [First Name8 (NamePattern2) 77] [First Name8 (NamePattern2) 2448] [Name8 (MD) ], M.D. [MD Number(1) 2449] Dictated By:[Last Name (NamePattern1) 2168] MEDQUIST36 D: [2122-5-22] 14:19 T: [2122-5-22] 16:22 JOB#: [Job Number 7613] Name: [Known lastname 3141], [Known firstname ] Unit No: [Numeric Identifier 7612] Admission Date: [2122-5-19] Discharge Date: [2122-5-26] Date of Birth: [2040-9-4] Sex: M Service: C-MEDICINE The patient was transferred out of the CCU to the C-Medicine service on [2122-5-22]. He continued to remain in normal sinus rhythm with a controlled rate on his Amiodarone and his Coumadin for anticoagulation. His Coumadin dose was increased to keep his INR between 2.0 and 3.0. His creatinine normalized to 0.8 with excellent urine output. He was restarted on his outpatient oral Lasix dose as well as low dose Spironolactone for adequate daily diuresis. He was also started on low dose Metoprolol and Lisinopril for optimal medical management of his coronary artery disease and his congestive heart failure. His oxygenation continued to improve and his oxygen saturation at the time of discharge was ranging between 93 to 96% on five liters nasal cannula. He was continued on a ten day course of oral Levaquin for his urinary tract infection and remained afebrile throughout his stay. MEDICATIONS ON DISCHARGE: 1. Coumadin 4 mg q.h.s. (this dose will need to be adjusted as needed to keep INR between 2.0 and 3.0). 2. Lisinopril 2.5 mg once daily. 3. Lipitor 10 mg p.o. q.h.s. 4. Metoprolol 12.5 mg twice a day. 5. Levaquin 250 mg p.o. once daily. (last dose [2122-5-29]). 6. Amiodarone 200 mg once daily times three months, then 100 mg once daily. 7. Multivitamin once daily. 8. Aspirin 325 mg p.o. once daily. 9. Aldactone 12.5 mg p.o. once daily. DISCHARGE STATUS: The patient was discharged in good condition to a subacute nursing facility. FOLLOW-UP: He is to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in four to six weeks. He is to have his pulmonary function tests performed as an outpatient since he will be on Amiodarone. His INR is to be followed closely and his Coumadin to be adjusted as needed to keep his INR at a value between 2.0 and 3.0. [Name6 (MD) 116] [Last Name (NamePattern4) 2879], M.D. [MD Number(1) 5308] Dictated By:[First Name (STitle) 7614] MEDQUIST36 D: [2122-5-25] 11:06 T: [2122-5-25] 11:29 JOB#: [Job Number 7615] Name: [Known lastname 3141], [Known firstname ] Unit No: [Numeric Identifier 7612] Admission Date: [2122-5-19] Discharge Date: [2122-6-4] Date of Birth: [2040-9-4] Sex: M Service: ADDENDUM: The patient was kept in the hospital due to subsequent respiratory failure that occurred the morning of [2122-5-28]. The patient was found to be choking during breakfast and subsequently became somnolent. The patient had a deceased respiratory rate and was hypoxic. ABG done showed a blood gas of 7.16, PC02 103, and 02 of 116 on 100% nonrebreather. The patient was intubated and transferred to the MICU for hypercarbic respiratory failure. The patient was stabilized and extubated the following day. He was initially continued on levofloxacin which he had been taking for a URI and Flagyl was added for possible aspiration pneumonia. This was continued for several days; however, the patient had repeat CT angio scan which revealed no evidence of pneumonia and the antibiotics were discontinued. The patient was kept n.p.o. He initially had a swallow study which he failed but repeat swallow evaluation with a video swallow showed no evidence of aspiration. It was recommended that the patient should be continued on a diet of very soft solids and thin liquids. His medications should be taken whole with water. The patient should eat in bolt upright position for meals. He should have supervised feedings to ensure that he takes small bites, chews well, and has two swallows per bite. It should be emphasized that the patient should not talk until each bite and sip is swallowed. Please see Speech and Swallow RX. Pulmonary wise, the patient throughout the hospital course would have episodes of desaturation to the 80s. It was found that if he was placed on face mask he would return to the low 90s. Due to his severe COPD, it was felt that he should be kept between 02 sats between 88% and 92%. A CT angio was performed to evaluate for his hypoxia and revealed no evidence of PE. It showed pulmonary hypertension with abrupt change in the caliber of the peripheral arteries. It also showed diffuse reticular changes in the lung parenchyma with signs of asbestosis and chronic interstitial lung disease. The patient currently is saturating well on nasal cannula. He has been around 4 liters and has fluctuated between the low 90s, occasionally dropping into the low 80s; however, he returns to the low 90s with face mask. The patient does have a tendency to desaturate with ambulation, presumably this will improve with conditioning. Cardiac wise, since DC cardioversion, the patient has been on Amiodarone with anticoagulation. EP was consulted concerning the risk of continuing his Amiodarone in the setting of his severe interstitial lung disease. It is felt that rather than continuing him on Amiodarone at a dose of 400 mg b.i.d., it would be reasonable to decrease it to 400 mg q.d. while he was in-house and discharge him on 200 mg q.d. for three months, at which time he could then be tapered to 100 mg q.d. He will follow-up with Dr. [Last Name (STitle) ] in six to eight weeks. The patient was continued on the low-dose ACE inhibitor as a cardioprotective mechanism. He will also be continued on the Lipitor and aspirin. He has remained anticoagulated well as an inpatient. His INR was supratherapeutic following a short course of levofloxacin and the fact that he was n.p.o. It was felt that it was mainly due to the antibiotics and poor nutrition that his INR became elevated. His Coumadin has been held for the last several days prior to discharge. His INR should be rechecked in two days and he should be reestablished on Coumadin as appropriately, aiming to keep his INR between [2-2]. Near the end of his hospital course stay, the patient had trauma to his penis due to his Foley catheter. He had hematuria which gradually resolved with CBI. The patient was started on Flomax. He should be continued with the Foley catheter and in one to two days, a voiding trial could be attempted to see if the Foley catheter can be discontinued. If necessary, the patient should follow-up with GU. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSIS: 1. Paroxysmal atrial fibrillation, status post TE cardioversion, now on Amiodarone and anticoagulation. 2. Systolic congestive heart failure. 3. Pulmonary fibrosis and signs of asbestosis with frequent desaturations to the 80s. 4. Syncope secondary to new onset rapid atrial fibrillation. 5. Prerenal azotemia secondary to aggressive diuresis. 6. Pulmonary hypertension. 7. Coronary artery disease. 8. Chronic obstructive pulmonary disease. 9. Interstitial lung disease. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Multivitamin q.d. 3. Coumadin, currently being held but to be restarted as appropriate. 4. Colace 100 mg p.o. b.i.d. p.r.n. 5. Amiodarone 200 mg q.d. times three months and then 100 mg q.d. 6. Lipitor 10 mg q.d. 7. Lisinopril 2.5 mg q.d. 8. Flomax 0.4 mg p.o. q.h.s. 9. Should be restarted on q.o.d. dosing of Lasix 20 mg if his lower extremity edema starts worsening, currently he has 1+ pitting edema. FOLLOW-UP: The patient should follow-up with Dr. [Last Name (STitle) ] in six to eight weeks. He should call [Telephone/Fax (1) 7616] to schedule. The patient should also follow-up with Dr. [Last Name (STitle) ] in one to two weeks, the telephone number is [Telephone/Fax (1) 7617]. The patient should have PFTs done as an outpatient. His INR should be checked in two days and his Coumadin dosing should be adjusted accordingly in order to keep the INR between [2-2]. His potassium should be rechecked in one week. CODE STATUS: The patient is DNR/DNI. DIET: The patient is on a low-fat, low-sodium diet, soft, with thin liquids. Please see swallow recommendations. [Name6 (MD) 116] [Last Name (NamePattern4) 2879], M.D. [MD Number(1) 5308] Dictated By:[Dictator Info ] MEDQUIST36 D: [2122-6-4] 11:17 T: [2122-6-4] 13:36 JOB#: [Job Number 7618]	[ "428.23", "599.7", "427.31", "518.81", "276.5", "428.0", "584.9", "515", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "00.13", "96.71", "88.72", "99.62" ]	icd9pcs	[ [ [] ] ]							2777, 2859		21179, 22560		20675, 21156	15219, 20582	2605, 2760	9314, 13233																													3047, 4314						1790, 1977							121, 169																198, 1770																	13258, 13543	2000, 2578	2876, 3024	20606, 20654
74,502	109,730	6890	Discharge summary	report	Admission Date: [2171-12-17] Discharge Date: [2171-12-25] Date of Birth: [2094-5-4] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 4365] Chief Complaint: fall Major Surgical or Invasive Procedure: 1. Anterior diskectomy C6-C7. 2. Fusion C6-C7. 3. Anterior instrumentation C6-C7. 4. Structural allograft. History of Present Illness: Mr. [Known lastname ] is a 77 year old man with history of fall at home the night before admission. He noted that he was stepping backwards to get into bed when he fell around 7pm; he does not remember how it happened but did not lose consciousness. He had been drinking alcohol prior to fall. He fell backwards and hit the back of his head against the windowsill and then hit his buttocks on the ground. He believed he may have landed afterwards on his left shoulder. He got back into bed and tried to go to sleep. Around 2-3AM, he was in so much pain from his left shoulder that he called out to his son in the next room to call the nurse on call from his primary care doctor's office. He denies ever having had any neck pain. He had drank some alcohol the evening prior to his fall. . He went to [Hospital3 ] by EMS for initial evaluation and was transferred to [Hospital1 18] because of the trauma and orthopedic surgical services. Patient was noted to not have any neurological deficits, except a left sided foot drop which he has had at baseline. . Patient has a history of known spinal disc bulging in two places in his spine, including his neck, and has had two surgeries in the past. He notes that he has intermittent tingling in his left hand, fourth and fifth digits, at baseline, but he feels no new symptoms of numbness, tingling or weakness. He does have a history of recurrent UTIs at baseline, often experiencing symptoms of urinary urgency and frequency; he takes nitrofurantoin daily for prophylaxis. He denies urinary incontinence, except very occasionally, though not new since his recent fall. He denies any urinary retention or incontinence of stool. Past Medical History: -Headaches -Cervical stenosis - has intermittent tingling of 4th and 5th digits of left hand -Basal Cell Carcinoma ([2157]) -Osteoarthritis (since [2158]) -COPD (since [2158]) -Carotid Artery Stenosis ([2159]) - s/p L carotid endarterectomy in [2155] following TIA; carotid u/s [7-23] shows 50% occlusion on L and widely patent right carotid; followed by Dr. [Last Name (STitle) 17974]; carotid ultrasound [8-25] showed 50% occlusion of right carotid; carotid u/s done [10-27] at NSMC showed <50% stenosis prox r ICA and up to 50% stenosis prox left ICA -Hypertension, Essential -Hypercholesterolemia -Prostate Cancer - s/p TURP and radiation in [2160] -Coronary Artery Disease - s/p Cath [2167-2-23] showed proximal 80% LAD. Right coronary had 65% ostial right left ventric branch and 55% prox right posterior descending artery stenosis. Circumflex was 100% occluded in midposition w collateral filling ... Given 3vessel CAD and L ventric dysfunction, surgical revasc recommended. Dr. [Last Name (STitle) ] did 4vessel CABG bypass. He had a LIMA to LAD. Had a vein graft to posterior descending artery. Additionally had a Y vein graft w the 1st component connecting aorta to obtuse marginal and a wide veing graft connecting to the first diagonal. -s/p CABG -Depressive Disorder -Alcohol Dependence ([2145]) - quit for 28 years and started again in [2170] after wife died -Gastritis/Duodenitis -Transient Ischemic Attack - d/t carotid stenosis -Actinic Keratosis -Cardiac Arrhythmia - an EP study [9-23] at [Hospital1 112] positive w easily inducible monomorphic V-tach. An ICD was placed w/o complications both for management of his inducible ventricular tachycardia and also observed periods of bradyarrhythmia -Lumbar Disc Disease - lumbar MRI [3-21] showed [Last Name (un) ] disc disease at multiple levels; developed left foot drop and L5 radiculopathy. L4-L5 discectomy [11-20] w AFO fitting for L foot drop. Atrial Fibrillation -Long-term Anticoagulation - Goal [1-22] -Sleep Apnea -Goiter - nontoxic multinodular -Peripheral Vascular Disease -Implantable Defibrillator -Diverticulosis -Syncope ([2168]) -Urethral stricture- post-op -Bladder Diverticulum -Left Foot Drop -Recurrent UTIs -Melanoma - - superficial spreading RUQ abdomen [2171-5-20] w extension to margin; re-excised [7-27] w clear margins -Cerebrovascular Disease -Ataxia [1-21] Cerebrovascular Disease - chronic due to cerebrovascular disease ; unsteady w abrupt changes in direction; head CT [Hospital1 2025] [4-26] showed: No acute intracranial process. Specifically no evidence of intracranial hemorrhage, acute territorial infarction or mass lesion. Remote lacunar infarct involving R head of the caudate/right anterior limb of internal capsule. Remote R superior cerebellar infarction. Nonspecific white matter hypoattenuation likely representing chronic microangiopathic change Social History: Lives at home with son. Wife died in [2170-12-20]. Son sleeps in bedroom next to his. Reports prior history of significant alcohol use; he states that he quit using alcohol for 28 years until this year. PCP notes that he has had a couple of episodes of drinking this fall associated with depression after wife's death. He notes that he quit smoking 20 years ago. Used to work for the [Location (un) 86] Globe as a type setter but lost his job after everything became computerized. Family History: Notable for a significant history of CAD with premature death. The patient's brother died at age 40 from an MI. A nephew died at 38 from MI. His father died at age 60 from MI/lung disease. Sister died at 76 from MI. Mother died at 72 from natural causes. No other brothers or sisters. One son and one daughter; both generally healthy. Physical Exam: VS: 96.9 150/90 70 20 95% on 2L GA: AOx3, NAD HEENT: PERRLA. slightly dry mucus membranes. dry blood in left outer ear. NECK: supple. CV: Rate 70s, Regular Rhythm w occasional irreg beats. no murmurs/gallops/rubs noted Pulm: clear to auscultation with diffuse expiratory wheezing, basilar crackles Abd: soft, obese, nontender, nondistended, +BS Back: Extremities: wwp, no edema. DPs, PTs 2+. Skin: dry, old ecchymosis on forearms Neuro: CN II-XII grossly intact; bilateral deltoids [4-22], Bilat Biceps [4-22], Left Tricep [3-23], right Tricep [4-22]; left Hip flexor 3+/5, right Hip flexor [4-22]; left dorsiflexion [3-23], right dorsiflexion [4-22] Pertinent Results: CT Head w/o contrast [2171-12-17]: 1. No acute bleed, mass, or infarct present. 2. Prominence of the superior ophthalmic veins, right greater than left. Recommend clinical correlation, an MRI would be useful if further imaging characterization is deemed necessary. . CT C-spine [2171-12-17]: 1. Anterolisthesis of the C6 vertebra with a bilateral pedicle fractures and a jumped facet on the left. An MRI of the C-Spine is recommended if there is concern for a ligamentous injury. 2. Severe narrowing of the spinal canal at the C3-C4 and C4-C5 level and moderate narrowing at the C5-C6 and C6-C7 level. . CT Chest w/out Contrast [2171-12-18]: 1. Intralobular septal thickening consistent with hydrostatic edema probably due to volume overload. Additional dependent ground-glass opacities affecting right lung more than the left may reflect dependent edema or secondary process such as aspiration. 2. Small right and trace left dependent pleural effusions. 3. No evidence of thoracic spine or rib acute fracture. Please see separately dictated CT of the cervical spine study, which reports bilateral pedicle fractures at the C6 vertebral body level. 4. 3-mm diameter right apical nodule, statistically very likely benign. Enlarged mediastinal lymph nodes including 12 mm lower left paratracheal and 15 mm subcarinal nodes are probably hyperplastic or edematous. However, recommend a followup CT in six months to document resolution of the enlarged nodes and anticipated stability of the right apical nodule. 5. Narrowing of bronchus intermedius, probably due to bronchomalacia related to chronic extrinsic compression by an adjacent anterolateral osteophyte. If warranted clinically, dynamic expiratory sequence could be added to the followup CT (if ordered as a CT trachea study) to more fully evaluate for bronchomalacia. 6. Low-attenuation left renal lesions are probably cysts but incompletely evaluated. Ultrasound examination on an outpatient basis could be performed to confirm simple cystic characteristics if warranted clinically. 7. Dependent gallstones within the gallbladder. 8. Mild emphysema. . X-ray C-spine [2171-12-20]: Plate and screws seen in C5, C6, C7 region. Alignment appears satisfactory. . X-ray Portable Chest [2171-12-20]: Median sternotomy wires and AICD is unchanged from prior. There is unchanged cardiomegaly. Pulmonary vascular prominence has improved since the previous study. There is no consolidation or pleural effusions. . [2171-12-17] 06:46AM BLOOD WBC-8.7 RBC-4.37* Hgb-13.1* Hct-38.7* MCV-89 MCH-29.9 MCHC-33.8 RDW-13.9 Plt Ct-154 [2171-12-21] 04:53AM BLOOD WBC-8.5 RBC-3.79* Hgb-11.6* Hct-33.6* MCV-89 MCH-30.6 MCHC-34.5 RDW-14.2 Plt Ct-106* [2171-12-17] 06:46AM BLOOD PT-16.4* PTT-27.9 INR(PT)-1.5* [2171-12-21] 04:53AM BLOOD PT-13.8* PTT-27.0 INR(PT)-1.2* [2171-12-17] 06:46AM BLOOD Glucose-128* UreaN-23* Creat-0.7 Na-141 K-4.6 Cl-104 HCO3-24 AnGap-18 [2171-12-21] 04:53AM BLOOD Glucose-108* UreaN-15 Creat-0.8 Na-140 K-4.3 Cl-105 HCO3-28 AnGap-11 [2171-12-20] 04:17AM BLOOD ALT-18 AST-36 AlkPhos-43 [2171-12-21] 04:53AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0 [2171-12-19] 08:20PM BLOOD TSH-1.5 [2171-12-17] 06:46AM BLOOD Ethanol-15* [2171-12-19] 02:01PM BLOOD Type-ART pO2-81* pCO2-46* pH-7.45 calTCO2-33* Base XS-6 Intubat-NOT INTUBA [2171-12-19] 02:01PM BLOOD Glucose-93 Lactate-1.0 Na-140 K-3.5 Cl-97* Further Imaging: Trans Esophageal Echocardiogram: IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with cavity dilation and regional systolic dysfunction c/w CAD (PDA distribution). Moderate mitral regurgitation. Pulmonary artery systolic hypertension Brief Hospital Course: Mr. [Known lastname ] is a 77 year old male with history of COPD, chronic systolic CHF, atrial fibrillation, s/p pacemaker/ICD, CAD s/p CABG, depression, who presented status post fall after drinking alcohol. . # C6 Fracture: Patient admitted with a fall in the context of EtOH consumption. His ICD was interrogated on [12-18] and did not show any e/o arrythmia to have prompted the fall. He underwent fixation of his C6 vertebrae by Orthopaedics on HD3 and was then transferred to CCU overnight for monitoring after hypotension during surgery. He remained in a c-spine collar throughout his hospital stay. He was pain controlled with non-narcotics (Ultram and Tylenol) as he was felt to become delirious with opiates. He will follow up with ortho spine. . # Alcohol Use: Patient quit drinking 28 years ago, after his wife died, he became more depressed and began drinking again. His EtOH consumption is thought to have caused his injury as his blood EtOH level on admission was elevated. He was started on a CIWA scale as an inpatient, but did not require any Diazepam. . # Atrial Fibrillation, s/p pacemaker/ICD: Patient with a h/o atrial fibrillation with an a-paced pacemaker. He demonstrated good ventricular conduction on presentation and was in sinus rhythm per ECG. Prior to surgery, however, his pacemaker was interrogated by the Electrophysiology team and the patient was found to be in afib. A magnet was applied to his pacemaker during surgery and his coumadin was held for the procedure. Patient was transferred to the CCU post-op for hypotension in the setting of Afib & intraoperative sedation. He was transferred on a neo and esmolol drip. Overnight, the patient was weaned off pressors and the esmolol gtt was discontinued the following morning. His blood pressure improved to 130s overnight. He continued to be in afib, and was rate-controlled with IV diltiazem, followed by PO diltiazem and metoprolol. On transfer back to the floor, his rate was in the 80's. As he was 36 hours post-procedure at that time, he was started on a heparin gtt bridge to coumadin before transfer to the general medicine floor. Upon transfer to the medicine floor, the patient's heart rate increased to the 150s while in afib on 3 seperate occasions. He was titrated to 75 QID of metoprolol and 90 QID of Diltiazem. His heart rate sustained in the 80s to 90s with this regimen. He was so stable, he will no longer need telemetry in rehab. He was to be transitioned to long acting forms of these medications, but patient had a dophoff placed, and the long acting forms could not be crushed. Once his dophoff is removed, the patient is to be switched to these long acting medications. . # Left Atrial Clot: Patient with left atrial thrombus found on TEE intra-operatively by Anesthesiology. The patient's home warfarin & ASA were initially held prior to surgery, so it is unclear whether this clot could be described as new or old. A TTE was later performed which could not appreciate a clot. It is noted that a TTE is not the best tool to visualize a left atrial clot, as the TEE is. Unfortunately, cardiology could not find the images of the TEE performed in the OR to assess the presence of clot. Nevertheless, he was treated with anti-coagulation. Approximately 36 hours post surgery, he was placed on a heparin gtt with bridge to his Coumadin. Upon discharge his INR was not therapeutic, but was discharged to an LTAC on a heparin gtt until he becomes therapeutic on Warfarin. He was continued on aspirin 81 mg. His home medication of sotalol was discontinued, as the risk of throwing a clot if he converted back to sinus rhythm due to this medication was too great. This should be re-evaluated in the outpatient setting. . # Chronic Systolic CHF: Patient demonstrated some evidence of fluid overload on admission per clinical exam and CT chest, with an O2 requirement of 2L. He was diuresed 3L prior to surgery and was weaned from O2 successfully. A TTE was performed which showed LVEF = 40 % and 2+ MR. After surgery, he appeared euvolemic as well. Lisinopril was held prior to surgery, and this was restarted prior to discharge. . # COPD: Patient was stable in the CCU, requiring low amounts of O2 by NC along with Ipratropium & Albuterol nebs initially, but was weaned successfully. He was transitioned from scheduled atrovent, to prn, and he tolerated this well. . # Aspiration: Upon transfer to the floor, the patient was noted to choke on his medications. He also had a slowly increasing oxygen requirement. He was initially on Room air and transitioned to 3 Liters O2. A chest x-ray was unrevealing. He was placed on aspiration precautions and speech and swallow evaluated him. He was found to have posterior pharyngeal swelling secondary to intubation in surgery. He was noted to aspirate everything he swallowed. He was placed NPO and a dophoff was placed for medications and nutrition. He was placed on tube feeds. He will need to be evaluated by Speed and Swallow near the end of the week to assess whether the swelling has improved, as this is expected. Once he passes this evaluation, the dophoff can be removed. . # Depression: Patient with e/o depressed affect in the context of alcohol abuse and per report he has become increasingly depressed since his wife's death. . # Urinary Tract Infection: Patient was noted to have pyuria on urinalysis in the CCU. He was started on Ciprofloxacin 250 mg q 12 hours, but on day 6 of 7 of his treatment, his urine culture grew Cipro resistant E. coli. Since he was asymptomatic, cipro was d'c'd and no new antibiotic was started. If he becomes symptomatic, he should have a repeat UA and consider starting another antibiotic other than Cipro. # Code status: Patient remained FULL CODE throughout this hospitalization. Medications on Admission: - lisinopril 20mg - lyrica 225mg [Hospital1 ] - metoprolol 75mg [Hospital1 ] - tamsulosin 0.4mg daily (30min after breakfast) - skelaxin (metaxalone) 800mg [Hospital1 ] PRN pain - furosemide 40mg daily - nitrofurantoin macrocrystal 100mg QHS - Avodart (dutasteride) 0.5mg daily - sotalol 80mg [Hospital1 ] - Ipratropium-Albuterol 0.5mg-2.5mg Nebs Q3h - Combivent 18mcg-103mcg inhaler 2puffs QID prn SOB/wheeze - Flovent HFA 110 mcg inhale 1 puff [Hospital1 ] - nitroglycerin 0.4mg sublingual prn chest pain - warfarin 2.5mg tabs-- 1.5 tabs daily - monurol 3g oral packet PRN symptoms of dysuria (must [Name8 (MD) 138] MD prior to taking) - aspirin 81 - simvastatin 40mg ALLERGIES: PCNs ([12/2145]), Fluoxetine ([2-/2168]), NSAIDS ([5-/2162]) Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: Not to exceed more than 4 grams in 24 hours. 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: Please apply to left shoulder back 12 hours on and 12 hours off. 10. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for sedation. 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Hold for sedation or RR < 12; to be given for breakthrough pain. 15. 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. 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. 17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Heparin drip Please titrate to PTT goal of 60-80. 20. Diltiazem HCl 60 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 21. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 22. Colace 100 mg Capsule Sig: [12-21] Capsules PO twice a day as needed for constipation: Hold for loose stools. 23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Hold for loose stools. 24. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold for systolic blood pressure < 100. 25. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold for sbp < 100. 26. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO twice a day as needed for muscle spasms. 27. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary: C6 fracture s/p C6-C7 Fusion Atrial Fibrillation Systolic Congestive Heart Failure Urinary Tract Infection Aspiration Secondary: Hypertension Coronary Artery Disease Depression Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair Discharge Instructions: You were admitted to the hospital because you had fallen and broken one of the bones in your sixth cervical vertebrae. You went to the operating room and a C6-C7 fusion was performed. During the surgery, your heart rate became very fast and your blood pressure became low. Strong medications needed to be given through your veins to decrease your heart rate and increase your blood pressure. You were taken to the Cardiac Care Unit for close monitoring. You were successfully taken off of these medications. You then were transferred to the regular medical floor. Your heart rate became fast intermittently, and your medications were adjusted to control this. Since these medications controlled your heart rate so well, it is not indicated for you to remain on telemetry during your rehab course. During your operation, an ultrasound of your heart was performed, it demonstrated a possible clot in your left atrium. You were started on a heparin drip with coumadin once it was safe to do so after your surgery. You will continue to be on this drip until your INR is at a therapeutic goal of [1-22]. You were also noted to be choking on your food and pills after your surgery. Speech and swallow evaluated you and saw that you had extensive swelling in your throat secondary to your intubation in surgery. A feeding tube was placed and your medications and feeding occurred through this tube. You will be evaluated near the end of the week to see if the swelling has decreased. Once you are able to swallow without aspirating, your feeding tube will be removed. You developed a urinary tract infection during your hospital stay. You were started on Ciprofloxacin. After 6 days of taking this medication, your urine culture grew bacteria resistant to this antibiotic. Since your symptoms improved, this medication was discontinued and you were not started on another antibiotic. If you experience burning while urinating, increased frequency or any other symptom that is concerning to you, you should be re-evaluated for a urinary tract infection. Your Medication changes: You are to stop taking sotalol until you see your primary care doctor or cardiologist re-evaluates you. Your metoprolol was increased to 75 mg four times per day. Once your feeding tube is removed, this medication can be changed to a once a day long acting form. The long acting form cannot be administered through your feeding tube. You have a new medication called diltiazem 90 mg four times per day. This is for your fast heart rate. Again, this can be changed to a longer acting form once a day dosing once your feeding tube comes We have increased your Coumadin to 5 mg daily (from 3.75 mg daily). This is because your INR goal was not increasing very fast. Your doses should be adjusted by your doctor once you leave the hospital. For pain, you are taking Ultram 50 mg tablets as needed for pain. Once your pain subsides in your neck and back, this medication should be stopped. You should contact your primary care doctor or go directly to the emergency room if you experience sudden loss of strength/sensation in your arms. Severe pain not relieved with your pain medications. Chest pain, shortness of breath, palpitations, or any other symptom that is concerning to you. Followup Instructions: You are to follow up with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 25980] upon discharge from your rehab facility. You need to call and make this appointment. . You are to follow up with Orthopedic Surgery, Dr.[Name (NI) 12040] office [Numeric Identifier 25981] [2171-1-9] 10am [Hospital Ward Name 23] 2. . You are to follow up with your cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 25982] [Telephone/Fax (1) 25983] [2-13] at 10:20 in [Location (un) 1468]	[ "V12.54", "997.1", "729.89", "V45.02", "410.90", "805.06", "303.91", "293.0", "788.20", "496", "412", "291.81", "724.00", "401.9", "414.00", "V58.61", "427.31", "736.79", "300.00", "507.8", "V45.81", "E885.9", "V10.46", "787.23", "599.0", "428.23", "327.23", "428.0", "458.8", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "94.62", "88.72", "99.77", "81.02", "80.51", "96.6", "84.52", "81.62" ]	icd9pcs	[ [ [] ] ]	19856, 19928	10425, 16213	278, 387	20158, 20158	6703, 10402	23600, 24206	5647, 5983		17042, 19833		19949, 20137		16239, 17019			20314, 22373										5998, 6684																									22393, 23577					234, 240																415, 2105										20172, 20290								2127, 5121	5137, 5630
74,496	138,943	40418	Discharge summary	report	Admission Date: [2142-6-17] Discharge Date: [2142-7-2] Date of Birth: [2101-8-11] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: abdominal pain, fever Major Surgical or Invasive Procedure: [2142-6-25] IR drainage abd collections [2142-6-17] ex-lap, ileocecectomy, ileostomy, mucous fistula History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 40 year old male who complains of abdominal pain. The patient underwent surgery with small bowel resection for small bowel traction on at [Hospital1 18] on [6-13]. He was discharged yesterday feeling well. During tonight the patient developed sharp abdominal pain and progressive shortness of breath and presented to [Hospital6 50929]. Chest x-ray showed free air in the abdomen. The patient has been feeling nauseated. Timing: Sudden Onset Quality: Sharp Severity: Severe Duration: Hours Location: Abdomen Context/Circumstances: Recent small bowel resection for S. by mouth Associated Signs/Symptoms: Fever Past Medical History: -Crohn's disease: Diagnosed 1.5 years ago ([2140]), presented with severe obstruction, resolved with bowel rest x 7 days. Was started on alternative treatment (does not remember which, then started on mercaptapurine with intermittent steroids). This admission is his second major obstructive flare. -Bipolar disorder -Paranoid schizophrenia -Gastroesophageal reflux disease -Right Knee surgery for torn cartilage -Pinning of left wrist fracture. -? h/o craniotomy per LGH ED paperwork Social History: Lives in [Hospital1 487], MA by himself although he had family around. He denies current alcohol or illicit drug use, although in the chart there are reports that he was formerly a drinker and used drugs, specifically MJ. He does smoke 1.5-2 packs per day x 22 years. His brother that lives upstairs from him, checks on him occasionally. Family History: Father died of MI at age 81. Mother died at age of 58 from complications of emphysema Physical Exam: PHYSICAL EXAMINATION Temp: 97.4 HR: 130 BP: 102/62 Resp: 18 O(2)Sat: 96 NRB, 80% on nasal cannula Low Constitutional: Uncomfortable, in significant pain and in respiratory distress. HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Midline surgical scar with staples in place. The wound is clean dry and intact. The abdomen is diffusely tender with guarding and rebound tenderness., Nondistended Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: [2142-7-1] 04:38AM BLOOD WBC-8.9 RBC-2.95* Hgb-8.6* Hct-25.9* MCV-88 MCH-29.0 MCHC-33.0 RDW-18.5* Plt Ct-343 [2142-6-29] 02:18AM BLOOD WBC-10.2 RBC-3.01* Hgb-8.7* Hct-26.3* MCV-88 MCH-28.8 MCHC-32.9 RDW-19.1* Plt Ct-390 [2142-6-28] 04:30AM BLOOD WBC-11.4* RBC-3.03# Hgb-8.7 Hct-25.9* MCV-86 MCH-28.8 MCHC-33.6 RDW-19.0* Plt Ct-339 [2142-6-17] 05:50PM BLOOD WBC-4.8# RBC-3.28* Hgb-9.7* Hct-29.6* MCV-91 MCH-29.5 MCHC-32.6 RDW-19.2* Plt Ct-128* [2142-6-17] 12:41PM BLOOD WBC-2.6# RBC-2.88 Hgb-8.5* Hct-26.6* MCV-93 MCH-29.5 MCHC-31.9 RDW-19.5* Plt Ct-100* [2142-6-16] 05:10AM BLOOD WBC-4.9 RBC-3.23* Hgb-9.8* Hct-29.4* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.6* Plt Ct-112* [2142-6-26] 02:18AM BLOOD Neuts-75* Bands-2 Lymphs-10* Monos-6 Eos-6* Baso-0 Atyps-0 Metas-1* Myelos-0 [2142-6-19] 03:08AM BLOOD Neuts-71* Bands-8* Lymphs-9* Monos-5 Eos-7* Baso-0 Atyps-0 Metas-0 Myelos-0 [2142-7-1] 04:38AM BLOOD Plt Ct-343 [2142-6-29] 02:18AM BLOOD Plt Ct-390 [2142-6-29] 02:18AM BLOOD PT-14.9* PTT-30.1 INR(PT)-1.3* [2142-7-1] 04:38AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-137 K-4.3 Cl-105 HCO3-23 AnGap-13 [2142-6-29] 02:18AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-139 K-4.1 Cl-106 HCO3-25 AnGap-12 [2142-6-28] 04:30AM BLOOD Glucose-108* UreaN-9 Creat-0.5 Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 [2142-6-16] 05:10AM BLOOD Glucose-111* UreaN-6 Creat-0.7 Na-137 K-3.8 Cl-101 HCO3-27 AnGap-13 [2142-6-29] 02:18AM BLOOD ALT-6 AST-14 AlkPhos-78 TotBili-0.8 [2142-7-1] 04:38AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.0 [2142-6-29] 02:18AM BLOOD Albumin-2.6* Calcium-8.3* Phos-4.1 Mg-2.0 [2142-6-28] 04:30AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [2142-6-25] 01:29AM BLOOD Triglyc-241* [2142-7-2] 05:26AM BLOOD Vanco-22.0* [2142-6-30] 11:42AM BLOOD Vanco-25.4* [2142-6-25] 06:35AM BLOOD Vanco-17.3 [2142-6-26] 02:32AM BLOOD Type-ART pO2-105 pCO2-55* pH-7.39 calTCO2-35* Base XS-6 [2142-6-25] 12:31PM BLOOD Type-ART pO2-119* pCO2-54* pH-7.38 calTCO2-33* Base XS-5 [2142-6-23] 05:14AM BLOOD Type-ART Temp-37.8 Rates-/21 Tidal V-420 PEEP-5 FiO2-50 pO2-125* pCO2-54* pH-7.39 calTCO2-34* Base XS-6 Intubat-INTUBATED Vent-SPONTANEOU [2142-6-26] 02:32AM BLOOD Glucose-126* [2142-6-23] 12:14AM BLOOD Lactate-0.7 [2142-6-20] 10:25AM BLOOD Lactate-0.6 [2142-6-20] 01:01AM BLOOD Lactate-0.8 [2142-6-19] 07:15PM BLOOD Glucose-112* Na-142 K-3.3* Cl-112 [2142-6-28] 04:48AM BLOOD freeCa-1.13 [2142-6-26] 02:32AM BLOOD freeCa-1.09* [2142-6-23] 12:14AM BLOOD freeCa-1.17 EKG: Sinus tachycardia. Early R wave transition and probable right ventricular conduction abnormality. Compared to the previous tracing of [2142-1-17] the sinus rate is now accelerated. Otherwise, no diagnostic change. [2142-6-17]: chest x-ray: IMPRESSION: 1. No evidence of pneumoperitoneum. 2. Low lung volumes. Left basilar atelectasis and/or residual consolidation, overall improved as compared [2142-6-7]. 3. Difficult to exclude early consolidation at the medial right lung base, but this could relate to low lung volumes. [2142-6-18]: chest x-ray: IMPRESSION: NG tube appropriately located with the tip in the stomach. Progression of a retrocardiac opacity could be related to atelectasis although an underlying pneumonia cannot be excluded. Gaseous bowel distension appears improved from [6-10] but persistent since the recent chest radiograph from [6-17]. [2142-6-19]: chest x-ray: FINDINGS: In comparison with the earlier study of this date, there is little overall change. Again there is diffuse heterogeneous opacification throughout both lungs consistent with widespread infection due to hematogenous dissemination. Some substantial element of pulmonary vascular congestion may also be present. The monitoring and support disease devices are in unchanged position [2142-6-20]: chest x-ray: Bilateral pleural effusions. Improvement in bilateral airspace opacities likely relate to pulmonary edema. The right lower lobe opacity persists suggesting a pneumonia in that area [2142-6-22]: chest x-ray: Diffuse bilateral airspace opacities appear unchanged over multiple prior examinations. These could relate to worsening pneumonia or ARDS. [2142-6-23]: cat scan abdomen and pelvis: Small bilateral pleural effusions, with consolidation of the bilateral lower lobes. Given dependency, volume loss, and relatively homogenous enhancement of the consolidated lung parenchyma this most likely represents substantial atelectasis rather than pnuemonia. However, a concurrent pneumonia is impossible to exclude by imaging. 2. Diffuse septal thickening and ground-glass opacity, compatible with pulmonary edema. 3. Mediastinal adenopathy, increased from prior study, likely reactive. 4. Small-moderate ascites, with diffuse peritoneal enhancement and multiple loculations, concerning for peritonitis. 5. Diffusely abnormal small bowel, with areas of wall thickening and multiple dilated loops extending to the patient's left lower quadrant ostomy. There is no distinct transition point identified, and given reportedly good ostomy output, these finding may reflect inflammation and ileus secondary to peritonitis. 6. Unremarkable colonic mucous fistula in the right lower quadrant. Residual retained stool is seen within the transverse and left colon. [2142-6-25]: IR: IMPRESSION: Successful CT-guided placement of two drainage catheters into separate peritoneal fluid collections as above. Culture and sensitivity pending. [2142-6-27]: EKG: Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2142-6-27] heart rate is reduced. Otherwise, no signficant change. TRACING #2 [2142-6-28]: chest x-ray: IMPRESSION: Interval development of mild-to-moderate pulmonary edema. Minimal bibasal atelectasis and pleural effusions which are relatively unchanged [2142-6-25]: sub-hepatic fluid collection: [2142-6-25] 4:45 pm FLUID,OTHER SUBHEPATIC. FINAL REPORT [2142-7-1] GRAM STAIN (Final [2142-6-25]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2142-6-28]): NO GROWTH. ANAEROBIC CULTURE (Final [2142-7-1]): NO GROWTH. [2142-6-26]: catheter tip: [2142-6-26] 11:02 pm CATHETER TIP-IV Site: A LINE FINAL REPORT [2142-6-29] WOUND CULTURE (Final [2142-6-29]): No significant growth. [2142-6-20]: blood culture: [2142-6-20] 6:09 pm BLOOD CULTURE Source: Line-arterial. FINAL REPORT [2142-6-27] Blood Culture, Routine (Final [2142-6-27]): KLEBSIELLA PNEUMONIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 326-2968R [2142-6-20]. [2142-6-22]: wound culture: [2142-6-22] 9:29 am SWAB Source: wound. FINAL REPORT [2142-6-26] WOUND CULTURE (Final [2142-6-26]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- 16 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S [2142-6-24]: blood culture: [2142-6-24] 11:20 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2142-6-30] Blood Culture, Routine (Final [2142-6-30]): NO GROWTH. Brief Hospital Course: The patient was admitted to the ACS service on [6-17] and went to the OR for ex-lap & ileocecetomy w/ ileostomy (LEFT abdomen) and ascending colonic mucus fistula on RIGHT abdomen. The patient remained intubated post-operatively. He was in shock, started on levophed and phenylephrine upon arrival to PACU. He was admitted to the TICU from the pacu. He was given fluid bolus and albumin and neo was weaned off. On [6-18], the patient was still requiring extra fluid resuscitation for soft blood pressures. He was given addition 500mL 5% Albumin given, and 500LR x2 for persistent tachycardia. He was weaned off pressors. However, patient began to have increased work of breathing, and CXR showed Left effusion, and patient was started on BiPAP. He became intermittently cnofused and self d/c'd his NGT, which was replaced. On [6-20]: Patient was re-intubated due to increased work of breathing, bronch/BAL showed no gross mucus or large plugs. Tobramycin started (per VAP protocol). Pt mildly hypotensive 100s/50s & tachy to 100s. 500mL 5% Albumin given x 2. Tube feeds were started for poor nutrition. [6-21]: Hct dropped from 26 to 22.6 s/p 1500mL 5% Albumin. There was no obvious source of bleeding, but serial HCTs were checked and patient's HCT improved. [6-22]: CT torso was performed that showed loculated enhancing collections in the abdomen. This was conducted after GNRs were noted in the blood. Abx were switched to vanc/[Last Name (un) 2830] per sensitivities. [6-25]: The patient underwent IR guided CT drainage of abscesses, staple removed from abd incision by ACS for drainage from the inferior aspect of the wound. A subhepatic + pelvic drains placed by IR, both draining purulent material. [6-26]: The patient was extubated and NGT was placed, which patient self dc'd. On [6-27], the patient received 2 units of blood for HCT of 21.8 and this bumped to 25.9. He was hemodynamically stable and was transferred to the floor on [2142-6-29]: Transferred to the surgical floor on [2142-6-29]: He continued on the meropenum and vancomycin for + klebseilla blood culture. His meropenum was discontinued on [7-2]. He was evaluated by Psychiatry and recommendations made for managment of his episodes of agitation and his clozapine has been resumed. He has been cooperative. He was seen by the ostomy nurse for instruction and supervision in managment of his ostomy. He resumed his regular diet and his TPN was weaned off. His vital signs are stable and he is afebrile. His white blood cell count is 8.9. He has been followed by Infectious disease and recommendations made for antibiotic coverage upon discharge. He is preparing for discharge to an extended care facility to help him increase his endurance and assist him managment of his ostomy. He will follow up with the acute care service in 2 weeks and with ID. Please follow up with your primaary care provider about resuming your mercaptopurine. The telephone number is 1-[Telephone/Fax (1) 34574]. Medications on Admission: [Last Name (un) 1724]: Mercaptopurine, Depakote, Protonix, Clozapine, Benadryl, Dextroamphetamine Discharge Medications: 1. clozapine 100 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily) as needed for bipolar. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)). 6. loxapine succinate 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Heparin Flush (10 units/ml) 1 mL IV PRN line flush 8. Lorazepam 0.5 mg IV Q4H:PRN anxiety hold for sedation 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for increased sedation, resp. rate <12. 10. insulin sc per flow sheet 11. Meropenem 500 mg IV Q6H Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: sepsis anastomotic leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were re-admitted to the hospital after you were discharged with abdominal pain and fever. You were immediately taken to the operating room for repair of a intestinal leakage from your prior surgical procedure. You were monitored in the intensive care unit after the surgery until your vital signs stabilized. You are now preparing for discharge to a rehabilitation facility where you can regain your strength and mobility. Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule your appointment by calling # [Telephone/Fax (1) 600] You will also need to follow up with Infectious disease in 2 weeks. Please call this number # [Telephone/Fax (1) 88588] You will also need to follow up with the wound nurse: please schedule your appointment on the same day as the other appointments. The telephone number is [Telephone/Fax (1) 23664]. Completed by:[2142-7-2]	[ "785.52", "E878.2", "038.9", "518.0", "511.9", "314.01", "482.0", "E878.3", "998.32", "296.80", "295.30", "997.4", "789.59", "555.9", "995.92", "E849.9" ]	icd9cm	[ [ [] ] ]	[ "46.93", "96.6", "45.72", "54.91", "96.72", "96.04", "99.15", "96.71", "33.24", "46.20" ]	icd9pcs	[ [ [] ] ]	15973, 16020	11863, 14898	324, 435	16088, 16088	2930, 11840	16693, 17170	2174, 2261		15051, 15950		16041, 16067		14924, 15028			16239, 16670										2276, 2911																														263, 286																463, 1285										16103, 16215								1307, 1798	1814, 2158
24,729	185,499	43711	Discharge summary	report	Admission Date: [2173-7-30] Discharge Date: [2173-8-3] Service: Cardiology HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female who presents with shortness of breath. The patient has a past medical history significant for type 2 diabetes and hypertension, but no known coronary artery disease. The patient and family reports that she has not been feeling well every since forced to evacuate their apartment on [8-25]. Her main symptom was lethargy. The patient was shortness of breath the morning prior to admission. She also complains of nausea and vomiting that same day. She called Emergency Medical Service and was brought to the Emergency Room. In the Emergency Room her pulse was 130, blood pressure 120/65, respirations of 36, and an oxygen saturation of 96% on room air. The patient was started on intravenous nitroglycerin, BiPAP, and given Lasix and aspirin. Her symptoms improved with BiPAP. Now admitted to the Coronary Care Unit for further management. She denied any complaints of chest pain, abdominal pain, diarrhea or swelling of the feet. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Degenerative joint disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Medications at home include nifedipine-XR 60 mg p.o. q.d., Fentanyl patch 25 q.d., Darvocet p.r.n., glipizide 5 mg p.o. q.d., Flexeril 10 mg p.o. q.h.s. SOCIAL HISTORY: The patient does not smoke or drink alcohol. Lives in [Location 686] with a daughter one floor above her. PHYSICAL EXAMINATION ON ADMISSION: Vital signs were temperature of 97, heart rate 115, blood pressure 110/70, respiratory rate 26, and oxygen saturation of 96% on room air. General appearance was pleasant. HEENT revealed 5-cm of jugular venous distention. Right pupil was reactive. Left pupil was opaque. Oropharynx were clear with moist mucous membranes. Lungs had rales one-third of the way up bilaterally. Cardiovascular was tachycardic, distant heart sounds. No murmurs. Abdomen was obese and nondistended, minimally diffusely tender throughout. Normal active bowel sounds. Guaiac-negative as per Emergency Room. Extremities had trace edema. Neurologically, alert and oriented times two (thought it was [Month (only) 205]). RADIOLOGY/IMAGING: Electrocardiogram with normal sinus rhythm at 123, poor R wave progression, slight ST depressions in I, aVL, and V6 with slight ST elevations in V1 to V3, a Q wave in lead III. Chest x-ray showed pulmonary edema (signs of congestive heart failure). LABORATORY DATA ON ADMISSION: Arterial blood gas on 100% nonrebreather of 7.41/33/80/22. Lactate 5.5. Creatine kinase #1 was 120, troponin 6.3. Creatine kinase #2 was 381, MB 41, index 11, troponin greater than 50. Creatine kinase #3 was 63, MB 30, index 8, troponin greater than 50. Creatine kinase #4 was 262, MB 15, index 6, troponin 42.8. HOSPITAL COURSE: The patient is an 86-year-old female with a past medical history only significant for diabetes mellitus and hypertension who presents with shortness of breath. Her examination and chest x-ray were consistent with congestive heart failure. The patient also had lactic acidosis which may have been secondary to decreased perfusion and low cardiac output. The patient's cardiac enzymes ruled her in for a myocardial infarction. The patient was started on a heparin drip. Both captopril and Lopressor were started and titrated up. Aspirin was continued. An echocardiogram was obtained and revealed an ejection fraction of 15% to 20% with severely depressed left ventricular systolic function and severe global left ventricular hypokinesis with 3+ mitral regurgitation and 3+ tricuspid regurgitation. It was decided the patient would only be treated medically for her acute coronary syndrome. In addition, Lipitor was started. On [2173-8-3] (on hospital day five) the patient was deemed medically stable for discharge to home. Physical Therapy consultation recommended discharge home with home physical therapy. The patient was to follow up with primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 3510], in one week and he will set up a Cardiology appointment for the patient. The patient was scheduled to see Dr. [Last Name (STitle) ] (cardiologist). The patient will need to be scheduled for cardiac rehabilitation. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Status post myocardial infarction. 2. Congestive heart failure. 3. Type 2 diabetes mellitus. 4. Hypertension. 5. Degenerative joint disease. MEDICATIONS ON DISCHARGE: 1. Glipizide 5 mg p.o. q.d. 2. Lisinopril 10 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Atenolol 50 mg p.o. q.d. 5. Lasix 40 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Fentanyl patch 25 mcg q.72h. 8. Home physical therapy. [First Name8 (NamePattern2) 1575] [Last Name (NamePattern1) 12203], MD [MD Number(1) 12204] Dictated By:[Last Name (NamePattern1) 1183] MEDQUIST36 D: [2173-9-9] 14:45 T: [2173-9-14] 11:16 JOB#: [Job Number 29283]	[ "397.0", "293.0", "401.9", "428.0", "250.00", "272.0", "410.71", "424.0", "285.9" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]								4493, 4643				4669, 5181	1262, 1416	2930, 4448																															4463, 4472																											122, 1103								2593, 2911										1125, 1235	1433, 1565
81,069	116,259	40191	Discharge summary	report	Admission Date: [2121-4-30] Discharge Date: [2121-5-7] Date of Birth: [2053-11-18] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: intramucosal esophageal adenocarcinoma Major Surgical or Invasive Procedure: [2121-4-30] minimally invasive esophagogastrectomy History of Present Illness: Patient is a 67-year-old gentleman who had a workup for anemia, which included an upper endoscopy with biopsies, which showed at least high-grade dysplasia. Further investigations have shown what appeared to be intramucosal carcinoma. Endomucosal resection was attempted, demonstrating intramucosal carcinoma without invasion into the submucosa. However, the margin of the endomucosal resection was positive. He has had no dysphagia and otherwise feels well. Past Medical History: PMHx: coronary artery disease s/p drug-eluting stent placed [2117], chronic lung disease, Type 2 diabetes, and hypertension. PSurgHx: bilateral inguinal hernia repair Social History: Denies drinking. He has a 70-pack-year history of smoking cigarettes, but quit 10 years ago. He has smoked [3-29] cigar per day for the last three years. He works as a writer. Family History: Mother deceased from lung cancer Physical Exam: post-op exam: T 97.8 HR 67 BP 144/57 RR 14 SpO2 100% on 12L NC gen: NAD cardiac: RRR chest: decreased breath sounds right lower lobe, chest tube to -20 sxn without leak abd: mod distended, tender, middle port site dressing with serosanguinous drainage, other dressings clean Pertinent Results: [2121-4-30] 08:30AM PT-13.5* PTT-24.3 INR(PT)-1.2* [2121-4-30] 08:30AM PLT COUNT-280 [2121-4-30] 08:30AM WBC-5.6 RBC-4.44* HGB-10.3* HCT-33.1* MCV-74* MCH-23.2* MCHC-31.2 RDW-16.1* [2121-4-30] 08:30AM ALBUMIN-4.6 CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.9 URIC ACID-5.0 [2121-4-30] 08:30AM GLUCOSE-91 UREA N-15 CREAT-0.8 SODIUM-139 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 Pathology [2121-4-30]: pT1a pN0 adenocarcinoma of lower thoracic esophagus, margins clear CXR [2121-5-5]: As compared to the previous radiograph, there is no relevant change. The appearance of the right lung, including the site of surgery, is unchanged, the monitoring and support devices are constant. A second line along the nasogastric tube appears to be exterior to the patient. The small right pleural effusion and the postoperative opacities in the right lung have not increased in size. Unchanged small left pleural effusion and retrocardiac atelectasis. [2121-5-5] UGI: 1. No evidence of leak or obstruction. 2. Small amount of oral contrast material is seen tracking into the airway, consistent with aspiration. [2121-5-6] video oropharyngeal swallow: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is no gross aspiration or penetration. For more details, please refer to the speech and swallow division note in OMR. Brief Hospital Course: Patient was admitted [2121-4-30] for a minimally invasive esophagogastrectomy. Refer to operative notes from Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] for further detail. Patient was transferred stable and extubated to the ICU with an NG tube, right [Doctor Last Name 406] chest tube, J-tube, Foley, and neck JP drain. Pain was well-controlled on PCA. On [2121-5-1] chest tube was changed from suction to water seal and patient was transferred from the ICU to the floor. Tube feeds were started and advanced to goal of 115 mL/hr over 16 hours. Since his surgery, patient maintained a persistent oxygen requirement, likely related to his chronic lung disease, and would desaturate to the mid-80s, though as low as 60s-70s, on room air. Chest xrays were checked daily and showed L>R atelectasis and no evidence of pneumothorax. On [5-5] patient underwent esophogram, which showed no evidence of leak but a question of aspiration, which in retrospect appear to have been artifactual. NG tube, chest tube, and Foley were discontinued. Patient was continued on NPO status until [5-6] when video oropharyngeal swallow study was performed, which showed no evidence of aspiration or penetration. Patient was started on a full diet and tube feeds were advanced to goal. On [5-7] JP was removed as output was minimal. Patient was evaluated by physical therapy over his stay and found to have good function. Oxygen therapy was attempted to be weaned multiple times, but patient was still requiring 3L NC as of discharge. Patient was tolerating a full diet, ambulating, and was receiving good pain control. He was discharged home on home oxygen and tube feeds via J-tube. Medications on Admission: atorvastatin 80', carvedilol 6.25', clopidogrel 75', glyburide 2.5', lisinopril 10', metformin 850', nitroglycerin 0.4 SL, omeprazole 40", vit C 1000', ASA 81', vit D3 1000U', vit B12', iron 325' Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) mL PO twice a day. Disp:750 mL Refills:1 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:150 ML(s) Refills:0 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 850 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. home oxygen therapy indication: room air SpO2 <88% 3L/min continuous for portability pulse dose system 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: esophageal intramucosal adenocarcinoma Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the West 3 surgery service for minimally-invasive esophagectomy. Please call your doctor or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. You are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. You steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Continue to use home oxygen as directed until your oxygen saturation improves. Followup Instructions: Call ([Telephone/Fax (1) 1483] to make an appointment to see Dr. [Last Name (STitle) ] 10-14 days after your discharge. Call ([Telephone/Fax (1) 1483] to make an appointment to see Dr. [Last Name (STitle) ] 10-14 days after your discharge.	[ "V45.82", "530.85", "285.9", "150.5", "530.81", "305.1", "250.00", "412", "401.9", "496", "518.0", "272.4" ]	icd9cm	[ [ [] ] ]	[ "42.42", "46.39", "42.52", "40.3", "96.6" ]	icd9pcs	[ [ [] ] ]	6150, 6208	3079, 4779	342, 399	6328, 6328	1646, 3056	8755, 9015	1302, 1336		5026, 6127		6229, 6307		4805, 5003			6479, 7455								8249, 8732		1351, 1627																												7487, 8234		264, 304																427, 891										6343, 6455								913, 1086	1102, 1286
44,377	122,854	11747	Discharge summary	report	Admission Date: [2164-4-18] Discharge Date: [2164-4-23] Date of Birth: [2133-4-8] Sex: F Service: MEDICINE Allergies: Keflex / Flagyl Attending:[First Name3 (LF) 1257] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: Incision and debridement of gluteal abscess History of Present Illness: 31 YO woman with insulin-dependent diabetes mellitus type 1?, gastritis, depression, hypertension, chronic low-back pain and history of non-adherance to her insulin regimen comes with nausea and vomitting. She was in her prior state of health until aproximately 1 week ago when she started noticing a rash in her perineal area that started as a pimple and enlarged until it "popped and started to have purulent drainage. Subsequently she noted fatigue and poor apetite and therefore started to cut down her insulin until she fully stopped it. She noted polydipsia and polyuria. Three days prior to the current presentation she started noticing abdominal pain, nausea and vomit. She has had poor PO given poor apetite and nausea. Today she was much more fatigued and started to be dizzy and have palpitations so she decided to come to the emergency room. . She denies any chest pain, palpitations, shorntess of breath, changes in her bowel movements, changes in her urine, dysuria, hematuria, flank pain or other skin rashes (other than mentioned above). . Int he ED her initial VS were 7 98.7 120 136/95 36 100%, fingerstick >555. Her physical exam was significant for A&O x3, ketotic breath, following commands, very dry mucous membranes, normal abdominal exam, but had peri-anal erythema spreading to her right buttock as well as some cellulitis in her right leg. There was no crepitus. Her initla labs were: WBC of 28 with left shit: N:88 Band:2 L:8 M:2 E:0 Bas:0, HCT 36, PLTs 612, 129, K 5.2, Cl 90 , CO2 <5, BUN 2, Cr 1.4, AG 32 (not corrected for albumin), ABG: 7.26/14/121, LFTs unremarcable other than AP 164, UA clean other than glucose, protein and keytones, lactate 1.9, normal coags. The ED resident performed ultrasound of the erythematous area and found no fluid collection. She was very difficult stick and required A-Stick for labs. RIJ was placed as well as a 22G in the right arm. She received 2 L NS and 1 L NS with 10 mEq of KCl. She received 10 U of regular insulin and was started on insulin gtt at 10 U/hr. She received Vanc/Zosyn for her cellulitis. She is being admitted to the MICU for further management of her DKA. Her VS prior to transfer were: HR 108, BP 134/82, RR 27, 100% RA and sugar of 412. BMP-7 was sent and pending.. . In the ED she also got morphine 4 mg IV, zofran 4 mg IV. CT scan of pelvis was discussed, but attending decided against it given renal failure and dehydration. Past Medical History: * Insulin dependent diabetes mellitus: Complicated by retinopathy, gastroparesis, diagnosed at 16 years old (?Type 1 vs. Type 2) * Gastritis * Chronic constipation * Depression * Hypertension * Chronic lower back pain * Cataract surgery X1, C-sections X2, one elective abortion Social History: Denies tobacco and nicotine use. Denies illicit drug use. Continues to live with father of her youngest child [Name (NI) 6409] with her two young children (~1 and 8 years old). Not currently employed. Family History: Significant for cancer and cardiac problems. Mother with diabetes. Grandmother with breast cancer (unknwon age). Physical Exam: Admission: VITAL SIGNS - Temp 98.1 F, BP 129/77 mmHg, HR 109 BPM, RR 22 X', O2-sat 100% RA GENERAL - ill-appearing woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva), curled in bed, not using any accesory muscles, keytone breath HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, dry mucous membranes, central uvula NECK - supple, no thyromegaly, JVD 5 cm, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use, Kussmaul HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - induration in perineal area with an opening of 3 mm with purulent drainage, erythema in groin, no crepitations LYMPH - no cervical, axillary, or inguinal LAD NEUROLOGIC: Mental status: Awake and alert, cooperative with exam, normal affect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Non papilledema on fundoscopic exam. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1- V3. Facial movement symmetric. Hearing symetric L=R. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Pertinent Results: ADMISSION LABS -------------- [2164-4-18] 11:10PM GLUCOSE-322* UREA N-22* CREAT-1.1 SODIUM-139 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-10* ANION GAP-28* [2164-4-18] 11:10PM OSMOLAL-312* [2164-4-18] 11:10PM ALBUMIN-3.5 [2164-4-18] 10:55PM LACTATE-1.9 [2164-4-18] 10:35PM PT-13.4 PTT-19.5* INR(PT)-1.1 [2164-4-18] 10:26PM PO2-121* PCO2-14* PH-7.26* TOTAL CO2-7* BASE XS--17 [2164-4-18] 08:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2164-4-18] 08:45PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 [2164-4-18] 08:45PM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 [2164-4-18] 08:10PM GLUCOSE-601* UREA N-26* CREAT-1.4* SODIUM-129* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-<5 [2164-4-18] 08:10PM ALT(SGPT)-10 AST(SGOT)-11 ALK PHOS-164* TOT BILI-0.3 [2164-4-18] 08:10PM LIPASE-20 [2164-4-18] 08:10PM ACETONE-LARGE [2164-4-18] 08:10PM WBC-28.3# RBC-4.01 HGB-11.7* HCT-36.1 MCV-90 MCH-29.3 MCHC-32.5 RDW-14.1 [2164-4-19] 07:48AM BLOOD %HbA1c-15.9* eAG-410* . MICROBIOLOGY ------------ Abscess Cx: WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed. BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. STAPH AUREUS COAG + SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. IMAGING ------- CXR [4-18]: FINDINGS: The left lateral chest wall and soft tissues are not fully imaged. Lung volumes are low. No focal consolidation, pleural effusion, or pneumothorax is seen. There is a right internal jugular catheter with tip in the region of the cavoatrial junction. Heart and mediastinal contours are unremarkable. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 31 year old woman with Type 1 DM, gastroparesis, depression, hypertension, chronic low-back pain and history of non-adherance to her insulin regimen who presented with nausea and vomiting and was found to have severe DKA with gluteal abscess with associated cellulitis. She initially presented with an elevated anion gap (34) due to severe DKA and acute renal failure. Insulin gtt was initiated in ED and patient was aggressively resucitated with IVF & Potassium. Labs monitored frequently and as anion gap closed. She had a Hgb A1c of 15.9% indicating very poor compliance with insulin. She was NPO initially and then a diabetic diet was advanced. The most likely trigger for DKA was gluteal abscess/infection, which was partially drained in ED and packed. Surgery was consulted and performed incision and drainage of abscess and cultures were sent. [Last Name (un) ] was consulted and assisted with management of her blood sugars. She was transferred to the medicine floor and abscess culture returned positive for Streptococcus and MSSA species. Her antibiotics were transitioned to Unasyn and then later augmentin with ongoing improvement of the cellulitis/abscess. Hospital course was complicated by intermittent nausea and vomiting which seemed to resolve with treatment of the underlying soft tissue infection. Medications on Admission: Lantus 16 Units in PM Humalog TID with meals Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. potassium & sodium phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day). Disp:60 Powder in Packet(s) Refills:2 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty Five (25) units Subcutaneous once a day. Disp:4 pens Refills:2 7. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Novolog 100 unit/mL Solution Sig: see sliding scale units Subcutaneous three times a day. Disp:1 month Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Severe DKA, Acidosis Cellulitis with abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with severe diabetic ketoacidosis and a soft tissue infection with abscess over the left buttocks. You were admitted to the ICU initially for management of the DKA and acute infection. You were seen by surgery who performed a bedside drainage of the abscess. You will need to continue taking antibiotics for another 7 days. The [Last Name (un) ] Diabetes team has been working with you to get better blood sugar control and you will need to follow up with them. Followup Instructions: Please call your PCP on Tuesday to schedule a follow up appointment in less than 1 week.	[ "238.71", "536.3", "V58.67", "584.9", "275.3", "362.01", "250.53", "401.9", "280.9", "311", "682.5", "338.29", "276.51", "535.50", "250.63", "V15.81", "724.2", "250.13", "041.11" ]	icd9cm	[ [ [] ] ]	[ "38.97", "83.09" ]	icd9pcs	[ [ [] ] ]	9563, 9621	7051, 8384	295, 340	9718, 9718	4835, 5988	10381, 10472	3332, 3447		8480, 9540		9642, 9697		8410, 8457			9868, 10358										3462, 4336																														236, 257							6023, 6578									368, 2791	4422, 4816								6614, 7028	9733, 9844								2813, 3093	3109, 3316
27,372	184,811	33433	Discharge summary	report	Admission Date: [2103-2-16] Discharge Date: [2103-2-24] Date of Birth: [2025-7-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2745] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: IR placement of percutaneous cholecystostomy tube History of Present Illness: Ms. [Known lastname 36509] is a 77 year old woman with bipolar disorder, dementia, prior CVA, who presented to the [Hospital1 ] [Location (un) 620] ED complaining of several days of abdominal pain with fevers. The patient was unable to give the details of her recent symptoms upon admission, presumably due to her dementia, and history was obtained from her son. Two weeks PTA, she started complaining of abdominal distension. Three days PTA, she started getting up throughout the night Q30 mins to go to the bathroom and was found defecating and urinating on floor. Her son noticed her urine was [Location (un) 2452]-colored. At [Hospital1 ] [Location (un) 620], she was febrile to 100.8. An abdominal ultrasound showed evidence of acute cholecystitis. An abdominal CT was performed which showed an enhancing adrenal mass, a hepatic mass (likely a cyst), and a hypodense splenic lesion. She was transferred to [Hospital1 18] out of concern for malignancy and further management of the cholecystitis. She was also given ceftriaxone and metronidazole. Of note, she had a potassium of 2.3 on presentation to [Hospital1 ] [Location (un) 620] (she has a long-standing history of hypokalemia). Urinalysis was consistent with UTI. Blood and urine cultures were drawn. At [Hospital1 18] on transfer, she was afebrile with HR 98, BP 146/80, RR 18, Sat 98% on 2L NC. Past Medical History: -Bipolar disorder h/o suicide attempt in [4-25] with [Last Name (un) 68785] hospitaliziation -prior CVA in [2094] (slurred speech, facial droop, L arm weakness, unsteady gait --> good recovery with some residual L arm weakness) -hypothyroidism -dementia; baseline MS reportedly poor -CAD -HTN -hypercholesterolemia -hypokalemia (documented since [2094], with baseline K+ 3.0-3.8) -CRI -Atrial fibrillation Social History: Lives with her son and daughter who describe her as "an invalid at baseline". She has 5 children, but is estranged from 3 of them. Her husband died 8 years ago. She has a history of suicide attempt in [2102-4-18] with hospitalization at [Last Name (un) 68785]. Currently there is no tobacco or alcohol use. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: T 99.8 BP 174/88 HR 89 RR 22 Sat 97% on 2 L/min General: obese, sleeping but arousable; inattentive when asked to follow commands HEENT: no icterus, (+) hirsutism Neck: supple, no LAD Chest: CTA b/l, no w/r/r CV: irregular heartrate, no m/r/g Abdomen: soft, (+) tenderness to moderate palpation in RUQ, no rebound/guarding, (+) [Doctor Last Name 515] Extremities: no edema, 2+ PT pulses Skin: no jaundice Neuro: sleepy, oriented to self only Pertinent Results: LABS ADMISSION LABS (on transfer from [Hospital1 ] [Location (un) 620]): [2103-2-16] 07:40PM BLOOD WBC-15.8* RBC-5.04 Hgb-14.4 Hct-41.3 MCV-82 MCH-28.5 MCHC-34.7 RDW-13.9 Plt Ct-138* [2103-2-16] 07:40PM BLOOD Neuts-90.3* Bands-0 Lymphs-6.5* Monos-2.9 Eos-0.2 Baso-0.2 [2103-2-16] 07:40PM BLOOD PT-15.6* PTT-27.0 INR(PT)-1.4* [2103-2-17] 03:04PM BLOOD Fibrino-656* [2103-2-16] 07:40PM BLOOD Glucose-165* UreaN-19 Creat-1.0 Na-141 K-2.6* Cl-101 HCO3-29 AnGap-14 [2103-2-16] 07:40PM BLOOD Albumin-3.7 Calcium-9.8 Phos-2.1* Mg-1.2* [2103-2-16] 07:40PM BLOOD ALT-55* AST-40 LD(LDH)-185 AlkPhos-93 Amylase-7 TotBili-3.9* DirBili-1.7* IndBili-2.2 Lipase-10 ABG: [2103-2-17] 11:56AM BLOOD Type-ART pO2-169* pCO2-31* pH-7.41 calTCO2-20* Base XS--3 ENDOCRINE LABS: [2103-2-17] 01:15AM BLOOD Cortsol-44.1* [2103-2-23] 05:16AM BLOOD FreeTes-PND [2103-2-21] 12:28PM BLOOD ALDOSTERONE-PND [2103-2-21] 12:28PM BLOOD RENIN-PND [2103-2-21] 12:28PM BLOOD Metanephrines (Plasma)-PND [2103-2-21] 12:28PM BLOOD METHYLMALONIC ACID-PND [2103-2-17] 09:55AM BLOOD ALDOSTERONE-PND CARDIAC ENZYMES: [2103-2-18] 02:40PM BLOOD CK-MB-NotDone cTropnT-0.07* [2103-2-19] 03:25AM BLOOD CK-MB-NotDone cTropnT-0.07* ECG ([2103-2-16]): Atrial fibrillation with ventricular rate of 93 bpm. nl axis, nl intervals. No ST/T wave changes IMAGING CT Abdomen/Pelvis (from [Location (un) 620], [2103-2-16]): The left atrium is enlarged. Mild bibasilar dependent atelectasis is noted. Within the right middle lobe, air space consolidation with associated air bronchograms are noted. Within segment [1-21] and 4, there is a 1.4 x 4.1 cm low attenuation slightly ill-defined focus visualized (image 17, series 2) with a peripheral calcification . In addition, along the periphery of segment 4, there is a 1.4 x 3.3 cm slightly ill-defined partially peripherally enhancing low attenuation focus and along the periphery of segment [1-21], and 4, there is a well-circumscribed 3.0 x 2.5 cm low attenuation focus that likely represents a cyst. The gallbladder is distended associated with adjacent stranding. Within the gallbladder, there are dependent ill-defined high density foci. Within the spleen, there is a 5.5 mm indeterminate low attenuation focus seen. Arising from the left adrenal gland, a 2.7 x 2.1 cm enhancing mass is noted. Bilateral peripelvic cysts are seen. Multiple nonpathologically enlarged retroperitoneal lymph nodes are seen. There is a Foley within the bladder. Air is noted within the bladder likely secondary to instrumentation. Please note there is an associated peripheral calcification along the low attenuation focus I described in the liver that measures 4.1 x 1.4 cm. A fat containing umbilical hernia is present. The uterus is absent. The bones are diffusely demineralized. Degenerative changes are noted. RUQ ultrasound (from [Hospital1 ] [Location (un) 620] [2103-2-16]): The gallbladder is distended and filled with mobile stones and sludge. A son[Name (NI) 493] [Name2 (NI) 515] sign was elicited during the examination. There is questionable focal thickening of the gallbladder in the region of the fundal neck junction. No significant gallbladder wall thickening nor pericholecystic fluid is seen. The common bile duct is within normal limits measuring 4.5 mm. [2103-2-17] CXR: A single portable image of the chest was obtained. The cardiac silhouette is at the upper limits of normal. There are low lung volumes. There is perihilar fullness, may be exaggerated secondary to underlying mild pulmonary venous congestion. No focal airspace opacity is seen. There is minimal left basilar streaky opacities likely secondary to underlying atelectasis. The bony thorax is grossly intact. [2103-2-22] CXR: New patchy opacities in the left lower lobe and inferior lingula. Although a component of volume loss is present suggesting atelectasis, coexistent pneumonia should be considered in the appropriate clinical setting. [2103-2-19] ECHO: The left and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic leaflets are mildly thickened. No aortic stenosis is seen. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global systolic function. Mild aortic regurgitation. [2103-2-22] MRI: *** Limited study The examination is limited due to inability to cooperate with breath-hold imaging and absence of contrast administration. * There are a number of liver lesions. There is a focal irregularly marginated area of intermediate-to-high signal at the liver hilum measuring 2.3 x 3.8 x 2.9 cm in diameter. This predominantly involves segments [Doctor First Name 690] and II. The mass is incompletely characterized. The location raises the possibility of cholangiocarcinoma, but the absence of proximal intrahepatic biliary dilatation makes cholangiocarcinoma less likely. There are a number of additional liver lesions. There is a 1.3-cm segment VII lesion. There is a 1.7 x 2.8 cm segment [Doctor First Name 690]/b lesion. Both these lesions are incompletely characterized but are high signal on T2-weighted sequences and low signal on T1. There is a 3-cm segment [Doctor First Name 690] liver cyst. * The gallbladder wall is thickened and the gallbladder contains multiple calculi. Some free fluid anterior to the liver may relate to previous recent instrumentation. There are a number of low-signal filling defects, compatible with calculi, in the distal common bile duct. The largest of these measures 8 mm in diameter. The common bile duct measures 9 mm in diameter. There is no pancreatic duct dilatation. * There is a 1.5-cm left adrenal mass. The signal characteristics are hypointense to liver on T1-weighted in-phase imaging. There is signal drop-off on the out-of-phase sequence. This is compatible with a left adrenal adenoma. * There are bilateral basal small pleural effusions. There is a 1-cm right epicardiac fat pad lymph node. There is a cholecystostomy catheter in situ. * The spleen is normal in size. There is a small nonspecific high signal on T2-weighted sequence lesion measuring approximately 8 mm in diameter. * There are a number of vertebral body lesions high signal on T1- and T2- weighted sequence, compatible with hemangiomas. IMPRESSION: 1. Gallbladder and distal common duct calculi. 2. Cholecystostomy in situ. 3. Several incompletely characterized liver lesions the largest of which is at segment [Doctor First Name 690]/II. 4. Left adrenal adenoma. MICROBIOLOGY [2103-2-17] BILE CULTURE: STREPTOCOCCUS BOVIS . MODERATE GROWTH. KLEBSIELLA OXYTOCA. RARE GROWTH. PRESUMPTIVE CLOSTRIDIUM PERFRINGENS. KLEBSIELLA OXYTOCA SENSITIVITIES: MIC expressed in MCG/ML \| AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2103-2-16] BLOOD CULTURE: No growth in four vials [2103-2-17] BLOOD CULTURE: No growth in two vials [2103-2-18] BLOOD CULTURE: NGTD in two vials [2103-2-16] URINE CULTURE (from [Location (un) 620]): greater than 10^5 Klebsiella species [2103-2-18] URINE CULTURE: No growth Brief Hospital Course: ACUTE CHOLECYSTITIS: Ms. [Known lastname 36509] was noted to have several weeks of abdominal pain and distention prior to presentation with acute cholecystitis. The surgical service was consulted and recommended a percutaneous cholecystostomy tube for drainage, and the tube was placed by interventional radiology on [2103-2-17] without complication. She was started empirically on IV vacnomycin and zosyn while bile cultures were pending. On [2103-2-17], she developed hypoxia and rigors requiring a transfer to the MICU. She was never intubated and remained hemodynamically stable, although she did not need all home hypertension medicines while in-house (she was kept on metoprolol, isosorbide dinitrate and amlodipine, HCTZ was held). Lung exam revealed wheezes, and she was started on ipratropium and albuterol nebulizers with good response. Bile cultures returned Streptococcus bovis, Clostridium perfringens and Klebsiella oxytoca susceptible to zosyn. On [2103-2-21], vancomycin was discontinued; she defervesced and had improvement of her leukocytosis on zosyn (WBC from 25.2 on [2-17] to 6.6 on discharge). Of note, all blood cultures were negative throughout the admission. It was noted that her gallbladder was distended, filled with stones and sludge. Presumably, her cholecystitis was secondary to obstruction by stones/sludge as stones were also noted in the CBD (although there was no dilatation of the CBD on imaging). Upon discharge, the cholecystostomy tube was left in place for ongoing drainage and will be left in place indefinitely until she has the out-patient surgery follow-up appointment. She is also to remain on IV zosyn (with a PICC line in place) until she returns for surgical follow-up, at which point the antibiotics and tube may be discontinued pending clinical improvement. She was discharged on a full diet, with minimal RUQ abdominal pain and nausea. HYPOKALEMIA: Ms. [Known lastname 36509] has a history of hypokalemia at baseline. [First Name8 (NamePattern2) ] [Location (un) 620] records, K+ has been low as far back as [2094], with a baseline between 3.0 and 3.8. [First Name8 (NamePattern2) ] [Location (un) 620] notes, she has taken potassium supplements in the past, but was not on supplements upon admission. She was noted to be persistently hypokalemic thorughout the admission, dependent on 40 - 60 mEq PO potassium repletion daily. She was also kept on spironolactone 25 mg QD. She was discharged on potassium chloride 40 mEq QD, with suggestion to check potassium levels Q2 - 3 days initially in rehab. An endocrinology consult was placed to work-up the hypokalemia (and adrenal mass). Aldosterone, renin and ACTH levels were pending at the time of discharge, although it is noted that spironolactone administration may prevent proper interpretation of these results. ADRENAL MASS: Records from her prior endocrinologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], and previous CT scans show that this adrenal mass was known previously. Comparison to prior studies seemed to show that the mass was stable in size. Cortisol level was 44 on admission, and aldosterone, renin and ACTH levels were pending at the time of discharge. MRI of the abdomen was ordered for further evaluation and showed the adrneal mass was consistent with an adenoma. We have recommended out-patient evaluation and appointment with Dr. [First Name (STitle) ] for further work-up and management. ATRIAL FIBRILLATION: The patient was known to have atrial fibrillation and has had evaluations in the past. She was not admitted on anticoagulation and was kept on subcutaneous heparin for DVT prophylaxis while in the hospital. The decision to begin anticoagulation has been deferred to out-patient PCP [Last Name (NamePattern4) 702]. MENTAL STATUS/DEMENTIA: The patient was noted to be oriented to person upon admission and also at discharge; she was somnolent at times, but easily arousable and able to carry on a conversation. According to her son, she was at baseline mental status. She was continued on olanzapine while in the hospital. PENDING ISSUES FOR FOLLOW-UP (1) Potassium levels should be checked every 2 - 3 days initially upon discharge to ensure that the patient's potassium level remains stable on 40 mEq KCl daily supplementation. (2) Blood pressure should be followed, as HCTZ were held in the hospital because of relatively low blood pressures. The need for HCTZ and increasing doses of current meds should be readdressed at her primay care follow-up appointment. (3) It is noted that she has rate-controlled atrial fibrillation, but is not on anticoagulation. The risks and benefits of long-term anticoagulation should be readdressed in primary care follow-up. No changes were made to her out-patient regimen at this time. (4) The adrenal mass has been followed as an out-patient and does not seem malignant given its slow rate of growth. The need for repeat imaging and further work-up shoud be determined by the PCP and endocrinologist. In addition, the aldosterone, ACTH, renin, testosterone and DHEA-S levels were pending at the time of discharge and should be reviewed as an out-patient to ensure there have been no changes since they were last measured. (5) The need for further zosyn treatment and cholecystostomy tube should be addressed at her sugical follow-up appointment, as well as need for surgical cholecystectomy. Medications on Admission: olanzapine 5 mg once daily amlodipine 10 mg daily oxybutinin 5 mg simvastatin 20 mg daily HCTZ 12.5 mg daily levothyroxine 150 mcg metoprolol 50 mg once daily isosorbide (? mono- vs dinitrate) 15 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 11. Albuterol 90 mcg/Actuation Aerosol Sig: [12-20] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: Primary Diagnoses: Acute cholecystitis Adrenal mass Hypokalemia Urinary tract infection Secondary Diagnoses: Hypertension Dementia Atrial Fibrillation Discharge Condition: Stable-- afebrile; breathing comfortably in the mid-90's on room air; oriented to self at baseline; still with occasional abdominal pain, but significnatly improved from admission. Discharge Instructions: Please call your primary care doctor if you have worsening abdominal pain or fevers. If you cannot reach your doctor, or if you feel severely worse or SOB, please return to the emergency department. You have been put on antibiotics through the vein for your gallbladder infection. You will need to be on them at least through your surgery appointment on [3-2]. They will decide whether you need to remain on antibiotics and whether the tube can come out at that visit. You have been started on a potassium supplement. You have been on a supplement in the past and were restarted on this because your potassium levels were low in the hospital. Please follow the medication list carefully and take only what is on the list at the doses that are written. Several changes have been made to what you used to take, so please follow it closely. Followup Instructions: You have the following follow-up appointments: (1) You have an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in general surgery on [2103-3-2], at 1:45 pm for follow-up on your gall bladdder. The office is on the [Location (un) ] of the [Hospital Ward Name 23] Building on the [Hospital Ward Name 516] of [Hospital1 ] Hospital. Their phone number is ([Telephone/Fax (1) 30009]. You must call the office before your appointment to register with them over the phone. (2) Please see your primary care doctor, Dr. [Last Name (STitle) 29111] [Name (STitle) 11302], at [Telephone/Fax (1) 29110]. You should call to set up an appointment to be seen in the next 2 - 3 weeks. (3) Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in endocrinology to make an appointment for follow-up in the next 3 - 4 weeks. This is to follow-up on your low potassium levels and adrenal mass. The phone number is [Telephone/Fax (1) 19946]. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] called on [2103-2-23] to try to set up an appointment, but was unable to speak to someone directly. She left a message with the staff at the office to call your home number ot set something up. If you do not hear from them, you will need to call to set something up.	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7,391	135,421	27492	Discharge summary	report	Admission Date: [2201-8-26] Discharge Date: [2201-11-6] Date of Birth: [2133-7-8] Sex: F Service: SURGERY Allergies: Demerol Attending:[First Name3 (LF) 4111] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: None History of Present Illness: This is a 68 year-old female with a history of Crohn's disease with ileostomy and abdominal fistula, who is status post enterocutaneous fistula repair at [Hospital1 18] on [2201-8-1]. On [2201-8-21] whe was admitted to [Hospital1 15331] Hosptial after a fall at home where she sustained a left clavicular fracture. While hospitalized she experienced fevers, nausea, and vomiting. Her Hickman catheter was removed with suspicion for line sepsis, and an abdominal CT was obtained which reportedly showed fluid collections. She was transferred to [Hospital1 18] on [2201-8-26] for sepsis. Past Medical History: 1.Crohn's disease s/p proctocolectomy and s/p total abdominal colectomy, proctectomy, and end ileostomy in [2187]. 2.Incarcerated parastomal hernia s/p repair with mesh in [2198]. 3.Stenosis of an ileostomy in [2200] s/p multiple operations 4.Multiple enterocutaneous fistulas 5.Diabetes Mellitus II 6.Hypertension 7.Depression Social History: She takes no ethanol, prior tobacco use, quit 20 years ago. Family History: Non-contributory Physical Exam: Initial Physical Exam - [2201-8-26] 98.3 108 104/54 16 93%RA Somnolent but arousable, AxOx2 Right chest s/p removal Hickman, no drainage, no erythema RRR, B CTA, No tenderness over B clavicles, tender sternum on palpation, no bruises Abd soft, mildly tender, lower midline hernia, G-tube, ostomy vital and working, BS+ Perineum without rectum, 2 small abrasions Bilateral LE WNP, no edema Discharge PE - [2201-10-29] GEN: NAD CARD: RRR LUNGS: CTAB ABD: +BS, soft, nontender, nondistended - ostomy/fistulae/G-Jtube intact/no leaks Neuro: AxOx3 Pertinent Results: Admission Labs: [2201-8-27] 01:06AM BLOOD WBC-24.8# RBC-2.77 Hgb-8.3* Hct-24.0* MCV-87 MCH-29.8 MCHC-34.3 RDW-14.9 Plt Ct-144# [2201-8-27] 01:06AM BLOOD Neuts-89 Bands-3 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [2201-8-27] 01:06AM BLOOD PT-15.9* PTT-34.1 INR(PT)-1.5* [2201-8-27] 01:06AM BLOOD Glucose-92 UreaN-25* Creat-2.4# Na-128 K-5.6* Cl-96 HCO3-18* AnGap-20 [2201-8-27] 01:06AM BLOOD ALT-21 AST-27 LD(LDH)-293* CK(CPK)-137 AlkPhos-360* Amylase-21 TotBili-0.5 [2201-8-27] 01:06AM BLOOD Albumin-2.5* Calcium-7.7* Phos-4.1 Mg-1.2* ----------NUTRITION LABS---------- Date-----Fe-----TIBC-----[Last Name (un) ]-----TRF-----Alb [8-31]-----47-----[Telephone/Fax (1) 67249]-----2.2 [9-7]-----52-----[Telephone/Fax (1) 67250]-----3.3 [9-13]-----29-----[0-0-]-----3.1 [9-21]-----69-----[0-0-]-----2.7 [9-28]-----76-----209--------------161-----3.0 [10-5]-----90-----[Telephone/Fax (1) 67251]-----3.0 [10-12]-----88-----[Telephone/Fax (1) 67252]-----2.4 [10-19]-----52-----[Telephone/Fax (1) 67253]-----2.7 [10-26]-----49-----[Telephone/Fax (1) 67254]-----3.1 [11-2]-----18-----[Telephone/Fax (1) 67255]-----2.7 Recent Labs Prior to Discharge: [2201-10-6] 05:04AM BLOOD WBC-11.7* RBC-3.24* Hgb-9.9* Hct-28.6* MCV-88 MCH-30.6 MCHC-34.6 RDW-16.9* Plt Ct-248 [2201-10-16] 04:23AM BLOOD WBC-12.6* RBC-2.60* Hgb-8.1* Hct-23.2* MCV-89 MCH-31.2 MCHC-35.0 RDW-17.8* Plt Ct-255 [2201-10-26] 04:05AM BLOOD WBC-11.2* RBC-3.20* Hgb-9.8* Hct-29.1# MCV-91 MCH-30.6 MCHC-33.6 RDW-18.1 Plt Ct-398# [2201-10-29] 04:22AM BLOOD Glucose-148* UreaN-19 Creat-0.5 Na-132* K-4.3 Cl-102 HCO3-23 AnGap-11 [2201-10-30] 08:04AM BLOOD Glucose-179* UreaN-21* Creat-0.5 Na-131* K-5.1 Cl-99 HCO3-26 AnGap-11 [2201-10-31] 07:59AM BLOOD Glucose-149* UreaN-21* Creat-0.5 Na-127* K-5.6* Cl-98 HCO3-24 AnGap-11 [2201-10-31] 12:52PM BLOOD Glucose-102 UreaN-20 Creat-0.5 Na-127* K-5.4* Cl-96 HCO3-25 AnGap-11 [2201-11-1] 04:49AM BLOOD Glucose-112* UreaN-20 Creat-0.5 Na-131* K-5.7* Cl-100 HCO3-27 AnGap-10 [2201-11-2] 04:53AM BLOOD Glucose-116* UreaN-22* Creat-0.6 Na-128* K-6.1* Cl-96 HCO3-26 AnGap-12 [2201-11-2] 10:44AM BLOOD Glucose-85 UreaN-23* Creat-0.6 Na-128* K-6.3* Cl-96 HCO3-26 AnGap-12 [2201-11-2] 04:40PM BLOOD Glucose-150* UreaN-23* Creat-0.7 Na-129* K-5.0 Cl-94* HCO3-26 AnGap-14 [2201-11-3] 07:17AM BLOOD Glucose-151* UreaN-23* Creat-0.6 Na-132* K-4.1 Cl-95* HCO3-31 AnGap-10 [2201-11-4] 05:01AM BLOOD Glucose-151* UreaN-19 Creat-0.5 Na-133 K-4.1 Cl-98 HCO3-29 AnGap-10 [2201-11-5] 04:32AM BLOOD Glucose-163* UreaN-16 Creat-0.5 Na-130* K-3.9 Cl-95* HCO3-27 AnGap-12 [2201-11-6] 03:52AM BLOOD Glucose-158* UreaN-13 Creat-0.5 Na-134 K-3.5 Cl-97 HCO3-28 AnGap-13 [2201-11-2] 04:53AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.1 Mg-1.7 Iron-18* [2201-11-2] 10:44AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.7 [2201-11-2] 04:40PM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8 [2201-11-3] 07:17AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7 [2201-11-4] 05:01AM BLOOD Phos-2.6* Mg-1.5* [2201-11-5] 04:32AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.5* [2201-11-6] 03:52AM BLOOD Phos-2.7 Mg-2.2 [2201-10-1] 02:58PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2201-10-1] 02:58PM BLOOD TSH-3.3 ----------CULTURES---------- [9-1] Abdominal wound- yeast, rare growth (F) [9-18] URINE: consistent w/ fecal contimination (F) [9-18] BLOOD: Neg x2 (F) [9-23] C.DIFF: Neg (F) [9-24] URINE: VRE (F) [9-24] BLOOD: VRE (F) [9-25] BLOOD: Neg (F) [9-28] MRSA SCREEN: Pos (F) [9-29] PICC TIP: Neg (F) [10-29] URINE: Citrobacter (Imipenem) (F) [11-4] URINE: <10,000 colonies CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: R/O fluid collection - infectious source Field of view: 36 [Hospital 93] MEDICAL CONDITION: 68 year old woman with h/o Crohn's s/p enterocutaneous fistula takedown who came with sepsis and ARF s/p fall, now with enterocutaneous fistula and leukocytosis. R/O fluid collection REASON FOR THIS EXAMINATION: R/O fluid collection - infectious source CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 68-year-old woman with history of Crohn's disease status post enterocutaneous fistula takedown with sepsis and acute renal failure. COMPARISON: [2201-9-15]. TECHNIQUE: Multidetector contiguous axial images of the abdomen were obtained following oral contrast administration. No IV contrast was used. Reformatted images in the coronal and sagittal planes were obtained. FINDINGS: Few images through the lung bases demonstrate no pleural effusions. The study is slightly limited by patient breathing and motion artifact. Percutaneous gastrojejunostomy tube tip is in the proximal-to-mid jejunum. The patient is status post cholecystectomy. The previously seen anterior abdominal wall collection has been decompressed in the interval. There are multiple oral-contrast filled cutaneous fistulae of the anterior abdominal wall that appear to be contiguous to a small amount of free oral contrast and air in the region of the right anterior abdomen extrinsic to bowel loops (images 47-59). This collection has decreased in size compared to the prior study. No dilated bowel loops are seen. CT PELVIS WITHOUT IV CONTRAST: There is a Foley catheter in bladder. However, there is an unusually large amount of air in the bladder and within the inferior dependent portion there is contrast material (image 69), (also confirmed on the associated reformatted coronal and sagittal images). Please note that the patient did not have intravenous contrast on today's exam and the patient's prior study with intravenous contrast was nine days ago. As such, the small amount of contrast seen in the bladder on today's exam is suggestive of an enterovesical fistula. There are enlarged inguinal nodes bilaterally. A small amount of fluid is seen adjacent to the uterus in the deep pelvis. Patient is status post colectomy. IMPRESSION: 1. Decrease in size of small abdominal collection containing contrast which is in communication with multiple cutaneous fistulas. 2. Air and contrast in the bladder is suggestive of an enterovesical fistula. T-SPINE Xray Reason: eval for fx [Hospital 93] MEDICAL CONDITION: 68 year old woman c/o back pain REASON FOR THIS EXAMINATION: eval for fx INDICATION: 68-year-old woman with back pain. T-SPINE, AP AND LATERAL VIEWS: A moderate compression deformity of the T6 vertebra and a mild compression deformity of the fifth thoracic vertebra are seen. These findings are new since [9-4], [2201]. A right-sided PICC line is present with its tip at the brachiocephalic/SVC junction. Aortic arch calcification is noted. IMPRESSION: Compression fractures at T5 and T6, new compared to 7/[2201]. The precise chronicity of these findings is uncertain and could be assessed with MR [First Name (Titles) ] [Last Name (Titles) 10015] necessary. Brief Hospital Course: Mrs. [Known lastname 67256] was admitted to the surgery service on [2201-8-26] in care of Dr. [Last Name (STitle) 957] after being transferred from [Hospital1 67257] for sepsis. She had a Hickman catheter during admission at [Hospital1 15331], which was removed for suspicion of line sepsis and was reported to be positive for MRSA. She presented to [Hospital1 18] with leukocytosis at 23, and acute renal failure with creatinine at 2.3. Upon admission she was started on Fluconazole and Linezolid. An ophthalmology consult was obtained to rule out retinitis, secondary to suspect bacteremia/fungemia, which was negative. An echo was completed to rule out endocarditis, which was negative. Two units of blood were transfused for low hematocrit. Urinalysis and urine culture were collected and were negative for infection. On HD3 she experienced decreased urine output which was treated with intravenous hydration. Her gastrostomy tube was rewired to a gastrojejunostomy by interventional radiology. She was then started on tube feeds. On HD4 blood cultures were sent and these were negative for infection. On HD 5 a central line was placed. TPN with NephrAmine was initiated. On HD6 she experienced nausea and vomiting;her abdomen was distended. She was placed NPO and abdominal films were obtained which were negative for obstruction. Her ostomy output was decreased, and for this, her ostomy was dilated and a catheter placed to maintain patency. Because her central line was found to be initially positioned in an accessory vein, rewire attempts were made, however it was found that her left brachial cephalic vein was occluded and therefore the catheter could only be placed in an accessory hemiazygos vein. On HD 7 there was a small area of fluid collection with erythema at her midline abdomen above the ostomy site. This was incised and drained of purulent fluid and sent for culture which showed rare growth of yeast, presumptively not c. albicans. At this point in her hospital stay she was moderately depressed. Physical therapy was consulted to begin rehabilitation and improve mobility, but she was not motivated to participate. Psychiatry was consulted to evaluate her depressed mood. It was recommended that she continue her Wellbutrin in order to allow for affect and start on Dexedrine to increase her energy levels. These recommendations were followed. By HD 10 her Linezolid was stopped and she was taking Zosyn to treat her cellulitic areas at the midline of her abdomen. Her TPN was advanced and she was getting out of bed to chair for short periods of time. She remained afebrile and her creatinine and urine output were normalizing. She continued to complain of pain at her left arm and sternum for which she was receiving IV pain medication. For this, a PCA was provided. In addition to pain, she also complained of left arm weakness for which Neurology was consulted to evaluate. From this consult there was some concern for cervical spine pathology; a MRI was recommended. However, due to her recent history of acute renal failure, this was not completed. By HD15 her cultures were negative and she remained afebrile. Hence, her antibiotics were discontinued. At HD 20 she was more participative and her mood was improved. An abdominal CT scan was performed after renal protection with hydration, Mucomyst and bicarbonate. The scan showed an interval increase in the size of the anterior abdominal wall collection, which appeared to communicate with the bowel. There was an adjacent intraperitoneal collection. On HD 22 a fistula gram was performed through the patient's end ileostomy. No opacification of a fistulous tract was identified. Whistle-tip catheter was placed into the ostomy and sutured into place. On HD 23 a chest CT without contrast was performed to evaluate for sternal fracture, as she continued to have reproducible chest pain and her chest xrays were negative. This showed a mildly displaced and angulated inferior manubrial fracture. On HD 24 she manifested low grade temperatures. Blood and urine cultures were obtained and she was set up to have her PICC line changed for possible line sepsis. Ceftriaxone and Fluconazole were started. At HD 27 she was found to have two enterocutaneous fistula sites adjacent to her ileostomy which were integrated into her ostomy pouch by the wound care nurse. On HD 30 her WBC count was elevated at >30 and she did not appear well. Her tube feedings were stopped and Zosyn was started. A CT scan of the abdomen was performed to evaluate for septic source which showed air and contrast in the bladder, suggestive of an enterovesical fistula. No significant fluid collections were noted. At this point her blood cultures drawn from the onset of her low grade temperatures were negative and her urine culture was found to have fecal contamination. She was transferred to the ICU for further care. On admission to the ICU she was started on Vancomycin and Caspofungin, in addition to her Zosyn. Her Wellbutrin, Paxil, and Dexedrine were discontinued per psychiatry recommendation during this acute period. Her tube feedings and TPN were continued. At this point the original PICC line that was supposed to be rewired at HD 25 was still in place, as there was difficulty scheduling her for interventional radiology. This was also delayed due to her acute illness and transfer to ICU. Previous cultures drawn from the PICC site were negative and due to her highly elevated WBC at >30, line sepsis was low on the differential for infectious source. The enterovescicular fistula supported a more likely diagnosis of urosepsis. On HD 34 repeat blood cultures were negative, MRSA and VRE screens came back positive. She was doing better, was afebrile, and her leukocytosis was trending downward. Her Vancomycin was changed to Linezolid for VRE and her Caspofungin was discontinued. On HD 36 she was transferred back to the floor and her PICC line was exchanged over wire, with the tip sent for culture. After the PICC line was changed she had an episode of hypoglycemia, with a BS of 47. She was difficult to arouse and hypotensive. Her BS and pressure came back to baseline after 1 amp of D50, her cardiac enzymes were negative x 3. On HD 37 her TPN was stopped. [Last Name (un) ] was consulted to evaluate and treat her labile blood glucose. She was started on Lantus with sliding scale coverage. At this point she continued to cry regarding pain medication. We started her on Fentanyl patch, Dr. [Last Name (STitle) 957] talked with her regarding dependency issues with narcotics, and her Diluadid was weaned. At HD 40 her sodium was consistently low and she was started on maintenance IV normal saline. When there was no response, 3% hypertonic saline was started daily. At HD 49 she continued with low sodium. Her potassium was elevated to 5.7. In suspecting adrenal suppression, a cortisol stem test was completed which was within normal parameters. She was also experiencing intermittent episodes of nausea and emesis. A KUB was performed and was negative for obstruction. At HD 50 psychiatry continued to evaluate. They felt that she showed some improvement since discharge from the ICU, but found her to exhibit catatonic properties on physical exam. They recommended discontinuing Reglan and Paxil which was followed. Although the cortisol stem test was normal, hydrocortisone was ordered to see if her electrolytes would normalize. Fludrocortisone was started on a daily basis. Her Zosyn and Linezolid courses were completed and Bactrim was started to treat her urinary infection r/t her enterovescicular fistula. At HD 56 she was doing better from a psychosocial standpoint. She was doing better with pain and rarely asked for pain medication. She was agreeable to work with physical therapy and was walking via walker and assistance. Her mood had improved and her catatonia was resolving. However, she was experiencing more nausea and vomiting and it was felt that it would be best to start back her Reglan so that she could tolerate tube feeds. At HD 58 the hypertonic saline was discontinued, as it was not improving her sodium level. The reglan appeared to improve her nausea and vomiting. Her tube feeds were advanced. At HD 60 it was unclear if the [Name (NI) 67258] was improving her electrolyte imbalance and so it was stopped. At HD 62 she complained of back pain. There was an area of questionable deformity and tenderness at her thoracic spine. No ecchymosis noted. A thoracic spine film was done which showed compression fractures at T5 and T6 new from 7/[2201]. There was no history or report of injury. It was this day that her insurance company visited her in the hospital. They did not want her to stay in the hospital any longer. However they would not approve acute rehabilitation and we did not feel that it was safe to send her to a [Hospital1 1501] related to her need for frequent electrolyte replacement and monitoring. On HD 64 her g-tube was clamped and a soft diet was started which she tolerated well. She continued to work with physical therapy and was walking with walker. Her diet was advanced to regular and she seemed to tolerate this for a couple of days until she began to have frequent emesis. Her HOB was elevated > 30 degrees and we limited food after 5pm however this did not decrease her vomiting. Hence we un clamped her G-tube and placed her NPO with allowance of ~60ml ice chips or water per hour. A KUB was negative for obstruction. Her Reglan was increased to 10mg q6 hours. It was difficult to keep her Magnesium and Phosphate repleted and so we started her on Magnesium injections every other day and Neutra-Phos twice daily. At HD69 her sodium was low and her potassium was elevated to 6.3. EKG showed peaked t-waves and cardiac enzymes were negative for acute event. She was monitored closely. She was treated with Insulin/D50 and Lasix. Her tube feeds were changed from impact to Nepro 1/2 strength. Fludorocortisone was restarted. A repeat urine culture showed Citrobacter sensitive to imipenem. Her Bactrim was stopped and imipenem started. At HD 73 she was doing better. Her sodium and potassium had improved and a repeat urine culture showed <10,000 organisms. On [2201-11-6] she was discharged to [Last Name (un) 16844] Acute Rehabilitation in stable condition. Her tube feeds were Nepro 1/2 strength at 65 with 26g Bene protein. Her G-tube remained un clamped and she was taking ~ 60ml/hr PO without problems. She was to have 5 more days of IV Imipenem. She was to follow up with Dr. [Last Name (STitle) 957] in 3 weeks. Medications on Admission: Trazadone Neutraphos Wellbutrin Metclopramide Sodium Bicarbonate Metoprolol Lovenox Levaquin Vancomycin Toradol Zofran Discharge Medications: 1. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 2. Sulfasalazine 500 mg Tablet Sig: Four (4) tablets PO DAILY (Daily): Please crush 2 grams and place in tube feeds daily for total of 2 grams per day. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 4. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day: Please give 8 units at breakfast. 5. Humulin R 100 unit/mL Solution Sig: Per Sliding Scale Injection Per Sliding Scale: Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [2-9] amp D50 61-160 mg/dL 0 Units 161-200 mg/dL 3 Units 201-240 mg/dL 6 Units 241-280 mg/dL 9 Units 281-320 mg/dL 12 Units > 320 mg/dL Notify M.D. . 6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous QD (). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): Lansoprazole Oral Suspension 30 mg J TUBE DAILY . 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Metoclopramide 5 mg/5 mL Solution Sig: Ten (10) ml PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Magnesium Sulfate 50 % (4 mEq/mL) Solution Sig: One (1) gm Injection EVERY OTHER DAY (Every Other Day): 1 gram IM every other day. 14. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q6H (every 6 hours) for 5 days. 15. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for PAIN. 17. Neutra-Phos [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital 16844] Hospital - [Location (un) 1157] Discharge Diagnosis: Crohn's Disease Enterocutaneous Fistulae Colovescicular Fistula Discharge Condition: Stable Discharge Instructions: Please contact or return if you experience: Persistent nausea or vomiting * Fever 101 F or greater * Abdominal pain * Removal or misplacement of tubes * Any other concerns Followup Instructions: Please follow up with Dr. [Last Name (STitle) 957] in [4-11] weeks. Please call for an appointment. The number is ([Telephone/Fax (1) 376]. Completed by:[2201-11-6]	[ "995.92", "781.99", "569.81", "579.3", "276.1", "682.2", "805.2", "275.2", "275.41", "596.1", "401.9", "304.70", "293.0", "038.9", "250.00", "584.9", "V55.2", "555.9", "536.2", "311", "E888.9", "807.2" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "96.6", "00.14", "99.15", "86.04", "46.32" ]	icd9pcs	[ [ [] ] ]	21977, 22060	9025, 19699	273, 280	22167, 22176	1990, 1990	22400, 22584	1376, 1394		19868, 21954	8318, 8350	22081, 22146		19725, 19845			22200, 22375										1409, 1971																														227, 235	8379, 9002															308, 919						2007, 5870												941, 1282	1298, 1360
1,522	109,569	4131	Discharge summary	report	Admission Date: [2103-11-3] Discharge Date: [2103-11-14] Date of Birth: [2054-6-27] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: [Known firstname ] [Known lastname 18074] is a 49 year old gentleman who was transferred from [Hospital6 2561] after being struck by a car. The patient had multiple trauma issues. Earlier that night, prior to be taken to [Hospital6 18075], the patient was seen at [Hospital 8] Hospital, where he signed out against medical advice after being intoxicated. The patient was later struck by a car, mobilized to Mouth [Hospital ] Hospital, where he was stabilized and then transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. Upon arrival to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], the patient was hemodynamically stable, with [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] coma score of 14. He had a left scalp abrasion, a left clavicle fracture, a left tibial plateau fracture, a left superior-inferior pubic rami fracture which was stable, and a right hemopneumothorax. The patient also suffered an iatrogenic right subclavian traumatic central line insertion, which penetrated into his mediastinum at [Hospital6 ]. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Hepatitis B and C. 3. Pancreatitis. 4. Cirrhosis. MEDICATIONS ON ADMISSION: Serazapine, dose not available. ALLERGIES: Penicillin and Bactrim. PHYSICAL EXAMINATION: On physical examination in the Emergency Room, the patient had a pulse of 108, blood pressure 138/74, respiratory rate 12 and oxygen saturation 94% on four liters nasal cannula. His [Location (un) 2611] coma score was 15. Head, eyes, ears, nose and throat: Scalp abrasion, extraocular movements intact, pupils equal, round, and reactive to light and accommodation, oropharynx clear, trachea midline. Chest: Clear breath sounds, although diminished in the right chest, left clavicular ecchymosis with a palpable fracture of the left clavicle. Cardiovascular: Normal S1 and S2. Abdomen: Soft, nontender, nondistended, pelvis stable and nontender. Rectal: No gross blood, guaiac negative with normal prostate. Extremities: Left lower extremity tender and swollen although neither thigh nor calf were tight; bilateral dorsalis pedis and posterior tibialis pulses. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit, where he remained stable. On [2103-11-8], he underwent an open reduction and internal fixation of his left tibial plateau fracture by orthopedic surgery. The patient tolerated the procedure well and was returned to the Surgical Intensive Care Unit, where he continued to do well. Complicating the [Hospital 228] hospital course was that the patient was withdrawing from alcohol and suffering from delirium tremens. He was therefore placed on a CIWA protocol schedule. The patient continued to do well in the Surgical Intensive Care Unit and was transferred to the floor, where he remained stable. The patient was able to tolerate orals without any difficulty. His chest tube was removed without any difficulty. Psychiatry was consulted for suicidal ideation. The was given a sitter, who remained with him at all times. He continued to improve from a surgical standpoint and was ready for discharge on [2103-11-12]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 11889] Dictated By:[Name8 (MD) 18076] MEDQUIST36 D: [2103-11-12] 09:19 T: [2103-11-12] 10:08 JOB#: [Job Number 18077]	[ "511.8", "291.0", "808.2", "823.00", "810.00", "E819.7", "910.0", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "79.36" ]	icd9pcs	[ [ [] ] ]													1538, 1608	2525, 3790																													1631, 2507																													170, 1409																		1432, 1511
76,598	109,206	36284	Discharge summary	report	Admission Date: [2107-5-24] Discharge Date: [2107-5-29] Date of Birth: [2050-4-20] Sex: M Service: ORTHOPAEDICS Allergies: Avandia / Cefoxitin / Humalog / Lantus / Glucophage / Ibuprofen / Neurontin / Tylenol / Glucovance / Glyburide / Levaquin / Keflex / Topamax / Aspirin / Cymbalta / Metformin / Shellfish Derived Attending:[First Name3 (LF) 64] Chief Complaint: Right hip pain / Osteoarthritis Major Surgical or Invasive Procedure: [2107-5-24] Right total hip replacement History of Present Illness: 57M with B/L hip OA, s/p L THA in '[05] now presents for right THA. Past Medical History: htn,OSA,CHF,dyslipid,ischemic heart disease,s/p MI,PVD,DM,reflux,renal insuffic,anemia of chronic disease Social History: smoker,currently [12-25] PPD but formerly as much as 4 PPD. quit etoh in [2091]. Lives alone. Employment:used to work for Stop and Shop Family History: nc Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with baseline neuropathy RLE. Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength TA/GS/[Last Name (un) 938]/FHL * [Last Name (un) ]: neuropathy RLE as per baseline. * Toes warm Pertinent Results: [2107-5-28] 05:40AM BLOOD WBC-10.0 RBC-2.96* Hgb-9.9* Hct-30.1* MCV-102* MCH-33.5* MCHC-32.9 RDW-13.3 Plt Ct-193 [2107-5-27] 05:23AM BLOOD WBC-12.0* RBC-2.94* Hgb-10.1* Hct-30.0* MCV-102* MCH-34.4* MCHC-33.7 RDW-13.6 Plt Ct-164 [2107-5-26] 03:35AM BLOOD WBC-13.1* RBC-3.29* Hgb-11.4* Hct-33.1* MCV-101* MCH-34.6* MCHC-34.4 RDW-13.8 Plt Ct-171 [2107-5-25] 11:04PM BLOOD Hct-32.2* [2107-5-25] 12:15PM BLOOD WBC-14.2* RBC-3.47* Hgb-11.4* Hct-34.6* MCV-100* MCH-32.8* MCHC-32.8 RDW-13.4 Plt Ct-180 [2107-5-25] 04:09AM BLOOD WBC-15.1* RBC-3.92* Hgb-13.2# Hct-39.6 MCV-101* MCH-33.6* MCHC-33.3 RDW-13.7 Plt Ct-238 [2107-5-25] 02:14AM BLOOD Hct-37.9# [2107-5-24] 07:25PM BLOOD WBC-17.5 RBC-4.99 Hgb-16.3 Hct-50.3 MCV-101* MCH-32.7* MCHC-32.5 RDW-13.4 Plt Ct-183 [2107-5-29] 08:30AM BLOOD PT-15.6* INR(PT)-1.4* [2107-5-28] 05:40AM BLOOD Plt Ct-193 [2107-5-28] 05:40AM BLOOD PT-12.8 INR(PT)-1.1 [2107-5-28] 05:40AM BLOOD Glucose-227* UreaN-18 Creat-1.5* Na-135 K-4.6 Cl-99 HCO3-27 AnGap-14 [2107-5-27] 05:23AM BLOOD Glucose-179* UreaN-16 Creat-1.4* Na-133 K-4.6 Cl-101 HCO3-26 AnGap-11 [2107-5-25] 11:04PM BLOOD Glucose-312* UreaN-22* Creat-1.7* Na-133 K-4.6 Cl-101 HCO3-21* AnGap-16 [2107-5-25] 12:15PM BLOOD Glucose-349* UreaN-23* Creat-2.0* Na-129* K-5.2* Cl-100 HCO3-21* AnGap-13 [2107-5-25] 04:09AM BLOOD Glucose-288* UreaN-26* Creat-2.1* Na-134 K-6.2* Cl-103 HCO3-21* AnGap-16 [2107-5-24] 07:25PM BLOOD Glucose-201* UreaN-22* Creat-1.9* Na-137 K-5.2* Cl-105 HCO3-24 AnGap-13 [2107-5-28] 05:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7 [2107-5-27] 05:23AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8 [2107-5-26] 03:35AM BLOOD calTIBC-241* VitB12-355 Folate-GREATER TH Ferritn-250 TRF-185* Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received heparin GTT to PTT>60 then lovenox 120mg [Hospital1 ] for DVT prophylaxis starting on POD 0 until INR >2. medicine service was consulted and aided in overall management. They do recommend PCP to do [Name Initial (PRE) ] OSA w/u after discharge as an outpatient. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. No blood transfusion was required. At the time of discharge the patient was tolerating a regular diabetic diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. His BS were followed by the Diabetic team, [Last Name (un) ], while inhouse and improved throughout his stay though they will need to be followed at rehab closely. The operative extremity was neurovascularly stable and the wound was benign. At time of discharge, patient was deemed stable for safe discharge to rehab. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior hip precautions. Medications on Admission: Allopurinol, atenolol, buproprion, cilostazol, plavix, dilaudid, novolog, levemir, omperazole, lyrica, simvastatin, ASA Discharge Medications: 1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 12. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 20. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid (). 21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 23. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Q MONDAY TO THURSDAY (): Check daily INR. When INR >2, DC lovenox and dose coumadin to INR [1-26]. . 24. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Check daily INR. When INR >2, DC lovenox and dose coumadin to INR [1-26]. . 25. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 27. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 28. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for Pain: Do not drive, operate machinery or instruments while taking this medication. Disp:80 Tablet(s) Refills:0 29. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Q FRIDAY, SATURDAY AND SUNDAY (): Take 4mg po MON-TH Take 7mg po FRI-SUN Your INR will be checked while in rehab and you will need labs drawn once an outpt with f/u of your INR levels by your PCP. [Name10 (NameIs) ] daily INR. . Disp:100 Tablet(s) Refills:1 30. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take 4mg po MON-TH Take 7mg po FRI-SUN Your INR will be checked while in rehab and you will need labs drawn once an outpt with f/u of your INR levels by your PCP. [Name10 (NameIs) ] daily INR. . Disp:100 Tablet(s) Refills:1 31. Insulin Detemir 100 unit/mL Solution Sig: Eighty (80) U Subcutaneous twice a day: Breakfast/bedtime. 32. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous every six (6) hours: SScale inhouse: Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units mg/dL Units Units Units Units . 33. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea/vomiting. 34. Promethazine 25 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital ] Rehabilitation and Nursing Center - [Location (un) 701] Discharge Diagnosis: Right hip osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Your INR will be checked while in rehab and you will need labs drawn once an outpt with f/u of your INR levels by your PCP. [Name10 (NameIs) ] daily INR. When INR >2, DC lovenox and dose coumadin to INR [1-26]. You will then continue coumadin as an outpt with your PCP checking the INR level and dosing it. If you have any questions, please call [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) ]. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE. Posterior hip precautions. Treatments Frequency: 1. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 2. Your INR will be checked while in rehab and you will need labs drawn once an outpt with f/u of your INR levels by your PCP. [Name10 (NameIs) ] daily INR. When INR >2, DC lovenox and dose coumadin to INR [1-26]. Followup Instructions: You will need to follow-up with pulmonary and will likely will need to have sleep study. Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2107-6-24] 11:20 Completed by:[2107-5-29]	[ "272.4", "585.9", "285.21", "276.2", "414.01", "276.52", "403.90", "V45.82", "518.0", "790.01", "584.9", "327.23", "278.01", "428.22", "412", "530.81", "V85.4", "799.02", "414.8", "305.1", "715.35", "443.9", "V12.51", "428.0", "276.7", "250.00" ]	icd9cm	[ [ [] ] ]	[ "81.51" ]	icd9pcs	[ [ [] ] ]	9834, 9936	3318, 5171	488, 534	10005, 10005	1541, 3295	13560, 13881	944, 948		5341, 9811		9957, 9984		5197, 5318			10066, 12138										963, 1522	12920, 12957	12979, 13537																												417, 450														12150, 12902		562, 636										10020, 10042								658, 766	782, 928
6,212	195,604	50506	Discharge summary	report	Admission Date: [2107-11-22] Discharge Date: [2107-12-3] Date of Birth: [2047-11-24] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 59-year-old gentleman had a prior history of myocardial infarction, had recent increasing symptoms of shortness of breath and dyspnea on exertion. Had a positive exercise tolerance test, and echocardiogram which showed some aortic disease. The patient had cardiac catheterization which also showed 90% left anterior descending artery lesion, 100% circumflex blockage, and approximately 80% right coronary artery lesion with an ejection fraction of 40%. The echocardiogram done in [Month (only) ] showed an ejection fraction of 45%, mitral annular calcification, moderate mitral regurgitation which had increased. PAST MEDICAL HISTORY: 1. Status post pituitary adenoma with a transphenoidal surgery. 2. Status post excision of parotid tumor. 3. History of cerebrovascular accident with no neurologic remaining deficits. 4. Status post surgery left thumb. 5. Atrial fibrillation. 6. Insulin dependent diabetes. 7. Hypertension. ALLERGIES: Codeine and Morphine, both of which cause nausea and vomiting. MEDICATIONS PRIOR TO ADMISSION: 1. Atenolol. 2. Lipitor. 3. Lantus insulin 30 units every morning, Humulin regular insulin-sliding scale. 4. Coumadin, which had been discontinued prior to being seen on the [6-1]. Aspirin. 6. Lisinopril. 7. Zocor. PHYSICAL EXAMINATION: On examination, the patient had no jugular venous distention or bruits. He did have a well-healed parotidectomy scar. His lungs were clear bilaterally. His heart was regular, rate, and rhythm. He had a systolic ejection murmur grade [1-19]. Extremities had no clubbing, cyanosis, or edema. Patient had peripheral pulses present. PREOPERATIVE LABORATORIES: White count of 10.1, hematocrit 37.8, PT 13.1, PTT 28.2, INR 1.1, sodium 137, potassium 4.0, chloride 100, CO2 26, BUN 27, creatinine 1.2, and a blood sugar of 151. Chest x-ray was within normal limits. Electrocardiogram showed atrial fibrillation with possible inferior ischemia. The patient had stopped Coumadin and aspirin both two weeks prior to being seen on preadmission testing. On[11-22], the patient underwent coronary artery bypass grafting by Dr. [Last Name (Prefixes) ] as well as a mitral valve repair. Patient had a LIMA to the left anterior descending artery and a vein graft to the PDA as well as a 28 mm [Doctor Last Name 405] ring. The patient was transferred to the Cardiothoracic Intensive Care Unit on milrinone drip at 0.5 mcg/kg/min and a propofol drip at 10 mcg/kg/min in stable condition. On postoperative day one, the patient had received a fair amount of volume for hypotension, and had gone on and off Neo-Synephrine drip. He had a somewhat poor PAO2 with intermittent atrial fibrillation. The patient had been extubated, in the morning was on a Neo-Synephrine drip at 1.75 and a milrinone drip at 0.25, as well as an amiodarone drip at 0.5 and insulin drip. The patient was in atrial fibrillation at the time and a heart rate in the 70s, blood pressure 110/47. Postoperative hematocrit was 27.2 with a temperature max of 99.1. Postoperative laboratories were 139 sodium, potassium 4.7, chloride 111, CO2 22, BUN 31, creatinine 1.1 with a blood sugar of 138. Swan and pacing wires remained in. The patient continued on amiodarone drip. Beta blocker was started and diuresis was begun as tolerated, and diet was advanced. Pulmonary toilet continued, and the patient remained on his drip. On postoperative day two, the patient was given additional Lasix for wheezing, also getting 50 mg of hydrocortisone q8h. The patient was back on milrinone for an increased cardiac index which then rose to 3.3. The patient also had another dose of Lasix overnight for congestive heart failure which showed on his chest x-ray. Continued on a milrinone drip and an amiodarone drip in atrial fibrillation with a heart rate in the 80s. He had coarse breath sounds bilaterally. His heart was regular, rate, and rhythm. Hematocrit stabilized at 27.9. Creatinine rose slightly to 1.2 with a potassium of 5.1. The patient was given Dilaudid for pain. The plan was to continue to wean the milrinone and switch patient over to po amiodarone. Diet was advanced. The patient continued with Lasix, diuresed as patient was seen by case management, and Physical Therapy. Was also screened by the clinical nutrition team. On postoperative day three, the patient continued with additional Lasix and hydrocortisone, remained in atrial fibrillation on both the Neo-Synephrine and milrinone drips, and insulin drip. With plans to anticoagulate the patient, since he remained in atrial fibrillation, the Foley was discontinued. The patient was seen by Cardiology. Patient was given a regimen of amiodarone po with recommendations to increase ACE inhibitor and do additional laboratory work for amiodarone baseline. The patient remained in the Intensive Care Unit on postoperative day four. Milrinone was weaned to off. The Heparin drip was started and amiodarone was continued as the patient was on atrial fibrillation per Cardiology recommendations. Captopril was also given to the patient as he was being anticoagulated. On postoperative day five, Swan was discontinued. Wires were discontinued. Patient was started on Coumadin. Hematocrit remained stable at 25.9. Creatinine dropped to 1.1. Patient continued on po amiodarone as well as Heparinization awaiting therapeutic INR for the atrial fibrillation. Patient continued to work with Physical Therapy and remained in the Intensive Care Unit on postoperative day six. Beta blocker was started at that point. There were no particular issue as the ACE inhibitor and the beta blocker were given time to work with the amiodarone. On postoperative day seven, the patient was transferred to the floor for increase work with Physical Therapy and the nurses for ambulation. There was no issues overnight. The patient continued on Heparin drip. The lungs were clear. Sternal incision was healing nicely and was stable. INR on the 14th was 1.5 with a therapeutic goal in the 2-3 range. The patient remained in chronic atrial fibrillation. The patient continued over the next several days with Coumadinization in an attempt to get his INR within a therapeutic range. It was very slow to climb, and it took two more days for it to climb to 1.6. The patient also continued to be followed by case management. A special hospital bed was ordered for the patient per request. Coumadin dosing was increased to the 7.5 mg range. On the 17th, awaiting INR to arise above 2, the patient continued in atrial fibrillation with occasional PVCs, had a good blood pressure of 148/58, sating 98% on room air. Both sternal and left leg incisions were clean, dry, and intact. The patient received some Dilaudid for pain overnight, and on the 18th, the patient was discharged to home with VNA services with instructions for blood draws at the cardiologist at [Hospital6 31672]. The INR on the morning of the 18th, the day of discharge was 2.1. DISCHARGE DIAGNOSES: 1. Status post mitral valve annuloplasty repair. 2. Coronary artery bypass grafting times two. 3. Status post cerebrovascular accident preoperatively. 4. Chronic atrial fibrillation. 5. Insulin dependent-diabetes mellitus. 6. Coronary artery disease. 7. Status post parotidectomy. 8. Status post pituitary adenoma, transphenoidal surgery. 9. Status post traumatic surgery of the left thumb. 10. Hypertension. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg po bid. 2. Captopril 6.25 mg po tid. 3. Protonix 40 mg po q day. 4. Simvastatin 40 mg po q day. 5. Amiodarone 200 mg po q day. 6. Dilaudid 2-4 mg po q4-6h prn pain. 7. Lasix 40 mg po bid x7 days, then Lasix 40 mg po q day. 8. Coumadin 5 mg and 7.5 mg alternating beginning with 5 mg on the day of discharge, [12-3], then 7.5 mg the following night, etc. The patient was instructed to check the INR with a goal range of 2.3 with VNA service, and call results to Dr. [Last Name (STitle) 41364], the cardiologist on [12-5], Monday. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient was also instructed to followup with Dr. [Last Name (Prefixes) ] at approximately four weeks for his postoperative surgical visit. Again the patient was discharged to home with VNA services on [2107-12-3]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 37991] MEDQUIST36 D: [2108-1-26] 13:44 T: [2108-1-26] 13:53 JOB#: [Job Number 105195]	[ "424.0", "414.01", "412", "250.00", "427.31", "401.9", "272.0", "440.21", "794.31" ]	icd9cm	[ [ [] ] ]	[ "35.33", "89.68", "36.15", "36.11", "39.61" ]	icd9pcs	[ [ [] ] ]								7201, 7611	7634, 8739																														1234, 1454				1477, 7180																													186, 812																		834, 1202
12,733	148,375	6446	Discharge summary	report	Admission Date: [2191-1-5] Discharge Date: [2191-1-9] Date of Birth: [2128-7-16] Sex: M Service: VSU HISTORY OF PRESENT ILLNESS: This is a 62-year-old male with known peripheral vascular disease and diabetes type 2 along with coronary artery disease, congestive heart failure with an ejection fraction of 30% that presented on [2191-1-5], for chronic ischemic changes in his right leg with a right foot ulcer. He had been having this for some time and had increase in difficulty in walking and was only able to ambulate short distances due to pain, especially worse in his right leg and his calf. He had also had this ulcer for several months now that was nonhealing in nature. PHYSICAL EXAMINATION: On admission, the patient was with stable vital signs in no apparent distress. He had no neck bruits. He was in regular rate and rhythm with no murmurs, rubs or gallops. His lungs were clear to auscultation bilaterally. His abdomen was obese and he was nondistended with normoactive bowel sounds, was soft and nontender throughout. His right foot was noted to be cool with a right heel ulcer that appeared slightly necrotic in nature. It did not have any gross pus or significant erythema around it but it had been nonhealing for some time. His signals were faintly dopplerable in the right foot, but he did have good femoral pulses at this time in the bilateral groins. HOSPITAL COURSE: On [2191-1-5], the patient was brought to the operating room on the day of admission and underwent the right iliofemoral endarterectomy with Dacron patch, right common iliac artery stent graft, right external iliac artery stent graft and a right SFA angioplasty x2. The patient tolerated the procedure well and was able to be extubated after the procedure, however, he did require emergent hemodialysis afterwards and was transferred to the surgical intensive care unit. The dialysis was done here because he needed a high level of monitoring during this with a history of congestive heart failure. He remained in the intensive care unit until postoperative day 2 when he was able to receive a floor bed. There, he progressed well and had another round of hemodialysis and was noted to be fit for discharge on [2191-1-9], postoperative day #4. He is stable at this time with plans to follow-up with Dr. [Last Name (STitle) ] and to call to schedule an appointment. He was followed closely by Dr. [First Name (STitle) 805] of nephrology who plans to maintain him on his Monday, Wednesday, Friday dialysis schedule. DISCHARGE DIAGNOSES: 1. Peripheral vascular disease. 2. Coronary artery disease. 3. Congestive heart failure with ejection fraction of 30%. 4. Endstage renal disease. 5. Diabetes mellitus type 2. 6. Hypertension. 7. Melanoma. 8. Prior gastrointestinal bleed secondary to Plavix. 9. History of left below the knee amputation. 10. History of transmetatarsal amputation in [2181], and left AV fistula in the arm. DISCHARGE INSTRUCTIONS: The patient to be discharged to home and to follow-up with Dr. [Last Name (STitle) ] and to call to schedule an to the ER if having worsening pain, fever, chills, groin swelling, nausea, vomiting, chest pain, shortness of breath, with any questions or concerns. DISPOSITION: The patient to be discharged to home. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2191-1-16] 10:36:33 T: [2191-1-16] 12:39:21 Job#: [Job Number 24795]	[ "V10.82", "440.23", "428.0", "403.91", "250.00", "707.14", "585.6" ]	icd9cm	[ [ [] ] ]	[ "38.18", "39.79", "39.50", "39.95", "00.42", "88.48", "99.04" ]	icd9pcs	[ [ [] ] ]								2582, 2989						1430, 2561		3014, 3605																											740, 1412																													163, 717
584	167,135	46594	Discharge summary	report	Admission Date: [2114-10-21] Discharge Date: [2114-10-25] Service: [Hospital Unit Name 196] Allergies: Penicillins Attending:[First Name3 (LF) 2704] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Echo [10-22] Cardiac Cath [10-23] Cardiac Cath [10-24] History of Present Illness: This is a [Age over 90 ] year old woman with a history of diabetes mellitus, coronary artery disease status post coronary artery bypass graft [2109] and PCI in [2110] who presents with exertional angina, doe and pnd with + stress test for cardiac cath. Pt c/o 3-4 weeks of progressive doe and increased sob. Pt previously able to walk and do house work, however now unable to do chores around the house. States no sob at rest, but gets sob with minimal exertion. She was seen by her cardiologist on [10-16], Dr. [First Name8 (NamePattern2) 487] [Known lastname ], who noted angina, shortness of breath, pnd, and orthopnea, worsened since her last visit. She had a stres test on [2114-9-4] showing LV dilation with exertion. Pt direct admit for cardiac catheterization on [10-22]. ROS: Pt also reports that she felt week and feel 2-3 weeks ago. States did not lose conciousness, however, fall not witnessed by anyone. Denies any residual weakness from the fall. Past Medical History: 1. Coronary artery disease status post myocardial infarction in [2109];3VD status post coronary artery bypass graft [3-/2109] with saphenous vein graft to left anterior descending, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal-1 and obtuse marginal-2. Status post PCI to the vein graft with LAD under the care of Dr. [Last Name (STitle) ] in [2110]. Old Q waves inferiorly 2. Diabetes mellitus type 2. 3. Hypertension. 4. Mild AS on Cath in 99 Social History: The patient lives alone in [Hospital3 4634] in [Location (un) 538] with a granddaughter involved. The patient was full code. There is no history of ethanol or tobacco use. Family History: Non Contributory Physical Exam: T A. [Month (only) ], BP 102/67, HR 70, RR 20, O2 sat 94%RA Gen: Pleasant spanish elderly female. able to speak in full sentences, but dyspnic after a sentence HEENT: PERRL, MMM, JVP up to the angle of jaw. no carotid bruits Chest: Crackles upto middle of lung fields bilaterally CVR: nl s1, s2. II/VI early systolic murmor heard best over left upper sternal border. no change with valsalva. no radiation to carotids. Abdomen: Soft, nt, +bs Ext: 1+ Femoral pulses bilaterally. Popliteal/dp/pt pulses non palpable. Right 1st metatarsal-tarsal joint tender. +erythema, no warmth to touch. Neuro: communicative, grossly intact Pertinent Results: Echo: [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated, EF 15%, severe global LV hypokinesis, 2 X 1.2 cm globular thrombus in LV. Cath [2114-10-22] 1) Native vessels. - Severe native three vessel coronary artery disease. The LMCA with no signifiant lesion. - The LAD was diffusely diseased with narrowing to 50% in the proximal vessel and then serial 80-90% lesions in the mid and distal vessel. - The LCX was diffusely diseased with serial 90% lesions in the proximal segment. The LCX supplied a large, bifurcating OM1 that had diffuse luminal irregularities and a focal 80% lesion at the bifurcation. - The RCA was diffusely diseased with an 80% ostial narrowing and serial 90% lesions in the proximal and mid vessel. 2) Grafts - The SVG->LAD had 90% in-stent restenosis in the proximal segment(cypher stent -> no residual stenosis) and an 80% tubular stenosis in the distal graft just prior to the touchdown (cypher stent -> negative 20% residual stenosis) - The SVG->OM was known to be totally occluded. 3) Hemodynamics - mean RA pressure of 13 mmHg and a mean PCWP of 17 mmHg. The cardiac output was severely reduced at 2.5 L/min with an SVR of 2592 dynes-sec/cm5. There was also evidence of pulmonary hypertension with PA pressures of 72/23/40 mmHg and a PVR of 736 dynes-sec/cm5. Left ventricular filling pressures were not obtained due to the patient's known LV clot. Cath [2114-10-23] 1) Coronary arteries -The LAD had severe proximal and midvessel disease with distal competitive filling via the SVG-LAD. LCx as above cath [10-22]. - The RCA was not selectively engaged. - The SVG-LAD had no angiographically apparent, flow-limiting disease. 2) Resting hemodynamics revealed central hypertension with blood pressure 170/82 mmHg. PA systolic pressures were elevated at 39 mmHg. Mean PCWP was 11 mmHg. Cardiac index was 1.9 L/min/m2 by Fick. 3) Successful treatment of LCx with three overlapping Cypher drug-eluting stents after rotational atherectomy. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow. [2114-10-21] 04:30PM BLOOD WBC-7.0 RBC-4.89 Hgb-13.5 Hct-42.0 MCV-86 MCH-27.7 MCHC-32.2 RDW-14.5 Plt Ct-257 [2114-10-21] 04:30PM BLOOD PT-13.9* PTT-22.5 INR(PT)-1.2 [2114-10-21] 04:30PM BLOOD Glucose-124* UreaN-27* Creat-1.4* Na-138 K-5.4* Cl-103 HCO3-22 AnGap-18 [2114-10-22] 09:37PM BLOOD CK(CPK)-27 [2114-10-25] 10:30AM BLOOD CK-MB-NotDone cTropnT-0.09* [2114-10-21] 04:30PM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0 [2114-10-22] 05:35AM BLOOD Triglyc-126 HDL-34 CHOL/HD-3.5 LDLcalc-61 [2114-10-22] 05:35AM BLOOD TSH-2.5 Brief Hospital Course: A/P The pt is an elderly Cuban Woman w pmh of DM, CAD s/p MI and CABG,who presents for coronary angiography due to + stress test and continued symptoms of angina and chf. 1) CAD - Pt with h/o MI, s/p cabg and pci with 3 weeks of doe and sob and +stress test revealing fixed inferior and lateral wall perfusion defects and lv dilation. Pt admitted for cath [2114-10-22]. Pt's Creatinine was 1.5 on admission and pt received mucomyst and bicarb hydration prior to cath on [10-22]. Pt also had an echo done prior to cath, which showed a 2X1 cm thrombus in LV. At cath, LV cavity was not entered. Pt had 2 stents placed in SVG->LAD graft. Pt was transferred to ccu post cath and was taken back to cath on [10-23] and had 3 stents placed in LCx. Pt denied any CP, orthopnea or PND after the procedures. 2) CHF - Pt volume overloaded on exam, elevated jvp and bibasilar crackles. DOE may have been secondary to CAD vs. CHF. Pt was initially diuresed with IV lasix on the floor. Echo [10-22] was remarkable for global hypokinesis and a thrombus in LV cavity. Hemodynamics at cath on [2114-10-22] were PCW 18, PA 62/21, CO (Fick) 2.43 and CI 1.63 at cath and pt transferred to CCU. Pt required milrinone 0.28mcg/kg/min IV infusion and nesiritide 0.01mcg/kg/min. During the cath on [10-22], SVG -> LAD stenosis was opened with 2 cypher stents. On [10-23] she underwent a second cardiac cath where LCx lesions were stented open with 3 cypher stents. Pt was gently diuresed -1L day one and -400 cc day 2 in the ICU. Pt was weaned off milronone and niseritide and was transferred back to floor after 2 days in ccu. Hemodynamics on cath [10-23], PA 45/20, PCW 11, CO 4.7, CI 3.1. Post CCU pt was diuresesed with lasix on the floor. She had some SOB with exertion however denied CP, orthopnea and pnd. 3) CRI - Creatinine on admission 1.5. The renal insuff on presentation may have been a combination of CRI secondary to DM as well as pt being prerenal due to severly depressed CO seen on first PCI. Creatinine 0.9 post cath [10-23], in setting of post cath hydration. Her creatinine was 1.2 on [10-25] which maybe near her baseline creatinine. ACEI was held since pt had received 2 dye loads. She should have Potassium and Creatinine checked on [10-26]. And PCP can restart the ACEI when pt is seen on monday [10-29]. 4) LV thrombus - Pt with a 2X1 cm thrombus on Echo [10-22]. Consideration was given to oral coumadin anticoagulation as outpt, in addition to asa and plavix. After speaking with Dr. [Known lastname ], given pt's age and recent fall 3 weeks ago, plan is to continue to anticoag with asa and plavix and hold off on coumadin. 5) DM - Glipizide was held in patinet and pt was covered with RISS. Her sugars remained in 100-210 range. 6) HTN - Pt was switched over to lopressor 50 po bid (taking atenelol 50 po qd outpt) and ACEI was continued initially. Lisinopril was held post cath since pt had received 2 dye loads in 2 days. PCP can restart on [10-29]. 7) Dispo - Pt was evaluated by Physical Therapy prior to discharge. Medications on Admission: 1. Lisinopril 10 mg p.o. q. day. 2. Glipizide 5 mg p.o. q. day. 3. Atenolol 50 mg p.o. q. day. 4. Pantoprazole sodium 40 mg p.o. q. day. 5. Isosorbide mononitrate 60 mg p.o. q. day. 6. Furosemide 40 mg p.o. q. day. 7. Aspirin 81 mg p.o. q. day. Discharge Medications: 1. Toprol XL 100 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 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: 1. Coronary artery disease a)status post myocardial infarction in [2109]; 3VD status post coronary artery bypass graft [3-/2109] with saphenous vein graft to left anterior descending, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal-1 and obtuse marginal-2. b) Status post PCI to the vein graft with LAD under the care of c) status post PCI X 2 in [10-15]. 2 stents placed in SVG->LAD graft, 3 stents placed in LCX. 2. Diabetes mellitus type 2. 3. Hypertension. 4. CHF 5. CRI (baseline creatinine ~1.2) Discharge Condition: Fair Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 cc Please call your PCP if you have Shortness of Breath. Also if you have chest pain take one sublingual nitroglycerin. If pain is not relieved take another tablet in 5 minutes and call 911. Followup Instructions: Provider: [Name10 (NameIs) 357] follow up with your pcp, [Last Name (NamePattern4) ]. [Last Name (STitle) ],[First Name3 (LF) 8207] M. ([Telephone/Fax (1) 608]) on Monday [2114-10-29] @ 11:30AM. Completed by:[2114-10-25]	[ "250.40", "413.9", "V45.81", "272.0", "414.01", "E879.0", "403.91", "996.72", "428.0" ]	icd9cm	[ [ [] ] ]	[ "36.01", "36.07", "99.04", "88.56", "89.64", "00.13", "37.23" ]	icd9pcs	[ [ [] ] ]	9708, 9763	5486, 8604	261, 329	10367, 10373	2802, 5463	10739, 10990	2104, 2122		8899, 9685		9784, 10346		8630, 8876			10397, 10716										2137, 2783																														202, 223																357, 1362																		1384, 1890	1906, 2088
24,745	189,405	10582	Discharge summary	report	Admission Date: [2138-12-23] Discharge Date: [2139-1-22] Date of Birth: [2081-3-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Right toe gangrene PEA arrest Major Surgical or Invasive Procedure: s/p intubation s/p right internal jugular line s/p femoral vascular study with right SFA stent s/p thoracentesis on [12-25] s/p G-J tube placement under fluoroscopic guidance [1-8] s/p R PICC line placement under fluoroscopic guidance [1-13] s/p repeat PICC line placement under fluoroscopy [1-16] History of Present Illness: Patient is a 57- year-old male patient of Dr. [First Name8 (NamePattern2) 4468] [Last Name (NamePattern1) ] with h/o CAD, CHF, ESRD, DM2, PVD, and right SFA narrowing. Patient was admitted to the [Hospital1 1474] on [12-17] with bilateral LE cellulitis vs. gangrene. Recently fell at home and broke his ribs PTA and hit his head. He is also noted to have a right pleural effusion. Has severe neuropathy at baseline, ambulated with walker. Transferred from OSH for SFA cath/stent with Dr. [First Name (STitle) ] on 4 liters of O2 and sats 90-92%. On arrival patient appeared to be volume overloaded and unable to lie flat for angio procedure so patient went to HD instead of procedure. Per family, pt has been confused and increasingly lethargic over this past week. They were very concerned about his fall at home. After HD and uneventful cath to SMA with stent pt returned to the floor on nasal cannula. At approximately 5am pt was noted to brady down and have PEA arrest. Received treatment and pulses returned once intubated. Past Medical History: CAD ?IMI CHF EF unknown PVD ESRD on HD Tues, Thurs, Sat, DM2 HTN Dyslipidemia s/p broken ribs with recent fall BPH s/p TURP h/o MRSA HD catheter infection '[35] gerd frequent UTIS Prostatitis h/o bradycardic/hypoxic/unresponsive episode at home hypoglycemia s/p intubation and micu stay '[35] Social History: Patient lives with his mother, recently lost wife. Denies etoh or tobacco use. [Name (NI) ] son, [Name (NI) ], is his healthcare proxy. [Name (NI) ] is very involved in the patient's care and is currently making medical decisions for the patient. His contact number is his cell# [Telephone/Fax (1) 34812]. Family History: Non-contributory Physical Exam: T 98.4 Bp 140/60 RR 20 O2Sat 97% 4L Pain [3-9] Wt 182 lbs Ht 5'5" Gen: Patient sitting up in bed, breathing heavily, appears discheveled and slightyl confused but able to answer questions HEENT: PERRL, + conjuctival injections, OP clear, MM dry Neck: No JVD appreciated Chest: Diffuse crackles about [12-2] way up Abd: distended, soft, NT, NABS Extrem: no edema, hyperpigmented skin upto shins b/l; necrotic toes on right foot (all 5 digits) and necrotic toes on left foot. Non-tender to palpation. Neuro: Patient has decreased sensation in his LE b/l Pertinent Results: Admission Labs: [2138-12-23] 11:23AM BLOOD WBC-11.0 RBC-3.14* Hgb-10.4* Hct-30.2* MCV-96 MCH-33.2* MCHC-34.5 RDW-15.1 Plt Ct-276 Neuts-76* Bands-10* Lymphs-4* Monos-5 Eos-4 Baso-0 Atyps-0 Metas-1* Myelos-0 . [2138-12-24] 05:55AM BLOOD PT-32.2* PTT-35.3* INR(PT)-3.4* [2138-12-24] 04:34PM BLOOD PT-40.5* PTT-62.6* INR(PT)-4.6* [2138-12-25] 08:26AM BLOOD PT-19.9* PTT-54.4* INR(PT)-1.9* [2138-12-26] 04:21AM BLOOD PT-15.0* PTT-27.0 INR(PT)-1.4* . [2138-12-24] 09:09AM BLOOD Fibrino-930* [2138-12-23] 11:23AM BLOOD Glucose-160* UreaN-75* Creat-8.7* Na-133 K-6.0* Cl-88* HCO3-25 AnGap-26* [2138-12-23] 11:23AM BLOOD ALT-<4 AST-19 LD(LDH)-199 AlkPhos-252* TotBili-2.6* [2138-12-24] 04:34PM BLOOD ALT-7 AST-183* LD(LDH)-349* CK(CPK)-168 AlkPhos-218* TotBili-2.2* [2138-12-24] 09:09AM BLOOD Lipase-160* . [2138-12-24] 09:09AM BLOOD Cortsol-49.3* [2138-12-24] 05:55AM BLOOD CK(CPK)-132 CK-MB-3 cTropnT-0.18* [2138-12-24] 04:34PM BLOOD CK(CPK)-168 CK-MB-5 cTropnT-0.23* [2138-12-26] 04:21AM BLOOD CK(CPK)-113 CK-MB-2 Pertinent Labs/Studies: . Vanco trough: [2139-1-21] - 16.7 . WBC: 11.0 ->> 23.1 ->> 9.6 . Cardiac Enzymes: ([12-24] - [12-26]) CK: 132 -> 168 -> 116 MB: 3 -> 5 -> 2 T: .18 -> .23 . Pleural Fluid [2138-12-25] Hct Fl: Less than 1 WBC-385* RBC-[2087]* Polys-38* Lymphs-8* Monos-1* Meso-8* Macro-45* Chemistry: TotProt-4.6 Glucose-165 LD(LDH)-242 TotBili-1.5 . *********** Microbiology: ********* Blood cx: [12-24] ; [12-25] ; [12-27] ; [12-28] ; [12-29] ; [1-4] ; [1-10] : all no growth . Urine cx: [12-29] - no growth [1-2] - 10-100K yeast . Stool cx: [12-30] ; [12-31] ; [1-14] ; [1-1] ->> negative for C. Diff x 4 [1-1]: C. Diff toxin B - negative Stool O+P : negative x 3 (performed for eosiniphilia) . Sputum cx: [12-26]: Gram Stain - >25 PMN, <10 Epi 1+ (<1 per 1000X FIELD): BUDDING YEAST. cx: Absent OP flora, sparse growth yeast [12-28]: Gram Stain - > 25PMN, < 10 Epi 1+ (<1 per 1000X FIELD): YEAST(S). cx: Absent OP flora. rare growth yeast . [12-25] Pleural fluid: Gram stain - No PMN, no microorganisms seen cx: No growth . [12-31]: Cryptococcal antigen negative . [12-24]: MRSA screen (nasal) - positive [12-25]: MRSA screen (rectal) - negative . ***** Imaging: ***** . [2138-12-24]: CXR The upper margin of this film is T1 and the lateral aspect of the left lower chest is excluded. A segment of tubing projects over the midline ending at the thoracic inlet. I cannot tell whether this is an ET tube or nasogastric tube. Tip of the right central venous catheter projects over the right brachiocephalic vein but is angled at the tip and may be entering a small branch. Cardiac silhouette is moderately enlarged and a small right pleural effusion is present. Lungs are grossly clear. Stomach is mildly distended with gas. There is no indication of pneumothorax. . [2138-12-24] Head CT: FINDINGS: There is intravascular and dural enhancement. Otherwise, no evidence for intracranial hemorrhage is present. There is no mass effect or shift of normally midline structures. The ventricles, sulci, and cisterns are normal in configuration. The [Doctor Last Name 352]-white matter junction appears distinct. Osseous structures are unremarkable. Fluid levels are present within the sphenoid sinuses that may be secondary to intubation. There is also some mucosal thickening of the ethmoid sinuses. The maxillary sinuses are clear. The mastoid air cells are clear. IMPRESSION: No evidence for intracranial mass effect or gross hemorrhage. MR is more sensitive for the evaluation of acute brain ischemia. . [2138-12-24]: CT Chest FINDINGS: There is no pulmonary embolism to the level of the subsegmental pulmonary arteries. Pre-contrast images demonstrate no dense intramural hematoma in the aorta. There is aortic and coronary artery atherosclerosis. There is a mildly enlarged right hilar lymph node measuring 1.5 x 1.8 cm in diameter. There is no aortic dissection. There is four-chamber cardiomegaly. The interventricular septum is bowed toward the left ventricle indicative of elevated right heart pressures. There is a large right pleural effusion. There is no pericardial effusion. There is no left pleural effusion. Lung windows demonstrate near complete atelectasis of the right lower lobe. The right middle and right upper lobe are well aerated. There is subsegmental atelectasis in the dependent portions of the left lung. The airways are clear. No mass is visualized. The endotracheal tube is above the carina. There is a nasogastric tube present. Images of the upper abdomen demonstrate hepatomegaly and contrast material in the IVC consistent with elevated right heart pressures. The enlarged liver may be secondary to chronic passive venous congestion. There is a nasogastric tube present coursing through the gastric lumen. Its tip is not visualized. Bone windows demonstrate no blastic or lytic lesions. Degenerative changes are present in the spine. IMPRESSION: 1. No pulmonary embolism to the level of subsegmental pulmonary arteries as clinically questioned. 2. Near complete atelectasis of the right lower lobe and associated large right pleural effusion. An underlying pneumonia cannot be excluded. 3. Three-vessel coronary artery disease and markedly elevated right heart pressures as evidenced by bowing of the interventricular septum to the left. The enlarged liver is also likely secondary to chronic passive hepatic congestion. The clinical service was notified of these findings on [2138-12-24]. . [2138-12-26]: X-RAY THREE VIEWS, RIGHT FOOT: There is diffuse osteopenia. Soft tissue defects adjacent to the first distal phalanx. The adjacent cortex is indistinct and osteomyelitis cannot be excluded. There are fractures of the third, fourth, and possibly fifth proximal phalanges without significant callus formation. These are age indeterminant. There are vascular calcifications. THREE VIEWS, LEFT FOOT: There is diffuse osteopenia. There are intraarticular fractures of the first proximal phalanx. Joint spaces are preserved. Vascular calcifications. IMPRESSION: 1. Soft tissue defect and indistinct cortex of right first distal phalanx. Osteomyelitis cannot be excluded. 2. Fractures of the third, fourth and fifth proximal phalynx and left first proximal phalanx, age indeterminant. . [2138-12-26]: Lower extremity arterial non-invasives. REASON: Status post right SFA stent and left popliteal PTA with gangrenous toes. FINDINGS: Pulse volume recordings were obtained of bilateral lower extremity. There is waveform broadening at the level of the thigh bilaterally with absence of the peak dicrotic notch. The amplitude is dampened on the left relative to the right at the thigh. There is some calf augmentation on the right but an absence of calf augmentation on the left. There is some further dampening at the level of the ankle bilaterally and more so at the level of the metatarsals with approximately 7 mm of deflection at the metatarsal level bilaterally. IMPRESSION: Bilateral lower extremity arterial occlusive disease, location is multilevel. These waveforms are improved bilaterally compared to the previous study dated [2138-12-24]. . [2138-12-29]: MR BRAIN W & W/O CONTRAST FINDINGS: Unfortunately, the diffusion-weighted images are nearly uninterpretable and vastly inferior quality compared to the prior study of [12-27]. Therefore, it is quite possible that the small high signal foci seen previously are simply not imaged for technical reasons, as opposed to actual evolution of ischemic pathology to a subacute status. . Using the conventional images, there is negligible alteration in the extent or size of multiple small foci of FLAIR hyperintensity within the white matter of both cerebral hemispheres. Previously, these were characterized as potentially new infarctions. One of the areas of T2 hyperintensity, within the right centrum semiovale appears to exhibit slight contrast enhancement, which can be seen in the setting of subacute infarction, although enhancement can obviously be seen in other disease classes including neoplastic and infectious processes. There is no hydrocephalus or shift of normally midline structures. There is considerable high T2 signal again seen within both mastoid sinus complexes, with fluid levels noted in the sphenoid sinus and minimal mucosal thickening in the maxillary sinus. Presumably, the sinus abnormalities relate to intubation. . [2138-12-29]: CT C/A/P with contrast An endotracheal tube appears in satisfactory position. There is calcification of the aortic arch and descending aorta, as well as coronary artery calcifications. The pulmonary arteries are unremarkable, although this is not a dedicated study. There is a stable 1.5 cm right hilar lymph node. There are no pathologically enlarged axillary or mediastinal lymph nodes. There is cardiomegaly. There is interval reduction in the right pleural effusion, with residual bibasilar atelectasis, right greater than left. At the right base there is consolidation similar to that seen on [2138-12-24] - however, based on imaging infection superimposed on atelectasis is possible. There is no left pleural effusion or pericardial effusion. There are no pulmonary nodules. The areas are patent to the level of the subsegmental bronchi bilaterally. . ABDOMEN WITH CONTRAST: A gastric tube is in place. The liver, spleen, gallbladder, pancreas, and adrenal glands are within normal limits. There is dense calcification of the descending aorta, and at the celiac axis, superior mesenteric artery and inferior mesenteric artery branch points. There is a low attenuation within the upper pole of the left kidney, too small to characterize, likely represents a cyst. There is nonspecific stranding around both kidneys. Within the lower pole of the left kidney is a 2.1 x 1.9 cm mass with [Doctor Last Name ] of 75. There is no free air or free fluid. The large and small bowel are unremarkable. There is no abscess. . PELVIS WITH CONTRAST: The prostate, distal ureters, rectum, sigmoid colon, and bladder are normal. There is no lymphadenopathy or free fluid. Pelvic floor insufficiency. . REFORMATTED IMAGES: There is sclerotic and lytic change with minimal loss of height of the L2 vertebral body. . IMPRESSION: No evidence of abscess or other infectious process within the abdomen or pelvis. Persistent right lower lobe atelectasis - superimposed infection is possible. 68 [Doctor Last Name ] lesion within the left kidney, incompletely characterized on this post-contrast only study (could represent a hyperdense cyst or solid tumor). Consider renal MRI prior to and after contrast injection to characterize. L2 vertebral body sclerotic/lytic lesion, which could represnet Pagets disease. Correlate with any prior imaging. . [2139-1-7]: STUDY: Lower extremity arterial non-invasives. FINDINGS: Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right, Doppler tracings are monophasic at the femoral and popliteal levels only. They are absent below. Thus, there is no ankle brachial index. Pulse volume recordings are somewhat dampened at the low thigh level and approximately 3 mm at the metatarsals. . On the left, Doppler tracings are monophasic at the femoral and popliteal levels only. They are absent below. Thus, there is no ankle brachial index. Pulse volume recordings are dampened at the low thigh level and approximately 2 mm at the metatarsals. Discharge Labs: (last performed on [2139-1-21] after hemodialysis, no labs performed [2139-1-22]) Next hemodialysis due [2139-1-23]. Patient will require random vanco after this HD. Patient is receiving 1gm Vanc for level < 15 after HD. . [2139-1-21*] 05:05AM BLOOD WBC-9.6 RBC-2.89 Hgb-9.9* Hct-28.6* MCV-99* MCH-34.3* MCHC-34.8 RDW-18.7* Plt Ct-193 [2139-1-21] 05:05AM BLOOD Neuts-40* Bands-0 Lymphs-21 Monos-10 Eos-28* Baso-1 Atyps-0 Metas-0 Myelos-0 [2139-1-21] 05:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [2139-1-21] 05:05AM BLOOD Glucose-85 UreaN-22* Creat-6.8# Na-136 K-4.0 Cl-97 HCO3-27 AnGap-16 [2139-1-21] 05:05AM BLOOD Calcium-10.2 Phos-4.3 Mg-2.0 [2139-1-21] 05:02PM BLOOD Vanco-16.7 Brief Hospital Course: Hospital Course by Problem: . # ID: The patient was admitted initially to the hospital for planned SFA stenting of his right SFA. On presentation, the patient was without fever or elevated white count. As outlined in H+P, the patient??????s course was complicated by a PEA arrest. On [12-24] the patient developed a WBC of 16.1. The patient??????s course was further complicated by fever with marked leukocytosis and bandemia (max WBC 23.1). The source was unknown, but presumed to be his gangrenous lower extremities. Other potential sources included urine (a positive urinalysis and urine culture were thought to reflect colonization in hemodialysis-dependent end stage renal disease) and pulmonary. The patient was initially on a very broad medical regimen given mental status changes and early concern for possible meningitis. The patient initially was on a medical regimen including Zosyn, Vanco, Azithromycin, Ampicillin. An LP was attempted x 1 but was not able to be performed as the patient became agitated and was moving frequently during the procedure. The patient??????s antibiotic regimen was eventually tailored down to IV Zosyn and vancomycin, with which he completed a 2 week empiric course with normalization of his leukocytosis and pyrexia. The patient??????s mental status with antibiotics however did not grossly improve rapidly. Although the patient initially defervesced, after discontinuation of antibiotics he again became febrile with leukocytosis. Zosyn and vancomycin were resumed for treatment of presumed lower extremity gangrene source although definite source of infection was never identified. Although the patient continued to have mental status alterations from baseline (see below) a repeat LP was not attempted as the patient had already completed what would be adequate therapy for meningitis and his mental status changes were thought more likely to be related unfortunately to anoxic brain injury. During his hospital course, the patient was also empirically treated with metronidazole for presumed C Difficile infection. This was changed to PO vancomycin for concern of Metronidazole-resistant species. However, all C. Diff toxin studies, including Toxin B studies were negative. Additionally, the patient had in total 13 sets of blood cultures drawn, none of which grew any bacteria. Currently, the plan of care is to continue antibiotic therapy for two to three weeks, treating the patient??????s LE gangrene. The patient??????s HCP would like to take this time to assess the patient with consideration towards the patient??????s mental status (see below). If the decision is made to go ahead with amputation, the patient should continue on antibiotics until the surgery is performed. . #. Neuro: The patient sustained a PEA arrest after superficial femoral artery stent placement. The etiology of his arrest was unclear although possibly secondary to hypoxia. As above, initially there was concern for possible meningitis as the patient was febrile with mental status change. However, despite adequate therapy for infection the patient continued to have mental status change from his baseline. Specifically, the patient is noted to be dysarthric with disorientation. The patient has waxing and [Doctor Last Name 688] mental status with variable orientation and memory. Over the course of the past few weeks however the patient has been thought to be making slow overall improvement. The patient was seen by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from the department of Behavioral Neurology to assess the patient??????s mental status and attempt to provide overall prognosis for recovery. This question is critically important as the decision to continue treatment by the patient??????s HCP weighs heavily upon the extent of expected recovery. The patient??????s HCP reports that he has had extensive conversations with his father who definitely would not want to live indefinitely in a nursing facility without reasonable mental faculties or normal life. At the time of first assessment by Dr. [Last Name (STitle) ], the patient was thought to be too disoriented for behavioral testing. Most concerning for the patient??????s persistent symptoms would be anoxic brain injury from his PEA arrest. However, as discussed with neurology, it is not possible to rule out yet a toxic/metabolic etiology for the patient??????s symptoms. If this were the case it would be expected that over the course of weeks the patient??????s mental status would improve, at which time more formal neurobehavioral testing might be able to better differentiate the extent of the patient??????s deficit as well as his overall prognosis towards neurologic recovery. As detailed in plans of care, currently the plan is to continue antibiotics as a bridge towards transmetatarsal amputation of the right lower extremity which is thought to be the likely source of the patient??????s infection. It the HCP decides in two to three weeks time that he would like to go ahead with surgery, this can be arranged through the staff at [Hospital1 18], for which the HCP has been provided appointments and appropriate phone numbers. An appointment has been made for the patient with Doctor [Hospital1 ] on [2139-2-11] for follow up evaluation towards this goal. . #. Limb Ischemia - Patient has gangrene of his right foot and left toes, secondary to severe peripheral vascular disease. He received a right superficial femoral stent. Arterial ultrasonography with Dopplers were significant for results detailed above. He was maintained on a medical regimen including aspirin, Plavix, and a statin. He also received antibiotics for presumed infection. He was discharged to a skilled nursing facility to complete a course of antibiotics, with plans to return for elective transmetatarsal amputation on the right as per decision of HCP. . #. CAD h/o inferior MI - Myocardial infarction was ruled out as potential source of PEA and also as secondary event related to prolonged cardiac arrest by EKG and serial cardiac enzymes. The patient had known PMH of IMI. EKG at the time of PEA showed q waves in inferior leads, STE in V1, and RBBB. Cardiac enzymes were followed and peaked at CK 168, CKMB 5, and TrT 0.23 on [12-24]. The following day the cardiac enzymes were observed to decrease. Throughout the hospital course, the patient did not have sxs or EKG findings suggestive of ischemia. The patient was continued on his outpatient regimens once vital signs were stabilized: ASA, Plavix, labetalol, captopril for vascular disease. . # ESRD - Mr. [Known lastname 34098] is hemodialysis dependent and came in on a Tu/[Doctor First Name ]/Sat schedule. Because of various procedures, he was changed to q Mon/Wed/Fri schedule and has been tolerating dialysis well. His blood pressure medications are held on the mornings prior to HD in order to prevent hypotension during HD. He is able to receive his blood pressure post-dialysis, without any resultant hypotension. His last hemodialysis session was on [2139-1-21]. His vancomycin levels are checked post-dialysis and the patient receives a dose of vancomycin for levels <15. Renal followed the patient while he was in-house and made recommendations for his nephrocaps, phoslo and tube feeds. . # Diarrhea - Mr. [Known lastname 34098] had persistent diarrhea of unclear etiology during the majority of his hospital stay. There was concern originally for C. diff, but three stool cultures and a C diff toxin B assay were all negative. Despite this, he was treated for C. diff because he had persistent voluminous watery stools, a fever, and a leukocytosis. He was treated with Flagyl (IV) originally, then switched to PO. However, it did not seem to improve his diarrhea and PO vancomycin was started. He improved with PO vanco and completed a 7 day course of treatment. However, after treatment, he did continue to have diarrhea. Again, repeat stool cultures were negative for C. diff. Stool O+P was negative. Banana flakes were added to his tube feeds to bulk his stool and Imodium was used prn to help with his diarrhea. The most likely diagnosis at this point is antibiotic-associated diarrhea and not an infectious etiology. . # GU - In investigation of the patient's persistent spiking fevers, urine cultures and urethral swabs were obtained three times and were considered negative each time. Urethral swab cultures were taken on [2138-12-27], and these cultures grew out mixed flora and coag neg staph. These were both considered to be skin flora contaminants. This was supported when repeat urine culture and legionella antigen screen taken on [12-29] both were negative. Urethral swab on [2139-1-2] grew sparse yeast and did not grow neisseria gonorrhea. Urine culture on [2139-1-2] grew 10,000-100,000 colonies of yeast. These were considered to be organisms colonizing the distal urethra, and therefore no anti-fungal treatment was added to the broad antibiotic regimen. The patient had no sxs of suprapubic pain or blood in urine (sparse [1-1] dialysis) throughout the hospital course. . # CHF - The patient has a history of CHF. Echocardiogram revealed preserved EF with diastolic dysfunction. Throughout the hospital course the patient remained euvolemic with fluid balance maintained with hemodialysis. The patient is without an oxygen requirement. The patient was continued on labetalol and captopril for afterload reduction. These medications were held the mornings of HD given mild hypotension with HD, but given in the afternoon. . # DM2: Patient's blood sugar was well controlled with current regimen of Lantus 10 units qhs with regular insulin sliding scale qACHS. . # Anemia - Patient has a known anemia secondary to chronic disease. The patient's Hct was stable throughout his hospital course, not requiring any blood transfusions except for 1 unit on first day of admission after having stent to SFA placed. The patient had few episodes of guaiac positive stools with some loose black stool after having a GJ tube placed. However, subsequent stools have been guaiac negative. The patient remained hemodynamically stable, with stable Hct, not requiring blood transfusion. . # FEN - Given severity of mental status changes initially the patient was felt unsafe to take PO. After discussion with family and HCP, the decision was made to have a GJ tube placed. The patient has been receiving tube feeds, currently at goal as outlined in discharge orders with supplemental ProMod and banana flakes. The patient was receiving nephrocaps and calcium acetate as recommended by the renal staff given his ESRD. Over the course of his admission, the patient was noted to have slowly improving mental status. The patient had a speech and swallow eval that cleaned him for thin liquids and pureed solids. However, despite this clearance the patient was maintained NPO given concern that he was having aspiration events with eating. As the patient's MS continues to improve this may be changed if desired by HCP. This decision should be made in context of overall goals of care with HCP. . # PPx - * MRSA precautions needed (MRSA screen positive) The patient was maintained on SC heparin, bowel regimen, pain control PRN. He was kept on fall precautions and aspiration precautions. . # Code - The patient is DNR/DNI, discussed with HCP on [2138-1-6] . # Communication - w/ son/HCP [Name (NI) ] cell # [Telephone/Fax (1) 34812] Medications on Admission: Lantus 10 units qhs Plavix 75mg Protonix 40mg daily Ditropan 5mg qam Proscar 5mg qhs Lasix 40mg [Hospital1 ] Lovenox Norvasc 10mg daily MVI Ceftriaxone 2g q24h Gatifloxacin 200mg qd Labetalol 300mg [Hospital1 ] phoslo Zocor TUMS Percocet prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 14. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g Intravenous Q8H (every 8 hours). 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous see instructions: Patient should receive 1 gram IV for random Vanco level < 15 AFTER Hemodialysis. 17. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit Subcutaneous see instructions: Please provide regular insulin sliding scale as detailed in scale provided. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Right toe gangrene PEA arrest Cryptogenic infection, likely secondary to LE gangrene Altered Mental Status s/p PEA arrest . Secondary: CAD with ? previous IMI CHF - preserved systolic function, diastolic dysfunction PVD complicated by gangrene ESRD on HD Tues, Thurs, Sat home (M/W/F home) DM2 HTN Dyslipidemia s/p broken ribs with recent fall BPH s/p TURP h/o MRSA HD catheter infection '[35] Gerd Frequent UTIS Prostatitis h/o bradycardic/hypoxic/unresponsive episode at home hypoglycemia s/p intubation and micu stay '[35] Discharge Condition: Fair. Patient is hemodynamically stable, afebrile, with O2 sats > 93% on room air. Patient has known lower extremity gangrene for which evaluation is ongoing. Patient additionally has known mental status changes after PEA arrest with residual symptoms of dysarthria and disorientation, although these symptoms are slowly improving over the course of weeks. The etiology of the patient's symptoms is thought to be secondary to either toxic/metabolic insult from infected LE gangrene and/or neurologic damage from his PEA arrest. Discharge Instructions: 1. Please take all medications as prescribed . 2. Please keep all outpatient appointments as appropriate. [Name (NI) ] son and HCP is actively involved in medical decision making. If the patient is interested in surgical treatment, it is important that he contact the appropriate staff. HCP may contact Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 7236], Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] ([Telephone/Fax (1) 7236], or any of the CCU housestaff with any questions/concerns or assistance to schedule surgery. . 3. Please return to hospital as appropriate as guided by decisions of HCP Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] of behavioral neurology on Wednesday, [2-11], at 1:30pm. His office is located on the [Hospital Ward Name 516] of [Hospital1 18], in [Hospital Ward Name 860] [Doctor Last Name ], [Location (un) ], [Apartment Address(1) ]. It is in a different location than the regular Neurology department. If you have any questions or need to reschedule, please call his office at [Telephone/Fax (1) 1690]. . 2. Please follow up with Dr. [First Name (STitle) ], a cardiologist and a peripheral vascular disease specialist, on Friday, [2-13] at 9:45am. Please call his office if you have any questions or need to reschedule. His office number is [Telephone/Fax (1) 4022]. . 3. If the decision is made for ongoing care, the patient should have a follow up appointment with his PCP one to two weeks after discharge from the nursing facility. The patient's PCP [Last Name (NamePattern4) ]. [Known firstname ] [Last Name (NamePattern1) 17887] at [Telephone/Fax (1) 3183**].	[ "585.6", "440.24", "427.5", "357.2", "428.30", "V58.67", "605", "V15.88", "787.91", "V54.19", "511.9", "682.6", "250.60", "276.0", "348.1" ]	icd9cm	[ [ [] ] ]	[ "88.48", "00.17", "00.45", "00.41", "39.90", "96.72", "39.95", "46.32", "96.04", "96.6", "99.60", "38.93", "39.50", "34.91", "00.40" ]	icd9pcs	[ [ [] ] ]	29015, 29085	15537, 15537	345, 660	29682, 30212	3032, 3032	30949, 32019	2418, 2436		27355, 28992		29106, 29106		27081, 27332			30236, 30926				14713, 15514						2452, 3013																								4214, 6059						276, 307												15565, 27055				688, 1738				6068, 14697		3048, 4197	29125, 29661											1760, 2062	2078, 2402
68,268	161,755	38227	Discharge summary	report	Admission Date: [2157-5-24] Discharge Date: [2157-6-17] Date of Birth: [2086-12-30] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: unable to give / pt intubated Major Surgical or Invasive Procedure: Craniectomy for evacuation of L SDH TRACHEOSTOMY [2157-6-2] PEG PLACEMENT [2157-6-2] History of Present Illness: Asked to eval this 70 year old white male for acute left sdh. Per the son [Name (NI) 449], who arrived shortly after initial eval, this pt was at work yesterday 6.15.10/ and left early for unknown reasons. The pt did not report for work today and the employer contact[Name (NI) ] the son. Ultimately the pt was found down at home by police. He was brought to an OSH and CT revealed large acute left SDH with MLS approx 1.5cm. Pt recieved dilantin load and was transferred by [Location (un) ] (already intubated). The OSH was contact[Name (NI) ] and reported an INR of 6.2. He recieved VITk, Prophylene 9 and FFP in our ED. Stat head CT revealed the same left SDH with MLS of 1.5 cm. No obvious change in scans for this examiner. No obvious infarct or intraparenchymal bleeding is noted. The left lateral ventricular system is compressed. History obtained from son. Past Medical History: DVT, high cholesterol Social History: lives alone/ widow /employed / Child Psychologist - has two sons Family History: father deceased 90 s/p MI, mother deceased 97/parkinsons. Physical Exam: O: T: BP:140's /70s' HR: 80-90's R overbreathing vent 14-20. 100 O2Sats Gen: WD/WN, No obvious trauma other than left shoulder bruise. HEENT: Pupils: Left 2mm NR, Right 3mm NR / weak left corneal, gaze conjugate / no battles or raccoons sign Neck: In collar Extrem: Warm and well-perfused. Neuro: GCS; 6T E1, M4, V1T....no eye opening to voice or noxious, + grimace, withdraws x 4 / no localization. LE's at times extend. Strong cough, strong gag reflex. ON DISCHARGE Patient expired Pertinent Results: CT HEAD W/O CONTRAST [2157-5-24] 1. ~11-12 mm thick L SDH, similar to prior study, without active extrav 2. 15 mm L -> R midline shift and with effacement of sulci & suprasellar cistern 3. no obstructive hydrocephalus CT HEAD W/O CONTRAST [2157-5-24] Interval left frontal craniectomy and evacuation of large left subdural hematoma with expected post-surgical pneumocephalus. Persistent but improved mass effect. No new hemorrhage or major vascular territory infarction. NOTE ADDED IN ATTENDING REVIEW: There is a geographic hypodense region, measuring roughly 3.4 x 1.7 cm, involving both [Doctor Last Name 352] and white matter of the medial aspect of the left occipital lobe (2:14-16), more evident than on the pre-operative study of some seven hours earlier. Given the clinical context, this likely represents an evolving PCA infarct, due to compression of vessel by central herniation in the region of the tentorial incisura. There is no other evidence of acute infarction. CT HEAD W/O CONTRAST [2157-5-25] 1. Interval decrease in grey-white matter differentiation within the left occipital lobe, likely due to infarction secondary to left PCA compression from transtentorial herniation seen preoperatively. 2. No significant change in the left subdural hematoma since [2157-5-24], with no evidence of new bleed or new mass effect. 3. Stable post-evacuation changes, including mild pneumocephalus and overlying soft tissue swelling. 4. Stable postoperative improvement of rightward subfalcine and downward transtentorial herniation. Slight right tonsillar herniation remains unchanged. \ CT HEAD W/O CONTRAST Study Date of [2157-5-28] 10:29 AM COMPARISON: [2157-5-27]. NON-CONTRAST HEAD CT: The patient is status post left craniectomy for evacuation of underlying subdural hematoma. There is residual thin subdural blood tracking over the left convexity and along the left tentorium, stable compared to one day prior. There is no new intracranial hemorrhage. Mild mass effect upon the left convexity, with mild sulcal effacement and approximately 3 mm rightward shift of midline structures, is similarly stable. Post-surgical changes in the overlying soft tissues are again noted. Hypodensity in the left occipital region is stable, again compatible with evolving left PCA territory infarct. There is no evidence for additional, acute transcortical infarction. Ventricles are stable in size. There is no hydrocephalus. The basal cisterns are preserved. Opacification of the ethmoid air cells, and air-fluid levels within the maxillary and sphenoid sinuses, are again noted, likely related to intubation. Air-fluid levels are also seen in the frontal sinuses. The left mastoid air cells are partially opacified. The right mastoid air cells remain clear. IMPRESSION: 1. Status post left craniectomy for evacuation of subdural hematoma. Small residual left subdural hematoma tracking along the entire left convexity and left tentorium is stable. Midline shift remains minimal (3 mm). 2. Left occipital hypodensity, compatible with evolving left PCA territory infarct, stable. 3. Extensive opacification and fluid levels in the paranasal sinuses, likely related to intubation. MR HEAD W/O CONTRAST Study Date of [2157-6-1] 2:15 PM Final Report STUDY: MRI of the head without contrast. CLINICAL INDICATION: 70-year-old man with left subdural hematoma, status post evacuation, evaluate for infarct, use DWI sequence. COMPARISON: Prior CT of the head dated [2157-5-28]. TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility, and axial diffusion-weighted sequences were obtained. FINDINGS: The patient is status post left craniectomy for evacuation of a subdural hematoma. In comparison with the prior examination, no significant change is demonstrated in the previously noted residual left subdural hematoma, along the entire left convexity and left tentorium, mild decrease in the midline shifting is demonstrated, approximately 2 mm of shifting is noted in the axial projection (5:11). There is no evidence of uncal herniation and the perimesencephalic cisterns are patent (8:16). On the diffusion-weighted sequence, there is no evidence of large areas of ischemia to suggest territorial infarction, there is a curvilinear area of high signal intensity along the left tentorium, likely consistent with residual blood products. The FLAIR sequence demonstrates minimal punctate areas in the subcortical white matter, likely consistent with chronic microvascular ischemic changes. Residual blood products and subdural hematoma is redemonstrated along the left temporal fossa, extending superiorly at the frontal and parietal regions with surgical defect, causing mild trans-galeal herniation of brain parenchyma. Bilateral opacities are demonstrated in the mastoid air cells, frontal sinus, ethmoidal air cells, sphenoid sinus, and both maxillary sinuses with air-fluid levels bilaterally. The flow voids are maintained. The orbits appear unremarkable. IMPRESSION: Status post left craniectomy and evacuation of a previously demonstrated subdural hematoma. There are persistent blood products along the frontoparietal and temporal regions, extending along the left tentorium, no frank evidence of restricted diffusion to suggest large territorial infarction, however, small area of possible restricted diffusion is noted along the medial aspect of the left tentorium, likely related with blood products. Small punctate microvascular ischemic changes are demonstrated in the subcortical and periventricular white matter. Pansinusitis and opacity of the mastoid air cells, with fluid levels in both maxillary sinuses. MR CERVICAL SPINE W/O CONTRAST Study Date of [2157-6-1] 2:15 PM Final Report STUDY: MRI of the cervical spine. CLINICAL INDICATION: A 70-year-old man with history of left subdural hematoma, status post evacuation, rule out ligamentous injury. COMPARISON: Prior CT of the cervical spine dated [2157-5-24]. TECHNIQUE: Sagittal T1, T2, and sagittal STIR sequences were obtained, axial T2 and gradient echo sequences were also performed. FINDINGS: This is a limited examination due to motion artifacts. Again, a subdural hematoma is identified on the left occipital region, extending along the tentorium. The foramen magnum appears patent. There is mild straightening of the cervical lordosis. The signal intensity in the bone marrow is slightly heterogeneous, likely consistent with bone marrow replacement for fat. An area of high signal intensity is noted anteriorly at the C2 vertebral body, likely consistent with a hemangioma versus fat deposit. At this level, there is no evidence of neural foraminal narrowing or spinal canal stenosis. C3/C4 level, demonstrates a posterior central disc bulge, causing anterior thecal sac deformity, there is also mild bilateral uncovertebral hypertrophy, right greater than left, and causing mild right side neural foraminal narrowing (7:14). At C4/C5 level, there is a posterior disc bulge and bilateral uncovertebral hypertrophy, causing anterior thecal sac deformity and bilateral neural foraminal narrowing (7:20, 7:21). At C5/C6, there is a left paracentral osteophytic disc bulge complex formation, causing anterior thecal sac deformity and left side neural foraminal narrowing, apparently impinging the left exiting nerve root (7:25). At C6/C7 level, there is mild posterior disc bulge with no evidence of nerve root compression. The visualized aspect of the upper thoracic spine appears unremarkable. The visualized paravertebral structures are grossly normal. IMPRESSION: Limited study due to motion artifacts. Mild straightening of the normal cervical lordosis. Heterogeneous signal intensity is noted in the bone marrow, likely consistent with bone marrow replacement for fat and a possible hemangioma anteriorly at C2 vertebral body as described above. Multilevel degenerative changes throughout the cervical spine, more significant at C3/C4, C4/C5, and C5/C6 levels. Within the limitations of this examination, no frank evidence of edema, mass, or focal areas of signal abnormality are detected within the cervical spinal cord. BILAT LOWER EXT VEINS Study Date of [2157-6-7] 8:57 AM IMPRESSION: No evidence of DVT. CHEST (PORTABLE AP) Study Date of [2157-6-7] 9:47 AM Final Report HISTORY: Respiratory failure with intracranial bleed. FINDINGS: In comparison with study of [6-4], the right basilar opacification has cleared and the hemidiaphragm is sharply seen. No evidence of acute pneumonia or vascular congestion. Tracheostomy tube remains in place. The PICC line is difficult to visualize, though it may still extend to the mid portion of the SVC. MRA BRAIN W/O CONTRAST [2157-6-15] Acute left cerebellar infarct with hemorrhage and mass effect on the brainstem with obliteration of the fourth ventricle and quadrigeminal cistern. Mild superior and inferior herniation of the cerebellum is identified. Ventriculomegaly with right-sided ventricular drain is identified with ventricular size unchanged from previous CT examination and blood products visualized in the occipital horns. Left-sided craniectomy and fluid within the scalp region are again noted. Fluid is seen in both mastoid air cells, left greater than right side. Brief Hospital Course: 70 y/o M on coumadin for DVT was found down at home, unresponsive. The patient did not show up for work and his colleagues became concerned. They checked his home where he was found down for what was thought to be approximately 24 hours. He was taken to an OSH where head CT showed a large L SDH with significant midline shift. Patient also had an INR of 6.2. He was transferred to [Hospital1 18] ED where he was given FFP, vitamin K and profiline-9 to reverse his INR. He was also taken emergently to the OR for a Left craniectomy to evacuate the SDH and decompress his brain. There were no intraoperative complications, a subgaleal drain was placed. Post operatively head CT showed slight improvement in midline shift and stable post operative changes. His exam initially demonstrated no eye opening but he w/d with B/L UE and was spontaneous with BLE's. There was decreased movement on the R side. Patient was not following commands. On [5-25], patient's exam improved to brisk localization with with LUE and weak attempt to localize with RUE. He was able to follow simple commands by wiggling toes bilaterally and w/d BLE to noxious stimuli. No eye opening, but patient grimised to noxious stimuli. His dressing and subgaleal drain were removed on [5-26]. Patient's exam continues to improve. He was also extubated but needed to have a nasal trumpet to help respiratory status. On [5-27], patient's exam was declining, patient was reintubated for respiratory needs and his repeat head CT showed improvement of midline shift. He developed sinusitis and his NGT was moved to OGT. He was started on Zithromax. He was eventually trach'd and peg'd. Cerebral MRI was obtained to assure that there was no underlying infarct - the MRI was negative for infarct. MRI of the cervical spine was obtained to rule out ligamentous injury - his cervical collar was then discontinued. He steadily improved and was transfered to the SDU - on his first day in the step down he had excessive coughing requiring sucitoning. The coughing was persistent. Anesthesia and the surgical team were asked to evaluated even though there were no periods of desaturation. He was mini-bronch'd at the bedside and it was determined that he had severe tracheal - bronchiomalacia. He was transfered back to the ICU and placed on the vent for peep and pressure support. He was much more comfortable on these settings. He was seen by interventional pulmonary for possible stent. He was formally bronched at the bedside to confirm the tracheal-bronchiomalacia. His exam wax's and wanes but is steadily improving. Routine CT and EEG were obtanied on [2157-6-8]. on [6-9] his drain stitch was removed and was still requiring ventilatory support. he was planned for possible stenting after the holiday weekend. Patient's neurological status remained stable and a routine follow up head CT was obtained on [6-14] which revealed cerebellar infarct compared to previous scan. On [6-15] upon examination the patient was not responsive and taken for an emergent Head CT which revealed hemorrhagic conversion of cerebellar infarction and obstructive hydrocephalus. An emergent EVD was placed and repeat Head CT confirmed adequate positioning and lack of further hemorrhage. The patients exam did not immediately improve therefore stroke neurology was consulted and an MRI was requested. The pulmonary team has decided that tracheal stenting is a greater risk than benefit. On [6-17], patient was made CMO and expired while in SICU. Medications on Admission: coumadin - dose unknown Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: left subdural hematoma respiratory failure left hemicraniectomy ventilator aquired pneumonia post operative fever drug reaction / vancomycin tracheo- bronchiomalacia acute sinusitis dysphagia Discharge Condition: Expired Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Expired Completed by:[2157-6-17]	[ "V58.61", "780.62", "997.31", "V12.51", "V66.7", "518.81", "331.4", "787.29", "461.9", "434.91", "263.9", "E930.8", "432.1", "519.19" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.72", "38.93", "02.39", "01.31", "43.11", "96.6", "33.22", "96.71", "33.21", "31.1" ]	icd9pcs	[ [ [] ] ]	15127, 15136	11473, 15023	348, 443	15372, 15382	2112, 3835	17315, 17354	1510, 1569		15098, 15104		15157, 15351		15049, 15075			15406, 17292										1584, 2093																														279, 310																471, 1366				3844, 11450														1388, 1411	1427, 1494
22,862	108,676	49655	Discharge summary	report	Admission Date: [2178-8-7] Discharge Date: [2178-8-11] Date of Birth: [2127-6-24] Sex: M Service: MEDICINE Allergies: Keflex / Vioxx / Codeine Attending:[Last Name (NamePattern1) 9662] Chief Complaint: LE edema and dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 51M with T2DM, unclear diastolic CHF, HTN and chronic pain on narcotics who presents with worsening LE edema and SOB at rehab. The patient states that over the past week, he has been having more LE edema and shortness of breath. Prior to 1 week ago, he was on Lasix 120mg qAM and 80mg qPM and was still c/o worsening LE edema and weight gain. He states that he has gained 19 pounds in the past 3 days. He was switched to torsemide 80mg [Hospital1 ] 7 days ago by his PCP [Name Initial (PRE) ] 3 days ago was admitted to [Hospital 4310] rehab for diuresis and because of falls at home. He states he has been falling more because of his LE edema and neuropathy in his feet, he denies lightheadedness or dizziness prior to the falls. During this time, he also endorses worsening DOE, although he denies orthopnea or PND (however, he states that he doesn't lay flat because of his size and not his breathing). States he is able to walk [3-13] blocks before feeling SOB now, previously not limited by his breathing. He has a chronic dry cough from his smoking but denies any change in his cough or productive coughing. He also reports having a fever to 103F at rehab, however speaking to his rehab they report no documented fevers. He denies chills or subjective fevers. He also states that he has been urinating much less than usual lately and that his urine has appeared darker in color. This change has been over the past few days. Denies dizziness when standing or lightheadedness. Prior notes mention that his dry weight is 385 lbs, he is currently 444 lbs in the ED. In the ED, initial VS were: 98.2 82 74/50 24 91% RA. He was initially placed on BiPAP 5/5 for hypoxia and was able to be weaned to a facemask. He was not able to tolerate nasal cannula as he was desatting to the mid 80s at rest. Labs were notable for a Cr of 4.0 (baseline l-1.5), BUN of 63, WBC of 13 and proBNP of 100. He was given levofloxacin 750mg IV and 500cc NS. He triggered for hypotension to 70/50s, however this was likely [3-12] using an inappropriately small BP cuff, SBP in 90-100s on repeat with large cuff. On arrival to the MICU, he is satting high 90s on 50% Venturi mask and complaining of only mild SOB at rest. Reports pain over his buttocks from lying on his back in the ED this evening and chronic pain in his shoulders and knees which is similar to his usual pain. Review of systems: (+) Per HPI (-) Denies chills, night sweats. Denies headache, sinus tenderness, rhinorrhea. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Restrictive lung disease. 2. LVH but no known history of systolic CHF, on lasix for venous insufficiency. 3. DM, type II, poorly controlled. Last A1c:12.9 on [2176-3-8]. 4. Morbid Obesity: undergoing screening for gastric bypass surgery. 5. Depression/Anxiety. 6. History of Alcoholism and polysubstance abuse: reports being sober now. 7. History of PUD: seen on EGD [1-16]. + for H. pylori, s/p treatment. Repeat EGD [2-/2176] normal. 8. History of rectal fissures, on stool softeners. 9. Status post multiple orthopedic procdures, most recently left shoulder arthroscopic biceps tenotomy, subacromial decompression, and open biceps tenodesis on [2176-5-16]. 10. History of pyelonephritis. 11. History of cellulitis. 12. Status post 6 abdominal hernia repairs with mesh. Social History: Lives alone at home prior to going to [Hospital 4310] rehab 3 days ago. He is retired. - Tobacco: 1ppd for 35 years - Alcohol: None - Illicits: None Family History: -Father - CAD and CABG -Mother - healthy Physical Exam: Admit exam: Vitals: T: 97.9 BP:97/70 P: 84 R: 18 O2: 96% on 50% venti mask General: Morbidly obese gentleman, awake but sleepy, speaking in full sentences, uncomfortable from pain HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, unable to assess JVP 2/2 habitus CV: Distant heart sounds, RRR, no m/r/g appreciated Lungs: Quiet breath sounds, scattered exp wheezing more prominent at the bases Abdomen: obese with mupltiple well-healed incisions, quiet BS, mild TTP in RLQ, soft. GU: no foley Ext: 3+ edema and mild erythema of the calves bilaterally. PT/DP pulses dopplerable bilaterally. Sensation grossly intact to touch in the feet. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Skin: multiple telangectasias on chest and back Discharge Exam: VS:T 97.7 BP 99/57 P 80 RR16 O295 RA General: Morbidly obese gentleman, speaking in full sentences, sitting in chair HEENT: Sclera anicteric, MMM, oropharynx clear Neck: difficult to assess JVD given body habitus, no cervical LAD CV: Distant heart sounds, RRR, no murmurs appreciated Lungs: Quiet breath sounds Abdomen: obese with mupltiple well-healed incisions, mildly hypoactive BS, soft, NT Ext: calves bandaged tightly, 4+ edema of feet bilaterally. Neuro: grossly normal sensation, A+Ox3 Pertinent Results: [2178-8-7] 11:10PM TYPE-ART TEMP-36.7 PO2-101 PCO2-55* PH-7.29* TOTAL CO2-28 BASE XS-0 VENT-SPONTANEOU [2178-8-7] 11:10PM TYPE-ART TEMP-36.7 PO2-101 PCO2-55* PH-7.29* TOTAL CO2-28 BASE XS-0 VENT-SPONTANEOU [2178-8-7] 11:10PM HGB-12.2* calcHCT-37 [2178-8-7] 11:10PM freeCa-1.10* [2178-8-7] 06:38PM VoidSpec-SPECIMEN C [2178-8-7] 04:15PM GLUCOSE-112* UREA N-63* CREAT-4.0# SODIUM-138 POTASSIUM-4.6 CHLORIDE-95 TOTAL CO2-25 ANION GAP-23* [2178-8-7] 04:15PM estGFR-Using this [2178-8-7] 04:15PM CK(CPK)-580* [2178-8-7] 04:15PM cTropnT-0.02* [2178-8-7] 04:15PM CK-MB-6 proBNP-107 [2178-8-7] 04:15PM WBC-13.2* RBC-4.22* HGB-12.9* HCT-39.2* MCV-93 MCH-30.4 MCHC-32.8 RDW-15.6* [2178-8-7] 04:15PM NEUTS-82.3* LYMPHS-13.1* MONOS-3.5 EOS-0.7 BASOS-0.5 [2178-8-7] 04:15PM PLT COUNT-301 DISCHAREGE LABS: [2178-8-11] 06:35AM BLOOD WBC-7.1 RBC-3.59* Hgb-11.0* Hct-33.3* MCV-93 MCH-30.5 MCHC-33.0 RDW-15.4 Plt Ct-243 [2178-8-11] 06:35AM BLOOD Glucose-193* UreaN-71* Creat-1.4* Na-131* K-4.3 Cl-93* HCO3-29 AnGap-13 [2178-8-11] 06:35AM BLOOD CK(CPK)-3208* MICROBIOLOGY: URINE CULTURE (Final [2178-8-9]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [2178-8-7] 4:15 pm BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: 51M with morbid obesity, T2DM, HTN, chronic venous stasis and unclear history of heart failure who p/w worsening LE edema, weight gain and shortness of breath and found to have [Last Name (un) ]. #Dyspnea - Patient was found to have elevated WBC and RLL opacity concerning for pneumonia. He was treated with levofloxacin and CTX. He initially required supplemental oxygen and Bipap, but was quickly weaned to room air and called out of the MICU. He was ruled out for an MI. TTE showed Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mildly dilated aortic root and ascending aorta (EF 60-70%). Patient was not dyspneic on the floor, and did not require supplemental O2. He finished a 5 day course of levofloxacin for possible CAP. His dyspnea is thought to be secondary to Obesity Hypoventilation syndrome. #[Last Name (un) ]/Rhabdomyolysis: unclear etiology of rhabdomyolysis. [Last Name (un) ] and CK elevation continued to trend down slowly. At discharge his Cr was 1..4 and his CK was 3208. Possible etiology of CK elevation include medication, overdiuresis, and lying in one position for may hours at rehab. #Agitation/elopement: patient left floor 3 times during admission after becoming agitated and demanding a cigarette. Patient was disconnected from tele and was allowed to go outside, however he was informed of the risk of leaving the floor. #T2DM - Laxt A1c was 10.4% in [6-/2178] suggesting poor control. He required significant amounts of sliding scale, so his Lantus was increased to 90units [Hospital1 ] #OSA - Known OSA prior to admission, doesn't wear CPAP as he states he cannot tolerate mask. #Depression/anxiety - Continue home Ativan/Prozac TRANSITIONAL-please re-check serum chemistry and CK level in [3-13] days. Please follow up with PCP after discharge from rehab facility. Patient should probably be re-challenged with statin at some point (though could try lipitor or crestor). Also may not need potassium supplementation (as he was receiving previously) as his diuretics were held on discharge. Follow-up with pulmonary for a sleep study. Encourage diet, exercise, weight loss, and smoking cessation. Consider [Last Name (un) ] consult for help with insulin titration given that patient is requiring high doses. Medications on Admission: -Advair 100-50 1 inhalation [Hospital1 ] -Amlodipine 10mg daily -Ammonium lactate 12% cream [Hospital1 ] to affected area -Ferrous sulfate 325mg daily -Fleet enema PRN -Gabapentin 1200mg q8h -Lidoderm patch daily -Lisinopril 40mg daily -Metformin 1000mg [Hospital1 ] -Metolazone 5mg [Hospital1 ] prior to torsemide -Metoprolol succinate 125mg daily -Nicotine patch 21mg/24h -Omeprazole 20mg daily -KCl 20mEq daily -Simvastatin 20mg daily -Torsemide 80mg [Hospital1 ] -Lorazepam 1mg tid:PRN anxiety -Fluoxetine 40mg daily -Trazodone 50mg [Hospital1 ] -Lantus 70mg SC bid -Humalog sliding scale (55-95 units with meals) Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. Fluoxetine 40 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 4. Gabapentin 600 mg PO Q8H 5. Glargine 90 Units Breakfast Glargine 90 Units Bedtime Insulin SC Sliding Scale using HUM InsulinMax Dose Override Reason: Severe insulin resistance 6. Lidocaine 5% Patch 1 PTCH TD DAILY 7. Lorazepam 1 mg PO Q8H:PRN anxiety 8. Nicotine Patch 21 mg TD DAILY 9. Omeprazole 20 mg PO DAILY 10. traZODONE 50 mg PO HS:PRN insomnia 11. Hydrocodone-Acetaminophen (5mg-500mg [2-9] TAB PO Q8H:PRN pain Hold for sedation or RR<10 12. Methadone 5 mg PO QPM Hold for sedation or RR<12 13. Methadone 10 mg PO QAM Hold for sedation or RR<10 14. Fleet Enema 1 Enema PR DAILY:PRN constipation 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > Discharge Disposition: Extended Care Facility: [Location (un) 4310] Care and Rehabilitation Center - [Location (un) 4310] Discharge Diagnosis: Primary: acute kidney injury, rhabdomyolysis Secondary: pneumonia, obesity hypoventilation syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure to take care of you at [Hospital1 18]. You were treated for shortness of breath and kidney injury. You were given antibiotics for pneumonia, and fluid to improve your kidney function. Your kidney function improved significantly during your time here. Your blood pressure medications, water pills, and cholesterol medications were stopped because of your blood pressur being low. Your methadone and gabapentin doses were decreased because of your kidney function.Please follow up with your primary care physician [Last Name (NamePattern4) ] 3 days to re-dose your medications. Followup Instructions: Please follow up with your rehab facility primary care provider [Last Name (NamePattern4) ] 3 days to re-dose your medications and follow up with your kidney labs (CHEMISTRY, CK) Department: [Hospital3 249] When: TUESDAY [2178-9-1] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10477], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PSYCHIATRY When: TUESDAY [2178-9-1] at 5:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 1387] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 551] Campus: EAST Best Parking: Main Garage Completed by:[2178-8-11]	[ "459.81", "584.9", "300.01", "401.9", "V11.3", "V15.88", "V12.71", "V58.67", "278.03", "250.02", "305.1", "728.88", "486", "278.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10850, 10959	6931, 9275	313, 319	11104, 11104	5537, 6872	11951, 12840	4151, 4194		9968, 10827		10980, 11083		9301, 9945			11287, 11928										4209, 5006							5022, 5518									6908, 6908							2745, 3144							253, 275																347, 2726										11119, 11263								3166, 3961	3977, 4135
672	119,707	5788	Discharge summary	report	Admission Date: [2199-4-23] Discharge Date: [2199-4-25] Date of Birth: [2152-10-21] Sex: M Service: MEDICINE Allergies: Vasotec Attending:[First Name3 (LF) 338] Chief Complaint: nausea and vomitting Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 46yoM with pmh sig for IDDM diagnosed at age 8, complicated by CAD, neuropathy, nephropathy, presenting with 2 days of nausea, vomitting, and weakness, with elevated fingerstick blood glucose readings at home. Pt states that 3 days prior to presentation he went out with friends and had three beers and "greasy" bar food. He normally has only one to two drinks per year. The following morning he began vomitting, had a fsbg in the 200s. Over the course of the day he vomitted approximately 20+ times. He never had diarrhea. He did have abdominal and chest diffuse "soreness" which worsening with retching during vomitting. He adjusted his insulin boluses per his insulin pump over the course of the day, but did not change the basal rate. Pt had a MI in the past and states that the soreness he feels today is nothing like the pain he felt at that time. . In the ED FSBG 415, labs pertinent for anion gap acidosis. He was given 2L NS and started on insulin drip, given ASA 325 mg po, and Zofran for nausea. . ROS: No dysuria/sob/cough/rhinorrhea/sinus tenderness/fever/chills Past Medical History: PAST MEDICAL HISTORY: 1. Type 1 diabetes - diagnosed age 8, followed by Dr. [Last Name (STitle) 10088] at the [Hospital ] Clinic - on an insulin pump - history of neuropathy, nephropathy, and retinopathy, status post multiple laser surgeries - last hospitalized for DKA approximately five years ago. - hemoglobin A1c was 7.6 in [2198-11-7] 2. Coronary artery disease, followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] - inferior myocardial infection in [2183] and status post CABG in [2184]. Last catheterization in [2190] with patent grafts. Last stress in [2198-11-7] showing moderate-to-severe inferior fixed wall motion abnormalities and an EF in 35%-40% range. 3. Hyperlipidemia - managed on Zocor. 4. Hypertension, currently managed on Cardizem, Cozaar, and metoprolol. 5. Chronic renal failure secondary to diabetic nephropathy 6. History of NSVT. 7. History of hematuria with normal renal ultrasound in [2191-11-7] per OMR. 8. History of seizures secondary to hypoglycemia. 9. History of gastroparesis. 10. History of left shoulder pain, diabetic cheiroarthropathy. Social History: H/o tobacco with a 30-pack-year history reformed for 15 years. Notes very rare alcohol use. Denies any drug use. Rarely exercises. He is married and wife [Name (NI) 2048] is HCP. On disability. Family History: Father with CABG in his 70s, Mother with type 2 diabetes. Physical Exam: PE: 98.4 103 162/72 16 100RA NAD Skin warm No carotid bruits No JVD Tachy, RRR nl s1s2, no mrg Lungs clear Abd soft nt nd nabs Ext wwp, No CCE Neuro AAOx3, CN 2-12 intact, strength 5/5 throughout, reflexed 2+ throughout Pertinent Results: CXR: no acute cardiopulmonary process . EKG: Sinus tachycardia, nl intervals, downsloping T wave inversions I/avL. V4-V6. . [2199-4-23] 09:10AM WBC-23.3# RBC-5.07 HGB-15.1 HCT-45.7 MCV-90 MCH-29.9 MCHC-33.2 RDW-15.0 [2199-4-23] 09:10AM ACETONE-MODERATE [2199-4-23] 02:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2199-4-23] 09:10AM GLUCOSE-351 UREA N-41* CREAT-2.3* SODIUM-130* POTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-22 ANION GAP-25 Brief Hospital Course: Pt presented in diabetic ketoacidosis with an anion gap. He was given IV fluids and insulin drip. His anion gap resolved and his FSBG's fell to goal quickly. He proved to be sensitive to Insulin drip and was hypoglycemic several times with lowest FSBG in the 30s. He had very difficult to control nausea with dy heaving. This was controlled best by compazine, and neither Zofran or Anzemet worked for him. He does have a h/o gastroparesis and plan was to try Reglan if he continued to have difficulty taking po's but he never required this. After 36 hours he was able to take po's and his insulin pump was restarted with a insulin drip bridge. He was discharged with no changes in his insulin basal rate. As for the cause of his DKA, work up for infectious cause was negative and cariac enzymes were cycled to rule out MI given his CAD history. Discharge Medications: 1. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours for 5 days. Disp:40 Tablet(s) Refills:0 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Insulin Pump Restart as per priot basal rate and boluses. Discharge Disposition: Home Discharge Diagnosis: DKA DM CAD Discharge Condition: stable Discharge Instructions: Please call your PCP with abdominal pain, nausea, vomitting, persistently elevated finger stick blood glucose. Followup Instructions: Follow up with your PCP or diabetes doctor within one week. Completed by:[2199-4-25]	[ "362.01", "250.13", "401.9", "583.81", "357.2", "272.4", "V45.81", "250.43", "585.9", "250.63", "414.00", "412", "250.53", "V58.67" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5064, 5070	3694, 4549	289, 296	5125, 5134	3147, 3671	5293, 5384	2828, 2888		4572, 5041		5091, 5104					5158, 5270										2903, 3128																														229, 251																324, 1418																		1462, 2593	2609, 2812
29,422	188,780	34784	Discharge summary	report	Admission Date: [2176-7-1] Discharge Date: [2176-7-8] Date of Birth: [2123-11-5] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2176-7-3] Coronary Artery Bypass Grafting x 4 (LIMA to LAD, SVG to RAMUS, SVG to OM, SVG to PDA) History of Present Illness: 52 yo male with history of [2-17] years of chest burning with radiation to throat after a heavy meal. Additional radiation noted to left arm in the past few years. No history of rest pain. Referred ultimately for cath which revealed severe three vessel coronary artery disease. Transferred to the [Hospital1 18] for surgical revascularization. Past Medical History: Coronary Artery Disease Active Smoker Hemorrhoids Vasectomy Inguinal Hernia Repair Axillary Lymph Node Biopsy Social History: Active smoker, admits to 35 pack year history. Denies ETOH over the last 19 years. He is married, lives with his wife. Family History: No premature coronary artery disease. Physical Exam: Vitals: 147/74, 45, 16 General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI. Poor denitition Neck: Supple, no JVD. No carotid bruits noted Lungs: CTA bilaterally Heart: Regular rate and rhythm, bradycardic, normal s1s2, no murmur or rub Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally. No femoral bruits noted. Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [2176-7-1] 03:34PM BLOOD WBC-5.5 RBC-3.99* Hgb-10.7* Hct-33.3* MCV-83 MCH-26.8* MCHC-32.1 RDW-15.4 Plt Ct-209 [2176-7-1] 03:34PM BLOOD PT-13.9* PTT-41.5* INR(PT)-1.2* [2176-7-1] 03:34PM BLOOD Glucose-100 UreaN-8 Creat-0.9 Na-139 K-3.8 Cl-107 HCO3-24 AnGap-12 [2176-7-1] 03:34PM BLOOD ALT-20 AST-18 LD(LDH)-151 AlkPhos-73 Amylase-39 TotBili-0.2 [2176-7-1] 03:34PM BLOOD CK-MB-3 cTropnT-0.03* [2176-7-1] 03:34PM BLOOD %HbA1c-6.0* [2176-7-1] 03:34PM BLOOD Albumin-3.9 Calcium-8.7 Mg-1.9 [2176-7-2] ECHO: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis and apical akinesis/hypokinesis. No definite apical thrombus seen but cannot exclude. 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 structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2176-7-8] 05:40AM BLOOD Hct-23.7* [2176-7-7] 07:30AM BLOOD WBC-6.5 RBC-2.85* Hgb-8.0* Hct-23.5* MCV-83 MCH-27.9 MCHC-33.8 RDW-16.7* Plt Ct-239 [2176-7-5] 05:05PM BLOOD WBC-7.6 RBC-3.01* Hgb-8.4* Hct-24.7* MCV-82 MCH-28.1 MCHC-34.2 RDW-16.3* Plt Ct-206 [2176-7-5] 02:48AM BLOOD WBC-8.3 RBC-2.99* Hgb-8.2* Hct-24.8* MCV-83 MCH-27.6 MCHC-33.2 RDW-15.3 Plt Ct-175 [2176-7-7] 07:30AM BLOOD Glucose-108* UreaN-11 Creat-0.9 Na-134 K-3.8 Cl-98 HCO3-30 AnGap-10 [2176-7-5] 05:05PM BLOOD Glucose-124* UreaN-12 Creat-1.0 Na-133 K-3.5 Cl-97 HCO3-30 AnGap-10 [2176-7-5] 02:48AM BLOOD Glucose-118* UreaN-12 Creat-1.0 Na-135 K-4.0 Cl-101 HCO3-27 AnGap-11 [2176-7-7] 07:30AM BLOOD Mg-2.1 [2176-7-7] Chest x-ray: Mild-to-moderate cardiomegaly has improved. There is no pneumothorax. There are low lung volumes. Bibasilar atelectasis are worse in the left side. Small bilateral left greater than right pleural effusions are stable. There is no overt CHF. Improved mediastinal widening. Sternal wires are aligned. Brief Hospital Course: Patient was admitted under cardiac surgery and underwent routine preoperative evaluation. Preoperative echocardiogram was notable for LVEF of 50-55%. Despite bradycardia, he was maintained on low dose beta blockade. Given his hypertension, he was maintained on intravenous Nitro. He remained pain free. Prior to surgical revascularization, he underwent EGD given his history of anemia and melanotic stools. EGD was notable for normal esophagus with some erythema/congestion within the distal stomach and duodenum. He was subsequently placed on [Hospital1 ] proton pump inhibitors, and cleared for surgery. On [7-3], Dr. [Last Name (STitle) ] performed coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. His CVICU course was uneventful and he transferred to the SDU on postoperative day two. He remained bradycardic but continued to tolerate low dose beta blockade. He maintained a normal sinus rhythm. Serial hematocrits were monitored and remained stable. Over several days, he continued to make clinical improvments with diuresis and was medically cleared for discharge to home on postoperative day five. Medications on Admission: Lovenox 100 [Hospital1 ], Lopressor 12.5 qid, Protonix 40 [Hospital1 ], Plavix, Aspirin 81 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months: or until not taking narcotic pain meds. 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:1 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Take for 7 days then discontinue. Please take with KCL. Disp:7 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days: Please take with Lasix. Stop after 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease - s/p CABG Hemorrhoids Anemia Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month call for fever greater than 100.5, redness or drainage shower daily, and pat incisions dry Followup Instructions: see Dr. [Last Name (STitle) ] in [11-15] weeks see Dr. [First Name (STitle) 1075] in [12-17] weeks see Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2176-7-8]	[ "530.81", "535.60", "796.2", "562.10", "305.1", "427.89", "411.1", "414.01", "280.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "45.23", "36.13", "45.13", "39.61" ]	icd9pcs	[ [ [] ] ]	7121, 7170	4066, 5406	330, 434	7268, 7275	1626, 4043	7532, 7750	1100, 1139		5558, 7098		7191, 7247		5432, 5535			7299, 7509										1154, 1607																														280, 292																462, 815																		837, 948	964, 1084
61,691	109,307	2431	Discharge summary	report	Admission Date: [2114-12-26] Discharge Date: [2114-12-28] Date of Birth: [2054-2-18] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: vertigo, decreased responsiveness Major Surgical or Invasive Procedure: intubated [2114-12-26] Extubated - [2114-12-27] History of Present Illness: The pt is a 60 year-old man with a history of Afib and periodic episodes of vertigo who presents with acute onset dizziness with severe nausea and vomiting, followed by increased lethargy and periods of apnea. According to Mr. [Known lastname 12499] wife, he was last seen normal around 1pm this afternoon, right before she went to work. Shortly thereafter, however, she reports getting a call that he had gone to the ED because of sudden onset of severe dizziness with nausea and vomiting. Reportedly on arrival to the ED he was complaining of severe vertigo, with frequent vomiting. He was also noted to be lethargic, not following commands appropriately, and refusing to open his eyes. The vomiting continued, and he was not appropriately protecting his airway. In addition he had several episodes of observed apnea. At this point the decision was made to intubate him, and get a CT/CTA, afterwhich Neurology was consulted. According to his wife and prior notes, Mr. [Known lastname ] has been having episodes of vertigo for many years, dating back to an episode of meningitis 20-30 years ago. He will usually have a mild degree of nausea and vomiting, and will often require IV fluids. He will occasionally take meclizine for symptomatic relief, however generally avoids it because it makes him quite somnolant. According to his wife, the degree of vomiting, as well as the accompanying lethargy were atypical for his usual episodes. He last had one of his episodes of vertigo ~3 days ago, and usually has these occur several times/year. No recent fever or illness. Past Medical History: - Afib, on Coumadin - Periodic episodes of vertigo - s/p tympanoplasty [8-19] for chronic otitis media Social History: Lives in [Location ] with his wife. [Name (NI) ] EtOH, no smoking, no illicits. Family History: Mother died at age 75 of CAD. Father died at age [Age over 90 ] of old age Physical Exam: Physical Exam: Vitals: T: 96.7 P: 97 R: 16 BP: 94/73 SaO2: 100% on vent 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: Irregular Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Intubated, not following commands off propofol, but can only briefly turn it off as he has significant cough and discomfort. -Cranial Nerves: Pupils 2->1.5mm bilaterally. Slight disconjugate gaze with medial deviation of R eye. Negative corneals, negative oculocephalics, intact gag. -Motor/Sensory: Briskly localizes with right arm to painful stimuli. Extensor posturing of left arm to pinch, but occasionally has small spontaneous movements on the left. Extensor posturing bilaterally of lower extremities to pinch. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 3 2 2 1 R 2 3 2 2 1 Plantar response was flexor bilaterally. Post extubation: MS:intact CN: no deficits Motor: full strength at upper and lower ext Sensory: no deficits in any modality Pertinent Results: [2114-12-27] 01:56AM BLOOD WBC-6.1 RBC-3.57* Hgb-10.8* Hct-32.0* MCV-90 MCH-30.3 MCHC-33.7 RDW-15.0 Plt Ct-156 [2114-12-26] 03:10PM BLOOD Neuts-59.8 Lymphs-34.4 Monos-3.2 Eos-2.2 Baso-0.5 [2114-12-27] 09:50AM BLOOD PT-20.0* PTT-94.3* INR(PT)-1.8* [2114-12-27] 07:50AM BLOOD PT-21.2* PTT-150* INR(PT)-2.0* [2114-12-27] 01:56AM BLOOD Glucose-124* UreaN-15 Creat-0.8 Na-143 K-3.3 Cl-113* HCO3-24 AnGap-9 [2114-12-27] 01:56AM BLOOD CK(CPK)-264* [2114-12-27] 01:56AM BLOOD CK-MB-7 cTropnT-<0.01 [2114-12-26] 03:10PM BLOOD cTropnT-<0.01 [2114-12-26] 03:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: MRI: There are no parenchymal signal or structural abnormalities. There is no acute infarct. There is right mastoid air cell effusion. There is mild mucosal thickening within the ethmoid sinuses. Fluid opacifies the nasopharynx, likely related to intubation. IMPRESSION: Right mastoid air cell effusion with an otherwise normal brain MRI. CTA: 1. No acute intracranial findings, vascular malformation, or high-grade stenoses. 2. Prominent right hilar nodes as well as several prominent level 1 and 2 nodes of unclear etiology. CXR: Comparison is made with prior study [12-26]. Mild cardiomegaly is stable. ET tube is in the standard position. NG tube tip is in the stomach. Bibasilar opacities consistent with atelectasis are stable. There are no new lung abnormalities to suggest acute respiratory event. There is no pleural effusion or pneumothorax. Brief Hospital Course: Patient is a 60 yo man with a history of Afib, sub therapeutic on Coumadin (INR 1.8), and episodic vertigo, presenting with acute onset dizziness, accompanied by severe nausea and vomiting, followed by increased lethargy and periods of apnea. Exam is notable for small but reactive pupils, slightly disconjugate gaze with negative oculocephalic, intact gag, brisk localization to stimuli on the R, but extensor posturing in L arm and bilateral lower extremities. CT and CTA were negative in the ED, but the overall picture of sudden onset dizziness, and progressively worsening exam, in the context of having Afib with a sub therapeutic INR are concerning for possible posterior circulation infarct. He was intubated in the ED for the concern of multiple emesis and increased responsiveness, that he was not protecting his airway. The patient was admitted to the ICU, and an MRI was obtained. The MRI did not show any evidence of acute stroke. Overnight the patient's exam significantly improved where he was following all commands. He was extubated on [2114-12-27]. After extubated the patient had a normal exam and was able to tolerate food without nausea or vomiting. On further history the patient has been complaining of some hearing loss associated with these episodes of severe vertigo. His symptoms were attributed to inner ear pathology. He was discharged after been evaluated by physical therapy. He underwent MRI of his brain which did not show evidence of stroke. He had some episodes of intermittent tachycardia which were sinus and thought to be related to dehydration/anxiety. His INR at the time of discharge was 1.8, hence he was bridged on Lovenox while discharge and was asked to follow up with PCP for further care. this was communicated to his PCP at the time of discharge. Medications on Admission: - Coumadin 7.5 m,w,f 5.0 s,t,t,s - Meclizine PRN Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([Doctor First Name ],TU,TH,SA). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous twice a day for 4 days: He needs to have INR checked on Sunday [12-30] and if his INR is therapeutic,( 2- 3) Lovenox should be stopped from Sunday. If INR is less than 2 he should be continued and get his INR checked again on Monday with same protocol to follow. Disp:8 Refills:0 5. Outpatient Lab Work blood work - PT/INR on [12-30] , on [12-31], please fax results Name: [Last Name (LF) ],[First Name3 (LF) ] Location: [Hospital1 ] HEALTHCARE - [Hospital ] MEDICAL GROUP Address: [Street Address(2) 2687],8TH FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 133] Fax: [Telephone/Fax (1) 445] Email: [University/College 12500] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Acute onset vertigo- resolved, mostly vestibular in origin Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with an episode of acute vertigo and severe nausea and vomiting. It was very severe and there was worry that you were going to aspirate and would not be able to protect your breathing. You had to be intubated (a breathing tube was placed in your lungs) and you were sedated for imaging. You had CT scan of your head and MRI which did not show any evidence of stroke. Please take your medicines as prescribed. Please call 911 or your doctor if you develop concerning symptoms. Followup Instructions: Please follow up with neurology clinic with Scheduled Appointments : Provider [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 1694] Date/Time:[2115-2-5] 4:00 Provider [Name9 (PRE) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2115-4-22] 3:40	[ "780.4", "427.31", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "38.91" ]	icd9pcs	[ [ [] ] ]	8254, 8311	5290, 7098	352, 409	8414, 8414	3730, 5267	9079, 9457	2284, 2366		7198, 8231		8332, 8393		7124, 7175			8559, 9056							3053, 3711			2396, 2895																														279, 314																437, 2030										8428, 8535								2052, 2161	2177, 2268
67,060	128,850	38417	Discharge summary	report	Admission Date: [2161-8-4] Discharge Date: [2161-8-11] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: s/p valvuloplasty Major Surgical or Invasive Procedure: valvuloplasty, BMS SVG-D1 History of Present Illness: Patient is an 87 y/o male with PMHx CAD s/p CABG, iCM (EF 35%), AS who presented to the ED with chest pain, DOE, and a near syncopal episode prior to presentation. . 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 recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, initial vitals were Afeb, 68, 134/38, 18, 100%RA. The patient recieved [First Name3 (LF) ] 325mg x 1. On the floors, the patient was kept on his home medications. He underwent a cardiac cath which showed 3 vessel disease as well as severe aortic stenosis. He was evaluated by Thoracic surgery for an AVR, however it was decided he would be a better patient for a valvuloplasty. He underwent valvuloplasty with Dr. [Last Name (STitle) ] on [8-3] where his gradine improved from 65 to 41 mmHg and increased of CO from 4.39 to 4.8. He also underwent BMS to SVG-D1. During the procedure he felt abdominal cramps such as if he were to move his bowels as well as nausea and vomitted x1 a black material that he reports looked like blood. His blood pressure decreased from 150/46 to 118/46 mmHg. At some point during procedure, nurse was concerned for a "seizure", but patient was awake and with normal exam when physicians evaluated him. He was transferred to the CCU for monitoring post procedure. Past Medical History: - Acute myocardial infarction [2126] and [8-/2154] - Aortic valve stenosis (peak gradient 83mm, Mean gradient 48mmHg, 0.8cm) - Moderate AI - LVEF 35-40% with inferior and basilar septal HK. - Paroxysmal Atrial Fibrillation 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -Coronary Artery Bypass Graft x 4 [2136] [Hospital1 336] (LIMA-LAD, SVG to rPRA, DM,OM) -PERCUTANEOUS CORONARY INTERVENTIONS: -Angiojet extraction of thrombus/PTCA with stenting of saphenous vein graft->Obtuse marginal artery [2153] [Hospital1 2025] 3. OTHER PAST MEDICAL: Gastroesophageal reflux disease Low grade dementia with memory loss and emotional lability Hiatal hernia Hematuria -Hernia repair -Appendectomy Social History: -Tobacco history:70 pk yr smoking history, Quit 2 months ago. -ETOH: No excessive ETOH intake. -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T= 97.8 BP=131/56 mmHg HR=53 RR=12 O2 sat=99% 2 L PHYSICAL EXAMINATION: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple, no LAD, no carotid bruits, JVP of 4cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. NSR on exam. SEM harsh, in RUSB louder, but audible through precordium, radiates towards both carotid arteries. He also has a [12-29] diastolic murmur best heard in LLSB. No r/g. No thrills, lifts. No S3 or S4. LUNGS: + occ cough, Resp were unlabored, no accessory muscle use. Rhonchi in bilateral upper lobes and diffuse end exp wheezing. ABDOMEN: Soft, NTND. + bowel sounds. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. Radiation of murmur to R groin. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: [2161-8-3] 06:50AM PLT COUNT-153 [2161-8-3] 06:50AM WBC-9.0 RBC-3.41* HGB-10.3* HCT-30.0* MCV-88 MCH-30.2 MCHC-34.3 RDW-13.5 [2161-8-3] 06:50AM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.4 [2161-8-3] 06:50AM GLUCOSE-101* UREA N-34* CREAT-1.4* SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12 [2161-8-3] 05:44PM PLT COUNT-151 [2161-8-3] 05:44PM calTIBC-244 FERRITIN-342 TRF-188* [2161-8-3] 05:44PM IRON-20* [2161-8-3] 05:44PM CK-MB-8 [2161-8-3] 05:44PM CK(CPK)-93 [2161-8-3] 05:44PM SODIUM-139 POTASSIUM-4.4 CHLORIDE-106 [2161-8-4] 05:15AM PT-11.5 PTT-24.0 INR(PT)-1.0 [2161-8-4] 05:15AM PLT COUNT-144* [2161-8-4] 05:15AM WBC-8.4 RBC-3.20* HGB-9.8* HCT-28.0* MCV-87 MCH-30.7 MCHC-35.1* RDW-13.6 [2161-8-4] 05:15AM CALCIUM-8.5 PHOSPHATE-4.2 MAGNESIUM-2.3 [2161-8-4] 05:15AM CK-MB-5 [2161-8-4] 05:15AM CK(CPK)-71 [2161-8-4] 05:15AM GLUCOSE-119* UREA N-30* CREAT-1.5* SODIUM-138 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [2161-8-4] 08:10PM PT-13.0 PTT-28.4 INR(PT)-1.1 [2161-8-4] 08:10PM PLT COUNT-154 [2161-8-4] 08:10PM NEUTS-90.3* LYMPHS-5.9* MONOS-3.3 EOS-0.3 BASOS-0.2 [2161-8-4] 08:10PM WBC-14.6# RBC-3.33 HGB-10.2* HCT-29.3* MCV-88 MCH-30.7 MCHC-34.8 RDW-13.9 [2161-8-4] 08:10PM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.1 [2161-8-4] 08:10PM CK-MB-3 [2161-8-4] 08:10PM cTropnT-0.17* [2161-8-4] 08:10PM ALT(SGPT)-12 AST(SGOT)-21 CK(CPK)-60 ALK PHOS-63 [2161-8-7] 03:47AM BLOOD WBC-9.8 RBC-2.67* Hgb-8.3* Hct-23.9* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.3 Plt Ct-174 [2161-8-7] 10:40AM BLOOD Hct-24.2* [2161-8-8] 04:17AM BLOOD WBC-8.9 RBC-2.68* Hgb-8.3* Hct-23.4* MCV-87 MCH-31.1 MCHC-35.6* RDW-14.4 Plt Ct-168 [2161-8-9] 07:10AM BLOOD WBC-10.8 RBC-2.90* Hgb-8.8* Hct-25.9* MCV-89 MCH-30.2 MCHC-33.9 RDW-15.1 Plt Ct-228 [2161-8-10] 08:00AM BLOOD WBC-11.1* RBC-3.09* Hgb-9.3* Hct-27.5* MCV-89 MCH-30.3 MCHC-33.9 RDW-15.8* Plt Ct-276 [2161-8-6] 05:00AM BLOOD Glucose-136* UreaN-27* Creat-1.5* Na-139 K-4.5 Cl-110* HCO3-19* AnGap-15 [2161-8-8] 04:17AM BLOOD Glucose-145* UreaN-36* Creat-1.5* Na-135 K-4.5 Cl-104 HCO3-21* AnGap-15 [2161-8-10] 08:00AM BLOOD Glucose-112* UreaN-43* Creat-1.8* Na-140 K-3.9 Cl-104 HCO3-26 AnGap-14 Urine Cx: URINE CULTURE (Final [2161-8-8]): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. MEROPENEM <= 1 MCG/ML. Cefepime <=2 MCG/ML. sensitivity testing performed by Microscan. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| CEFEPIME-------------- S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- <=0.5 S GENTAMICIN------------ <=1 S MEROPENEM------------- S PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=2 S TEE: [2161-8-10] 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. Overall left ventricular systolic function is low normal (LVEF 50-55%). There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. The aortic valve leaflets are severely thickened/deformed. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Brief Hospital Course: #Sepsis: Patient presented after experiencing multiple episodes of emesis at home. In the ED he was found to be febrile with a temperature of 102 and decreased BP into the 80s, positive UA and leukocytosis. He was given a total of 4 liters of fluid and pressors were begun with resulting increase in BP. Patient was weaned off pressors by the morning after admission. Patient was also found to have WBCs and bacteria in his urine, which later grew Enterobacter susceptible to Cipro. Patient was initially started on Ciprofloxacin and Vancomycin in the ED, with eventual continuation of Cipro alone for a 14 day total course. Patient was afebrile throughout the remainder of his hospitalization with no compromise in BP. . #Atrial fibrillation: Patient presented with non-rapid atrial fibrillation. Has history of paroxysmal A-fib. Patient had previously been on coumadin, but had been stopped due to perceived fall risk and episode of urethral bleeding. Patient [Country ] score was 4, so a trial of heparin anticoagulation was started. While on heparin, patient's urine became tea colored. The heparin was stopped and the urine subsequently cleared. Patient had multiple episodes of paroxysmal atrial fibrillation with RVR. Patient was initially started on Metoprolol for rate control, titrated up to 25mg TID. After TEE, which showed no evidence of thrombus. Patient self-converted back to sinus rhythm and amiodarone 400mg [Hospital1 ] was started for stabilization of his rhythm. Patient had remained in sinus rhythm and was in sinus rhythm at discharge. Patient will not be anticoagulated with coumadin due to the hematuria, but does have some protection with [Hospital1 ] and aspirin. #Pulmonary Edema: Patient had worsening respiratory status after development of pulmonary edema. Patient had diffuse wheezing on exam with DOE from commode to bed. Patient also developed a cough. He has a history of smoking, but no known history of COPD. No evidence of PNA on CXR and was afebrile after admission. He was given ipratropium inhaler and aggressive diuresis. Symptoms improved after diuresis. Etiology of pulmonary edema likely secondary to 4liters IVF received in the ED after became hypotensive, along with decreased CO in setting of A-fib. Symptoms and exam improved with diuresis and control of A-fib. AT time of d/c pt was comfortable on room air. . #Anemia: Normocytic, normochromic normal RDW. Hct decreased to 23.4. In setting of CAD, patient could have received transufion, however a conservative approach was taken and further evaluation of possible bleeding sites was undertaken. Patient did have ecchymoses bilaterally at groin sites after procedure. Ultrasound of the groin did not show evidence of bleeding, aneurysm, or pseudoaneurysm. All stools were guiac negative, and no episodes of hematemesis. Serial hematocrits showed some improvement and patient was close to Hct that he presented with. Decrease hct was likely secondary to hemodilution and increased intravascular volume, some blood loss during procedure, and mild blood loss with hematuria. . #Hematuria: No evidence of bleeding on UA at admission. Patient did have history of urethral bleeding in past with anticoagulation. Due to high risk of embolic event secondary to A-fib, patient was given a trial of anticoagulation with heparin. Patient began to develop tea colored urine and the heparin was discontinued, with clearance of his urine. Patient has no known previous work up for hematuria. Follow up appointment was made for urological workup, thought particularly important as patient is elderly and has history of smoking. Although rare, work up for possible malignancy is necessary. . #RUQ pain: Patient transiently complained of RUQ pain after multiple episodes of emesis prior to admission. His abdominal exam was consistently benign with no abnormalities on LFTs. Guiaic of all stools were negative. Patient was given ranitidine with some resolution of symptoms. . #CAD: Patient staus post CABG and s/p BMS to SVG-D1 during valvuloplasty shortly before readmission. Patient had mildly elevated troponin to 0.17 at admission, but believed to be secondary to procedure. Patient also had LBBB that was new after the procedure; also believed to be secondary to the procedure rather than ACS. Patient denied any symptoms of chest pain and TEE did not show any evidence of regional wall motion abnormalities. Patient was continued on his [Last Name (LF) ], [First Name3 (LF) ], and simvastatin. Patient will follow up with Dr. [Last Name (STitle) 5076]. . #Hypertension: Patient was given metoprolol 25mg TID for both rate control and blood pressure control. Also given Norvasc 2.5mg to further decrease afterload after TEE [8-7] showed evidence of moderate AI. Patient's home ramipril was initially held secondary to patients worsened kidney function (incr serum cr), but was restarted prior to discharge. . #Chronic Kidney Disease: Patient has history of stage 3b CKD with unknown baseline creatinine. Patient's creatinine initially improved with diuresis; however, did increase prior to discharge to 1.9. . #Diabetes Mellitus: HbA1c resulted at 6.5, diagnostic for DM. Patient had no history of DM. He was placed on a sliding scale, with minimal insulin administration. Patient will be followed up as an outpatient for further management as deemed necessary. Patient's ramipril was restarted prior to discharge. Medications on Admission: Lasix 40mg daily Metoprolol 25mg twice daily Ramipril 2.5mg daily Zocor 40mg daily Aspirin 81mg daily (Coumadin recently discontinued) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:3 2. [Month/Year (2) ] 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:3 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days: take until [8-19]. Disp:18 Tablet(s) Refills:0 9. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: UTI with enterobacter, acute on chronic systolic congestive heart failure (EF 35%) Secondary:HTN, HL, DM, Anemia, CKD, CAD s/p CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 85550], It was a pleasure taking care of you. You were admitted to the hospital after experiencing vomiting after a procedure for one of your heart valves. In the emergency room your blood pressure decreased and you were given a large amount of IV fluids. You were also found to have a urinary tract infection which likely led to the low blood pressure. We treated the infection with antibiotics. Your blood pressure quickly improved when you were in the Cardiac Care Unit. In the CCU, you began having some shortness of breath and a cough because some of that fluid you had previously received was building up in your lungs. We gave you a medication, lasix, to remove the extra fluid, and your symptoms improved. Your heart did have an irregular rhythm at one point and you were given medication to control it. You were also given a blood thinner, but you had some blood in your urine, so we decided to stop that. You will follow up with a urologist to further evaluate why you had blood in your urine. Please make the following changes to your medications: CHANGE: Lasix 80 mg by mouth daily - This is a water pill to decrease the fluid in your body. This is increased from your prior dose of 40 mg daily. NEW: Ciprofloxacin 500mg every 12 hours - antibiotic for your UTI, please take until [2161-8-19]. NEW: Clopidogrel 75mg daily - This is important because it decreases the risk of developing blockages in your new heart stent which keeps your heart artery open NEW: Amiodarone 400mg daily - This is used to help control your heart rhythm NEW: Ranitidine 150mg twice daily - This will decrease the acid in your stomach, which could have been part of the cause of some the abdominal pain you experienced NEW: Amlodipine 2.5 mg daily - This medication is to control your blood pressure. . Please follow up with your doctors at the [Name5 (PTitle) 4314] below. Followup Instructions: Please follow up with the following [Name5 (PTitle) 4314]: Internal Medicine Dr. [Last Name (STitle) ], Monday [8-17], 1:45pm [Hospital1 69], [Hospital Ward Name 23] [Location (un) ] [Location (un) 86], [Numeric Identifier 40974] Phone: [Telephone/Fax (1) 250] . Urology Dr. [Last Name (STitle) ], [Hospital Ward Name 23] [Location (un) 470] Tuesday [9-8] 8:00am [Hospital1 69], [Hospital Ward Name 23] [Location (un) 470] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 277] . Cardiology Dr. [Last Name (STitle) ], Tuesday [9-8] at 3:40pm Same day as GU [Hospital1 18] Cardiovascular Institute, [Hospital Ward Name ] [Location (un) ] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 62] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "599.0", "789.01", "V15.1", "403.90", "272.4", "426.3", "285.9", "785.52", "585.3", "038.49", "412", "V45.81", "285.29", "995.92", "V45.82", "428.23", "428.0", "288.60", "427.31", "530.81", "425.4" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	14911, 14960	8240, 13673	280, 307	15146, 15146	4015, 8217	17224, 18204	2978, 3093		13859, 14888		14981, 15125		13699, 13836			15297, 16358										3108, 3163				2384, 2826													3185, 3996					16387, 17201								222, 242																335, 2058										15161, 15273								2080, 2364	2842, 2962
72,511	175,936	33533+33534+57855	Discharge summary	report+report+addendum	Admission Date: [2174-10-9] Discharge Date: [2174-10-17] Date of Birth: [2092-9-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Angina Major Surgical or Invasive Procedure: [2174-10-12] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA), Aortic Valve Replacement (23mm St. [Male First Name (un) 923] Epic porcine valve) History of Present Illness: This year old white male has known CAD and is followed by his cardiologist. He underwent a stress test in [3-5] which was positive and then underwent cardiac catheterization which revealed three vessel disease with moderate aortic stenosis. He remained stable and a followup catheterization on [10-7] revealed progression of his coronary disease with new occlusive disease of the right artery. his aortic valve orifice was 1.6 cm2. He was referred for surgery. Past Medical History: Coronary Artery Disease Aortic Stenosis Hypertension Hyperlipidemia Diabetes Mellitus Hypothyroidism Chronic Renal Insufficiency Benign Prostatic Hypertrophy h/o Prostate Cancer s/p Zenker's Divertriculum repair Social History: Denies tobacco use. Admits to occasional ETOH use. Family History: Brother died from MI at age 53. Father died at 79, was s/p CABG. Physical Exam: VSS, alert and oriented Lungs- slightly decreased BS at bases. Cor- SR at 62. crisp valve sounds Abdomen- benign extremities- warm, trace edema pretibially EVH wounds clean and dry. Sternum stable. Pertinent Results: [10-12] Echo: PRE CPB The left atrium is moderately 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.5 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-29]+) mitral regurgitation is seen. There was some inflow into the right atrium which, at first, appeared may represent an anomalous pulmonary vein. However, furter investigation suggests that it was simply inferior vena c aval inflow oriented somewhat differently. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST CPB There is normal biventricular systolic function. A bioprosthesis is well seated in the aortic position. The leaflets are not well seen. There is no aortic regurgitation appreciated. The maximum gradient across the aortic valve is 8 mm Hg with a mean gradient of 4 mm Hg with a cardiac output of 7 liters/minute. The thoracic aorta appears intact. The mitral regurgitatiion is somewhat improved - now mild. [2174-10-17] 05:25AM BLOOD Hct-26.1* [2174-10-16] 07:20AM BLOOD WBC-9.2 RBC-3.32# Hgb-10.5# Hct-29.6# MCV-89 MCH-31.6 MCHC-35.5 RDW-16.7* Plt Ct-133* [2174-10-17] 05:25AM BLOOD PT-15.9* INR(PT)-1.4* [2174-10-16] 07:20AM BLOOD PT-13.9* INR(PT)-1.2* [2174-10-15] 06:55AM BLOOD PT-13.2 PTT-25.9 INR(PT)-1.1 [2174-10-17] 05:25AM BLOOD UreaN-40* Creat-2.0* K-3.8 [2174-10-16] 07:20AM BLOOD Glucose-48* UreaN-39* Creat-2.0* Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 [2174-10-15] 06:55AM BLOOD Glucose-37* UreaN-45* Creat-2.0* Na-138 K-4.1 Cl-107 HCO3-23 AnGap-12 [2174-10-14] 05:30AM BLOOD Glucose-82 UreaN-39* Creat-1.8* Na-135 K-5.3* Cl-106 HCO3-24 AnGap-10 [2174-10-13] 02:36AM BLOOD Glucose-98 UreaN-31* Creat-1.3* Na-138 K-4.2 Cl-111* HCO3-23 AnGap-8 Brief Hospital Course: Following admission the patient completed his preoperative workup. This included an echocardiogram which revealed slightly impaired left ventricular function and moderate aortic stenosis ( [Location (un) 109] ~1.1 cm, gradient 35 mmHg). Carotid ultrasound demonstrated no significant lesions. On [10-12] he was brought to the operating room where he underwent a coronary artery bypass graft x 4 and aortic valve replacement. Please see operative report for surgical details. He weaned from bypass on propofol and phenylephrine in stable condition. Following surgery he was transferred to the CVICU for invasive monitoring. He remained stable and was extubated easily after surgery and weaned from pressor. He was transferred to the floor on POD 1. Following transfer he developed atrial fibrillation for which amiodarone was begun. He converted to sinus rhythm on [10-16] and remained there. Coumadin was begun during his time in atrial fibrillation. He was ready for discharge home. His creatinine which was mildly elevated chronically at 1.5, rose to 2 after surgery, where it remained. This will be rechecked a week after discharge. His INR was 1.2 at discharge and he will take 4 mg [10-17] and 21. He will have a PT/INR drawn on [10-19] with results sent to Dr. [Last Name (STitle) 6051] for regulation, with a target INR of [1-29].5. Medications on Admission: Colace 100mg [Hospital1 ], Protonix 40mg qd, Aspirin 325mg qd, Amlodopine 10mg qd, Levothyroxine 112mcg qd, Lisinopril 10mg qd, Niacin 500mg qd, Zetia 10mg qd, Simvastatin 80mg qd, Atenolol 100mg qd, HCTZ 25mg qd, Terazosin 5mg qd Discharge Medications: 1. Influen Tr-Split [2173] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks. 7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY (Daily): INR target 2-2.5. 14. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 17. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 18. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: s/p Coronary Artery Bypass Graft x 4 Aortic Stenosis s/p Aortic Valve Replacement Hypertension Hyperlipidemia Diabetes Mellitus Hypothyroidism Chronic Renal Insufficiency Benign Prostatic Hypertrophy h/o Prostate Cancer s/p Zenker's Divertriculum repair paroxysmal atrial fibrillation Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any redness of or drainage from incisions report any weight gain greater than 3 pound in a day or 5 pounds in a weak report any temperature greater than 100.5 take all medications as directed Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) Dr. [Last Name (STitle) 1295] in [1-30] weeks Dr. [Last Name (STitle) 6051] in [12-29] weeks ([Telephone/Fax (1) 77748], also regulating Coumadin (FAX [Telephone/Fax (1) 25494]) Please call to make appointments Completed by:[2174-10-17] Admission Date: [2174-10-9] Discharge Date: [2174-10-17] Date of Birth: [2092-9-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: coronary artery disease aortic stenosis Major Surgical or Invasive Procedure: [2174-10-12] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)& Aortic Valve Replacement (23mm St. [Male First Name (un) 923] Epic porcine valve) History of Present Illness: This 82 year old white male with known coronary artery disease underwent repeat catheterization recently to show progression of triple vessel disease with aortic stenosis. echocardiography revealed moderate stenosis and he was referred for surgical intervention. Past Medical History: chronic renal insufficiency hypothyroidism hypertension coronart artery disease diabetes mellitus hyperlipidemia aortic stenosis benign prostatic hypertrophy Social History: Denies tobacco use. Admits to occasional ETOH use. Family History: Brother died from MI at age 53. Father died at 79, was s/p CABG. Physical Exam: alert and oriented Lungs clear cor SR at 82 exts- 1+ edema Wounds- healing well Pertinent Results: [2174-10-16] 07:20AM BLOOD WBC-9.2 RBC-3.32# Hgb-10.5# Hct-29.6# MCV-89 MCH-31.6 MCHC-35.5 RDW-16.7* Plt Ct-133* [2174-10-17] 05:25AM BLOOD PT-15.9* INR(PT)-1.4* [2174-10-16] 07:20AM BLOOD PT-13.9* INR(PT)-1.2* [2174-10-15] 06:55AM BLOOD PT-13.2 PTT-25.9 INR(PT)-1.1 [2174-10-16] 07:20AM BLOOD Glucose-48* UreaN-39* Creat-2.0* Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 [2174-10-17] 05:25AM BLOOD UreaN-40* Creat-2.0* K-3.8 [2174-10-15] 06:55AM BLOOD Glucose-37* UreaN-45* Creat-2.0* Na-138 K-4.1 Cl-107 HCO3-23 AnGap-12 [2174-10-14] 05:30AM BLOOD Glucose-82 UreaN-39* Creat-1.8* Na-135 K-5.3* Cl-106 HCO3-24 AnGap-10 Brief Hospital Course: Following admission the patient underwent echocardiography and was prepared for aortic valve replacement and coronary revascularization which were performed on [10-12]. He weaned from bypass easily on phenylephrine and was weaned and extubated easily and pressor was weaned off. Postoperatively he did well, developing atrial fibrillation after transfer, converting to sinus rhyth with beta blocker and amiodarone. Coumadin was begun for his fibrillation and was continued at discharge. He was ambulatory and coumadin will be managed by his primary care physician. [Name10 (NameIs) 69430] for this were made. His creatinine rose from a baseline of 1.5 to 2.0 and will be repeated later this week. Medications on Admission: [Last Name (LF) 6196], [First Name3 (LF) ], Norvasc10/D, Synthroid 112mcg/D, Lisinopril 10mg/D,Terazosin5mg/D,Niacin, Zetia 10mg/D,Zocor80mg/D,Atenolol 100mg/D Discharge Medications: 1. Influen Tr-Split [2173] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks. 7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY (Daily): INR target 2-2.5. Disp:100 Tablet(s) Refills:2 13. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 14. [Year (4 digits) 6196] 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 17. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Aortic Stenosis s/p Aortic Valve Replacement Hypertension Hyperlipidemia Diabetes Mellitus Hypothyroidism Chronic Renal Insufficiency Benign Prostatic Hypertrophy h/o Prostate Cancer s/p Zenker's Divertriculum repair paroxysmal atrial fibrillation Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any redness of, or drainage from incisions report any weight gain greater than 3 pound in a day or 5 pounds in a week report any temperature greater than 100.5 take all medications as directed Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) Dr. [Last Name (STitle) 1295] in [1-30] weeks Dr. [Last Name (STitle) 6051] in [12-29] weeks ([Telephone/Fax (1) 77748], also regulating Coumadin Please call to make appointments Completed by:[2174-10-17] Name: [Known lastname 12565],[Known firstname 394] R Unit No: [Numeric Identifier 12566] Admission Date: [2174-10-9] Discharge Date: [2174-10-17] Date of Birth: [2092-9-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 741] Addendum: The patient's baseline creatinine of 1.7 rose to 2.0 in the perioperative period. This was treated expectently and remained stable at 2. The patient was discharged and the creatinine was to be repeated after discharge. Chief Complaint: Coronary artery disease, aortic stenosis Major Surgical or Invasive Procedure: [2174-10-12] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA)& Aortic Valve Replacement (23mm St. [Male First Name (un) 744] Epic porcine valve) History of Present Illness: see discharge summary Past Medical History: Coronary Artery Disease Aortic Stenosis Hypertension Hyperlipidemia Diabetes Mellitus Hypothyroidism Chronic Renal Insufficiency Benign Prostatic Hypertrophy h/o Prostate Cancer s/p Zenker's Divertriculum repair acute renal dysfunction/failure Social History: Denies tobacco use. Admits to occasional ETOH use. Family History: Brother died from MI at age 53. Father died at 79, was s/p CABG. Physical Exam: see summary Pertinent Results: [2174-10-16] 07:20AM BLOOD WBC-9.2 RBC-3.32# Hgb-10.5# Hct-29.6# MCV-89 MCH-31.6 MCHC-35.5 RDW-16.7* Plt Ct-133* [2174-10-17] 05:25AM BLOOD PT-15.9* INR(PT)-1.4* [2174-10-17] 05:25AM BLOOD UreaN-40* Creat-2.0* K-3.8 [2174-10-16] 07:20AM BLOOD Glucose-48* UreaN-39* Creat-2.0* Na-138 K-4.2 Cl-104 HCO3-26 AnGap-12 [2174-10-15] 06:55AM BLOOD Glucose-37* UreaN-45* Creat-2.0* Na-138 K-4.1 Cl-107 HCO3-23 AnGap-12 [2174-10-14] 05:30AM BLOOD Glucose-82 UreaN-39* Creat-1.8* Na-135 K-5.3* Cl-106 HCO3-24 AnGap-10 [2174-10-13] 02:36AM BLOOD Glucose-98 UreaN-31* Creat-1.3* Na-138 K-4.2 Cl-111* HCO3-23 AnGap-8 [2174-10-12] 05:59PM BLOOD UreaN-36* Creat-1.4* Cl-115* HCO3-23 [2174-10-9] 02:50PM BLOOD Glucose-138* UreaN-35* Creat-1.7* Na-142 K-3.9 Cl-106 HCO3-27 AnGap-13 Brief Hospital Course: see summary Medications on Admission: see summary Discharge Medications: 1. Influen Tr-Split [2173] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks. 7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY (Daily): INR target 2-2.5. Disp:100 Tablet(s) Refills:2 13. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 17. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 136] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Aortic Stenosis s/p Aortic Valve Replacement Hypertension Hyperlipidemia Diabetes Mellitus Hypothyroidism Chronic Renal Insufficiency Benign Prostatic Hypertrophy h/o Prostate Cancer s/p Zenker's Divertriculum repair paroxysmal atrial fibrillation Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any redness of, or drainage from incisions report any weight gain greater than 3 pound in a day or 5 pounds in a week report any temperature greater than 100.5 take all medications as directed Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 1477]) Dr. [Last Name (STitle) 7592] in [1-30] weeks Dr. [Last Name (STitle) ] in [12-29] weeks ([Telephone/Fax (1) 12567], also regulating Coumadin Please call to make appointments [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2174-11-16]	[ "411.1", "250.00", "424.1", "414.01", "585.9", "427.31", "V10.46", "997.1", "V17.3", "403.90", "426.11", "512.1", "E878.2", "244.9", "V58.61", "511.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "96.71", "36.15", "35.21", "88.72", "36.13", "99.04" ]	icd9pcs	[ [ [] ] ]	18502, 18560	16619, 16632	15086, 15275	18913, 18920	15791, 16596	19335, 19729	15678, 15744		16694, 18479		18581, 18892		16658, 16671			18944, 19312										15759, 15772																														15006, 15048																15303, 15326																		15348, 15593	15609, 15662
27,391	103,296	34303	Discharge summary	report	Admission Date: [2143-8-13] Discharge Date: [2143-8-21] Date of Birth: [2063-2-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: Temporary pacing wire placement History of Present Illness: Patient is an 80yoM with a history of AVR, hx abd aortic aneurysm repair, htn, hyperlipidemia, transferred from [Hospital 7912] for prosthetic AV valve endocarditis who presented to [Hospital6 ] [8-3] w/CC "weakness and fall" without aura, lightheadedness, or signs of seizure. Found to have L-sided weakness, +new hypodensity R frontal lobe, L posterior parietal lobe (with supratherapeutic INR). Had bradyarrythmias (seen by EP [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 23651]), slow afib noted with high-grade AV-Wenkebach. On [8-10], pt febrile, [2-26] bottle grew GPC chains, initiated on vanco (with subsequent bottles negative). ID consult high suspicion for AV endocarditis, TEE [8-13] then showed mechanical valve prosthesis, mobile echodensity 7mm on ventr side of aortic valve, +echolucency along posterior annulus, concern for abscess, trace AR. Pt transferred to [Hospital1 18] for treatment and assessment for valve replacement. Upon arrival to [Hospital1 18] CCU [8-13] 23:45, pt on 99% ra, sbp 121/63, hr 73, moving all extremities, heparin gtt infusing. Per [Month (only) 16] from [Hospital3 ], ampicillin 2000mg q4hrs, gentamycin 55mg q12hrs, vanco 1g q24hrs. The patient denies chest pain, shortness of breath. He denies any loss of muscle strength, changes in speech or vision. He reports a diminished appetite for several months and an unintentional weight loss of ~15lbs over the past year. He denies any other symptoms. . ECHO - LV ef 55%, av mobile density (as above) 7mm, echolucency along posterior annulus. Past Medical History: Aortic valve replacement - mechanical [Company ] [Doctor Last Name ], [Hospital1 2025] (~[2124]) Atrial fibrillation - on coumadin Abdominal aortic aneurysm - s/p repair (unknown date) Hyperlipidemia Squamous cell cancer Spinal Stenosis Social History: Married, has 3 children, former director software company, lives in [Location (un) ], no etoh or tobacco use. Family History: Father with CVA. Physical Exam: PE: T 99.0 , BP 121/63 , HR77 , RR22 , O2 96 % on RA Gen: thin middle aged man in NAD. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2 with systolic ejection click best at left SB. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Unlabored respirations, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: thin, +hyperactive bowel sounds, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: Diffuse echymosis on BLUE, multiple small bruises and healing skin wounds on legs. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Neuro: Alert and oriented x3. Cranial nerves [2-5] intack. [4-29] strength through all limb flexors/extensors. Sensation intact. 3+ patellar reflexes, 5 beats clonus at right ankle, 9 beats on left. Pertinent Results: Admission labs: [2143-8-14] 01:30AM BLOOD WBC-9.6 RBC-3.32* Hgb-8.6* Hct-27.6* MCV-83 MCH-26.0* MCHC-31.3 RDW-13.5 Plt Ct-382 [2143-8-14] 01:30AM BLOOD PT-14.9* PTT-51.1* INR(PT)-1.3* [2143-8-14] 01:30AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-25 AnGap-13 [2143-8-14] 01:30AM BLOOD ALT-24 AST-39 LD(LDH)-249 AlkPhos-89 TotBili-0.4 [2143-8-14] 01:30AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.7 . Discharge labs: [2143-8-20] 05:58AM BLOOD WBC-7.4 RBC-3.13* Hgb-8.4* Hct-26.2* MCV-84 MCH-26.8* MCHC-32.0 RDW-14.4 Plt Ct-431 [2143-8-20] 05:58AM BLOOD Glucose-191* UreaN-8 Creat-1.1 Na-134 K-3.4 Cl-103 HCO3-21* AnGap-13 [2143-8-20] 05:58AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 [2143-8-15] 09:30AM BLOOD calTIBC-156* Ferritn-372 TRF-120* [2143-8-18] 06:32AM BLOOD PSA-0.2 [2143-8-14] 01:30AM BLOOD CRP-112.6* [2143-8-15] 04:10AM BLOOD ESR-86* [2143-8-16] 05:06AM BLOOD SPEP-NO SPECIFIC ABNORMALITIES SEEN . CHEST (PORTABLE AP) Study Date of [2143-8-14] Cardiac size is normal. The aorta is elongated. The lungs are clear. There is no pneumothorax or sizable pleural effusion. Note is made that the left lateral CP angle was not included on the film. Right central venous pacemaker leads terminate in the right ventricle. . CT HEAD W/O CONTRAST Study Date of [2143-8-15] 1. Hypoattenuating areas in the right frontal and left parietal lobes are concerning for acute or subacute infarcts given the patient's history. Further characterization with MRI is recommended. 2. Probable old infarcts in the right frontotemporal lobe and left occipital lobe. 3. Enlargement of the ventricles out of proportion to the sulci, which may be related to central atrophy, the normal pressure hydrocephalus should be excluded clinically. Dr. [First Name8 (NamePattern2) 1439] [Last Name (NamePattern1) 22924] has been paged with these findings. . CT ABDOMEN W/CONTRAST Study Date of [2143-8-15] IMPRESSION: 1. No evidence of abscess in the abdomen or pelvis. 2. The colon appears normal without colonic wall thickening or mass lesion. 3. Reticular opacities are noted in the lung bases, consistent with chronic interstitial lung disease. 4. Cholelithiasis. 5. Findings consistent with prior granulomatous disease in the spleen. 6. Patient is status post aortobifemoral bypass graft. The graft is patent. . CAROTID SERIES COMPLETE PORT Study Date of [2143-8-16] PRELIM: R >70% diameter reduction, L >50-69% diameter reduction . TEE (Complete) Done [2143-8-19] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). There are simple atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present with a small vegetation (0.4cm) on the ventricular side of the valve. There is an area of echolucency on the perimeter of the prosthesis near the inter-atrial septum that could be a paravalvular [Last Name (LF) 3564], [First Name3 (LF) ] annular abscess or a combination of both. It is contiguous to but not involving the anterior mitral leaflet. Moderate (2+), eccentric aortic regurgitation is seen through the paravalvular abcess.The severity of aortic regurgitation may be underestimated due to shadowing. The mitral valve leaflets are mildly thickened but no distinct vegetation is seen. Mild to moderate ([12-26]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Aortic prosthetic valve endocarditis with probable abscess and at least moderate aortic regurgitation. Compared with the prior study (images reviewed) of [2143-8-13], the echolucent area is larger, suggesting an enlarging abscess or worsening valve dehiscence. Brief Hospital Course: A/P: 80 yo man s/p AVR [2124], history of abdominal aortic aneurysm repair, a fib, hypertension, hyperlipidemia, transferred from [Hospital6 33] on [8-13] for prosthetic valve endocarditis in setting of R-frontal embolic stroke and new second degree heart block. . 1) Rhythm--atrial fibrillation, 2nd degree heart block: Pt has a history of afib on Coumadin. He presents with worsening of AV-nodal disease; EKG shows 2nd-degree AV block with increasing intervals compared to [8-12] EKG at OSH. Pt was initially anticoagulated on heparin gtt and transitioned to warfarin by discharge. Given the marked AV block and risk of progression to complete HB, temporary pacer was placed. His beta blocker was stopped. After discussion of risks and benefits, patient has declined to have a permanent pacer, a procedure that would have been risky given his active infection. . 2) Valves--Endocarditis: Patient presented with aortic valve endocarditis on mechanical valve with abscess. Blood cultures at OSH showed E. faecalis, sensitive to Vancomycin and Amp. ID was consulted and recommended 4 week course of Amp/Gentamycin. Surveillance cultures at [Hospital1 18] were all negative or no growth to date. CT Surgery was consulted and discussed with the patient and his family the risks/benefits of CT surgery. The patient has declined surgery at this time. He does have an outpatient cardiac surgery appointment scheduled should he change his mind. TEE showed possible progression of abscess. . 3) CAD/Ischemia: Pt had no evidence of acute ischemic changes. Pt was continued on Aspirin 81 mg, Simvastatin 40 mg, Lisinopril 10 mg. . 4) Neuro/embolic stroke: Pt had minimal residual neurological deficits upon transfer to [Hospital1 18]. CT head showed "(a) Hypoattenuating areas in the right frontal and left parietal lobes (acute or subacute infarcts given the patient's history). (b) Probable old infarcts in the right frontotemporal lobe and left occipital lobe. (c) Enlargement of the ventricles out of proportion to the sulci, which may be related to central atrophy." Serial neuro exams showed no gross changes. . 5) Anemia: Pt was found to have guaiac positive stool; last colonoscopy was 15 years ago. Pt also reported gross hematuria x 3 days 3 wks PTA and underwent cystoscopy at [Hospital3 ]. Report is not currently available; we are awaiting the fax. In addition, iron profile was consistent with ACD. SPEP was checked and was negative. He did not require blood transfusions. HCT remained stable between 24-27. . 6) HTN: Pt was continued on Lisinopril 10 mg PO daily. His atenolol was discontinued due to heart block. . 7) GERD: Pt was continued on Protonix. . 8) Code: DNR/DNI . 9) Disposition: Patient expressed that his main goal is to go home. After discussion with ID, cardiac surgery, palliative care, and the primary team, pt has decided to go home with antibiotics, NO pacemaker, and NO plans for cardiac surgery. He will go home with hospice care. Patient will have INR levels drawn by his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], and he will continue Lovenox injections until his INR is therapeutic. Patient will have labs drawn for vancomycin trough, gentamicin trough, ESR, CRP, and Cr weekly, and these results will be faxed to the Infectious Disease department. Medications on Admission: MEDs at-home: 1. lanoxin 0.125mg qd 2. tenormin 25mg qd 3. prinivil 10mg qd 4. zocor 40mg qd 5. protonix 40mg qd 6. coumadin 5mg qd . MEDs on transfer: 1. tylenol prn 2. pantoprazole 40mg qd 3. lisinopril 10mg qd 4. aspirin 81mg qd 5. vanco 1g q24hr (d#1? [8-13]) 6. heparin gtt (d#1? [8-13]) Discharge Medications: 1. Gentamicin Sulfate (PF) 100 mg/10 mL Solution Sig: One Hundred (100) mg Intravenous twice a day for 4 weeks: To be continued until [9-13]. Disp:50 solutions Refills:0 2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush for 4 weeks. Disp:qs x 4 weeks ML(s) Refills:0 3. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 4. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) mL Injection once a day as needed for line care for 4 weeks. Disp:qs x 4 weeks Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Outpatient Lab Work Please draw weekly Creatinine, gentamicin trough, vancomycin trough, Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP) every Monday while on IV antibiotics and please call results in to [Hospital ] clinic at ([Telephone/Fax (1) 6313] Attn: Dr. [Last Name (STitle) 111]. 12. Outpatient Lab Work Please check INR on [2143-8-23] and call in result to Dr. [Last Name (STitle) ],[First Name3 (LF) 177] D [Telephone/Fax (1) 33129]. Please also check gentamicin/vancomycin trough with same blood draw and call results to [Hospital ] clinic at ([Telephone/Fax (1) 6313] Attn: Dr. [Last Name (STitle) 111]. 13. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Vancomycin 1,000 mg Recon Soln Sig: One (1) bag Intravenous q 12 hours for 28 days: Please draw trough vanco level each monday. Disp:56 bags Refills:0 15. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO up to q 1 hour sublingual as needed for pain. Disp:60 cc Refills:0 16. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for agitation. Disp:20 Tablet(s) Refills:0 17. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for increased secretions. Disp:5 patches Refills:0 18. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 4-6 hours as needed for increased secretions. Disp:20 Refills:0 19. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): Use daily but stop after your Warfarin level is more than 2.0. Disp:6 syringes Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) ] Discharge Diagnosis: Primary: Endocarditis . Secondary: Second degree heart block Embolic stroke Anemia Hypertension Discharge Condition: Good condition. HR 69-74 , SBP 133-165/50-60's , temp 97.9. O2 sat 96% on RA. Discharge Instructions: You were admitted to the hospital for a bacterial infection on your heart valve. The Infectious Disease doctors have [Name5 (PTitle) 12314] [Name5 (PTitle) ] in the hospital and have recommended a 4-week course of antibiotics (gentamicin and vancomycin). In addition, a temporary pacemaker was placed to make sure your heart beats correctly. You have decided against having a permanent pacemaker placed. The Cardiac Surgery team has also discussed the benefits and risk of cardiac surgery. You expressed understanding that surgery is likely the only option in completely curing the bacterial infection; however, at this time, you did not want to pursue surgery. An appointment with Cardiac Surgery is scheduled for [2143-9-3] if you decide to pursue surgery. Please call [Telephone/Fax (1) 170] if you want to cancel the appt. The Pallative Care team has also visited you and you have clearly stated that your main goal is to return home. We have arranged to have hospice nurse help care for you at home. You will have visiting nurses to help administer your IV antibiotics. . Your medications have been changed. You will STOP the following medications: lanoxin and tenormin. You will continue zocor (simvastatin) and coumadin. NEW medications include the antibiotics vancomycin and gentamicin that will go through your PICC line. Please see the attached list. You will need to have Lovenox injections once daily to prevent blood clots until your coumadin level is therapeutic (between [1-27])Dr.[Name (NI) 78948] office will tell you when to stop the Lovenox injections. . If you develop fevers, chest pain, shortness of breath, bleeding, black stools, blood in your stools, lightheadedness or any other concerning symptoms, please call your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Telephone/Fax (1) 33129] or 911. Followup Instructions: Cardiac Surgery: Provider: [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2143-9-3] 2:30 Primary care: [Last Name (LF) ],[Name6 (MD) 177] D, MD Phone: [Telephone/Fax (1) 33129] Date/Time: Office will call you at home to set up an appt Cardiology: [Last Name (LF) ],[Name8 (MD) 819], MD Phone: ([Telephone/Fax (1) 64863] [Hospital ] Medical Associates [Street Address(2) ],[Location (un) 936], [Numeric Identifier 78949] Date/time: [8-27] at 10 am. Completed by:[2143-8-21]	[ "305.1", "599.7", "530.81", "996.61", "434.11", "285.9", "E878.1", "421.0", "427.31", "272.4", "426.13", "401.9", "041.04", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.72", "38.93", "37.78" ]	icd9pcs	[ [ [] ] ]	14055, 14106	7391, 10752	327, 361	14246, 14327	3590, 3590	16280, 16879	2425, 2443		11115, 14032		14127, 14225		10778, 10918			14351, 16257				4038, 7368						2458, 3571																														275, 289																389, 2002						3606, 4022												2024, 2278	2294, 2409		10936, 11092
23,915	141,444	14754	Discharge summary	report	Admission Date: [2103-6-24] Discharge Date: [2103-6-29] Date of Birth: [2034-3-18] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: The patient is a 69 year old male with a history of coronary artery disease status post coronary artery bypass graft, abdominal aortic aneurysm status post repair, paroxysmal atrial fibrillation on Coumadin, and renal cell carcinoma status post left nephrectomy, transferred from [Hospital3 15174] for further management of a right adrenal hemorrhage. The patient was visiting his son in central [State 350] and developed the sudden onset of right flank pain on the morning of [6-23], with radiation to his epigastrium. At [Hospital1 ], he was noted to have a blood pressure of 168/107 with an INR of 2.3. CT scan of the abdomen revealed a right adrenal hemorrhage. His INR was corrected with 6 units of fresh frozen plasma and 2.5 mg of Vitamin K, which brought it down to 1.4. His hematocrit dropped from 41 to 28; the patient was transfused two units of packed red blood cells. His hematocrit was subsequently stable in the low 30s. Repeat CT scan on [6-24], revealed no change in the size of the hemorrhage. The patient was noted to be in congestive heart failure with decreased oxygen saturation and edema on chest x-ray. The congestive heart failure was presumed to be secondary to high volume blood products resuscitation. The patient was diuresed with intravenous Lasix. The patient's hypertension was difficult to control and he was started on Nipride, Hydralazine, Norvasc, Minoxidil, Toprol XL and Aldomet. The patient's blood pressures typically run at approximately 180/120 at home. He was subsequently transferred to [Hospital1 1444] for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2092]. 2. Hypertension. 3. Obstructive sleep apnea not on C-PAP. 4. Abdominal aortic aneurysm status post repair in [2090], complicated by an abdominal wall hernia. 5. Hypercholesterolemia. 6. Chronic obstructive pulmonary disease. 7. Thoracic aortic aneurysm. 8. Low back pain. 9. Renal cell carcinoma status post left nephrectomy in [2090]. 10. Atrial fibrillation with a history of transient ischemic attacks on Coumadin. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Protonix 40 mg p.o. q. day. 2. Flomax 0.4 mg p.o. q. day. 3. Norvasc 10 mg p.o. q. day. 4. Aldomet 500 mg p.o. three times a day. 5. Lipitor 10 mg p.o. q. day. 6. Atrovent two puffs four times a day. 7. Albuterol two puffs four times a day. 8. Nystatin swish and swallow, four times a day. 9. Flovent two puffs twice a day. 10. Levaquin 500 mg p.o. q. day. 11. Colace. 12. Toprol XL 200 mg p.o. q. day. 13. Hydralazine 50 mg p.o. q. six. 14. Senna two p.o. q. h.s. SOCIAL HISTORY: The patient resides in [State 531]. He is a retired firefighter. He has a positive tobacco history and smoked approximately two pack per day for the past 50 years. He denies any alcohol use. He has five children and nine grandchildren. PHYSICAL EXAMINATION: The patient had a blood pressure of 180/83; pulse of 71; respiratory rate of 24; saturation 92% on room air; he was afebrile. In general, he was an alert, mildly dyspneic gentleman in no acute distress. His pupils equally round and reactive to light. His extraocular movements are intact. His mucous membranes were moist. His oropharynx was clear. His neck was supple without lymphadenopathy or any visible jugular venous distention. Cardiovascular examination: He had a regular rate and rhythm without any murmurs. On respiratory examination, he had diffuse expiratory wheezing bilaterally. His abdomen was soft, nontender, nondistended with normoactive bowel sounds. His extremities were warm without cyanosis, clubbing or edema. LABORATORY: On transfer, the patient had a white blood cell count of 7.6, hematocrit of 32.3, platelet count of 108. He had a sodium of 137, potassium of 3.8, chloride of 101, CO2 of 27, BUN of 18, creatinine of 1.6, glucose of 81. He had a magnesium of 1.9, phosphate of 3.4, albumin of 3.4 and INR of 1.2. PTT of 33.3. He had an EKG which revealed normal sinus rhythm at 80. He was noted to have non-specific T wave inversions laterally in V2 through V6, unchanged from the prior cardiogram [2103-6-23]. Chest x-ray revealed no evidence of congestive heart failure or pneumonia. He was noted to have findings consistent with chronic obstructive pulmonary disease as well as a questionable mediastinal widening secondary to a vascular structure. He had a renal ultrasound which revealed a right kidney mildly enlarged but with normal echo texture. HOSPITAL COURSE: This is a 69 year old male with a history of coronary artery disease status post coronary artery bypass graft, hypertension, abdominal aortic aneurysm status post repair, and renal cell carcinoma status post left nephrectomy, who presents with a right adrenal hemorrhage in the setting of an INR of 2.3. His hospital course up to this point has been notable for persistent malignant hypertension necessitating a Nipride drip and multiple oral agents. 1. Endocrine: With regard to the adrenal mass, we are uncertain of the cause; however, his hematocrit was noted to remain stable throughout the remainder of his hospital stay. Furthermore, he did not have any evidence of adrenal insufficiency. One possibility on our differential was that the patient may have a tumor which resulted in the adrenal hemorrhage. He subsequently had an MRI of his abdomen to evaluate for possible mass abutting the adrenal gland. The MRI revealed a focal collection consistent with the previously noted hemorrhage. We held the patient's Coumadin given this acute event. At this time, we remain uncertain about the cause of his adrenal hemorrhage. 2. Hypertension: We started the patient on a regimen of Labetalol, Hydralazine and Norvasc. This resulted in adequate blood pressure control. Our initial goal was a systolic blood pressure of approximately 150 mm of Mercury given the patient's baseline systolic blood pressure of 180 mm of Mercury. The patient tolerated this regimen well without any difficulties. Toward the end of his hospital stay, we gently titrated up the Labetalol in order to maximize blood pressure control. We performed an MRA of the patient's renal arteries in order to evaluate for potential secondary cause of malignant hypertension. The patient was found to have a 70% renal artery stenosis on the right side. In addition, his right kidney was noted to be of normal size and, therefore, is likely viable. The patient is likely a good candidate for angioplasty. However, given his recent hemorrhage, he is not currently a candidate for the anti-coagulation necessary for this procedure, therefore, we will control his blood pressure with oral agents and he will follow as an outpatient for further management of his renal artery stenosis. 3. Chronic obstructive pulmonary disease: The patient was noted to be dyspneic with limited ambulation. He had expiratory wheezing on examination. We initially treated him with a five-day course of Zithromax for possible bronchitis. We subsequently ended up starting the patient on a Prednisone taper. He tolerated the Prednisone quite well and had a marked improvement in his respiratory status. He was continued on his Metered-Dose Inhalers and had instructions by Respiratory Therapy for the appropriate use of the inhalers. 4. Cardiovascular: With regards to his paroxysmal atrial fibrillation, the patient was noted to be in sinus rhythm during his hospital stay. We have held his Coumadin given his adrenal hemorrhage. We recommend that this be held for the time being and that it be started in several weeks with caution as an outpatient. 5. Vascular: during his stay, the patient was noted to have an asymmetric lower extremity edema, left greater than right. He had a lower extremity ultrasound which revealed dilatation of the right common femoral artery to 2.4 cm with an atheromatous plaque within. The patient was seen by the Vascular Surgery consultation service. They did not think that intervention is necessary at this time. However, they have recommended the patient to follow with his vascular surgeon in [State 531] for further management. DISCHARGE DIAGNOSES: 1. Right adrenal hemorrhage. 2. Right renal artery stenosis. 3. Chronic obstructive pulmonary disease exacerbation. 4. Coronary artery disease status post coronary artery bypass graft. 5. Abdominal aortic aneurysm status post repair. 6. Thoracic aortic aneurysm. 7. Common femoral artery dilatation. DISCHARGE MEDICATIONS: 1. Labetalol 150 mg p.o. twice a day. 2. Prednisone taper. 3. Zithromax 250 mg p.o. q. day times three days. 4. Atrovent two puffs four times a day. 5. Albuterol two puffs q. four to six hours p.r.n. 6. Flovent two puffs twice a day. 7. Hydralazine 50 mg p.o. q. six hours. 8. Norvasc 10 mg p.o. q. day. 9. Lipitor 10 mg p.o. q. day. 10. Flomax 0.4 mg p.o. q. day. 11. Protonix 40 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with his primary care provider and vascular surgeon in [State 531]. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 11732] MEDQUIST36 D: [2103-6-29] 16:37 T: [2103-7-3] 08:13 JOB#: [Job Number 20723]	[ "255.4", "427.31", "401.0", "440.1", "496", "428.0", "V45.81", "272.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								8450, 8758	8781, 9188					4779, 8429		9212, 9578																											3156, 4761																													163, 1773																	2394, 2872	1795, 2369	2889, 3133
772	186,398	9312	Discharge summary	report	Admission Date: [2189-10-9] Discharge Date: [2189-10-19] Date of Birth: [2123-4-25] Sex: M Service: Vascular Surgery HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old gentleman with known coronary artery disease (status post myocardial infarction in [2186-4-15] and status post percutaneous transluminal coronary angioplasty with a stent in [2186-4-15] also to the distal right coronary artery and posterior left ventricular branch). The patient was admitted to an outside hospital on [10-8] with chest pain over a 5-day period and ruled in for a myocardial infarction. His cardiac catheterization showed 3-vessel disease with an ejection fraction of 55% at the outside hospital, and he was transferred to [Hospital1 346] for coronary bypass surgery. PAST MEDICAL HISTORY: 1. Myocardial infarction. 2. Hypercholesterolemia. 3. Insulin-dependent diabetes mellitus. 4. Status post laparoscopic cholecystectomy in [2189-9-14]. 5. Hypertension. 6. Question chronic renal insufficiency (with a baseline creatinine of 1.3). MEDICATIONS ON ADMISSION: (Medications at home on admission were as follows) 1. NPH insulin 45 units subcutaneously twice per day. 2. Lipitor 80 mg by mouth once per day. 3. Aspirin. 4. Norvasc. MEDICATIONS IN HOSPITAL: 1. Zocor. 2. Lopressor 25 mg by mouth twice per day. 3. Heparin. 4. Intravenous Integrilin. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient's heart rate was 72 (in sinus rhythm), his blood pressure was 139/65, his respiratory rate was 19, and his oxygen saturation was 98%. At the time of examination the patient was on an Integrilin drip at 2, a nitroglycerin drip at 0.3 mcg/kg per minute, and heparin at 1200 units per hour. PERTINENT LABORATORY VALUES ON PRESENTATION: Preoperative laboratories were as follows. The patient's white blood cell count was 11, his hematocrit was 43.4, and his platelet count was 303,000. Sodium was 137, potassium was 4, chloride was 105, bicarbonate was 21, blood urea nitrogen was 13, creatinine was 0.8, and blood glucose was 156. In general, the patient was alert and oriented. He had excellent strength in all four extremities. He was a Spanish-speaking gentleman. His lungs were clear bilaterally. Cardiovascular examination revealed his heart was regular in rate and rhythm. No murmurs or rubs. He had several well-healed 2-cm surgical scars from his laparoscopic cholecystectomy. He had bowel sounds. His abdomen was soft with mild tenderness to deep palpation over the epigastric area. The abdomen was nondistended, and there was no hepatosplenomegaly. Extremity examination revealed the extremities were warm with no varicosities. He had no cyanosis, clubbing, or edema. He had peripheral pulses present for femoral, popliteal, dorsalis pedis, posterior tibialis pulses, and radial arteries. He had no bruits in his carotid. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was seen by Cardiothoracic Surgery and referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ]. He was continued on his heparin, nitroglycerin, and Integrilin drips. A bedside echocardiogram was done preoperatively by Cardiology which showed a depressed left ventricular function and anteroapical septal hypokinesis, but no severe mitral regurgitation or effusion. Please refer to the complete report. The patient remained in house prior to surgery on Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Last Name (Prefixes) 2546] Service for the next few days prior to his operation. His sheaths were pulled. His creatinine was stable at 0.9. Additional laboratories came back with an aspartate aminotransferase of 27, alanine-aminotransferase of 27, and a total bilirubin of 0.9. The patient remained in the Cardiothoracic Surgery Recovery Unit for monitoring on his heparin, nitroglycerin, and Integrilin drips. On [10-11], his heparin was held for an elevated partial thromboplastin time. Adjustments were made in his medication. He had a carotid study done which showed no significant stenoses on [10-12] preoperatively. Please refer to the Radiology report. Preoperatively, his prothrombin time was 13.4, his INR was 1.2, with a partial thromboplastin time of 75 on heparin. He continued to receive his beta blocker. On [10-13], the patient underwent coronary artery bypass grafting times four by Dr. [First Name (STitle) ] [Last Name (Prefixes) ] with a left internal mammary artery to the left anterior descending artery, a vein graft to the posterior descending artery, a vein graft to the obtuse marginal, and a vein graft to the diagonal. The patient was transferred to the Cardiothoracic Intensive Care Unit on a milrinone drip at 0.5 mcg/kg per minute and a Levophed drip at 0.025 mcg/kg per minute in stable condition. On postoperative day one, the patient's Levophed was weaned off. He remained on a milrinone drip and an insulin drip. Temperature maximum was 99.5 degrees Fahrenheit, his blood pressure was 140/62, in sinus rhythm at 91. His lungs were clear. His heart was regular in rate and rhythm. His dressings were clean, dry, and intact. Chest tubes were discontinued. The patient was continued on his perioperative antibiotic. Postoperatively, his white blood cell count was 9.6, his hematocrit was 30.1, and his platelet count was 205,000. His potassium was 4.5, blood urea nitrogen was 14, and creatinine was 0.9. The patient was screened by the Clinical Nutrition team. He was extubated early in the morning on postoperative day one after having been rested overnight on the ventilator. On postoperative day two, the patient had a temperature maximum of 100.8 degrees Fahrenheit. He was hemodynamically stable and in sinus rhythm. He was awake and appropriate. He had decreased breath sounds at the left base, but otherwise his examination was unremarkable. His chest tubes were pulled. He was started on captopril and restarted on his Lopressor. His hematocrit remained stable at 29.1. He was transferred out to [Hospital Ward Name 121] Two where he was evaluated by the Physical Therapy team. He started ambulating out on the floor. He was seen by the case manager. Once during the day, on postoperative day two, the patient refused to walk with Physical Therapy complaining of fatigue. Again, a Spanish interpreter was present to help make clear the team's wishes for his ambulation. On postoperative day three, he had no specific complaints. His wires were discontinued. His Foley catheter was pulled. He remained in a sinus rhythm. He was neurologically appropriate. His hematocrit rose slightly to 31.5 with a white blood cell count of 11.1. His creatinine was stable at 1. His blood sugars were slightly elevated. His NPH was increased. He continued with physical therapy and ambulation. Over the next day, he complained of a little bit of incisional pain but this was well controlled with Percocet. He had no events overnight. He was saturating 92% on room air. His hematocrit was stable, but his creatinine rose from 1 to 1.2 on postoperative day four with plans to recheck his creatinine in the evening and stop his captopril if his creatinine rose precipitously. On postoperative day five, his electrocardiograms the night prior showed a bundle branch block in aVF. Cardiac enzymes were cycled. He had no chest pain overnight. His troponin was 0.21, with a creatine kinase of 164, and a MB fraction of 3. He was alert and oriented and comfortable in bed. He had decreased breath sounds at the left base with some crackles. His heart was regular in rate and rhythm. It was determined that his electrocardiogram changes were not due to enzymes elevation; not necessarily consistent with chest pain or unstable angina. A repeat electrocardiogram was ordered. He did have one run of ventricular tachycardia of about 150 per minute times nine beats with no previous ventricular ectopy. He was given magnesium 2 g times two doses, and he was encouraged to have aggressive chest physical therapy. and nebulizer treatments, as well as incentive spirometry work to help increase his pulmonary toilet with hopes of discharging him shortly. On postoperative day six, he had a slight left-sided chest rub. His sternal incision was okay. The wound had no erythema. Heart was regular in rate and rhythm. He was in a sinus rhythm in the 80s. His temperature maximum was 99.4 degrees Fahrenheit. His blood pressure was 140/92. He was saturating 96% on room air. His creatinine stabilized at 1. His potassium was 4.5. He had some slight erythema at his right knee wound from the saphenectomy site, but minimal edema otherwise in his extremities. DISCHARGE DISPOSITION: The patient was discharged to home on [10-19]. MEDICATIONS ON DISCHARGE: 1. Metoprolol 20 mg by mouth twice per day. 2. Lasix 20 mg by mouth twice per day (times seven days). 3. Colace 100 mg by mouth twice per day. 4. Aspirin 325 mg by mouth once per day. 5. Percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed (for pain). 6. Lipitor 80 mg by mouth once per day. 7. Captopril 25 mg by mouth three times per day. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times four. 2. Status post myocardial infarction times two. 3. Status post percutaneous transluminal coronary angioplasty with stent in [2186-4-15]. 4. Hypercholesterolemia. 5. Insulin-dependent diabetes mellitus. 6. Hypertension. 7. Question chronic renal insufficiency. DISCHARGE STATUS: The patient was discharged to home. CONDITION AT DISCHARGE: Condition on discharge was stable on [2189-10-19]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2189-12-3] 12:23 T: [2189-12-4] 09:57 JOB#: [Job Number 31864]	[ "401.9", "414.01", "593.9", "410.71", "427.1", "250.00", "412", "997.1", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.13" ]	icd9pcs	[ [ [] ] ]	8804, 8856							9269, 9663				8882, 9248	1112, 2941																									2970, 8780							9678, 9997																											175, 807																		829, 1085
25,009	148,765	22842	Discharge summary	report	Admission Date: [2136-1-11] Discharge Date: [2136-2-17] Date of Birth: [2075-3-5] Sex: F Service: MEDICINE Allergies: Xanax Attending:[First Name3 (LF) 1115] Chief Complaint: right lower extremity worsening heel ulcer Major Surgical or Invasive Procedure: [2136-1-12]: Debridement of right heel skin and subcutaneous tissue down to bone. [2136-1-14]: Right excisional debridement, partial calcanectomy right side. [2136-1-23]: Debridement of skin and subcutaneous tissues right heel. [2136-1-23]: Debridement of open wounds right side and right ischium measuring 12 x 12 cm on the right thigh, and 9 x 8 cm on the right ischium, and placement of vacuum-assisted closure dressing. History of Present Illness: Ms. [Known lastname 17025] is a 60 year old woman who presents to the ED with wet gangrene of her right heel. She is s/p b/l femoral-popliteal bypasses and a TMA of her left foot. Her symptoms began 1 month ago when she noted redness of her right leg and foot. She treated this with some form of ointment after which she noted worsening drainage from her heel prompting her to be admitted to [Hospital 1474] Hospital. She was started on Invanz, a PICC line was placed on [1-3] and she was transferred to a rehab facility. Per the rehab records she initially was admitted with dry gangrene of the heel which has progressively worsened. She was evaluated by wound care nursing and a [Month/Day (4) 1106] surgeon who felt inpatient admission and debridement would be needed and she was therefore transferred to [Hospital1 18] for further care. She denies fevers and chills, but does report significant pain in her right foot. Past Medical History: PMH: Diabetes, Hypertension, Obesity, Smoking, Anemia, CAD, CHF, GERD, hx of VRE PSH: - CABG x2 c/b sternal wound infections requiring multiple debridements and skin grafting '[30] - ventral hernia repair '[30] - L CFA-AK [Doctor Last Name ] BPG c/b left groin MRSA infection [7-3] - L TMA [9-2] - s/p ORIF L supracondylar femur fx on [2133-6-4] and revision [2133-7-4] - Angioplasty of L BPG [12-4] - R CFA-AK [Doctor Last Name ] BPG w/ NRSV c/b groin infection w/ proteus, pseudomonas requiring debridement [12-4] Social History: Former smoker 2ppd x 20 years, quit 25 years ago. Denies alcohol or IVD use. Lives with sister. Family History: non-contributory Physical Exam: Vital Signs: Temp: 97.4 RR: 20 Pulse: 69 BP: 139/60 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, abnormal: Obese, large midline scar from hernia repair. Extremities: Abnormal: Difficult groin exam given significant pannus. B/L venous stasis changes, L TMA well healed. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE DP: P. PT: P. LLE DP: P. PT: D. DESCRIPTION OF WOUND: Large area of wet gangrene over right heel with surrounding erythema, unable to express puss. Does not probe to bone. Pertinent Results: [2136-2-17] 09:17AM BLOOD WBC-11.3* RBC-2.84* Hgb-8.0* Hct-24.8* MCV-87 MCH-28.2 MCHC-32.2 RDW-17.6* Plt Ct-358 [2136-1-11] 05:15PM BLOOD Glucose-190* UreaN-34* Creat-1.2* Na-138 K-4.5 Cl-99 HCO3-30 AnGap-14 [2136-1-23] 06:00AM BLOOD Glucose-94 UreaN-42* Creat-2.2* Na-138 K-4.0 Cl-105 HCO3-26 AnGap-11 [2136-1-29] 04:29AM BLOOD Glucose-115* UreaN-52* Creat-3.7* Na-135 K-3.7 Cl-103 HCO3-25 AnGap-11 [2136-1-30] 04:40AM BLOOD Glucose-80 UreaN-53* Creat-4.2* Na-134 K-3.5 Cl-101 HCO3-23 AnGap-14 [2136-1-30] 03:30PM BLOOD Glucose-94 UreaN-55* Creat-4.3* Na-136 K-3.8 Cl-102 HCO3-24 AnGap-14 [2136-1-31] 03:54AM BLOOD Glucose-80 UreaN-56* Creat-4.4* Na-135 K-3.8 Cl-102 HCO3-25 AnGap-12 [2136-1-31] 05:03PM BLOOD Glucose-136* UreaN-55* Creat-4.2* Na-134 K-3.9 Cl-101 HCO3-24 AnGap-13 [2136-2-1] 04:10AM BLOOD Glucose-95 UreaN-56* Creat-4.2* Na-136 K-3.6 Cl-101 HCO3-26 AnGap-13 [2136-2-1] 05:57PM BLOOD UreaN-55* Creat-4.0* Na-135 K-3.5 Cl-99 HCO3-25 AnGap-15 [2136-2-2] 04:06AM BLOOD Glucose-115* UreaN-53* Creat-3.9* Na-137 K-3.9 Cl-101 HCO3-26 AnGap-14 [2136-2-7] 08:03PM BLOOD UreaN-42* Creat-2.8* Na-131* K-3.9 Cl-94* [2136-2-14] 05:10AM BLOOD Glucose-121* UreaN-46* Creat-2.1* Na-133 K-4.2 Cl-92* HCO3-32 AnGap-13 [2136-2-15] 05:37AM BLOOD Glucose-107* UreaN-44* Creat-1.9* Na-135 K-4.1 Cl-94* HCO3-32 AnGap-13 [2136-2-15] 02:54PM BLOOD Glucose-155* UreaN-42* Creat-1.9* Na-136 K-4.0 Cl-96 HCO3-31 AnGap-13 [2136-2-16] 05:19AM BLOOD Glucose-88 UreaN-43* Creat-1.9* Na-137 K-4.3 Cl-95* HCO3-34* AnGap-12 [2136-2-16] 11:15PM BLOOD Glucose-135* UreaN-43* Creat-1.9* Na-135 K-4.2 Cl-95* HCO3-31 AnGap-13 [2136-2-17] 09:17AM BLOOD Glucose-134* UreaN-42* Creat-1.8* Na-137 K-4.4 Cl-97 HCO3-31 AnGap-13 [2136-2-14] 05:10AM BLOOD Tobra-3.3* [2136-2-15] 05:37AM BLOOD Tobra-1.8* [2136-2-17] 09:17AM BLOOD Tobra-0.8* . Foot X rays: IMPRESSION: Diffuse soft tissue swelling without definite signs of soft tissue gas or foreign body. Probable ulceration along the soft tissues at the heel without underlying signs of osteomyelitis. . [2136-1-11] 10:47 pm FOOT CULTURE Source: R heel. FINAL REPORT [2136-1-15] GRAM STAIN (Final [2136-1-12]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [2136-1-15]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 2 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Time Taken Not Noted Log-In Date/Time: [2136-1-12] 9:27 am TISSUE RIGHT FOOT. FINAL REPORT [2136-1-29] GRAM STAIN (Final [2136-1-12]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. TISSUE (Final [2136-1-16]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 59049] [2136-1-12]. ANAEROBIC CULTURE (Final [2136-1-16]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [2136-1-29]): NO FUNGUS ISOLATED. [2136-1-14] 2:55 pm TISSUE RIGHT HEEL. FINAL REPORT [2136-1-18] GRAM STAIN (Final [2136-1-14]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2136-1-18]): STAPH AUREUS COAG +. 1 COLONY ON 1 PLATE. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [2136-1-18]): NO ANAEROBES ISOLATED. [2136-1-14] 3:05 pm TISSUE RIGHT HEEL MARGIN. FINAL REPORT [2136-1-20] GRAM STAIN (Final [2136-1-14]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. TISSUE (Final [2136-1-17]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Final [2136-1-20]): NO ANAEROBES ISOLATED. [2136-1-17] 10:44 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2136-1-17] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2136-1-17]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). FINAL REPORT [2136-1-25] GRAM STAIN (Final [2136-1-23]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2136-1-25]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. [2136-1-23] 1:00 pm TISSUE RIGHT ISCHIAL WOUND. FINAL REPORT [2136-2-6] GRAM STAIN (Final [2136-1-23]): REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 59050] @ 630PM [1-22]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final [2136-1-27]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. PROBABLE ENTEROCOCCUS. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. YEAST, PRESUMPTIVELY NOT C. ALBICANS. SPARSE GROWTH. [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SECOND MORPHOLOGY. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 32 R 32 R CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S 2 S MEROPENEM------------- 4 S 2 S PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ <=1 S <=1 S ANAEROBIC CULTURE (Final [2136-1-27]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [2136-2-6]): [Female First Name (un) ] ALBICANS. SENSITIVE TO Fluconazole. sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [Hospital1 69] Clinical Microbiology Laboratory.. SENSITIVITIES REQUESTED BY DR [Last Name (STitle) ] [2136-1-28]. [2136-1-23] 1:00 pm TISSUE RIGHT THIGH WOUND TISSUE. FINAL REPORT [2136-2-6] GRAM STAIN (Final [2136-1-23]): REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 59050] @ 630PM [2136-1-23]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. TISSUE (Final [2136-2-2]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. SENSITIVITIES PER DR [Last Name (STitle) 59051] [2136-1-27]. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES PER DR [Last Name (STitle) 59051] [2136-1-27]. Daptomycin Susceptibility testing requested by K [Doctor Last Name 3689] [3-/4872] [2136-1-31]. Daptomycin =3MCG/ML Sensitivity testing performed by Etest. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. SPARSE GROWTH. Further workup requested by DR [Last Name (STitle) ].FLASH [2136-1-27]. SENSITIVE TO Fluconazole , sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [Hospital1 69] Clinical Microbiology Laboratory.. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 59052], [2136-1-23]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 59052], [2136-1-23]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ =>32 R CLINDAMYCIN-----------<=0.25 S DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- 4 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>64 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S =>32 R ANAEROBIC CULTURE (Final [2136-1-27]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [2136-2-6]): [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. [2136-2-6] 4:36 pm BLOOD CULTURE Source: Line-Picc. FINAL REPORT [2136-2-12] Blood Culture, Routine (Final [2136-2-12]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. OF TWO COLONIAL MORPHOLOGIES. Aerobic Bottle Gram Stain (Final [2136-2-7]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5143] @ 720PM [2136-2-7]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [2136-2-8] 12:25 pm SWAB Source: Deep Right Buttocks. FINAL REPORT [2136-2-12] GRAM STAIN (Final [2136-2-8]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [2136-2-12]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 4 S MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2136-2-12]): NO ANAEROBES ISOLATED. [2136-2-8] 12:25 pm SWAB Source: Right Ischial ulcer . GRAM STAIN (Final [2136-2-8]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. WORK UP REQUESTED PER DR. [Last Name (STitle) 10000] [2136-2-9] . DR [Last Name (STitle) 10000] ([Numeric Identifier 37310]) REQUESTED DORIPENEM AND COLISTIN SENSITIVITIES ON THE 2 PS. AERUGINOSA ISOLATES [2136-2-12]. AMIKACIN Sensitivity testing per DR [First Name (STitle) 9462] FLASH #[Numeric Identifier 59053], [2135-2-15]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. DORIPENEM = 12 MCG/ML, NON-SUSCEPTIBLE, Sensitivity testing performed by Etest Doripenem MIC interpretations are based on manufacturer's guidelines that are FDA approved. Interpret results with caution. ISOLATE SENT TO [Hospital1 4534] LABORATORIES FOR DORIPENEM CONFIRMATION AND COLISTIN SENSITIVITY TESTING ([2136-2-14]). PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. STRAIN 2. DORIPENEM = 16 MCG/ML, NON-SUSCEPTIBLE, Sensitivity testing performed by Etest Doripenem MIC interpretations are based on manufacturer's guidelines that are FDA approved. Interpret results with caution. ISOLATE SENT TO [Hospital1 4534] LABORATORIES FOR DORIPENEM CONFIRMATION AND COLISTIN SENSITIVITY TESTING ([2136-2-14]). ENTEROCOCCUS SP.. SPARSE GROWTH. Daptomycin Sensitivity testing per DR [First Name (STitle) 9462] FLASH #[Numeric Identifier 59053]. PROTEUS MIRABILIS. RARE GROWTH. PRESUMPTIVE IDENTIFICATION. IMIPENEM REQUESTED BY DR.[Last Name (STitle) ],[Doctor First Name 9462] [2136-2-17] AT 1135. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| ENTEROCOCCUS SP. \| \| \| PROTEUS MIRABILI \| \| \| \| AMIKACIN-------------- <=2 S 32 I <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 S CEFEPIME-------------- =>64 R =>64 R <=1 S CEFTAZIDIME----------- =>64 R =>64 R <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R 2 I =>4 R GENTAMICIN------------ <=1 S 8 I 8 I IMIPENEM-------------- 4 S LINEZOLID------------- 2 S MEROPENEM------------- =>16 R =>16 R <=0.25 S PENICILLIN G---------- =>64 R PIPERACILLIN/TAZO----- =>128 R =>128 R <=4 S TOBRAMYCIN------------ <=1 S <=1 S 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [2136-2-10]): UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. ALL No growth [2136-2-11] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2136-2-10] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2136-2-10] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2136-2-9] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2136-2-9] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2136-2-8] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT Brief Hospital Course: Ms. [Known lastname 17025] had a long (37days) and complicated admission here at [Hospital1 18]. Briefly, she was initially admitted on [2136-1-11] for debridement of gangrenous heel ulcers by [Year (4 digits) 1106] surgey, her post operative course was complicated by septic shock [2-29] multiple MDR organisms (VRE, Pseudomoas, [Female First Name (un) 564]), [Last Name (un) ], Hypoxia, and Neutropenia. A problem oriented list follows with presenation, interventions and follow up for each issue. #Heel Ulcers: Initially, Ms. [Known lastname 17025] presented to the ED with wet gangrene of her right heel. She is s/p bilateral femoral-popliteal bypasses and a TMA of her left foot. She had previously been at a rehab for the infection of her right foot and she was transferred to [Hospital1 18] when they noted its worsening appearance. She was admitted to the [Hospital1 ] Surgery service on [2136-1-11] and was started on vanc and zosyn given her history of MRSA and pseudomonas infection and was taken to the OR on hospital day 2 for debridement of her right heel and subcutaneous tissue down to bone. Podiatry took her to the OR for additional debridement and calcanectomy for osteomyelitis on the following day. The area was resected to create a clean margin of healthy bone. Post-op she was noted to become tachycardic, hypotensive and oliguric in the PACU, after which she was transferred to the CVICU for sepsis. She ultimately underwent multiple debridments of her heel by [Date Range 1106] surgery and the wound was dressed with a VAC dressing in the interim. On hospital day 9 she was transferred to the VICU. Her course continued to be complicated, with respiratory distress, acute renal failure, fluid overload and CHF and she was transferred to the medical service on hospital day 15. [Date Range ] Surgery continued to follow the patient. Over the course of her hospital stay, after the initial debridement and calcanectomy the heel wound looked progressively better with good granulation tissue forming. The plan is to continue managing the wound with a VAC dressing until it has granulated in. She is unlikely to be ambulatory in the near future and the issue of possible BKA can be readdressed at a later date if ambulation becomes an issue. Action Plan: - Continue VAC dressing - Follow up with [Date Range ] as outlined in DC planning . # Wound infections: Tissue samples and cultures from serial wound debridements grew out multiple multi drug resistant organisms. She is currently on a heavy regimen of IV antibiotics and has a PICC line in place to receive them. She is recieving daptomycin for VRE, Imipenem and Tobramycin for Pseudomonas, fluconazole for [Female First Name (un) ]. She is being followed closely by Infectious disese at [Hospital1 18] and all questions regarding her antibiotic dosing and monitoring labs should be directed to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9461] at [Telephone/Fax (1) 457]. Her antibiotics will continue until [3-28]. Detailed dosing/monitoring instructions/ as well as culture data can be found elsewhere in this discharge packet. ACTION PLAN: - Weekly safety labs (see attached) - Tobramycin monitoring (see attached) - Follow up with ID # Ischial/thigh ulcers: She was seen by Plastic Surgery for management of pressure ulcers on the posterior aspect of her thighs bilaterally. They also performed multiple debridements in the operating room as well as at bedside and determined that the dressing for these wounds should be wet-to-dry [Hospital1 ] changes. She should follow up with them in 1 week. ACTION PLAN: - Wet to dry dressings [Hospital1 ] - F/U with plastics in one week . # Non-[Hospital1 ] of a left supracondylar femur fracture: She was also seen by orthopaedic surgery for an incidentally found non-[Hospital1 ] of a left supracondylar femur fracture which was sustained in [6-3]. She previously underwent ORIF and then 2 revision surgeries. Since she had been non-ambulatory prior to admission, she had not been aware of this persistent injury. Orthopaedic surgery determined that the patient would not benefit from further revision surgery and recommend that she could undergo knee replacement when medically stable. # Hypoxic respiratory failure: Patients hyhpoxia was felt to be multifactorial: Volume overload, obesity hypoventilation, question of COPD. Patient was not felt to have had a PE nor a PNA as there was no evidece on symtpoms or imaging to support either. She was agressivly diuresed and is currently satting >95% on 2L NC for more than 24 hours. She requires BiPAP in the evening for OSA. Her I/O's should be followed closely with a goal of net even to 500cc negative each day. She should also have three times a week Chem 7's drawn to monitor her electrolytes. If her Cr begins to rise you may adjust her lasix and or fluid restriction as you see fit to maintain her fluid status. Her weight on discharge was 151kg. Action plan: - I/O's daily: Goal even to 500 cc negative - Fluid restrict to 1200cc/day - Lasix 120mg IV QHS - Supplemental O2 PRN - Nocturnal BiPAP . # [Last Name (un) ]: Ms. [Name13 (STitle) ] was admitted with a Cr of 1.2, following her bout of sepsis it rose to a peak of 4.4. Renal was consulted and although she suffered severe fluid overload she was able to eventually be diruesed and avoided HD. Her Cr has been gradually correcting and on the day of discharge was 1.8. She is currently making between 30-50cc of urine an hour. As her Cr corrects further her antibiotics will need to be adjusted to ensure they are achieving adequate levels in the setting of improving renal function ACTION PLAN: - Trend Cr three times a week - Continue to diuresis as above until euvolemic; will require close monitoring of volume status - *Ensure antibiotics are renally dosed as kidney function continues to improve . . Gram positive bacteremia: On [2136-2-6] the patient became febrile to 101 and a blood culture grew out staph aureus. The patient was already on broad spectrum gram positive coverage and HD stable. Her PICC line was removed and surveilance cultures were sent for 3 days with no growth. She remained afebrile throughout her line holiday and after three days a new PICC line was placed. She has been afebrile and HD stable since. ACTION PLAN - Monitor vitals . # Leukopenia: Patient developed neutropenia over the course of her stay with an ANC of 0 for several days. She was put on neutropenic precautions and seen by hematology who felt it was secondary to a brief stint on fluroquniolones she received. Her ABX regimen was optimzed for coverage and she was given neupogen for several days. After Resolved after 6 days and her Differential and white count has been normal since. Action Plan - Avoid Fluroquinolones in the future - Weekly CBC with differential while on Antibiotics . # CAD: s/p CABG x2. Trop peaked to 0.37, and has trended down, CK-MB flat and ECG was unchanged. This was thought to be secondary to demand ischemia. Her cardiovascular medications wer continued where appropriate. Action plan - Cont low dose metoprolol - Continue Aspirin - Continue statin . # HTN: Had required pressors in CVICU, thought to be secondary to sepsis. Antihypertensives were held. Once off pressors her metoprolol was restarted but at a lower dose. Action Plan - continue BB; may need to uptitrate as she continues to recover from this acute infection . # Diabetes: Her sugars fluctuated throughout her stay but her glycemic control was optimzed through basal, meal time and SSI insulin. Action Plan -- 16 U Lantus QAM -- 8 units of Humalog SC priot to breakfast, lunch and dinner -- SSI humalog at mealtimes: Glucose/Insulin Humalog 71-100 / 0 101-150/ 2 151-200/ 4 [Telephone/Fax (2) 59054]-300/ 8 [Telephone/Fax (2) 59055]1-400/ 12 >400/ recheck and notify MD # Anemia: Normocytic iron studies c/w AICD. Her hct has fluctuated between 22 and 27 throughout her stay. At one point it did drop to 21 although no etiology could be elucidated. She recieved a total of 12 units of PRBCs while in house with a transfusion threshold of 21. Her HCT has been stable for the last 4 days. Given that she has no evidence of active bleeding, a stable hematocrit and is asyptomatic at this time we dod not feel that her anemia warrants continued inpatient monitoring. It shoudl be followed closely by her PCP and [Name9 (PRE) ] facility. Action Plan - Three times weekly CBC - transfuse for HCT<21 or symptoms of end organ ischemia . # Morbid Obesity: Patient at baseline uses wheelchair. Non weightbearing on RLE. - DVT ppx with heparin SC Medications on Admission: Aspirin 325 Daily, Colace 100 [Hospital1 ], multivitamin, zinc sulfate 220 daily, KCl 10 meq daily, ascorbic acid 500 [Hospital1 ], ertapenem 1g daily, SQ heparin TID, Insulin SS, Lantus 16units [Hospital1 ], esomeprazole 50 daily, metoprolol 25mg [Hospital1 ], miconazole tp, simvastatin 80 daily, trazodone 150 daily, citalopram 40 daily, bacitracin topically to decubitus ulcer, lasix 80mg qAM, 40mg qPM, morphine 2mg IV prn, albuterol 2 puffs q4hr prn 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. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for daily BM. 5. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 40 days. 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast. 12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 15. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous QAM. 16. insulin lispro 100 unit/mL Solution Sig: Eight (8) units Subcutaneous AC. 17. Humalog 100 unit/mL Solution Sig: [2-8] Subcutaneous AC: Per Sliding Scale. 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for hard stool. 19. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 40 days. 21. imipenem-cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous every six (6) hours for 40 days. 22. tobramycin sulfate 40 mg/mL Solution Sig: One (1) Injection as directed for levels less than 1.0 for 40 days: Check Tobrmycin levels 48 hours following administration. If Less than 1.0 re-dose. If >1.0 hold dose and recheck levels daily until <1.0 then redose. 23. furosemide 10 mg/mL Solution Sig: One [Age over 90 ]y (120) mg Injection at bedtime. 24. morphine 100 mg/4 mL Solution Sig: 1-2 mg Intravenous every 4-6 hours as needed for pain: Hold for oversedation or rr<10. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Infected ulcers of the bilateral heels, right thigh and ischium. Acute Kidney Injury Septic Shock Hypoxic respiratory failure Neutropenia Morbid obesity Hypertension Coronary Artery Disease Discharge Condition: + Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Non- weightbearing right lower extremity Discharge Instructions: You were initially admitted to [Hospital1 18] for debridement of your [Hospital1 1106] ulcers on your leg. Your hospital course was complicated by a severe infection, kidney failure, respiratory failure and low white blood cells. While you were here your complications were addressed and it is felt that after a long stay you are well enough and stable enough to return to your extended care facility. There were several changes made to your medications while you were here. You are being discharged with an up to date medication list that you and your PCP will review and make changes to as necessasry. You will also have a number of follow up appointments to keep in the next week to months. It is very important that you keep these appointments. Followup Instructions: Department: [Hospital1 ] SURGERY When: THURSDAY [2136-3-15] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD [Telephone/Fax (1) 2625] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2136-2-28] at 3:30 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [2136-3-28] at 9:30 AM With: [Name6 (MD) 9462] FLASH, MD [Telephone/Fax (1) 457] . Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ], [First Name7 (NamePattern1) 11705] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] PLASTIC SURGERY, PC Address: [Street Address(2) ], [Apartment Address(1) 1427], [Location (un) ],[Numeric Identifier 1415] Phone: [Telephone/Fax (1) 1416] Appt: [2-22**] at 10:15am	[ "580.9", "401.9", "278.03", "112.3", "730.25", "E878.1", "785.52", "995.92", "428.33", "428.0", "414.8", "707.04", "041.7", "288.03", "731.8", "V09.91", "440.24", "999.31", "996.49", "496", "584.5", "518.81", "707.14", "707.05", "038.8", "V45.81", "707.24", "250.80", "327.23", "599.0", "V02.54", "278.01", "730.17", "293.0", "733.82", "E930.8" ]	icd9cm	[ [ [] ] ]	[ "86.28", "77.88", "83.45" ]	icd9pcs	[ [ [] ] ]	35039, 35111	23448, 32175	308, 751	35345, 35347	3358, 19475	36345, 37615	2440, 2458		32698, 35016		35132, 35324		32201, 32675			35564, 36322										2473, 3339																														226, 270							19510, 23425									779, 1729										35362, 35540								1751, 2310	2326, 2424
27,323	101,310	33118	Discharge summary	report	Admission Date: [2191-12-18] Discharge Date: [2191-12-26] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: s/p fall with right leg pain Major Surgical or Invasive Procedure: History of Present Illness: Ms. [Known lastname 76979] is an 88 year old female who sustained a mechanical fall at home. She was taken to [Hospital3 3583] and was found to have a right distal femur fracture. She was then transferred to the [Hospital1 18] for further care. Past Medical History: PMH: 1. total R knee and hip replacement ~[2155] 2. hypertension 3. anxiety/insomnia - treated for years with klonopin/paxil 4. endometriosis 5. arthritis 6. paraoxysmal atrial fibrillation - pt reports hx of "irregular heartbeat," unsure of most recent episode. Has never been on aspirin, has been on "coumadin" for a duration >1 year, but pt unsure of indication. *No history of cardiac issues - denies MI or heart failure. Had a stress test (per pt) > 10yrs prior, had to stop the test early bc "legs hurt," but denies chest pain or shortness of breath. Last colonoscopy >15yrs ago (per pt), was told it was normal. . PSH: 1. hysterectomy - >20yrs for ?endometriosis 2. appendectomy - >40yrs ago 3. other "female procedure' prior to hysterectomy, so "i could have children." Social History: Lives at independent living by herself, on [Location (un) 448]. Walks without the use of a walker or cane. Reports difficulty with balance over recent months, must use handrails to make steps. Active church goer. Continues to drive independently, buys groceries independently. Family History: n/a Physical Exam: Upon admission PE - T 98.7 BP 122/72 HR72 RR 16 100% Gen - NAD, A/Ox3, lying in bed, conversant, cooperative, intermittently repeated thoughts, but overall, very oriented. HEENT - no conjunctival pallor, no scleral icterus appreciated, MMM, no posterior pharyngeal erythema appreciated. NECK - no posterior/anterior LAD, no JVD appreciated. No carotid bruits appreciated bilaterally. No thyroid massess/nodules apprec. CV - RRR, S1+S2+S3-S4-, no murmurs or rubs appreciated. LUNGS - CTAB, good air movement bilaterally, no crackles appreciated, no wheezes appreciated ABD - NABS, soft, non-tender, non-distended. No organomegaly appreciated. Infraumbilical scars in place. Foley in place, draining urine. EXT - no lower extremity edema. 2+ palpable pulses bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all 2+. R lower extremity with deformity R distal though, TTP, SILT, DP/SP/T, [4-23] [Last Name (un) 938]/FHL/GS/TA NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not do fundoscopy. Preserved sensation throughout. 1+ reflexes L4 on L. PSYCH - Listens, responds to questions appropriately, mildly anxious. Brief Hospital Course: Ms. [Known lastname 76979] presented to the [Hospital1 18] on [2191-12-18] via transfer from [Hospital3 3583]. She was evaluated by the orthopaedic surgery department and found to have a right distal femur fracture. She was admitted, consented for surgery, cleared for surgery by medicine. On [2191-12-19] she was taken to the operating room and underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) 101] plate to her right femur fracture. She tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On [2191-12-20] she was transfused with 2 units of packed red blood cells due to acute post operative anemia. She was seen by physical therapy to improve her strength and mobility. On the evening of [2191-12-21] the patient developed atrial fibrillation with heartrate up to the 170's that was not controlled with IV metoprolol and diltiazem. Thus, on [2191-12-22] the patient was transferred to the SICU. In the SICU the patient's atrial fibrillation was converted to normal sinus rhythm on a diltiazem drip and was subsequently maintained on oral atenolol with oral diltiazem as needed. She was also transfused with 2 units of packed red blood cells due to acute post operative anemia. On [2191-12-23] she was transferred out of the SICU onto the orthopaedic floor. The rest of her hospital stay was uneventful with her lab data and vital signs within normal limits and her pain controlled. She is being discharged today in stable condition. Medications on Admission: 1. klonopin qhs 2. atenolol 25mg qd (pt unsure of dose) 3. paxil qd (pt unsure of dose) 4. calcium qd (pt unsure of dose) Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: s/p fall Right distal femur fracture Acute post operative anemia Atrial fibriliation Discharge Condition: Stable Discharge Instructions: Continue to be touchdown weight bearing on your right leg Continue your lovenox injections for a total of 4 weeks after surgery You may resume your home medications as prescribed by your doctor If you notice any increased redness, draiange, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department Physical Therapy: Activity: As tolerated Right lower extremity: Touchdown weight bearing [Doctor Last Name ] Brace: Unlocked at all times, may take off for passive ROM to the knee and for daily care. Treatments Frequency: Staples/sutures out 14 days after surgery Dry sterile dressing daily or as needed for drainage or comfort Followup Instructions: Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in orthopaedic clinic in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment. Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 7962] [Telephone/Fax (1) 25562] as your heart medication have been changed due to your A-fib [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417*]	[ "V43.65", "401.9", "300.00", "E885.9", "996.44", "427.31", "285.1", "V43.64", "307.42" ]	icd9cm	[ [ [] ] ]	[ "99.04", "79.35" ]	icd9pcs	[ [ [] ] ]	4630, 4744	2903, 4457	299, 299	4873, 4882		5632, 6148	1713, 1718				4765, 4852		4483, 4607			4906, 5270										1733, 2880	5288, 5479	5501, 5609																												230, 260																327, 587																		609, 1399	1415, 1697
15,675	190,349	27033	Discharge summary	report	Admission Date: [2192-10-13] Discharge Date: [2192-10-19] Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 348] Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: Colonoscopy Endoscopy Video Capsule Study History of Present Illness: 89 yo M w/ h/o diabetes, stroke in [2190] with residual left sided weakness (on Plavix), DJD, h/o bleeding ulcer several years ago. Transferred to [Hospital1 18] from [Hospital ] Hospital for management of lower GI bleed. Pt presented to [Hospital ] Hospital on [2192-10-5] with weakness and presyncopal episodes. Patient had a fall at home on the day of admission. There was no LOC, vision changes, bladder/bowel incontinence, head or neck injury. He denied CP, dizziness, LH, palpitations. His Hct=37, HR=79, BP=128/56. Work up for pre-syncope included Head CT, echo, MRI/MRA of neck (see results below). He ruled out for MI with three sets of cardiac enzymes. On HD #2, the patient started passing multiple dark stools and Hct dropped to 25 range. The patient received two units pRBCs on [2192-10-8]. EGD [2192-10-6] was normal. Colonoscopy [2192-10-6] showed dark blood in cecum (prep was suboptimal) but no clear source was identified. Tagged RBCs scan [2192-10-6] and showed focus in the region of hepatic fx c/w acute GI bleed. Patient continued to have small amounts of bleeding but Hct remained stable in 26-27 range. On the morning of transfer, [2192-10-13], the patient started passing BRBPR again and was transferred to [Hospital1 ] after receiving one unit pRBCs. He also transiently had BP 88/54. Last Hct prior ot tx 28.5. BP 144/58. . The patient denies NSAIDs prior to admission. He has been on Plavix at home. Past Medical History: --NIDDM for 8-9 years --S/p R basal ganglia CVA in [2191-9-9] --Prostate cancer s/p orchiectomy --Arthritis/DJD --Back pain with h/o compression fx --Interstitial fibrosis --H/o bleeding ulcer 3 years ago --s/p CCY --s/p left knee "plate" 3 years ago Social History: Lives at home with wife. [Name (NI) ], [Name (NI) ], is a POA. [Name (NI) 1139]: quit 25 years ago. No EtOH or IVDU. Family History: Not contributory Physical Exam: T=98, HR=81, BP=105/50, RR=16, O2 98% on RA GEN: confortable, hard of hearing, HEENT: PERRLA, EOMI, MMM, no JVD Heart: S1/S2, regular, [2-12] holosystolic murmur, no r/g Lungs: basal crackles bilaterally Abd: soft, NT, ND, no rebound, no guarding, no organomegaly, BS + Ext: no pitting edema, pneumoboots on Neuro: A&O x 3, NAD Pertinent Results: CHEST (PORTABLE AP) [2192-10-14] Reason: eval placement HISTORY: Nasogastric tube placement. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Nasogastric tube passes to the distal esophagus loops and turns upwards passing back into the neck and out of view. Interstitial abnormality in the lower and peripheral lungs is probably pulmonary fibrosis. Heart normal in size. No pulmonary edema or pleural abnormality. Thoracic aorta is calcified but not dilated. No pneumothorax. **************** CHEST (PA & LAT) [2192-10-18] Reason: ? PNA IMPRESSION: No evidence for pneumonia. Bilateral interstitial disease consistent with interstitial fibrosis, unchanged. ************* Pathology: Colonic polyps, two, polypectomies: A. Cecum: Fragments of adenoma. B. 15 cm: Hyperplastic polyp. Clinical: Occult blood in stool. Iron deficiency anemia. Polyps at appendiceal orifice and distal colon. Gross: The specimen is received in two formalin filled containers labeled with the patient's name, "[Known lastname ], [Known firstname ]," the medical record number and "cecum polyp" and "15 cm polyp," and consists of multiple tissue fragments measuring up to 0. 4 cm, entirely submitted in cassettes coded A-B, respectively. ************ Endoscopy [2192-10-15] Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Impression: Normal EGD to second part of the duodenum *********** Colonoscopy [2192-10-15] Impression: Polyp in the distal sigmoid colon at 15 cm Diverticulosis of the sigmoid colon Polyp in the cecum near the appendiceal orifice Otherwise normal colonoscopy to cecum Recommendations: Follow-up biopsy results, repeat colonoscopy in 3 yr if adenoma High fiber diet The above findings do not account for the anemia and GIB ********* Video Capsule Study [2192-10-17] Findings: 1. Two non-bleeding small bowel angioectasia within reach of enteroscope 2. No active bleeding 3. Capsule reached colon Recommend: Push enteroscopy to cauterize angioectasias in small bowel (if continues to bleed) ********* [2192-10-19*] 06:55AM BLOOD WBC-9.1 RBC-3.02 Hgb-10.1* Hct-29.0* MCV-96 MCH-33.3* MCHC-34.6 RDW-14.0 Plt Ct-211 [2192-10-18] 09:00PM BLOOD Hct-29.4* [2192-10-18] 05:40PM BLOOD Hct-30.6* [2192-10-18] 06:05AM BLOOD WBC-7.3 RBC-2.89* Hgb-9.6* Hct-27.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.3 Plt Ct-196 [2192-10-19] 06:55AM BLOOD Plt Ct-211 [2192-10-17] 04:50AM BLOOD PT-13.5* PTT-30.9 INR(PT)-1.2 [2192-10-19] 06:55AM BLOOD Glucose-116* UreaN-10 Creat-1.0 Na-139 K-3.5 Cl-106 HCO3-25 AnGap-12 [2192-10-19] 06:55AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.4* Brief Hospital Course: #. GI bleeding. Per tagged RBC and colonoscopy from OSH patient with bleed, likely coming from right colon in the region of the hepatic flexure. EGD/Colonoscopy at [Hospital1 18] showed some non-bleeding polyps without any source of bleeding. Capsule study showed nonbleeding angioectasias. Recommended push enteroscopy if patient continued to bleed. Recieved PRBC's for HCT less than 25. Was on Protonix, intially IV, then PO. We were holding his Plavix and Aspirin. These should be restarted in consultation with his primary care physician. [Name10 (NameIs) ] had bowel movements before discharge. The stools were guiaic negative. Patient will need colonoscopy follow up in 3 yrs for his colonic adenoma. . #. DM - reasonable controlled on NPH and ISS. We did not continue him on Glipizide that he was taking at home. . #. S/P CVA with residual left sided weakness. continued to hold ASA and Plavix given GI bleeding. PCP can consider restarting this in [12-11] weeks. . #. Hyperlipidemia: Continued on Lipitor . #. Leg cramps: Continued on Quinine prn. . #. PPx: Protonix qd; pneumoboots; aspiration precautions . #. Code: Full (but no prolonged intubation) Medications on Admission: OUTPT MEDS: --Vicodin 1mg po q 8hrs prn --Plavix 75mg po daily --Lasix 20 mg po daily --Quinine 260 mg po qd --Lipitor 10 mg po qd --Glipizide (? dose) MEDS ON TRANSFER: --1000 ml D5 1/2NS continuous at 100 ml/hr --Quinine Sulfate 260 mg PO HS:PRN leg cramps --Acetaminophen 325-650 mg PO Q4-6H:PRN pain, fever --Atorvastatin 10 mg PO DAILY --Docusate Sodium 100 mg PO BID --Insulin SC SS --Pantoprazole 40 mg IV Q24H Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for leg cramps. 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glipizide Oral 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Chartwell House Discharge Diagnosis: Lower Gastrointestinal Bleed Discharge Condition: All vitals are stable. Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to you physician if you have any changes in bowel movements or dark/red colored stools or any other concerns. . Please see your Primary care physician [Last Name (NamePattern4) ] [12-11] weeks for further assessment and consider restarting Plavix. . If you have any further drop in your red blood cell count or any more gastrointestinal bleed, we will consider doing a push enteroscopy. Followup Instructions: Please make an appointment to see your primary care physician [Last Name (NamePattern4) ] [12-11] weeks days after discharge. Please discuss with him about restarting Plavix. . If you have any further drop in your red blood cell count or further lower gastrointestinal bleed, we might have to do a enteroscopy. . Biopsy from Colon showed adenomatous polyp. You will need to undergo a follow up colonoscopy in 3 years. Completed by:[2192-10-19]	[ "569.85", "285.1", "211.3", "250.00", "V10.46", "515", "438.89" ]	icd9cm	[ [ [] ] ]	[ "45.42", "45.13", "45.19", "99.04" ]	icd9pcs	[ [ [] ] ]	7542, 7584	5313, 6487	231, 274	7657, 7682	2602, 5290	8227, 8685	2216, 2234		6957, 7519		7605, 7636		6513, 6667			7706, 8204										2249, 2583																														177, 193																302, 1776																		1798, 2054	2070, 2200		6685, 6934
6,160	104,091	27501	Discharge summary	report	Admission Date: [2123-6-26] Discharge Date: [2123-7-19] Date of Birth: [2080-2-1] Sex: M Service: MEDICINE Allergies: Zemplar / Ampicillin Attending:[First Name3 (LF) 826] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: Patient is a 43 yo Thai speaking male with ESRD on HD, HTN presented to [Hospital1 18] on [6-26] after being notified that blood cultures drawn on [6-24] returned positive for GPC in [1-28] bottles. He arrived to HD on [6-24] with rigors and chills, but was afebrile to 99.1, and had blood cx's drawn. On arrival to the ED, he was afebrile to 96.8, with BP 92/38, and was admitted to medicine for further work-up. He was given 1g vanco x1, 1 g ceftaz x1, which were continued on the floor. ROS were negative for any fever, cough, SOB, dysuria, odynophagia or any other localizing symptoms. It was felt that his tunneled HD line was likely the source, and it was planned to have that line removed. Pt was dialyzed on [6-26] through his still maturing AVF in his L arm. On [6-27], pt became increasingly hypotensive, with BPs at 80/40. He was otherwise afebrile to 97.8, but Tmax 100.3, with HR 70s, RR 20s, and satting 100% on RA. He was given 1L NS bolus without improvement in his blood pressure. Pt was transferred to the ICU for closer monitoring. He was transferred to the floor after he was hemodynamically stable. Past Medical History: HTN ESRD ([1-28] HTN) AVF placed [2123-4-9] (awaiting maturation) Anemia (baseline hct 30) CHF EF 40% Uric acid elevation Social History: No smoking, no alcohol, no drug use. Family History: Father and mother died at age 40-50. Brothers with HTN. No family history of stroke or MI. Physical Exam: VS: T 98 BP80/34 HR72 RR o2sat: GEN: lying on bed, does not appear toxic. able to speak in full sentences without difficulty. HEENT: PERRL, EOMI, anicteric, MM dry. NECK: Supple, no elev JVP. CHEST: CTAB, no c/w/r. HEART: RRR, nl S1 and S2, no m/r/g ABD: Soft, NTND, NABS, no bruits, no HSM EXT: Warm, 2+ pulses bilaterally, 1+ pitting edema bilaterally Neuro: A&O x 3, no focal neurologic signs. Brief Hospital Course: Patient is a 43 yo male with history of ESRD [1-28] HTN presents with high-grade bacteremia with 2/2 bottles of pansensitive Enterococcus and Enterobacter and 4/4 bottles of GNR. 1. Enterococcal/Enterobacter bacteremia: Patient with polymicrobial bacteremia secondary to infected tunneled HD line; no other localizing symptoms on admission. Initially hypotensive with BPs in 80/40's consistent with sepsis. He was transferred to the MICU for closer management, no pressors were required. His tunneled HD Line was pulled and he was started on Vancomycin and Levaquin, as per ID. He also had been on Ceftaz, Meperidine, and Linezolid, all of which were stopped in the MICU. TTE was done and did not suggest any vegetations or abcesses. TEE was then done and showed a moderate sized aortic vegetation that was consistent with aortic regurgitation, which was auscultated on exam. Patient was seen by CT surgery and felt that he would require AVR after he had completed his 6 week course of antibiotics and suggested he undergo cardiac catheterization as part of the pre-op evaluation. Patient was also seen by cardiology was consulted Vancomycin was changed to Ampicillin, as per ID, who felt that Enterococcus was more sensitive to this drug. Two weeks later he became neutropenic, developed a diffuse erythematous rash, and started spiking temperatures. 2. ESRD: Patient on hemodialysis TTHSat d/t ESRD from HTN. s/p HD yest on [6-26], not due for HD until Tues. tunneled line pulled on [6-26], renal consulting, following, dialyzed through mature av fistula on [6-29]. 3. HTN - Hold antihypertensives given sepsis, restart on floor once stable 4. Anemia: At baseline Hct ~30. Continue Epo 6000units qhd. Medications on Admission: Meds at home: Metoprolol 75mg PO bid norvasc 10mg PO qday tums 500mg PO tid epo 6000 units qhd calajex 2mcg qhd Discharge Medications: 1. Vancomycin HCl 1250 mg IV QHD Please dose at hemodialysis 2. Gentamicin 60 mg IV QHD 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 4. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:2 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). Disp:15 Tablet(s) Refills:0 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Endocarditis 2. End stage renal disease on HD 3. Hypertension Discharge Condition: Stable Discharge Instructions: 1. You are being treated for a bacterial infection with 3 antibiotics for 6 weeks ([Date range (1) 67279]). Two of the antibiotics will be given at hemodialysis. The third antibiotic is Levaquin. You will take 1 tablet every 2 days until [2123-8-12]. 2. Recommended follow-up as listed below 3. If you experience any fevers, chills, chest pain, SOB or any other concerning symptoms please return to the ER> Followup Instructions: 1. You will getting hemodialysis on Tuesdays, Thursdays, and Saturdays at [Hospital1 18]. You will be informed about the time and place. 2. Please have labs done at hemodialysis. Weekly CBC, LFTs, vancomycin trough, and gentamycin peak/trough levels should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] at [Telephone/Fax (1) 1419]. 3. You are scheduled for an appointment with Cardiothoracic Surgery on [8-11] at 2:30pm. 4. You are scheduled to have an echocardiogram on Thursday, [8-5] at 8am in the [Hospital Ward Name 23] Building, [Location (un) 436]. Phone number [Telephone/Fax (1) 128]. 5. Dr. [Last Name (STitle) ] will be contacting you regarding your appointment for tooth extraction. 6. You are scheduled for an appointment with Infectious Disease clinic, DR. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2123-8-17] 11:00	[ "288.3", "288.0", "041.04", "693.0", "285.21", "421.0", "E930.0", "790.7", "427.89", "041.85", "996.62", "403.91", "585.6" ]	icd9cm	[ [ [] ] ]	[ "88.72", "37.22", "38.93", "88.56", "39.95" ]	icd9pcs	[ [ [] ] ]	4919, 4925	2254, 3979	290, 323	5034, 5043		5508, 6480	1725, 1817		4142, 4896		4946, 5013		4005, 4119			5067, 5485										1832, 2231																														240, 252																351, 1500																		1522, 1654	1670, 1709
32,032	179,458	45151	Discharge summary	report	Admission Date: [2100-11-7] Discharge Date: [2100-11-23] Date of Birth: [2028-2-28] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr / Lipitor / Zetia Attending:[First Name3 (LF) 922] Chief Complaint: non-healing chest wound Major Surgical or Invasive Procedure: left thoracotomy/removal pacer leads [2100-11-15] History of Present Illness: 72 yo male s/p original abdominal pacer placement in [2053] for myocarditis. This failed due to infection and hemothorax. Subsequently a pacer was placed in the left chest which was complicated and difficult. Has had multiple surgeries including 16 generator changes. Developed a mass in the left chest which proved to be a retained sponge from a prior surgery. This was removed surgically in [12-22] along with a new generator change. This incision developed a MRSA infection and did not heal. Referred for surgery to remove hardware. Past Medical History: Myocarditis s/p pacemaker CHF, most recent echo showing normal LV function. Last report shows EF 40-45% CAD, s/p prior stenting (LAD and OM) hypertension hyperlipidemia atrial flutter/fib on coumadin hepatitis C mass on left chest wall - negative needle biospy B renal cysts erectile dysfunction Bipolar disorder [Last Name (un) ]. arthritis of spine Social History: Social history is significant for the absence of current tobacco use.Smoked pipe for 2 years. There is no history of alcohol abuse. He lives alone in basement apartment in [State ] with some local friends, but no family nearby. He has a brother, Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 96500] (Urologist) in LA who is involved in his life. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: 69", 186# T:98.3, 106/58,P:60, RR:20,100% O2SAT on R/A General: A&Ox3, NAD HEENT: WNL CVS:irreg.irreg, v-paced Lungs:decreased bases Abd: benign Extr:venous stasis changes, 1+edema left thoracotomy wound vac intact/staples intact Pertinent Results: Conclusions [2100-11-23] 09:09AM BLOOD WBC-4.9 RBC-2.70* Hgb-9.0* Hct-27.2* MCV-101* MCH-33.3* MCHC-33.1 RDW-15.8* Plt Ct-117* [2100-11-8] 12:53AM BLOOD WBC-6.8 RBC-3.21* Hgb-10.4* Hct-30.5* MCV-95 MCH-32.5* MCHC-34.1 RDW-14.9 Plt Ct-103* [2100-11-23] 09:09AM BLOOD PT-23.6* INR(PT)-2.3* [2100-11-8] 05:50AM BLOOD PT-17.6* PTT-36.7* INR(PT)-1.6* [2100-11-22] 05:01AM BLOOD Glucose-89 UreaN-42* Creat-1.8* Na-135 K-4.0 Cl-106 HCO3-24 AnGap-9 [2100-11-8] 12:53AM BLOOD Glucose-119* UreaN-23* Creat-1.3* Na-135 K-3.8 Cl-104 HCO3-25 AnGap-10 [2100-11-19] 06:13AM BLOOD ALT-68* AST-75* LD(LDH)-313* AlkPhos-90 TotBili-1.2 [2100-11-8] 12:53AM BLOOD calTIBC-295 VitB12-1401* Folate-GREATER TH Ferritn-207 TRF-227 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Last Name (LF) ], [Known firstname 900] [Hospital1 18] [Numeric Identifier 96501] (Complete) Done [2100-11-15] at 1:28:24 PM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2028-2-28] Age (years): 72 M Hgt (in): 69 BP (mm Hg): 123/69 Wgt (lb): 180 HR (bpm): 60 BSA (m2): 1.98 m2 Indication: evaluate for endocarditis, intraoperative management ICD-9 Codes: 440.0 Test Information Date/Time: [2100-11-15] at 13:28 Interpret MD: [Name6 (MD) 15425] [Name8 (MD) 15426], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 15426], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.2 cm <= 5.2 cm Left Atrium - Volume: 52 ml < 32 ml Left Atrium - LA Volume/BSA: 26 ml/m2 < 22 ml/m2 Right Atrium - Four Chamber Length: 5.2 cm <= 5.0 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: 4.5 cm Left Ventricle - Fractional Shortening: 0.15 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.1 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. 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 and cavity size. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Complex (>4mm) atheroma in the ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened aortic valve leaflets. Mild to moderate ([12-16]+) AR. Eccentric AR jet. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were Conclusions 1. The left atrium is moderately dilated. 2. No atrial septal defect or PFO is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are complex (>4mm) atheroma in the ascending aorta, the aortic arch and descending thoracic aorta. 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are mildly thickened. Mild to moderate ([12-16]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric originating from the base of the right and left coronary leaflets. No aortic vegetations seen.. 7. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. No mitral vegetations seen. 8. Moderate [2+] tricuspid regurgitation is seen. No tricuspid vegetations seen. 9. There is no pericardial effusion. 10. A circumflex artery aneurysm is noted 11. Dr. [Last Name (STitle) 914] was notified in person of the results during the surgery. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [Name6 (MD) 15425] [Name8 (MD) 15426], MD, Interpreting physician Brief Hospital Course: The patient is a 71 year old male with a history of multiple revisions of pace-maker, coronary artery disease, chronic systolic congestive heart failure-?acute on chronic systolic CHF, and bipolar disorder who presents from [State ] for evaluation of non-healing wound and likely pacemaker revision. Non-healing wound, pacemaker: Patient with first pacer placed [2054] cardiomyopathy secondary to myocarditis. This was an abdominal pacemaker and his course was complicated by infection; patient reportedly has a fistula. Since that time, he has had multiple revisions, with one hematoma. He reports that he has had continued drainage and bleeding from his chest wall abnormality that is concerning for persistent infection (either abscess, infected new or old wires that are in place) in setting of sinus tract. He has had no fevers, chills, or other features to suggest systemic disease. He had been on Levofloxacin for treatment for approximately ten days prior to admission, however he was started on Vancomycin upon admission. His wound culture subsequently grew MRSA. An ECHO was obtained which showed no vegetation. Cardiac surgery evaluated the patient for hardware removal and this was done by Dr. [Last Name (STitle) 914] on [11-15]. Extubated that evening.Please refer to operative report for further details. POD #1EP interrogated pacer. Mr.[Name14 (STitle) 96500] had postoperative confusion. Narcotics were discontinued. No focal defecit.Id following with antibiotic reccommendations->Vanco x 14 days, start date [11-16];trough level maintained 15-20. He was restarted on Coumadin for chronic AFib. INR goal 2.0. Transiently postoperative he was placed on Tube Feeds to improve nutritional intake. Speech and swallow was consulted. Supervised feedings were instituted. POD#7 Mini vac dressing was applied to left thoracotomy leteral wound. Staples remain in place, to be discontinued at wound clinic scheduled with Dr[Last Name (STitle) 5305] office at 1 week following discharge to rehab [2100-12-1]. Postoperative delerium continues to improve. On POD#8 Mr.[Name14 (STitle) 96500] continued to progress and he was discharged to rehab. All follow up appointments were advised. Medications on Admission: ASA 81 mg daily Calcium plus D 600 mg TID digoxin 0.25 mg daily folic acid 400 mcg daily iron 325 mg daily lasix 40 mg daily levofloxacin lithobid 600 mg HS lopressor 25 mg [Hospital1 ] MVI daily NTG prn warfarin 5 mg daily (LD [11-4]) vit. C 500 mg daily Vit. E 200 units daily Vancomycin ( started at admission) Discharge Medications: 1. Aspirin 81 mg [Month/Year (2) 8426], Delayed Release (E.C.) Sig: One (1) [Month/Year (2) 8426], Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Calcium Carbonate 500 mg [Month/Year (2) 8426], Chewable Sig: One (1) [Month/Year (2) 8426], Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 5. Folic Acid 1 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 7. Ascorbic Acid 500 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO BID (2 times a day). 8. Multivitamin [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Lithium Carbonate 300 mg [Month/Year (2) 8426] Sustained Release Sig: Two (2) [Month/Year (2) 8426] Sustained Release PO QHS (once a day (at bedtime)). 11. Tramadol 50 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO Q6H (every 6 hours) as needed. 12. Simvastatin 10 mg [Month/Year (2) 8426] Sig: Two (2) [Month/Year (2) 8426] PO DAILY (Daily). 13. Furosemide 40 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 14. Ranitidine HCl 150 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO BID (2 times a day). 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 17. Warfarin 1 mg [Month/Year (2) 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) 8426] PO Once Daily at 4 PM. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Bisacodyl 5 mg [Last Name (Titles) 8426], Delayed Release (E.C.) Sig: Two (2) [Last Name (Titles) 8426], Delayed Release (E.C.) PO BID (2 times a day) as needed. 20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 21. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. 23. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: pacer lead site infection s/p left thoracotomy/removal of pacer leads hypertension myocarditis/cardiomyopathy congestive heart failure/EF 40-45% A fib/flutter hepatitis C bil. renal cysts coronary artery disease s/p LAD and OM stents left chest wall hematoma [2091] removal of chest wall foreign body/pacer generator change [12-22] prior pacer [2053] ( removed)/subsequent 16 generator changes bipolar disorder erectile dysfunction hyperlipidemia [Last Name (un) ]. arthritis of spine Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet call for fever greater than 100.5, redness or drainage no driving for at least 2-3 weeks AND until off all narcotics shower daily and pat incision dry no lotions, creams or powders on any incision Followup Instructions: see Dr. [Last Name (STitle) 96502] in [12-16] weeks see Dr. [Last Name (STitle) 1911] in [1-17] weeks see Dr. [Last Name (STitle) 914] at Clinic for wound check/staple removal on [2100-12-1] at 1:30pm.#[Telephone/Fax (1) 170] Completed by:[2100-11-23]	[ "414.01", "585.9", "593.2", "607.84", "V45.82", "998.6", "787.20", "287.4", "V45.01", "530.81", "786.2", "403.90", "425.4", "780.62", "272.4", "721.90", "V58.61", "070.70", "E878.1", "428.0", "427.32", "041.12", "998.32", "428.22", "996.61", "427.31", "285.9", "477.9", "296.80" ]	icd9cm	[ [ [] ] ]	[ "37.77", "86.22", "37.89", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	12509, 12581	7241, 9473	366, 423	13126, 13133	2132, 7218	13478, 13764	1784, 1866		9845, 12486		12602, 13105		9499, 9822			13157, 13455										1881, 2113																														303, 328																451, 996																		1018, 1375	1391, 1768
18,408	111,275	5232	Discharge summary	report	Admission Date: [2103-7-26] Discharge Date: [2103-8-1] Date of Birth: [2041-1-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: CP, EtOH withdrawal Major Surgical or Invasive Procedure: EGD - [7-27] History of Present Illness: 62M with PMH significant for CAD and EtOH abuse ([1-4] vodka qD) with h/o DTs and seizures, presenting with CP at home at 5pm while walking down the street. He describes the pain as dull, and admitted some mild dyspnea and associated diaphoresis. No N/V or radiation of pain to arm, jaw, or back. He states that the pain feels similar to previous occasions during which he was experiencing EtOH withdrawal. Past Medical History: - EtOH abuse with h/o DTs with visual hallucinations and withdrawal seizures. - ?CAD: Was apparently cathed at [Hospital1 2025] 3 years ago and underwent angioplasty. Does not know whether stent was placed. Was told he showed evidence of a previous MI. - HTN Social History: Parents deceased; remains close to two sisters, one in [Name (NI) 21380] and the other in [State 1727]. Educated through high school. Ex-marine. Worked 22 years at Digital Corp in film reproduction/development. Has lost job at homeless shelter [2-1] EtOH abuse. Twice married and divorced, no children Family History: "Mild" depression in sister Physical Exam: On admission: PE: T: 99.8F BP: 192/92 HR: 127 RR: 19 SaO2: 99% 2L NC Gen: Disheveled gentleman, slightly diaphoretic and tremulous, interacting and in NAD HEENT: PERRL, Large ecchymosis around L eye with subconjunctival hemorrhage, OP somewhat dry. Neck: Cleared C-spine, no pain on neck flexion/extension or rotation. Supple, no LAD CV: Tachycardic, regular rhythm. Loud S1 and S2, II/VI SEM LUSB radiating to carotids Chest: CTAB, no w/r/r Abd: Soft, obese, NT/ND, no HSM, hypoactive BS Ext: No LE edema, trace DPs bilaterally Pertinent Results: [2103-7-26] 10:50AM CK(CPK)-53 [2103-7-26] 10:50AM CK-MB-3 cTropnT-<0.01 [2103-7-26] 02:34AM GLUCOSE-123* UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21* [2103-7-26] 02:34AM WBC-6.3 RBC-3.41# HGB-10.1# HCT-31.1# MCV-91 MCH-29.8 MCHC-32.6 RDW-17.3 [2103-7-26] 12:35AM TYPE-[Last Name (un) ] PO2-88 PCO2-37 PH-7.21* TOTAL CO2-16* BASE XS--12 [2103-7-25] 11:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2103-7-25] 11:58PM URINE RBC-0-2 WBC-[3-4] BACTERIA-MOD YEAST-NONE EPI-[3-4] [2103-7-25] 07:20PM D-DIMER-5207* [2103-7-25] 07:00PM LD(LDH)-252* CK(CPK)-58 [2103-7-25] 07:00PM ASA-NEG ETHANOL-229* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: In the ED he was noted to be tachycardic, anxious and diaphoretic. his VS were T 99.2F BP 187/107 HR 131 RR 16 SaO2 98% 2L NC. He had no ECG changes other than tachycardia. Ddimer was positive at 5207, but chest CTA was negative for dissection or PE. First set CEs negative at CK 58, trop <.01. Mr. [Known lastname ] stated that his last drink was 24h prior to admission. Serum EtOH in ED was 229. Serum and urine tox was otherwise negative. Initial labs were notable for a large AG metabolic acidosis, with HCO3 13 and AG 32, delta-delta 1.7. Mg 1.6, Phos 5.1. VBG was 7.21/37/88. Urine ketones were positive at 50, and urine was negative under Wood's lamp for ethylene glycol, with one amorphous crystal seen. Subsequent lytes drawn 4 hours later and after 2L NS demonstrated closure of the AG to 13, with VBG 7.41/31/76. An addendum was added to CTA report, noting thickening of the gastric mucosa c/w gastritis vs lymphoma vs TB, and recommended an EGD to further evaluate. Mr. [Known lastname ] was given valium 10mg IV x 3, and was placed briefly on ativan drip with little effect on his chest pain. He was transferred to the [Hospital Unit Name 153] for further management. . In the [Name (NI) 153], pt was placed on CIWA scale and received PO Valium for CIWA>10. First night received ~70 mg Valium o/n and second night received ~30 mg. No significant withdrawal sxs and no seizures. EGD performed [7-27] to further characterize abnormality seen on CTA revealed ulcers in the antrum and pre-pyloric area. Remained AF and VSS. He was txed to the floor on [7-28] 1) ETOH abuse social worker saw pt; all of us counseled him to quit use he was alert and oriented without any w/d sxs at dc 2) GI Had EGD on [7-27] which revealed multiple antral and pre-pyloric ulcers. Pt had H. Pylori biopsies which are pending. Was started on PPI therapy [Hospital1 ] in the hospital; changed to QD therapy at discharge. 3) Htn Poor control; meds were titrated up 4) Acute gout developed pain in ankles and knees requiring initiation of po prednisone. Sxs markedly improved with prednisone. Plan is to have him taper them down as an outpt. 5) Ileus had ileus in ICU which improved on floor; tolerating a nl diet on discharge without any abd pain 6) Hypomag and hypokalemia pt's potassium and mag were replaced with improvement 7) UTI had pansensitive e. coli treated pt with cipro - advised him to stay out of sun given risk of photosensitivity blood cultures neg at time of discharge Medications on Admission: Atenolol - unknown dose (25mg PO qd in [2097] note) Lisinopril - unknown dose Discharge Medications: 1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:2 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 10 days. Disp:20 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 6. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1) Ketosis due to ETOH abuse and dehydration 2) Peptic ulcer disease 3) Urinary tract infection 4) Ileus 5) htn 6) Acute gouty flare Discharge Condition: STable Discharge Instructions: seek medical attention if you are not feeling well Followup Instructions: Followup with your pcp, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3235] [Last Name (NamePattern1) 6164] at the [Location (un) 686] House	[ "560.1", "733.90", "300.00", "599.0", "275.2", "276.51", "401.9", "414.01", "303.01", "274.0", "786.59", "041.4", "276.2", "276.8" ]	icd9cm	[ [ [] ] ]	[ "45.16" ]	icd9pcs	[ [ [] ] ]	6461, 6467	2848, 5363	334, 352	6644, 6653	2020, 2825	6752, 6923	1426, 1455		5496, 6438		6488, 6623		5389, 5473			6677, 6729										1470, 1470																														275, 296																380, 792								1484, 2001										814, 1079	1095, 1410
77,691	143,007	42574	Discharge summary	report	Admission Date: [2176-1-31] Discharge Date: [2176-2-6] Date of Birth: [2100-6-3] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa(Sulfonamide Antibiotics) / Cephalosporins / Codeine / morphine / Codeine / morphine Attending:[First Name3 (LF) 473] Chief Complaint: Recent pancreatitis and ascending cholangitis s/p ERCP, found to have increasing abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy [2176-1-31] History of Present Illness: 75 yo F with COPD on 3-4L of oxygen at home and h/o pancreatitis of unknown etiology who initially presented to OSH with a presumed diagnosis of ascending cholangitis and was treated with abx, but left AMA, presented here for outpatient ERCP [2176-1-31]. . The patient was a poor historian but said that she was symptom free prior to her ERCP and developed epigastric abdominal pain post-procedure. She said the pain was similar to prior episodes of pancreatitis, denied radiation or alleviating or exacerbating factors. She also said that she was somewhat SOB, more so than her baseline. . ROS was otherwise negative Past Medical History: -COPD on 3-4L on oxygen at home -h/o pancreatitis, etiology unknown -h/o cholecytitis and possible ascending cholangitis -GERD -Hypercholesterolemia -DM -HTN -Echo > 70% -Rectocele -cataracts -Afib with RVR -Fracture dist radius Social History: -lives with sister, drinks three times a week when well (Scotch reportedly [2-4] drinks per week), is retired, has a living will which indicates DNR/DNI status. -quit smoking 2 months ago, has a ~60 py history Family History: -was adopted, unsure of family hx Physical Exam: Admission PE 96.5 148/65 74 15-16 94-95 on 3L NC General: AAOX3, in NAD, somewhat of a poor historian and has eyes closed during most of PE HEENT: CN 2-12 grossly intact, MMM CV: RRR, no rmg Lungs: distant BS, decreased BS at bases, posterior end expiratory wheeze and anterior rhonchi Abdomen: soft, ND, TTP in epigastrum-moderate and mild TTP in RUQ and LUQ, no rebound, no hsm Extremities: WWP, pulses 2+ and equal Neuro: CN and MS wnl, sensation and strength wnl Derm: no obvious rashes Psych: mood and affect wnl Pertinent Results: [2176-1-31] ERCP Severe stenosis of the major papilla was noted Given severe papillary stenosis, a small precut sphincterotomy was performed with successful cannulation of the bile duct. Sphincterotomy was then extended in the 12 o'clock position using a sphincterotome over an existing guidewire Normal cholangiogram Normal pancreatogram Balloon sweep was performed, no stones or sludge noted . [2176-1-31] 09:10AM UREA N-17 CREAT-0.8 SODIUM-140 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-31 ANION GAP-10 [2176-1-31] 09:10AM estGFR-Using this [2176-1-31] 09:10AM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-47 AMYLASE-34 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [2176-1-31] 09:10AM LIPASE-27 [2176-1-31] 09:10AM WBC-8.4 RBC-3.69* HGB-11.3* HCT-33.2* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.1 [2176-1-31] 09:10AM PLT COUNT-320 [2176-1-31] 09:10AM PT-10.6 PTT-27.3 INR(PT)-1.0 . [2176-2-6] 08:22AM BLOOD WBC-8.3 RBC-2.93* Hgb-8.8* Hct-25.6* MCV-87 MCH-30.1 MCHC-34.4 RDW-14.2 Plt Ct-12* [2176-2-6] 08:22AM BLOOD Plt Ct-12* [2176-2-6] 08:22AM BLOOD Glucose-189* UreaN-60* Creat-1.8* Na-133 K-4.5 Cl-101 HCO3-23 AnGap-14 [2176-2-6] 08:22AM BLOOD Calcium-7.6* Phos-4.3 Mg-2.2 [2176-2-6] 08:31AM BLOOD Type-ART pO2-68* pCO2-49* pH-7.32* calTCO2-26 Base XS--1 Brief Hospital Course: 75 yo F w/ h/o COPD on 3-4L of oxygen, h/o pancreaitis and presumed ascending cholangitis who was treated previoiusly at OSH and left AMA without ERCP who presented here for ERCP [2176-1-31] that found severe stenosis of the major papilla s/p sphinterotomy. She was admitted to the medical service for observation, given her poor baseline respiratory and functional status. She then developed epigastric pain and SOB after the procedure. The patient was a poor historian but said that she was symptom free prior to her ERCP and the epigastric abdominal pain was new. She said the pain was similar to prior episodes of pancreatitis, and denied radiation or alleviating or exacerbating factors. Over the course of the evening, she spiked a fever to 102. The next morning, she was noted to have an increasing leukocytosis to 15. She was given Cipro/Flagyl due to her allergy to PCN and cephalosporins, and later Vancomycin was added. The patient stated that her abdominal pain was [9-11] and unlike any pain that she has ever had. She denied nausea or vomiting. She became increasingly tachycardic to the 110s with one episode of desaturation to 80% briefly requiring a non-rebreather. Given these new findings, HPB surgery service was consulted and she was transferred to the TSICU on the [Hospital Ward Name ]. [2176-2-1]: On Dilaudid for pain however was still diffusely tender. HR controlled w/ beta-blocker (Rate control <100). Pulmonary status was stable overall, received stress dose steroids for COPD exacerbation, encouraged IS and written for Nebs PRN. Her NGT was advanced into stomach to continue decompression, NPO status. Foley was intact w/ adequate urine output. Urine & Blood cx were pending. She was started on vancomycin, ciprofloxacin, and metronidazole. [2176-2-2]: Had low UOP in AM, given 5% albumin x 1, UOP improved ~30 cc/hr; abd exam unchanged w/ persistent TTP, +rebound, guarding. She had desaturations to 80's in evening w/ increased work of breathing, and worsening respiratory acidosis. This was attributed to a COPD exacerbation. Given her DNR/DNI code status, SICU intensivist and team spoke w/ the patient extensively early on regarding the potential for intubation. The patient initially did not want to discuss code status and potential intubation when she was in moderate respiratory distress. However, when her respiratory status worsened despite medical therapy she was agreeable to being intubated. She was intubated without complication and placed on CMV, a R IJ CVL and a-line were placed as well. However, she became dissynchronous w/ ventilator and required paralyzation. She also developed Afib w/ RVR, placed on diltiazem gtt and was rate controlled. NICOM was placed and she was found to be euvolemic but still had low UOP ~20cc/hr. Cr slightly elevated to 1.3. [2176-2-3]: Continued paralysis for ventilator. Given albumin bolus with NS and weaned from pressors. Weaned off dilt gtt, converted to metoprolol IV q6h. Had one episode of hypotension to the 80s overnight, given IVF bolus with albumin. Still no resolution of hypotension, restarted on low dose neo with improvement in BP. Pt's Cr also rising, found to be prerenal by FeUrea, started on maintenance fluids. Plts decreased significantly, 135->45, unclear etiology, sent HIT antibody. Consider vancomycin as a cause as well. Stress dose steroids continued. NGT was removed and replaced with OGT for decompression. Continued stress ulcer prophylaxis with IV PPI. [2176-2-4]: Poor UOP, no response to Lasix 20, given Lasix 80 with better UOP. IVF held, Updated daughter, sister during visit today. Weaned paralysis and sedation, weak but responsive. Weaned to CPAP. Overnight, required increasing FiO2 to maintain O2Sat>90. Evidence of fluid overload on CXR. Episode of a-fib, on dilt gtt, with increasing Neo requirement. Platelets 11, very concerning now for HIT, SQH held. [2176-2-5]: Pain controlled with midaz for sedation. Persistent afib, dilt gtt at 10, Neo weaned to keep MAP >65. Plan for return to home steroid dose 3/6. Blood cultures pending. Family meeting held. Discussed potential benefits and difficulties with surgical resection and risk of mortality, prolonged recovery, and likely need for long term respiratory and nutrition support. Decision reached to make patient's status comfort measures only [2176-2-6]: Comfort measures only: extubated with family at bedside. Intermittend dilaudid for pain, ativan for anxiety. Pressors, dilt gtt, antibiotics discontinued. Fluids discontinued. RIJ and Foley kept for medication access and comfort. Family declined surgical interventions, requesting comfort care only as tolerated. Ms. [Name13 (STitle) 23531] was transferred to the surgical floor for continued comfort care. Pain and anxiety were controlled with intermittent dilaudid and ativan. Family remained at bedside until 2115, when nursing and resident staff were notified that the patient had stopped breathing. Time of death was confirmed by exam at 2115 on [2176-2-6], and autopsy was offerred to the family, who accepted. Consent signed by [Name (NI) 1094] sister and HCP, [Name (NI) 92126]. Chief resident, Admitting office, medical examiner, and Pathology notified per protocol. As this case was accepted by the office of the Medical examiner, records were transferred as requested. Medications on Admission: prednisone 10 po qd prilosec 20 po qd toprol xl 100 qd pravastain 20 po qd asa 81 po QD lasix 20 qd trazadone 50 qpm albuterol prn oxygen 3-4L at home Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Pancreatitis s/p ERCP c/b duodenal perforation Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "V49.86", "300.00", "E878.8", "491.21", "530.81", "287.5", "V46.2", "V15.82", "E870.0", "567.9", "998.2", "V14.0", "276.2", "584.9", "250.00", "788.29", "401.9", "V58.65", "998.59", "272.0", "427.31", "576.2", "V66.7", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.97", "51.85", "38.91", "96.04" ]	icd9pcs	[ [ [] ] ]	9214, 9223	3560, 8983	456, 498	9313, 9322	2239, 3537	9378, 9388	1651, 1686		9185, 9191		9244, 9292		9009, 9162			9346, 9355										1701, 2220																														321, 418																526, 1151																		1173, 1404	1420, 1635
54,830	192,153	53072	Discharge summary	report	Admission Date: [2124-4-13] Discharge Date: [2124-5-3] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 18794] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None. History of Present Illness: Ms [Known lastname 27218] is a [Age over 90 ] year-old female with hx of recent cdiff [1-26], hip fracture [11-23], admission for massive GIB [12-26] who was referred to the ED by VNA with fever, increased diarrhea, mild dyspnea, and hypotension. The patient was recently discharged from rehab and was seen by a visiting nurse today who found her congested and unable to bring up her seretions. She had a temp of 100.7 at home and BP of 100/50. VNA was unable to get a pulse ox [Location (un) 1131]. She has been having diarrhea for 3 days. She was told to go to the ED for evaluation. She admits to weakness, abdominal pain. Denies SOB. Has been off antibiotics for some time. . In the ED, initial VS: HR 82 BP 67/40 RR 24 Sat 98% on RA%. She was given 2.5L NS and her SBP increased to the 100s. She had many stools which smelled concerning for Cdiff. Guaiac negative. Bilat lower quadrant tenderness. Labs were significant for lactate of 3.2 (on recheck after fluids of 2.4), WBC of 22.0. Repeat VS at 1800: 99.4, 104/46, 83, 24, 99%RA. She underwent a CTA and CT abd/pelvis which was consistent with colitis, but showed no megacolon. She was given 1000 mg of tylenol, 750 mg of levofloxacin (for ? PNA with hypoxia initially prior to CXR which was clear), and 500 mg of flagyl. . Vitals in ED prior to transfer- T99.4 P80 BP92/60 RR30 O2 sat 100% on 2L NC. 2 18 guage PIVs. Foly put out 250 in last 6 hrs. Got 2.7 L NS in ED. Put out 2 gallons of stool in ED. . On arrival to the ICU, pt states she is doing ok. She appears confused and slow to answer questions. When pts' nephew and sister were [Name (NI) 653], they stated the pt is usually quite sharp and completely oriented. Now, pt does not know year or anyone's phone numbers. She states he diarrhea started today and that she no longer has any belly pain. Pt also states she has had a cough recently Past Medical History: 1. Systolic heart failure (EF 30-35 [7-23]) 2. Atrial fibrillation on warfarin 3. Hypertension 4. Dyslipidemia 5. PVD s/p fem [Doctor Last Name ] bypass 6. Uterine tumor, s/p total hysterectomy > 45yrs ago 7. Cystic Kidneys, with one reportedly "underdeveloped" 8. Esophageal ulcer and gastritis on EGD 9. Normocytic anemia- does not want colonoscopy 10. Bilateral aortoiliac bypass 11. Diverticulitis 12. Depression/anxiety 13. Benign cysts in breast removed X 2 Social History: The patient lives in a two family house in [Location (un) 2251], MA. She was never married and currently lives in the lower half of the house with her sister-in-law (another octogenerian). She formerly worked as a greeting card maker in a factory and retired over 20 years ago. She is still quite independent and can do her own shopping and meal preparation. Pt admits to smoking one pack/day for around 25 years and quitting entirely when she was in her 40's. She drinks wine very rarely on holidays and denies any history of other drugs. . She eats a healthy diet that she prepares at home and tries to limit her sodium and fluid intake. She tries to exercise by walking daily, but her walking is limited by leg pain. Family History: Mother has h/o of loss of consciousness from "heart problems" that eventually caused her death. Father died of cirrhosis (non-alcoholic). Physical Exam: VS: T=, BP=110/70, HR=90, RR=15, O2 sat=100%RA GENERAL: Elderly white female in no apparent distress. Able to answer questions. Seems mildly confused, able to say full name, knows its [Month (only) 547] but thinks its [2115], knows that she is at [Hospital 61] Hospital. Coughing intermittently during our conversation. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membranes are moist NECK: Supple with JVP of 10cm CARDIAC: Irregular rhythm, rate controlled, no murmurs. LUNGS: Diffuse bilateral wheezes and late inspiratory crackles. ABDOMEN: Non distended, soft, mild tenderness to deep palpation in the peri-umbilical region. EXTREMITIES: No c/c/e. Pertinent Results: CT torso with contrast: IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Moderate pancolitis and proctitis. Clinical correlation is recommended. This can be secondary to pseudomembranous colitis or other infectious/inflammatory etiology. Ischemic etiology is less likely due to distribution. 3. L1 severe compression fracture with 5mm of retropulsion is new since [2123-12-24]. . Brief Hospital Course: #. C. difficile colitis: Patient presented with profuse diarrhea up to 2 gallons every couple of hours (per ED report) and was found to be hypotensive with a lactate of 3.2 and Cr of 1.3 from a baseline of <1.0. She was initially admitted to the MICU where she was given IVF resuscitation, started on IV metronidazole and PO vancomycin (125 mg q6h) and flexiseal was placed as patient was producing a very large amount of diarrhea (>2 L daily). CT abd/pel showed toxic megacolon with colon measuring >6 cm and C diff testing subsequently was found to be positive. Her hypotension and ARF resolved with IVF and she was subsequently transferred to the medical floor. On the medical floor she continued to have profuse diarrhea and her PO vancomycin was subsequently increased to 500 mg q6h. Her flexiseal was removed early in her course but her abdomen became distended very rapidly and this was re-introduced. At this point a GI consult was obtained and they recommended adding PR vancomycin at the same PO dose and consulting ID. An ID consult was obtained and given her condition metronidazole was changed to tigecycline. Serial abdominal X-rays were obtained with her colon measuring 9.5 cm and despite all of our efforts her diarrhea persisted. Given the severity of her disease and her DNR/DNI status a conversation was held with the patient about colectomy which was the only viable option for cure at the time. She declined surgery and subsequently a family meeting was held and her family decided to respect her wishes of not having surgery and having a trial of maximal medical therapy. At this meeting, given her poor prognosis, it was decided to remove her flexiseal as this was very painful to the patient. After this was done she continued to have diarrhea but its amount reduced throughout the hospitalization. A palliative care consult was obtained and the patient and family decided to return home with a hospice program. IV tigecycline was stopped on the day of discharge; oral vancomycin should be tapered to a decreased dose, but continued for life. #. Electrolyte abnormalities: Patient??????s course was complicated by persistent electrolyte abnormalitis, including potassium, magnesium, calcium and bicarbonate loss due to the large amount of diarrhea that she was producing daily and her NPO status. These were repleted both via IV and PO routes. #. Delirium: Patient was found to be delirious at times during her hospitalization but she remained mostly AOX2-3. This was attributed to the severity of her disease and her long hospital course. #. UTI: Patient was found to have +UA on 2 different occasions during her hospitalization. The initial one was treated with 3 days of PO cipro. This was later thought not to have been appropriate and a second UA was found to be positive as well. This was treated with 3 days of IV cipro and this was discontinued as a recommendation of the ID team. She had a foley catheter throughout her hospitalization, which was removed prior to discharge. #. ARF: Patient presented with a Cr of 1.3 from a baseline of 0.7. This was thought to represent pre-renal azotemia due to severe dehydration as it resolved after IVF resuscitation. #. Code: Patient was DNR/DNI. Medications on Admission: citalopram 20 daily cyanocobalamin 1000mcg IM monthly digoxin 125mcg every other day folic acid 1mg daily lisinopril 10 daily metoprolol 12.5 TID omeprazole 20 daily warfarin (? if pt currently using) ferrous sulfate 325 daily fish oil daily Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:120 Capsule(s) Refills:3 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. compazine Sig: One (1) 10mg Transdermal every six (6) hours as needed for nausea: Please provide gel. Disp:1 tube Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Clostridium Difficile Pancolitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a severe infection in your colon called C. difficile. Your colon was very inflammed, with a condition called "colitis", requiring a tube to drain your stools. Your colon function has recovered, but you will need lifelong therapy with the antibiotic "vancomycin" to keep the infection at bay. We met with you and your family, and the decision was made to have you return to your home with hospice services. This was arranged with our case managers. The hospice agency will be available to you to help manage any discomfort and to access any resources needed to optimize your care at home. Followup Instructions: The hospice nurses affiliated with your agency are available for any acute needs.	[ "530.20", "V15.51", "041.4", "531.90", "428.22", "593.2", "276.2", "440.20", "V12.04", "584.9", "275.2", "276.8", "780.09", "008.45", "562.10", "599.0", "288.60", "300.4", "285.9", "275.41", "401.9", "276.51", "427.31", "556.6", "428.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8669, 8744	4736, 7966	271, 279	8821, 8821	4301, 4713	9640, 9725	3454, 3593		8258, 8646		8765, 8800		7992, 8235			9001, 9617										3608, 4282																														223, 233																307, 2199										8836, 8977								2221, 2695	2711, 3438
31,198	141,322	33023	Discharge summary	report	Admission Date: [2201-11-3] [Month/Day/Year ] Date: [2201-11-12] Date of Birth: [2165-2-26] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Reglan / Morphine / Prochlorperazine / Doxycycline Attending:[Doctor First Name 3290] Chief Complaint: Tylenol overdose/suicide attempt Major Surgical or Invasive Procedure: none History of Present Illness: 36 y/o M with PMHx of Morbid Obesity, DM, Hydradenitis, Depression, Personality D/o and chronic pancreatitis (recent admission with flare) now presenting with nausea/vomiting and abd pain after ingestion of approx 200 tablets extra-strength tylenol in a suicide attempt. . VS on arrival to ED: T 97.4 HR 94 BP 167/104 RR 18 Sats 100%. Toxicology was consulted for Tylenol level of 184 approx 20hrs s/p ingestion. ED had difficulty with attaining access, now s/p PICC placement. NAC infusion recommended and pt just starting bolus of NAC upon transfer to floor. He was also given Dilaudid 1mg IV x1 and Zofran 4mg IV prior to transfer. Pt was reporting right sided chest pain and EKGs were reported normal. RUQ ultrasound showed fatty infiltration but overall unchanged from prior. UA was requested for elevated anion gap though not yet completed. . On arrival to the floor, pt was tearful and complaining of abdominal pain, nausea and right sided chest pain. Pt was seen with social work and reported the events from monday consistently, having ingested a total of 200 tabs of tylenol in an attempt to kill himself. He denied any ETOH or other ingestions and was not really remorseful about the attempt. He is anxious and reports some mild SOB but no fevers/chills. He has baseline diarrhea but has not noted any episodes today, denies bloody stools but had 2 episodes of non-bloody (green) emesis yesterday after the ingestion. He noted a worsening in his hydradenitis rash, denies dysuria or lower extremity edema. . Provides history of 2 other suicide attempts- the first involving a hanging that required ICU admission and prolonged hospital course in [Location (un) 3844]. Would not expand upon the second attempt. . 10 pt ROS otherwise negative Past Medical History: # Diabetes Mellitus - insulin dependent # Hydradenitis Suppuritiva - frequent flares # Fournier's Gangrene, s/p Diverting Colostomy - [2198] @ [Hospital1 2025] # Colostomy Revision [2199-6-23] # PE [6-/2199] - post op, anticoagulated x 5.5 months # abdominal hernia # s/p cholecystectomy # s/p umbilical hernia repair # Depression - history of prior suicide attempt, though truthfulness of this attempt is in question per psychiatry # Primary Personality Disorder/concern for factitious or malingering disorder - raised in setting of psych hospitalization [4-/2199] for ?suicide attempt # Frequent missed [Year (4 digits) 4314]/poor follow up # Hyperlipidemia # h/o chronic pancreatitis [2-24] high triglycerides to 6000 - first episode [2199-12-23] # Psoriatic arthritis Social History: Works as a mover and truck driver. He lives alone. Mother, sister and friends are involved and appear to be living with him. Mother with a significant psychiatric history as well. He continues to deny tobacco, alcohol, other illicits including opioid abuse. Family History: Relatives with COPD, MS, ovarian CA, uterine CA, bladder CA, mother and uncle with diabetes mellitus II, [Year (4 digits) ] with SLE, mother has hidradenitis suppurativa (severe, in axillae and groin). Mother also has MS. [First Name (Titles) ] [Last Name (Titles) ] has very high cholesterol and triglycerides and related complications. Physical Exam: T 96.1 BP 104/62 HR 66 RR 22 Sats 100% RA BS 383 GEN: NAD, lying in bed, tearful [Last Name (Titles) 4459]: [Last Name (Titles) 12476], EOMI, MMM CV: Mildly tachycardic, no apprec m/r/g RESP: CTAB no w/r ABD: asymetric baseline, [Month (only) ] BS, soft, mildly TTP diffusely, no rebound/guarding GU: no foley EXTR: no edema, warmth NEURO: alert, oriented, depressed, no asterixis Pertinent Results: [2201-11-3] 07:45AM BLOOD WBC-9.1 RBC-4.88 Hgb-13.9* Hct-40.1 MCV-82 MCH-28.5 MCHC-34.7 RDW-16.6* Plt Ct-318 [2201-11-3] 07:45AM BLOOD Neuts-81.4* Lymphs-13.0* Monos-3.7 Eos-1.6 Baso-0.3 [2201-11-3] 07:45AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1 [2201-11-3] 07:45AM BLOOD Glucose-385* UreaN-12 Creat-1.0 Na-134 K-3.9 Cl-99 HCO3-20* AnGap-19 [2201-11-3] 07:45AM BLOOD ALT-71* AST-116* CK(CPK)-339* AlkPhos-107 TotBili-0.6 [2201-11-3] 07:45AM BLOOD Albumin-3.8 Calcium-8.9 Phos-2.9 Mg-1.8 [2201-11-3] 07:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-184* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2201-11-3] 08:01AM BLOOD Lactate-1.6 K-4.1 CXR Portable [2201-11-1]: There is a right-sided peripherally inserted central catheter with the tip terminating at the junction between the SVC and the right atrium. The film is limited by AP technique and poor penetration. The lungs are clear with no evidence of consolidation or redistribution of pulmonary vasculature. There are no effusions or pneumothoraces. No abdominal free air. There are no bony abnormality seen. IMPRESSION: Satisfactory position of right-sided PICC. This result was communicated with the PICC nurse at the time of line placement. EKG showed NSR with TW flattening in III, similar to prior tracings. Pt was also noted to have some ectopy (PVCs)on telemetry. RUQ u/s [2201-11-3] IMPRESSION: 1. Prominence of the common bile duct, which measures up to 9 mm but is essentially unchanged from previous exam. 2. Diffuse increased hepatic echogenicity, findings compatible with fatty infiltration. As stated previously, additional forms of liver disease and more advanced liver disease such as hepatic fibrosis and cirrhosis cannot be excluded on this exam. Repeat LFTs: [2201-11-3] 04:21PM BLOOD ALT-219* AST-143* LD(LDH)-343* CK(CPK)-78 AlkPhos-102 TotBili-1.0 [2201-11-3] 09:36PM BLOOD ALT-191* AST-81* LD(LDH)-328* AlkPhos-103 TotBili-0.9 [2201-11-4] 01:39AM BLOOD ALT-156* AST-46* LD(LDH)-238 CK(CPK)-68 AlkPhos-91 TotBili-0.7 [2201-11-4] 05:38AM BLOOD ALT-147* AST-43* LD(LDH)-291* AlkPhos-92 TotBili-0.6 [2201-11-4] 09:36AM BLOOD ALT-126* AST-39 LD(LDH)-273* CK(CPK)-49 AlkPhos-75 TotBili-0.4 [2201-11-4] 04:03PM BLOOD ALT-126* AST-43* LD(LDH)-212 AlkPhos-79 TotBili-0.5 [2201-11-3] 07:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-184* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG repeat acetaminophen: [2201-11-3] 04:21PM BLOOD Acetmnp-18 [2201-11-4] 04:03PM BLOOD Acetmnp-NEG . TESTICULAR ULTRASOUND: IMPRESSION: Soft tissue induration, without focal fluid collection or abscess. . Renal u/s (prelim) [2201-11-12]: mild fullness in right kidney, likely physiological from not voiding. Brief Hospital Course: This is a 36 yo male with 2 previous suicide attempts, now presented 18 hours after intentional overdose on Tylenol. Originally in the MICU, then transferred to Medicine floor upon normalization of his tylenol levels and downtrending of his LFTs. . MICU course: Pt ingested approx 200 tabs of Tylenol 500mg with only 1-2 episodes of vomiting and no pills visualized. Acetaminophen level on arrival was 187, putting him at high risk for liver injury on nomogram. Initial labs showed mild transaminitis and elevated INR with no clinical evidence of liver impairment (ie encephalopathy or asterixis). Pt was placed on IV NAC infusion with serial monitoring of LFTs, coags, lytes and acetaminophen level. Transaminitis peaked at ALT of 219 and AST of 143, INR peaked at 1.7. IV NAC was continued until [2201-11-4] when Tylenol level became 0 and LFTs trended down. Patient maintained with 1:1 sitter. Psychiatry was consulted and recommended transfer to psych unit once pt was medically cleared. . # Anion gap metabolic acidosis: Pt had a slight acidosis without clear cause that was thought to be due to DKA despite the lack of ketonuria. The gap closed with insulin drip. Pt was then transitioned to SC insulin (currently on half the home basal dose since pt's PO intake not completely baseline). . Medicine floor course starting HD2. . # APAP OD: At time of transfer to the floor, Tylenol level decreased to 0, so the NAC was discontinued. LFTs and INR continued to trend down. Pt did continue to have abdominal pain, which was controlled with PO Dilaudid. He expressed great remorse over his suicidal attempt. Pt's home statin, fibrate and niacin were eventually reinstated upon normalization of his LFTs and were well tolerated. He remained on a 1:1 sitter due to his suicidal attempt. His hospitalization was extended by a PICC line infection. Upon clearance of this infection, the psychiatry team felt that he was no longer suicidal and revised their recommendation for inpatient psychiatric admission. He was discharged to home with a partial inpatient day-program for further psychiatric care. . # Diabetes Type 1: Pt was back to SC insulin by the time of transfer to the floor. He takes a large amount of insulin at home 125units qAM and 90units qhs. His insulin was slowly reinstated due to poor PO. He became obsessed with what he perceived as very poor glucose control, though his FSG remained 200-250. He was very agitated and frustrated that his home regimen was not reinstated immediately, complaining of worsening neuropathy and multiple other consequences. [Last Name (un) ] was consulted and adjusted his NPH and sliding scale. He was discharged on 115units NPH qAM, and 75qPM in addition to a humalog sliding scale. . #. Fevers, Leukocytosis: The patient developed high fevers to 103.5 on [11-6] accompanied by leukocytosis and general malaise. He was started empirically on vanco and zosyn, and due to his known hydradenitis suppuritiva which involved open sores on his abdomen and groin, clindamycin was also added to cover skin pathogens. Due to testicular pain and his history of Fournier's gangrene, surgery and [Month/Year (2) ] were consulted. Both consult teams felt that the likelihood of Fourniers was low based on his clinical appearance. He did have a healing ulcer on his scrotum. Ultrasound of the soft tissues of the scrotum and groin demonstrated no evidence of Fourniers, or abscesses. There was soft tissue induration consistent with hydradenitis. His blood cultures demonstrated GPCs in pairs and chains. Infectious disease was consulted, and recommended discontinuing clindamycin. His PICC line was subsequently removed, and tip culture grew coagulase negative staphylococcus. Zosyn was subsequently stopped due to the development of a fluid nonresponsive ARF thought to be toxic ATN in the context of antibiotics. Vancomycin was then switched to linezolid [2201-11-10] in the context of his [Last Name (un) ]. His blood culture eventually grew strep viridans on [11-11], which was felt to be a contaminant. He was treated for a PICC line infection and will complete a 7 day antibiotic course with an additional 2 days of linezolid as an outpatient. His fevers and leukocytosis resolved within 36 hours and he remained afebrile for the remainder of his hospitalization. . #. Acute kidney injury: His creatinine increased from baseline 0.9 on [11-7] to 1.3 on [11-8], then peaked at 2.3 the following day. His renal function did not respond to fluids and his FeNa was elevated at 5.4%, demonstrating a likely intrinsic renal source. We suspect an AIN or toxic ATN in response to antibiotics over that time period. His urine sediment was bland without urinary eosinophils. His zosyn and vancomycin were discontinued and he was transitioned to linezolid to complete the remainder of his antibiotic course. He also underwent a renal u/s as well which showed mild fullness in right kidney, likely from not voiding, not pathological. Final read was pending at time of [Month/Year (2) ]. Of note, his creatinine had also been elevated to 1.3 early in his ICU course which was felt to be secondary to dehydration and responded promptly to fluids. . # Elevated Troponin: Patient had elevated troponin to 0.07 in the ICU without EKG changes. This elevation had occurred in the context of worsening renal function, likely related to renal function but received ASA. CK and MB were negative. Low index of suspicion for ACS. Pt was continued on Carvedilol. . # Abdominal Pain: Possible capsular stretch in context of hepatitis vs exacerbation of chronic abdominal pain secondary to his known chronic pancreatitis. He required po dilaudid 2mg Q4hr for pain control. He was transitioned to home-dose oxycodone at [Month/Year (2) ]. . #. [Female First Name (un) 564] dermatitis: He developed panniculitis demonstrating a diffuse erythematous rash consistent with [Female First Name (un) ]. Was placed on topical miconazole and oral fluconazole with subsequent improvement of his rash. Also, completed 5 day course of Flucanozole. . #. Hydradenitis suppuritiva: He has chronic hydradenitis with open ulcerations on his right lower abdomen and groin. Dermatology was consulted regarding chronic treatment. They recommended continuation of his clindamycin cream in addition to [Hospital1 ] hibiclens washes. He will follow up with his [Hospital1 756] dermatologist and plastic surgeon for definitive and likely surgical treatment. . #. Tinea Barbae: he had a tinea-like rash over his left cheek and was treated with topical ketaconazole, followed by PO fluconazole with subsequent improvement of his symptoms. . # HTN: He was restarted on antihypertensives once clinically stabilized, though valsartan was held in the context of [Last Name (un) ]. . # HL: Restarted pravastatin, Fenofibrate, Niaspan after the LFTs normalized. Medications on Admission: Clindamycin topically Amlodipine 10 mg daily Carvedilol 25 mg [Hospital1 ] Valsartan 160 mg daily Niaspan 1,000 mg [Hospital1 ] Tricor 145 mg Tablet Simvastatin 40 mg daily gabapentin 600 mg TID Pancrease 3 tabs TID Duloxetine 60 mg daily Fish Oil 1,000 mg [Hospital1 ] Insulin NPH 125units qam and 95 units qpm Humalog adjust per sliding scale. Oxycodone 5 mg prn for 5 days [Hospital1 ] Medications: 1. clindamycin phosphate 1 % Solution Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for hydradenitis. 2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 4. insulin NPH & regular human 100 unit/mL (70-30) Cartridge Sig: Thirty Five (35) units Subcutaneous qam. 5. insulin NPH & regular human 100 unit/mL (70-30) Cartridge Sig: Sixty (60) units Subcutaneous qpm. 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 8. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. 9. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:4 Tablet(s) Refills:0 10. Hibiclens 4 % Liquid Sig: One (1) application Topical [Hospital1 ] (2 times a day). 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. [Hospital1 ] Disposition: Home With Service Facility: [Location (un) ] Care Alliance Network Health Alliance [Location (un) ] Diagnosis: PRIMARY DIAGNOSES: 1. Tylenol overdose 2. Coagulase negative staphylococcus aureus bacteremia 3. Hydradenitis suppuritiva 4. Acute Kidney Injury 5. Tinea barbae 6. [Female First Name (un) 564] dermatitis 7. chronic pancreatitis [Female First Name (un) ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [Female First Name (un) ] Instructions: Dear Mr. [Known lastname 76780], You were admitted to the hospital because of an intentional Tylenol overdose. Your liver tests were abnormal and Tylenol level in your blood was elevated. You were treated with a medication called IV Acetylcysteine which is the antidote. Your liver function improved and the Tylenol level normalized to zero. You were evaluated by Psychiatry who initially thought that you would benefit from an inpatient treatment program, but by the time of [Known lastname ] had instead decided upon an outpatient day-program. You developed significant fevers secondary to an infection of your PICC line that seeded your blood. You were treated with antibiotics, and will complete two more days following [Known lastname ]. Your kidney function declined during this treatment, presumably due to the antibiotics you were given. We switched your medications and your kidneys started to improve by [Known lastname ]. You will need to see your PCP later this week to have your labs checked again. Your chronic medical problems were managed as well, including diabetes and hydradenitis. You did have some new testicular pain which was evaluated with an ultrasound that showed normal results. You have [Known lastname 4314] with your dermatologist and plastic surgeon to treat your hydradenitis. Please make the following changes to your meds: CHANGE your insulin to NPH 115units in the morning and 75 units before bed. Continue your sliding scale as before. START LINEZOLID 600mg twice a day for the next 2 days for your infection. STOP VALSARTAN until instructed to resume by your PCP, [Name10 (NameIs) ] it can slow the improvement of your renal function. STOP DULOXETINE while taking linezolid due to the possibility of a significant side effect. Speak with your PCP about when to restart. Please resume all other medications as prescribed by your other providers. It was a pleasure caring for you, Mr. [Known lastname 76780]. We wish you the best. Followup Instructions: You have an appointment to see your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 76783], on [Last Name (STitle) 2974] [2201-11-13] at 11:40AM. You will be contact[Name (NI) ] should this appointment change. The phone number is [Telephone/Fax (1) 25050]. You also have an appointment to meet with your dermatologist, Dr. [Last Name (STitle) 76792] on [2201-11-24] at 1:45PM to address your hydradenitis suppurativa. His office phone is [Telephone/Fax (1) 76793] You also have an appointment to meet with your plastic surgeon, Dr. [Last Name (STitle) 27163] on [2201-11-24] at 10:15AM, to address your hydradenitis suppurativa. His office phone is [Telephone/Fax (1) 76794] If you cannot make it to your [Telephone/Fax (1) 4314], please let the respective offices know. Completed by:[2201-11-12]	[ "250.12", "E930.8", "705.83", "729.39", "999.31", "112.3", "577.1", "965.4", "584.5", "110.0", "357.2", "787.91", "E950.0", "707.8", "041.11", "250.62", "401.9", "311", "790.7" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]		6822, 13783	386, 392		4089, 6799	18166, 19034	3309, 3660						13809, 14199													3675, 4070																										15683, 15958				314, 348				15562, 15651	14229, 15532											420, 2187										15973, 18143								2209, 3014	3030, 3293
27,362	138,833	33065	Discharge summary	report	Admission Date: [2179-7-5] Discharge Date: [2179-7-12] Date of Birth: [2158-5-11] Sex: F Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 668] Chief Complaint: Malignant hypertension s/p failed kidney transplant Major Surgical or Invasive Procedure: [2179-7-5]: transplant nephrectomy History of Present Illness: 21 y/o female with past medical history significant for renal failure secondary to MPGN, s/p LRRT in [7-13], now with recurrence of MPGN and on peritoneal dialysis with labile hypertension and chronic daily headaches. Here for transplant nephrectomy. Past Medical History: ) MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[2175]. Post transplant pt was doing well, but had rising Cr for two year. In [6-/2178] pt presented with uncontrolled BP requiring ICU admission for Isradipine drip. Repeat biopsy showed a type 1 MPGN. Negative HepC,HepB,[Doctor First Name ], and renal U/S from NMEC showed stable AVF. Her creatinine peaked to 4's and she was started on steroids, prograf and cellcept. In [1-/2179], she required 3 sessions of HD through a right upper chest catheter. Creatinine slowly recovered to 3.2. Plasmapheresis was then initiated with plan to then treat with Rituximab. She only underwent 3 sessions of [Year (4 digits) ]. She is now transferred her care to Dr. [Last Name (STitle) ] at [Hospital1 18] to an adult clinic. 2) Peripheral edema and abdominal striae [1-9] steroids 3) HTN [1-9] steroids and renal disease, multiple admissions for Hypertensive emergency. 4) Hemolytic Anemia - was seen by heme/onc who felt it was [1-9] to malignant hypertension. 5) Migraines Social History: Lives at home with [Month/Day (2) ], brother and sister, college student at [Name (NI) 498] [Name (NI) 86] in the health sciences. Denies ETOH, illicit drugs, tobacco. Family History: No history of kidney disease, malignancy, heart disease, or diabetes. Physical Exam: BP 198/126 HR 66 RR 16 98% RA Gen: tired but AOx3, NAD [Name (NI) 4459]: MMM, anicteric sclera; tunneled HD line c/d/i Heart: RRR, Lungs: CTAB, Abdomen: soft, NT/ND, old txp scar, PD catheter intact Extremities: No LE edema, 2+ DP/PT pulses bilaterally Pertinent Results: Post Op: [2179-7-5] WBC-7.7 RBC-3.92* Hgb-11.8* Hct-36.5 MCV-93 MCH-30.2 MCHC-32.5 RDW-18.4* Plt Ct-248 PT-12.5 PTT-22.1 INR(PT)-1.1 Glucose-112* UreaN-69* Creat-9.9* Na-141 K-5.2* Cl-103 HCO3-24 AnGap-19 Calcium-9.6 Phos-7.0* Mg-2.0 On Discharge [2179-7-12] WBC-5.1 RBC-3.54* Hgb-10.8* Hct-33.6* MCV-95 MCH-30.4 MCHC-32.0 RDW-17.7* Plt Ct-241 Glucose-108* UreaN-43* Creat-9.1* Na-139 K-5.2* Cl-95* HCO3-31 AnGap-18 Calcium-9.7 Phos-6.7# Mg-2.3 Brief Hospital Course: 21 y/o female admitted for transplant nephrectomy. Blood pressure was initially very difficult to control and surgery was postponed 1 day until administration of IV BP lowering agents were added to PO regimen in preparation for surgery on [7-7]. Patient was taken to the OR with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Please see the operative [Last Name (un) ] for surgical detail. In summary, the kidney was removed leaving the capsule in place. She tolerated the procedure well and did not have any intra-op complications. In the post op period she required IV labatelol and nitroprusside drip. Once she was transitioned off these medications, she was transferred to the regular surgical floor. BP's were around 140-150 systolic generally and diastolic still remains around 105. She continued her peritoneal dialysis under the recommendations of the Renal team. She was using CAPD during the hospitalization. She will return to the Cycler once home. There was no evidence of fluid leak. Her pain control was difficult to manage, and required the re-addition of the PCA (Dilaudid)on POD 2. She was able to transition to solely PO Oxycodone with additional Tylenol with much better effect by POD 4. Incision remained clean/dry/intact, no evidence of infection. She had a very high serum phosphorus level (>9) that was treated with Sevelemer and a short term trial of Alternagel. Phos down to 6.7 on day of discharge. She used Benadryl and Atarax with fair relief of symptoms. Patient was also followed by outpatient nephrologist Dr [Last Name (STitle) 118] who will continue her BP medication management as an outpatient. Adjustments were made for home. Immunosuppression was changed to prednisone 2.5 mg every other day, and she is now off Cellcept. By day of discharge she is ambulating, tolerating diet and pain is under much better control. Per Dr [First Name (STitle) ], HD catheter is to [Last Name (un) 7387] in place until follow up clinic visit with him. She will resume the cycler at home and is to contact her outpatient PD nurse for further monitoring. Medications on Admission: vit B/C, prednisone 5', zofran, mmf 250", lopressor 150", losartan 100", lisinopril 40', isradipine 15"', isradipine SR 15"', hydralizine 100"', clonidine .2mg patch Qwk, clonidine .1"', aliskiren 150' Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Losartan 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Lopressor 50 mg Tablet Sig: Three (3) Tablet PO twice a day. 5. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO three times a day. 7. Isradipine 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Three (3) Tab,Sust Rel Osmotic Push 24hr PO three times a day. 8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 9. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s)* Refills:2 11. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO ONCE (Once) as needed for itching for 1 doses. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 15. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: malignant hypertension s/p renal transplant nephrectomy Discharge Condition: Good Discharge Instructions: Please call Dr [First Name (STitle) ] at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down medications. Continue PD per Dr [Last Name (STitle) 76879] recommendations, you will return to the Cycler on discharge home. Please call [Doctor Last Name 2563], your PD nurse on day of discharge. Monitor incision for redness, drainage or bleeding Please do not shower until HD catheter removed, which will be done by Dr [First Name (STitle) ] at your clinic visit. [Month (only) 116] use spray shower below waist, allow water to run over incision and PD exit site. Pat area dry, dress PD exit site per protocol No tub bath or swimming until cleared by Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] heavy lifting Do not drive if taking narcotic pain medications Continue stool softener There have been changes to your blood pressure medications to include discontinuing the Aliskaren, change hydralazine to 50 mg TID. Immunosuppression changes include prednisone 2.5 mg every other day and discontinue cellcept. Followup Instructions: [Name6 (MD) ] [Name8 (MD) 8222], MD Phone:[Telephone/Fax (1) 2928] Date/Time:[2179-7-13] 6:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2179-7-22] 1:00 [Name6 (MD) 2105] [Name8 (MD) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2179-7-30] 8:20 Completed by:[2179-7-12]	[ "585.6", "403.01", "E878.0", "275.3", "996.81", "583.2" ]	icd9cm	[ [ [] ] ]	[ "54.98", "55.53" ]	icd9pcs	[ [ [] ] ]	6536, 6542	2789, 4907	317, 358	6642, 6649	2311, 2766	7819, 8214	1941, 2013		5161, 6513		6563, 6621		4934, 5138			6673, 7796										2029, 2292																														226, 279																386, 643																		665, 1727	1743, 1925
18,947	148,899	51299+59331+59332	Discharge summary	report+addendum+addendum	Admission Date: [2179-3-13] Discharge Date: [2179-4-1] Date of Birth: [2132-10-23] Sex: F Service: GYN/ONCOLOGY ADMITTING DIAGNOSIS: Pelvic mass. DISCHARGE DIAGNOSIS: Stage IV poorly differentiated papillary serous carcinoma of the ovary. HISTORY OF THE PRESENT ILLNESS: This is a 46-year-old gravida II, para II-0-0-II, who presented to the Emergency Room with complaints of constipation, nausea, vomiting, and anorexia for the last two weeks. The workup in the Emergency Room included a CT which showed bilateral pleural effusions, a large multiloculated mass filling the entire cul-de-sac measuring 15.8 cm in greatest dimension, extending out of the pelvis above the umbilicus towards the liver. There was omental caking and minimal ascites. The ovaries were not well visualized. There was some questionable retroperitoneal lymphadenopathy. Because of the patient's GI complaints, she was admitted and placed on bowel rest with the diagnosis of a partial small bowel obstruction. Her initial laboratory results revealed a white blood cell count of 27.8 with 89% neutrophils, 9% lymphocytes. Her initial PT was 14.4 with an INR of 1.4. Her sodium was 133. Her liver function tests were within normal limits. Her amylase and lipase were also within normal limits. The patient was admitted for further evaluation of her pelvic mass, GI symptoms, and fever. HOSPITAL COURSE: 1. PARTIAL SBO: The patient was admitted to the hospital and placed on bowel rest. Her electrolytes were checked on a daily basis and were repleted as needed. The patient's symptoms of nausea, bloating, and constipation continued until her surgery. Her postoperative course from a GI standpoint was significant for a postoperative ileus which resolved on postoperative day number seven with the passage of flatus. The patient was started on TPN on postoperative day number two given that she had been on bowel rest preoperatively. We continued to check her electrolytes on a daily basis and replete them through her TPN. On postoperative day number eight, the patient's diet was advanced to fluids. The patient was able to tolerate the fluids as she continued to ambulate and pass flatus. Her diet was advanced. By postoperative day number 11, she was tolerating solid foods. In addition, the patient was also spontaneously passing flatus and having bowel movements. The patient will be discharged home on a regular diet with Boost supplements. 2. HEMATOLOGIC: A lower extremity Doppler was performed on the patient on hospital day number two after suspicion for DVT was raised on the initial CT of the pelvis. It demonstrated a left superficial femoral deep venous thrombosis. A CTA showed probably not clinically significant emboli. The patient was started on heparin and [Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter was placed on hospital day number four. This was done by Interventional Radiology with no complications. The patient was continued on heparin up until approximately seven hours prior to surgery. The patient had her coagulation panel and CBC checked daily. Just prior to surgery, the patient received 2 mg of vitamin K and 1 unit of FFP per the Hematology Service recommendations. In addition, preoperatively, the patient received 2 units of packed red blood cells given that her preoperative hematocrit was 25. Intraoperatively, the patient received 2 additional units of packed red blood cells and 1 additional unit of FFP. Postoperatively, the patient's hematocrit was stable in the low 30s. Her heparin anticoagulation was restarted on postoperative day number four for one day. At that point, the decision was made to change her to Lovenox 40 mg subcutaneously b.i.d. per recommendations from the Hematology Service. A low-molecular weight serum level was drawn and was found to be subtherapeutic. Therefore, the dose was increased to Lovenox 60 b.i.d. The Lovenox was discontinued on postoperative day number ten due to the development of an incisional hematoma. The patient will not be discharged on Lovenox but will probably restart the Lovenox on an outpatient basis with her hematologist. The patient's hematocrit on the day prior to discharge was 27 and given that she will undergo chemotherapy, the decision was made to give the patient 1 additional unit of packed red blood cells. The patient was started on Epogen 40,000 units subcutaneously q. week (starting on Wednesday) plus iron 325 mg q.d. The patient will be discharged to home on the iron and the Epogen. 3. ONCOLOGIC: A FNA of the breast demonstrated a poorly differentiated epithelial tumor, unknown primary. The Breast Surgery Service was consulted and their opinion was that the pelvic mass primary was most likely not breast in origin. The patient underwent an uncomplicated exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and cytoreduction procedure on [2179-3-20]. The estimated blood loss was 1,200 cc. The patient received 5 liters of crystalloid, 2 units of FFP, 4 units of packed red blood cells (including her preoperative transfusion). The intraoperative findings included multiple tumor nodules on the mesentery, small bowel, diaphragm. There was a large pelvic mass arising from and replacing the entire left ovary. The right ovary was normal and small in appearance. The omentum was replaced by tumor caking. There was 1,200 cc of straw-colored ascites. There was no evidence of mechanical bowel obstruction. Postoperatively, the patient was transferred to the ICU for her immediate postoperative recovery. While she was in the ICU, her pain was adequately controlled. Her CA-125 returned at 475 and her CA19.9 was 14 (within normal limits). The patient's pain was controlled initially with a Dilaudid PCA. An intraoperative NG tube was continued on low intermittent suction. The patient's urine output was adequate and her Foley was discontinued on postoperative day number two. The patient remained afebrile during the immediate postoperative period. The rest of her vital signs were stable. Her breathing remained the same (slightly with feelings of slight shortness of breath but overall breathing without difficulty). The final pathology from the surgery revealed a poorly differentiated papillary serous carcinoma arising from the ovary. The Oncology Service was consulted and arrangements were setup for in-house chemotherapy for cycle number one. On postoperative day number 16, the patient underwent her first cycle of single [Doctor Last Name 360] carboplatin chemotherapy with Decadron premedication. The patient tolerated the chemotherapy well and will follow-up for her chemotherapy on an outpatient basis. From a pain control standpoint, the patient was continued on Dilaudid PCA until postoperative day number seven. At that point, she was changed over to Toradol. The patient was continued on the Toradol until she was able to tolerate more p.o. and at that point, she was changed to p.o. Motrin and Percocet with Oxycodone for breakthrough pain. The patient was continued on the Toradol for a total of four days and Motrin for one day. At that point, she developed an incisional hematoma which was initially followed clinically as it was not expanding. However, on postoperative day number 12, the incision began to drain and the patient spiked a temperature up to 101.2. The decision was then made to proceed with an I&D of this incisional hematoma. This was done at the bedside using 1% lidocaine for local anesthesia. A three inch area of the incision was opened and approximately 200 cc of clot was drained. The wound was flushed with sterile saline and gently packed with gauze. The patient from that point onward will be having b.i.d. to t.i.d. wet-to-dry wound dressing changes. The patient will have VNA services when she goes home to assist her with the dressing changes. During the temperature spike, the patient had been pan cultured. Her blood cultures have been negative to date. The triple lumen catheter that was placed intraoperatively was pulled and the tip was sent for culture. The urine culture was positive for coagulase-negative Staphylococcus. The patient was started on Kefzol and will be discharged home on Keflex 500 q.i.d. Since that temperature spike, the patient has remained afebrile. 4. INFECTIOUS DISEASE: From an ID standpoint, the patient's initial presenting temperature was 101.2. The patient defervesced immediately afterwards. She was started at on amp, gent, and Flagyl. She was continued on amp, gent, and Flagyl for a total of eight days. All of her cultures at that time were negative for any organisms. In addition, the patient remained afebrile. The patient did have a temperature, as previously stated, on postoperative day number 12 up to 101.2. The patient will be discharged to home afebrile. DISPOSITION: The patient has had one course of single [Doctor Last Name 360] carboplatin chemotherapy. She has received a total of 5 units of packed red blood cells during this hospitalization, 4 pre and intraoperatively, and 1 the day of discharge. The patient received 2 units of FFP pre and intraoperatively. The patient will be discharged home on the following medications. DISCHARGE MEDICATIONS: 1. Compazine 10 mg t.i.d. around the clock times two days and then p.r.n. thereafter. 2. Percocet p.r.n. 3. Colace 100 b.i.d. 4. Simethicone 80 q.i.d. 5. Keflex 500 mg q.i.d. times six days. 6. Oxycodone 5-10 mg q. 4-6 hours p.r.n. breakthrough pain. 7. Dulcolax 10 mg suppository p.r.n. no bowel movement times four days. 8. Ativan 1 mg q.h.s. p.r.n. sleep. 9. Reglan 5-10 mg q.i.d. p.r.n. FOLLOW-UP: The patient will follow-up with Dr. [Last Name (STitle) 2406] from GYN/Oncology on [2179-4-12] at 1:30. She will follow-up with Dr. [Last Name (STitle) 150] from Hematology/Oncology on [2179-4-8] at 2:00 p.m. She will start her Lovenox with Dr. [Last Name (STitle) 150] who will also follow her serum levels to achieve therapeutic levels. CONDITION ON DISCHARGE: Stable. She was discharged to home with VNA services. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2407], M.D. [MD Number(1) 2408] Dictated By:[Name8 (MD) 4872] MEDQUIST36 D: [2179-4-1] 11:42 T: [2179-4-1] 22:22 JOB#: [Job Number 106422] Name: [Known lastname 17341], [Known firstname 4193] Unit No: [Numeric Identifier 17342] Admission Date: [2179-3-13] Discharge Date: [2179-4-5] Date of Birth: [2132-10-23] Sex: F Service: GYN/ONC HISTORY OF PRESENT ILLNESS: The patient on [2179-4-1] started to experience progressively worse nausea and vomiting after receiving her first cycle of carboplatin on [2179-3-31]. The patient's nausea continued to persist despite the Zofran, which was changed to Anzemet. In addition, the patient was receiving Compazine around the clock as recommended by the Oncology Service. The patient was able to tolerate minimal po in between her episodes of nausea and vomiting. The patient continued to spontaneously pass flatus, continued to ambulate and continued to void without difficulty. The patient's nausea and vomiting persisted and on postoperative day number 15 had a dystonic reaction, which was felt to be attributed to the Compazine around the clock and the Reglan prn that she had been receiving. The Compazine and Reglan were both discontinued. She was continued on the Anzemet and the Ativan. The patient received Benadryl for the dystonic reaction with good results. She continues to get Benadryl around the clock as well as Ativan on a prn basis. The patient was continued on the Benadryl around the clock until postop day 17. At that time the dystonia had subsided significantly. The patient continued to have nausea and vomiting despite the Anzemet, therefore Decadron was added. The patient was maintained on the Anzemet and Decadron with some relief of the nausea and vomiting. On postop day number one the patient underwent an uncomplicated right sided pleurocentesis under ultrasound guidance. This was done, because the patient reported increased difficulty in breathing. The pleurocentesis yielded approximately 1 liter of straw colored sputum that was negative for malignancy on cytology evaluation. The patient after the tap felt an improvement in her breathing. In the middle of the day on postoperative day number 18 the patient stated that her nausea had improved and she had not vomited. She was able to tolerate solids and liquids throughout the day. The patient will be discharged to home with Zofran prn as well as Ativan prn for sleep. The patient will follow up with Dr. [Last Name (STitle) ] on [2179-4-12] at 1:30 p.m. and Dr. [Last Name (STitle) 6581] in heme/onc on [2179-4-8] at 2:00 p.m. MEDICATIONS ON DISCHARGE: Zofran 4 mg t.i.d. prn, ferrous sulfate 325 mg po q day, Epogen 40,000 mg subQ q week on Wednesday, Ativan 1 mg po q.h.s. prn, Oxycodone 5 to 10 mg po q 4 to 6 hours prn, Keflex 500 mg q.i.d. times one day and Simethicone 80 mg q.i.d. prn and Percocet 5/325 one to two tablets q 4 to 6 hours prn. CONDITION ON DISCHARGE: Good. She is discharged to home with VNA Services. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2921], M.D. [MD Number(1) 2922] Dictated By:[Name8 (MD) 14827] MEDQUIST36 D: [2179-4-5] 04:14 T: [2179-4-7] 07:07 JOB#: [Job Number ] Name: [Known lastname 17341], [Known firstname 4193] Unit No: [Numeric Identifier 17342] Admission Date: [2179-3-13] Discharge Date: [2179-4-5] Date of Birth: [2132-10-23] Sex: F Service: ADDENDUM TO DISCHARGE SUMMARY: HISTORY OF PRESENT ILLNESS: On postoperative day number one, the patient had undergone an uncomplicated right sided pleurocentesis under ultrasound guidance. This was done because of the patient's reported increased difficulty in breathing. This thoracentesis yielded approximately one liter of chocolate fluid that was negative for malignancy on cytology evaluation. The patient reported that after this tap, she felt an improvement in her breathing. Patient on [2179-4-1] started to experience progressively worse nausea and vomiting after receiving her first cycle of carboplatin on [2179-3-31]. The patient's nausea continued to persist despite the Zofran which was changed on Anzemet. In addition, the patient was receiving Compazine around the clock as recommended by the Oncology Service. The patient was able to tolerate minimal po in between her episodes of nausea and vomiting. The patient continued to spontaneously pass flatus, continued to ambulate, and continued to void without difficulty. The patient's nausea and vomiting persisted and on postoperative day #15 had a dystonic reaction which is felt to be contributed to Compazine around the clock and the Reglan prn that she has been receiving. The Compazine and Reglan was both discontinued. She was continued on the Anzemet and Ativan. The patient received Benadryl for the dystonic reaction with good results. She continued to get Benadryl around the clock as well as Ativan on a prn basis. The patient was continued on the Benadryl around the clock until postoperative day #17. At that time the dystonia had subsided significantly. The patient continued to have nausea and vomiting despite the Anzemet, therefore Decadron was added. The patient was maintained on the Anzemet and Decadron with some relief of the nausea and vomiting. By the middle of the day of postoperative day number 18, the patient stated that her nausea had improved and that she had not vomited today. She was able to tolerate solids and liquids throughout the day. The patient will be discharged to home with Zofran p.r.n. as well as Ativan p.r.n. for sleep. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [Last Name (STitle) ] on [2179-4-12] at 01:30 p.m. 2. Follow-up with Dr. [Last Name (STitle) 17343] of Hematology/Oncology on [2179-4-8] at 02:00 p.m. DISCHARGE MEDICATIONS: 1. Zofran 4 mg three times a day p.r.n. 2. Ferrous sulfate 325 mg p.o. q. day. 3. Epogen 40,000 mg q. week on Wednesday. 4. Ativan 1 mg p.o. q. h.s. p.r.n. 5. Oxy-Codon 5 to 10 mg p.o. q. four to six hours p.r.n. 6. Keflex 500 mg four times a day times one day. 7. Simethicone 80 mg four times a day p.r.n. 8. Percocet 5/325 one to two tablets q. four to six hours p.r.n. CONDITION AT DISCHARGE: Good. DISPOSITION: She is discharged to home with [Hospital6 2050] services. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 4784] Dictated By:[Name8 (MD) 14827] MEDQUIST36 D: [2179-4-5] 16:14 T: [2179-4-7] 06:39 JOB#: [Job Number ]	[ "197.6", "415.19", "599.0", "183.0", "998.11", "560.9", "560.1", "789.5", "998.12" ]	icd9cm	[ [ [] ] ]	[ "34.91", "85.91", "65.61", "99.15", "68.6", "86.04", "99.25", "38.7", "54.4", "38.93", "88.51" ]	icd9pcs	[ [ [] ] ]									16320, 16711		199, 1404	13018, 13316		1422, 9325		16088, 16297																													16727, 17082																											13961, 16064											163, 177									13341, 13932
27,431	122,175	723	Discharge summary	report	Admission Date: [2148-3-20] Discharge Date: [2148-3-29] Date of Birth: [2070-10-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: CVL placement Intubation J-tube placement History of Present Illness: Mr. [Known lastname 5345] is a 77 year-old male with a history of CAD, s/p CABG, HTN, schizophrenia, recent admission for hypoxia/hypotension with unknown etiology who presents from rehab with hypoxia to 78 on RA - 88 on NC. His PCP at [Name9 (PRE) 5346] started him on cefepime 1g IV bid for one week starting on [3-14] for a positive UA in setting of elevated white count. According to her, she sent three C diff samples that were negative and had given him empiric flagyl for three days in the interim. . He was sent to the ER, where he was found to be 92-96 on NRB mask. His BP ranged from 90s-120s. He was intubated for hypoxia (etomidate and succinylcholine given). CXR was performed and he was given levoflox and ctx x 1. OGT was placed. Thick yellow sputum was suctioned from his ETT. He recieved 3L NS. Troponin returned at 0.13 with flat CK and his EKG (Qs in V1-4 but no change from prior) was faxed to cardiology, who did not suspect acute MI and recommended he be given aspirin only (he was given ASA 325 mg po x 1). His WBC was 25.6 with 92% PMNs and no bands. UA was negative. Lactate was 1.7. Electrolytes were normal. . Of note, he was recently hospitalized [Date range (1) 5347] in the ICU after being admitted for desat to 80s, hypotension. He was started on empiric antibiotics at that time for possible aspiration pna, however all culture data and imaging was negative and was stopped. Imaging of his L ankle decubitus ulcer did not show osteomyelitis. He was also worked up for AMS with head CT and neuro c/s. Neuro felt he may have had a small TIA with R sided weakness and transient R sided facial droop. He was continued on aspirin, an increased dose of statin and Plavix. His neurological symptoms had resolved at the time of discharge. He was fed through an NGT, however when he was discharged to his NH this was pulled and he continued to have poor nutritional intake, which is not ideal especially given his chronic decubitus ulcers (5 of them). He has an appointment for PEG placement on [3-22] for poor nutritional status. Echo during his last hospitalization showed EF 35%, and EKG and CEs were consistent with likely MI prior to admission (trop 0.14). He was admitted to the MICU for further care. . ROS: Unable to assess given pt sedated, intubated Past Medical History: Recent hospitalization for hypoxia, hypotension of unknown etiology TIA in [3-5] Schizophrenia, per PCP, [Name Initial (NameIs) 5348] AAOx1, verbally abusive Depression HTN Dementia R eye cataract CAD, s/p CABG Social History: Eats a pureed diet. Mostly bedbound at [Name Initial (NameIs) 5348]. Pt has no family. Has legal guardian, [Name (NI) 3608] [Name (NI) 4334]. Per discussion with PCP, [Name10 (NameIs) 3608] is not comfortable making code decision for pt so there was a court date on [3-19] to appoint a guardian ad [Name2 (NI) 5349] for the purposes of making code decision for pt. This person has yet to be appointed. Family History: Non-contributory Physical Exam: Vitals: T: 97.9 BP: 116/64 HR: 88 RR: 18-20 O2Sat: 100% on AC 50014, RR 16, FiO2 0.5 GEN: opens eyes to name, does not withdraw to pain, sedated, intubated. HEENT: R eye surgical pupil, bilat pupils small, L eye sluggish response. COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, decreased at bases bilat ABD: Soft, NT, ND, diminished BS, no HSM EXT: No C/C/E, 1+bilat dp pulses, thickened toenails, decubitus ulcer on L lateral ankle to bone wrapped in gauze NEURO: does not withdraw, toes downgoing bilat Pertinent Results: [2148-3-20] 09:12AM BLOOD WBC-25.6# RBC-4.28# Hgb-13.0# Hct-39.4# MCV-92 MCH-30.5 MCHC-33.1 RDW-15.7 Plt Ct-498# [2148-3-21] 04:46AM BLOOD WBC-13.2 RBC-3.55* Hgb-10.9* Hct-33.2* MCV-93 MCH-30.6 MCHC-32.8 RDW-15.5 Plt Ct-351 [2148-3-23] 03:10AM BLOOD WBC-16.7* RBC-3.31* Hgb-10.3* Hct-30.6* MCV-93 MCH-31.1 MCHC-33.5 RDW-15.2 Plt Ct-398 [2148-3-25] 05:41AM BLOOD WBC-13.2* RBC-3.41* Hgb-10.3* Hct-31.1* MCV-91 MCH-30.1 MCHC-33.1 RDW-15.4 Plt Ct-430 [2148-3-27] 06:25AM BLOOD WBC-10.2 RBC-3.46* Hgb-10.7* Hct-32.1* MCV-93 MCH-30.8 MCHC-33.2 RDW-16.0* Plt Ct-448* [2148-3-29] 06:40AM BLOOD WBC-10.9 RBC-3.52* Hgb-10.9* Hct-32.1* MCV-91 MCH-30.9 MCHC-33.9 RDW-15.9* Plt Ct-436 [2148-3-20] 09:12AM BLOOD Neuts-91.7* Bands-0 Lymphs-4.9* Monos-2.6 Eos-0.6 Baso-0.1 [2148-3-20] 03:10PM BLOOD Neuts-90.6* Bands-0 Lymphs-5.8* Monos-2.2 Eos-1.1 Baso-0.3 [2148-3-27] 06:25AM BLOOD Neuts-76* Bands-0 Lymphs-11* Monos-5 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 [2148-3-28] 08:50AM BLOOD Neuts-78.4* Lymphs-13.0* Monos-4.1 Eos-4.4* Baso-0.1 [2148-3-20] 09:12AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.3* [2148-3-21] 04:46AM BLOOD PT-14.9* PTT-32.7 INR(PT)-1.3* [2148-3-22] 06:11AM BLOOD PT-15.3* PTT-37.4* INR(PT)-1.3* [2148-3-23] 03:10AM BLOOD PT-16.3* PTT-39.2* INR(PT)-1.5* [2148-3-25] 05:41AM BLOOD PT-14.3* PTT-32.3 INR(PT)-1.2* [2148-3-26] 03:15AM BLOOD PT-14.7* PTT-36.4* INR(PT)-1.3* [2148-3-28] 08:50AM BLOOD PT-16.0* PTT-30.5 INR(PT)-1.4* [2148-3-20] 09:12AM BLOOD Glucose-121* UreaN-7 Creat-0.6 Na-136 K-4.3 Cl-102 HCO3-25 AnGap-13 [2148-3-22] 06:11AM BLOOD Glucose-102 UreaN-5* Creat-0.4* Na-138 K-3.1* Cl-105 HCO3-23 AnGap-13 [2148-3-23] 03:38PM BLOOD Glucose-86 UreaN-3* Creat-0.4* Na-139 K-4.2 Cl-112* HCO3-20* AnGap-11 [2148-3-27] 06:25AM BLOOD Glucose-79 UreaN-5* Creat-0.5 Na-145 K-3.1* Cl-107 HCO3-28 AnGap-13 [2148-3-20] 09:12AM BLOOD ALT-31 AST-47* LD(LDH)-450* CK(CPK)-87 AlkPhos-85 Amylase-51 TotBili-0.7 [2148-3-21] 04:46AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.3 [2148-3-22] 06:11AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.1* Mg-1.9 [2148-3-25] 05:41AM BLOOD Calcium-8.4 Phos-1.5* Mg-2.0 [2148-3-26] 03:15AM BLOOD Calcium-8.7 Phos-2.4* Mg-4.1* [2148-3-27] 06:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 [2148-3-28] 08:50AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.0 [2148-3-29] 06:40AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.0 [2148-3-27] 06:25AM BLOOD CRP-35.0* [2148-3-21] 01:10PM BLOOD Vanco-10.6 [2148-3-22] 01:10PM BLOOD Vanco-23.8* [2148-3-29] 06:35AM BLOOD Vanco-43.6* [2148-3-20] 10:34AM BLOOD Type-ART Rates-14/ PEEP-5 FiO2-50 pO2-104 pCO2-36 pH-7.41 calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2148-3-20] 12:18PM BLOOD Type-ART pO2-181* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 [2148-3-20] 09:07PM BLOOD Type-ART pO2-146* pCO2-31* pH-7.48* calTCO2-24 Base XS-1 . ECG: NSR at 100, LAFT, LAD, Qs in V1-4 (old), low voltages. No change from one week prior. . Imaging: CXR: 1. Relatively low lying ET tube, which should be partially withdrawn approximately 2 cm. 2. Relatively high-riding endogastric tube, which should be advanced several cm. 3. "Deep" left lateral costophrenic sulcus; a loculated basilar pneumothorax cannot be excluded. 4. Patchy, streaky opacities at the medial lung bases, which may represent chronic aspiration. . CXR repeat: 1. No evidence of pneumothorax. 2. ET tube 6.2 cm above the carina partly explained by neck hyperextension. 3. NG tube terminating in the gastric cardia. Further advancement by 7-8 cm is recommended. 4. Patchy bibasilar streaky opacification, more confluent in the left; an acute infectious process cannot be excluded. . [3-4] ankle film (L): Patchy regional osteopenia. No acute injury identified. Osseous remodeling of the distal metaphyses of the tibia and fibula may represent the sequela of remote trauma. . [3-4] Echo: mild symmetric left ventricular hypertrophy with normal cavity size. severe hypokinesis/akinesis of the distal half of the anterior septum and anterior walls and distal inferior wall. The apex is mildly aneurysmal and dyskinetic. The remaining segments contract normally (LVEF = 35-40 %). Mild aortic regurgitation. Mild mitral regurgitation. . CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Left lower lobe collapse. 3. Evaluation of lung parenchyma is limited due to respiratory motion. Mild nodular and ground-glass opacity within the right lung base may represent early onset of infection. No evidence of consolidation. 4. Enlarged right hilar lymph node with borderline enlarged mediastinal lymph nodes. These findings are nonspecific and could represent the sequelae of prior infection or inflammation. . ANKLE (AP, MORTISE & LAT) LEFT [2148-3-21] 9:36 AM [Hospital 93] MEDICAL CONDITION: 77 year old man with Stage IV decubitus ulcer REASON FOR THIS EXAMINATION: Please assess for osteo. Three radiographs of the left leg and ankle demonstrate regional demineralization about the left ankle, hind, and mid foot and represent the sequela of remote trauma. No subcutaneous emphysema is evident. Assessment of the regional soft tissues is limited by dressing material overlying the medial malleolus. There is curvilinear density seen along the skin surface overlying the medial malleolus, possibly representing silver nitrate. The finding does not extend to the bone on these images. No subcutaneous emphysema is evident. The mortise is congruent, although assessment of the lateral mortise is somewhat limited by position. Plantar calcaneal spurs unchanged. No cortical fragmentation is evident. IMPRESSION: Curvilinear density on the skin overlying the medial malleolus. The finding may represent silver nitrate. The finding does not extend to the bone. No cortical fragmentation or subcutaneous emphysema is identified. Regional demineralization about the left ankle, mid, and hindfoot is unchanged. No acute injury is identified. . CHEST (PORTABLE AP) Reason: Evaluate for interval change. [Hospital 93] MEDICAL CONDITION: 77 year old man with hypoxia. REASON FOR THIS EXAMINATION: Evaluate for interval change. HISTORY: Hypoxia, to evaluate for change. FINDINGS: In comparison with study of [3-25], the opacification at the left base has almost completely cleared. The remainder of the lung is within normal limits. Nasogastric tube again extends well into the stomach and probably into the duodenum. Brief Hospital Course: # Hypoxia: Likely due to aspiration. Although CXR not impressive for infectious cause, GPCs on gram stain of sputum (while pt had been on outpatient cefepime) and on admission had thick secretions, so empirically treated with vanc/zosyn for possible hospital acquired pna. Extubated [3-21] to nasal cannula. Cultures were negative, so antibiotics were discontinued on [2148-3-23] (sputum culture with oropharyngeal flora only, blood cultures with only 1 bottle coag neg staph). However, increased secretions and WBC rising on [3-25]. Pan-cultured again (since off abx x2 days) and restarted on vanc/zosyn, still no growth at discharge. Patient also had repeated episodes of hypoxia while still in the ICU requiring face mask which suggests mucous plugging vs. aspiration which are resolving with chest PT. Patient has been satting well on room air since admission to the medicine floor. Also appears euvolemic to dry on exam, no rales so likely not fluid overloaded. He will continue on vancomycin/zosyn for a 14 day course (day 1=[3-20]). His vancomycin trough on the day of discharge was elevated to 43 so his doses were held. If possible, vanc trough should be checked daily each morning, and vancomycin can be restarted if trough <20 before [2148-4-2]. Additionally, patient has a percutaneous J-tube in place nutrition given his history of aspiration. Tube feeds were restarted on [2148-3-28] and are advancing to goal of 65cc/hr. No need for supplemental oxygen at this time as satting well on room air (>95%). . # Hypotension: Has been stable and not required fluid boluses since [3-23]. [Month/Year (2) ] SBP appears to be in the 90s, but transient dips into the 80s have resolved spontaneously with no intervention. No evidence of sepsis (HR stable, white count decreasing, blood pressure stable, no clear source of infection other than possible aspiration). Blood cultures still pending at the time of dischage, have all been no growth to date. Patient can have IVF prn to maintain BP if needed. His ACEI and beta blocker have been held due to hypotension and his systolic BPs have been in the high 90s and low 100s over the last week. Given ectopy on telemetry, could consider restarting his beta blocker at a low dose in the near future pending increase in his blood pressure. . # Leukocytosis: Trending downward after restart of his antibiotics. Most likely source is pulmonary as UA negative, no diarrhea, LFTs relatively within normal limits at time of admission. Also may be due to sacral or heel pressure ulcer. Has had plain film without e/o osteomyelitis. CRP and ESR trending downward. Continue antibiotics as above. . # Poor nutritional status: Poor PO intake especially important given sacral decubs. Tube feeds restarted via J-tube and advancing to goal. Continuing vit C and zinc as per outpatient regimen. . # Electrolytes: Patient has been hypernatremic and hypokalemic over the last few days. J-tube free water flushes were increased and patient is receiving occasional free water as needed. Potassium repletion as well given ectopy on telemetry. His electrolytes should be monitored daily for the next few days given restart of his tube feeds. . # Wound care/decubitus ulcers: Chronic problem for patient who does not walk at [Month/Year (2) 5348]. No evidence of osteo of L ankle on plain film. Wound care was consulting and recommendations are being followed for management. . # S/p TIA last admission: continue aspirin and plavix per outpt doses. . # CAD s/p CABG and possible prior NSTEMI: Continue statin, low dose ASA. Pt not on BB or ACE, which were held for hypotension as above. . # Anemia: Pt with [Month/Year (2) 5348] hct 30, likely hemoconcentrated on admission. Continues to be stable. . # Schizophrenia: Continued on Zyprexa 7.5mg po qhs prn and Mirtazapine. . # Dementia: Continue outpt dose of Namenda and Aricept. Pt at [Month/Year (2) 5348] is oriented x 1 and speaks (often with cursing) . # FEN: Tube feeds and electrolyte repletion as above. Speech and swallow were consulted to assess patient's aspiration risk. Patient can have nectar thick liquids and puree in small quantities with 1:1 supervision for pleasure feeds. . # PPx: PPI, heparin SQ. . # Code: Full code pending further discussion with guardian (legal guardian is [Name (NI) 3608] [Name (NI) 4334] [Telephone/Fax (1) 5350], who will make all decisions except code status. PCP is [First Name8 (NamePattern2) 335] [Last Name (NamePattern1) 5351] [Telephone/Fax (1) 608]. Guardian ad [Name2 (NI) 5352] not yet appointed) . # Access: Right midline, 20 gauge Medications on Admission: since discharge on [3-7]: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day. 6. Colace 1.5 g Suppository Sig: One (1) Rectal once a day as needed for constipation. 7. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 8. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 15. Cefepime 1g IV q12hr for one week (planned) - day 1: [2148-3-14] for UTI. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 gm Intravenous Q8H (every 8 hours) for 4 days. 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qday (). 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid Dissolves PO QHS (once a day (at bedtime)) as needed. 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 16. Critic-Aid 20-51 % Paste Sig: One (1) dose Topical once a day: Apply to Right lateral maleolus daily . 17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 4 days: PLEASE HOLD FOR VANC TROUGH >20. DO NOT GIVE UNTIL TROUGH HAS BEEN CHECKED. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Aspiration pneumonia . Secondary: Malnutrition Coronary artery disease Schizophrenia Dementia Pressure ulcers Discharge Condition: Hemodynamically stable Discharge Instructions: You were admitted with hypoxia and were initially intubated. You were treated for pneumonia and were able to be extubated. You should continue your antibiotics for a total of 14 days. If you develop new hypoxia, hypotension, chest pain, or other concerning symptoms, you should proceed to the Emergency Room as soon as possible. Followup Instructions: You should follow up with your primary care physician. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "311", "783.7", "707.03", "787.20", "V12.54", "366.9", "295.90", "427.1", "276.0", "707.06", "276.8", "410.72", "V45.81", "401.9", "707.04", "263.9", "507.0", "294.8", "428.22", "414.00", "428.0", "518.81", "458.9", "427.89" ]	icd9cm	[ [ [] ] ]	[ "46.32", "96.71", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	18049, 18120	10471, 15129	322, 365	18274, 18299	3972, 8785	18678, 18866	3405, 3423		16359, 18026	10063, 10093	18141, 18253		15155, 16336			18323, 18655										3438, 3953																														275, 284	10122, 10448															393, 2702																		2724, 2944	2960, 3389
75,314	195,041	37148	Discharge summary	report	Admission Date: [2200-12-3] Discharge Date: [2200-12-13] Date of Birth: [2137-1-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: chest pressure on exertion Major Surgical or Invasive Procedure: [12-8] Coronary Artery Bypass Graft x 4 (Left internal mammary artery to left anterior descending, saphenous vein graft to ramus, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) [12-3] Cardiac catheterization, coronary angiogarm, left ventriculogram History of Present Illness: This 63 year old male developed exertional chest pressure approximately 6 months ago,noticed while walking up inclines and resolving with rest. It did not occur when walking on flat surfaces. Approximately 2 weeks ago he was involved in a fire drill at work and on return to his office he attempted to climb 8 flights of stairs and developed severe chest pressure along with a "congestion" sensation in his chest, resolving after 10 minutes of rest. He [Month/Year (2) 1834] out patient stress testing which revealed an inferior lateral defect and was referred for cardiac catheterization which revealed coronary artery disease. He was referred for surgical evaluation. Past Medical History: Hyperlipidemia Gastroesophageal reflux disease s/p bilateral knee arthroscopy Social History: Race: Caucasian Last Dental Exam: 4 mos ago Lives with: spouse and child Occupation: financial industry Tobacco: smoked for 6 mos and quit 40 years ago ETOH: 2 beers a week Family History: Father with MI at 65 Physical Exam: Admission: Pulse:61 SR Resp: 16 O2 sat: 98% RA B/P Right: 110/65 Left: Height: 6' Weight: 87.5 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [x] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [2200-12-11] 06:30AM BLOOD WBC-7.0 RBC-2.95* Hgb-9.6* Hct-27.4* MCV-93 MCH-32.4* MCHC-35.0 RDW-13.6 Plt Ct-168 [2200-12-10] 03:07AM BLOOD WBC-10.8 RBC-3.22* Hgb-10.2* Hct-29.6* MCV-92 MCH-31.7 MCHC-34.5 RDW-13.6 Plt Ct-230 [2200-12-11] 06:30AM BLOOD Glucose-128* UreaN-16 Creat-1.2 Na-139 K-4.3 Cl-105 HCO3-27 AnGap-11 [2200-12-10] 03:07AM BLOOD Glucose-130* UreaN-17 Creat-1.2 Na-138 K-4.2 Cl-103 HCO3-29 AnGap-10 Brief Hospital Course: As noted, Mr. [Known lastname 10132] [Last Name (Titles) 1834] cardiac catheterization on [12-3] which revealed severe coronary artery disease. Therefore, he was admitted following his catheterization, awaited Plavix washout and [Month/Year (2) 1834] complete pre-operative surgical work-up. On [12-8] he was brought to the Operating Room where he [Month/Year (2) 1834] coronary artery bypass graft x 4. Please see operative report for surgical details. He weaned from bypass easily on low dose Neosynephrine and Propofol. He was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Pressors were weaned off as well. On post-op day one patient he complained of a "scratching" sensation in his right eye. Ophthalmology was consulted and diagnosed him with exposure keratopathy. Topical antibiotic ointment and artificial tears were prescribed and the discomfort cleared. He transferred to the floor, CTs and temporary pacing wirese were removed per protocol. Physical Therapy worked with him for mobility and strenghtening. Beta blockers were begun and he was diuresed towards his preoperative weight. Diuretics were continued for a week after discharge as he was still several kilograms above his admission weight. He developed rapid atrial fibrillation on [12-11] and this was treated with Amiodarone with conversion to sinus rhythm. He tolerated this well.. He will receive a 4 week course of Amiodarone after discharge. Medications, precautions and folow up were discussed with him prior to going home. Medications on Admission: Plavix 75 mg PO daily Zocor 20 mg PO daily ASA 81 mg PO daily MVI 1 PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 5. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q8H (every 8 hours) for 3 days. Disp:qs 1 Refills:0 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temp. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-10] Drops Ophthalmic QID (4 times a day) for 3 days. Disp:qs 1 Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day) for 4 weeks: 2 tablets twice a day for a week then one tablet twice daily for three weeks. Disp:70 Tablet(s) Refills:0 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] vna Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Hyperlipidemia Gastroesophageal reflux disease s/p bilateral knee arthroscopy Discharge Condition: awake and alert, ambulatory Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions NO lotions, cream, powder, or ointments to incisions 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 or taking narcotics and 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) 914] in 4 weeks ([Telephone/Fax (1) 170])- [2201-1-13] at 1:15pm Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [1-10] weeks Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [1-10] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2200-12-13]	[ "E938.4", "458.29", "370.34", "918.1", "411.1", "272.0", "530.81", "414.01", "427.31", "423.9", "285.9" ]	icd9cm	[ [ [] ] ]	[ "36.13", "36.15", "88.56", "39.61", "88.53", "37.22" ]	icd9pcs	[ [ [] ] ]	6275, 6330	2807, 4456	347, 653	6513, 6543	2352, 2784	7093, 7591	1663, 1685		4583, 6252		6351, 6492		4482, 4560			6567, 7070										1700, 2333																														281, 309																681, 1356																		1378, 1457	1473, 1647
8,406	165,938	17751+56886+56888	Discharge summary	report+addendum+addendum	Admission Date: [2149-6-29] Discharge Date: Date of Birth: [2117-6-28] Sex: F Service: [Hospital1 ] CHIEF COMPLAINT: Fever. HISTORY OF THE PRESENT ILLNESS: The patient is a 31-year-old female status post a motor vehicle accident in [2149-4-22], traumatic brain injury, [Location (un) 2611] Coma Scale of III at that time, increased intracranial pressure, status post hyperosmolar [Doctor Last Name 360], phenobarbital, coma. The patient developed diabetes insipidus, MRSA bronchitis, E. coli, pneumonia, gram-negative rods, sepsis, was trached and percutaneous gastrostomy tube placed at her last admission and was discharged to rehabilitation on [2149-5-22]. On [2149-5-30], the patient was noted to have a new thalamic hemorrhage on MRI as well as having evidence of a DVT for which she had a filter placed. The patient had been at [Location (un) 48297] Rehabilitation and has been nonverbal and responsive since her original injury. The patient spiked to 103 on [2149-6-27]. She was started on Levaquin, vancomycin, and received a dose of gentamicin. On [2149-6-28], the patient's 02 sats were noted to be down to 86% on 28% trach mask. Temperature was 103.8, heart rate 150, respiratory rate 50-56, blood pressure 162/110, 02 sats came back up with nebs. The patient spiked a temperature again and was started on gentamicin. On transfer to the Emergency Department at [Hospital6 1760], the temperature was 104 degrees rectally, heart rate in the 120s to 150s, saturating 95% on 50% Ventimask. The blood pressure was ranging from the 170s to 180s. The patient was started on Flagyl, vancomycin, and Zosyn. The week prior to admission, the patient had a UTI with VRE and MSSA in her sputum. Also, positive tracking eyes past midline at baseline, however, not following and these are likely roving eye movements. PAST MEDICAL HISTORY: 1. Status post MVA in [4-23]. Central diabetes insipidus. 3. Right internal carotid small dissection, small right vertebral artery injury. 4. Status post PEG placement. 5. Status post tracheostomy placement. 6. Stress related increase in blood sugar. 7. DVT. ADMISSION MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Desmopressin 2 micrograms IV b.i.d. 3. Insulin NPH 5 units q.d. 4. Epogen subcutaneously q. Monday. 5. Free water boluses q. six hours. 6. Regular insulin sliding scale. 7. Albuterol p.r.n. 8. Atrovent p.r.n. 9. Colace p.r.n. 10. Dulcolax p.r.n. 11. Provigil 200 mg p.o. q.d. 12. Zinc q.d. 13. Gentamicin. 14. Vancomycin. 15. Levaquin. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 103.4, heart rate 139, blood pressure 129/76, respiratory rate in the 40s. General: The patient was unresponsive to verbal or painful stimuli, in no acute distress. HEENT: No eye movements. The pupils were equal, round, and reactive to light. Neck: Positive rigidity. No lymphadenopathy. Lungs: Clear to auscultation with bilateral upper airway rhonchi sounds. Cardiovascular: Tachycardiac, normal S1, S2, II/VI systolic murmur. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: Warm, no edema. Neurologic: Unresponsive, positive spontaneous movement of left lower extremity, increased tone. Skin: Diaphoretic, warm. LABORATORY/RADIOLOGIC DATA: White blood count 12.4, hematocrit 47.3, platelets 317,000. Sodium 145, potassium 3.5, chloride 100, bicarbonate 29, BUN 19, creatinine 0.6, glucose 155. Chest x-ray revealed no evidence of pneumonia. No evidence of effusions. The urinalysis revealed trace blood, nitrate negative. Culture data from past admissions showed on [2149-6-19], MSSA in sputum, MRSA screen on [2149-5-19] was negative. The patient has no known evidence of MRSA, however, does have evidence of VRE by urine culture done at [Location (un) 4480] Rehabilitation. IMPRESSION: The patient is a 31-year-old female status post MVA with traumatic brain injury, diabetes insipidus, now with fever of unclear source. HOSPITAL COURSE: 1. FEVER: The etiology of the fever was felt to be either infectious or central versus due to her DVT that is already known to exist. The workup for infection was fairly extensive and included a chest x-ray which showed no evidence of infiltrate, a urinalysis which showed no evidence of urinary tract infection. Urine culture was negative for any evidence of infection. Her sputum at one point did grow MSSA; however, the growth was rare and did not seem to be a likely pathogen. Clostridium difficile toxin was sent which showed no evidence of Clostridium difficile culture. Blood cultures were sent on [2149-6-29], [2149-6-30], [2149-7-3], and [2149-7-5], all which showed no evidence of bacterial growth. The patient's fever curve started to trend up two days into her hospitalization with a rectal temperature of 105.8. Cooling measures were employed which included cooling blankets, ice packs, Tylenol, none of which were able to allow for defervescence and for this reason, she was transferred to the Intensive Care Unit for more aggressive cooling. The measures employed included continued ice packing as well as increase in the dose of Tylenol. Her fever did come down somewhat to under 104; however, she continued to be febrile. No clear source for infection. For this reason, a more extensive workup was continued with a CT of the torso which showed no evidence of focal infection including no abscess. Lumbar puncture was performed which showed no evidence of bacterial or viral or fungal meningitis. An echocardiogram was done which showed no evidence of endocarditis. A CT of the sinuses showed no evidence of sinusitis. Oral Surgery was consulted who felt that there was no evidence of dental abscess. MRI was performed on [2149-6-30] which showed no evidence of new infarct and showed resolving hemorrhagic right thalamic infarct. However, no significant change from prior MRIs. As a result, the fever was of unclear etiology and for this reason a tagged white blood cell scan was done on [2149-7-8] which showed no evidence of focal white blood cell collection to suggest a source of infection. At this point, the decision was made by the Infectious Disease Team to discontinue antibiotics. The acyclovir which the patient was started on was discontinued when the HSV PCR from the CSF analysis also came back negative. The patient was briefly on fluconazole for a seven day course for a fungal infection of her groin. After discontinuation of antibiotics, the patient continues to intermittently spike temperatures to 101 rectally, again with no clear source. The Neurology Service was consulted to determine if there was any possibility of central fevers that could be responsible for persistently high temperatures. On discussion with the Neurology Team who reviewed the patient's imaging as well as a clinical history, it was felt that central fevers were somewhat lower on our differential given the fact that circulation to the areas of the hypothalamus that are responsible for thermoregulation are fairly robustly supplied with collateral arteries and had no evidence of infarct. There was also no evidence of hemorrhage in the hypothalamus and no evidence of other hypothalamic dysfunction to suggest damage that might be causing these high-spiking fevers. Also confusing, is the fact that the fevers did occasionally go away completely for several days at a time, also tending to argue against central sources of fever. These findings as well as the overall poor prognosis for neurological recovery were conveyed to the family that felt that the patient's wishes were well known to the family, saying that she did not want to be kept alive by any artificial means if her neurological functioning were such that she would be at the point of an "adequate quality of life" did not have which she would consider a good quality of life. For this reason, the family decided that further aggressive measures towards working up the patient's condition would likely more prolong the patient's life and not towards making her more comfortable and for this reason they decided to make her comfort measures only. 2. DIABETES INSIPIDUS: The source of the diabetes insipidus is likely central given the traumatic brain injury and the response to vasopressin. The vasopressin was initially given IV; however, after the PICC line was discontinued on transfer to [Hospital6 256], intranasal form was attempted, however, urine output was quite copious and is back to IV desmopressin. At the time of this dictation, the desmopressin is continuing, however, it is likely that this will be discontinued prior to discharge. The patient has a known left-sided DVT in her common femoral vein which was .................... repeated while in-house in order to ascertain if extension of the clot had occurred; however, there is no evidence that this had happened. The common femoral DVT .................... placed and there was no evidence of right lower extremity DVT. The remainder of the hospital course as well as discharge diagnosis and condition and medications are to be dictated at a later date. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 29803] Dictated By:[Name8 (MD) 4630] MEDQUIST36 D: [2149-7-12] 07:30 T: [2149-7-12] 07:48 JOB#: [Job Number 49328] Name: [Known lastname 9146], [Known firstname ] Unit No: [Numeric Identifier 9147] Admission Date: [2149-6-29] Discharge Date: [2149-8-3] Date of Birth: [2117-6-28] Sex: F Service: [Hospital1 248] ADDENDUM: Beginning [2149-7-14], the patient continued to be afebrile. She had increased secretions thought to be secondary to aspiration. A family meeting was held on [2149-7-14]. The patient was made CMO (comfort measures only). Case workers and Palliative Care Service were also involved in discussing placement issues. The patient was started on Baclofen and she seemed to be in some distress with facial grimaces and tenting of her upper extremities. DDAVP was discontinued. The patient initially diuresed large amounts of urine and urine output decreased. She continued to make urine, however, in the following two weeks and continued to make urine at the time of this dictation. The patient was placed on a morphine drip, Ativan p.r.n., Scopolamine patch was initiated in an effort to dry up secretions. A family meeting was held to determine whether the patient could be moved to a hospice facility on [2149-7-17]; however, with the possibility of death in the next few days, it was decided that the patient should stay. CMO care was continued for the following two weeks. The family was present on a daily basis. The patient appeared to be resting comfortably, nonresponsive, and without significant change in her status. On [2149-7-24], the patient was noted to have increased thick secretions being suctioned. Respiratory rate was noted to be 10-12 per minute. Comfort measures were continued. On [2149-7-31], the decision was made to stop deep suctioning as this was uncomfortable for the patient and not consistent with the goals of care. At the time of this dictation, the patient was resting comfortably with a respiratory rate 10-16. Comfort measures are continued. The remainder of the hospital course as well as discharge diagnoses and condition and medications are to be dictated at a later date. DR.[First Name (STitle) ],[First Name3 (LF) 27] 12-944 Dictated By:[Last Name (NamePattern1) 2685] MEDQUIST36 D: [2149-8-3] 05:45 T: [2149-8-3] 18:49 JOB#: [Job Number 9148] Name: [Known lastname 9146], [Known firstname ] Unit No: [Numeric Identifier 9147] Admission Date: [2149-6-29] Discharge Date: [2149-9-7] Date of Birth: [2117-6-28] Sex: F Service: ADDENDUM: This is a brief Addendum to the Discharge Summary dated [2149-8-3] reporting the patient's death. The interval summary of hospital course revealed the patient was continued under comfort measures only care. A morphine drip was continued and titrated to comfort for the patient. This effort represented both the visual appearance of the patient and a respiratory rate of less than 20. Ativan was used as needed. A scopolamine patch was continued to help dry up secretions. The family visited the patient frequently and provided the patient with support. The staff was extremely supportive of the family. The patient had a long course on comfort measures only care with minimal fluids, oxygen (only to provide a mist), and suctioning for comfort. The patient did finally expire on [2149-9-6]. Th family and attending were notified. [Name6 (MD) ] [Last Name (NamePattern4) 424], M.D. [MD Number(1) 425] Dictated By:[Last Name (NamePattern1) 2223] MEDQUIST36 D: [2149-9-8] 16:02 T: [2149-9-8] 18:39 JOB#: [Job Number 9152]	[ "276.5", "906.4", "253.5", "780.01", "507.0", "780.6", "038.9", "780.39", "276.0" ]	icd9cm	[ [ [] ] ]	[ "03.31", "00.14", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]														4122, 13254				2214, 2666																																						150, 1898																								2681, 4104										1920, 2191
67,281	193,371	43553	Discharge summary	report	Admission Date: [2130-2-22] Discharge Date: [2130-3-10] Date of Birth: [2072-11-5] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 5893] Chief Complaint: Cough, worsening chest CT Major Surgical or Invasive Procedure: Intubated History of Present Illness: Ms. [Known lastname 20858] is a 57 y/o F with PMHx of CLL s/p MUD allo transplant in [2-27] and relapse in [10-27] now s/p REPOCH, RESHAP (ANC 103) recently treated with bendamustine and rituximab [12-28], who initially presented from clinic 7 days prior with worsening of her cough, hypoxia and known infiltrates on chest CT (RSV, fungal, polymicrobial PNA [2130-1-20]) and is now being transferred to [Hospital Unit Name 153] for worsening hypoxia. Last admission ([Date range (1) 93703]), she was diagnosed with RSV and treated with IVIG. During a prior admission [1-25], she had a CT scan suggestive of fungal pneumonia with positive beta glucan and had BAL [2130-1-26] which grew Moraxella, MSSA, and Enterobacter treated with 21 day course of levofloxacin and started on voriconazole which was continued until this admission. In clinic initially, oxygen saturation was 91% on room air and she complained of worsening cough productive of clear sputum and associated rhinorrhea and nasal congestion. She denies any fever/chills, decreased po intake, n/v/d, abdominal pain, or chest pain. On the floor, patient underwent BAL [2130-2-24] which is negative thus far except for positive RSV. She received Pavilizumab for RSV and vori was initially changed to posaconazole then ambisome (first dose [2130-2-28]). Repeat chest CT [2130-2-27] revealed progression of bronchogenic infiltrates compared with [2130-2-22]. Dermatology was also consulted for evaluation of rash. This am, patient had initially been satting high 90s on 2L but then progressively required more oxygen throughout the day (93-94% on 7 L face mask with ABG prior to transfer 7.54/35/72 with lactate 1.4). Upon arrival to the [Hospital Unit Name 153], patient is asymptomatic other than mild cough and DOE. Denies SOB at rest. Also notes stable symmetric LE edema. Denies SOB, CP, abdominal pain, rash, N/V/D, dysuria, headache. Past Medical History: CLL Dx [6-/2126] w stage IV disease with cytogenetics notable for p53 mutation: - c/b autoimmune hemolytic anemia on presentation - 2 cycles of CVP starting in [7-/2126] - Rituxan added in [8-/2126] - [11/2126] started 13 wks Campath - [9-/2127] in setting of rising WBC, additional 2 cycles of CVP - [10/2127] d/t poor response to CVP, received fludarabine, Cytoxan, and Rituxan (had 3 cycles of this) - [1-/2128] had mini-MUD allo SCT - [11/2128] persistent disease by her [Year (4 digits) 500] marrow, marked lymphadenopathy and an elevated LDH: [Year (4 digits) ] marrow biopsy showed approximately 80% of the marrow involved with her CLL/SLL. Cytogenetics: no abnl. FISH showed continued expression of p53 - Cycle 1 [Hospital1 ] c/b E. coli bacteremia - s/p FCR Cycle #: 3 Day 1: [2128-1-5] Cycle end: [2128-2-1] - s/p BENDAmustine 170 mg IV Days 1 and 2. ([2129-11-21] and [2129-11-22]) (100 mg/m2) - Most recent Tx Rituximab 50 mg IV Day 1 [2130-1-2], Rituximab 100 mg IV Day 2 [2130-1-3], Rituximab 490 mg IV Day 3 [2130-1-4] Other Past Medical History: - CLL s/p allo transplant as above - Autoimmune Hemolytic Anemia - Depression - GERD - Menopause at age 50 - Avascular necrosis of the right femoral head (f/u with Dr. [First Name (STitle) 4223] - s/p cholecystectomy [9-/2129] Social History: Widowed. Has three children. Used to drink [1-21] mixed drinks daily, but stopped 4-5 years ago. Used to smoke [1-21] ppd but quit 4-5 years ago. Family History: Mother with [Name2 (NI) 499] cancer at 69, alive. Father had non-Hodgkin's lymphoma. Also, reports family history of DM. Physical Exam: Deceased Pertinent Results: Not applicable Brief Hospital Course: Mrs. [Known lastname 20858] was admitted to the BMT service for worsening chest CT likely secondary to worsening polymicrobial infection. She continued to worsen on the BMT service with progressive hypoxia and was admitted to the [Hospital Unit Name 153] for further management. She was continued on Ambisome for fungal pneumonia, bactrim for stenotrophomonas although may be colonizer, Vancomycin and cefepime for bacterial HAP. She continued to decline and became increasingly hypoxic. Diuresis was attempted with no improvement of her hypoxia. Her decline was thought to be secondary to her neutropenia. Multiple goals of care discussions were held and the pt was made aware of her poor prognosis, particularly if she ended up on a ventilator. She still preferred to be intubated for respiratory failure. She was eventually intubated, despite her family's wishes of her not to undergo intubation given the poor likelihood of a good outcome. The family then asked for the pt to be extubated as they did not want her to suffer. However, we could not terminally extubate given the patient's expressed wishes for intubation over several conversations over the past several days. Under the auspice of the patient's oncologist, Dr. [Last Name (STitle) 410], the compromise was not to escalate care (ie add a third pressor, or rescucitate) given its medical futility. The pt continued to decline and developed ARDS and sepsis. Was started on pressors, eventually maxed out on 2 pressors and continued to worsen. Her severe thrombocytopenia persisted, and she developed oliguric renal failure secondary to shock and began to develop severe multiorgan system failure. She died on [2130-3-10] at 0830. Her family was notified and they declined an autopsy. Medications on Admission: 1. Acyclovir 400mg Q8h 2. Omeprazole 20 mg daily 3. Voriconazole 300mg [Hospital1 ] 4. Budesonide 3 mg Q8H 5. Folic Acid 1 mg daily 6. Lorazepam 0.5 mg Q6h PRN: anxiety 7. Alendronate 70 mg once a month 8. Pentamidine 300 mg Qmonth 9. Magnesium Oxide 400 mg [Hospital1 ] 10. Vitamin D 11. Calcium 12. Benzonatate 100 mg TID:PRN cough. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2130-3-11]	[ "038.9", "V15.82", "484.6", "530.81", "511.9", "287.30", "311", "427.0", "288.03", "204.12", "784.7", "117.3", "V16.0", "117.9", "283.0", "995.92", "484.7", "276.4", "V18.0", "584.9", "279.50", "E933.1", "785.52", "482.9", "518.81", "276.6", "799.02", "V42.81", "480.1", "V16.7", "276.7" ]	icd9cm	[ [ [] ] ]	[ "99.05", "96.71", "96.04", "33.24", "96.6", "99.21", "86.11", "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	6274, 6283	4085, 5851	295, 306	6335, 6345	4046, 4062	6402, 6441	3876, 4002		6245, 6251		6304, 6314		5877, 6222			6369, 6379										4017, 4027																														230, 257																334, 2294																		3451, 3688	3704, 3860
11,295	178,550	5431	Discharge summary	report	Admission Date: [2158-2-20] Discharge Date: [2158-4-27] Date of Birth: [2084-6-29] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 17683] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: Small bowel resection Small bowel-large bowel bypass History of Present Illness: Mr. [Known lastname ] is a 73 year old man with AIDS (CD4 126 on [12/2157]), type II diabetes mellitus, and an invasive squamous cell carcinoma of the anorectal canal (s/p chemo-radiation therapy and extensive surgery [11-12]) with chief complaint of vomiting over the last month. He says that, for about the last month, he has been vomiting now daily. He denies any blood or coffee grounds in his vomtius. He vomits food or gastric contents. He has stopped eating solid foods due to fear of vomiting. He vomits up any food that he has eaten, even up to 6 hours prior, but has been able to keep liquids and his medications down. His colostomy is working well, although he has noted an increase in bowel movements despite cutting back on his diet. He has no blood in the stools, and no black stools. Stools are liquidy brown and "cocoa -colored." He has had intermittent right lower quadrant "crampy" pain, but is not sure of the association of this with the vomiting or bowel movements. He has had no fevers, and denies night sweats. He says he has been taking all of his medications on time and as directed, and has not been eating outside of his home or had any unusual or poorly cooked meals. His partner notes that he is becoming weaker, and has to rest after walking only a few feet because he's "tired." He denies any shortness of breath. At the time of his prior office visit in [12/2157], he was going for daily walks w/o problems. His partner also thinks that Mr. [Known lastname ] also seems to be confused: Forgetting things/elements of conversations, and not following conversations. Past Medical History: 1. AIDS: He was found to be HIV positive in [2144]; his (only) risk factor is (homo-)sexual exposure(s). He has a multi-resistant virus, due to serial monotherapy in the early [2142]'s and some adherence problems thereafter. [Name2 (NI) ] is currently on a regimen of atazanavir 300 mg/day boosted by ritonavir 100 mg/day, emtrictabine 200 mg/day, tenofovir 300 mg/day, and zidovudine 300 mg po bid. His last CD4 count in [12/2157] was 126, with a corresponding viral load that was undetectable. . 2. Invasive Squamous Cell carcinoma of the Anorectal Canal: In early [4-/2157] had BRBPR. Colonscopy [2157-5-10] showed 8 mm sessile polyp in the sigmoid colon,and a fugating 3.5 cm mass just above the anal verge. The biopsies of both lesions revealed focally invasive squamous cell carcinoma. He had a complicated course since the tumor was necrotic, infected, and obstructing the rectal canal. He needed a diverting colonoscopy to be placed, and had two admissions for fevers due to infection of the tumor. In [6-12], he started radiation therapy with chemotherapy for augmentation (5- fluorouracil and cisplatin).In early [11/2157], he had an antrior/posterior resection of the primary tumor. Pathology of the tissue removed revealed foci of active tumor. . 3. DM2: Diagnosed in [2153]. This was initially treated with dietary intervention. He had been on a regimen of Actos and glyburide, but has had medications withdrawn since marked weight loss during the chemo-radiation therapy. His last glycated hemoglobin in [12-14] was 4.5%. . 4. Remote EtOH abuse:He has a history of ethanol abuse, but this has been inremission for over 10 years. . 5. Lung Nodule: He has a calcified pulmonary nodule on a chest X ray in 11/93.His sister had tuberculosis, but he had minimal exposure to her. . 6. Syphilis: He has a history of syphilis in the late [2132]'s and does not recall what therapy he received. . 7. cystic parotiditis [2152] . 8. Normal ETT MIBI: In [9-/2154], he had a CT Scan of his heart (as part of a study)that revealed extensive calcifications of his coronary arteries.He, therefore, had an exercise thallium study that revealed an EF of 62% and no perfusion defects at a 111% predicted heart rate. . 9. Hyperlipidemia:Was on statins before losing weight. . 10. COPD: "COPD" by CT scan in [2154]. Initial CT scan showed ground glass opacities. Seen by pulmonolgy at [Hospital1 18] and repeat CT scan was normal. . Past Surgical History: 1. He had some cosmetic surgery at the age of 18 to correct a scar on his head sustained in some childhood head trauma. 2. He had an appendectomy at the age of 45. Social History: Social History: He was in the Air Force, and then got a college education.After that, he moved to [State 531] and worked as an interior designer for several decades, and retired to [Location 3615], Mass. He has traveled to Europe, the Middle East, the SW USA, and [State 108]. He lives with his partner. [Name (NI) ] has several dogs at home. Tobacoo: None x 12 years, but previous 40 pack year history; EtOH: Prior alcoholism, but none for 12 years; Illicit Drugs: None. Family History: Family History: Mother who died at the age of 94. His father died at the age of 101. He has 1 sister who had tuberculosis, and 2 sisters died of breast cancer. He has one brother who has had a melanoma, and one brother has arthritis. No other disorders that he is aware of run in his family. Physical Exam: T 97.7 BP 106/60 HR 83 20 97%RA Gen: Chronically ill appearing male in no respiratory distress HEENT: Moderate facial wasting. Anictertic sclera. Conjunctivae not pale.Mucous membranes moist. Poor dentition. O/P clear. Neck: Supple, no lymphadenopathy. Thyroid smooth and not enlarged. JVP at 1cm above angle. Lungs: Clear to auscultation bilateally, no wheezes, rhonchi or rales Cor: Regular rate, nl s1 and s2, II/VI systolic murmur at the LSB. Abd: soft, non-tender (although exam in [Hospital ] clinic notable for RLQ tenderness)hypoactive BS. No masses. Ostomy site without redness. Liquid brown stool in colostomy. Ext: There is no clubbing or edema. Rectal: 2cm opening with white fluid at prximal edge of flap, no tenderness, no surrounding erythema. No drainage. No fluctuance. Otherwise well-healed flap. Neuro:Orientated x 3 to time, place, person. The cranial nerves III to XII are normal. The toes are down-going, and reflexes are equal and intact bilaterally. Strength is [4-13] and symmetric in upper and lower extremities. Brief Hospital Course: A/P 73 yo male with AIDS, DM2, invasive carcinoma of the anorectal canal s/p resection and diverting colostomy [11-12] presented with vomiting and and intermittent RLQ pain. He was diagnosed with a partial small bowel obstruction until [2-27], when his symptoms failed to resolve and a CT scan showed a transition point. He was taken to the operating room and underwent extensive lysis of adhesions and a biopsy of a small bowel mass. The operation was made much more challenging by the existence of radiation changes in his pelvis after treatment for anal cancer. His recovery was arduous, and bowel function was slow to recover. He was started on TPN. On [3-30], he developed gross hematuria, and a Urology consult recommended a cystoscopy. As a follow-up surgery was planned for [4-5], the cystoscopy was done at this time. His surgery on [4-5] consisted of an ex lap and construction of an ileocolic bypass. Cystopscopy revealed only small clot and expected inflammatory changes. Unsurprisingly, his bowel function was again slow to return. He continued TPN, and continued to have high NGT outputs. Although his ostomy output continued to be negligible, the tissue itself was viable, and there was no indication of frank obstruction. A repeat small-bowel follow through on [4-18] was negative for obstruction, and in fact the contrast could be seen freely passing from the ostomy site. On [4-19], his urine again darkened and became quite cloudy. He was fluid resuscitated and his urine color and output improved. Initially the cloudiness was concerning for a colovesical fistula, but a sterile urinalysis and subsequent clearing of the urine argue definitively against this. By [4-19] there was some return of bowel function, with evidence and gas and liquid contents in the ostomy bag, and his NGT was discontinued. The pt experienced no nausea subsequently. He resumed a diet on [4-21] and continued to tolerate this well. Although he was clearly improved, it was felt he would be unable to support himself nutritionally, and a Dobhoff feeding tube was placed on [4-25] and he was placed on Ultracal 1/2strength without fiber at 30cc/h. Unfortunately he vomited this out on [4-26]. However, he was able to increase his oral caloric intake. It is our belief that he can successfully wean off the TPN and onto regular food. At all times he should try to support himself with food intake, unless his abdominal symptoms return. Medications on Admission: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 7. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 11. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 13. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs 1* Refills:2 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:2 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs 1 Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:qs 1 Refills:0 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). Disp:qs 1 Refills:2 7. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:180 Capsule(s) Refills:2 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:120 Capsule(s) Refills:2 11. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:30 Capsule(s) Refills:2 13. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:qs 1 Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Small Bowel Obstruction Anal Cancer Diabetes Mellitus Type II Hypertension Discharge Condition: stable Discharge Instructions: Routine Ostomy care. Physical therapy. Nutritional [Hospital 22018] Medical Management of HIV Followup Instructions: Please call Dr[Name (NI) 22019] office to schedule your follow up appointment. [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845]	[ "560.81", "042", "V55.3", "599.7", "560.1", "707.03", "V10.06", "V15.3", "496", "486", "250.60", "997.4", "599.0", "799.4", "998.2" ]	icd9cm	[ [ [] ] ]	[ "57.0", "99.15", "96.6", "46.73", "45.93", "99.04", "38.93", "96.07", "54.59", "45.15" ]	icd9pcs	[ [ [] ] ]	12340, 12419	6621, 9099	295, 350	12537, 12545		12692, 12874	5254, 5534		10484, 12317		12440, 12516		9125, 10461			12569, 12669									4549, 4714	5549, 6598																														247, 257																378, 2003																		2025, 4526	4746, 5222
2,170	158,069	11001	Discharge summary	report	Admission Date: [2109-4-28] Discharge Date: [2109-5-2] Date of Birth: [2058-4-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Fever, cough and shortness of breath. Major Surgical or Invasive Procedure: Placement of central venous catheter in right subclavian vein. History of Present Illness: The pt. is a 50 year-old male with a history of hepatitis C cirrhosis who presented with a 2 day history of progressive shortness of breath, productive cough of whitish sputum, subjective fevers, pleuritic right shoulder pain and generalized malaise. The pt. stated the he began to progressively decline over a 2 day period PTA. He developed a fever to 103F. EMS was called and the pt was found to be hypoxic at 84% on RA up to 94% on NRB. He was initially described as "wheezy" in the ED which resolved with nebulizers and steroids. His admission ABG was 7.46/41/35 on RA. Lactate was found to be 5.6, so MICU evaluation was called for enrollment into MUST protocol. Admission ROS was negative for nausea, vomitin, diarrhea, abdominal pain, back pain, rash, hematuria, melena, BRBPR or lightheadedness. He denied recent ill contacts. In the ED, her received azithromycin, ceftriaxone, steroids and nebulizers. Past Medical History: -Hepatitis C dx [2094] declined tx -Hepatitis B SAb+ CAb- SAg- -h/o IVDA with h/o epidural abscesses -s/p laminectomy in [2099] -recurrent LE cellulitis -chronic LE edema with pain -left hip arthritis (h/o septic arthritis per pt.) Social History: He lives with female partner in [Name (NI) 8], has 2 kids at home, a daughter in high school and a step-son. [Name (NI) ] admitted to social use of alcohol on rare occasions. He quit tobacco 20 yrs ago (2pkx 14 yrs). He has a h/o IV cocaine and heroin use, no use since [5-18]. Worked in [Location (un) 86] DPH in needle sharing program ?while using. Now is a writer. PCP is [First Name8 (NamePattern2) 15165] [Last Name (NamePattern1) 7677] at [Location (un) 2274]. [First Name4 (NamePattern1) 4457] [Last Name (NamePattern1) 35659] at [Location (un) 2274] is pain specialist. Walks with crutches. [Hospital 2514] clinic is [Doctor Last Name 35660] center for addiction at [Hospital 8] Hosp. Family History: -maternal aunt w/ pancreatic Ca -other family members w/ cancer as well Physical Exam: 98.7 102 138/66 25 95%on NRB CVP14 SVO2 69% gen- tachypneic, speaking in full sentences heent- EOMI. no icterus. OP clear. no thrush pulm- crackles/decrease BS R base. otherwise clear. no wheezes. no accesory muscle use. CV- RRR. normal s1/s2. no m/r/g abd- soft, NT/ND. no ascites. no stigmata of liver disease. NABS. no HSM. ext- chronic venous stasis change b/l LE. no open ulcers. no warm or tender lesions. RUE/LUE w/ old scarring w/ no active bleeding or pus. neuro- CN II-XII intact. no motor deficits. decreased sensation b/l lower extremities. no asterixis. Pertinent Results: Admission Labs: --------------- CBC: WBC 20.9 (72 N, 13 Bands), Hct 34.7, Plt 217, MCV 71 Chem 7: Na 136 K 2.9 Cl 95 CO2 25 BUN 13 Cr 1.0; AG =16 LFTs: ALT 68, AST 87, [Doctor First Name ] 61, Lip 30, A/P 117, Tbili 1.3 Coags: INR 1.3, PTT 26.8 Acetone: negative Ammonia: 50 Blood Cx- Pending Urine Cx- Pedning U/A- neg for leuks/nitr sputum Cx- pending * CXR: RLL PNA * Lactate trend: [2109-4-28] 12:11AM BLOOD Lactate-5.0* [2109-4-28] 03:07AM BLOOD Lactate-5.6* [2109-4-28] 05:16AM BLOOD Lactate-5.8* [2109-4-28] 07:05AM BLOOD Lactate-4.2* Recent Labs: 21>29.6<194 [Age over 90 ]\|102\|19 /116 3.7\|30 \|0.8\ ALT-46* AST-52* AlkPhos-78 TotBili-1.0 Calcium-8.8 Phos-1.9* Mg-2.0 ABG: pO2-77* pCO2-49* pH-7.42 calHCO3-33* Lactate-1.8 CT CHEST WITH IV CONTRAST: The main airways are patent to the segmental level. There is right lower lobe consolidation, with air bronchograms, consistent with pneumonia. Fluid tracking along the right middle fissure. Patchy infiltrate superior to the dominant area of consolidation, likely also a component of the infectious process. Fluid tracking along the major fissure as well. Atelectasis at the base. The right lung is otherwise clear. The left lung is essentially clear with mild atelectasis at the base. There is no evidence to suggest significant interstitial lung disease. There are no pathologically enlarged axillary, mediastinal, or hilar lymph nodes. The heart and pericardium are unremarkable. A right-sided IJ catheter is in place. There is no evidence to suggest a mass obstructing the right lower lobe bronchus. Contrast bolus is not adequate to evaluate for pulmonary embolus, however, there is no evidence of major central embolus. Limited evaluation of the upper abdomen demonstrates no abnormalities. The gallbladder is distended but demonstrates no evidence of stones or other signs to suggest cholecystitis. BONE WINDOWS: No suspicious lytic or blastic lesions. IMPRESSION: Right lower lobe pneumonia. No evidence of obstructing mass. No evidence to suggest interstitial lung disease. Brief Hospital Course: MICU Course: In the MICU, the pt. was maintained on ceftriaxone and azithromycin after a CT scan was performed and confirmed a RLL infiltrate suggestive of pneumonia. He improved substantially on this antibiotic regimen. This, in conjunction with nebulizer treatments, allowed the pt. to be slowly weaned down to 4L O2 via NC at the time of transfer to the floor. His blood pressure remained stable for the duration of the MICU stay and at no point did the pt. require pressors. All of the pt's other medical problems remained stable. At the time of transfer, the pt. offered no complaints and felt well. He stated that he is breathing very easy on the nasal cannula. He reported he had felt afebrile for roughly 24 hours. The following issues were addressed upon transfer to the floor: 1. Right lower lobe pneumonia: Respiratory culture grew out strep pneumoniae. Once sensitivies were resulted, the pt. was changed from IV ceftriaxone and azithromycin to oral levofloxacin. His leukocytosis trended down over the remainder of the hospitalization and he was successfully weaned off of supplemental oxygen to the point where he was breathing comfortably on room air at discharge. He did experience some episodes of hemoptysis which were felt to be due to his underlying pneumonia. He was given morphine prn for back and radicular pain exacerbated by cough. Blood cultures were without growth at the time of discharge. 2. Anemia: The pt. was discovered to be iron deficient and was started on iron supplementation. His hematocrit remained stable for the duration of the hospital stay. It was recommended that he undergo a colonoscopy as an outpatient. 3. HTN: Once the pt's blood pressure was determined to be stable, he was restarted on his usual outpatient regimen of HCTZ and amlodipine. 4. H/O IV drug abuse: The pt. was maintained on his usual dose of methadone during the hospital stay. Medications on Admission: methadone 180 daily since [5-18] norvasc 10mg daily HCTZ 25mg daily buproprion 150 [Hospital1 ] adderall 30 [Hospital1 ] protonix 40 daily lactulose qod for constipation rare albuterol and serevent recent course diclox Discharge Medications: 1. Methadone HCl 40 mg Tablet, Soluble Sig: 4.5 Tablet, Solubles PO DAILY (Daily). 2. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: -community-acquired pneumonia Discharge Condition: Afebrile. Discharge Instructions: Please continue all medications as prescribed. Followup Instructions: Please follow-up with your primary care doctor within the next 7-10 days. It is recommended that you undergo an EGD and colonoscopy as an outpatient to work-up your diagnosis of anemia.	[ "070.30", "782.3", "314.01", "276.8", "355.8", "070.70", "459.81", "518.81", "304.01", "571.5", "481", "280.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	8196, 8253	5175, 7083	351, 415	8326, 8337	3080, 3080	8432, 8622	2403, 2476		7364, 8173		8274, 8305		7109, 7341			8361, 8409										2491, 3061																														274, 313																443, 1360						3096, 5152												1382, 1623	1639, 2387
47,677	199,534	3550+55484	Discharge summary	report+addendum	Admission Date: [2111-3-3] Discharge Date: [2111-3-11] Date of Birth: [2035-6-27] Sex: F Service: MEDICINE Allergies: Codeine / Percocet Attending:[Doctor First Name 2080] Chief Complaint: Abdominal Pain, Chills Major Surgical or Invasive Procedure: Percutaneous Nephrostomy Tube Placement History of Present Illness: Ms. [Known lastname 16232] is a 75 y/o female with a h/o a recent episode of ischemic colitis, thyroid cancer and OSA who initially presented to the ER with complaints of sharp epigastric abdominal pain that radiated to her back, associated with nausea, shortness of breath, one episode of emesis and constipation. The patient was concerned that this pain could be her ischemic colitis recurrence or related to her worsening back pain so she called her doctor who referred her into the ER. Additionally she has been experiencing shaking chills overnight Sunday and Monday nights, she says that she woke up at 2am both nights with shaking chills and had difficulty sleeping from the chills. In the ED, initial VS were: 99.2, 84, 116/58, 16, 98% on RA. On examination by the resident she was noted to be febrile to 104.4 and rigoring, she was given acetaminophen and empirically covered with vancomycin and cefepime. Additionally, she was found to have blood pressures that were discordant by 15mmHg in each arm and given her description of stabbing epigastric pain that radiated to her back and her h/o ischemic colitis she was sent for CTA torso. The CTA did not show any evidence aortic disection or ischemic colitis, but did show a large 1cmx1.4cm obstructing renal stone with associated moderate left hydronephrosis. Urology was consulted who recommended urgent placement of a percutaneous nephrostomy tube with IR. She was also given 100mcg of fentanyl for pain and 8mg of zofran for nausea, a total of 2LNS and admitted to the MICU for further management. VS on transfer: 101.2, 96, 108/62, 24, 98% on RA. . On arrival to the MICU, initial VS were: 98.3, 89, 104/59, 23, 98% on RA. Shortly after her arrival to the MICU her blood pressure fell to the 80's systolic, she was bolused 1L NS and taken to IR for percutaneous nephrostomy placement. The procedure was uncomplicated but on return to the MICU was rigoring and uncomfortable. . Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PAF Ischemic Colitis Diastolic dysfunction with preserved EF Aortic stenosis - per chart but not seen on [2107] TTE Obesity Thyroid cancer Vitamin D deficiency Hypothyroidism Barrett's esophagus HTN Hypercholesterolemia Obstructive sleep apnea Social History: Lives alone, independent. Retired executive director of an organization. No tobacco, occasional alcohol, no illicits. Family History: No known fhx of colon cancer Physical Exam: ADMISSION EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM Pertinent Results: ADMISSION LABS [2111-3-3] 04:50PM BLOOD WBC-10.5# RBC-4.52 Hgb-13.2 Hct-43.1 MCV-96 MCH-29.2 MCHC-30.5* RDW-14.4 Plt Ct-188 [2111-3-5] 04:18AM BLOOD Neuts-88.1* Lymphs-7.6* Monos-2.9 Eos-1.2 Baso-0.2 [2111-3-3] 06:30PM BLOOD PT-13.2* PTT-29.1 INR(PT)-1.2* [2111-3-3] 04:50PM BLOOD Glucose-110* UreaN-23* Creat-1.1 Na-140 K-4.1 Cl-105 HCO3-20* AnGap-19 [2111-3-3] 04:50PM BLOOD ALT-15 AST-30 AlkPhos-82 TotBili-0.8 [2111-3-4] 02:04AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.6 [2111-3-3] 06:38PM BLOOD Lactate-1.5 [2111-3-3] 06:35PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.012 [2111-3-3] 06:35PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG [2111-3-3] 06:35PM URINE RBC-5* WBC-124* Bacteri-FEW Yeast-NONE Epi-2 MICROBIOLOGY [3-3] Blood Culture, Routine (Final [2111-3-9]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2111-3-4]): GRAM NEGATIVE ROD(S). . Blood cultures 4/4,[3-5]- NGTD . URINE CULTURE (Final [2111-3-4]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . [2111-3-3] 11:41 pm URINE,KIDNEY Source: Kidney. FINAL REPORT [2111-3-6] FLUID CULTURE (Final [2111-3-6]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . STUDIES EKG Sinus rhythm. Left axis deviation with left anterior fascicular block. Left ventricular hypertrophy by voltage criteria. Non-diagnostic Q waves in the lateral limb leads. Early anterior R wave transition. Intraventricular conduction delay. Compared to the previous tracing of [2110-10-6], T wave ampitude is improved in the inferolateral leads. Depolarization patterns are similar. . CTA chest abdomen pelvis 1. Moderate left hydronephrosis secondary to a 14 x 10 mm obstructing stone in the pelviureteric junction. Additional non-obstructing left renal stone in the upper pole. Possible superimposed infection in the left renal collecting system. 2. No evidence of aortic dissection or bowel ischemia. 3. Unchanged stenosis of the celiac origin, with likely retrograde flow in the distal celiac trunk. 4. Aneurysms of the pancreaticoduodenal artery, stable since the recent study of [2109], but slightly larger since the earliest study of [2106]. 5. Extensive sigmoid colonic diverticulosis without evidence of acute diverticulitis. Brief Hospital Course: Ms. [Known lastname 16232] is a 75 y/o F with a recent history of ischemic colitis, CAD, OSA not on home bipap who presented with abominal pain found to have an obstructing renal stone, urinary tract infection and sepsis. . #) Sepsis due to UTI: urinary tract infection/pyelonephritis as the primary source from the obstructive renal stone, found to have high grade E.coli bacteremia. On the night of admission underwent emergent percutaneous nephrostomy tube placement, for decompression with drainage of pus, that also grew out E.coli. Her first night in the ICU was complicated by significant hypotension that was IV fluid responsive requiring large volume fluid resuscitation. She was initially broadly covered with vancomycin and cefepime, the vancomycin was discontinued when her blood cultures grew out GNR's. Over the next twenty four hours her blood pressure stabilized she was able to be called out the ICU to the general medical floor. On the general medical floor her antibiotics were narrowed to ceftriaxone for a planned 2 week course from first negative culture. Pressures remained stable and patient was discharged home with IV antibiotic therapy to complete a 14 day course of ceftriaxone (Cipro was deferred given the Flecainide cross reactivity and possible gut edema from her CHF). She will then transition to PO bactrim to be continued until she has definitive management of her stone. Additionally infectious disease has recommended IV ceftriaxone (1 dose) in the peri-procedure period. . #) Obstructing Renal Stone: large renal stone on CT 1.4cm x 1cm, percutaneous nephrostomy tube was placed on the night of admission. Urology was consulted, they initially recommended percutaneous nephrostomy tube placement and outpatient follow up once her infection had resolved for discussion about removal of her stone. She will follow-up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] [2111-3-18]. . #) Acute Renal Failure: moderate amount of hydronephrosis on the left, Cr still within normal limits but up from her baseline of 0.6 to 0.7. Improved with aggressive IV fluid resuscitation, initially thought to be due to prerenal with the improvement with IV fluids and remained stable throughout the remainder of her admission. . #) Acute diastolic CHF- On transfer to the floor the patient was noted to be markedly volume overloaded. This was attributed to the large amount of fluid received in the ICU. Once on the general medicine floor pressures stabilized and she diuresed with 20 mg bolus doses of IV lasix. In total she was diuresed 13 L over 6 days. Her weight on discharge was 304 lbs (max weight 331.5 lbs). She was restarted on her home oral lasix at the time of discharge. . STABLE ISSUES #) Paroxysmal AF: continued her home flecanide and ASA but held her metoprolol in the ICU given her hypotension. This was restarted on the floor . #) Hypertension: hypotensive in the ICU so held her home antihypertensives. Her home antihypertensives were restarted prior to discharge. . #) Hypothyroidism: Patient was continued on her home synthroid . TRANSITIONAL ISSUES - Blood cultures were pending at the time of discharge - Patient will follow-up with urology and her PCP [Name Initial (PRE) ] [Name Initial (NameIs) ]/DNI Medications on Admission: -ergocalciferol 50,000 unit three times monthly -flecainide 100 mg twice a day -furosemide 20 mg once a day -levothyroxine 200 mcg daily -lisinopril 10 mg once a day -metoprolol succinate 12.5mg once a day -omeprazole 20 mg once a day -rosuvastatin 5mg once a day -venlafaxine 37.5 mg once a day -aspirin 325 mg once a day -Benefiber twice a day Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 3. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 3 times a month. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. 10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Benefiber (wheat dextrin) 1 gram Tablet Sig: One (1) Tablet PO twice a day. 12. loratadine-pseudoephedrine 10-240 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day as needed for allergy symptoms. 13. Bariatric Rolling Walker 14. Outpatient Lab Work Please check CBC with diff, chem-7 and LFTs on [2111-3-16] and fax results to Dr [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) 1968] at [Telephone/Fax (1) 16236] 15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 7 days. Disp:7 gram Refills:0 16. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: PRIMARY DIAGNOSIS Nephroliathisis Sepsis SECONDARY DIAGNOSIS Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [Known lastname 16232], It was a pleasure participating in your care while you were admitted to [Hospital1 69]. As you know you were admitted with with fevers and pain. A CT scan was done which showed a kidney stone that was blocking the tube leading from your kidney to your bladder. A drain was placed to remove this blockage. The fluid from the drain showed an infection. You also grew bacteria in your blood. You were given antibiotics through the IV which you will need to continue for 7 more days. You will then be switched to oral antibiotics. You received a special IV called a PICC line so that you can get these antibiotics at home. The drain will need to stay in place until you see the urologist Dr. [Last Name (STitle) ] [Last Name (STitle) 1023] will need to remove the kidney stone. We made the following changes to your medications 1. START ceftriaxone 2 gram daily for 7 more days 2. START Bactrim 1 SS tablet twice a day once you finish IV antibiotics (first day [2111-3-19]) until the urologist does a procedure to remove the stone You should continue to take your other medications as instructed. Please feel free to call with any questions or concerns. Followup Instructions: Department: BIDHC [Location (un) ] When: TUESDAY [2111-3-17] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10604], MD [Telephone/Fax (1) 3329] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: SURGICAL SPECIALTIES When: WEDNESDAY [2111-3-18] at 4:00 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 921] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Known lastname 2560],[Known firstname 565] Unit No: [Numeric Identifier 2561] Admission Date: [2111-3-3] Discharge Date: [2111-3-11] Date of Birth: [2035-6-27] Sex: F Service: MEDICINE Allergies: Codeine / Percocet Attending:[Doctor First Name 1299] Addendum: . Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 3. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 3 times a month. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. 10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Benefiber (wheat dextrin) 1 gram Tablet Sig: One (1) Tablet PO twice a day. 12. loratadine-pseudoephedrine 10-240 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day as needed for allergy symptoms. 13. Bariatric Rolling Walker 14. Outpatient Lab Work Please check CBC with diff, chem-7 and LFTs on [2111-3-16] and fax results to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 2562] 15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 7 days. Disp:7 gram Refills:0 16. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) 102] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1300] MD [MD Number(2) 1301] Completed by:[2111-3-12]	[ "785.52", "268.9", "428.0", "428.31", "278.01", "V10.87", "327.23", "584.9", "272.0", "038.42", "427.31", "995.92", "V49.86", "593.4", "591", "592.0", "401.1", "590.80", "244.0" ]	icd9cm	[ [ [] ] ]	[ "38.97", "55.03", "38.93" ]	icd9pcs	[ [ [] ] ]	17288, 17523	7881, 11164	302, 343	13331, 13331	3803, 7858	14709, 15708	3113, 3143		15731, 17265		13222, 13310		11190, 11538			13482, 14686										3158, 3784																							2346, 2687							240, 264																371, 2327										13346, 13458								2709, 2959	2975, 3097
51,195	183,632	49681	Discharge summary	report	Admission Date: [2123-8-9] Discharge Date: [2123-8-17] Date of Birth: [2044-10-23] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / hydrochlorothiazide / Enalapril Attending:[First Name3 (LF) 2195] Chief Complaint: Coffee ground hematemesis Major Surgical or Invasive Procedure: EGD -- [8-10] *pending* History of Present Illness: 78F w/ h/o small cell lung ca s/p radiation and chemo in [2116], gastric AVMs, left CVA w/ residual R hemiparesis and aphasia who presents from nursing home w/ abdominal pain and coffee ground emesis. Per nursing home records, patient vomited coffee grounds x2 positive for occult blood. Also with large "coffee ground BM." Of note, is on aspirin and lovenox (0.7 mL [Hospital1 ]) per nursing home records. She was sent to ED for further evaluation. At time of transfer, VSS w/ BP 111/56, HR90, RR18, T97.3, O2 sat 77%?. . Of note, patient has h/o gastric AVMs noted in [2-/2121] at [Hospital1 3278] when she was admitted for GI bleed. During that admission she underwent EGD which showed four areas of AVMs in body of stomach and fundus which were anticoagulated with Argon beam. Also w/ h/o cecal mass s/p right hemicolectomy in [2111]. was recently admitted in [2123-5-19] for MRSA pneumonia, requiring MICU stay and intubation. During this hospitalization it was noted that patient had elevated LDH as high as 611, concerning for recurrence of her small cell ca and outpatient follow up at [Hospital1 3278] was recommended. . In the ED, initial vs were: HR 95 BP 80/40 (triage), 106/58 repeat RR 30 O2 sat 99% RA. Patient triggered for hypotension and was bolused 1.5 L NS. Exam was notable for diffuse abdominal tenderness w/o peritoneal signs and melanotic stools in diaper. Labs notable for hct of 19.3 (baseline 23) and WBC 12.4; BUN 69, creatinine 0.8. Potassium was 5.9 with slightly peaked T waves on EKG, for which she received D50, insulin and calcium gluconate w/ improvement to 4.7. PEG tube lavage was performed and notable for coffee grounds, which cleared after 350 ccs. She was started on IV PPI gtt and received 2 units of pRBCs. She was seen by GI who recommened NPO status and plan to scope today. She empirically received cipro and flagyl for concern for colitis as well as zofran and morphine 6mg total. KUB was performed which showed normal placement of PEG and CXR with worsened R pleural effusion. Patient underwent CT Abd/Pelvis which was notable for new large retroperitoneal mass engulfing aorta, SMA, celiac, and renal arteries, as well as IVC and left portal vein thromboses. VS on transfer were: 99.0, 90, 105/50, 18, 99% RA. . On arrival to the ICU, patient appears comfortable. She is aphasic, but moves all extremities spontaneously. Past Medical History: - L capsular CVA with right sided hemiparesis and aphasia - Small cell lung cancer s/p XRT to RUL and 4 cycles cisplatin in [2116] - Gastric AVMs on EGD in [2-/2121] - HTN - HL - Depression - Hypothyroidism - s/p R hemicolectomy for h/o cecal mass in [2111] - Osteopenia - s/p PEG placement for failed speech and swallow in [5-29] Social History: Lives in nursing home. Has lived there since stroke. Ex-smoker. No alcohol or illicit drug use. Family History: Sister with CVA. Father with h/o HTN. Physical Exam: Admission Physical Exam: Vitals: T: 98.4 BP: 103/56 P: 67 R: 19 O2: 92% on RA General: Alert, oriented to place, but minimally verbal, following simple commands no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, crackles in CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender, distended, hyperactive bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, faint DPs, no clubbing, cyanosis; b/[Initials (NamePattern4) ] [Last Name (NamePattern4) ], R>L; moves all extremities spontaneously, but R UE and LE weaker than left . Pertinent Results: Admission Labs: [2123-8-9] 12:25AM WBC-12.4# RBC-2.41 HGB-5.9* HCT-19.3* MCV-80* PLT COUNT-611# PT-13.5 PTT-33.5 INR(PT)-1.2* GLC-134* UREA N-69* CR-0.8 SODIUM-140 POTASSIUM-5.9* CHLORIDE-108 CO2-19* ALT(SGPT)-153* AST(SGOT)-145* LD(LDH)-705* ALK PHOS-870* TOT BILI-0.4 Microbiology: Urine culture ([8-9]): 8000 GNR's UCx [8-10]: No growth Blood culture ([8-9], [8-11]): NGTD Stool cultures ([8-12], [8-13]): Negative for C.difficile Stool C.Difficile PCR: Pending at time of discharge Imaging: CXR ([8-9]): 1. No pneumoperitoneum. 2. Increased small right pleural effusion. Possible right hilar mass. 3. Persistent right upper lobe collapse or, depending on surgical history, apical pleural collection after upper lobectomy. KUB ([8-9]): G-tube located in the left upper quadrant. Exact location would be better assessed with a tube study with contrast under fluoroscopy. CT abdomen/pelvis ([8-9]): 1. Large 5 x 12 cm soft tissue mass engulfing the aorta, SMA, celiac and renal arteries and extending into the IVC which is thrombosed. This most certainly represents a neoplastic mass. With a history of lung cancer this may represent metastasis. 2. Moderate intrahepatic biliary dilatation and infiltrative lesions. Thrombosis of the left portal vein. 3. Diffuse anasarca, moderate right pleural effusion. CXR ([8-11]): 1. Decreased aeration at the right base compatible with increased pleural effusion and associated atelectasis. Underlying infection cannot be excluded. 2. Right hilar enlargement, suggestive of mass. 3. Persistent right upper hemithorax opacification, which could represent upper lobe collapse or post-surgical/post-radiation changes. Discharge Labs: [2123-8-17] 07:45AM WBC-8.7 RBC-3.11* Hgb-8.1* Hct-26.0* MCV-84 Plt Ct-346 Glucose-121* UreaN-29* Creat-0.6 Na-136 K-4.4 Cl-108 HCO3-17* Mg-2.1 Brief Hospital Course: 78 yo F w/ h/o gastric AVMs, cecal mass, small cell lung ca s/p radiation and chemotherapy now p/w hematemesis and found to have a retroperitoneal soft tissue mass as well as IVC and left portal vein thromboses. # UGIB - The patient presented with coffee ground emesis, melanotic stools, and coffee grounds on G tube lavage suggestive of UGIB. The patient has a known history of gastric AVMs s/p argon laser in [2120]. On presentation, the patient had Hct 19.3 from a baseline of 24. She was treated with two units of PRBCs. She remained hemodynamically stable with no signs of poor perfusion. Of note, the patient has been on therapeutic lovenox (for DVT/PE) and aspirin. An IV PPI was started and her anti-coagulation medications held. GI was consulted and an EGD was performed on [8-11] which revealed an ulcer around the G-tube. This was discussed with IR, who felt that the G-tube was in good position and that the location of the ulcer was coincidental. They felt there was no indication to remove or replace the G-tube. Her tube feeds were restarted 24 hours after the endoscopy and she tolerated these well with a stable hematocrit. She was also evaluated by speech and swallow as she was asking to drink. She underwent a video swallow study. Based on these results, she was recommended to start thin liquids by cup (no straw), pureed foods with oral suctioning after every feed. She did well with this regimen. Her hematocrit remained stable with eating. Lovenox was restarted on [2123-8-13]. If repeat Hct check after discharge is stable her home aspirin can be re-started. # Retroperitoneal mass - A CT Abdomen and Pelvis performed on admission showed an impressive RP mass engulfing the aorta, SMA, celiac and renal arteries. This was concerning for metastasis given the patient's history of small cell lung cancer. The CT also showed IVC and left portal vein thrombosis of unknown chronicity. Vascular surgery was consulted and determined that there was no possible surgical intervention. Per discussion with the patient's sister (her HCP), this was actually not a new mass but had been discovered by her oncologist at [Hospital1 3278] [Hospital1 336]. The patient is not aware of the mass. The family feels strongly that the patient would not want to hear about the mass without family support. The family was unable to come to [Hospital1 18] during this hospitalization. Given that there was no intention of pursuing treatment (this was confirmed with the [Hospital 228] healthcare proxy) and this was largely unrelated to her hospitalization, the family's wishes to wait to disclose to the patient were respected. The need for disclosure was emphasized to the patient's sister and she stated that she would disclose as soon as she could get to [Location (un) 86] (her husband is very sick right now). # Leukocytosis - On presentation the patient was found to have leukocytosis to 12.4, but with no left shift. There was no fever or cough, and CXR showed only chronic right pleural effusion. Given the known GIB, this seemed to be a stress response. Cultures were sent to rule out infectious origin; these were negative at the time of discharge. # Diarrhea - She was noted to have diarrhea during her hospitalization. C. Diff stool toxin was checked twice and was negative both times. A stool C.diff PCR is pending at the time of discharge, but her diarrhea improved significantly with adjustment of her tube feeding regimen. # Positive UA/urine cx: Pt was noted to have bacteria and pyuria in UA. Pt was with a Foley catheter so it was replaced. Abx were not started as pt appeared asymptomatic. A repeat UA and urine culture were sent after Foley was replaced and these were within normal limits. # Metabolic acidosis - On presentation the patient had a metabolic, non-gap, acidosis. This was thought to be due to GI loses as well as some uremia and resolved. # Anemia - She presented with acute on chronic anemia given current GI bleed. Her baseline anemia is consistent with anemia of chronic disease. Her Hct was monitored in light of bleeding. She received a total of 2 units PRBCs during her stay, and responded well to these transfusions. # Hypernatremia - She was noted to be hypernatremic during her hospitalization. This was managed with free water replacement and titration of her free water flushes in her tube feeds. # h/o CVA - her aspirin was held. If she continues to tolerate lovenox without any evidence of recurrent GI bleeding, would consider adding back her aspirin. Pt was DNR/DNI, confirmed with HCP [First Name4 (NamePattern1) ] [Name (NI) 284] [Telephone/Fax (1) 103891], cell [Telephone/Fax (1) 103894]) Medications on Admission: Admission Medications (per nursing home records): levothyroxine 50 mcg Tablet PO DAILY lovenox 70 mg q12hr aspirin 81 mg ipratropium bromide 0.02 % 1 Neb q6HRs PRN albuterol sulfate 2.5 mg /3 mL (0.083 %) 1 neb Q6H prn bisacodyl 10 mg PR prn percocet 1-2 tabs q4hr prn lactulose 15 mL daily PRN famotidine 40 mg NG qHS loperamide 2 mg PO TID prn simvastatin 20 mg PO daily atenolol 50 mg PO DAILY multivitamin 1 Tablet PO DAILY ferrous sulfate 300 mg (60 mg iron) po Daily sertraline 50 mg NG daily senna 8.6 mg Capsule PO BID PRN docusate sodium 100 mg PO BID acetaminophen 1000 mg [Hospital1 ] Discharge Medications: 1. sertraline 50 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 4. erythromycin 5 mg/gram (0.5 %) Ointment [Hospital1 ]: One (1) application Ophthalmic QID (4 times a day). 5. metoprolol tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO TID (3 times a day). 6. enoxaparin 80 mg/0.8 mL Syringe [Hospital1 ]: Seventy (70) mg Subcutaneous Q12H (every 12 hours). 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 8. atenolol 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - Heathwood - [Location (un) 55] Discharge Diagnosis: Upper GI Bleed Discharge Condition: Mental Status: Aphasic Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with a GI bleed. This was likely caused by an ulcer. You improved with medicine. You were restarted on your lovenox but your aspirin has been held. This should be restarted if your blood count remains stable. Your hospital course was complicated by diarrhea, which was thought to be due to your tube feeds. You were seen by nutrition and had your tube feeds adjusted with improvement in your diarrhea. A stool test was sent that is pending at the time of discharge and will need to be followed-up. Followup Instructions: Please follow-up with your primary care provider [Last Name (NamePattern4) ]/when you are discharged from your skilled nursing facility.	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9,271	188,232	44256	Discharge summary	report	Admission Date: [2193-11-18] Discharge Date: [2193-11-26] Date of Birth: [2138-11-23] Sex: F Service: MEDICINE Allergies: Codeine / Aspirin / Augmentin / Trazodone Hcl / Ibuprofen / Atrovent / Reglan / Ampicillin / Lipitor / Lisinopril Attending:[First Name3 (LF) 2745] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: 54 y/o female with h/o DM, Asthma, Diastolic CHF, chronic renal failure and prior unprovoked PE presented with 5-day history of SOB. Reports having difficulty taking full breaths after walking for a few feet. Says pain is different from asthma pain,similar to pain of prior PE but worse, tried albuterol treatment with no relief. Noted sharp, retrosternal pain night prior to admission that lasted for minutes and then resolved. Denies diaphoresis or pain radiation. She presented to the ED and A CT scan showed bialteral pulmonary emboli. Past Medical History: Asthma CHF - diastolic (last echo [1-/2193], EF > 55%, diastolic dysfunction) DM BiPolar H/O prior PE - diagnosed @ [Hospital1 2025], repordedly fully worked up for hypercoagulable state and negative. HTN GERD Obesity Uterine Fibroids Migraines Fibromyalgia Anemia Renal failure . Social History: Lives alone, not currently employed. Has one daughter and three granddaughters. Denies any tobacco, alcohol or drug use. Family History: Mother had HTN, CAD, died at the age of 34 of an MI. DM on mother??????s side of family. Grandfather died of colon CA in his 70??????s. Three sisters, one age 51 with Lupus. One brother with Asthma. Physical Exam: 98.9 136/70 75 22 97% 4L GEN: a/O, NAD, some work with breathing HEENT: moon facies, buffalo hump noted RESP: slight expiratory wheezes CV RR, no Murmurs ABD: obese, non-tender, + bowel sounds EXT: no edema Pertinent Results: CT: Multiple filling defects involving both right and left pulmonary arteries and their branches. Equivocal evidence for right heart strain. Recommend correlation with EKG . CXR: IMPRESSION: No effusion or pneumonia. Limited study; dedicated PA/lateral recommended if continued concern for pneumonia . ECHO: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Compared with the prior study (images reviewed) of [2193-2-25], the images the findings are similar. . EKG: Compared to previous tracing of [2193-6-16] P-R interval appears to be considerably longer. No ischemic changes. [2193-11-18] 11:30AM BLOOD WBC-10.5 RBC-3.87* Hgb-11.7* Hct-33.8* MCV-87 MCH-30.2 MCHC-34.7 RDW-15.2 Plt Ct-139* [2193-11-22] 05:45AM BLOOD WBC-8.5 RBC-4.25 Hgb-12.5 Hct-38.6 MCV-91 MCH-29.3 MCHC-32.3 RDW-15.4 Plt Ct-202 [2193-11-18] 11:30AM BLOOD Neuts-68.4 Lymphs-27.8 Monos-2.4 Eos-1.3 Baso-0.1 [2193-11-18] 11:30AM BLOOD PT-12.1 PTT-28.7 INR(PT)-1.0 [2193-11-18] 11:30AM BLOOD D-Dimer-3051* [2193-11-18] 11:30AM BLOOD Glucose-259* UreaN-28* Creat-1.4* Na-140 K-5.5* Cl-108 HCO3-21* AnGap-17 [2193-11-22] 05:45AM BLOOD Glucose-238* UreaN-44* Creat-1.6* Na-140 K-4.9 Cl-101 HCO3-25 AnGap-19 [2193-11-18] 11:30AM BLOOD CK(CPK)-200* [2193-11-18] 11:30AM BLOOD CK-MB-4 cTropnT-0.01 [2193-11-19] 06:50AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.4 [2193-11-19] 06:50AM BLOOD Cortsol-11.8 [2193-11-25] 06:15AM BLOOD WBC-6.6 RBC-4.11* Hgb-11.9* Hct-37.2 MCV-90 MCH-29.0 MCHC-32.1 RDW-15.7* Plt Ct-197 [2193-11-25] 06:15AM BLOOD PT-25.5* PTT-81.8* INR(PT)-2.6* [2193-11-25] 06:15AM BLOOD Glucose-188* UreaN-43* Creat-1.7* Na-139 K-4.3 Cl-103 HCO3-26 AnGap-14 Brief Hospital Course: Pulmonary Emboli: The patient was admitted to the MICU and placed on a heparin drip. She maintained her blood pressure and oxygen saturation in the 90's on supplemental 02. She did not require intubation or pressors. She recieved a 10mg loading dose of Coumadin on [11-19], followed by 5mg for the next 2 days. On [11-20] she was transferred to the general medical floor. The patient did well and the supplemental oxygen was discontinued on [11-22]. On [11-22] her coumadin dose was increased to 7.5 mg due to continued subtherapeutic INR. INR reached 2.4 on [11-24]. Heparin was discontinued on [11-25]. She was seen by phyical therapy who recommended inpatient rehabilitation for the patient's decreased pulmonary status. She should remain on coumadin for life given this second occurrence of unprovoked PE. . Diabetes: In the MICU, she had a fasting blood suger over 400 consistently despite sliding scale and so insulin drip was started in unit. The high blood sugar was thought to be due to steroids given by EMT and in the ED. After she was transferred to the floor, She was taken off of her insulin drip and her home insulin regimen was restarted with reasonable glucose control. However, blood sugars ranged from AM values of 200 to afternoon values of 340's. Her standing NPH doses have been increased accordingly and may need to be further titrated if BG remain high. We continued her Ace-inhibitor. . Hypertension: Was well controlled throughout admission. Patient was continued on Ace-inhibitor, verapamil. Lasix was held for one day in the MICU due to the given dye load with CTA. Lasix was then restarted. on [11-23] the patient's creatinine rose to 1.9; Lasix was then discontinued again and can likely be restarted tomorrow given that Cr is improving now. . Diastolic CHF: Chronic, no evidence of current exacerbation. Continued Lasix and other medications for hypertension control. Lasix has now been held for a few days due to elevated Cr (see below) but can be restarted tomorrow. . Chronic Renal Failure: secondary to diabetetic nephropathy. Patient's kidney function during this hospitalization was stable, although on [2193-11-23] had a bump in her creatinine to 1.9. This improved with gentle fluids and holding of lasix. Lasix can likely be restarted tomorrow given improvement in Cr. She was continued on her ace-inhibitor. . Asthma: Ms. [Known lastname ] experienced some asthmatic symptoms, such as wheezing and shortness of breath that were probably exacerbated by her pulmonary embolisms. She was continued on advair, singulair, albuterol nebulizer, and albuterol inhaler. Her asthma was well-controlled during her hospitalization. . Prior hemoptysis: Patient had one episode of hemoptysis which appeared to be in the setting of acute bronchitis. She was monitored for hemoptysis and none was noted. If hemoptysis recurs, outpatient bronchoscopy could be considered. . Fibromyalgia:Patient recieved pain control as needed. . Prophylaxis: Patient was placed on an H2 blocker,IV anticoagulation, and a bowel regimen Medications on Admission: advair 250/50 [Hospital1 ] albuterol prn cacitriol 0.25mcg po M,W,F clonazepam 1mg po QHS colace [Hospital1 ] Effexor 150 mg po qAM fiorricet 325-40 TID prn (migraine) NPH 58 units in AM 42 units in PM Sliding scale regular insulin for coverage lasix 40mg po BID lisinopril 40mg po qday miralax prn nitroglycerin sublingual prn percocet prn prilosec QD ranitidine QHS renagel 800mg TID Simvistatin 10mg PO QD seroquel 400mg po Qhs seroquel 50mg po QAM singulair 10mg QHS topamax 25m gpo qday verapamil 360mg po qday wellbutrin 100mkg po Qam Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [1-29] Inhalation Q6H (every 6 hours) as needed. 3. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF (Monday-Wednesday-Friday). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. Verapamil 180 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q24H (every 24 hours). 14. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Held for elevated Cr - can be restarted tomorrow ([2193-11-27]). 18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 19. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed Release(E.C.)(s) 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Seventy (70) units Subcutaneous at breakfast daily. 21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty Five (45) units Subcutaneous at bedtime. 22. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day: sliding scale prn. 23. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): adjust based on INR. Current dose is 7.5mg daily. 24. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 25. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 26. Outpatient Lab Work patient should close monitoring of INR for adjustment of coumadin dose until dosing regimen stabilized. (Next INR no later than [2193-11-28]) Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Pulmonary Emboli, bilateral Secondary Diagnoses: Asthma CHF - diastolic, chronic (last echo [1-/2193], EF > 55%, diastolic dysfunction) Diabetes mellitus type 2 Chronic Renal Failure Hypertension GERD Obesity Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for shortness of breath. A CAT scan done in the emergency room showed clots in both veins going to your lungs (known as pulmonary embolism). You were admitted to the hospital and treated with Heparin. You were also started on Coumadin which you will most likely need to continue for the rest of your life to help prevent future clots from forming. If you experience any shortness of breath, chest pain, or any other concerning symptoms, please call your primary care physician or go back to the emergency room. You will need close followup of your INR so that your coumadin dose can be adjusted. We have also been holding your lasix because of a slight elevation in your kidney function labs, but this can be restarted tomorrow. Your insulin dose has also been increased because your blood sugars have been high. This can be adjusted further at rehab if needed. Please follow up with Dr. [Last Name (STitle) ] at your scheduled appointment on [12-16]. See below. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] on [12-16] at 10:40AM. You also have the following appointments scheduled: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 11596],[Name Initial (NameIs) ] Phone:[Telephone/Fax (1) 250] Date/Time:[2193-11-25] 3:00 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 11596],[Name Initial (NameIs) ] Phone:[Telephone/Fax (1) 250] Date/Time:[2193-12-2] 12:00 Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. Phone:[Telephone/Fax (1) 1228] Date/Time:[2193-12-10] 11:15	[ "530.81", "250.92", "415.19", "296.80", "584.9", "729.1", "285.9", "403.90", "428.32", "V58.67", "V17.49", "278.00", "585.9", "V58.61", "V12.51", "428.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10052, 10122	3708, 6793	397, 404	10398, 10406	1884, 3685	11465, 12093	1440, 1640		7393, 10029		10143, 10143		6819, 7370			10430, 11442										1656, 1865			10211, 10377																											338, 359																432, 974							10162, 10190											996, 1286	1302, 1424
11,093	170,300	513	Discharge summary	report	Admission Date: [2144-12-2] Discharge Date: [2144-12-16] Date of Birth: [2103-3-23] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides Attending:[First Name3 (LF) 338] Chief Complaint: Found unresponsive by friends. Major Surgical or Invasive Procedure: Endotracheal intubation Ventriculostomy Lumbar punctures History of Present Illness: 41 year-old female with a PMHx significant for major depression and migraine headaches, transferred from Mt. [Hospital 4257] Hospital where she was brought after being found unresponsive by her friends. Per report, Ms. [Known lastname 4258] was diagnosed with otitis media in the week prior to admission and treated with Z-pac and cortisporin ear drops. 2 days PTA, she complained of a severe headache, "possibly worst ever", accompanied by vomiting and fatigue. No one saw her in the following 2 days. On the day of admission, she was found unresponsive in her house on a couch, with "hoarse breathing". EMS were called and Ms. [Known lastname 4258] was taken to [Hospital1 4259], where she was electively intubated for airway protection. She was given fentanyl, Mannitol, NS X 1 liter, and etomidate. A tox screen at the OSH was positive for BDZ and opioids (on amphetamines and a sleeping pill at home, and possibly received opioids prior to intubation and tox screen). Her exam raised concern for increased ICP with extensor posturing and lack of corneal relexes. A CT head was remarkable for foci of parenchymal hemorrhage, and she was transferred to [Hospital1 18] for further evaluation and consideration for neurosurgery. Past Medical History: Major depression Migraine headaches Status post emergent colectomy in [2143-5-9] for cecal volvulus Recurrent ovarian cysts on ultrasound Status post nasal septoplasty Hemorrhoids status post hemorrhoidectomy Social History: Per friends, patient is a lawyer and teaches [Name (NI) 1017] school. She is divorced. Her family lives in [State 4260]. No known history of tobacco or EtOH consumption. Family History: Father with anxiety. Physical Exam: Per MICU evaluation note: VITALS: T 99.2, BP 100-130/60-80, HR 50-115 VENT AC 550 X 12 (RR 16) 100% GEN: Thin female, intubated and sedated. HEENT: Pupils pinpoint 1mm, non reactive. Nares with blood bilaterally. ETT and OGT in place. RESP: CTA bilaterally. No wheezing or rhonchi. CV: RRR, normal S1, S2. No S3, S4. No murmur/rub. GI: BS normoactive. Abdomen soft. No HSM. No palpable mass. EXT: Thin, + ecchymoses on knees, elbows. No pedal edema. Warm. NEURO: Sedated. Withdraws to painful stimuli. Toes upgoing bilaterally. + rigidity. + corneal reflexes. INTEGUMENT: Dry skin. Ecchymoses over flanks bilaterally. Pertinent Results: Relevant data on admission: CBC: WBC-21.3# RBC-3.61 Hgb-11.3* Hct-30.7* MCV-85 MCH-31.3 MCHC-36.9* RDW-12.5 Plt Ct-236 (Neuts-93.4* Bands-0 Lymphs-3.5* Monos-2.8 Eos-0.3 Baso-0) Coagulation profile: PT-14.0* PTT-38.6* INR(PT)-1.2 Chemistry: Glucose-128* UreaN-18 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-21* AnGap-18 ALT-30 AST-76* LD(LDH)-237 CK(CPK)-1269* AlkPhos-89 Amylase-143* TotBili-0.7 Albumin-3.1* Calcium-8.1* Phos-2.5* Mg-2.3 UricAcd-3.2 Iron-8* Misc: ESR-72* [2144-12-2] 07:31PM BLOOD Acetone-NEG Osmolal-295 [2144-12-2] 07:31PM BLOOD Phenoba-<1.2* Phenyto-<0.6* Valproa-<3.0* [2144-12-2] 07:31PM BLOOD ASA-4 Ethanol-NEG Carbamz-<1.0* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2144-12-2] 09:01PM BLOOD Lactate-1.9 [2144-12-2] CT HEAD: At least three punctate foci of parenchymal hemorrhage are identified, one within the left frontal subcortical white matter, the second within the right inferior temporal lobe, and the third in the high right posterior parietal lobe. There is no appreciable mass effect. There is no shift of the normally midline structures. Ventricles and sulci are normal in size and configuration. Basal cisterns remain patent. There is a large area of hypodensity in the right cerebellum. No abnormally enhancing lesions are identified following the administration of contrast. The osseous structures appear grossly normal. Note is made of fluid within the right mastoid air cells and middle ear, a finding concerning for mastoiditis in light of reports of patient right ear pain. No underlying abscess is identified on the post- contrast images. There is aerosolized fluid within the ethmoid air cells, likely relating to intubation. IMPRESSION 1. At least three tiny foci of parenchymal hemorrhage as above. 2. Findings consistent with mastoiditis in a patient with an elevated white blood cell count and ear pain. 3. No evidence of intracranial abscess. Brief Hospital Course: The patient's ICU course will be reviewed by problems. 1. Meningitis: The initial LP on [12-2] was remarkable for an opening pressure of 32, and CSF fluid with diplococci (later identified as Streptococcus pneumonia). Given her recent otitis media, ENT was consulted to rule out ongoing seeding +/- mastoiditis. A bedside myringotomy was performed on [12-2]. Subsequent imaging data and clinical examination ruled out mastoiditis. Neurology and neurosurgery were also consulted on admission. Ms. [Known lastname 4258] was empirically started on Ceftriaxone 2 gm IV BID, Vancomycin 1 gm IV BID and Acyclovir. She was also initially given Flagyl per ORL for anaerobic coverage. Antibiotherapy was subsequently tailored given pansensitive Strep pneumo (all subsequent CSF cultures sterile). Flagyl was D/C'd on [12-4], and Vanco and Acyclo were D/C'd on [12-7]. She was continued on CTX (query allergy to PCN) with the plan to complete a 14-day course. She was also started on IV decadron 10 mg Q 6H on admission, along with mannitol for management of high ICP. On [12-3] and [12-4], her clinical exam was suggestive of slow neurological decline. Imaging studies (CT head and MRI) were also consistent with increasing cerebral edema. Per neuro, daily LPs were performed, both diagnostic and therapeutic, with results as follows: [12-3]: OP 38, Closing pressure 23; [12-4] OP 25/ CP 17, removed 20cc; [12-5]: OP 25, CP 13, removed 25 cc. On [12-6], the patient was noted to have a new downward and adducted left eye, prompting a repeat CT head which showed stable punctate hemorrhages, increased white matter edema, mass effect on the lateral 3rd ventricle, extensive bilateral watershed infarcts, acute infarct in the left thalamus, and query uncal herniation. Neurosurgery was called and a ventriculostomy drain was placed at the bedside. Insertion was notable for a normal opening pressure, an ominous sign suggesting that the edema was of parenchymal origin. Her ICP remained low over the next 24 hours, and decision was made to remove the EVD. She was subsequently weaned off Mannitol and Dexamethasone. On [12-7], an EEG was performed to rule out seizure activity given new ocular bobbing on exam. Per neuro, the patient was also started on seizure prophylaxis with Dilantin. From [12-7] onward, serial neurological exams revealed no meaningful recovery. Her brainstem reflexes, however, were intact throughout. Serial CTs also revealed stable edema and hemorrhages. Per the family's wishes, given the lack of meaningful recovery despite adequate therapy, decision was made to withdraw care on [2144-12-16]. 2. Respiratory: Ms. [Known lastname 4258] was intubated at the OSH for airway protection. She was kept intubated until completion of the antibiotic course. Serial ABGs were consistent with respiratory alkalosis. She was extubated on [2144-12-16] per family's wishes, and expired shortly thereafter. 3. Elevated amylase and lipase: In the ICU, rising amylase and lipase were noted, the etiology of which was unclear. A RUQ U/S revealed mild edema without obstruction/gallstone. Our suspicion was low for acalculous cholecystitis. A medication list review could not identify a clear culprit. A literature review revealed possible pancreatic enzyme elevation in the setting of intracranial hemorrhage. Enzymes trended down with IVF, and NPO status. 4. Rash: A new rash was noted on [12-9], erythematous, with papules and comedones over the anterior chest, non-dermatomal, and expanding. Dermatology was consulted. The rash was consistent with steroid acne, which was not treated. 5. Communication: Her parents travelled here from [State 4260] on [12-2]. The family was kept abreast of developments. The plan was for continued aggressive care until completion of 14 days of antibiotherapy, and then reassessment of direction of care. Given the lack of meaningful recovery despite aggressive therapy, a family meeting was held on [2144-12-15] with Dr. [Last Name (STitle) 4261], neurology team, ICU team, and SW present. Per family's wishes, the decision was taken to withdraw care on [2144-12-16]. The NE Organ Bank was called at the family's request, and procedures were initiated for potential organ donation should the patient expire rapidly after extubation. The patient was extubated on [2144-12-16]. All medications were withdrawn and comfort measures were instituted. She past away on [2144-12-16] at night, >4 hours after extubation. Medications on Admission: Symbalta 20 mg PO QD Dexadrine 10 mg PO QD Ambien HS PRN Vitamin B12 Vitamin B6 Alprazolam 0.5 mg PO PRN Dextroamphetamine 5 mg PO QD Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Streptococcus pneumonia meningitis Intracerebral hemorrhages Cerebral edema Anemia Steroid acne Pancreatitis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2145-1-28]	[ "577.0", "320.2", "431", "V66.7", "382.9", "276.4", "518.81", "296.30", "285.9", "693.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "20.09", "96.6", "02.39", "03.31", "99.04", "96.72", "99.15" ]	icd9pcs	[ [ [] ] ]	9504, 9513	4723, 9280	318, 376	9665, 9674	2780, 2794	9730, 9768	2105, 2127		9464, 9481		9534, 9644		9306, 9441			9698, 9707										2142, 2761																														248, 280																404, 1657		3554, 4700						2808, 3545										1679, 1894	1910, 2089
67,833	115,080	51672	Discharge summary	report	Admission Date: [2125-10-4] Discharge Date: [2125-10-12] Date of Birth: [2040-1-27] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2125-10-8] - Coronary bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery; reverse saphenous vein graft from the aorta to the first diagonal coronary; reverse saphenous vein graft from aorta to ramus intermedius coronary artery. [2125-10-4] - Cardiac Catheterization History of Present Illness: Mr. [Known lastname 107057] is an 85 year-old male with history of hypertension, hypercholesterolemia, colorectal cancer s/p hemicolectomy in [2125-7-8] admitted following cardiac catheterization for left main disease where patient was found to have 80% blockage of left main. The patient was admitted for cardic surgery evaluation and further managment. . For more than three months, Mr. [Known lastname 107057] has experienced exertional substernal chest pain for more than three [Last Name (un) 94303], that is worse after eating a large meal. He initially attributed his symptoms to indigestion because his symptoms were relieved by burping and he did not seek out medical treatment. He underwent an exercise tolerance test on [2125-9-24] where he exercised for four minutes achieving 89% of his predicted max heart rate without anginal symptoms. The resting EKG showed voltage for LVH. There was also 2-[Street Address(2) 79078] depression noted. The nuclear portion shows a fixed perfusion abnormality at the inferolateral wall with mild hypokinesis of the inferior wall and an LVEF of 54%. . Of note, he had a post surgery chest CT recently that revealed a right upper lobe lung mass and a 1cm hilar adenopathy. He is now referred for a cardiac catheterization with a possible radial approach given the possibility of a future pulmonary diagnostic procedure. . On the floor the patient feels well post catheterization. He denies chest pain, shortness of breath, bleeding from the catheterization site. . On review of systems, he denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: multiple skin cancers cataract surgery bilaterally arthritis in right knee cervical disc disease hypertension hypercholesterolemia glaucoma Coronary artery disease Social History: Married, worked as an engineer at Polaroid, does not smoke, drinks alcohol very occasionally Family History: Brother died of MI in late 50s. No family history of arrhythmia, cardiomyopathies; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=97.6, BP=163/68, HR=64, RR=18, O2 sat= 96% on RA GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevated JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. 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: Patient with multiple scars over head and neck consistent with prior diagnosis of cancer. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [2125-10-8] ECHO Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. There is calcification of the aortic valve resulting in incomplete opening between the LEFT and NON coronary cusps, although this does not result in significant stenosis, there is mild aortic insufficiency which originates at this same location and has a central component. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results. Post CPB: Left ventricular systolic function continues to be normal. Trivial mitral regurgitation and mild aortic regurgitation persist. The thoracic aorta is intact. [2125-10-5] Carotid Ultrasound Significant plaque with a right 70-79% carotid stenosis. On the left there is less than 40% stenosis. [2125-10-4] Cardiac Catheterization 1. Selective coronary angiography in this right dominant system demonsratrated left main and three vessel coronary artery disease. The LMCA had a distal 80-90% stenosis that extended into an 80% stenosis of the proximal LAD. The LCX was 100% stenosed proximally. The RCA was 100% stenosed in the proximal vessel with a network of bridging right to right collaterals providing distal blood flow. There were also right to left collaterals. 2. Limited resting hemodynamics revealed moderate systemic arterial systolic hypertension with SBP 153 mmHg. The left ventricular filling pressure with elevated with LVEDP 15mmHg. 3. There was no evidence of aortic stenosis on careful pullback of the JR catheter from the left ventricle to the ascending aorta. [2125-10-4] 05:08PM BLOOD WBC-5.6 RBC-4.54* Hgb-13.7* Hct-39.7* MCV-87 MCH-30.2 MCHC-34.5 RDW-13.3 Plt Ct-178 [2125-10-10] 04:12AM BLOOD WBC-8.0 RBC-3.19* Hgb-10.0* Hct-28.6* MCV-90 MCH-31.5 MCHC-35.1* RDW-13.5 Plt Ct-123* [2125-10-4] 05:08PM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2* [2125-10-12] 05:10AM BLOOD PT-12.5 INR(PT)-1.1 [2125-10-4] 05:08PM BLOOD Glucose-82 UreaN-18 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-31 AnGap-11 [2125-10-12] 05:10AM BLOOD UreaN-27* Creat-1.1 Na-134 K-4.2 Cl-96 [2125-10-4] 05:08PM BLOOD Glucose-82 UreaN-18 Creat-0.9 Na-138 K-4.2 Cl-100 HCO3-31 AnGap-11 [2125-10-12] 05:10AM BLOOD UreaN-27* Creat-1.1 Na-134 K-4.2 Cl-96 [2125-10-4] 07:05PM BLOOD ALT-21 AST-21 AlkPhos-102 TotBili-0.4 [2125-10-4] 05:08PM BLOOD Calcium-9.5 Phos-4.1 Mg-2.1 Brief Hospital Course: Mr. [Known lastname 107057] was admitted to the [Hospital1 18] on [2125-10-4] following his cardiac catheterization which revealed severe left main disease. Heparin was started as he had a known pulmonary embolism. Given the severity of his disease, the cardiac surgical service was consulted for surgical evaluation. He was worked up in the usual preoperative manner including a carotid ultrasound which revealed a 70-79% right internal carotid artery stenosis and a less then 40% stenosis on the left. On [2125-10-8], Mr. [Known lastname 107057] was taken to the operating room where he underwent coronary artery bypass grafting to 4 vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. Mr. [Known lastname 107057] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The patient developed rate controlled atrial fibrillation. Amiodarone was started, and beta blocker titrated as tolerated. Coumadin was initiated as well. He continued to make steady progress and was discharged to home with PT on POD 4. Coumadin will be followed by Dr. [Last Name (STitle) ] with INR draws by VNA the day after discharge. And then on Monday, Wednesday and Friday. Results to be sent to Dr. [Last Name (STitle) ]. Medications on Admission: Simvastatin 20 mg Daily Finasteride 5 mg daily Timolol maleate 0.5% 1 drop both eyes every other day Medications - OTC GLUCOSAMINE &CHONDROIT-MV-MIN3 [GLUCOTEN] - (Prescribed by Other Provider) - 375 mg-300 mg-25 mg-68.75 mg-0.5 mg-100 mcg-5 mcg-3.75 mg Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain PEG 400-PROPYLENE GLYCOL [SYSTANE] - (Prescribed by Other Provider) - 0.3 %-0.4 % Drops - 1 drop in each eye as needed Multivitamin Ascoric Acid 500 mg daily Colace 100 mg [Hospital1 ] PRN Tylenol 500 q6 PRN Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take to two 200 mg tablets twice daily for 1 week. Then one 200 mg tablets twice daily for 1 week. Then 1 200 mg tablet daily until stopped by cardiologist. Disp:60 Tablet(s) Refills:2 8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Coumadin for atrial fibrillation. Goal 2-2.5. Take two 2 mg tablets initially with first INR draw the day after discharge. INR draw then on Monday, Wednesday and Friday. Dr. [Last Name (STitle) ] will follow INR/Coumadin dosing. VNA to call results to Dr. [Last Name (STitle) ]. Disp:60 Tablet(s) Refills:2 9. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2 weeks. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass Hypertension Hypercholesterolemia benign prostatic hypertrophy s/p Sigmoidcolectomy for cancer [7-/2125] S/p Skin cancer excisions - basal & Squamous (head, face, neck, ears) h/o pulmonary embolism Cervical disc disease s/p bilateral Cataract surgery with lens implants Glaucoma osteoarthritis of right knee Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema: 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] ([Telephone/Fax (1) 170]) on [2125-11-6] at 1PM Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2125-11-13] at 11:30AM Please call to schedule appointments with: Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [3-12] weeks ([Telephone/Fax (1) 3858]) Dr. [Last Name (STitle) ] will follow INR/coumadin dosing, VNA to call results to Dr. [Last Name (STitle) ] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours scheduled Appointments: Provider: [Name10 (NameIs) ] [Last Name (NamePattern5) 21185], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2125-11-7] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23551], MD Phone:[Telephone/Fax (1) 447] Date/Time:[2125-11-7] 3:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2125-12-18] 2:15 Completed by:[2125-10-12]	[ "427.31", "V10.05", "433.10", "433.30", "414.01", "401.9", "715.96", "786.6", "722.4", "272.0", "414.2", "365.9", "415.19", "V10.83", "600.00" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.15", "36.13", "37.22", "39.61" ]	icd9pcs	[ [ [] ] ]	10958, 11029	7114, 8688	289, 695	11435, 11643	4128, 5186	12566, 13778	3055, 3167		9313, 10935		11050, 11414		8714, 9290			11667, 12543										3182, 3192																	3214, 4109													239, 251																723, 2742																		2764, 2929	2945, 3039			5196, 7091
19,817	165,170	24195	Discharge summary	report	Admission Date: [2170-5-15] Discharge Date: [2170-5-24] Date of Birth: [2108-4-1] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[Last Name (NamePattern1) 61456] Chief Complaint: TF for cirrhosis and GI bleed Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: This is a 62 year old woman transferred from NEBH for increased ascites and GI bleeding. She was initially admitted there on [2170-5-9] directly from the office for workup of ascites. She initally was noted to have increased LFT's and hepatic enlargement in [2170-1-4], and ultrasound showed homogenous liver surrounded by ascites. She then was lost to follow up until [Month (only) 958], when she noted increasing abdominal girth. She was admitted to NEBH and noted to have ascites and LE edema. CT of the chest, abdomen, pelvis with only oral contrast was remarkable for possible cirrhosis, massive ascites, no splenomegaly, no hepatic lesion, and thick esophagus. She had a large volume paracentesis of 5 liters of [5-11]. She was stable until [5-14] when she developed coffee ground emesis and liquid stool. She then began to vomit increasing amounts of bright red blood the morning of [2170-5-15] and became lightheaded. Her hct fell to 26 and she received a total of 4 units of blood. Emergent EGD showed lots of blood in teh stomach, grade IV varices without ulcer, and a wheal on one varix. She was transferred to [Hospital1 18] for further evaluation and treatment. . She admits to drinking about 1 liter of wine daily, but hasn't had a drink since [3-12]. Workup for her increased abdominal girth and ascites included normal alpha 1 antitrypsin, negative Hep B surface antigen, equivocal Hep B core antibody, normal ferritin of 63, negative AMA. . She reports about a 40 pound weight gain over the last few months. She has felt depressed over the last few days and missed some meals and had increased somnolence. She reports less frequent urination recently, and loose stools that turned black over the last day. She reports no shortness oof breath or chest pain. No changes in skin color, pruritis. No fevers but occasional chills at home. Past Medical History: Aortic stenosis Hypertension Hypercholesterolemia Asthma Gastroesophageal Reflux Disease s/p r. Total Hip Replacement 99 s/p Tonsillectomy Social History: The patient is [Name8 (MD) ] RN, widowed. Nonsmoker but drink s about a liter of wine daily and used to drink vodka when her husband was alive. Family History: father died during CEA. Mom had [Name2 (NI) ]. No FH of liver problems, diabetes, emphysema. Physical Exam: T98.8 P93 BP 126/63 R18 96% 2LNC Gen: No apparent distress, coughing intermittently HEENT: scleral icterus, PERRLA, OP clear, MM slightly dry Neck: No JVD Resp: coarse bilaterally no wheezes CV: RRR n1 s1s2 2/6 SEM RUSM Abd: very distended, obese, tense, tympanic to palpation over upper areas with dullness on sides. +BS Ext: 2+ pitting edema, no cyanosis, clubbing, edema Neuro: A+Ox3, no asterixis, strength 5/5 UE and LE. Pertinent Results: CXR: no acute cardiopulmonary process . ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2169-6-27], probably no major change. . [2170-5-15] 08:00PM GLUCOSE-126* UREA N-16 CREAT-0.5 SODIUM-135 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-13 [2170-5-15] 08:00PM ALT(SGPT)-11 AST(SGOT)-27 LD(LDH)-204 ALK PHOS-54 TOT BILI-2.8* [2170-5-15] 08:00PM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-3.5 MAGNESIUM-1.5* [2170-5-15] 08:00PM WBC-10.4 RBC-3.07* HGB-9.4* HCT-27.8* MCV-91 MCH-30.7 MCHC-33.9 RDW-18.1* Brief Hospital Course: #) GI bleed with varices - according to OSH report, grade IV varices present with stigmata of bleeding. Patient s/p EGD which showed gIII varices s/p 3 bands [5-16], no active bleeding. Patient also required 1 unit PRBCs for Hct 23 -> 26 on [5-16]. Patient does have history of EtOH abuse, but no evidence of cirrhosis on US, although fatty liver is still a possibility. Patient also has portal vein thrombosis which may be contributing to her portal HTN and variceal stigmata. The patient was transfused 3 units of PRBCs initially, hct stabilized. She finished a five-day course of octreotide and a 7-day course of Levofloxacin for prophylaxis, and a PPI [Hospital1 ]. Repeat EGD on [5-23] showed grade I varices with no bleeding. Nadolol and a carafate slurry were started, and the pt was discharged with GI followup and recommendation to repeat EGD in 6 weeks. . #) Hypoxia/persistent oxygen dependence. Pt arrived on 3 L. Patient has h/o asthma since childhood, but never hospitalized or required steroids. Nl Echo on [6-8], although no comment on MV, had AS. An echo was repeated, which was essentially unchanged. Her breathing improved with standing nebs and advair. She did not have any symptoms to suggest PNA as cause of hypoxia. By discharge, she was breathing comfortably and satting in the low- to mid-90s on room air. . #) Cirrhosis of unclear etiology - had antitrypsin, AMA, Hep B. On admission, hepatitis serologies and [Doctor First Name ] were sent, which showed that she was Hep B Immunized, and an Hep A vaccine ordered. She had an abdominal ultrasound that was positive for portal vein thrombus, no evidence of cirrhosis. A AFP was nl @ 1.4. She underwent a diagnostic/therapeutic of 6 L on [5-16]; no evidence of SBP; SAAG (2.5 - <1.0 = > 1.1); tProtein 0.7. She underwent a second paracentesis on [5-18] with 6 L removed and albumin replaced. She was also started on lasix and Aldactone. She underwent a third large volume paracentesis on [5-22] with 7L removed and albumin replaced. She was discharged on 60mg Lasix qd and 100mg spironolactone qd. . #) hypertension - normotensive. . #) depression - celexa was held until she was tolerating PO meds . #) aortic valve replacement - tissue valve so no need for anticoagulation Medications on Admission: norvasc 10 mg po qd lipitor 20 mg po qd xanax 0.5 mg prn glucosamine chondroitin prn MVI asa 81 mg po qd zantac 150 mg po bid celexa 40 mg po qd vasotec 10 mg po qd Discharge Medications: 1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation [Hospital1 ] (2 times a day). Disp:1 month supply Refills:2 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: esophageal varices Secondary: cirrhosis, ascites, hypertension, asthma Discharge Condition: good, O2sat in low- to mid-90s on room air, ambulating with cane Discharge Instructions: If you have any blood in your stool, nausea or vomiting, lightheadedness or dizziness, episodes of passing out, chest pain, or shortness of breath, call your doctor or seek medical attention immediately. Please take your medications as prescribed and follow up with all of your appointments. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ]. You have an appointment on Friday [6-1], 10:15am. You may call her office at [Telephone/Fax (1) 61457] with any questions. At that appointment, you will have blood drawn to check your electrolytes and creatinine levels. Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD (Gastroenterology) Phone:[Telephone/Fax (1) 2422] Date/Time:[2170-6-7] 11:30 You should have a repeat endoscopy in approximately 6 weeks. This can be scheduled through Dr.[Name (NI) 6670] office.	[ "V43.64", "571.2", "278.00", "V42.2", "452", "456.20", "311", "789.5", "799.02", "401.9", "285.1", "493.90", "272.0" ]	icd9cm	[ [ [] ] ]	[ "45.13", "54.91", "99.04" ]	icd9pcs	[ [ [] ] ]	8099, 8105	4573, 6872	317, 335	8229, 8296	3153, 4550	8637, 9287	2592, 2691		7088, 8076		8126, 8208		6898, 7065			8320, 8614										2706, 3134																														247, 279																363, 2248																		2270, 2410	2426, 2576
42,525	106,586	4901	Discharge summary	report	Admission Date: [2125-4-11] Discharge Date: [2125-4-15] Date of Birth: [2048-4-24] Sex: F Service: CARDIOTHORACIC Allergies: Disopyramide Attending:[First Name3 (LF) 922] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p MVR/(33Onx),CABG-0m,MAZE,repair AV groove.IABP,open chest [4-13] History of Present Illness: 76-year-old woman who previously had been admitted for management of atrial fibrillation and polymorphic ventricular tachycardia. The latter was thought to be due to QT prolongation from disopyramide, leading to torsade de pointes. She had no further episodes of VT. Regarding her atrial fibrillation, this was managed with both amiodarone and diltiazem to control her rate. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor after discharge on [2125-2-13], showed atrial fibrillation at rates of 60-110. During the hospitalization also, she was discovered to have severe mitral and tricuspid regurgitation. Past Medical History: DM2 dyslipidemia hypertension CVA, residual L-sided weakness, on warfarin hypothyroidism CARDIAC RISK FACTORS: Diabetes(+), Dyslipidemia(+), Hypertension(+) Social History: Occupation: retired school teacher Lives Alone Race caucasian Tobacco 18 pack year history - quit in her 30's ETOH occassional glass wine Family History: No family history of early MI, otherwise non-contributory. Physical Exam: Pulse: 80 Resp: 18 O2 sat: 98% B/P 134/89 Height: 5'4" Weight: 60.7 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x]no lymphademopathy Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur 3/6 systolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] last bm [4-9] Extremities: Warm [x], well-perfused [x] Edema + 2 pitting in ankles Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2125-4-11] 11:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [2125-4-11] 04:15PM GLUCOSE-70 UREA N-18 CREAT-1.2* SODIUM-139 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [2125-4-11] 04:15PM ALT(SGPT)-18 AST(SGOT)-16 LD(LDH)-218 ALK PHOS-104 TOT BILI-0.3 [2125-4-11] 04:15PM ALBUMIN-4.6 [2125-4-11] 04:15PM %HbA1c-6.6* [2125-4-11] 04:15PM TSH-1.9 [2125-4-11] 04:15PM WBC-10.1 RBC-4.42 HGB-11.7* HCT-36.6 MCV-83 MCH-26.4* MCHC-31.9 RDW-16.0* [2125-4-11] 04:15PM PLT COUNT-438 [2125-4-11] 04:15PM PT-15.9* PTT-21.4* INR(PT)-1.4* [2125-4-15] 04:08PM BLOOD WBC-20.4* RBC-3.95* Hgb-11.6* Hct-33.7* MCV-85 MCH-29.2 MCHC-34.3 RDW-17.1* Plt Ct-29# [2125-4-15] 04:08PM BLOOD Plt Ct-29# [2125-4-15] 04:08PM BLOOD PT-90* PTT-150* INR(PT)-11.7* [2125-4-15] 04:08PM BLOOD Glucose-56* UreaN-26* Creat-1.9* Na-145 K-6.0* Cl-104 HCO3-14* AnGap-33* [2125-4-15] 04:08PM BLOOD ALT-2939* AST-4633* LD(LDH)-6005* AlkPhos-54 Amylase-68 TotBili-8.5* [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 20437], [Known firstname 8207] [Hospital1 18] [Numeric Identifier 20438] (Complete) Done [2125-4-13] at 9:17:13 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2048-4-24] Age (years): 76 F Hgt (in): 64 BP (mm Hg): 125/78 Wgt (lb): 130 HR (bpm): 78 BSA (m2): 1.63 m2 Indication: Intraoperative TEE for Mitral valve replacement , MAZE procedure and left atrial appendage ligation. ICD-9 Codes: 427.31, 786.05, 440.0, 424.0, 424.2 Test Information Date/Time: [2125-4-13] at 09:17 Interpret MD: [Name6 (MD) 1509] [Name8 (MD) 1510], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 1510], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: [Last Name (un) 20439] 3D Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% >= 55% Aorta - Annulus: 1.6 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Mitral Valve - MVA (P [11-24] T): 1.4 cm2 Findings LEFT ATRIUM: Dilated LA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: 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. Normal regional LV systolic function. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. Moderate mitral annular calcification. Moderate valvular MS (MVA 1.0-1.5cm2) Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR. PERICARDIUM: Small 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. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass 1. The left atrium is dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). with mild global RV free wall hypokinesis. 3.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 4. The mitral valve shows characteristic rheumatic deformity. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen. 5. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation is 3 + when the blood pressure is 135/80 and the PA pressures are 60/26. Findings discussed with Drs [Last Name (STitle) 914] and [Name5 (PTitle) 171] ( present in the room). Decision made to leave the tricuspid valve alone. 6. There is a small pericardial effusion. 7. Dr. [Last Name (STitle) 914] was notified in person of the results on [2125-4-13] at 800am. Post bypass First attempt at separation from CPB complicated by AV dissociation. Emergently went back on CPB. Patient is AV paced and receiving an infusion of epinephrine, milrinone and norepinephrine. 1. Unable to assess LV systolic function due to very poor transgastric views. 2. Mechanical valve seen in the mitral position. Leaflets move well and valve appears well seated. Washing jets seen. 3. Tricuspid regurgitation is mild to moderate. 4. Aorta is intact post decannulation. 5. The left atrial appendage has been ligated. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD, Interpreting physician [Last Name (NamePattern4) ] [2125-4-13] 16:45 CXR Final Report REASON FOR EXAMINATION: Followup of the patient after extensive thoracic surgery. Portable AP chest radiograph was compared to [2125-4-14], obtained 09:30 a.m. The intra-aortic balloon pump was repositioned and is currently approximately 1.8 cm below the expected position of the roof of the aortic arch. The Swan-Ganz catheter tip is at the right main pulmonary artery. The position of the chest tubes, mediastinal drains and NG tube is unchanged. It is difficult to evaluate the pr?cised location of the ET tube. The left retrocardiac opacity has not been significantly changed, consistent with atelectasis. No evidence of pneumothorax is present. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] ============================================ Brief Hospital Course: Ms [Known lastname ] was admitted ot the operating room for MVR/CABG/maze. She experienced difficulties in the operating room, please see the OR report for details. She was transferred from the operating room to the ICU in critical condition with an IABP and open chest. She improved hemodynamically over the next few days but then took a turn for the worse and on POD 2 she developed mesanteric ischemia. After detailed discussions with the family she was made comfort measures only and expired a short time later. Medications on Admission: Amiodarone 200 mg daily amoxicillin prn Lipitor 20 mg daily Cardizem 240 mg twice daily Glyburide 5 mg daily Levoxyl 50 mcg daily Losartan 25 mg daily metformin 500 mg daily Coumadin 1-4 mg dose changing - last dose sunday [4-8] calcium with vitamin D. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2125-5-1]	[ "438.89", "729.73", "V58.61", "998.11", "244.9", "998.89", "394.2", "250.00", "557.0", "997.1", "428.0", "428.32", "272.4", "E947.8", "427.31", "401.9", "427.5", "427.1", "785.51" ]	icd9cm	[ [ [] ] ]	[ "37.74", "39.61", "35.39", "35.24", "54.11", "37.61", "39.31", "35.23", "37.36", "36.11" ]	icd9pcs	[ [ [] ] ]	9483, 9492	8623, 9144	300, 374	9543, 9552	2210, 8600	9608, 9645	1424, 1484		9451, 9460		9513, 9522		9170, 9428			9576, 9585										1499, 2191																														240, 262																402, 1051																		1073, 1234	1250, 1408
82,928	131,628	41759	Discharge summary	report	Admission Date: [2153-10-16] Discharge Date: [2153-10-21] Service: NEUROSURGERY Allergies: Ciprofloxacin / Amoxicillin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1835] Chief Complaint: syncopal episode Major Surgical or Invasive Procedure: none History of Present Illness: This is a 87 year old woman with past medical history which includes atrial fibrillation on coumadin and aspirin. The patient was in her usual state of health until she syncopized the evening of admission [2153-10-16]. She denies any changes in her medical care recently and has been feeling fine. She was taken to an OSH where CT revealed tSAH and IPH in the setting of INR of 3.3. She was given 10mg Vit K and transferred to [Hospital1 18]. Past Medical History: Atrial Fibrillation diverticulitis HyperLipidemia Hypertension Gout Right Total Knee Replacement Social History: no tobacco, etoh or drugs Family History: non-contributory Physical Exam: On admission: PHYSICAL EXAM: O: BP: 212/62 HR:84 R 15 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. Abd: Soft, NT Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension but perseverative at times. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally 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 [6-7] throughout. No pronator drift. left shoulder ecchymosis but full ROM and denies pain. Sensation: Intact to light touch On the day of discharge [2153-10-21]: Eyes open spontaneously, right eye eccymosis, pupils are 4-3mm, the patient is unable to answer orientation questions, she is aphasic, the patient moves all extremities antigravity to command. does not follow complex commands. No pronator drift Pertinent Results: CT Head [2153-10-16]: Interval increase in size of left frontal intraparenchymal hematoma with increase in associated edema and local mass effect. Small right temporoparietal intraparenchymal hematoma is newly noted. Subarachnoid blood is little changed. No evidence of herniation. Cardiology Report ECG Study Date of [2153-10-16] 9:04:12 PM Normal sinus rhythm. Q wave in leads III and aVF. Mild baseline artifact. Slight non-specific ST segment changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 148 84 382/413 39 0 77 CT HEAD W/O CONTRAST Study Date of [2153-10-17] 5:19 AM FINDINGS: Overall the exam is stable. The left frontal parenchymal hemorrhage with associated edema and local mass effect is unchanged in size and configuration. The small right temporoparietal parenchymal hemorrhage is also stable. The volume and distribution of the subarachnoid hemorrhage overlying the right cerebral convexity, the left frontal lobe and the right cerebellar hemisphere are unchanged. The ventricles and quadrigeminal cistern are unremarkable. There is slight stable effacement of the right suprasellar cistern. No fracture is identified. The mastoid air cells, middle ear cavities and paranasal sinuses are clear. No significant soft tissue swelling noted. IMPRESSION: Stable examination, with no new hemorrhage, edema or central herniation. CT HEAD W/O CONTRAST Study Date of [2153-10-17] 8:32 PM IMPRESSION: No change from study performed earlier the same day. No new or increase in the previously existent multicompartmental intracranial hemorrhage. Follow up as clinically indicated. [10-17] Carotid Duplex: Impression: Right ICA <40% stenosis. Left ICA no stenosis. [10-18] Echo: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild calcific aortic stenosis. Mild pulmonary artery systolic hypertension. [2153-10-18] CT Head: IMPRESSION: 1. New left sided subdural hematoma along the convexity and left occipital region. 2. No change in intraparenchymal hematomas and scattered subarachnoid hemorrhages. These findings were discussed with Dr. [Last Name (STitle) 90712] at 1500 on [2153-10-18] by telephone. 3. Small amount of dense material in the right maxillary sinus likely from hemorrhage, not seen on prior studies; a small fracture fragment in the anterior aspect of maxilla- needs dedicated imaging with CT Sinus/facial bones. Pending d/w the req. doctor. Cardiology Report ECG Study Date of [2153-10-19] 8:02:10 AM Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing of [2153-10-16] inferior Q waves are less apparent. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 138 84 376/418 31 -4 73 CT HEAD W/O CONTRAST Study Date of [2153-10-19] 9:18 PM IMPRESSION: 1. No interval change in multifocal multicompartment intracranial hemorrhage compared to [2153-10-18]. In particular, a diffuse though thin left subdural hematoma newly noted on the prior study is stable. 2. Redemonstration of hyperdense opacification of the right maxillary sinus, with suspected associated fracture, incompletely imaged. [2153-10-16] 09:13PM PT-22.8* PTT-32.8 INR(PT)-2.1* [2153-10-16] 09:13PM PLT COUNT-200 [2153-10-16] 09:13PM NEUTS-76.2* LYMPHS-17.7* MONOS-3.5 EOS-2.1 BASOS-0.3 [2153-10-16] 09:13PM WBC-8.9 RBC-4.13* HGB-12.6 HCT-36.6 MCV-89 MCH-30.5 MCHC-34.4 RDW-15.6* [2153-10-16] 09:13PM estGFR-Using this [2153-10-16] 09:13PM GLUCOSE-121* UREA N-38* CREAT-1.4* SODIUM-138 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-19 [2153-10-16] 11:37PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [2153-10-16] 11:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [2153-10-16] 11:37PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2153-10-16] 11:37PM URINE GR HOLD-HOLD [2153-10-16] 11:37PM URINE HOURS-RANDOM [2153-10-21] 05:05AM BLOOD WBC-6.9 RBC-3.24* Hgb-10.1* Hct-29.8* MCV-92 MCH-31.3 MCHC-33.9 RDW-15.1 Plt Ct-202 [2153-10-21] 05:05AM BLOOD Plt Ct-202 [2153-10-21] 05:05AM BLOOD Glucose-79 UreaN-27* Creat-1.2* Na-141 K-4.1 Cl-108 HCO3-25 AnGap-12 [2153-10-21] 05:05AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.2* Mg-2.3 [2153-10-21] 05:05AM BLOOD Phenyto-9.3* Brief Hospital Course: This is a 87 year old female admitted after a syncopal episode that resulting in head trauma with an INR of 3.3. The patient was given Vitamin K at the Outside hospital then profiline in the [Hospital3 ] Emergency Department. The patient was admitted to the Neuro ICU under Neurosurgery on [2153-10-16]. She was monitored closely overnight as her initial repeat CT showed some worsening of the left frontal contusion. She received two units of platelets and Vit K x 3. She was bolused with Dilantin. A syncopal work up was ordered. On [10-17], AM The head CT was consistent with stable hemorrhage. The patient was cleared for transfer to the step down unit. On [10-18], the patient sustained a fall from the commode striking the right side of her head. A temporal laceration was noted on exam. A stat Head CT was obtained which revealed a small maxillary fracture and a new left sided subdural hematoma along the convexity. On [10-19], The patient began subQ heparin. The bowel regemin was increased and the had two bowel movements. She did have one episode of nausea and vomiting. There were 2 brief episodes of tachycardia to 160 and lopressor was initiated. an EKG was performed which was consistent with Sinus rhythm. Non-specific ST-T wave changes. PT and OT recommend discharge to rehab. On [10-20], the patient's systolic blood pressure was 140-170 and the patient's heart rate was in the 50-60s. The patient was restarted on her home medication of Carvedilol 3.125 mg PO/NG [Hospital1 ] per the daughters request. Nursing had held the lopressor due to heart rates in the 50s and the medication was discontinued. the patients magnesium and postassium levels were low and these were repleated. The foley catheter was replaced for urinary retention. On [10-21], the day of discharge, the patient was sitting in bed eating breakfast. eyes open spontaneously, still aphasic, but stating words here and there. There was no pronator drift. The patient was able to lift all extremities off the bed to command. The patient continues to have borderline hypertension with systolic SBP 130-160s. With pain or right prior to the time blood pressure medication has been due the systolic blood presuure has been up to 170 but only for brief periods of time. The patient continues to require assist with meals and transfers. The foley catheter is in place. bowel sonds are present and the last BM was 2 days ago. Medications on Admission: glucosamine asa lasix coumadin mvi felodipine lipitor clonidine folic acid allopurinol Discharge Medications: . 1. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 10. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. felodipine 2.5 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 19. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. oxycodone-acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: hold rr < 12, do not exceed 4 grams tylenol in 24 hours. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Traumatic SubAarchnoid Hemorhage Left frontal contusion Cerebral edema Hypertension Discharge Condition: eyes are open spontaneously, aphasic, patient will say 'yeah', but will not answer questions of orientation, patient requires assit for transfers, sitting balance and standing balance, patient is able to move all extremities to command antigravity, there is no pronator drift. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You were on a medication Coumadin (Warfarin)and Aspirin prior to your injury, you may safely resume taking this on [10-23]. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed. It is not neccesary to follow levels as you have not experienced seizures in the past. During your stay your serum BUN and Creatine have been elevated but improving. On admission your BUN 38 was and Creatine 1.4 was and now they have improved to BUN 27 and Creat 1.2. Please follow up with your primary care physician regarding these laboratory levels that reflect your kidney function. Please follow up with your cardiologist at [Hospital3 19345] for your prior syncopal events, ongoing hypertension and occasional brief epidoses of tachycardia. Followup Instructions: Please follow-up with Dr [Last Name (STitle) ] in 4 weeks with a Head CT without contrast. Please call [Telephone/Fax (1) 3231] to make this appointment. Please restart your Coumadin/Aspirin on [10-23] and discuss this with your primary care physician. Please follow up with your cardiologist at [Hospital3 ] for your ongoing Hypertension and occasional tachycardia and prior syncopal events. You may follow up with Opthomology for your right eye on an as needed basis. Completed by:[2153-10-21]	[ "E885.9", "274.9", "780.2", "427.31", "853.02", "788.29", "852.02", "784.3", "V43.65", "272.4", "E849.7", "V58.61", "348.5", "E884.6", "401.9", "802.4", "852.22" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11845, 11892	7600, 10052	292, 299	12020, 12299	2412, 5074	13662, 14183	964, 983		10190, 11822		11913, 11999		10078, 10167			12323, 13639										1027, 1254																														236, 254																327, 783	1467, 2393	5083, 7577						1012, 1012		1269, 1451								805, 904	920, 948
3,917	106,333	5975	Discharge summary	report	Admission Date: [2103-1-14] Discharge Date: [2103-1-17] Date of Birth: [2055-7-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: Chest pain and alcohol withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 47 yo M with ETOH abuse c/b dilated cardiomyopathy (EF 49% 9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w etoh withdrawal and chronic reproducible chest pain. He currently drinks [1-3] gallon of vodka daily, his last drink was evening of [2102-1-13]. He reports that after his recent d/c from the hospital on [1-6], he attempted to make multiple follow up appointments with MDs and detox, but "did not hear back"; he became frustrated and again began drinking [1-3] gallon of vodka/day. He reports he has also been having chest pain which is chronic in nature which he reports gets worse when he's drinking significant amounts. He reports it "hurts every time my heart pumps". He denies CP with deep inspiration and denies SOB. He has had no cough or hemoptysis. He reports since being in the ED, he feels increasingly tremulous and anxious and is hypertensive "because he's withdrawing." He denies hallucinations. In the ED, initial vitals were 97.3 98 [Telephone/Fax (2) 23538]% on 2L NC. Urine tox was positive for benzos and cocaine; serum EtOH level was 249. ECG reportedly with "NSST depressions and J pt elevations". CEs were negative x2 sets. CXR was performed which showed stable radiographic appearance of known cavitary lesions in both lung apices with no new process identified. Plan was initially for d/c from ED given negative CEs, however patient began to withdraw in ED with sx of tremulousness, anxiety, hypertension. He received thiamine, folic acid, MVI. He received a total of 40mg diazepam (30mg IV, 10mg PO). He was hypertensive to the 170s-230s systolic and received his home dose lisinopril and IV hydralazine x2. His home dose beta blocker was held given urine tox positive for cocaine. Of note, he has had multiple past admissions for CP and EtOH withdrawal, most recently from [Date range (1) 23539] at which time he required large amounts of benzos for safe detox. He was discharged home with plans to be admitted to inpatient substance abuse program at [Hospital1 882], however he did not do this. He is now being admitted to the ICU for EtOH withdrawal for q30min-1h CIWA. ROS: No fevers/chills. No cough/sob, no palpitations. No N/V/diarrhea. No melena/hematochezia. No dysuria/hematuria. No rashes. Wound on back from recent fall is healing well. Past Medical History: Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (EF 25%) - cocaine abuse (last use ~ 3 weeks ago) - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [2093] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [Female First Name (un) 564] albicans [2-/2102] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies) Social History: Smokes < [1-3] ppd recently; prior to that he smoked 1 ppd x30 years. Heavy EtOH use (usually >1 gallon vodka per day). Sober x10 years up until ~2 years ago; more recently, reports several months of sobriety. +Cocaine abuse; last use several wks ago. He denies IVDA. Sexually active with his girlfriend. Family History: Mother with CAD. Sister with h/o CVA. Physical Exam: VS: Temp: 97.5 BP: 185/119 HR:102 RR:19 O2sat 97%RA GEN: Appears mildly tremulous, moderate distress [Month/Day (2) 4459]: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules, left anterior neck with soft tissue defect s/p surgery for head and neck cancer RESP: CTA b/l CV: rrr, soft II/VI systolic murmur at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice, wound mid low back healing without erythema, induration, warmth, fluctuance NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTRs-patellar and biceps. Pertinent Results: [2103-1-14] 01:24AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG* bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2103-1-14] 08:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG Brief Hospital Course: # Alcohol withdrawal: His last drink was on [2103-1-13] and on admission he was tremulous and required increasing CIWA scale. On hospital day #2, he was transferred to the ICU for q30min-1h CIWA. In the ICU on [1-14], he received 200 mg total of valium, on CIWA scales for anxiety and tremor. On [1-15] he received 140 mg valium in the ICU. He was transferred to the medicine floor on [1-15] and was continued on a CIWA scale. Psychatry was consulted due to high [Month/Year (2) ] requirement. He was started on a standing valium regimen and was tapered, in addition to the CIWA scale. He was also continued on MVI, thiamine and folate. On transfer to [Hospital1 882] Level 4 detox program on [2103-1-17], his standing valium dose was tapered to 15 mg [Hospital1 ]. In addition, he was continued on his CIWA scale. . # Polysubstance abuse: In the ED, his toxicology screen was positive for ETOH, benzos, and cocaine. In the setting of cocaine use, his beta blocker was discontinued on admission. . # Chest pain: He reported intermittent chest pain that has been chronic in nature. Per his history, his pain worsens in the setting of withdrawl and bodyaches. Of note, his exercise MIBI is without evidence of ischemia from [9-9]. In addition,, his pain is reproducible on exam and thus appears most consistent with musculoskeletal pain. . # Hypertension: He was hypertensive on admission in the setting of withdrawl. His beta blocker was discontinued and he was continued on his home regimen of lisinopril. . # Dilated Cardiomyopathy (EF 25%): He remained euvolemic throughout hospitalization. He was continued on ASA and ACE-I. . Medications on Admission: Aspirin 81 mg PO DAILY Levothyroxine 75 mcg PO DAILY Buspirone 10 mg PO BID Toprol XL 150 mg Tablet PO once a day Lisinopril 30 mg PO DAILY Trazodone 50 mg PO HS Olanzapine 5 mg PO HS B-complex with vitamin C Hexavitamin Folic acid 1mg PO daily Thiamine 100mg PO daily Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO every twenty-four(24) hours. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 11. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Alcohol abuse Secondary Polysubstance abuse Congestive heart failure Hypertension Hypothyrodism Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for alcohol withdrawal. You should continue to abstain from alcohol use. Please take all of your medications as prescribed. If you develop chest pain, shortness of breath, persistent fever > 101, or any other serious concerns, please return to the nearest emergency room. Followup Instructions: Please follow up with your primary care provider at [Name9 (PRE) ] Community Health Center at [Telephone/Fax (1) 23520] in [3-6] weeks. You will need further evaluation of your difficulty swallowing. Completed by:[2103-1-31]	[ "070.70", "425.5", "303.01", "244.9", "401.9", "786.59", "291.81", "V10.89", "117.3", "305.60", "300.00" ]	icd9cm	[ [ [] ] ]	[ "94.62" ]	icd9pcs	[ [ [] ] ]	7449, 7464	4590, 6274	349, 355	7612, 7621	4358, 4567	7977, 8221	3526, 3566		6593, 7426		7485, 7591		6300, 6570			7645, 7954										3581, 4339																														276, 311																383, 2733																		2777, 3183	3199, 3510
4,066	153,642	27688	Discharge summary	report	Admission Date: [2129-5-24] Discharge Date: [2129-6-23] Date of Birth: [2105-6-10] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: EGD [2129-6-15] Open gastrostomy and Percutaneous tracheostomy [2129-5-30] Exploration, recent laparotomy, abdominal wall closure with retention sutures [2129-6-2] Placement of inferior vena cava filter [2129-6-15] History of Present Illness: 23 yo male s/p rollover motor vehicle crash with ejection; unresponsive at scene. Taken to an area hospital where he was intubated. Head CT scan revealed intraparenchymal hemorrhage; he was then transferred to [Hospital1 18] for continued trauma care. Past Medical History: None Family History: Noncontributory Pertinent Results: [2129-5-24] 10:53PM GLUCOSE-105 UREA N-12 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13 [2129-5-24] 10:53PM CALCIUM-7.9* PHOSPHATE-2.9 MAGNESIUM-2.2 [2129-5-24] 10:53PM WBC-8.4 RBC-3.72* HGB-11.4* HCT-31.9* MCV-86 MCH-30.6 MCHC-35.6* RDW-13.8 [2129-5-24] 10:53PM PLT COUNT-202 [2129-5-24] 11:03AM WBC-11.6* RBC-3.89* HGB-12.0* HCT-33.3* MCV-86 MCH-30.8 MCHC-36.0* RDW-13.7 [2129-5-24] 11:03AM PLT COUNT-246 [2129-5-24] 07:45AM PLT COUNT-278 [2129-5-24] 07:45AM PT-11.8 PTT-20.5* INR(PT)-1.0 MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: [Month/Day/Year ] pontine lesion, please perform with Gad Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 23 year old man with ?[Doctor First Name ] s/p MVC and increasing rigidity on exam in all extremities REASON FOR THIS EXAMINATION: [Doctor First Name ] pontine lesion, please perform with Gad CONTRAINDICATIONS for IV CONTRAST: None. MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: [First Name9 (NamePattern2) ] [Doctor First Name ] [Hospital 93] MEDICAL CONDITION: 23 year old man s/p MVC c IPH in R basal ganglia and occipital lobe REASON FOR THIS EXAMINATION: [First Name9 (NamePattern2) ] [Doctor First Name ] MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY HISTORY: Evaluate extent of diffuse axonal injury. Status post motor vehicle collision. TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained. COMPARISON STUDY: CT scan of the same day. FINDINGS: Previously noted multiple intraparenchymal hemorrhages as well as right occipital [Doctor Last Name 534] hemorrhage are redemonstrated, with probable additional tiny amounts of blood within the left occipital [Doctor Last Name 534]. Tere are probable additional smaller areas of hemorrhage within the cerebellum and throughout the cerebral hemispheres, as seen on the susceptibility weighted scans. Also noted is high T2 signal within the right side of the pons and the left side of the splenium of the corpus callosum. Given the history of major head trauma, these latter lesions presumably represent nonhemorrhagic shear injuries, as well. There is no hydrocephalus or shift of normally midline structures. There is fairly extensive subgaleal swelling, somewhat more evident on the left side, and most prominent on both sides near the cerebral vertex. CONCLUSION: More extensive shearing injury, both nonhemorrhagic and hemorrhagic, compared to the recent CT scan, as noted above. MR ANGIOGRAPHY OF THE CIRCLE OF [Location (un) ] AND ITS TRIBUTARIES TECHNIQUE: Three-dimensional time-of-flight imaging with multiplanar reconstructions. FINDINGS: The major vascular tributaries of the circle of [Location (un) 431] appear patent. There is no definite evidence for the presence of vascular injury or aneurysm, within the limitations of this modality. INDICATION: Question [Doctor First Name ] status post MVC and increasing rigidity on exam in all extremities, evaluate pontine lesion, please perform with gadolinium. COMPARISON: MR brain dated [2129-5-25] and non-contrast head CT dated [2129-6-3]. TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed through the brain prior to and following the administration of gadolinium. Diffusion- weighted imaging was performed. MR OF THE BRAIN: The examination is markedly limited by patient motion during image acquisition on nearly all sequences. A right frontal subdural collection containing hemorrhagic products which are hyperintense on T1 and hypointense on gradient echo sequences, is increased in size from the prior MR [First Name (Titles) ] [5-25] and probably stable in size in comparison with the head CT of [6-3], [2128]. Multiple bilateral foci of intraparenchymal hemorrhage, as well as hemorrhage within the occipital [Doctor Last Name 534] of the right lateral ventricle, appear stable in size. T2 hyperintensity and small focus of hemorrhage within the splenium, consistent with patient's known diffuse axonal injury, appear unchanged. Evaluation of the signal abnormality within the right pons, which appears contiguous with signal abnormality involving the right internal capsule, is somewhat limited due to motion artifact, although probably unchanged. No new areas of intracranial hemorrhage are identified. There is no hydrocephalus or shift of normally midline structures. No areas of abnormal enhancement are identified within the brain parenchyma following the administration of gadolinium, although evaluation is limited by motion artifact. There is probable dural enhancement about the right convexity at the site of the subdural collection. No areas of slowed diffusion are identified to suggest a new acute minor or major vascular territorial infarct. IMPRESSION: 1. Right subdural hematoma, increased since [5-25] but probably unchanged since [2129-6-3]. 2. Unchanged bilateral parenchymal hemorrhages and intraventricular hemorrhage. 3. Edema within the splenium of the corpus callosum as well as within the right pons and internal capsule, consistent with patient's diffuse axonal injury, are probably unchanged allowing for technical limitations due to marked patient motion. MRA OF THE CIRCLE OF [Location (un) ]: TECHNIQUE: 3D time-of-flight imaging with multiplanar reconstructions. MRA OF THE CIRCLE OF [Location (un) ] AND ITS TRIBUTARIES: The vessels of the circle of [Location (un) 431] and its major tributaries are patent without evidence of hemodynamically significant stenosis, occlusion, or aneurysm. IMPRESSION: Normal circle of [Location (un) 431] MRA. PORTABLE ABDOMEN Reason: [Location (un) ] obstruction [Hospital 93] MEDICAL CONDITION: 23 year old man with diffuse axonal injury s/p open G-tube placement, with emesis REASON FOR THIS EXAMINATION: [Hospital ] obstruction INDICATION: 70-year-old male with head trauma, NG tube placement. Patient presents with hematemesis. COMPARISONS: Comparison is made to [2129-6-19]. TECHNIQUE: AP supine single view of the abdomen. FINDINGS: The NG tube is in unchanged position in the left mid abdomen. There is again noted contrast within the colon. The IVC filter is in place. No dilated loops of small bowel are seen. The NG tube has been removed. IMPRESSION: No dilated loops of small bowel to suggest SBO. Brief Hospital Course: Patient admitted to the trauma service. Once stabilized in the Emergency room he was taken to the Trauma ICU. Neurosurgery was immediately consulted because of his head injury. He underwent further imaging of his head; MRA did not reveal any vascular injuries; MRI of the head did reveal diffuse axonal injury. His injuries were nonoperative. Mannitol was given for diuresis. He was also placed on Dilantin for seizure prophylaxis; this was eventually discontinued. He will follow up with Dr. [Last Name (STitle) 63264] in 3 months with repeat head imaging. He remained in the ICU for several weeks; he initially had problems with elevated heart rate and blood pressure; both improved with IV Lopressor and Hydralazine. A tracheostomy and PEG were placed on [5-30]; he was eventually weaned off the ventilator. He remained in the ICU for several weeks and was then transferred to the floor. Patient pulled his tracheostomy out on HD #30; he maintained adequate airway control throughout the day and evening and so the tracheostomy was not replaced. He did have an ileus with fevers, concerning for obstruction; his tube feedings were placed on hold. he was started on TPN. The ileus did eventually resolve; his tube feedings were restarted; he was started on Reglan and is currently tolerating these with minimal residuals. Vascular surgery was consulted for placement of IVC filter given his high risk for thromboembolism. Filter was placed on [2129-6-15] without complication. He was also followed by Neurology during his hospital stay; EEG monitoring was performed and revealed no seizure activity. His mental status in general has improved dramatically over the course of his stay; he is more alert and communicating verbally. Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Metoclopramide 10 mg IV Q6H 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Pantoprazole 40 mg IV Q12H 5. Colace 150 mg/15 mL Liquid Sig: Fifteen (15) ML's PO twice a day: hold for loose stools. 6. Fleets enema Sig: One (1) once a day as needed for constipation. 7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: s/p Motor vehicle crash Diffuse axonal injury Intraparenchymal hemorrhages Left maxillary sinus fracture Discharge Condition: Stable Discharge Instructions: Follow up with Trauma and Neurosurgery. Followup Instructions: Follow up in Trauma Clinic with Dr. [Last Name (STitle) ] in [1-22] weeks, call [Telephone/Fax (1) 6439] for an appointment. Follow up with Neurosurgery, Dr. [Last Name (STitle) 63264], in 3 months, call [Telephone/Fax (1) 1669] for an appointment. Inform the office that a repeat head CT scan will be needed for this appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2129-6-23]	[ "041.11", "560.1", "790.01", "482.41", "337.9", "276.0", "276.9", "682.2", "998.31", "518.5", "530.19", "801.25", "998.59", "578.0", "401.9", "V09.0", "863.89", "285.9", "854.05", "E818.0" ]	icd9cm	[ [ [] ] ]	[ "54.12", "45.13", "96.6", "38.91", "31.1", "38.7", "99.15", "54.11", "99.04", "38.93", "96.72", "43.19" ]	icd9pcs	[ [ [] ] ]	9671, 9741	7340, 9090	295, 531	9890, 9899	896, 1605	9987, 10498	860, 877		9113, 9648	6689, 6771	9762, 9869					9923, 9964																																								232, 257	6800, 7317															559, 816																		838, 844
10,635	184,034	50068	Discharge summary	report	Admission Date: [2124-8-28] Discharge Date: [2124-9-16] Date of Birth: [2068-11-10] Sex: F Service: MED Allergies: Azmacort / Clindamycin / Versed / Fentanyl / Morphine Attending:[First Name3 (LF) 1055] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 55 yo woman with chronic demyelinating disease and chronic pulmonary disease p/w worsening dyspnea and hypoxia. Had productive cough with greenish sputum for several days. +fever up to 101.4 over the weekend. Went for regular office visit today. Found to be SOB and hypoxic with O2 sats of 70% on RA, which increased to 80% on 8L nc, and increased to 90% on non-rebreather. Pt has hx sig for bronchiectasis In ED, VS:97.6, p84, 108/50, 22, 91% face mask. Was put on continuous nebs. CXR showed no pneumonia. Pt was given 125mg IV solumedrol and 500mg levaquin. Admitted to MICU for close monitoring with ? asthma exacerbation. Past Medical History: Asthma. Restrictive lung disease. Unknown demyelinating syndrome (L leg paresis, bilateral arm weakness, demyelination on brain MRI, neurogenic bladder) Adrenal insufficiency. Osteoporosis. Hypothyroidism. History of chest nodules. Dyslipidemia. History of K breast papilloma with nipple discharge. Anxiety. Labile hypertension. History of right IJ thrombus in [2112]. IgG deficiency. Anemia. Status post cholecystectomy in [2112]. Dysfunctional uterine bleeding by history. Atypical pap smears. Common bile duct stenosis s/p sphincterotomy. Gastritis and prepyloric ulcers per EGD. Bilateral hearing loss. G-tube and self-catheterization Social History: The patient states she lives with her husband. Over 50 pack year smoking hx; quit in [2109]. Denies any recent alcohol or IV drug abuse. Family History: Family history is notable for coronary artery disease. Father had [Name2 (NI) 499] cancer, her mother had breast cancer, and her sister had brain cancer. Physical Exam: Vital signs Temp:98.4F Pulse:88bpm BP:108/70 RR:18/min O2Sat:88-95%5LNC FS: 176 Gen: alert, pleasant 55y/o female in mild respiratory distress (audible secretions, coughing) Derm: skin normal coloration, no rash, no atypical nevi. HEENT: Eyes: no scleral icterus. PERRLA, EOM full and smooth Ears: normal shape and external auditory canals. Reduced hearing in R ear on finger rub test. Nose: septum midline; no discharge or sinus tenderness Throat: Oropharynx clear. Mucous membranes moist. Top and bottom dentures. Enlarged, tender cervical lymph nodes bilaterally. No thyromegaly. Pulm: symmetrical expansion; use of accessory muscles (sternocleidomastoids, no intercostals retraction). Phlegm in airways audible on inspiration. Tenderness to palpation in lower rib area bilaterally. Normal to percussion. Loud inspiratory and expiratory rhonchi and bronchial breath sounds anteriorly; loud expiratory rhonchi posteriorly throughout both lung fields. CV: S1, S2 normal, RRR. No clicks/murmurs/rubs/extra heart sounds. Pedal and radial pulses symmetrical and strong. No leg edema Abd: Round shape. Symmetrical. No scars/herniae. Umbilicus normal. Bowel sounds present. No aorta/renal artery bruits. Hollow to percussion. No guarding, tenderness, masses. Liver, spleen not palpable. Ext: no cyanosis, clubbing, or edema Neuro: coarse tremor in both UE Motor: muscle tone decreased in both LEs, L less tone than R; rigidity in both LEs, L>R. LE: adduction, abduction, extension at the hip - +5 both sides; knee extensors and flexors - +4 R, +3 L. ankle strength - +4 R, +3 L. Toe strength +4 R, +3L. light touch sensation intact in upper and lower extremities and face. Brief Hospital Course: 1. Respiratory insufficiency(pneumonia, hypoxia, asthma/COPD): in the MICU, it was felt that hypoxia was likely multifactorial from COPD flare/asthma exacerbation, and intermittent mucous plugging, in the setting of chronic pulmonary disease. To treat possible PNA, pt was started on ceftriaxone (which was switched to ceftazidime to have pseudomonas coverage given concern for bronchiectasis), azithromax, and IV hydrocortisone. She was continued on prn nebs and inhalers, and aggressive chest PT was given. For her reactive component, [Doctor First Name 130], singulair, and advair were continued. Sputum culture showed respiratory flora, and legionella antigen was negative. She was transferred to the floor on [2124-8-30]--her antibiotics had been switched to vancomycin and pip-tazo per ID consult, and she was on 5L supplemental O2 by nasal cannula (she was never intubated in the MICU). They had tried BiPap, but she did not tolerate this. She had 2 desat events on [8-31] and [9-1] to the 70s, which manifested as confusion. This was thought to be caused by inability to clear secretions. We had her on Percocet to control severe rib pain, in an attempt to reduce her splinting and help her to clear secretions better. Our initiall attempts at BiPap were also unsuccessful, and we started her on aggressive suctioning, CPT when tolerated, incentive spirometry, flutter valve, humidified O2, getting OOB daily, and IV fluids to thin out secretions. Pulmonary edema showed up on CXR, so we stopped the IV fluids and diuresed her with Lasix. The CHF resolved on CXR. She had no known h/o CHF, but this may have shown up as a result of her bradycardic episodes while in the hospital that had since resolved. Initial TTE showed normal EF so there was question whether her shortness of breath had been due to volume overload. She We switched her antibiotics to po levofloxacin, which we dc'ed on [2124-9-7] due to development of presumed C. Diff infection, and worked to combat atelectasis. We continued incentive spirometry, flutter valve, and PT/OOB daily. Per pulmonary consult, we got PFTs which showed worsening of her restrictive disease with no obstructive component, added Flovent 2 puffs 220mg [Hospital1 ], and started BiPAP 3-4h/day which again she refused. We changed her Percocet to Tylenol 1g q6h and oxycodone prn, to prevent suppression of respiratory drive. On [2124-9-8], she was weaned off her O2, with sats 90-95. While on the floor, we also weaned her IV steroids slightly and then switched to PO prednisone, which was then fairly quickly tapered. She went home on 10mg, with a plan to taper off over 2 weeks. 2. Increased WBCs/Diarrhea. On [2124-9-7], Mrs.[Known lastname 104544] CBCs showed a white count of 21.8. Since she had been having diarrhea and RLQ discomfort a few days prior, it was most likely she had a C. Diff infection. We sent her stool for sample which was negative. We started empiric Flagyl for C. Diff after 2 days of significantly elevated WBCs but discontinued it after Cdiff toxin assay came back negative. We also DC'ed her Foley, and sent off a U/A which showed yeast infection--we treated her with three days of fluconazole. We also took out her central line and sent the tip for culture which came back positive for coagulase negative staph and she was restrated on a 5 day course of vancomycin. Blood cultures came back negative, On [2124-9-8], she developed abdominal distention and absence of BM for 36 hours; we ordered a KUB which came back negative for obstruction or ileus athough she continued to have abdominal pain and an elevated WBC so an abdominal CT was obtained. Abdominal CT was obtained which showed what appeared to be a large left renal infarct, and after futher review there also appeared to be a thrombus in the right renal vein. Source workup including TEE and all four extremity venous ultrasound studies were obtained all of which were negative, although TEE revealed a small secundum ASD raising the possiblity of a parodoxical embolus. Consults from Renal, Urology, Rheumatologyn all of whom agreed with the plan for a hypercoagulable work-up and anticoagulate the patient. Hypercoagulability labs sent included:Factor V Leiden, Protein C and S, B2 glycoprotein, anti-cardiolipin, antithrombin III mutation, antithrombin Ab, lupus anticoagulant. She was started on coumadin on [9-17] along with and lovenox and was discharge on lovenox and coumadin with plan for INR check on [9-18] and PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] emailed regarding follow-up of hypercoagulability workup. Since the differential for the finding on CT included pyelonephritis and she was growing yeast in her urine(with negative U/A) she was discharged on a five day course of fluconazole. 3. Bradycardia. On [2124-9-1] Mrs. [Known lastname 104543] developed sudden bradycardia to the 30s, but was asymptomatic (no lightheadness, syncope, CP). We put her on telemetry and tried an atropine challenge, which brought her HR to the 70s. We wrote for 1mg atropine for bradycardia, which she needed later that night. External pacing pads were also ready if needed. Her HR stayed in the normal range after that night. EP consult thought bradycardia most likely due to increased vagal tone and demyelinating disease. TSH levels came back low. We ordered an echo on [9-8], which came back normal. On review of previous admits, she did have a similar episode in the past which also resolved on its own. This event may have contributed to her transient CHF as above though. She developed a similar episode of day of discharge but felt mildly dizzy. She was found to be orthostatic and symptoms resolved after a 500cc bolus of NS. 4. Chronic demyelinating disease with leg spasms: We continued tizanidine HCl 8mg po tid, baclofen 10mg po tid and lorazepam 2mg po tid; with lorazepam 2-8mg IV q4h:prn spasm. Patient had problems with severe spasms, requiring 6-11mg IV Ativan. We had PT see her, and they deemed her close to baseline functionally. She states that the spasms are more often and more severe when she is in the hospital. Unclear what she does if she has a severe spasm like this at home, as no IV ativan available there, although she says they do not occur as regularly when she is outside the hospital. 5. Anemia: slightly macrocytic anemia upon admission. Her anemia studies were as follows: normal B12 (275), folate (2.7), elevated haptoglobin (244), Ferritin low normal (19), TIBC normal (294). Retics normal (2.2). Her blood methylmalonic acid levels were normal. We gave her ferric gluconate infusions, and hct remained stable. 6. Osteoporosis. We continued vitamin D 400Unit po qd. She also got 3 50,000unit doses of vitamin D started on [2124-9-4]. Vitamin D25 hydroxy levels from [9-2] came back normal. While in hospital she also received her q3mo dose of Pamidronate. 7. Adrenal insufficiency She was started on hydrocortisone Na Succ. 100mg IV q8h in the MICU. We switched her to po prednisone on [9-1] and tapered her gradually as above. 8. Allergies: We initially continued diphenydramine HCl 25 mg po q24h:prn and Fexofenadine 60mg po bid. The diphenhydramine was stopped on [2124-9-4]. 10. Hypothyroidism. We continued levothyroxine Sodium 50mcg po qd; TSH levels came back low, showing adequate treatment of her hypothyroidism. 11. Gastritis and prepyloric ulcers per EGD: We continued pantoprazole 40mg po q24h, switched to q12h on [2124-9-8], considering abdominal discomfort later on during her stay which she was continued on throughout her hospitalization. 12. Anxiety: We continued buspirone 10mg po tid, clonazepam 2 mg po tid. She still had some anxious moods/angry moods, but these were mostly controlled. 13. FEN: She was on tube feeding in the MICU. had her on a diabetic diet on the floor, but switched to house diet to improve po intake. In addition, the nurses were able to give her Boost and similar supplements through her G-tube as well. She does this at home as well. She refused to use G-tube on floor despite thought by the pulmonary team that micro chronic aspiration is likely contributing to her desaturations. Medications on Admission: Vitamin D 400mg qd Baclofen 20mg tid Buspar 10mg tid Lipitor 10mg qd Benadryl Levoxyl 50 mcg qd Klonipin 2mg tid [Year (4 digits) 102130] 8mg tid Ativan 2mg tid Protonix 20mg [Hospital1 ] Oxazepam 30mg Ativan 6-8mg IV for spasm Discharge Medications: 1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 5. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Tizanidine HCl 4 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [Hospital1 ] (2 times a day). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 17. Warfarin Sodium 3 mg Tablet Sig: Three (3) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 18. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO q6h prn as needed for pain. Disp:20 Tablet(s) Refills:0 19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 20. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 10 days: Will be stopped once INR is therapeutic [1-18]. Disp:24 60mg syringe Refills:0 Discharge Disposition: Home Discharge Diagnosis: Asthma. Restrictive lung disease. Unknown demyelinating syndrome (L leg paresis, bilateral arm weakness, demyelination on brain MRI, neurogenic bladder) Adrenal insufficiency. Osteoporosis. Hypothyroidism. History of chest nodules. Dyslipidemia. Anxiety. Labile hypertension. History of right IJ thrombus in [2112]. IgG deficiency. Anemia. Status post cholecystectomy in [2112]. Common bile duct stenosis s/p sphincterotomy. Gastritis and prepyloric ulcers per EGD. Renal infarct Discharge Condition: Pt was breathing much easier on discharge. She did not require any oxygen to maintain adequate O2 sats. She was eating and drinking well. Her spasms were well controlled on her medication. Her vital signs were stable and she was afebrile. She continued to have rib pain due to fractures, but this was well controlled on oxycodone Discharge Instructions: Please call Dr [First Name (STitle) ] or return to the hospital if you have another flare of your asthma and have difficulty breathing or chest pain. Also call or return if you feel lightheaded, dizzy, or if you develop a fever or chills. You have been started on lovenox and coumadin while in the hospital which are blood thinners. You will have to administer the shots of lovenox to yourself twice a day as done in hospital. You should also have the visiting nurse check you INR or coumadin level on Monday [2124-9-18] to make sure that the dosing is appropriate. If you develop any pain or swelling in any of your extremities please call your PCP or if he/she is not available proceed to the nearest emergency room. You are also on Prednisone which was started when you were in hospital and this will be tapered over the next 2 weeks as prescribed. Followup Instructions: Please call [Telephone/Fax (1) 250] to make an appointment to follow-up with Dr [First Name (STitle) ] in 2 weeks [10-2] at 12:20p.m. You will also need to follow-up with Rheumatology within the next month by scheduling at [Telephone/Fax (1) 2226]. There are multiple test for a hypercoagulability workup that both your PCP and [Name9 (PRE) 68053] will be following up on.	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50,991	178,779	36354	Discharge summary	report	Admission Date: [2170-1-22] [Year/Month/Day ] Date: [2170-2-9] Date of Birth: [2093-3-2] Sex: M Service: MEDICINE Allergies: Ampicillin / Golytely / Fortaz / Levaquin in D5W / Fluconazole / Clindamycin / Trimethoprim / Sulfamethoxazole / aspirin / ciprofloxacin / clopidogrel / Zolpidem / ceftazidime Attending:[First Name3 (LF) 10593] Chief Complaint: Gastrointestinal bleed Major Surgical or Invasive Procedure: Rigid bronchoscopy with biopsy, bronchial brush, bronchoalveolar lavage [2170-1-30] PICC line placement [2170-2-5] History of Present Illness: 76-year-old male with complicated past medical history of dCHF, PVD, COPD, HTN, esopageal CA s/p esophagectomy who was diagnosed with bilateral PEs on [2169-12-22] and started on anticoagulation who now presents from OSH with GI bleed. . Per the [Date Range ] summary, the patient was diagnosed with a bilateral PE on [2169-12-22] at [Hospital3 417] Hospital. He was started on a lovenox bridge and transitioned to warfarin. Per report, his INR has remained at goal since that time. Since this time he has developed pneumonia requiring courses with meropenem and vancomycin and imipenem. . Sometime prior to [2170-1-18] he developed frank rectal bleeding with a hematocrit drop to 23. His anticoagulation was discontinued and he had ultrasounds done of his extremities. His legs and left upper extremity were normal. His RUE showed extensive clot burden and an SVC filter was placed on [2170-1-18]. The Hct continued to trend down and he required transfusion with 2 u PRBC. The patient was transferred to [Hospital1 18] for evaluation of GIB. . Of note, the patient was empirically placed on antibiotics for pneumonia, however, these were discontinued by the primary physician prior to transfer to [Hospital1 18]. . The patient notes that he has some shortness of breath and lightheadedness. He notes an oxygen requirement since his diagnosis of pulmonary emboli. He denies chest pain, abdominal pain, back pain or other symptoms. He denies fevers but endorses cough with some yellow sputum. His last GI bleed was prior to the weekend per patient report. Past Medical History: - esophageal cancer s/p esophagoectomy with colon interposition - COPD - HTN - HLD - Cardiomyopathy - Diastolic CHF - PVD - AAA - bilateral pulmonary emboli [2169-12-22] - horseshoe kidney - cataract surgery - bladder stricture - h/o [First Name8 (NamePattern2) ] [Location (un) ] syndrome - Ileocolostomy - tonsillectomy - tracheostomy [4-26] - G-tube placement Past Surgical History [2169-10-18] Direct laryngoscopy with left vocal fold injection with Radiesse Voice Gel [2169-10-16] Esophagogastroduodenoscopy and dilation Cataract surgery Tonsillectomy as a child [2168-5-13] Tracheostomy [2168-5-4] Redo neck exploration; redo laparotomy with harvesting of left colon, substernal colon interposition [2167-9-8] Esophagogastroduodenoscopy with guidewire-assisted dilatation Social History: Home: Bachelor, lives with sister (former RN) and two dogs in [Name (NI) 5165] (though more recently at rehab) Occ: Retired/disabled letter carrier Travel: none recently Tob: 1.5-2ppd x 60 years, quit [2166] EtOH: rare Illicits: denies Family History: Liver cancer in father (deceased at 54). CAD in mother (deceased at 79). Physical Exam: Physical Exam on Admission: VS - Temp 95.6 F Ax, BP 120/51, HR 77, R 20, O2-sat 94 % 4L GENERAL - ill appearing male, comfortable, tired HEENT - dry MM, OP without lesions NECK - supple, low JVD LUNGS - Anterior exam, no wheezes, decreased breath sounds HEART - RR, nl rate, no MRG ABDOMEN - NABS, soft/NT/ND, multiple scars, GTube in place c/d/i EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - sacral pressure ulcer NEURO - awake, A&Ox3, weak throughout, unable to ambulate Physical Exam on [Year (4 digits) ]: VS - Tc 97.6 HR 69 BP 100/55 RR 20 O2 98% 4L NC General: Cachectic elderly male, AOx3, good affect, in no acute distress HEENT: Sclera anicteric, MM slightly dry, oropharynx clear. Temporal wasting bilaterally. Lungs: Mild wheezes in all lung fields; upper airway + LUL rhonchi; mild dry crackles at bases CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. J-tube in place, small region of erythema around site, unchanged from prior, clean/dry/intact, bandaged. Multiple surgical scars, well-healed. Ext: extremities warm, 1+ pulses b/l, no clubbing or cyanosis, trace pedal edema. Derm: Stage II decubitus ulcer noted on sacrum, mildly improved from prior. Pertinent Results: ADMISSION LABS: [2170-1-22] 11:58PM BLOOD WBC-1.9# RBC-3.82 Hgb-11.0* Hct-33.8* MCV-89 MCH-28.8 MCHC-32.5 RDW-16.2* Plt Ct-289 [2170-1-22] 11:58PM BLOOD Neuts-59 Bands-1 Lymphs-21 Monos-17* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* [2170-1-22] 11:58PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2170-1-22] 11:58PM BLOOD PT-11.1 PTT-28.8 INR(PT)-1.0 [2170-1-22] 11:58PM BLOOD Glucose-82 UreaN-19 Creat-0.3* Na-138 K-4.6 Cl-101 HCO3-31 AnGap-11 [2170-1-22] 11:58PM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1 [2170-1-26] 06:35AM BLOOD WBC-3.0* RBC-3.82* Hgb-10.9* Hct-33.5* MCV-88 MCH-28.5 MCHC-32.4 RDW-17.3* Plt Ct-348 [2170-1-30] 11:45PM BLOOD WBC-12.1* RBC-3.83* Hgb-10.7* Hct-33.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-16.8* Plt Ct-444* [2170-1-31] 06:00AM BLOOD WBC-9.2 RBC-3.27* Hgb-9.4* Hct-28.5* MCV-87 MCH-28.7 MCHC-33.0 RDW-16.3* Plt Ct-414 [2170-2-1] 06:53AM BLOOD WBC-8.6 RBC-3.08* Hgb-9.0* Hct-26.9* MCV-87 MCH-29.3 MCHC-33.5 RDW-16.7* Plt Ct-386 [2170-2-6] 04:49AM BLOOD WBC-7.6 RBC-3.13* Hgb-8.9* Hct-27.2* MCV-87 MCH-28.5 MCHC-32.8 RDW-16.4* Plt Ct-579* [2170-1-30] 06:44PM BLOOD Type-ART pO2-60* pCO2-36 pH-7.51* calTCO2-30 Base XS-5 Intubat-NOT INTUBA Comment-O2 EDELIVE [2170-2-1] 03:51PM BLOOD Type-ART FiO2-50 pO2-64* pCO2-41 pH-7.51* calTCO2-34* Base XS-8 Intubat-NOT INTUBA [2170-2-3] 09:30PM BLOOD Type-ART FiO2-91 O2 Flow-4 pO2-75* pCO2-40 pH-7.49* calTCO2-31* Base XS-6 AADO2-535 REQ O2-89 [Month/Day/Year 894] LABS: [2170-2-9] 05:25AM BLOOD Hct-25.7* [2170-2-9] 05:25AM BLOOD PT-13.1* PTT-98.2* INR(PT)-1.2* [2170-2-9] 05:25AM BLOOD Glucose-101* UreaN-16 Creat-0.2* Na-135 K-4.8 Cl-98 HCO3-32 AnGap-10 [2170-2-8] 04:59PM BLOOD Mg-2.1 CT CHEST W/O CONTRAST [2170-1-23]: 1. Large necrotizing pneumonia, incipient lung abscess, left upper lobe, probably due to aspiration, given more severe bibasilar peribronchial infiltration around chronic bronchiectasis and retained secretions in the bronchial tree. 2. New left hilar adenopathy could be reactive or malignant, mildly narrows but does not obstruct the upper lobe bronchus. Mild generalized mediastinal adenopathy, unchanged since [Month (only) 359] [2166]. No good evidence for active recurrence of esophageal carcinoma. 3. Severe emphysema. 4. Gastrostomy balloon at the pylorus might interfere with gastric emptying. ART DUP EXT UP UNI OR LMTD RIGHT [2170-1-25]: There is no evidence of arterial stenosis in the right upper extremity. UNILAT UP EXT VEINS US RIGHT [2170-1-25]: Non-occlusive DVT in the axillary and one of the brachial veins. Nearly completely occlusive thrombus involving the basilic vein. G/GJ/GI TUBE CHECK [2170-1-28]: The tip appears to be in the loops of the jejunum in the right mid-lower quadrant. No extravasation of contrast is demonstrated on this limited one static image. ECG Study Date of [2170-1-30]: Sinus tachycardia. Frequent ventricular ectopy. Left axis deviation. Non-specific ST-T wave changes. Compared to the previous tracing of [2169-9-28] the rate is faster and ventricular ectopy is new. CHEST (PORTABLE AP) [2170-1-30]: The substantial increase in consolidation in the necrotizing left upper lobe pneumonia that took place between [1-22] and [1-30] after left upper lobe bronchoscopic biopsy, has improved little, but is still quite substantial. There is no pneumothorax or appreciable left pleural effusion. Cardiac silhouette is normal. Right lung is grossly clear. CHEST PORT. LINE PLACEMENT [2170-2-5]: Interval placement of left subclavian PICC line with its tip at the superior aspect of a superior vena caval filter. There is persistent opacity in the left upper and mid lung suggestive of pneumonia. The right lung is grossly clear. No pneumothorax is seen. No evidence of pulmonary edema. CXR [2170-2-8]: Cardiomediastinal contours are unchanged. Left upper lobe opacity, consistent with known pneumonia, is grossly unchanged. Increasing opacities in the left lower lobe are consistent with increasing atelectasis. Right lower lobe opacities could be atelectasis or pneumonia. Surgical clips project in the right upper hemithorax. There is scoliosis. Patient has severe emphysema. LEFT LUNG, UPPER LOBE BIOPSY [2170-1-30]: Lung tissue and vessels with mild chronic inflammation, fibrosis, and hemorrhage. No malignancy identified. MICROBIOLOGY: [2170-1-24] Legionella Urinary Antigen: negative [2170-1-30] Blood cultures: negative [2170-1-30] LUL tissue: proteus vulgaris [2170-1-30] Bronchial brush: proteus mirabilis, proteus vulgaris [2170-1-30] BAL: PROTEUS MIRABILIS \| PROTEUS VULGARIS \| \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S 4 R CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: 76M with a complex medical history, most notably including T1 esopheageal cancer s/p esophagectomy [2166] and colonic interposition/J-tube placement in [2167], diastolic CHF, COPD, PVD, hypertension, recent bilateral PEs [12/2169], multiple recent aspiration PNAs, who developed GIB in setting of being started on warfarin for PEs. Initially presented to OSH where he was transfused 2 units pRBCs and had SVC filter placement, transfered to [Hospital1 18] for further evaluation of GIB, with course notable for LUL necrotizing pneumonia. # GI bleed: Pt initially presented to OSH with BRBPR and Hct drop to 23 in setting of recently being started on warfarin for bilateral PEs. Warfarin d/c'd and pt transfused 2 units pRBCs. Of note, patient also had SVC filter placed after he was found to have RUE DVT. Was transferred to [Hospital1 18] for further eval. Here, Hct initially remained stable, and patient did not have further GI bleeding. GI was consulted, and once Hct stable, they felt that need for anticoagulation outweighed risk of further bleeding, despite increased risk due to his many surgical anastamoses. EGD/colonoscopy were recommended, though given tenuous respiratory status these will be deferred to the outpatient setting. Patient will likely need MAC anesthesia for the procedure. Will follow-up with GI in one month, and they will reassess plan for procedures at that time. Patient was continued on [Hospital1 ] PPI this admission. Was restarted on anticoagulation as below. Did have one 6 point drop in Hct, though this was in setting of probable dilutional effect and hemoptysis. He did not require additional tranfusions. # LUL necrotizing pneumonia: Pt w/extensive recent history of consolidations beginning [2169-11-27]. Treatment of these probable aspiration pneumonias (which grew Klebsiella, Morganella, and Pseudomonas) was c/b pt's extensive antibiotic allergies. Prior antibiotic courses included tigecycline, tetracycline, and most recently a 6 day course of vancomycin and meropenem that was discontinued just prior to transfer to [Hospital1 18] with concern with developing neutropenia. His admission exam was less concerning for an acute respiratory process. He was weaned from 4L to 1L over the first 6 days of his hospital course, with subjective improvement in breathing. However, in setting of increased rhonchi on lung exam, CT chest obtained and demonstrated a LUL necrotizing pneumonia and developing abscess. Interventional pulmonology consulted, and recommended bronchoscopy. Infectious Disease also consulted, and recommended holding antibiotics until culture results could be obtained from bronchoscopy samples. Rigid bronchoscopy done [2170-1-30], with two biopsy samples, bronchial brush, and BAL collected. Post-procedure, patient required brief admission to MICU for stabilization of tachycardia, tachypnea, and increased oxygen requirement. Did have 6 point drop in Hct at this time, in setting of receiving IVF and developing blood-tinged secretions and a mild amount of frank hemoptysis. However, Hct subsequently remained stable, and frank hemoptysis resolved. Post-bronch, patient started on broad spectrum antibiotics with vanc/meropenem, and abx were later narrowed to just meropenem after cultures demonstrated proteus. Per ID, patient was continued on meropenem, and will be transitioned to ertapenem on [Month/Day/Year ] to complete a total four week course of abx to end [2170-2-28]. Patient continued to require 3-5L NC, with occasional desats to the 80s. These may have been secondary to mucous plugging, as patient would quickly respond with improvement in sats when placed on oxygen face mask, and with nebulizer treatments and clearance of secretions. At time of [Month/Day/Year ], oxygen requirement 4L NC. # Pulmonary embolism: Pt diagnosed with bilateral PEs [2169-12-22] at [Hospital3 417] Hospital. Warfarin, started after this event, was d/c'd on [2170-1-18] at OSH after GI bleed. Given GIB and high risk for repeat events given numerous surgical anastamoses, was concern for restarting anticoagulation. However, given known large clot burden, including not only the PEs but also a RUE DVT (for which SVC filter placed at OSH), was felt that benefits of anticoagulation outweighed risks. For easy titration and reversibility, heparin gtt drip was chosen for initial prevention of clot extension, rather than immediately restarting warfarin. Heparin was started without bolus and titrated to goal of PTT 60-80. Heparin gtt was held prior to bronch on [2170-1-30], and was not restarted until [2170-2-2] after patient developed 6 point drop in Hct post-bronch with increased bloody secretions. However, Hct remained stable thereafter, and heparin gtt restarted without issue. Warfarin was restarted on [2170-2-6] at 5 mg daily. INR only 1.2 at time of [Date Range ]. Patient will continue on heparin gtt until INR has been therapeutic >48 hours. Goal INR [1-19], and patient will need at least 6 months of anticoagulation. # Right upper extremity DVT: Noted at OSH, and patient had SVC filter placed prior to transfer as his anticoagulation was being held in the setting of GIB. Ultrasound of RUE on HD4 revealed no arterial obstruction or stenosis, but did show non-occlusive venous embolism in the axillary and brachial veins and nearly complete obstruction of the basilic vein. The patient was anticoagulated as above, with heparin gtt and restarting of warfarin prior to [Month/Day (3) ]. After discussion with IR, decision was made to leave SVC filter in place, as given large clot burden was felt risks of removing filter outweighed the benefits. # Tachycardia: Patient noted to have intermittent sinus tachycardia, occasionally with frequent PVCs and ventricular trigeminy. Patient was asymptomatic during these episodes, with stable BP. He responded well to IVF boluses of 500cc NS. Electrolytes were WNL. He was switched from carvedilol to metoprolol, though dose could not be uptitrated due to blood pressure (SBP in high 90s-low 100s). # COPD: Pt was on prednisone taper initially begun for COPD exacerbation at OSH on [2170-1-2]. Initial dose was 60 mg/day; dose was at 40 mg/day on admission. On HD2, decision was made to taper dose to prevent immunosuppressive effects in the face of neutropenia and pneumonia. Accordingly, tapering was initated with 20 mg HD2-4, 10 mg HD5-8, and 5 mg HD9-11. Prednisone was d/c'd on HD11. Patient received albuterol/ipratropium nebs Q6H, with additional albuterol nebs as needed. He was also restarted on Advair this admission, with good effect. # Leukopenia: The patient was noted in his last ([2170-1-22]) [Month/Day/Year ] summary to be leukopenic, with concern expressed that it may be related to antibiotics. Accordingly the patient was transferred to [Hospital1 18] with no active antibiotic prescriptions. His admission WBC count was 1.9; he remained in the 1.8-2.7 range on HD2-4. On HD5 his WBC rose to 3.0 and on HD6 to 6.9. Concern remained through HD6-9 that WBC may be rising in setting of developing PNA. WBC count briefly spiked to 12.1 post-bronch while patient in MICU, but returned to <10 on HD10 and remained in the 7-9 range afterwards despite the restart of meropenem on HD9. # Diastolic CHF: Per a [2168] report, patient's CHF diastolic in nature with a known EF of > 55%. Patient was on furosemide and spironolactone at time of admission, though these were held in setting of lower BPs, with SBP in 90s-110s throughout much of hospital course. Patient did not have evidence of pulmonary edema on exam or imaging, and he did not appear volume overloaded on exam. Furosemide and spironolactone held on d/c, but may need to be restarted in outpt setting as pt recovers from his infection. # Tube feeds s/p colonic interposition: The patient arrived with a previously placed J-tube in situ. Due to anticipated EGD, his feeds were not immediately restarted. Once EGD was deferred, tube feeds were restarted to titrate up to the previous (OSH) goal of 60 mL/hr. TF were d/c'd late on HD8 in preparation for his bronchoscopy on HD9, and were restarted post-procedure. # Decubitus ulcer: Pt arrived with a Stage II decubitus ulcer on the buttocks. Wound care was consulted, who oversaw dressing of the ulcer throughout the patient's stay. The ulcer remained approximately stable throughout his stay. Transitional issues: -Patient was a FULL CODE this admission. He was seen by both Social Work and Palliative Care. -Once acute issues resolved, consider removal of SVC filter. -Patient noted to have left hilar lymphadenopathy on imaging this admission, possibly reactive vs. malignant. This should be reassessed after acute infectious issues have resolved, and if not improved would consider biopsy to exclude malignancy. -Patient will follow-up with GI, and ultimately may need outpt EGD/colonoscopy. -Patient should continue on ertapenem through [2170-2-28] and follow-up with ID as scheduled. PICC line in place. -Patient should continue on heparin gtt until INR therapeutic for >48 hours. Goal INR [1-19]. Warfarin dose may need adjusting. -Patient should have periodic monitoring of Hct, given recent GIB and ongoing anticoagulation. -Would recommend nutrition follow patient as outpatient, given recent weight loss. Would consider increasing tube feed rate if patient will tolerate. -Please check weekly CBC, chem 7, LFTs while patient on antibiotics and send results to ID nurses via fax at [Telephone/Fax (1) 1419]. -Hct on [2-9] was 25.7. Medications on Admission: MEDICATIONS AT [Month/Year (2) 894]: - acetaminophen 325 mg PO q4hours prn - calcium carbonate 500 mg calcium (1,250 mg) PO three times a day via G-tube - carvedilol 6.25 mg PO BID - spironolactone 25 mg PO DAILY - ipratropium bromide 0.02 % Solution Sig: [12-18] Inhalation Q8H - furosemide 20 mg PO DAILY - prednisone 50 mg PO DAILY - guaifenesin 100 mg/5 mL Fifteen (15) ML PO Q6H - Ativan 1 mg PO at bedtime prn insomnia - Protonix 40 mg PO twice a day - Glucose Gel 40 % Gel 30 mg PO before meals and at QHS - Tube feeds - isosource 1.5 @ 60cc/hr 150ml flush 4x per day . MEDICATIONS AT TRANSFER: - Esomeprazole 40mg Gtube Q12H - Calcium Carbonate 1250mg Gtube TID - Carvedilol 6.25mg GTube [Hospital1 ] - Spironolactone 25mg GTube daily - Furosemide 20mg GTube daily - Miconazole nitrate application [Hospital1 ] - Prednisone 40mg GTube daily - Albuterol/Ipratropium duoneb inhaler q6H - Vancomycin 1 gram IV BID until [1-25] (on hold) - Imipenem/Cilastatin 500mg IV q6hrs until [1-25] (on hold) - Acetaminophen 325mg gtube q4H prn - Guaifenesin syrup 300mg GTube q6H prn - Lorazepam 1mg GTube qHS prn [Month/Day (4) ] Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): via J-tube. 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 6. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough: via J-tube. 8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Colace 60 mg/15 mL Syrup Sig: One Hundred (100) mg PO twice a day. 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: may need dose adjustment pending INR. 17. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: as directed Intravenous ASDIR (AS DIRECTED). 18. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 17 days: last day [2170-2-28]. 19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 20. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO BID (2 times a day) as needed for unclog J-tube. [Month/Day/Year ] Disposition: Extended Care Facility: [Hospital1 ]/ [Location (un) ], ma [Location (un) ] Diagnosis: Primary diagnoses: Gastrointestinal bleed Pulmonary embolism Pneumonia Secondary diagnoses: Decubitus ulcer Deep venous thrombosis, right upper extremity Chronic obstructive pulmonary disease Congestive heart failure, diastolic type Hypertension [Location (un) ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. [Location (un) ] Instructions: Mr. [Known lastname 82149], You were initially transferred to [Hospital1 18] with bleeding from your gastrointestinal tract. While you were here, the bleeding stopped and your blood counts stabilized. You were seen by the gastroenterology doctors, who recommended that you follow-up with them after you leave the hospital. You may need an endoscopy and colonoscopy to look for potential causes of the bleeding. While you were here, a CT scan of your chest showed a severe pneumonia in your left lung. You underwent a procedure called a bronchoscopy, in which they looked inside the lung with a small camera and took biopsies. You were started on antibiotics for your pneumonia, and will continue receiving an antibiotic called ertapenem through [2170-2-28]. You will follow-up with the Infectious Disease doctors after [Name5 (PTitle) ] leave the hospital. Once your bleeding stabilized, we started you back on heparin to help thin the blood. This is treatment for the blood clots in your lung. We also restarted your Coumadin. Your breathing improved while you were here, but you are still requiring oxygen at this time. You should continue using the nebulizer treatments after you leave the hopsital. You had a filter placed in your SVC (superior vena cava) at the other hospital. This filter is intended to prevent the blood clot in your arm from going to the lung. Right now, it is too risky to remove the clot, but you should talk to you doctors about whether the filter should be removed in the future. We made the following changes to your medications: STARTED: -Warfarin 5 mg daily -Heparin IV sliding scale -Bowel regimen with colace, senna, bisacodyl (for constipation) -Advair 250/50 inhaled twice a day -Metoprolol 25 mg twice a day -Vitamin D 800 units daily -Ertapenem 1 gram daily until [2170-2-28] (for pneumonia) -Pancrealipase 5000 units, 2 caps twice daily as needed to unclog J-tube CHANGED DOSING OF: -calcium -guiafenesin STOPPED: -Carvedilol -Spironolactone -Furosemide -Prednisone (you completed a taper for your COPD exacerbation) We did not make any other changes to your medications. Please continue to take them as you have been doing. Please keep follow-up appointments as below, and please follow-up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] from rehab. Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [2170-2-20] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4593], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2170-3-6] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2170-3-13] at 9:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4091], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2170-3-13] at 2:30 PM With: [First Name8 (NamePattern2) 4503] [Last Name (NamePattern1) 4504], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for [Location (un) ].	[ "401.9", "453.81", "V12.55", "513.0", "V12.51", "496", "486", "V58.61", "707.22", "453.84", "428.32", "578.9", "518.81", "428.0", "799.4", "V10.03", "288.50", "707.03" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "33.27", "33.24" ]	icd9pcs	[ [ [] ] ]		10040, 18537	470, 596		4789, 4789	26070, 27529	3329, 3405						19734, 23176													3420, 3434			23301, 23457																		18558, 19708	25272, 26047				23208, 23280				408, 432			23489, 23489			23678, 25242										624, 2212						4805, 10017		3448, 4770		23504, 23643								2234, 3051	3067, 3313
81,011	109,873	2607	Discharge summary	report	Admission Date: [2166-3-20] Discharge Date: [2166-3-24] Date of Birth: [2114-3-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10435] Chief Complaint: Melena, hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 51 yo M with HCV, s/p interferon/ribavirin with sustained virologic response, cirrhosis, liver AVM, GIII esophageal varices presents with one-2 day of melena and hematemesis. . The patient was admitted to [Hospital1 18] from [2-24] to [2166-3-4] for abdominal pain of unclear etiology. During that admission his work up EGD with G3 esophageal varices which were not seen on EGD [2162]. He also underwent a liver MRI which showed a liver AVM which was believed to be worsening his portal hypertension. He was scheduled for a planned IR coiling of his AVM tomorrow. However, yesterday he had an episode of melena/BRBPR and today had what he describes as one cups of hematemesis. He denies dizziness or lightheadedness but does endorse crampy abd pain. In the ED, initial VS were: 112 119/85 18 98%. He was given on liter of fluid and was given a dose of ceftriaxone, pantoprazole and was started on a octreotide gtt. Hepatology was consulted who recommended admission and likely endoscopy in the AM. His tachycardia resolved to HR 77 with 119/56 prior to transfer. . On arrival to the MICU, inital vitals were: HR 77 BP 135/77 16 97% on RA . He is complaining of abdominal pain that he says is severe. The pain started in the ED, is epigastric, associated with nausea, not associated with SOB or CP. . Past Medical History: Hepatitis C cirrhosis -s/p interferon with SVR GIII esophageal varices GERD HTN Diverticulosis ([12/2163]) RBBB Hiatal Hernia Esophogeal Spasm eczema herpes simplex s/p lipoma removal MRSA buttock abscess s/p tonsillectomy s/p lap CCY ([2164-1-16]) PML fissure s/p botox and perianal dermatitis Social History: Used to smoke 1-1.5 ppd x 30 years, now just smokes cigars on occassion. Former EtOH user 20 years ago. Former IVDU (heroin) 18 yrs ago. Currently going through a divorce. He is sexually active with multiple female partners, always uses condoms except with his wife. Family History: History of CVA in his family. Mother being treated for stomach cancer. Physical Exam: ADMISSION EXAM: Vitals: HR 77 BP 135/77 16 97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, minimally-tender in RUQ, minimally-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: ADMISSION LABS: [2166-3-20] 06:45PM WBC-8.3 RBC-3.98* HGB-12.0# HCT-37.3 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.5 [2166-3-20] 06:45PM NEUTS-76.2* LYMPHS-17.8* MONOS-4.1 EOS-1.6 BASOS-0.2 [2166-3-20] 06:45PM PLT COUNT-180 [2166-3-20] 06:45PM GLUCOSE-169* UREA N-19 CREAT-0.6 SODIUM-140 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-12 [2166-3-20] 06:45PM ALT(SGPT)-56* AST(SGOT)-58* ALK PHOS-63 AMYLASE-114* TOT BILI-0.8 [2166-3-20] 06:45PM LIPASE-108* [2166-3-20] 06:45PM ALBUMIN-3.3* [2166-3-20] 06:45PM PT-14.1* PTT-27.7 INR(PT)-1.3* . DISCHARGE LABS: [2166-3-24] 05:30AM BLOOD WBC-7.3 RBC-3.32* Hgb-9.9* Hct-30.6* MCV-92 MCH-30.0 MCHC-32.5 RDW-14.8 Plt Ct-152 [2166-3-24] 05:30AM BLOOD PT-12.0 PTT-29.6 INR(PT)-1.1 [2166-3-24] 05:30AM BLOOD Glucose-105* UreaN-16 Creat-1.0 Na-136 K-3.5 Cl-102 HCO3-27 AnGap-11 [2166-3-24] 05:30AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.0 . IMAGING: [2166-3-21] EGD: Findings: Esophagus: Protruding Lesions 4 cords of grade III varices were seen in the lower third of the esophagus. There were stigmata of recent bleeding. 3 bands were successfully placed. Stomach: Contents: Clotted blood was seen in the fundus. There was no gastric varix underneath. Duodenum: Normal duodenum. Impression: Varices at the lower third of the esophagus (ligation) Blood in the fundus Otherwise normal EGD to second part of the duodenum . [2166-3-21] Hepatic Angiogram by IR: 1. High flow arterioportal fistula supplied by the right hepatic arteryinvolving the border zone parenchyma between the segments VII and VIII of the right hepatic lobe. 2. Successful deployment of a 6-mm Amplatzer endovascular plug effectively shutting down the flow through the arterioportal fistula. 3. Variant early origin of the right hepatic lobar artery directly from the celiac trunk. 4. Successful deployment of 6 French Angio-Seal closure device in the right common femoral artery. Brief Hospital Course: 51 yo M with HCV, s/p interferon/ribavirin with sustained virologic response, cirrhosis, liver AVM, GIII esophageal varices presents with one day of melena and hematemesis. . . ACTIVE ISSUES: # UGIB: Likely UGIB given hematemesis and known varices. He underwent EGD which showed four cords of grade 3 varices with stigmata of recent bleeding, but no active bleeding. Three bands were applied. Hct was 37.3 in ED, baseline low 40s. Was tachycardic in ED but resolved with 1 L IVF. He was placed on an octreotide drip and a pantoprazole drip at the time of admission. His HCTs were trended and stabilized. He was then transferred to the floor, where his Hct remained stable. Hct at the time of discharge was 20.6. Patient was started on nadolol 40 mg daily to reduce risk of further variceal bleeding. He tolerated this well. Additionally, he was treated with 5 days of ceftriaxone IV to prevent development of SBP. . # Liver AVM: Patient was scheduled for planned ablation during the time period of this hospitalization. He did receive this procedure on [2166-3-21] with successful closure of arterioportal fistula by amplatzer plug deployment by interventional radiology. This procedure was uncomplicated. . # Abdominal pain: Patient developed epigastric pain on the first night of this admission. Etiology of epigastric pain is unclear; may be related to esophageal spasm (as patient believes) vs. banding of varices vs. coiling of AVM vs. gastropathy. No noted gastritis on EGD Differential diagnosis also includes pancreatitis, but amylase only mildly elevated (108). Pain was well-controlled with morphine IV initially, then oxycodone PO. Prior to discharge, he was not requiring any PRN pain meds. . . CHRONIC ISSUES: # HCV Cirrhosis: HCV treated successfully with ribivarin and interferon in [2163]-[2164] with sustained response. HCV viral load undetectable in 3/[2165]. Cirrhosis complicated by portal hypertension and GIII varices which may be exacerbated by AVM. MELD 9 on admission. Received thourough imaging last admission including RUQ US, Liver MRI, EGD and [Last Name (un) ]. This issue was stable throughout his admission. . # Herpes simplex: History of genital herpes. No noted lesions at present. Patient continued valacyclovir 1000 mg PO daily. . . TRANSITIONAL ISSUES: # Patient should be scheduled for follow-up EGD to ensure improvement of varices. # CODE: Full (confirmed) # HCP: wife, [Name (NI) ] - [Telephone/Fax (3) 13135] Medications on Admission: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO HS (at bedtime). 3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. cholestyramine (with sugar) 4 gram Packet Sig: One (1) PO once a day. 5. Zofran 4-8 mg po q8h prn nausea/vomiting(called in) disp 30 Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO at bedtime. 3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. cholestyramine (bulk) Powder Sig: Four (4) g Miscellaneous once a day. 5. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. 6. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Esophageal variceal bleed . Secondary diagnosis: Liver AVM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 5730], It was pleasure to participate in your care here at [Hospital1 771]! You were admitted with an upper gastrointestinal bleed, from esophageal varices, which were banded in your upper endoscopy procedure. Your blood count stabilized after this procedure, and you did not require any blood transfusions. While you were here, you also had the arterial-venous malformation in your liver coiled by Interventional Radiology. This procedure went very well. Please note, the following changes have been made to your medications: - START nadolol 40 mg by mouth daily Resume all of your other outpatient medications. It is important that you keep your follow-up appointments, as listed below. Wishing you all the best! Followup Instructions: Department: GASTROENTEROLOGY When: WEDNESDAY [2166-3-26] at 9:00 AM With: [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: [Hospital3 249] When: WEDNESDAY [2166-4-2] at 9:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: LIVER CENTER When: THURSDAY [2166-4-3] at 2:20 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: TUESDAY [2166-4-15] at 7:30 AM [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 10438]	[ "553.3", "789.06", "456.20", "070.54", "289.51", "530.81", "401.9", "054.10", "573.8", "416.8", "692.9", "572.3" ]	icd9cm	[ [ [] ] ]	[ "42.33", "39.79" ]	icd9pcs	[ [ [] ] ]	8433, 8439	4910, 5087	326, 331	8561, 8561	2934, 2934	9488, 10726	2309, 2381		7870, 8410		8460, 8460		7416, 7847			8712, 9465				3536, 4887						2396, 2915																					7220, 7390									266, 288		5102, 6621														359, 1678			8528, 8540			2950, 3520	8479, 8507			8576, 8688			6637, 7199					1700, 2007	2023, 2293
25,590	157,846	1029	Discharge summary	report	Admission Date: [2137-6-19] Discharge Date: [2137-6-27] Date of Birth: [2055-12-6] Sex: F Service: MEDICINE Allergies: Ibuprofen Attending:[First Name3 (LF) 2485] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Intubation [2137-6-21]. Extubation [2137-6-23]. History of Present Illness: 81 y/o F with history of idiopathic pulmonary fibrosis diagnosed by lung (on home O2 3 L with rest 6L with ambulation), severe pHTN, AFib who presented to OSH on [6-18] with worsening SOB x 1 week. Patient is s/p 2 steroid pulses for IPF; the most recent steroid pulse was tapered off last week. In the ED of the OSH, she was febrile to 103, tachpneic to the high 30s to 40s, and tachycardic. The patient underwent a CTA of the chest that revealed no PE, moderate b/l pleural effusion, ? PNA. She was placed on 100% NRB mask and transferred to OSH ICU where an ABG showed pH 7.35, pCO2 of 41, pO2 of 49. She was started on BiPAP, ABG showed pH 7.46, PC02 30 P02 56 on 70% FiO2. She was also given 20 mg IV Lasix bolus at this time and high-dose Solumedrol 80 mg IV q8. EKG at OSH also showed ST depression in the lateral leads, and patient's Troponins bumped from .39 to 7. Heparin drip was immediately started. By this morning ST depressions in these were less, but still present. She had an echo earlier today which showed LVH and an EF of 60%, with RVSP of 69. She was started on Levofloxacin/Ceftriaxone for presumed PNA. She was also found to have guiac positive stool and recieved 2 units of blood earlier this morning (Hct 25.4 to 35.2 post transfusion). Prior to transfer, patient was stable off BiPAP with pH 7.44, PCO2 22.5, and PO2 130. She was transferred to [Hospital1 18] because she is closely followed by Dr. [Last Name (STitle) 6786]. On arrival to the floor, patient was stable, T 96.8 HR 92 BP 117/52 RR 16 O2 95% 3 L NC. She arrived on a heparin drip and had no complaints of chest pain or SOB. Past Medical History: IPF on home O2 (3-6L) Pulmonary hypertension Atrial fibrillation on rate control Hypertension Hyperlipidemia PVD s/p aortobifem bypass in [2126] with R femoral thrombectomy and L femoral thromboendarterectomy GERD CAD, but no prior MI or cardiac catheterization. Social History: Lives at home with her husband. [Name (NI) ] 6 [Name2 (NI) 6694]. Remote smoking history of less than 15 pack years; quit 35 years ago. Denies EtOH. Retired floral designer with no industrial exposure. Family History: Non-contributory Physical Exam: Vitals: T 96.8 HR 92 BP 117/52 RR 16 O2 95% 3 L NCGeneral: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 8 cm, no LAD Lungs: Inspiratory velcro-like Crackles 2/3 up b/l CV: Regular rate and rhythm, III/VI holosystolic murmur loudest at RUSB 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: [2137-6-21] Echo: IMPRESSION: Moderate aortic valve stenosis. Mild regional left ventricular systolic dysfunction c/w CAD. Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [2136-1-4], the severity of aortic stenosis has progressed and mild regional left ventricular systolic dysfunction is now identifeid. The severity of mitral regurgitation has also increased. CLINICAL IMPLICATIONS: The patient has moderate aortic stenosis. Based on [2132] ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, a follow-up echocardiogram is suggested in [12-15] years. Based on [2133] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Mrs. [Known lastname 6692] was transfered from outside hospital for dyspnea x 1 week. # Respiratory Failure: Pt with underlying end stage IPF on home oxygen admitted to [Hospital Unit Name 153] for respiratory distress. Pt developed worsening hypoxic resipratory distress, hemoptysis, requiring intubation on [2137-6-21]. Pt had sputum cultures, viral cultures, BAL for thorough workup of pulmonary process. She was put on broad spectrum antibiotics and steroids. BAL showed alveolar hemorrhage. Pt gradually improved on pressure support ventilation and was extubated on [2137-6-23] after a successful spontaneous breathing trial on [4-17] and a RISP score 33. She will need to complete a 14 day course of antibiotics with Ceftriaxone and Levofloxacin (6 days post discharge). Hemorrhage most likely [1-15] anticoagulation during treatment of NSTEMI (see below). She was continued on steroids 60 mg daily, subsequently decreased to 50 mg daily. She will need to continue prednisone 50 mg daily for 1 week then decrease to 40 mg daily until she follows up with her outpatient pulmonologist, appointment has been arranged and is in discharge instructions. #Atrial Fibrillation: Pt had atrial fibrillation s/p intubation. She was given diltiazem and digitalis and was rate controlled. Anticoagulation was discontinued secondary to anemia and hemoptysis. diltiazem and digitalis were discontinued and patient was then restarted on metoprolol, titrated to a heart rate <100 for rate control. # NSTEMI Patient had ST depressions in anterior lateral leads and troponin spike to 7.56, likely NSTEMI. Initially started on heparin and plavix but subsequently had hemoptysis. Cardiology was consulted and did not catheterize given patient's instability and inability to go on anticoagulation due to hemoptysis and GI bleed. Echo showed moderate LV systolic dysfunction and worsening AS. Plan was to continue ASA, statins, hold anticoagulation. Cardiac enzymes trended down. Restarting plavix should be assessed as an outpatient. # Guiac positive stool and anemia. Likely due to heparin anticoagultion. Tranfused PRBCS for HCT<30. Hct stable at about 40 on transfer. Patient may benefit from outpatient gastroenterolgy evaluation. Medications on Admission: Prilosec 40 [Hospital1 ] Novolog SS q6 Solumedrol IV q8 Ceftriaxone 1 g IV daily Levaquin 750 IV Dig .125 qd Verapamil 40 TID Asp 325 Ativan PRN Plavix 75 qd Hep IV drip Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours) for 6 days: Take 3 tablets daily for six days. . 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): sliding scale: 151-200 give 2U, 201-250 give 4U, 251-300 give 6U, 301-350 give 8U, 351 to 400 give 10U. >400, notify MD. . 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [12-15] Inhalation Q6H (every 6 hours) as needed for wheezing, long expiratory phase. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous membrane [Hospital1 ] (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 9. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: Take five tabs or 50mg PO daily for one week (through [2137-7-2]) and then take 4 tabs or 40mg PO daily unitl you see your pulmonologist. . 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Tablet(s) 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia . 14. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 6 days: Please administer 1g iv q24hrs for six days (through [2137-7-3]). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: 1. Idiopathic Pulmonary Fibrosis 2. Pneumonia--likely community acquired 3. Pulmonary edema 4. Pulmonary hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [Known lastname 6692]: It was a pleasure to take care of you at [Hospital1 827]. You were transferred here because your respiratory status was deteriorating. We found that your idiopathic pulmonary fibrosis was made worse by infection in your lungs (pneumonia), fluid in your lungs, and bleeding in your lungs. You were given intravenous antibiotics to treat the infection, and you were given water pills to remove some of the fluid from your lungs. After about five days of these treatments, your breathing and your cough began to improve. You were able to get out of bed and sit in a chair comfortably. You are ready to be transferred to your extended care facility with continued care. Followup Instructions: You have the following follow-up appointments at [Hospital1 18]: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2137-8-12] 12:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2137-8-12] 1:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2137-8-12] 1:00 Completed by:[2137-6-27]	[ "486", "427.31", "414.01", "E934.2", "V58.66", "V46.2", "V58.65", "300.00", "416.8", "428.0", "272.4", "515", "496", "530.81", "786.3", "410.71", "578.9", "401.9", "428.33", "285.1", "518.81", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.91", "33.24", "96.04" ]	icd9pcs	[ [ [] ] ]	8259, 8331	4033, 6289	278, 335	8491, 8491	3059, 3552	9404, 9934	2527, 2545		6514, 8236		8352, 8470		6315, 6491			8667, 9381										2560, 3040								3575, 4010																						231, 240																363, 1993										8506, 8643								2015, 2283	2299, 2511
1,675	185,767	474	Discharge summary	report	Admission Date: [2155-7-4] Discharge Date: [2155-7-8] Date of Birth: [2082-11-22] Sex: M Service: Blue Surgery HISTORY OF PRESENT ILLNESS: Briefly, this is a 72-year-old male who is status post repair of a left inguinal hernia on [2155-6-26], who had been discharged home later in the day, who had been feeling well until one day prior to admission when he began to have fevers up to 101 and also had some chest pressure. He saw Dr. [Last Name (STitle) 957] in the office, who was concerned and sent the patient to the Emergency Room for evaluation. He denies chest pain, shortness of breath, nausea, vomiting, diarrhea, or any other symptoms. PAST MEDICAL HISTORY: 1. Prostate cancer status post prostatectomy. 2. Hypertension. ALLERGIES: Erythromycin. MEDICATIONS: 1. Triamcinolone. 2. Lipitor. 3. Zestril. 4. Terazosin. 5. Allopurinol. SOCIAL HISTORY: He does not smoke and he does not drink. PHYSICAL EXAMINATION: On physical exam, he is afebrile with vital signs stable. He was in no apparent distress. His lungs were clear to auscultation bilaterally. His heart was regular rate, no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended with normoactive bowel sounds. Incision was clean, dry, and intact. LABORATORIES: His white count was 4.9, hematocrit of 43.7, platelet count of 182. Urinalysis was negative. Chemistries: Sodium was 134, potassium 3.9, chloride of 102, bicarb of 26, BUN 18, creatinine of 1.3, blood sugar of 108, CK of 72, troponin was less than 0.3. He had a CTA to rule out pulmonary embolus which was negative and a chest x-ray which showed no pneumonia and only some mild atelectasis. Patient was admitted to the Intensive Care Unit for monitoring and planned evaluation. Upon admission to the Emergency Room, he had a temperature spike to 104 with fevers and chills. He had blood cultures done at that time, which ultimately grew nothing. He was started on broad-spectrum antibiotics, Vancomycin, gentamicin, and Flagyl and was cultured. On hospital day #2, he was changed to Vancomycin, levo, and Flagyl, and he continued to improve. His white count was normal throughout his entire hospital admission. His temperature max on hospital day #2 was 104.5. His primary care doctor also saw him and suggested a lower extremity ultrasound to rule out DVT which was done and was negative. His platelet count began to drop on [7-6]. His Heparin was stopped and a HIT antibody was sent, which is pending at the time of discharge. .............. was consulted for evaluation of mastoids. A head CT scan was done on [2155-7-6] which showed fluid in his left mastoid air cell. It was felt that this was unlikely cause of his fevers and is instructed to followup the [Hospital ] Clinic if necessary. Patient was transferred to the floor on [2155-7-6], and was stable. On hospital day #4, his temperature which had been the highest at 104.5 was down to 100.4, and he continued to do well. He was allowed to eat a regular diet. His platelet count dropped again, and his Vancomycin was stopped. On [2155-7-8], his platelet count and white blood cell count had elevated after his Heparin was stopped. His HIT was still pending at that time, and the Vancomycin had been stopped for a fear of his pancytopenia. On hospital day #5, he was afebrile now for 72 hours and it was felt safe that he could be discharged home. He is continued on levo/Flagyl for seven more days, and instructed to followup with Dr. [Last Name (STitle) 957] in [2-6] weeks, as well as follow up with his primary care physician. PRESCRIPTION MEDICATIONS: 1. Protonix 40 mg po q day. 2. Theophylline sustained release 200 mg po q day. 3. Levofloxacin 500 mg po q day. 4. Flagyl 500 mg po tid. DISCHARGE INSTRUCTIONS: Instructed to continue all of his home medications as normal, and patient was discharged home in stable condition on [2155-7-8]. FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr. [Last Name (STitle) 957] as well as his primary care doctor. DISCHARGE DIAGNOSES: 1. Fever now on antibiotics levofloxacin and Flagyl. 2. Pancytopenia now off Heparin and resolving. 3. Prostate cancer status post prostatectomy. 4. Hypertension. 5. Left inguinal hernia status post left inguinal hernia repair. CONDITION ON DISCHARGE: Stable. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4007] Dictated By:[First Name (STitle) 4008] MEDQUIST36 D: [2155-7-8] 08:57 T: [2155-7-8] 08:59 JOB#: [Job Number 4009]	[ "998.89", "780.6", "284.8", "401.9", "518.0", "V10.46", "E878.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								4113, 4343								3835, 3969																											970, 3810																													173, 689														3994, 4092				711, 888	905, 947	4368, 4611
53,462	189,566	2573	Discharge summary	report	Admission Date: [2169-12-13] Discharge Date: [2169-12-15] Date of Birth: [2103-1-31] Sex: M Service: NEUROSURGERY Allergies: erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) / Fosphenytoin Attending:[First Name3 (LF) 1835] Chief Complaint: seizure Major Surgical or Invasive Procedure: [2169-12-13]: Left frontal craniotomy and resection of lesion History of Present Illness: 66-year-old gentleman who was recently admitted to the [Hospital1 13010] Center for intracranial hemorrhage. Workup revealed a left-sided premotor lesion concerning for metastatic disease in the setting of melanoma. He now electively presents for craniotomy and resection of this lesion. Past Medical History: 1. CAD s/p CABG in [2153] and stent placement 2. HTN 3. HL 4. DM2 Social History: Lives in [Location 13011], MA with wife and [Name2 (NI) ] [Name (NI) ]. He works in sales (mattress production equipment). Recently inducted into [Location (un) 13011] [Doctor Last Name ] of Fame. Quit smoking four years ago. +rare EtOH use. Exercises qDay prior to going to work in AM. Family History: Mother with dementia, brother with [Name2 (NI) ]. Physical Exam: PHYSICAL EXAM UPON DISCHARGE: non focal. dsg C/D/I, dissolvable sutures Pertinent Results: [2169-12-13] MRI Brain- IMPRESSION: Subacute left frontal hematoma with or without unerlying lesion is redemonstrated for surgical planning. [2169-12-13] CT Head- IMPRESSION: Post-surgical changes related to left frontal craniotomy with associated small-to-moderate pneumocephalus. Multiple locules of gas and ill-defined areas of hyperattenuation within the resection bed likely represent post-procedural hemorrhage and edema. No new focus of acute intracranial hemorrhage is noted. [2169-12-14] MRI Brain- IMPRESSION: Status post left craniectomy with resection of an ovoid posterior left frontal hematoma with or without underlying lesion. Residual linear T1-hyperintense area in the surgical cavity could represent residual hematoma and/or residual neoplasm. Recommend attention on followup. Brief Hospital Course: Pt was electively admitted and underwent a left frontal craniotomy and mass resection. Surgery was without complication and he tolerated it well. He was extubated and transferred to the SICU. Post op head CT revealed no hemorrhage or stroke. He remained neurologically stable overnight. On POD#1 he was cleared for transfer to the floor. His decadron was weaned and he underwent an MRI. Neuro and Rad Onc were consulted for assistance with further treatment planning. On POD#2 he was again neurologically stable. His pain was controlled, he was ambulating independently, tolerating a PO diet and voiding without problem. His decadron was tapered and he was cleared for discharge home. His family and himself were in agreement with this plan. Medications on Admission: alprazolam dexamethasone glipizide Keppra lisinopril lorazepam metformin metoprolol tartrate nitroglycerin sertraline simvastatin Cialis Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: You may start 81mg aspirin on [12-16]. You may resume 325mg aspirin on [12-18]. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:60 Tablet(s) Refills:0 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): continue while on steroids. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. glipizide 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 14. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 5 days: 4mg Q8h [12-15], 3mg Q8h 1/7,2mg Q8h 1/8,1mg Q8h 1/9,1mg Q12 [12-19] then d/c. Disp:qs Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left frontal brain lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? You have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ?????? You have an appointment in the Brain [Hospital 341] Clinic on [2169-12-26] at 9:30AM. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. Completed by:[2169-12-15]	[ "V10.82", "414.00", "250.00", "V15.82", "401.9", "V45.81", "780.39", "729.89", "V45.82", "272.0", "198.3" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]	4565, 4571	2169, 2912	343, 411	4640, 4640	1334, 2146	6234, 6678	1172, 1227		3101, 4542		4592, 4619		2938, 3078			4790, 6211										1242, 1242																														296, 305													1272, 1315			439, 733										4655, 4766								755, 831	847, 1156
20,204	185,737	1216+1217	Discharge summary	report+report	Admission Date: [2168-5-27] Discharge Date: [2168-6-20] Date of Birth: [2087-5-5] Sex: M Service:VASCULAR ADMISSION DIAGNOSIS: 1. Expanding left hypogastric aneurysm. 2. Chronic obstructive pulmonary disease. 3. Coronary artery disease with congestive heart failure. 4. Bacteremia PROCEDURE PERFORMED: Left hypogastric open aneurysmorrhaphy with cystoscopy and ureteroureterostomy with ureteral stent placement. HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old man with a previously discovered left-sided hypogastric aneurysm with an endovascular repair with stent graft and outflow vessel coiling in [2167-12-13]. He was admitted for symptoms of fever and tenderness of the abdomen over the area of the aneurysm. During the course of his hospitalization, he became febrile, and a CAT scan showed an increase in the already very large aneurysm causing GI symptoms including hematochezia, melena and guaiac-positive stools. Due to the increasing size of the aneurysm and the possibility for infection and rupture, he was taken for aneurysm repair. HOSPITAL COURSE: The patient was taken to the operating room where he remained stable and successfully underwent a hypogastric aneurysm repair. The ureter was encased in the aneurysm sac and had to be transected to allow access to the deep feeding vessels. It was reconstructed over a stent. There was no evidence of bowel fistula or infection of the aneurysm itself. Postoperatively he was taken to the intensive care unit where he remained intubated for several days. During this time, he developed an episode of acute renal failure. He slowly had resolution of his renal function to a baseline [Known lastname ] with a creatinine of 1.6. He was eventually extubated but continued to have high oxygen demands. He subsequently taken to the VICU where continued respiratory support measures were taken. He continued to have respiratory difficulty and was dependent upon supplemental oxygen via shovel mask; however, his oxygen requirements continued to decrease with aggressive chest therapy, deep breathing exercised, incentive spirometry and immobilization with physical therapy. On the morning of postoperative day #21, the patient was in the chair and asked to come back with the help of the nursing staff and physical therapy. Upon moving back to the bed, he suffered an acute respiratory arrest and was found in PEA and quickly became asystolic. Following several minutes of ACLS resuscitative efforts including 3 rounds of epinephrine, his pulse was regained. He was intubated emergently at this time and was taken immediately to the intensive care unit. It was thought that the most probable diagnosis at this time was pulmonary embolism; however, given his previous history of renal insufficiency, the decision was made not to proceed with CT pulmonary angiogram but rather to empirically treat pulmonary embolism with high-dose heparin, which was initiated at the time of the code.It should be noted that throughout his whole course he was on 5000u SQ heparin TID. A transesophageal echocardiogram at this time showed dilated left ventricle and inferior vena cava with a left ventricular ejection fraction from 30%-50%. This was in contrast with a preoperative study showing an ejection fraction of 15%. He was extubated following 2 days of ICU care and was able to maintain his airway for roughly 12 hours; however, after this time, he was showing significant signs of respiratory distress and tiring and was electively intubated.In addition since he had a limited UE DVT at the brachial vein he was continued on heparin. Following the initial code event, a stat CT of his head was also obtained to evaluate his neurologic status; however, this showed no acute abnormalities. At the time of discharge, the patient was critically ill but stable. DISCHARGE REVIEW OF SYSTEMS: Neurologic: He is found to be neurologically intact and conversant at the time of short extubation. Currently his is moving all 4 extremities to command and opening his eyes. He was lightly sedated on propofol and Ativan. Cardiovascular: The patient has no acute cardiovascular issues. He is maintaining his outflow pressures and the range of 95-110 mmHg. He is not requiring any vasoactive medication. Pulmonary: He is orally intubated and seemed to be 40%, rate of 20, with a 12 of PEEP. He has been maintaining good saturations of 95%-100%. GI: A Dobbhoff feeding tube was placed, and the patient is tolerating tube feeds to goal. He is receiving Protonix prophylaxis. GU: The patient appears to have suffered another renal insult with creatinine [Known lastname 7681] climbing to 2.6; however, he continues to make urine at the rate of 20-25 cc/hr. The plan for this will be to followup closely. FEN: He has no electrolyte abnormalities. Heme: He is stable on heparin drip at 400 U/hr for goals of PTT between 60 and 80. The plan will be start Coumadin for 6-month anticoagulation treatment. Infectious disease: He continues on vancomycin which was begun on [2168-5-27]. He will continue this for a total of 6 weeks for vancomycin sensitive enterococcus. DISPOSITION: The patient will be discharged to the [Hospital6 1129] at the request of his daughter for further pulmonary care. DISCHARGE MEDICATIONS: Furosemide 40 mg IV b.i.d., heparin IV infusion, Protonix 40 mg IV p.o. daily, metoprolol 12.5 mg p.o. b.i.d., lorazepam 0.5-2.0 mg IV q.4 hours for agitation while intubated, propofol infusion 5-20 mg/kg/min titrated to sedation, albuterol/Atrovent nebs q.6 hours p.r.n., aspirin 325 mg p.o. daily, amiodarone 200 mg p.o. b.i.d. for atrial fibrillation, erythropoietin 4000 units subcu every Monday, Wednesday and Friday, Cipro 400 mg p.o. daily. DISCHARGE PLAN: The patient will be discharged to the [Hospital6 1129] for ongoing care. He will followup with Dr. [Last Name (STitle) ] as an outpatient at which time as that is feasible. All of his acute surgical issues are now dealt with. Please note, should there be any questions about the ongoing care of this patient, they need to be directed to the vascular fellow, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. She may be reached by cellular phone at area code [Telephone/Fax (1) 7682]. He should continue to be on ABX for at least 6 weeks post surgery and will need f/u on his ureteral stent. He can contact [Name (NI) 7683] office for any surgical f/u and Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] offfice for urologic issues. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] Dictated By:[Last Name (NamePattern1) 7684] MEDQUIST36 D: [2168-6-20] 18:39:24 T: [2168-6-20] 19:39:58 Job#: [Job Number 7685] Unit No: [Numeric Identifier 7686] Admission Date: Discharge Date: Date of Birth: Sex: Service: There is a previously dictated stat discharge summary for this patient. If that could please be faxed to the [Hospital6 1129] to the medical intensive care unit. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] Dictated By:[Last Name (NamePattern1) 7684] MEDQUIST36 D: [2168-6-20] 19:35:15 T: [2168-6-20] 20:13:58 Job#: [Job Number 7687]	[ "518.81", "591", "287.5", "596.8", "518.5", "V12.01", "788.20", "038.0", "496", "584.5", "428.0", "593.89", "415.19", "427.31", "578.9", "996.74", "442.84", "585.9", "453.8", "593.5" ]	icd9cm	[ [ [] ] ]	[ "59.8", "56.41", "88.72", "96.72", "99.60", "45.23", "38.93", "96.6", "99.04", "00.14", "57.32", "96.04", "39.52" ]	icd9pcs	[ [ [] ] ]									5325, 5774					1120, 3880																														159, 451					3900, 5301																							480, 1102																5791, 7399
7,621	159,263	7884	Discharge summary	report	Admission Date: [2150-10-29] Discharge Date: [2150-11-19] Date of Birth: [2082-2-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3624] Chief Complaint: colitis Major Surgical or Invasive Procedure: placement of PICC reinitiation of dialysis History of Present Illness: 68yo man with history of type II diabetes mellitus, s/p cadaveric kidney transplant in [12/2149] with complicated surgical course. Also with CAD, PVD s/p right BKA, and chronic sacral left heel ulcers. Patient presented from rehab with C.diff colitis, recurrent diarrhea. He had been hemodialyzed two times at rehabilitation. On presentation he complained of abdominal, chest, and leg pain. He denies shortness of breath. Past Medical History: PAST MEDICAL HISTORY: 1.Diabetes mellitus Type 2 times for 32 years associated with retinopathy, nephropathy and neuropathy. 2.end-stage renal disease s/p CKT [2150-1-15] with LUE fistula 3. hypertension, 4. CAD s/p CABG '[43] 5. PVD s/p R femoral distal bypass and RBKA hypercholesterolemia 6. R hip ORIF . PAST SURGICAL HISTORY: 1.Status post right open reduction, internal fixation hip [2150-2-13]. 2.CRT [2150-1-15], evacuation of the hematoma [2150-1-16], nephrostomy tube [2150-2-6] for urinoma 3. status post coronary artery bypass graft in [2143].\ 4. Right femoral-distal bypass 5. status post right below the knee amputation. 6. Left upper extremity atrioventricular fistula. Social History: Significant for distant use of tobacco. The patient quit in [2143]. There is no history of alcohol use or drug use. His wife has [Name2 (NI) 500] cancer. He has six children, all adults with the eldest son with a history of diabetes. He has a supportive family in the area. Currently lives alone at home with daughters visiting frequently. Family History: Noncontributory. Pertinent Results: [2150-11-11] 05:50AM BLOOD WBC-10.4 RBC-3.24* Hgb-9.8* Hct-28.6* MCV-88 MCH-30.3 MCHC-34.3 RDW-17.7* Plt Ct-361 [2150-11-10] 02:09AM BLOOD WBC-9.8 RBC-3.64* Hgb-10.1* Hct-31.8* MCV-87 MCH-27.7 MCHC-31.7 RDW-17.1* Plt Ct-333 [2150-11-9] 09:54PM BLOOD WBC-12.1* RBC-3.48* Hgb-10.5* Hct-30.3* MCV-87 MCH-30.1 MCHC-34.5 RDW-17.0* Plt Ct-348 [2150-11-9] 05:09AM BLOOD WBC-12.2* RBC-3.63* Hgb-10.0* Hct-31.8* MCV-88 MCH-27.7 MCHC-31.6 RDW-16.5* Plt Ct-364 [2150-11-7] 06:20AM BLOOD WBC-24.3* RBC-3.35* Hgb-9.5* Hct-29.7* MCV-89 MCH-28.4 MCHC-32.0 RDW-16.4* Plt Ct-511* [2150-11-6] 11:30AM BLOOD WBC-25.3* RBC-3.36* Hgb-9.5* Hct-29.8* MCV-89 MCH-28.2 MCHC-31.7 RDW-15.9* Plt Ct-497* [2150-11-4] 05:24AM BLOOD WBC-26.9# RBC-3.69 Hgb-10.3* Hct-32.2* MCV-87 MCH-27.8 MCHC-31.8 RDW-15.7* Plt Ct-479* [2150-10-31] 03:50PM BLOOD WBC-9.7 RBC-3.92* Hgb-11.1* Hct-34.5* MCV-88 MCH-28.4 MCHC-32.2 RDW-15.1 Plt Ct-272 [2150-10-29] 07:55PM BLOOD WBC-13.0# RBC-3.46 Hgb-9.9* Hct-30.3* MCV-88 MCH-28.7 MCHC-32.7 RDW-15.5 Plt Ct-225 [2150-11-6] 11:30AM BLOOD Neuts-87* Bands-1 Lymphs-6* Monos-4 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [2150-11-6] 04:14AM BLOOD Neuts-71.1* Bands-0 Lymphs-11.6* Monos-16.0* Eos-0.6 Baso-0.7 [2150-11-6] 11:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Burr-1+ [2150-11-11] 05:50AM BLOOD Plt Ct-361 [2150-11-11] 05:50AM BLOOD PT-14.8* PTT-32.1 INR(PT)-1.5 [2150-11-9] 05:09AM BLOOD Plt Ct-364 [2150-11-8] 05:39AM BLOOD Plt Ct-447* [2150-11-9] 09:54PM BLOOD PT-15.7* PTT-33.3 INR(PT)-1.7 [2150-11-6] 04:14AM BLOOD PT-16.8* PTT-37.1* INR(PT)-1.9 [2150-11-5] 03:23AM BLOOD Plt Ct-492* [2150-11-5] 03:23AM BLOOD PT-17.3* PTT-36.0* INR(PT)-2.1 [2150-11-4] 05:24AM BLOOD Plt Ct-479* [2150-11-2] 05:20AM BLOOD PT-12.7 PTT-24.6 INR(PT)-1.1 [2150-10-29] 07:55PM BLOOD PT-14.7* PTT-28.8 INR(PT)-1.5 [2150-11-11] 05:50AM BLOOD Glucose-111* UreaN-79* Creat-4.4* Na-137 K-5.1 Cl-107 HCO3-21* AnGap-14 [2150-11-10] 04:26PM BLOOD Glucose-191* UreaN-74* Creat-4.2* Na-136 K-4.2 Cl-107 HCO3-20* AnGap-13 [2150-11-10] 02:09AM BLOOD Glucose-232* UreaN-64* Creat-4.3* Na-139 K-4.4 Cl-109* HCO3-19* AnGap-15 [2150-11-9] 09:54PM BLOOD Glucose-222* UreaN-64* Creat-4.2* Na-140 K-4.4 Cl-110* HCO3-19* AnGap-15 [2150-11-7] 06:20AM BLOOD Glucose-175* UreaN-67* Creat-5.7# Na-144 K-5.5 Cl-109* HCO3-8* AnGap-33* [2150-11-6] 04:14AM BLOOD Glucose-63* UreaN-54* Creat-4.6* Na-141 K-4.4 Cl-109* HCO3-17* AnGap-19 [2150-11-3] 05:30AM BLOOD Glucose-72 UreaN-41* Creat-2.6* Na-139 K-4.2 Cl-104 HCO3-22 AnGap-17 [2150-11-1] 06:15AM BLOOD Glucose-47* UreaN-37* Creat-2.5* Na-140 K-3.9 Cl-103 HCO3-24 AnGap-17 [2150-10-29] 07:55PM BLOOD Glucose-302* UreaN-27* Creat-2.6* Na-138 K-3.5 Cl-101 HCO3-26 AnGap-15 [2150-11-10] 06:51AM BLOOD CK(CPK)-238* [2150-11-9] 09:54PM BLOOD CK(CPK)-329* [2150-11-7] 06:20AM BLOOD ALT-6 AST-20 AlkPhos-247* TotBili-0.5 [2150-11-5] 05:48PM BLOOD CK(CPK)-75 [2150-11-5] 03:23AM BLOOD CK(CPK)-61 [2150-11-11] 05:50AM BLOOD CK-MB-5 cTropnT-0.19* [2150-11-10] 04:26PM BLOOD CK-MB-5 cTropnT-0.16* [2150-11-10] 06:51AM BLOOD CK-MB-6 cTropnT-0.17* [2150-11-5] 03:23AM BLOOD CK-MB-NotDone cTropnT-0.34* [2150-11-3] 05:30AM BLOOD CK-MB-2 cTropnT-0.27* [2150-11-8] 05:39AM BLOOD Triglyc-243* [2150-11-5] 05:48PM BLOOD Triglyc-182* HDL-20 CHOL/HD-6.1 LDLcalc-65 [2150-11-11] 05:50AM BLOOD FK506-9.7 [2150-11-10] 06:51AM BLOOD FK506-5.6 [2150-11-9] 05:09AM BLOOD FK506-8.2 [2150-11-8] 05:39AM BLOOD FK506-7.3 [2150-11-6] 07:03AM BLOOD FK506-17.9 [2150-11-10] 09:40AM BLOOD freeCa-1.01* Brief Hospital Course: 68yo man with history of type II diabetes mellitus, s/p cadaveric kidney transplant in [12/2149] with complicated surgical course. Also with CAD, PVD s/p right BKA, and chronic sacral left heel ulcers. Patient presented from rehab with C.diff colitis, recurrent diarrhea. He was admitted to the transplant surgery service and treated with po vancomycin and metronidazole. He also developed a UTI, treated with Zosyn. Infectious disease and Renal teams followed. He went into unstable Afib, cardioverted with amiodarone, and was admitted to the SICU where he remained for a two days. Labs showed that he had sustained an NSTEMI. He was then transferred to the medical service. Hospital course was complicated by mental status changes secondary to uremia, requiring reinitiation of TIW hemodialysis. Immunosuppression was decreased with chronic rejection and risk of infection. He continued on Flagyl and vancomycin for one week after discontinuation of other Zosyn, and diarrhea resolved. His sacral ulcer continued to worsen despite regular debridement, daily dressing changes, and wound care consult. Hospital course was also complicated by poor po intake. TPN was administered initially with plans for feeding tube placement. The patient initially refused PEG placement. His mental status deteriorated, and psychiatry was consulted to assess capacity. It was determined that the patient did not have capacity due to acute delirium. A family meeting was held with the patient's 5 daughters, two of whom were previously identified as health care proxy's. The decision was made to pursue PEG placement, and to make the patient DNR/DNI. Palliative care services were also involved in this discussion. The following day the patient developed acute hypoxia and tachyardia. Oxygen saturation decreased despite being on a non-rebreather. Plans were in place for initiate BiPap when the patient went into PEA arrest. He expired on [2150-11-19]. An autopsy will be performed. Medications on Admission: unknown Discharge Disposition: Extended Care Discharge Diagnosis: Clostridium Difficile Colitis Acinetobacter Urinary Tract Infection renal transplant rejection type II diabetes end stage renal failure s/p NSTEMI - coronary artery disease paroxysmal atrial fibrillation sacral ulcer peripheral vascular disease malnurishment Discharge Condition: expired [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629]	[ "585.6", "250.60", "411.1", "707.03", "443.9", "263.9", "599.0", "E878.0", "357.2", "410.71", "250.50", "427.31", "272.0", "V45.81", "593.3", "584.5", "362.01", "008.45", "285.21", "250.40", "403.91", "V49.75", "996.81" ]	icd9cm	[ [ [] ] ]	[ "99.15", "39.95", "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	7794, 7809	5740, 7736	325, 369	8112, 8250	1985, 5717		1948, 1966				7830, 8091		7762, 7771												1190, 1566																															278, 287																397, 829																		873, 1167	1582, 1932
282	119,013	29286	Discharge summary	report	Admission Date: [2175-2-1] Discharge Date: [2175-2-8] Date of Birth: [2101-4-6] Sex: F Service: ORTHOPAEDICS Allergies: Morphine Attending:[First Name3 (LF) 11415] Chief Complaint: Bilateral femoral periprosthetic shaft fractures Major Surgical or Invasive Procedure: 1. Open reduction, internal fixation with percutaneous plating and reduction of right periprosthetic fracture. 2. Open reduction, internal fixation with percutaneous plating technique, minimally invasive technique of left femoral periprosthetic fracture. History of Present Illness: Ms. [Known lastname 70391] is a 73-year-old female patient who fell from standing resulting in bilateral femur fractures which were periprosthetic. On the left side, she has a hip hemiarthroplasty and total knee, and on the right side she has a hip hemiarthroplasty. The presence of implants precludes the performance of intramedullary nailing. The procedure of choice at this point is plating which we will perform through a percutaneous technique in order to minimize the morbidity to this elderly and very frail patient. Past Medical History: CVA 2.5yrs ago Seizure disorder h/o Urosepsis/UTI Hypertension Osteoporosis Pancreatic insufficiency h/o Depression/anxiety h/o alcoholic liver disease Hypothyroidism Chronic renal insufficiency - baseline CRE 1.4-1.8 h/o Hyperkalemia h/o Amenia Social History: Non-contributory Family History: Non-contributory Physical Exam: On discharge: Afebrile, All vital signs stable Gen: Alert and oriented, No acute distress Lungs: Clear to auscultation bilaterally Cardiac: regular rate and rhythm Abd: +bowel sounds, benign Extremities: bilateral lower Weight bearing: non weight bearing x8wks Incision: no swelling/erythema/drainage Dressing: clean/dry/intact +[Last Name (un) 938]/FHL/AT +SILT 2+ pulse, wiggles toes Capillary refill brisk Brief Hospital Course: Ms. [Known lastname 70391] presented to the Emergency Department from [Hospital3 ] Hospital with bilateral leg pain. She was evaluated by the Orthopaedics department and found to have bilateral periprostetic femur fractures. She is s/p Bilateral total hip replacements. Reduction was attempted, but unsucessful. She was placed in bilateral leg braces for stabilization. She was admitted to the medicine service and cleared for surgery. On [2175-2-2], she was prepped and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. She was then transferred to the floor for further recovery. On POD #1, she was transfused 2 units of PRBC for postoperative anemia. She then remained hemodynamically stable and her pain was controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged to a rehabilitation facility in stable condition. She was instructed to call Dr.[Name (NI) 4016] office at [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks after hospital discharge. Medications on Admission: Buspirone Aspirin Fosamax Synthroid Darvocet Keppra MVI Effexor XR Prevacid Norvasc Pancrease Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q24H (every 24 hours) for 4 weeks. 13. Insulin Regular Human 100 unit/mL Solution Sig: SSIR Injection ASDIR (AS DIRECTED). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 15. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for Anxiety. 16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) ] Discharge Diagnosis: Bilateral periprosthetic femur shaft fractures Discharge Condition: Stable Discharge Instructions: Keep the incision clean and dry. You may apply a dry sterile dressing as needed for drainage or comfort. If you are experiencing any increased redness, swelling, pain, or have a temperature >101.5, please call your doctor or go to the emergency room for evaluation. You may not bear weight on either leg. Your skin staples/sutures may be removed 2 weeks after surgery. Resume all of your home medication and take all medication as prescribed by your doctor. Continue your Lovenox injections as prescribed for preventing blood clots. Please call Dr.[Name (NI) 4016] office @ [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks after hospital discharge. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: Out of bed w/ assist Right lower extremity: Non weight bearing x8wks Left lower extremity: Non weight bearing x8wks Treatments Frequency: As stated above Followup Instructions: Please call Dr.[Name (NI) 4016] office for a follow-up appointment 2 week after hospital discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2175-2-8]	[ "401.9", "585.9", "438.9", "996.44", "E885.9", "244.9", "733.00", "780.39", "V43.64", "300.4", "V43.65", "599.0" ]	icd9cm	[ [ [] ] ]	[ "79.35" ]	icd9pcs	[ [ [] ] ]	4895, 4983	1960, 3316	320, 591	5074, 5083		6052, 6316	1467, 1485		3460, 4872		5004, 5053		3342, 3437			5107, 5840										1500, 1500	5858, 5990	6012, 6029																		1515, 1937										232, 282																619, 1148																		1170, 1417	1433, 1451
45,866	186,535	46317+58896	Discharge summary	report+addendum	Admission Date: [2167-7-5] Discharge Date: [2167-7-18] Date of Birth: [2098-2-3] Sex: F Service: NEUROLOGY Allergies: Lipitor Attending:[First Name3 (LF) 2569] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: [2167-7-14] PEG placement History of Present Illness: Ms. [Known lastname ] is a 69 year-old woman with a PMH of symptomatic paroxysmal a.fib with RVR s/p pacer and on Coumadin as well as HTN and DMII who was found unresponsive this AM. She was last seen well prior to going to sleep last night. This AM she was found by family in bed, with urinary incontinence and not responding. Her FSG at that time was 129. Per family, who arrived later, she was last seen well last night around 10 PM and was then found around 8:30 this morning in bed. Initially thought to be sleeping, but then remained unresponsive when checked again later, so EMS called and Ms. [Known lastname ] was brought to [Hospital1 18]. Past Medical History: Paroxysmal atrial fibrillation (s/p permanent pacemaker, anticoagulated with warfarin) Diabetes Mellitus type 2 Hypertension Hyperlipidemia Recurrent UTIs (E coli and GNR in recent past) Social History: Married, her husband has advanced [Name (NI) 5895]. She works in maintenance here at [Hospital1 ]. -Tobacco history: denies -EtOH: denies -Illicit drugs: denies Family History: NC Physical Exam: At admission: Vitals: T: P: 85 R: 18 BP: 194/95 SaO2: 100% on NRB General: unresponsive HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: lcta anteriorly Cardiac: RRR, S1S2 Abdomen: soft, nondistended, +BS Extremities: warm, well perfused Neurologic: no eye opening, no commands. Groans to sternal rub. R pupil 5 mm, irregular and nonresponsive to light. L pupil 1 mm and nonresponsive to light. R eye deviated to right in primary gaze, left eye in midline. No blink to threat when eyes held open. +Dolls eyes. + corneals, stronger on right than left. +gag reflex. No spontaneous movements. No movement initially to noxious stimuli UE b/l, though she did have some delayed slight movements of LUE after nailbed pressure. Brisk withdrawal of LE b/l to nailbed pressure. Grimaces to noxious stimuli throughout. Unable to elicit reflexes. Extensor plantar response on left, Equivocal response on right. At discharge: Neuro exam: responds with moderate stimulation, eyes have been opening spontaneously, grimaces to noxious, says some intelligble words occasionally, mod-severe dysarthria. Follows simple commands. Right pupil 5, left pupil 2 and both non-reactive. Brainstem reflexes intact otherwise. Moves all 4 ext, but the right less briskly. Makes purposeful movements with all extremities and withdraws to noxious stimuli x 4. Pertinent Results: [2167-7-5] 11:15AM WBC-6.5 RBC-4.75 HGB-14.0 HCT-40.1 MCV-84 MCH-29.5 MCHC-35.0 RDW-14.3 [2167-7-5] 11:15AM PT-16.3* PTT-22.5 INR(PT)-1.4* [2167-7-5] 11:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2167-7-5] 11:15AM cTropnT-<0.01 [2167-7-5] 11:15AM GLUCOSE-131* UREA N-11 CREAT-0.7 SODIUM-143 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-14 [2167-7-5] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2167-7-5] 11:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2167-7-5] 11:50AM URINE UCG-NEGATIVE [2167-7-5] 08:55PM TYPE-ART PO2-135* PCO2-42 PH-7.42 TOTAL CO2-28 BASE XS-3 Blood cultures on [7-5], and 2 on [7-8] were no growth. MRSA screen [7-5] was negative. Urine culture [2167-7-8]: URINE CULTURE (Final [2167-7-16]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. TETRACYCLINE SENSITIVE, MIC <= 2 MCG/ML. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S <=0.12 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TETRACYCLINE---------- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S Urine Culture [2167-7-12]: URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=2 S [7-5] EKG: Ventricular paced rhythm. Compared to the previous tracing of [2165-11-11] no change. [7-5] Head CT and Head and Neck CTA: FINDINGS: HEAD CT: Mild edema is visualized in the parietal lobe which may represent edema from an ischemic event in the proper clinical setting. However, there is no evidence of mass effect, hemorrhage, shift of normally midline structures, or large vessel territorial infarction. The ventricles and sulci are normal in size and configuration. No fracture is identified. HEAD AND NECK CTA: Recons are currently pending. However, the carotid and vertebral arteries and their major branches are patent with no evidence of stenosis. Mild atherosclerotic disease is visualized. There is no evidence of aneurysm formation or other vascular abnormality. IMPRESSION: 1. Mild edema is visualized in the right parietal lobe and may represent edema from an acute ischemic event in the proper clinical setting. If clinical suspicion for stroke is high, MRI is the recommended study of choice. 2. Recons are pending, but no evidence of distinct vascular occlusion or aneurysmal formation. NOTE ADDED AT ATTENDING REVIEW: I do not confirm the right parietal edema. There are extensive changes of subcortical white matter hypodensity suggesting chronic small vessel ischemia. There are no findings to suggest acute infarction. There are scattered cortical calcifications that may reflect old granulomatous disease. There is an infundibulum at the origin of the left posterior communicating artery. [7-6] CXR: IMPRESSION: 1. No evidence of congestive heart failure or pneumonia. 2. Apparent widening of mediastinum, likely due to accentuation of tortuous aorta by patient rotation. Attention to this area on a non-rotated radiograph would be helpful in this regard. [7-7] Abd Xray: FINDINGS: One view of the abdomen is provided. Bowel gas pattern is unremarkable. Visualized osseous structures are unremarkable. The lung bases appear clear. There is a pacemaker seen with wires in the atrium and ventricle. The NG tube is seen coursing through the esophagus into a low lying stomach. IMPRESSION: NG tube in stomach around area of pylorus. [7-8] CXR: ONE VIEW OF THE CHEST: The lungs are well expanded and clear. The cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. An NG tube terminates with its tip out of view below the diaphragm. A left-sided pacer terminates with its leads in the right atrium and right ventricle. IMPRESSION: No acute intrathoracic process. [7-10] CXR - Line Placement: FINDINGS: A left-sided PICC is seen ending in the right atrium. We recommend withdrawing the PICC approximately 4 cm for placement at the lower SVC/cavoatrial junction. Otherwise, good lung volumes without focal radiopacities. Cardiomediastinal and hilar contours are unremarkable, with the exception of a tortuous aorta and a stable moderate cardiomegaly. No pleural effusion or pneumothorax. Pacemaker leads ending in standard positions, in the right atrium and right ventricle, tip of the NG tube is beyond the frame of the radiograph. IMPRESSION: Tip of the PICC in the right atrium. No evidence of acute cardiopulmonary disease. [7-13] Portable CXR: FINDINGS: In comparison with study of [7-10], the patient is somewhat oblique, which limits evaluation of the heart and lungs. In addition, there are extensive pacemaker and other leads, obscuring the chest. Nevertheless, there is no definite evidence of acute pneumonia or vascular congestion. Brief Hospital Course: The patient Is a 69 year old woman with a history of paroxysmal atrial fibrillation on warfarin, diabetes mellitus, hypertension, and hyperlipidemia who was found unresponsive on the morning of [7-5] with at least 12.5 hours of depressed level of awareness, likely due to acute cerebral infarction affecting bilateral thalami from a cardioaortoembolic event while supratherapeutic on warfarin. She was brought to [Hospital1 18] late in the AM of [7-5] and she was not given thrombolytic therapy as she was outside the treatment time window. On exam, she would grimace to noxious stimuli and withdraw in all extremities but not follow commands or verbalize. On noncontrast head CT, she was found to have likely bilateral thalamic hypodensities and possibly a pontine hypodensity, however no brainstem lesion was seen on repeat imaging. NEURO: For her bilateral thalamic infarcts, she was started on a heparin infusion to anticoagulate her for prevention of further thromboembolism. Her exam has steadily improved, including the ability to repeat some phrases and follow a few simple commands although she remained very somnolent. We started her on Modafinil 100mg qAM to help improve her level of awareness and subsequently added methylphenidate 5mg qAm and qNOON. With the addition of these stimulant medications she is able to maintain alertness during the day. Coumadin was started on [7-16]. Goal INR is [1-8]. Heparin gtt is to be stopped once INR is therapeutic. ID: The patient was mildly febrile and developed a leukocytosis. She was pancultured and her UA and UCx were positive. She was initially treated with Bactrim for Proteus but when she continued to have low grade fevers and leukocytosis, she was re-cultured on [7-12]. These urine cultures are growing 2 types of GNR, pan-sensitive Proteus and enterococcus, sensitivites still pending. She was switched to Ceftriaxone on [2167-7-12] with a plan to treat for 7 days (end date [2167-7-19]). Leukocytosis and fevers have resolved since on the CTX. CARDS: After initially allowing BP to autoregulate, we restarted home meds Lostartan 100mg daily and Verapamil 80mg q8h (total 240 daily home does); additionally we added HCTZ 25 mg daily. Blood pressure has been well-controlled on this regimen. GI: The patient has had somnolence and decreased cough and gag reflex that has required an NGT, and then a PEG for tube feeds and medication delivery. The speech and swallow therapy team re-evaluated the patient on [7-16] and found that the patient did well during the day when awake, with purreed diet and nectar-thick liquids. Please allow this po intake only while the patient is under 1:1 supervision. Please continue tube feeds until the patient is able to take in enough nutrition by mouth. ENDO: For her diabetes type 2, the patient was maintained on an insulin sliding scale. Her HgbA1c is 6.7 and her fasting lipid panel showed TC 225/Trig 108/HDL 49/LDL 154. Pravastatin 40mg po daily was continued. PULM: No issues currently. Maintaining good O2 sats on room air. RENAL: Currently no issues. SOCIAL ISSUES: The [Hospital 228] hospital course was complicated by a visitor suspected of inappropriate behavior with the patient. Subsequently her visitors were screened and a password system was put in place. Social work was involved. Also there was concern for long term guardianship and the legal process in appointing a guardian has been initiated during this hospitalization. Medications on Admission: -Coumadin (noncompliant) -Metformin (noncompliant) -Verapamil XR 240 mg qAM and 120mg qPM -Sitagliptan (unknown dose) -Losartan 100 mg po qAM Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection four times a day: Insulin sliding scale. 2. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO LUNCH (Lunch). 3. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)): Please adjust per INR with goal INR value [1-8]. 6. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 1000 (1000) units Intravenous continuous: Please stop once INR is therapeutic. 7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 2 days: for UTI. 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 12. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. modafinil 100 mg Tablet Sig: One (1) Tablet PO qAM (). 14. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) mg Injection Q15MIN () as needed for hypoglycemia protocol. 15. dextrose 50% in water (D50W) Syringe Sig: 12.5 gram Intravenous PRN (as needed) as needed for hypoglycemia protocol. 16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Hospital1 8] Discharge Diagnosis: Acute ischemic stroke (bilateral thalamus) Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Neuro: responds to gentle tactile stimulation with eye opening. Speaks short words and phrases, dysarthric. Follows simple commands. Right pupil 5, left pupil 2 and both non-reactive. Brainstem reflexes intact otherwise. Purposefully moves both upper extremities and spontaneous movement of lower extremities bilaterally. Upper extremities power is at least antigravity ([2-7]) and lower extremities are at least [1-10]. Discharge Instructions: You were admitted to the hospital for decreased level of arousal and found to have strokes in bilateral thalami. The most likely cause of this was a clot from your heart given your history of atrial fibrillation with a subtherapeutic warfarin level. You were very sleepy when you first came in but slowly improved. We started you on two medicines to help your alertness, modafinial and methylphenidate. Unfortunately your swallowing ability was intially affected after your stroke. This has continued to improve over time but we had to insert a feeding tube in the interim. This would be able to be removed if you are able to eat and take medicines appropriately in the future. We have maintained you on a heparin gtt for anticoagulation during your stay. Please continue on this IV until your INR is therapeutic (goal INR [1-8]). Followup Instructions: [Hospital 878] Clinic: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2167-10-13] 1:30pm [Hospital1 18] [Hospital Ward Name 516], [Hospital Ward Name 23] Bldg, [Location (un) ] Cardiology: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2167-11-2] 3:00 Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2167-11-2] 3:40 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2168-6-11] 1:45 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Name: [Known lastname 3030],[Known firstname 15711] Unit No: [Numeric Identifier 15712] Admission Date: [2167-7-5] Discharge Date: [2167-7-18] Date of Birth: [2098-2-3] Sex: F Service: NEUROLOGY Allergies: Lipitor Attending:[First Name3 (LF) 3326] Addendum: The patient was not discharged on [7-17] due to no bed availability. The patient has a bed available today and will go to rehab. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Hospital1 15] Discharge Diagnosis: bilateral thalami infarct complicated UTI [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 3327] Completed by:[2167-7-18]	[ "401.9", "V58.61", "272.4", "041.6", "V45.01", "263.9", "427.31", "434.91", "250.00", "599.0", "V49.87", "041.04", "780.01" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93", "43.11", "96.6" ]	icd9pcs	[ [ [] ] ]	17371, 17433	9263, 12756	286, 317	14681, 14681	2836, 4846	16109, 17348	1422, 1426		12948, 14511		17454, 17635		12782, 12925			15250, 16086										1441, 2383																			2397, 2817											228, 248									4881, 5802							345, 1009				5811, 9240						14696, 15226								1031, 1219	1235, 1406
79,557	174,882	37193	Discharge summary	report	Admission Date: [2173-12-8] Discharge Date: [2173-12-11] Date of Birth: [2145-6-12] Sex: M Service: MEDICINE Allergies: Zinc Oxide Attending:[First Name3 (LF) 17865] Chief Complaint: Intentional insulin overdose Major Surgical or Invasive Procedure: None. History of Present Illness: 28-year-old homeless man with DM1 admitted after an intentional insulin overdose. He reports having taken 425U lantus and 100U humalog around 345 pm today in an attempt to secure pain medication and shelter given that it was raining. He denies suicidality or a history of suicide attempt, psychiatric disease, or psych hospitalization. He has admittedly done this repeatedly in the past at other institutions. He reports having being admitted at NYU 5 days ago, at which time he was treated for insulin overdose, as well as for xanax withdrawal with barbiturates. He was hospitalized at [Hospital6 ] yesterday and discharged with a list of shelters but he reports that they were full. He has felt lightheaded and sweaty today but has not lost consciousness. No fever, chills, cough, shortness of breath, abdominal pain, nausea, or diarrhea. He took a city bus to the [Hospital1 18] ED. In the ED, initial V/S 97.4 103 170/102 16 100%RA. L EJ placed. Started on D5 gtt. FS 333-209-133 at which point D10 gtt started. FS then 66, given amp D50. Also given morphine 8 mg IV for back pain. Vital signs prior to transfer 99 165/108 20 97% RA. On arrival in the MICU, complains of lower back pain radiating down the left leg. Past Medical History: DM type 1 MSSA pneumonia complicated by empyema requiring chest tube placement MVA complicated by chronic back pain hypothyroidism Social History: Homeless. Smokes 1 ppd. No ETOH. Rare MJ use. Former injection drug user, none in 6 years. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals T 99.2 BP 148/104 HR 101 RR 18 02sat 100%RA FSG 103 GENERAL: Well-appearing, NAD HEENT: PERRL NECK: supple no JVD CARDIAC: reg rate nl S1S2 no m/r/g LUNGS: CTAB no w/r/r ABDOMEN: soft NTND normoactive BS EXT: warm, dry full distal pulses no c/c/e NEURO: AA&Ox3, conversing appropriately DERM: multiple tattoos Pertinent Results: [2173-12-8] 09:57PM BLOOD WBC-9.9 RBC-3.92* Hgb-11.9* Hct-35.0* MCV-89 MCH-30.4 MCHC-34.0 RDW-17.2* Plt Ct-293 [2173-12-10] 01:37PM BLOOD WBC-7.5 RBC-3.81* Hgb-11.5* Hct-34.8* MCV-91 MCH-30.2 MCHC-33.1 RDW-17.2* Plt Ct-267 [2173-12-8] 09:57PM BLOOD Glucose-67* UreaN-11 Creat-0.9 Na-141 K-3.9 Cl-107 HCO3-25 AnGap-13 [2173-12-10] 01:37PM BLOOD Glucose-137* UreaN-20 Creat-0.9 Na-136 K-4.7 Cl-99 HCO3-29 AnGap-13 [2173-12-8] 09:57PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0 [2173-12-10] 01:37PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.0 [2173-12-8] 04:58PM BLOOD Type-ART pH-7.53* Comment-GREEN TOP [2173-12-8] 10:26PM BLOOD Type-[Last Name (un) ] pO2-45* pCO2-40 pH-7.43 calTCO2-27 Base XS-1 [2173-12-8] 04:58PM BLOOD Glucose-314* Lactate-2.9* Na-139 K-4.5 Cl-107 calHCO3-20* [2173-12-8] 10:26PM BLOOD Lactate-1.0 [2173-12-8] 04:58PM BLOOD freeCa-0.93* [2173-12-8] 10:26PM BLOOD freeCa-1.18 Cardiology Report ECG Study Date of [2173-12-8] 7:26:36 PM Sinus tachycardia. Otherwise, normal tracing. No previous tracing available for comparison. Brief Hospital Course: #Intentional insulin overdose - Treated with dextrose infusion and maintained on hourly finger sticks. Glucose normalized and patient transitioned to SC sliding scale insulin on hospital day 3. Evaluated by psychiatry who did not feel that 1:1 supervision, suicide precautions, or inpatient psychiatry transfer were indicated. Eloped on [12-11] and refused to sign AMA form, despite acknowledging the risk of doing so, including brain injury, coma, and death. Medications on Admission: insulin glargine 30 U humalog sliding scale oxycontin 80 mg TID xanax 2 mg TID Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day. 2. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous at meals and bedtime. 3. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO three times a day as needed for pain: do not drive or drink alcohol while taking this medication. 4. Xanax 2 mg Tablet Sig: One (1) Tablet PO three times a day: do not drive or drink alcohol while taking this medication. Discharge Disposition: Home Discharge Diagnosis: Intentional insulin overdose Discharge Condition: Eloped, refused to sign AMA form. Discharge Instructions: You were admitted to the hospital following an insulin overdose. Your blood sugar rose to a normal range with a dextrose infusion. You left the hospital against medical advice despite acknowledging the risk of doing so, including brain injury, coma, and death. Please feel free to contact Traveler??????s Aid at [Telephone/Fax (1) 83756] for assistance with travel resources. Followup Instructions: If you remain in the [Location (un) 86] area, you may call [Hospital1 771] [Hospital3 ] at ([Telephone/Fax (1) 1300] for a primary care appointment at your earliest convenience. Completed by:[2173-12-11]	[ "V60.0", "305.1", "244.9", "E950.4", "962.3", "311", "250.81", "724.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4480, 4486	3355, 3822	302, 310	4559, 4595	2241, 3332	5026, 5252	1847, 1865		3952, 4457		4507, 4538		3848, 3929			4619, 5003										1880, 2222																														234, 264																338, 1568																		1590, 1723	1739, 1831
54,940	176,817	53566	Discharge summary	report	Admission Date: [2182-4-19] Discharge Date: [2182-5-10] Date of Birth: [2157-5-22] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 613] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: TEE History of Present Illness: This is a 24 yof with history of IVDU who initially presented to [Hospital 4199] hospital on [4-18] with 2 days of right sided chest and abdominal pain, as well as difficulty breathing for 2 days. She reports haveing used about 1g of heroin/day as well as cocaine recently over the past 2.5 weeks. . Given her shortness of breath and tachycardia, a CT chest was obained on admission which showed no PE, but right middle and lower lobe air space opacities suggestive of multifocal consolidation, as well as multiple nodular densities in the right upper lobe, left upper lobe, and left lower lobe with associated central cavitation concerning for septic emboli. There was also evidence of mediastinal and axillary adenopathy. Due to her IVDU history and CT findings there was concern for endocarditis and was started on vanco/ceftriaxone. Of note, she has had history of MRSA cellulitis in the past. Echo was obtained showing 2 cm vegetation on the tricuspid valve, with potential concern for fungal vegetation. Blood cultures were drawn and are now growing out GPC clusters in [2-9] bottles. ID consult was obtained and abx were changed to vanc/cefepime. HIV and Hepatitis B and C serologies were sent given her IVDU and were pending on transfer. . Of note, given her subjective history of weightloss/fevers there was concern for TB, so PPD was placed. She remained tachycardic throughout admission presumed secondary to fevers, pain, and anxiety. . Given her endocarditis, she was transferred to [Hospital1 18] where she could have a cardiac surgery evaluation. . On arrival to the MICU, initial VS were 102.9 130 128/52 27 96% RA. She complains of significant chest pain that inhibits her taking a deep breath. She denies peripheral edema, n/v/d. She endorses night sweats and weight loss over the past several days . Review of systems: (+) Per HPI (-) Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -IVDU -Depression -MRSA cellulitis Social History: Lives at home with her dad, who was previously addicted to narcotics but sober x 15 yrs. Not working or in school. No ETOH, smokes [10-21] cigarettes/day, + heroin and cocaine abuse. Family History: Lung cancer in paternal GM with brain mets Mother with a h/o IVDU Physical Exam: Admission PE Vitals: 102.9 130 128/52 27 96% RA General: Alert, oriented, tachypenic, moderate distress HEENT: Sclera anicteric, PERRLA (3mm in diameter) MMM, oropharynx clear, EOMI Neck: supple, JVP not elevated, but difficult to interpret given tachypnia. no LAD CV: Tachy, regular, S1 + S2, difficult to appreciate murmur given tachycardia Lungs: Tachypenic, shallow breaths, clear to auscultation anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No splinters, oslers nodes, or [Last Name (un) ] lesions. Evidence of track marks over the arms. Some evidence of skin popping as well Neuro: CNII-XII intact, moving all extremities. Discharge PE: VS: 97.9 112/60 (110-112/68-83) 108 (104-116) 18 100RA General: Alert, oriented, laying comfortably in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple CV: Tachy, regular, S1 + S2, soft systolic murmur at LLSB Lungs: clear to auscultation b/l, no wheezes/rhonchi/crackles Abdomen: soft, non-tender, non-distended, +BS Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: slight petechiae over feet, resolving--> new petechiae scattered along LE b/l, nonblanching, nontender, ranging in size some pinpoint to 2 cm in diameter; slightly present on the lower back as well --> continuing to resolve, fading in color Neuro: CN 2-12 grossly intact, normal muscle strength and sensation throughout Pertinent Results: Admission labs: [2182-4-19] 08:20PM BLOOD WBC-11.3* RBC-3.25* Hgb-9.6* Hct-29.7* MCV-91 MCH-29.6 MCHC-32.5 RDW-12.9 Plt Ct-110* [2182-4-20] 03:38AM BLOOD WBC-14.2* RBC-3.12* Hgb-9.1* Hct-28.7* MCV-92 MCH-29.2 MCHC-31.7 RDW-12.9 Plt Ct-111* [2182-4-19] 08:20PM BLOOD Neuts-88.0* Lymphs-8.4* Monos-3.0 Eos-0.1 Baso-0.5 [2182-4-20] 03:38AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-3.6 Eos-0.1 Baso-0.3 [2182-4-19] 08:20PM BLOOD PT-17.7* PTT-33.1 INR(PT)-1.7* [2182-4-19] 08:20PM BLOOD Fibrino-513* [2182-4-20] 03:38AM BLOOD FDP-10-40* [2182-4-20] 12:37PM BLOOD ESR-100* [2182-4-21] 04:57AM BLOOD Ret Aut-0.7* [2182-4-19] 08:20PM BLOOD Glucose-101* UreaN-6 Creat-0.4 Na-140 K-3.0* Cl-106 HCO3-31 AnGap-6* [2182-4-20] 03:38AM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-139 K-3.2* Cl-106 HCO3-25 AnGap-11 [2182-4-19] 08:20PM BLOOD ALT-13 AST-16 LD(LDH)-220 AlkPhos-70 TotBili-0.5 [2182-4-20] 03:38AM BLOOD ALT-13 AST-14 LD(LDH)-229 AlkPhos-64 TotBili-0.5 [2182-4-19] 08:20PM BLOOD Albumin-2.3* Calcium-7.2* Phos-1.7* Mg-2.0 [2182-4-20] 03:38AM BLOOD Calcium-7.1* Phos-2.6* Mg-1.9 [2182-4-23] 05:22AM BLOOD calTIBC-137* Hapto-352* Ferritn-349* TRF-105* [2182-4-20] 12:37PM BLOOD CRP-245.2* Discharge labs: [2182-5-9] 05:55AM BLOOD WBC-9.3 RBC-3.53* Hgb-10.1* Hct-33.6* MCV-95 MCH-28.7 MCHC-30.1* RDW-14.4 Plt Ct-918* [2182-5-10] 06:06AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.5* Hct-31.5* MCV-95 MCH-28.5 MCHC-30.1* RDW-14.2 Plt Ct-871* [2182-5-10] 06:06AM BLOOD PT-12.5 PTT-30.1 INR(PT)-1.2* [2182-5-9] 05:55AM BLOOD Glucose-105* UreaN-17 Creat-0.7 Na-142 K-5.0 Cl-101 HCO3-32 AnGap-14 [2182-5-10] 06:06AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-142 K-4.5 Cl-102 HCO3-34* AnGap-11 [2182-5-10] 06:06AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.3 [2182-5-6] 09:16AM BLOOD Cryoglb-NO CRYOGLO [2182-4-19] 08:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [2182-4-19] 08:20PM BLOOD HCV Ab-POSITIVE* Studies: ECHO [2182-4-19]: IMPRESSION: Large tricuspid valve vegetation with mild (possibly underestimated) tricuspid regurgitation. No other valvular vegetations appreciated. Preserved biventricular regional and global left ventricular systolic function. Very small circumferential pericardial effusion. CT abd/pelvis: [2182-4-22] IMPRESSION: 1. New basilar consolidations concerning for septic emboli. 2. Increased bilateral pleural effusions since the reference study from [2182-4-18]. 3. New moderate ascites and body wall edema. TEE: [2182-4-23] IMPRESSION: There is a large vegatation on the tricuspid valve. Moderate to severe tricuspid regurgitation. Overall normal biventricular function. Very small pericardial effusion. RUQ u/s: [2182-4-23] IMPRESSION: -> No portal vein thrombosis identified. -> Trace of ascites in the pelvis. There are right and left pleural effusions noted. -> No focal collection is seen in either the spleen or liver. CT abd/pelvis: [2182-4-26] IMPRESSION: 1. Increasing bilateral pleural effusions and new moderate-sized pericardial effusion. Cavitating pulmonary nodules c/w septic emboli. 2. No evidence of septic emboli within the abdomen. 3. Moderate amount of free fluid in the dependent portion of the pelvis. CT chest [2182-4-27] IMPRESSION: 1. Worsening right upper and right middle lobe pneumonia with multiple bilateral septic emboli, many of which have cavitated, the most prominent of which appears to communicate with a branch of the right middle lobe bronchus and extends to the periphery, but given the lack of gas within the pleural space, bronchopleural fistula is not favored at this time. Findings discussed with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 22:39 on [2182-4-27] by [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 11623] over the phone. 2. Pleural and pericardial effusions as described above. CT chest: [2182-5-1] IMPRESSION: 1. Right upper lobe noncavitary consolidation has improved since the recent study, and a few nodules show new cavitation. However, dominant wedge-shaped areas of cavitary consolidation in the right middle lobe and lingula are not appreciably changed. 2. Resolved left pleural effusion, decreased right pleural effusion, and persistent moderate pericardial effusion. Brief Hospital Course: 24 yof with history of IVDU, past MRSA cellulitis, presenting to [Hospital 4199] hospital with breathing difficulty and tachycardia. CT torso showed cavitary lesions suggestive of septic emboli, and echo with large tricuspid vegitation suggestive of endocarditis. # Right-sided Endocarditis with septic pulmonary emboli: transferred from an OSH with know tricuspid valve endocarditis, cultures eventually speciated to MSSA. CT scan at the OSH with cavitary lung lesions, consistent with septic emboli from her known endocarditis. She was seen in consultation by the infectious disease service and the cardiac surgery service, she underwent a TEE which showed a 1.7cm x 1cm tricuspid valve vegetation, no abscess formation, and no involvement of any other valves. Given the TEE findings the cardiac surgery service felt that no surgical intervention was needed at this time. She remained on vancomycin with a goal trough of over 20, when the cultures from the OSH returned MSSA it was decided to continue her on vancomycin given her history of throat closing with amoxicillin. However, the patient later developed a new LE rash, which initially was thought could be related to vanc. Vanc was stopped and the patient was briefly on dapto, when it was decided by ID that she should undergo PCN desensitization so she could be on the appropriate NAfcillin for her MSSA endocarditis. . On the floor, the patient was hemodynamically stable, though she continued to be tachypneic to 30-40s and tachycardic to 120-130s. Her daily EKG's did not show any evidence of conduction system disease. A PICC was placed with plans for a total of 6 weeks of antibiotics based on date of first negative cultures, which was on [2182-4-23]. End date will be [2182-6-4]. . The patient was found to have an increasing white count and repeat CT chest was done on [2182-5-1]. Thoracics was consulted re: potential for any operable/resectable areas that could be causing this white count. However, CT chest showed improvement compared to priors, and thoracics said no intervention was needed at this time. . # PCN desensitization: The patient was transferred to the MICU for PCN desensitization, which she tolerated without any issue. She also received Nafcillin without incident and was able to be called out to the floor without issue. It is VERY important that the patient should not miss [First Name (Titles) 691] [Last Name (Titles) 4319] given her recent desensitization. . # Fevers/weight loss: Prior to transfer given the septic emboli on her chest CT and fevers and weight loss there was concern for possible TB. A PPD placed at the OSH was negative and she had three sputums negative for AFB. The patient was also noted to be HIV negative at OSH. . # Tachycardia: CTA negative for PE prior to transfer, thought to be related to pain, fever and withdrawal symptoms, she was monitored on telemetry and remained in sinus tachycardia throughout her stay. . # IVDU: Pt with long history of IVDU likely precipitating her endocarditits, HIV antibody negative at the OSH on [2182-4-19]. Hepatitis C antibody positive here with a viral load of 173,401. Hepatitis B serologies showed immunity. Hepatology was curbsided and said pt could follow up in hepatology clinic at any time for HCV treatment if she desired this. However, it is not urgent so they recommended she finish endocarditis treatment first and no longer be using IV drugs. The patient was also given clonidine PRN for any withdrawal symptoms. . # abdominal pain: The patient had an episode of abdominal pain, with exam notable for rebound tenderness. Surgery was consulted, and KUB was done. KUB was negative for free air or any evidence of obstruction; lactate was normal. Surgery recommended NPO until abdominal pain resolves. The patient's diet was advanced slowly, and her abdominal pain resolved. Given her recent diagnosis of HSP (see below), it is possible that this acute episode of abdominal pain was intussuception that had self resolved. . # diarrhea: The patient reported having some intermittent diarrhea while in patient; was found to be Cdiff negative x2. . # Anemia: The patient was found to be iron deficiency on studies, with no evidence of hemolysis, and she was started on ferrous sulfate. . # new BLE pupura: The patient was found to have new LE rash, which was initially thought to be secondary to Vanc. There was some improvement after Vanc was stopped. Derm was consulted and punch biopsies were done. Path was consistent with leukocytoclastic vasculitis, with IgA deposits in vessel walls, consistent with Henoch-Schonlein Purpura. This was thought to be most likely secondary to her underlying bacterial endocarditis. . # thrombocytosis: The patient had a persistent thrombocytosis during this admission, likely reactive in the setting of her endocarditis. Upon discharge, it had started trending down. Transitional Issues: # new Hep C: The patient should follow up as an outpatient in liver clinic once treatment for endocarditis is finished. . # bacterial endocarditis: The patient will need to complete six weeks total of antibiotics starting from 1st negative culture; end date will be [2182-6-4]. She will be discharged on Nafcillin. . # LE purpura s/p punch biopsy: The patient had punch biopsy done on [2182-5-7]. The patient will need to have sutures removed from biopsy site in two weeks ([2182-5-21]). The patient will also need outpatient dermatology follow up. Please call [Telephone/Fax (1) 1971] to make an appointment. # infectious disease follow up: The patient will follow up in [Hospital 4898] clinic on [2182-5-21] 10a with Dr. [Last Name (STitle) ] and [6-4] 11.30a with Dr. [Last Name (STitle) ]. Please send weekly CBC w/diff, BMP, LFTs to [Telephone/Fax (1) 1419]. # HSP: Please get urinalysis once weekly to monitor for hematuria for two months. Medications on Admission: none Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for withdrawals. 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: please hold for RR<12, altered mental status. 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 9. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every four (4) hours: PLEASE STOP [2182-6-4]. Discharge Disposition: Extended Care Facility: Tewsbury State Hospital Discharge Diagnosis: Primary: MSSA bacterial tricuspid endocarditis with pulmonary septic emboli intravenous drug use Hepatitis c Secondary: reactive thrombocytosis Henoch-Schonlein Purpura Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 35914], It was a pleasure taking care of you while you were hospitalized at [Hospital1 18]. You were transferred to [Hospital1 18] because you were found to have a bacterial infection in your blood, with bacteria on your heart valves and in your lungs. We started you on antibiotics to help treat this infection. Because you had an allergy to penicillin, we had to send you back to the intensive care unit for desensitization; you tolerated this well. It is VERY important that you do not NOT miss any of your [Hospital1 4319] of the antibiotic. We made the following changes to your medications: START Nafcillin 2 grams every four hours through your veins START Zofran 4 mg every 8 hours by mouth as needed for nausea START Sarna lotion, applied to your hands/feet, as needed for dry skin START Dilaudid 2-4 mg as needed for pain every 4 hours START clonidine 0.1 mg by mouth as needed every 4 hours START lorazepam 0.5 mg by mouth as needed for anxiety every fours hours START acetaminophen 650 mg as needed for fever/pain every 6 hours (do NOT exceed 2 grams daily) Followup Instructions: Please followup with your primary care physician [Name Initial (PRE) 176] [7-16] days regarding the course of this hospitalization. Please call [Telephone/Fax (1) 1971] to make an appointment to make an appointment with dermatology clinic. You will also have to follow up with the liver doctors as [Name5 (PTitle) ] outpatient, given your new diagnosis of Hepatitis C. Department: INFECTIOUS DISEASE When: TUESDAY [2182-5-21] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4593], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2182-6-4] at 11:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4091], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2182-5-10]	[ "511.9", "787.91", "486", "287.0", "305.1", "789.00", "276.8", "421.0", "280.9", "518.0", "238.71", "415.12", "292.0", "790.7", "304.01", "041.11", "V14.0", "286.6", "V07.1", "070.54", "287.5", "305.62", "789.59", "789.2" ]	icd9cm	[ [ [] ] ]	[ "86.11", "88.72", "38.97" ]	icd9pcs	[ [ [] ] ]	15564, 15614	8637, 13563	284, 289	15828, 15828	4298, 4298	17120, 18309	2679, 2746		14636, 15541		15635, 15807		14607, 14613			15979, 16594				5559, 8614						2761, 3529										14249, 14581											13584, 14238	16623, 17097	2184, 2398				3543, 4279			232, 246																317, 2165						4315, 5543				15843, 15955								2420, 2456	2472, 2663
1,312	131,720	52500	Discharge summary	report	Admission Date: [2113-5-31] Discharge Date: [2113-6-4] Service: CHIEF COMPLAINT: Lightheadedness HISTORY OF PRESENT ILLNESS: The patient is an 82 year old male with a history of stroke, supranuclear palsy who is usually alert and oriented times one who presents with dizziness times two days. The patient had an episode of sliding to the floor. No abdominal pain, melena, bright red blood per rectum or nausea, vomiting or diarrhea at home. The patient was found to have a hematocrit of 21 from a baseline of 43 and had guaiac positive stools. The patient had an episode of hematemesis in the Emergency Room and was found to have coffee ground by nasogastric tube lavage that cleared after 250 cc. The patient was also found to be tachycardiac from 100 to 120s with a blood pressure of 140. The patient had two left port intravenous lines placed and is currently getting saline and the first unit of packed red blood cells on admission. The patient received 40 mg of intravenous Protonix in the Emergency Department. PAST MEDICAL HISTORY: Transurethral resection of prostate in [2113-4-3] for benign prostatic hypertrophy. Meniere's disease with tinnitus and vertigo from [2051] to [2101]. History of subdural hematoma two years ago and the patient presented with aphasia. Right carotid artery stenosis, 80% asymptomatic. Questionable supranuclear palsy. History of stroke secondary to small vessel disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q. day Omega 3 Vitamin t.i.d. SOCIAL HISTORY: The patient lives with his wife, no children. He is a retired salesman and quit tobacco in the [2061], no alcohol. FAMILY HISTORY: Significant for mother with [Name (NI) 2481]. PHYSICAL EXAMINATION: Temperature 97.5, heartrate 116, blood pressure 140/72, respiratory rate 14, 100% on room air. In general the patient is alert, oriented to [Location (un) 86], not oriented to hospital or year. He has slurring of speech. Head, eyes, ears, nose and throat, pupils equal, round, and reactive to light, extraocular muscles intact, no left anterior descending. Cardiac, tachycardiac, II/VI holosystolic murmur at left lower sternal border. Respiratory, clear to auscultation bilaterally. Abdomen, soft, mildly tender over the epigastric region, positive bowel sounds, no rebound or guarding. Extremities, no edema. Neurological, cranial nerves 2 through 12 grossly intact. Strength 5/5. Rectal, black guaiac positive stools. LABORATORY DATA: White blood cell count 20.9, increased from 14.6 on previous, hematocrit 21.5, increased from 43.1 at baseline. Platelets 523, PT 13.2, PTT 23.5, INR 1.2. Chem-7 notable for a glucose of 199. Urinalysis negative. Liver function tests within normal limits. First CK was flat. Urine culture, no growth. Chest film, large gastric bubble, hazy left costophrenic angle, no gross infiltrates. Electrocardiogram, tachycardiac at 105, normal sinus rhythm, normal axis and intervals, questionable Q in 2, questionable ST depression in V4, otherwise unchanged from [2111-5-4]. HOSPITAL COURSE: The patient was admitted to the Medicine Intensive Care Unit and was transfused 6 units of packed red blood cells. The patient had an esophagogastroduodenoscopy done which showed a duodenal ulcer with visible vessel which was injected and cauterized. The patient was then transferred to the floor for further monitoring. The patient was also started on an intravenous Protonix drip. 1. Gastrointestinal - The patient's hematocrit remained stable at 33, post 6 unit transfusion. The patient's Protonix drip was discontinued and the patient was placed on Protonix 40 mg p.o. b.i.d. An Helicobacter pylori antibody was sent which was found to be positive. The patient will be started on Clarithromycin 500 mg p.o. b.i.d. times 14 days and Amoxicillin 1 gm p.o. b.i.d. times 14 days in addition to Protonix 40 mg p.o. b.i.d. times 14 days and then 40 mg p.o. q. day. The patient's diet was advanced to full liquids which he has tolerated by far. The patient will be advanced to full diet within the next 24 hours and if he is able to tolerate that should be discharged. Cough - On arrival to the floor it was noted that the patient had cough productive of sputum and a white count of 21. PA and lateral was done which showed congestive heart failure, chronic obstructive pulmonary disease-emphysema and although officially did not read any infiltrates, there was a questionable retrocardiac infiltrate on examination. The patient was started on intravenous Ceftriaxone and Azithromycin since he was unable to tolerate p.o. at the time. The patient will be switched to a p.o. regimen upon discharge. On the second day on the floor the patient's white count had decreased from 21 to 17 and cough appeared slightly better than before. In terms of the patient's congestive heart failure, maintenance intravenous fluids were discontinued and the patient will be repleted as needed. The patient was not actively diuresed since he had a recent large gastrointestinal bleed. He will continue to be monitored during this hospitalization. The patient's oxygen saturation on room air is 97%. Fluids, electrolytes and nutrition - The patient was found to be hypokalemic with a potassium of 2.9 on hospital day #3. The patient was repleted, although it is not clear why he is still hypokalemic at this time. We will continue to monitor. The patient will have a more advanced diet by the time of discharge. Access - The patient has two large bore intravenous lines. The patient was placed on aspiration and fall precautions due to his mental status. It appears at baseline, however, he has difficulty talking and has confusion at baseline due to his supranuclear palsy. The patient was evaluated by Physical Therapy who felt that the patient would benefit from inpatient rehabilitation at another facility. DISCHARGE DIAGNOSIS: 1. Peptic ulcer disease, most likely secondary to non-steroidal anti-inflammatory drugs and positive Helicobacter pylori, complicated by anemia and hemodynamic instability. 2. Bronchitis versus pneumonia. 3. Supranuclear palsy 4. Meniere's disease 5. Status post cerebrovascular accident times two DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d. times 14 days and then 40 mg p.o. q. day Clarithromycin 500 mg p.o. b.i.d. times 14 days Amoxicillin 1 gm p.o. b.i.d. times 14 days CONDITION ON DISCHARGE: The patient will be discharged to rehabilitation for further physical therapy treatment. The patient should have a regular diet but should observe aspiration precautions. The patient should follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in one to two weeks. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2113-6-2] 16:25 T: [2113-6-2] 20:32 JOB#: [Job Number 29877]	[ "V12.59", "492.8", "E935.9", "428.0", "433.10", "276.8", "356.8", "285.1", "532.00" ]	icd9cm	[ [ [] ] ]	[ "44.43", "96.33" ]	icd9pcs	[ [ [] ] ]							1725, 1776		6307, 6467		5980, 6284		1519, 1570	3145, 5959																													1799, 3127													101, 118																147, 1045																		1068, 1493	1587, 1708	6492, 7098
73,578	171,845	34457	Discharge summary	report	Admission Date: [2160-1-7] Discharge Date: [2160-1-23] Date of Birth: [2096-1-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: Rectal adenoca Major Surgical or Invasive Procedure: protectomy, partial colectomy, ileostomy History of Present Illness: Mr. [Known lastname 23226] is a 56yo male with locally advanced rectal cancer who underwent neoadjuvant chemoradiation and presents for definitive resection without evidence of metastatic disease. The patient had a left posterolateral tumor approximately in the distal one third of the rectum. Past Medical History: rectal ca, HTN, psoriasis Social History: Pt married and lives with his wife. Unclear of exact amount of etoh intake, about 5 vodka drinks per day Family History: noncontributory Physical Exam: At discharge: V.S: 98.4, 70, 118/74, 20, 98% ra Gen: A and O x 3 Resp: LSCTAB, nard CV: RRR, no M/R/G Abd: soft, nd, nt,+ BS, ostomy-stoma beefy red, midline incision ota with steri strips. GU: foley in place ext: no c/c/e Pertinent Results: [2160-1-12] 05:17AM BLOOD WBC-8.0 RBC-3.20* Hgb-10.7* Hct-31.4* MCV-98 MCH-33.3* MCHC-33.9 RDW-14.2 Plt Ct-275 [2160-1-8] 07:40AM BLOOD Glucose-138* UreaN-14 Creat-1.0 Na-141 K-5.0 Cl-106 HCO3-28 AnGap-12 [2160-1-23] 05:16AM BLOOD Glucose-104 UreaN-15 Creat-1.0 Na-130* K-5.1 Cl-100 HCO3-23 AnGap-12 [2160-1-8] 07:40AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.4 [2160-1-22] 06:00AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 [2160-1-23] 01:34PM BLOOD Glucose-111* UreaN-16 Creat-1.0 Na-131* K-4.9 Cl-100 HCO3-22 AnGap-14 [2160-1-22] 06:00AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 . [2160-1-21] URINE URINE CULTURE-FINAL INPATIENT - no growth [2160-1-12] URINE URINE CULTURE-FINAL INPATIENT - no growth [2160-1-11] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth [2160-1-11] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT - no growth . [1-7] Pathology: Residual adenocarcinoma, characterized by scattered, glands, extending transmurally into peri-rectal adipose tissue, clear margins, 0/14 LN. Diverticulosis. . CHEST (PORTABLE AP) Study Date of [2160-1-11] FINDINGS: In comparison with the study of [8-7], there are substantially lower lung volumes, which may account for much of the prominence of the cardiomediastinal silhouette. There is an area of increased opacification at the left base that could be consistent with aspiration, though atelectatic change cannot be excluded. A left central catheter extends to the mid portion of the SVC as on the previous study. . PORTABLE ABDOMEN Study Date of [2160-1-11] IMPRESSION: Probable postoperative ileus in this limited study . PORTABLE ABDOMEN Study Date of [2160-1-12] IMPRESSION: No ileus or obstruction . CHEST (PORTABLE AP) Study Date of [2160-1-12] : This study is just being presented for interpretation. No evidence of free intraperitoneal gas, though this does not truly appear to be a upright view. The opacification at the left base has substantially decreased since the previous study. No evidence of acute focal pneumonia. Brief Hospital Course: Mr. [Known lastname 23226] was admitted to [Hospital Ward Name 1950] 5 from the PACU s/p proctectomy, partial colectomy, coloproctostomy, diverting loop ileostomy. He was admitted to the floor with a PCA, IV hydration, foley, and was made NPO. The pt was also put on a CIWA scale secondary to his alcohol consumption at home, [4-6]+ tumblers of vodka/day. . On POD 4 pt became confused and agitated secondary to ETOH withdrawal. He was transferred to [Hospital Unit Name 153] for closer assessment. . [Hospital Unit Name 153] However on POD #4 he became confused and was admitted to the [Hospital Unit Name 153] for ETOH withdrawal. The pt had been on CIWA scale and initially required ativan 0.5-1mg Q4hrs and then went up to 1-2mg ativan Q2hrs. Pt was intermittently somnolent/quiet and then combative. Delirium/ETOH withdrawal was controlled with IV benzodiazepines and Haldol. . # Vomiting: placed NGT with immediate decompression of >1200cc of brown liquid Abd films negative for ileus. The pt was continued on bowel rest and NGT to low intermittent suction. . # Presumed aspiration: Given that pt was vomiting on floor prior to arrival in ICU and also had vomiting while placing NGT in [Hospital Unit Name 153] with brief desaturation to 85%, pt has likely aspirated some gastric material. - ppi to reduce acid pneumonitis - cipro/flagyl empirically . Pt returned to [Location 1950] 5 on POD 5. The pt's NGT was d/c'd and with return of flatus and bowel function he was started on sips to regular diet advanced as tolerated, which he tolerated well and his medications were than changed back to oral. # Dehydration Due to excessive ostomy output, up to 4 Liters/day pt became dehydrated. Metamucil wafers TID, Imodium 4mg QID and IVF replacement was ordered. With decreased ostomy output IVF was d/c'd. However the pt will remain on metamucil wafer TID, imodium 4 mg QID, and Tincture of Opium. # Failed voiding trial x 2 Attempted to remove foley however the pt failed to void and was straight cathed. PO Flomax started as well. The pt was still unable to void so a new foley was placed and the pt was sent home with a leg bag and a follow up appointment was made with urology for voiding trial on out-patient basis. # Hyponateremia On POD 15 pt's sodium decreased to 124 from 129 (admit sodium was 141). Medicine was consulted and recommended free water FR of 750 cc/day. On POD 16 Na increased to 130, repeat sodium to 131. He will have a repeat sodium level on Friday [2160-1-25] at [Month/Day/Year 3390]'s office. He will be advises accordingly regarding fluid restrictions per [Month/Day/Year 3390]. [Name10 (NameIs) 3390] office [Name (NI) 653], and patient's sitution discussed. . Abdominal incision OTA with steri strips. Staples removed prior to discharge. Visiting nurse services arranged for ostomy care and foley leg bag teaching at home. Medications on Admission: warfarin 1', lisinopril 20', indomethacin prn Discharge Medications: 1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:45 Tablet(s) Refills:0 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 6. Psyllium 1.7 g Wafer Sig: [1-4] Wafers PO TID (3 times a day). Disp:180 Wafer(s) Refills:2 7. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). Disp:240 Capsule(s) Refills:2 8. Opium Tincture 10 mg/mL Tincture Sig: Five (5) Drop PO Q6H (every 6 hours). Disp:QS Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: Rectal adenoca Detox from ETOH Dehydration secondary to ostomy output post-op urinary retention Post-op ileus . Secondary: Rectal cancer: s/p neoadjuvant chemo/XRT (F-5U) and resection (as above) Hypertension Psoriasis Discharge Condition: Stable. Tolerating well diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. . Ostomy: -Continue to assess ostomy output noting amount, color, consistency. -Make sure you stay hydrated with fluid, gatoraide and other sport drinks are the best option. -If you become dehydrated (signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing) please call Dr. [Last Name (STitle) 1120] at [Telephone/Fax (1) 160] -The VNA will come to your house to assist you with ostomy care/appliance changes, this should be done every three days and as needed. . Foley: -You were dischared with a foley because you were unable to void on your own when foley was removed. -You were sent home with two types of foley bags. A leg bag to use during the day and a larger bag to use at night. -Your nurse provided education on foley care. -You need to follow up with an urologist regarding this issue. . Medicaitons: 1.Psyllium Wafer/Metamucil Wafer -You were stared on this medicaiton to help bulk up your stool. -This should be taken three times a day. -Do not drink water 30 minutes prior and after you take this medication. . 2.Loperamide/Imodium -You were stared on this medicaiton to help decrease the amount of stool your ostomy puts out. -It should be taken four times a day. -If output increases you can increase this medicaiton to 4 mg four times a day. At this time contact Dr. [Last Name (STitle) 1120]. -Do not exceed more than 16mg of imodium per day. . 3. Tamsulosin/Flomax -You were started on this medication because of your difficulty voiding when your foley was removed. -This medicaiton should be taken once a day. -You need to follow up with an urologist regarding this. Followup Instructions: 1. Please call Dr.[Name (NI) 3377] [Telephone/Fax (1) 160] office to make an appointment in [2-5] weeks. 2. Please follow up with, Dr.[Last Name (STitle) 163] (urology),[Telephone/Fax (1) 921], on [2160-1-28] at 1:30 on [Hospital Ward Name 23] 3. 3. Please call you [Hospital Ward Name 3390], [Name10 (NameIs) ],[Name11 (NameIs) 20] [Name Initial (NameIs) ]. [Telephone/Fax (1) 14751], to make a follow up appointment in 1 week or as needed. SUMMARY NEITHER DICTATED NOR READ BY ME Completed by:[2160-1-23]	[ "276.51", "560.1", "997.4", "253.6", "154.1", "401.9", "291.81", "788.20", "272.4", "507.0", "V64.41", "E878.6" ]	icd9cm	[ [ [] ] ]	[ "45.75", "46.01" ]	icd9pcs	[ [ [] ] ]	7180, 7231	3243, 6159	327, 370	7505, 7581	1160, 3220	10642, 11203	885, 902		6256, 7157		7252, 7484		6186, 6233			7605, 8642								8657, 10619		917, 917																			931, 1141											273, 289																398, 698																		720, 747	763, 869
4,787	153,907	2559	Discharge summary	report	Admission Date: [2129-1-19] Discharge Date: [2129-1-21] Date of Birth: [2044-1-3] Sex: M Service: MEDICINE Allergies: Meropenem / Penicillins / Carbapenem Attending:[Doctor First Name 3290] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None. History of Present Illness: This is 85 year old ESRD on hemodialysis, CAD s/p MI, afib and CVA, presented with hypotension prior to beginning [Doctor First Name 2286] on [2129-1-19] (did not receive [Date Range 2286]). His last [Date Range 2286] was Monday [2129-1-17]. He was sent to the ED complaining of weakness for 1 week and generally feeling unwell. He appeared pale. Denied pain. He was admitted for a similar episode of hypotension in [Month (only) ] that responded to IVF w/o infectious source found and he was discharged on midodrine and his metoprolol was stopped. . In the ED yesterday he was afebrile. BP 82/49. ROS for infection was negative. He received 1 Liter bolus. Labs showed baseline anemia, and baseline electrolyte abnormalitis. Notably K 4.7 and troponin 0.05. A UA was significant for UA >182WBC lg leuk sm bld mod bact 0 epi. Urine and blood cultures - pending, Lactate 1.6. At that point his vitals were stable 112/58 68 96% home oxygen. He underwent a CTA of his torso which showed a stable aortic aneurysm/dissection. Then started on vancomycin, levofloxacin, and Flagyl for possible infection and transferred to the [Hospital Unit Name 153]. . In the [Hospital Unit Name 153] he was found to have pyuria and started on abx w/ urine cx pending. He was started on linezolid and tobramycin due to past resistance to antibiotics. D/ced given low suspicion of infx. He tolerated hemodialysis on the morning of [2129-1-20] w/out fluid bolus. He felt well and had 6 hours of obs w/ stable BPs (SBP 97-121). . Transfer vitals were 112/58 68 96% on 2l (home oxygen). . Upon arrival to the floor on [Hospital Ward Name ] 7 Mr. [Known lastname 12731] was feeling well. States that he has felt much better since [Known lastname 2286] this morning. No weakness, dizzyness, SOB, or N/V. He does endorse decreased food intake over the past week. . . Imaging: - bedside u/s: lg infrarenal aorta/iliacs c/f aneurysm vs dissection - CT torso: stable aneurysm Ekg: 62 LAD, RBBB w/ Left anterior fascicular block, twi III, avF consult: FYI'd renal . . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Primary Care Physician: [Name10 (NameIs) 7790], [Name11 (NameIs) ] . Past Medical History: - ESRD on HD (MWF) - CAD s/p MI - Afib, not anticoagulated - CVAs x2, residual R sided weakness, from 12 [Name11 (NameIs) 1686] then 5 [Name11 (NameIs) 1686] ago - Hx of GI Bleed - Nephrolithiasis - OSA, not using CPAP - Iron Deficiency Anemia - Depression - Hx of C.diff - Restrictive Ventalatory Pulmonary Defect - Pelvic and wrist fractures [1-29] - Recurrent UTIs, including VRE and klebsiella - Multiple episodes of line related bacteremia: - MRSA in [2125-9-6] treated for 6 weeks of vanc given possible clot in fistula. Line removed. TTE negative for vegetation. TEE not performed. - ESBL E.coli bacteremia in [2125-9-26] thought to be line related. - ESBL E.coli bacteremia in [2125-11-26]. Thought to be line related. s/p total 4-week course of meropenem/ertapenem. ([Date range (1) 12915]) for likely endovascular infection in setting of R IJ clot. - ESBL E.coli x 2 types, E. faecium [Name (NI) 12916] unclear source despite extensive work-up ([2126-6-27]). s/p 4 weeks of Vancomycin and Meropenem. - ESBL E. coli and E. faecium [Month/Day/Year 12916] ([2126-7-28]) thought to be line related s/p 2 weeks Vancomycin/Meropenem. - Pansusceptible Klebsiella pneumoniae [Month/Day/Year 12916] thought [1-20] 7mm CBD stone. s/p ERCP and stenting. Due for repeat ERCP Past Surgical History - [2127-7-31] C2 fracture dislocation with progressive collapse s/p ORIF C2 and posterior instrumentation C1-C5 and left iliac crest bone graft placement, complicated by osteomyelitis. - [2127-4-28] Right popliteal thrombosis s/p popliteal and tibial embolectomy and R below the knee popliteal and tibial vein path angioplasty - R AVF placement [1-28] - L UE fistulogram/angioplasty [8-28] - LUE fistulagram [10-27] - LUE fistulogram and angioplasty of central venous stenosis [7-27] - L AV brachiocephalic fistula [5-27] - cataract surgery [4-26] - R ureteral stent placement [5-25] - I&D R wrist [5-25] - R shoulder surgery [6-19] - L cataract surgery [11/2117] - L knee surgery Social History: Lives with wife [Name (NI) ], wife of 62 [Name2 (NI) 1686]; see is his primary caregiver. [Name (NI) ] is wheelchair bound but has a nurse to help with showering, daughter lives downstairs -h/o smoking [12-20] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. Family History: Non-contributory. Physical Exam: Admission to Medicine: Vitals: T:95.9 BP: 142/82 P: 70 R: 18 O2: 99% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, neck collar in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi 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, no CVA tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, CN II-XII w/out decrement, PERRL, [2-21] RLE strength, [3-24] RUE strength Discharge: Vitals: T:95.6 BP: 110/70 P: 74 R: 20 O2: 100% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, neck collar in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi 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, no CVA tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, CN II-XII w/out decrement, PERRL, [2-21] RLE strength, [3-24] RUE strength Pertinent Results: Admission: [2129-1-19] 12:05PM BLOOD WBC-8.6 RBC-3.51* Hgb-10.8* Hct-33.0* MCV-94 MCH-30.9 MCHC-32.9 RDW-15.7* Plt Ct-179 [2129-1-19] 12:05PM BLOOD Neuts-75.8* Lymphs-17.3* Monos-5.0 Eos-1.6 Baso-0.3 [2129-1-19] 12:05PM BLOOD PT-12.6* PTT-28.1 INR(PT)-1.2* [2129-1-19] 12:05PM BLOOD Glucose-98 UreaN-59* Creat-5.6# Na-138 K-4.5 Cl-100 HCO3-25 AnGap-18 [2129-1-19] 12:05PM BLOOD ALT-10 AST-11 AlkPhos-112 TotBili-0.2 [2129-1-19] 12:05PM BLOOD Lipase-18 [2129-1-19] 12:05PM BLOOD cTropnT-0.05 [2129-1-19] 12:05PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.1 Mg-1.9 [2129-1-19] 12:19PM BLOOD Lactate-1.6 [2129-1-19] 05:20PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.014 [2129-1-19] 05:20PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [2129-1-19] 05:20PM URINE RBC-10* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [2129-1-19] 05:20PM URINE WBC Clm-MANY Blood cultures pending x2 Urine culture pending CTA ABD & PELVIS Study Date of [2129-1-19] 2:39 PM \ Pending CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2129-1-19] 2:39 PM Pending Brief Hospital Course: Brief Hospital Course 85 M w/ hx of ESRD on HD, CAD, afib, CVA w/ residual R sided weakness who presented from [Date Range 2286] with hypotension. The cause of which is likely multifactorial including: Decreased PO intake, possibly worsening pulmonary hypertension, and changing [Date Range 2286] requirements. . Hypotension: He initially presented with hypotension of 82/49. The BP normalized in ED with one liter of IVF, which was reassuring. Of note the patient had a similar episode of hypotension several months ago that resolved with IVF. Blood cultures and urine cultures were sent with consideration of his prior infections (hx of ESBL e.coli, VRE, multiple episodes of sepsis). Although the patient was initially started on vanc/levofloxacin/flagyl in ED and later transitioned to more narrow coverage (linezolid and tobramycin), antibiotics were ultimately discontinued as no infectious cause could be found. His WBC has remained normal and he has had no fevers. CXR did not show signs of pneumonia. Blood pressure remained above 110 throughout the admission. Pyuria was present on UA and likely reflects ESRD on HD. Bedside U/s in the ED demonstrated a large aortic aneurysm, which appears stable on CT scan, and unlikely to be cause of hypotension. No signs of bleeding. Cultures need to be followed up as an outpatient. He was continued on mitodrine without uptitation per renal recommendation. A TTE was performed to assess for cardiogenic cause of hypotension. The patient and his wife expressed a strong desire for discharge prior to formal interpretation of his TTE. This will need to be followed up by his outpatient providers. His dry weight in HD was increased in an effort to prevent further peri-HD hypotension. . ESRD on HD: Patient has a MWF schedule. The last HD was on Monday prior to admission. He missed his Wednesday HD because of hypotension. While in the hospital he received HD on Thursday and Friday ([2129-1-20] and [2129-1-21]) which was well tolerated. Renal saw the patient while in the hospital and was involved in his care. All meds were renally dosed. On [2129-1-21] his [Date Range 2286] was optimized to leave him with a slightly higher dry weight. Follow up was arranged with his primary physician and the [Date Range 2286] clinic. . Hx of CAD: The patient does not have signs of active ischemia. There were no EKG changes from a recent comparison. The trop was 0.05 in this renal patient. Considering bifascicular block and risk for total heart block, should discuss with PCP. [Name10 (NameIs) ] statin and ASA were continued. Beta blockade continued to be held in setting of hypotension. . Pulmonary Hypertension: This was noted on TTE from Febuary of [2127]. He does not have signs of heart failure on exam; however, the concern was raised for the possibility of it being a factor in his episodes of hypotension. . INCIDENTAL FINDINGS 1. Eccentric bladder wall thickening, new from [2127-6-7] that needs to be correlated with U/A and cytology. A bladder ultrasound considered. He should follow up with his primary care physician. . Transitional Issues: 1. Follow-Up TTE, Follow-up bladder wall thickening 2. Code: Full Code discussion initiated in inpatient setting. The patient expressed desire to remain Full Code despite expressing worsening quality of life. He will follow-up with his primary care physician. Medications on Admission: (per last discharge): 1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Medications: 1. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day. 2. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 50 mg Capsule Sig: One (1) Capsule PO once a day. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 14. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO once a day. 15. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1. Hypotension 2. Pre-existing End stage renal disease on hemodialysis, pulmonary artery hypertension, A-fib, coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 12731], You were admitted to the hospital for hypotension prior to receiving [Known lastname 2286] on Wednesday ([2129-1-19]). In the emergency room your blood pressure was found to be 82/49. You received 1 Liter of fluid intravenously and your blood pressure rose to 112/58. You did not have a fever and a work up for infection was all negative so far. Blood and urine cultures were sent to the lab that need to be followed up. Antibiotics were started initially; however, they were discontinued due to decreasing concern for infection. Imaging of your stomach revealed that your abdominal aortic aneurism is stable. While in the hospital you were sent to the intensive care unit for further monitoring and then transferred to the medicine service. Throughout your stay your blood pressure has remained stable. You received hemodialysis on [2129-1-20] and [2129-1-21] in keeping with your original schedule. Please note that your [Month/Day/Year 2286] parameters were changed on [2129-1-21]. Also, it is important that you follow up with your doctor if you experience fatigue or dizzyness again. MEDICATION CHANGES: None. FOLLOW UP: -It is important that you follow-up with your primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7790] regarding your blood and urine cultures. -Your [Last Name (NamePattern1) 2286] regimen has changed. Your dry weight has been increased. -Follow-up with your physician regarding the use of metoprolol. It is currently being held. Followup Instructions: Department: [Hospital1 18] [Location (un) 2352] When: TUESDAY [2129-1-25] at 2:30 PM With: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: TRANSPLANT CENTER When: THURSDAY [2129-2-10] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital1 18] [Location (un) 2352] When: TUESDAY [2129-4-12] at 1:50 PM With: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "585.6", "V45.11", "280.9", "414.01", "780.79", "416.0", "412", "327.23", "276.52", "438.89", "427.31", "458.9" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	14023, 14029	7965, 11092	309, 317	14207, 14207	6769, 7942	16004, 17020	5419, 5438		12807, 14000		14050, 14186		11402, 12784			14383, 15536										5453, 6750										15575, 15981											11113, 11376		2451, 2976		15557, 15564					258, 271																345, 2432										14222, 14359								2998, 5079	5095, 5403
16,324	181,703	11135+11136+56215	Discharge summary	report+report+addendum	Admission Date: [2169-10-16] Discharge Date: [2169-10-20] Date of Birth: [2100-7-10] Sex: M Service: CARDIOTHOR HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: This is a 69-year-old gentlemen with a history of coronary artery disease, status post percutaneous transluminal coronary angioplasty of right coronary artery and circumflex since [2168-5-19]. Patient also has a history of sick sinus syndrome. The patient had pacemaker placement in [2166-6-18]. The patient presents with chief complaint of chest discomfort on exertion times three months, for which he underwent an exercise stress test which was positive for ischemia. Patient was referred for coronary artery bypass graft with Dr. [Last Name (Prefixes) ]. Patient denies nausea, vomiting, shortness of breath or diaphoresis. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, non-insulin dependent diabetes, stroke in [2166-5-19], sick sinus syndrome. PAST SURGICAL HISTORY: Pilonidal cyst removal in [2120]. Coronary artery stenting times two in [2168-5-19]. Patient had pacemaker placement in [2166-6-18]. Incision and drainage of rectal abscess in [2165-8-19]. MEDICATIONS ON ADMISSION: Toprol XL 100 mg po q.d., Lipitor 40 mg po q.d., isosorbide 30 mg po q.d., Zoloft 150 mg po q.d., Xanax 0.5 mg po b.i.d., enteric coated aspirin 325 mg po q.d., Glucophage 500 mg po q.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother died of pneumonia at age 70 with coronary artery disease. Brother died at age 70 of stomach cancer, status post coronary artery bypass graft. PHYSICAL EXAMINATION: Height: 5 foot 7 inches. Weight: 183 pounds. General impression: Well-appearing, well-nourished gentlemen in no apparent distress appearance consistent with stated age, somewhat anxious. Skin: No rashes, well-hydrated. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation. Extraocular muscles were intact. No dentures. Neck supple, no jugular venous distention, no lymphadenopathy, no thyromegaly, no carotid bruits. Chest: Clear to auscultation bilaterally, no wheezes, rhonchi or rales. Heart: Regular rate and rhythm, no murmurs. Abdomen soft, nontender, nondistended, normal bowel sounds, no guarding or rebound. Extremities: Warm, no edema, no cyanosis. No varicosities. Neurological exam: Cranial nerves II through XII are grossly intact. LABORATORY DATA: Left heart catheterization performed [2168-6-2] demonstrating three vessel coronary artery disease including right coronary artery, 70% stenosis in mid portion, left anterior descending coronary artery 60% stenosis in mid portion at the site of the take-off of the first diagonal, left circumflex coronary artery 90-95% stenosis in the proximal portion. CO[Last Name (STitle) 14945]SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery on [2169-10-16]. On the day of admission, the patient went to the Operating Room with Dr. [Last Name (Prefixes) ] and had a coronary artery bypass graft four vessels which he received anastomosis between the left internal mammary artery to the left anterior descending coronary artery, reverse saphenous vein graft to right coronary artery and a right reverse saphenous vein graft to obtuse marginal artery. Please see previously dictated operative note by Dr. [Last Name (Prefixes) ]. The patient tolerated the procedure well and was brought to the Cardiac Surgical Intensive Care Unit in stable condition. Shortly after his arrival in the Cardiothoracic Intensive Care Unit, the patient was extubated, weaned off cardioactive intravenous drips and was ready to be transferred to the patient care floor on postoperative day number one. On postoperative day number one, both chest tubes were removed without incident. When on the floor, the patient's Foley was removed on postoperative day number two. He was able to void without problem. By postoperative day number four, [10-20], the patient's pain was controlled with po medications, tolerating a regular diet without a problem and was ambulating in the hallway. CONDITION ON DISCHARGE: Stable. DISPOSITION: Discharged to rehabilitation. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft times four. MEDICATIONS ON DISCHARGE: 1. Toprol 100 mg po q.d. 2. Lipitor 40 mg po q.d. 3. Isosorbide 30 mg po q.d. 4. Zoloft 150 mg po q.d. 5. Xanax 0.5 mg po b.i.d. 6. Enteric coated aspirin 81 mg po q.d. 7. Glucophage 500 mg po b.i.d. 8. Percocet 1-2 tablets po q. 4-6 hours prn pain. 9. Colace 100 mg po b.i.d. FO[Last Name (STitle) ]P: The patient will follow-up with Dr. [Last Name (Prefixes) ] of Cardiothoracic Surgery. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2169-10-22] 10:56 T: [2169-10-22] 10:56 JOB#: [Job Number 35886] Admission Date: [2169-10-16] Discharge Date: [2169-10-21] Date of Birth: [2100-7-10] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This gentleman had increasing chest discomfort on exertion over three months with a known history of coronary artery disease. He had prior PTCA of his RCA and a circ in [2168-5-19]. He also had history of sick sinus syndrome and pacemaker placement in [2166-6-18]. He had a positive stress test and was referred for cardiac catheterization and coronary bypass surgery. PAST MEDICAL HISTORY: 1) Coronary artery disease. 2) Hypertension. 3) Hypercholesterolemia. 4) Non insulin dependent diabetes mellitus. 5) History of CVA in [2166-5-19]. 6) Sick sinus syndrome. PAST SURGICAL HISTORY: Includes two coronary stents in [2168-5-19], pilonidal cyst removal in [2120], pacemaker placement in [2166-6-18] and a rectal abscess in 9/97. MEDICATIONS: At home, Toprol XL 100 mg po q d, Lipitor 40 mg po q d, Isosorbide 30 mg po q d, Zoloft 150 mg po qid, Xanax 0.5 mg po q d, enteric coated Aspirin 325 mg po q d and Glucophage 500 mg po q d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On preadmission testing he was somewhat anxious, had no JVD, no carotid bruits, his lungs were clear bilaterally without any wheezing or rhonchi, heart was regular rate and rhythm, S1 and S2 with no murmurs. Abdominal exam was normal. Extremities were warm without edema or any cyanosis. Neurologically he was grossly intact. He had good peripheral pulses. He was found at cardiac catheterization to have three vessel disease. Please refer to his cardiac catheterization report. Cardiac catheterization report showed a 30% left main lesion, multiple lesions in the LAD with a mid 90% stenosis, 80% circumflex and 80% RCA lesion. He had preserved ejection fraction and was referred for coronary artery bypass grafting. LABORATORY DATA: Pre-operative laboratory work showed a sodium of 139, potassium 4.5, chloride 103, CO2 28, BUN 24, creatinine 1.0, white count 6.1, hematocrit 37 and INR 1.0. HOSPITAL COURSE: On [10-16] he underwent coronary artery bypass grafting times four with a LIMA to the LAD, vein graft to the RCA, vein graft to the OM and vein graft to the diagonal by Dr. [First Name (STitle) ] [Last Name (Prefixes) ]. He was transferred to the cardiothoracic ICU in stable condition. On postoperative day #1 he was hemodynamically stable, had been extubated and was on three liters nasal cannula with a good sat. His potassium was 4.4 with hematocrit of 40, blood sugar of 123. He was alert and following commands. His lungs were clear bilaterally. His incisions were clean, dry and intact. He began his Lopressor, Aspirin and Lasix diuresis and he was transferred out to the floor. He was seen by physical therapy. On postoperative day #2 he remained hemodynamically stable with a blood pressure of 128/68 and sinus rhythm. His blood sugars were running in the 190-207 range. Chest tubes were pulled. He had some edema of his upper extremities. His sternum was stable and his wounds were otherwise clean, dry and intact. His Lopressor was increased to slow his heart rate down a little bit. His Foley was removed. He continued to ambulate with PT. He was seen by case management. On postoperative day #3 his pain was controlled, he was ambulating well but had not done stairs yet. He had one episode of epistaxis the prior afternoon. He had some complaints of left hand coolness and decreased sensation. His heart rate was in the 70-80 range. His Foley was out and he had voided. He was otherwise comfortable, his lungs were clear, his heart was regular rate and rhythm. His chest tube sites were dry. His right lower extremity saphenectomy site was clean, dry and intact with trace edema. His left hand had a 2+ radial pulse. He had sensation to light touch and motor skills [4-22]. His pacer wires were removed. He continued ambulating with physical therapy and made good progress. On postoperative day #4 he had no complaints. He did stairs level V ambulation. He was tolerating his diet, remained stable with heart rate in the 80's and a good blood pressure of 146/70. He was comfortable, his lungs were clear, his incisions were clean, dry and intact. PT consult was obtained. His Lopressor was increased to 50 mg [Hospital1 ] and on postoperative day #5 he was discharged to home. His blood pressure was 138/73, he was satting 96% on room air, his heart rate was in the 70's, incisions were clean, dry and intact. His abdominal exam was benign. His lungs were clear. He was hemodynamically stable and was discharged on the following medications. DISCHARGE MEDICATIONS: Ibuprofen 400-600 mg po prn q 6 hours, Lipitor 40 mg po q d, Glucophage 500 mg po bid, Zoloft 150 mg po q d, Xanax 0.25 mg po q d, Lasix 20 mg po bid times 7 days, KCL 20 mEq po bid times 7 days, Colace 100 mg po bid, Aspirin 81 mg po q d, Lopressor 75 mg po bid and po Percocet as needed for pain. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times four. 2. Coronary artery disease. 3. Hypertension. 4. Hypercholesterolemia. 5. Non-insulin dependent diabetes mellitus. 6. Status post CVA. 7. Sick sinus syndrome with pacemaker placement in [2165]. DI[Last Name (STitle) 408]E INSTRUCTIONS: Follow-up with Dr. [Last Name (Prefixes) ] in [2-19] weeks and to see Dr. [Last Name (STitle) ], his primary care physician, [Name10 (NameIs) ] also 3-4 weeks and was discharged to home on [2169-10-21]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2169-11-1] 10:46 T: [2169-11-2] 12:29 JOB#: [Job Number 35887] Name: [Known lastname 6413], [Known firstname ] Unit No: [Numeric Identifier 6414] Admission Date: [2169-10-16] Discharge Date: [2169-10-21] Date of Birth: [2100-7-10] Sex: M Service: ADDENDUM: This is an addendum to previously dictated Discharge Summary. The patient decided to remain in the hospital one additional night. The reason for this course of action was that instead of going to rehabilitation, he chose to be discharged to home. The additional night was to help prepare him for discharge home. MEDICATIONS ON DISCHARGE: (Previously dictated medications were in error. His medications on discharge are) 1. Ibuprofen 400 mg to 600 mg p.o. q.6h. p.r.n. for pain. 2. Lipitor 40 mg p.o. q.h.s. 3. Zoloft 150 mg p.o. q.d. 4. Glucophage 500 mg p.o. b.i.d. 5. Xanax 0.25 mg p.o. b.i.d. 6. Lasix 20 mg p.o. b.i.d. times one week. 7. Potassium chloride 20 mEq p.o. q.12h. 8. Colace 100 mg p.o. b.i.d. while on narcotics. 9. Aspirin 81 mg p.o. q.d. 10. Lopressor 75 mg p.o. q.d. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 681] Dictated By:[Last Name (NamePattern1) 2383] MEDQUIST36 D: [2169-10-21] 19:33 T: [2169-10-27] 08:58 JOB#: [Job Number 6415] (cclist)	[ "V45.01", "401.9", "V45.82", "414.01", "272.0", "250.00" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.13", "39.61" ]	icd9pcs	[ [ [] ] ]							1480, 1631	10139, 11507	9818, 10118		4287, 4341	11534, 12272	1237, 1463	7181, 9794											5836, 6237													2898, 4186					6260, 7163												2408, 2868																	5227, 5608																		5631, 5812		4211, 4265
57,369	131,598	39963	Discharge summary	report	Admission Date: [2128-11-20] Discharge Date: [2128-11-22] Date of Birth: [2075-6-23] Sex: M Service: MEDICINE Allergies: Prinivil Attending:[First Name3 (LF) 99] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Atrial line Placement Mechanical Intubation Central Line Placement (Left IJ) Lumbar Puncture History of Present Illness: (obtained through family and med recs) 53 y/o with polysubstance abuse presents with cardiac arrest. Pt reported feelilng generally unwell today with fatigue significant enought to hault his normal smoking and drinking habits. He had nausea without vomitting. He did not complain of CP, SOB. This afternoon he was sitting with his friend watching TV, when he was noted to be gasping. The friend evaluated him, found that he was not breathing and called in the rest of the family / EMS. Per EMS they were dispatched at [2059] and arrived on seen at [2062]. On arrival he was apneic and in junctional rytheam. CPR was started. FSBG was 40. He then converted to PEA. He received 2mg of epi and 1mg of atropine. Approximately 20 minutes of CPR were performed. . In [Hospital3 4107] he received Bicarb, pRBC, and protonix. A right femoral line and PIV x2 was placed. He was started on dopamine which was converted to levaphed and vasopression. There he was noted to have 300cc of read NG output. Pulse was maintained throught the stay at [Hospital1 ] and BP improved from the SBP 50s on arrival. She received 3 units of RBC (3rd finishing on arrival to [Hospital1 ]). In the ED, initial vs were: T 98.7 P 88 BP 114/63 R 22 O2 sat 99% on AC. Patient was given CTX 1g iV, versed and fentanyl gtt in the setting of intubation, octreotide 50mcg x1 and 50mcg/hr gtt. Levophend and vaso were weaned. he had a small amount of red blood via NG tube and a large marroon bloody stool in the ED. HCT improved from 30 at [Hospital1 ] to 39 on admision. CT head obtained enroute was negative for CT head. . On the floor, the patient is intubated and sedated. Noted to intermittenly twitch in a nonpurposeful way. . Review of systems: (+) Per HPI otherwise unable to obtain Past Medical History: alcohol abuse complicated with seizures DM HTN ADD s/p splenectomy T2N2M0 squamous cell carcinoma of the tongue s/p recection, radiation. Social History: Patient lives with his elderly mother in [Name (NI) 5110]. - Tobacco: active long time smoker - Alcohol: active heavy drinker, h/o DTs. Last drink is day PTA - Illicits: h/o opiod addiction. Family denies additional use, however u tox cocaine positive. . Family History: NC Physical Exam: Vitals: T: 94 BP: 125/61 P: 92 R: 17 O2: 100% AC 500/18/50%/5 General: intubated, not arousable despite lack of sedation HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: RLL crakles . No wheezes, ronchi CV: tachy rate and regular rhythm, 2/6 SEM at aortic position Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: cool but well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: Pupils 1mm non reactive BL. corneal reflex absent. No gag. 1+ DTR. [Name (NI) 87925] [Name2 (NI) 6954]. Pertinent Results: Admission Labs [2128-11-20] 10:50PM GLUCOSE-212* LACTATE-11.8* NA+-139 K+-4.4 CL--105 TCO2-10* [2128-11-20] 10:40PM GLUCOSE-240* UREA N-12 CREAT-1.3* SODIUM-139 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-10* ANION GAP-35* [2128-11-20] 10:40PM estGFR-Using this [2128-11-20] 10:40PM ALT(SGPT)-364* AST(SGOT)-1186* ALK PHOS-116 TOT BILI-1.1 [2128-11-20] 10:40PM LIPASE-47 [2128-11-20] 10:40PM ALBUMIN-4.1 CALCIUM-7.9* PHOSPHATE-8.8* MAGNESIUM-1.7 [2128-11-20] 10:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2128-11-20] 10:40PM URINE HOURS-RANDOM [2128-11-20] 10:40PM URINE HOURS-RANDOM [2128-11-20] 10:40PM URINE GR HOLD-HOLD [2128-11-20] 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2128-11-20] 10:40PM WBC-5.9 RBC-4.06* HGB-13.0* HCT-39.1* MCV-96 MCH-32.1* MCHC-33.3 RDW-14.6 [2128-11-20] 10:40PM NEUTS-88.3* LYMPHS-9.0* MONOS-1.7* EOS-0.7 BASOS-0.3 [2128-11-20] 10:40PM PLT COUNT-200 [2128-11-20] 10:40PM PT-16.5* PTT-61.9* INR(PT)-1.5* [2128-11-20] 10:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2128-11-20] 10:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG . Discharge Labs [2128-11-22] 06:22AM BLOOD WBC-21.9* RBC-4.79 Hgb-15.5 Hct-45.0 MCV-94 MCH-32.3* MCHC-34.4 RDW-15.4 Plt Ct-120* [2128-11-21] 08:27PM BLOOD WBC-17.8* RBC-4.88 Hgb-15.8 Hct-45.2 MCV-93 MCH-32.5* MCHC-35.0 RDW-15.1 Plt Ct-165 [2128-11-21] 12:43PM BLOOD WBC-14.1* RBC-4.67 Hgb-14.8 Hct-44.0 MCV-94 MCH-31.8 MCHC-33.7 RDW-15.0 Plt Ct-187 [2128-11-20] 10:40PM BLOOD Neuts-88.3* Lymphs-9.0* Monos-1.7* Eos-0.7 Baso-0.3 [2128-11-22] 06:22AM BLOOD Plt Ct-120* [2128-11-22] 06:22AM BLOOD PT-30.1* PTT-41.9* INR(PT)-3.0* [2128-11-21] 08:27PM BLOOD Plt Ct-165 [2128-11-22] 06:22AM BLOOD Glucose-141* UreaN-30* Creat-2.6* Na-146* K-3.9 Cl-112* HCO3-19* AnGap-19 [2128-11-21] 08:27PM BLOOD Glucose-77 UreaN-25* Creat-2.0* Na-144 K-3.6 Cl-110* HCO3-20* AnGap-18 [2128-11-21] 05:52AM BLOOD Glucose-303* UreaN-17 Creat-1.6* Na-141 K-3.1* Cl-104 HCO3-18* AnGap-22* [2128-11-22] 06:22AM BLOOD ALT-1010* AST-2908* LD(LDH)-1414* CK(CPK)-[2038]* AlkPhos-78 TotBili-6.2* [2128-11-21] 08:27PM BLOOD CK(CPK)-2585* [2128-11-21] 12:43PM BLOOD ALT-947* AST-5274* CK(CPK)-2739* [2128-11-21] 05:52AM BLOOD CK(CPK)-2123* [2128-11-22] 06:22AM BLOOD CK-MB-37* MB Indx-1.9 cTropnT-2.69* [2128-11-21] 08:27PM BLOOD CK-MB-52* MB Indx-2.0 cTropnT-2.19* [2128-11-21] 12:43PM BLOOD CK-MB-45* MB Indx-1.6 cTropnT-3.49* [2128-11-22] 06:22AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.7 [2128-11-21] 08:27PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.9 [2128-11-21] 12:43PM BLOOD Calcium-7.5* Phos-2.0* Mg-2.1 [2128-11-20] 10:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2128-11-22] 06:59AM BLOOD Type-MIX Temp-39.3 pO2-61* pCO2-34* pH-7.29* calTCO2-17* Base XS--8 Comment-GREEN TOP [2128-11-21] 08:52PM BLOOD Type-[Last Name (un) ] pH-7.32* Comment-GREEN-TOP [2128-11-21] 03:58AM BLOOD Type-ART pO2-239* pCO2-27* pH-7.36 calTCO2-16* Base XS--8 [2128-11-22] 06:59AM BLOOD Glucose-125* Lactate-3.2* [2128-11-21] 03:58AM BLOOD Lactate-5.6* [2128-11-21] 08:52PM BLOOD freeCa-1.10* [2128-11-21] 03:58AM BLOOD freeCa-0.97* . [11-20] EKG Sinus rhythm. No previous tracing available for comparison. TRACING #1 . [11-10] CXR ET tube and feeding tubes in expected locations. Possible mild vascular plethora, but likely accentuated by supine position. . [11-21] CT head w/o Contrast IMPRESSION: 1. No evidence of acute intracranial process. 2. Pronounced hypoattenuation within posterior limbs of the internal capsule, of unclear significance. 3. Paranasal sinus disease. ATTENDING NOTE: The hypodensity in bilateral globus pallidus region are suggestive of hypoxic injury. No hemorrhage. Clinical service was notified. . [11-21] CXR An ET tube is present, tip approximately 3.5 cm above the carina. An NG tube is present, tip extending beneath diaphragm, portion of it extends beyond the film. It appears to loop, with the tip overlying the fundus. Heart size is at the upper limits of normal. The aorta is minimally calcified and slightly unfolded. There is no CHF, focal infiltrate, or effusion. No pneumothorax is detected. There is biapical pleural thickening, asymmetrically more prominent on the left with possible parenchymal scarring at the left lung apex. Dense carotid artery calcification is noted on both sides. IMPRESSION: 1. Lines and tubes as described. 2. No acute pulmonary process identified. Left greater than right apical pleural parenchymal scarring noted. 3. Dense bilateral carotid artery calcification. . [11-21] Portable Abdominal X ray IMPRESSION: Nonspecific bowel gas pattern. The transverse colon is mildly dilated, but the haustral folds are not effaced. This may represent ileus. . [11-22] Echocardiogram The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No valvular pathology or pathologic flow identified. . [11-22] CXR IMPRESSION: AP chest compared to [11-20] and 31: New region of consolidation in the left lung base could be developing pneumonia. Lungs are otherwise clear. No pulmonary edema. Normal cardiomediastinal silhouette. No pleural effusion or pneumothorax. ET tube in standard placement. Nasogastric tube takes a wide loop in the stomach. . Brief Hospital Course: 53 y/o hx. of polysubstance abuse presented with cardiac arrest and GI Bleed. . # Cardiac arrest: The order of events remains unclear, whether a GI Bleed lead to hypotension and PEA / arrest. The relative stable response to 3 units speaks against this hypothesis. Another possibility is that an MI from cocaine precipitated arrest, hypotension, and ischemic bowel. Troponins elevated to 2.35, peaked at 3.49 and now downtrended to 2.69. Cardiology was consulted and aspirin was held given bleed.Post cardiac arrest recs were followed: HOB elevation. no cooling given bleed.-TTE showed normal study. . # GI Bleed: likely UGIB given positive NG lavage and BRBPR. NG clearing with 150cc bolus. GI recommended continued antibiotics, IV PPI which were ordered. Defered EGD as pt has multiple comorbidities and prognosis is grim. 2 units of PRBC's given on arrival to unit. . # unresponsive: off sedation, lack of coordinated movements in setting of prolonged code concerning for anoxic brain injury. Per neuro, CT consistent with anoxic brain injury. MRI could not be performed due to inability to confirm surgical history. Neuro agreed with poor prognosis. After family meeting to discuss goals of care, poor prognosis and critical clinical status it was decided to extubate the patient and carry out comfort care. . # ? seizure activity: myoclonic jerks were seen. CT head neg. now without corneal reflex and therefore could have been fasciculations given brain injury. Fosphentyoin was continued. . # Fever: Central vs infectious. Aspiration PNA possible given respiratory distress; cxr showing LLQ pneumonia. Continued zosyn. F/u urine, blood, sputum cultures which were pending. . # cocaine abuse: pos in urine. avoided beta blockers . # ARF: ATN given code and hypotension vs prerenal. . # ETOH abuse: level 18 on admission. observed BP, tachycardia for signs of withdrawal. . After a family meeting which included his poor prognosis and description of the patient??????s critical medical condition it was decided to extubate the patient and carry out comfort measures only. I was called to the patient??????s room after he was found unresponsive. . I found the patient to be unresponsive to both name and touch. I visualized and auscultated no cardiopulmonary activity for 1 minute. The patient also had no corneal reflex or pupil reaction to direct light bilaterally. The patient had no radial or carotid pulse palpated bilaterally. I pronounced the patient had passed away at 3:27PM on [2128-11-22] with the family at bedside. Medications on Admission: metoprolol 25mg PO bid lisinopril 30mg PO BID dilantin 300mg qpm lovastatin 20mg qpm metformin 500mg [Hospital1 ] aspirin daily Discharge Medications: Patient passed away Discharge Disposition: Expired Discharge Diagnosis: Patient passed away Discharge Condition: Patient passed away Discharge Instructions: Patient passed away Followup Instructions: Patient passed away	[ "584.9", "V10.01", "E854.3", "E860.0", "314.01", "970.81", "304.21", "348.1", "427.89", "578.9", "980.0", "303.01", "427.5", "507.0", "E849.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	12445, 12454	9665, 12218	285, 380	12517, 12538	3318, 9642	12606, 12628	2652, 2657		12401, 12422		12475, 12496		12244, 12378			12562, 12583										2672, 3299																							2152, 2193							230, 247																408, 2133																		2215, 2355	2371, 2635
71,945	113,142	6736	Discharge summary	report	Admission Date: [2102-11-9] Discharge Date: [2102-11-22] Date of Birth: [2021-9-15] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 20506] Chief Complaint: Eyelid droop and weakness Major Surgical or Invasive Procedure: IVIG infusion. History of Present Illness: HPI: Patient is a 81 yo RHM with hx of HTN, DM, hyperlipidemia and chronic LBP here with question of myasthenia [Last Name (un) 2902]. Patient reports that 1 month ago, he suddenly awoke with L sided hearing loss. He also reported numbness of the L ear to touch and occasional clicking noise in the L side in addition to complete hearing loss that occurred overnight. He was seen per Dr. [Last Name (STitle) 3878] (ENT) who evaluated him with MRI of brain that did was not revealing (no mass) and treated him with 1 week of oral steroids with no improvement. Then about 2 weeks ago, patient was noticed to have L ptosis per son and developed vertical diplopia (items afar seem to be on top of each other). This diplopia is not present when he awakes but it starts within minutes after waking up. He was also noticed to be more fatigued and easily tired although still able to continue most of his daily activities including laundry, walking up/down the stairs and etc. Around 3 days ago, patient noticed that he was having trouble swallowing food/water in large gulps. If he drank or ate more than teaspoon at a time, things would come out his nose. He also felt that food was getting stuck in his throat and he had trouble expectorating. He also started to need to cut up his pills because he had trouble swallowing them whole. He went to see his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] for his monthly B12 shots and upon hearing his symptoms, referred the patient to Dr. [Last Name (STitle) ] for myasthenia [Last Name (un) 2902] evaluation and treatment. Patient reports that he has not taken any meds today. ROS otherwise negative including recent fever/chills, N/V/D, falls, HA or sick contact. At baseline, patient occasionally uses a cane for additional support but completely independent in all his ADLs including IADLs. Of note, patient underwent open cholecystectomy for failed ERCP in [7-11] with no post-operative complications including awaking from the anesthesia. Past Medical History: h/o facial basal cell carcinoma chronic lower back pain Aortic stenosis Hypertension Hyperlipidemia Diabetes Mellitus [2102-6-27] Left biliary duct stent placement for left duct stricture (jaundiced) [2102-7-4] open cholecystectomy Social History: Patient was in the navy and worked on boats his entire life. He is married and lives with his "bride". He denies tobacco, alcohol or drug use. He has a history of asbestos exposure. Family History: No family history of malignancy. Physical Exam: T 97.7 BP 117/64 HR 77 RR 16 O2Sat 100% RA - able to count to 20 in one breath. NIF -14 with mask and VC 900. Gen: Lying in bed, NAD Neck: No carotid or vertebral bruit CV: RRR, 2/6 SEM best heard LUSB Lung: Clear anteriorly Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive - able to do DOW backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [Location (un) ] intact. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV & VI: Extraocular movements intact bilaterally, no nystagmus. Develops transient vertical ptosis in 20 seconds. V: Sensation intact to LT and PP. VII: L ptosis. VIII: Hearing intact to finger rub only on R. X: Palate elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline, movements intact Motor: Normal bulk and tone bilaterally. No observed myoclonus or tremor. No asterixis or pronator drift - fatigable R delt -> weakens to 4- from 5-. Weak neck flexor but intact extensor. [Doctor First Name ] Tri [Hospital1 ] WE FE FF IP H Q DF PF R 5- 5- 5 5 5- 5 5- 5 5 5 5 L 5 5- 5 5 5- 5 5- 5 5 5 5 Sensation: Intact to light touch, pinprick, and cold but decreased vibratory sensation in both big toes and decreased proprioception, worse on R than L. Reflexes: 2s for UE and patellar but none for Achilles. Toes upgoing on L only. Coordination: FTN, FTF and HTSs normal. Gait: Deferred. Pertinent Results: [2102-11-8] 02:50PM WBC-4.4 RBC-4.82# HGB-14.1 HCT-42.9# MCV-89# MCH-29.2# MCHC-32.8 RDW-13.9 [2102-11-8] 02:50PM PLT COUNT-145* [2102-11-8] 02:50PM TSH-1.3 [2102-11-8] 02:50PM TOT PROT-7.4 ALBUMIN-4.1 GLOBULIN-3.3 CALCIUM-9.1 MAGNESIUM-2.1 [2102-11-8] 02:50PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-50 TOT BILI-0.8 [2102-11-8] 02:50PM estGFR-Using this [2102-11-8] 02:50PM UREA N-18 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14 [2102-11-8] 02:50PM GLUCOSE-218* [2102-11-9] 10:45AM PLT COUNT-129* [2102-11-9] 10:45AM NEUTS-69.0 LYMPHS-22.5 MONOS-6.3 EOS-0.8 BASOS-1.4 [2102-11-9] 10:45AM WBC-4.7 RBC-4.75 HGB-13.9* HCT-41.8 MCV-88 MCH-29.3 MCHC-33.2 RDW-14.5 [2102-11-9] 10:45AM GLUCOSE-175* UREA N-19 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-31 ANION GAP-11 [2102-11-9] 04:10PM PT-13.0 PTT-29.5 INR(PT)-1.1 Brief Hospital Course: The patient was admitted and the initial goal had been to start plasmapheresis, however given the significant aortic stenosis, this was deferred in favor of an initial attempt to treat with IVIG. He was also started on pyridostigmine. His baseline NIF and VC were low at -40 and 800, however he did not appear to be able to fully cooperate with testing and thus these numbers were thought to be partially artifically decreased. He had some minor improvement in his strength after 5 days of IVIG. Prior to initiation of steroid therapy, he was checked for a urine infection and incidentally found to have a urinary tract infection, and thus he was treated with antibiotics for a 5-day course initially with ceftriaxone, transitioned to ampicillin once sensitivities returned. He failed a speech and swallow evaluation, but initially refused to have an NG tube placed, thus he fed himself purees over the weekend [Date range (1) 21226]. He did not have any overt aspiration, however on [11-15] there continued to be extreme concern for aspiration, thus he did agree to an NG tube being placed and on [11-15] he began NG feeds. On [11-16] he developed acute onset of oxygen requirement and lethargy accompanied by a fall in his NIF and vital capacity to -20 and 400 cc. Given concern for acute respiratory failure, he was transferred to the medical intensive care unit. An ABG immediately prior to transfer was notable for a carbon dioxide level of 58, lower than was expected based upon the clinical picture. In the MICU, he was treated with BiPAP for one day with substantial improvement, and no alternative etiology was identified for his acute change in mental status. A pheresis catheter was placed due to the potential need to initiate plasmapheresis despite his aortic stenosis if he were not to regain his strength and require further respiratory support. However, he made a substantial improvement over the course of 24 hours, and was transferred back to the floor on [11-18] on 2L nasal cannula, again able to ambulate with a normal mental status. He was also found to have an elevated PTT due entirely to subcutaneous heparin (based on hepzyme test), thus he was no longer given subcutaneous heparin instead ambulation and pneumoboots for prophylaxis. He was started on prednisone 10 mg daily on [11-14] which was briefly held for his urinary tract infection and reinitiated on [11-16]. By day of discharge, this increased to prednisone 40 mg daily. He continued to have stable NIF and VC. His feeds were advanced to an oral diet after evaluation with video swallow study. He received physical therapy. He was discharged home with plan to receive physical therapy as an outpatient as well. Medications on Admission: 1. Pantoprazole 40mg [Hospital1 ] 2. Propranolol 80 mg daily 3. Enalapril Maleate 5 mg DAILY 4. Hydralazine 50 mg [Hospital1 ] 5. Niaspan 1000mg daily 6. Aspirin 325 mg daily 7. Vitamin D 8. Centrum Silver 9. Alendronate 70 - every Wednesday 10. B12 shots - monthly Discharge Medications: 1. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 8. Niacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Myasthenia [Last Name (un) ]. Discharge Condition: Stable, normal neurologic exam. Discharge Instructions: Your were admitted for eyelid droopiness and diagnosed with myasthenia [Last Name (un) 2902], treated with IVIG. The myasthenia causes it to be difficult ot swallow, and you required an NG tube to feed and take medications. Before discharge, your feeds were advanced to an oral diet. You briefly had difficulty breathing and so were transferred to the MICU for observation and treated with BiPAP support. Your breathing improved and were transferred back to the general floor. You received physical therapy. You were treated with prednisone which you will continue after discharge. 1. Take all medications as directed. 2. If you experience new or worsening symptoms, please contact your physician or if urgent, please proceed directly to the nearest emergency room. Followup Instructions: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2102-12-12] 9:00 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2102-12-15] 4:30 Completed by:[2102-12-17]	[ "041.04", "518.84", "272.4", "401.9", "724.2", "599.0", "250.00", "733.00", "389.15", "368.2", "288.50", "276.2", "V10.83", "358.01", "285.9", "787.22", "424.1", "374.32" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "93.90", "99.14" ]	icd9pcs	[ [ [] ] ]	9770, 9845	5691, 8444	344, 361	9923, 9957	4734, 5663	10781, 11112	2905, 2939		8769, 9747		9866, 9902		8470, 8746			9981, 10758										2954, 3221																														279, 306																389, 2427	3588, 4715									3260, 3572					3245, 3245			2449, 2690	2706, 2889
51,154	170,267	36561	Discharge summary	report	Admission Date: [2158-2-12] Discharge Date: [2158-2-25] Date of Birth: [2098-5-17] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7333] Chief Complaint: Symptoms: SOB, weight gain, lethargy Procedures: Right/Left Heart Cath, ICD hematoma Major Surgical or Invasive Procedure: ICD hematoma evacuation Cardiac Catheritization History of Present Illness: 59 yr old patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] with familial cardiomyopathy, afib, ASD closure as a child, AFIB w/complete heart block, s/p BIV ICD with recent Generator change c/b pocket hematoma. Per sign out he is scheduled for RHC on Monday for heart transplant evaluation. . He was admitted pre-procedurally, for potential diuresis, and possible evacuation of a pocket hematoma. . The patient has been is USOH, with notable fatigue and decreased energy recently. He had what was presumed to have several GI bleeds in the past few months, and received multiple transfusions. In the last few weeks he has been sleeping more, with a decrease in his functional status. He has noted increased DOE, which has acutely become worse over the past month. He also has an ICD hematoma which has not been evacuated. Positive ROS: calf claudication, 50 lb weight loss (unintentional). Negative ROS: No recent F/C/night sweats, nausea, emesis, BRBPR, diarrhea, or melena. . On review of systems, He denies any prior history of stroke, 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, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes (+) Dyslipidemia (+) Hypertension . 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: Admission to [Hospital1 18] [2-13] with chest pain/anemia, s/p transfusion and EGD/colonoscopy negative for bleed. Cath showed 40% LAD, followed by aneurysmal segment, then complex 80% stenosis in mid- distal LAD. LCX had a 70% stenosis in the small OM1 and 50% stenosis in larger Om2. No intervention done. -PACING/ICD: Biventricular ICD: [Company 1543] BiV ICD, Concerto C154DWD which was implanted at [Hospital3 ] Medical Center, [2149-12-5], generator change [1-13] with [Doctor Last Name ] . 3. OTHER PAST MEDICAL HISTORY: Atrial fibrillation s/p AVJ ablation [2149] Familial hypertrophic cardiomyopathy Dilated right ventricle Complete heart block s/p BIV ICD [2149] ASD closure as a child Admission [4-13] to local hospital with anemia, no source identified TIA [2140]. Social History: Lives with wife in Glenns Falls NY (north of [Name (NI) ]) Occupation: Retired Tobacco: 70 pack history, no longer smoking ETOH: 1-2 beers per day Recreational drug use: None Family History: - Mother with DM, CAD, and asthma - Father with CAD - Brother with HOCM, died of Staph infection of ICD - Son with HOCM, died of Staph infection of ICD Physical Exam: VS: W 74.8, T=94.6 BP=111/79 HR=71 RR=20 O2 sat= 98 RA GENERAL: NAD. Cachetic, A&O x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, No cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 0 cm at 45 degrees. Dilated EXJ vein. CARDIAC: PMI located in 5th intercostal space, midclavicular line, faint dime sized. Normal and regular 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. CTA on L with decreased BS on R and dullness to percussion on the R. ABDOMEN: Soft, NTND. Positive fluid wave and shifting dullness. EXTREMITIES: No c/c/e. Femoral bruits bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid; no bruit, Femoral 2+ DP 2+ PT 1+ Left: Carotid; no bruit, Femoral 2+ DP 2+ PT 1+ Pertinent Results: Admission Labs: [2158-2-12] 03:36PM BLOOD WBC-7.5 RBC-3.40* Hgb-10.9* Hct-33.2* MCV-98 MCH-32.2* MCHC-32.9 RDW-15.0 Plt Ct-186 [2158-2-12] 03:36PM BLOOD PT-18.1* PTT-28.4 INR(PT)-1.6* [2158-2-12] 03:36PM BLOOD Glucose-76 UreaN-55* Creat-2.2* Na-136 K-3.0* Cl-92* HCO3-29 AnGap-18 [2158-2-12] 03:36PM BLOOD ALT-31 AST-40 LD(LDH)-244 AlkPhos-510* TotBili-1.3 [2158-2-12] 03:36PM BLOOD Albumin-4.5 Calcium-9.8 Phos-4.2# Mg-2.1 . Discharge Labs: [2158-2-25] 08:10AM BLOOD WBC-6.0 RBC-3.34* Hgb-10.8* Hct-32.3* MCV-97 MCH-32.3* MCHC-33.4 RDW-14.1 Plt Ct-167 [2158-2-25] 08:10AM BLOOD PT-31.8* INR(PT)-3.2* [2158-2-25] 08:10AM BLOOD Glucose-123* UreaN-54* Creat-2.0* Na-135 K-3.6 Cl-91* HCO3-31 AnGap-17 [2158-2-25] 08:10AM BLOOD Calcium-9.9 Phos-3.6 Mg-2.2 . Microbiology: BC: NGTD Ascities Culture: NGTD Urine Culture: NGTD . Studies: Chest X-ray INDICATION: Hypertrophic cardiomyopathy and renal insufficiency. Evaluate pleural effusion. COMPARISON: Chest radiographs from [2157-2-10]. FINDINGS: The left pacemaker generator has been replaced. The right ventricular and coronary sinus pacer leads are unchanged in position. There is a new large pacer pocket hematoma or infection with associated left anterior chest wall swelling. The moderate right pleural effusion has dramatically increased and fluid is seen tracking up the incomplete right major fissure. There is no left pleural effusion. Moderate cardiomegaly is unchanged. The mediastinal contours are normal. There is persistent right basilar atelectasis. Persistent vascular congestion is present. No pneumothorax is identified. IMPRESSION: 1. New pacer pocket hematoma vs. infection. 2. Dramatically increased moderate right pleural effusion. 3. Unchanged moderate cardiomegaly. 4. Unchanged right basilar atelectasis. . ABDOMINAL ULTRASOUND CLINICAL INDICATION: Ascites, cardiac cirrhosis. COMPARISON STUDY: [2157-2-8]. Once again, the hepatic veins and inferior vena cava are markedly dilated, and the portal vein flow is forward, but pulsatile in nature consistent with right heart failure. There is a very large volume of ascites as well as a moderate right pleural effusion. The ascites appears to be increased in volume compared to the scan of [2-8]. . The gallbladder and bile ducts are normal as is the liver parenchyma with no focal abnormalities seen. The right kidney measures 9.6 cm in length and the left kidney 11 cm. There are two simple cysts in the mid portion of the left kidney and otherwise, the kidneys are normal in appearance. The spleen is mildly enlarged as previously noted. The pancreas shows no abnormality, but portions of the tail are obscured by bowel gas. The aorta and retroperitoneal structures cannot be visualized due to overlying bowel gas. . CONCLUSION: Findings are consistent with congestive heart failure and hepatic congestive hepatopathy. There is a moderately large right pleural effusion and large volume ascites which have increased since the prior scan of [2157-2-8]. . CARDIAC CATHETERIZATION COMMENTS: 1. Selective coronary angiography in this right dominant system revealed 2 vessel coronary artery disease. The LM was short and patent. The LAD was heavily calcified; ulcerated 50% mid LAd; mid-distal LAD tortous with 60% before an aneurysm and 80% after at the origin of a small D4 with diffusely diseaseed distal LAD beyond; modest upper pole of high diagonal with origin tubular 60%; larger lower pole of high 1st diagonal with proximal ulcerated 60%; larger S1. The LCx was modest caliber vessel; modest high vertically oriented OM1 with proximally 40-50% stenosis. Modest long vertically oriented OM2 with origin 40% and mild luminal irregularities. AV groove Cx 40% just after the origin of the OM2. Atrial branch arises from the proximal AV groove Cx before OM1 with modest origin stenosis of the atrial branch. The RCA was heavily calcified; mild luminal irregularities; large branching RPDA (arising from a lower AM) and RPL. 2. Limited resting hemodynamics revealed Fick average PA of 69/38/49mmHg with PASP ranging from 47-86mmHg. 20-25mmHg pulsus paradoxus. After angiography was completed, with 100% 02 via NRB, average PA 55/28/42, with PASP ranging from 41-67mmHg. with addition of milrinone to 100% via NRB (iNO machine in clincal use and not availalbe for use today), average PA 63/34/42, with PASP ranging from 48-72mmHg. There appeared to be a fall in PVR with addition of O2 and subsequently. However.... NOTE: All compuations above were performed using an assumed VO2 and not a measured VO2. Measurement of VO2 is not possible with our current equipment while patient is on supplemental oxygen. The patient had fluctuating levels of arousal during the procedure, ranging from awake and asking questions to sound asleep snoring. If the patient is more sedated (with VO2<125 mL/min/m2), then the PVR will be artifactually LOW (and more sedated (with VO2 <125mL/min/m2), then the PVR will be artifactually HIGH (and actually lower than computed). In addition, during all R+LHC measurements, although the "PCW" waveform often looked reasonable, there was a small end-diastolic gradient between "PCW" and LV suggestingve of mitral stenosis. During the milrinone phase, the 4 port and 2 port transducers were swapped, and the apparent end-diastolic gradient persisted, indicating that this was an artifact of the 2 transducers. The oxygen saturation drawn with the PWP in the "PCW" position was only 71%, indicating mixture of [MD Number(3) 82751] and catheter position NOT truly in PCW (despite multiple attempts to get PWP distally, with often large loops in the RV). Thus, the PCW measured is likely to be somewhat higher than the true PCW (with PA diastolic pressure entrained at end diastole), which results in an artifactually LOW PVR ( and actually higher than computed). Thus, the computed CO, CI and PVR are NOT likely to be entirely accurate and should be interpreted with caution. 3. Left ventriculography not preformed; clockwise rotated heart. Calcified aortic knob. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease involving multiple branches, with slight progression in the CAD in the aneurysmal mid-distal LAD with suboptimal run-off distally. 2. Severe pulmonary arterial hypertension with some fluctuations in baseline values. 3. Severe biventricular diastolic heart failure. 4. Slight improvement in PASP and mean PA with addition of O2 and milrinone, with apparent decrease in PVR due solely to apparent increase in CO, but interpretation of these are confounded by inablility to get the PWP into a good PCW position and by fluctuations in the patient's level of arousal (which determines actual VO2, which was assumed to be unchanged throughout, and the VO2 drives the PVR computation). 5. No evidence of right-to-left shunting. 6. Sheaths to be removed. 7. Reinforce secondary preventative measures against CAD and diastolic heart failure. 8. Additional plans per Dr. [First Name (STitle) 437] and Dr. [Last Name (STitle) ]. Brief Hospital Course: ASSESSMENT AND PLAN: This is a 59 y/o patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] with familial cardiomyopathy, afib, ASD closure as a child, AFIB w/complete heart block, s/p BiV ICD with recent Gen change c/b pocket hematoma. He was admitted for diuresis, R/L heart Cath in addition to evaluation for heart transplantation and Dr. [First Name (STitle) 437] consultation. . Active Hospital Issues: # Chronic diastolic heart failure with R ventricular systolic failure and pulmonary HTN: The patient presented with large volume ascites, an elevated JVP and a worsening R sided pleural effusion. He underwent a L/R heart catheterization which demonstrated elevated filling pressures in the presence of stable coronary artery disease. His heart failure, and elevated pulmonary pressures were felt to be secondary to acute on chronic diastolic heart failure. He was started on a lasix drip for diuresis and subsequently his respiratory function and ascites markedly improved. His dry weight is estimated to be 146 lbs. At discharge he was 148 lbs. While he was receiving lasix, he required frequent potassium repletion. However, his potassium requirement decreased when he was transitioned to oral diuretics. He was discharged home on metoprolol XL, digoxin, toursemide, and metolazone, with inspra. While on this oral regiment of diuretics in the hospital, he continued to maintain a negative fluid balance. He was instructed to limit his daily fluid intake to 2L. . # HCM: The patient has a known familial HCM, and presented with an elevation in his weight (when compared to his dry weight), and a persistent right pleural effusion. Per the consultation of [Hospital1 1388] heart failure specialist, Dr. [First Name (STitle) 437], he felt that the patient's prior ASD and closure were not the long standing antecedent cause for the patient's acute on chronic congestive heart failure. . # H/O Afib: While Mr. [Known lastname 80943] was admitted, he was monitored on tele. He was V paced. He was continued on rate controlling medications as noted above. . # Ascites: Mr. [Known lastname 80943] presented with large volume ascites. At the time of his presentation he was hypothermic, and a US and diagnostic paracentesis were preformed to rule out SBP. He did not have any positive ascites fluid cultures, and his blood cultures did not speciate any bacteria. In addition, he had a RUQ US which demonstrated a congestive hepatopathy but no evidence of cardiac cirrohsis. Of note, his AST and ALT were normal at the time of presentation. . # Acute on Chronic KI: Patient's CR was elevated at 2.1 upon admission and fluctuated with diuresis. It was hypothesized that the elevation in his CR was secondary to long-standing congestion due to a chronically increased LVEDP and RVEDP. Of note, diuresis to his dry weight did not result in improvement in his renal function. . # Coagulopathy: His INR was elevated prior to discharge, and his coumadin dose was held. He did not have recurrence of his ICD hematoma. He was scheduled for an INR check two days after discharge. The INR result was sent to his PCP for follow up. . # Persistent Hypokalemia: During the initial portion of his diuresis, Mr. [Known lastname 80943] required large volume repletion with IV potassium and oral potassium. He was restarted on his home dose Inspra, and he required less potassium during the remaining portion of his hospital stay. Chronic Issues: . # H/O Anemia: His Hgb and HCT were stable during his hospitalization. . # CAD: His coronary disease was stable based upon his Left heart catheterization. He was continued on his crestor and metoprolol. . # ICD hematoma: He had his pocket hematoma evacuated and he received 7 days of IV vancomycin as prophylaxis. After the hematoma was removed he had a pressure bandage in place for several days. After the bandage was removed he had mild swelling over the pocket. He also had some mild tenderness. But he never had any erythema, fevers, or chills while he was hospitalized. He was scheduled to have his sutures removed at his PCP visit two days after his discharge. His INR was monitored daily. He was given oxycodone for pain with adequate analgesia. TRANSITION OF CARE: CODE STATUS: FULL DISCHARGE: HOME FOLLOW UP: PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] to arrange follow up with a cardiologist in NY. Medications on Admission: ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day EPLERENONE [INSPRA] - (Prescribed by Other Provider) - 25 mg Tablet - 3 Tablet(s) by mouth once a day ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily METOLAZONE - 5 mg Tablet - 5mg Tablet(s) by mouth once a day - No Substitution METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 50mg Tablet(s) by mouth once a day - No Substitution ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day THEOPHYLLINE - 100 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth twice a day - No Substitution TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day (held starting [2-10]) Discharge Medications: 1. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 3. eplerenone 25 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 4. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. theophylline 100 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 7. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please take 1 tablet on Sunday. Disp:6 Tablet(s) Refills:0 11. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomina: Please do not take this medication prior to driving. DO NOT take this medication with oxycodone at bedtime. Disp:20 Tablet(s) Refills:0 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Please do not drive after taking this medication. Please do not take with Lorazepam. Disp:20 Tablet(s) Refills:0 13. Ensure Liquid Sig: One (1) PO once a day. Disp:30 Refills:2 14. Outpatient Occupational Therapy Please check INR, chem 7 (Na, K, Cl, Bicarb, BUN, Cr, glucose) on [2158-2-27]. Last INR was 3.2 on [2158-2-24] after coumadin dose (5 mg) was held for 48 hours. He took 1 mg of warfarin on [2158-2-26]. Please fax results to his PCP: [Name10 (NameIs) 82752],[Known firstname 275] MARK [Telephone/Fax (1) 82753] (phone number) 15. Suture Removal Please have your PCP remove your sutures on [2158-2-27]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Diastolic and Right sided Heart failure Secondary Diagnosis: ICD Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 80943]- You were admitted to the hospital for a Left and Right heart catheterization. The procedure demonstrated that you had coronary artery disease in addition to chronic heart failure. You were given medications to help you remove excess fluid from your body. You also had a hematoma around your ICD which was removed. You were given antibiotics for several days which are now complete. You will discharged with the follow up appointments listed below. Dr. [Last Name (STitle) ] will arrange for you to see a cardiologist in [Location (un) ]. The following medication changes were made: CHANGED: Escitalopram, Metolazone, Torsemide, Warfarin ADDED: Lorazepam, Oxycodone STOPPED: None Followup Instructions: Department: Primary Care Name: Dr. [Known firstname ] [Last Name (NamePattern1) ] When: Monday [2158-2-27] at 9:30 AM Location: QUEENSBURY FAMILY HEALTH CENTER Address: 14 MANOR DR, QUEENBURY,[Numeric Identifier 82754] Phone: [Telephone/Fax (1) 82753] Department: CARDIAC SERVICES When: MONDAY [2158-3-20] at 1 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You may cancel this appointment and follow up with your new cardiologist in [Location (un) ]. Please contact Dr.[Name2 (NI) 29750] at the same number above regarding the appointment. Completed by:[2158-2-28]	[ "425.4", "585.9", "996.72", "285.9", "428.33", "414.01", "427.31", "272.4", "584.9", "276.8", "309.0", "789.59", "416.8", "E879.8", "428.0", "V45.02", "403.90" ]	icd9cm	[ [ [] ] ]	[ "88.54", "37.23", "34.01", "54.91" ]	icd9pcs	[ [ [] ] ]	18636, 18642	11204, 14698	358, 408	18797, 18797	4137, 4137	19704, 20502	3059, 3213		16676, 18613		18663, 18663		15683, 16653		10215, 11181	18948, 19681				4599, 10198						3228, 4118				1973, 2548						15543, 15657																				233, 320																436, 1857			18761, 18776			4153, 4583	18682, 18740			18812, 18924		2579, 2846	14714, 15532					1879, 1953	2862, 3043
19,289	178,946	28122	Discharge summary	report	Admission Date: [2144-9-26] Discharge Date: [2144-11-4] Date of Birth: [2070-4-4] Sex: M Service: CARDIOTHORACIC Allergies: Sudafed / Amoxicillin Attending:[First Name3 (LF) 1283] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2144-9-30] Open repair thoracoabdominal aortic aneurysm [2144-10-12] Reintubation, left chest tube insertion, and bronchoscopy [2144-10-15] Redo left thoracotomy and drainage of left empyema, Right chest tube placement, Flexible bronchoscopy. [2144-10-19] Bronchoscopy [2144-10-27] An 8.0 Portex tracheostomy tube placement, 19- French percutaneous endoscopic gastrostomy Ponsky tube placement, flexible bronchoscopy. History of Present Illness: 74 year old male with acute onset of chest pain radiating to back while working on roof. History of poorly controlled hypertension. Had CTA at OSH which found to have type B aortic dissection with intramural hematoma. Past Medical History: Hypertension Benign Prostatic Hypertrophy Hernia Repair s/p Appy Gastric Esophageal reflux disease Left shoulder bursitis ETOH Social History: Lives with spouse ETOH 1 drink/day Tobacco: quit over 10 years ago Family History: NC Physical Exam: Admission 37.1, 80 SR, 20, 100/50 NAD, A/)x3 CV RRR Pulm CTAB Abd soft, NT, ND Pulses +2 equal bilat, nl CR Discharge 98.4, 75SR, 145/59, 20, 100% General NAD, Alert and oriented conversing using passy muir valve Able to lift and hold UE, moves right LE on bed, no movement left LE Resp:CTAB Cardiac RRR Abd soft, NT, ND +Bs Inc left thorocotomy with staples intact, no erythema, no drainage, small necrotic area on posterior aspect. Ext warm Pertinent Results: [2144-11-3] 12:45AM BLOOD WBC-9.6 RBC-2.91* Hgb-8.7* Hct-25.5* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.6* Plt Ct-205 [2144-9-26] 07:49PM BLOOD WBC-9.5 RBC-4.41* Hgb-13.0* Hct-35.5* MCV-81* MCH-29.4 MCHC-36.6* RDW-14.5 Plt Ct-244 [2144-10-31] 02:15AM BLOOD Neuts-80.4* Lymphs-14.6* Monos-2.4 Eos-2.4 Baso-0.2 [2144-9-26] 07:49PM BLOOD Neuts-83.5* Lymphs-10.9* Monos-5.1 Eos-0.2 Baso-0.2 [2144-10-12] 10:36PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Stipple-1+ [2144-11-3] 12:45AM BLOOD Plt Ct-205 [2144-11-3] 12:45AM BLOOD PT-15.1* PTT-39.2* INR(PT)-1.4* [2144-9-26] 07:49PM BLOOD Plt Ct-244 [2144-9-26] 07:49PM BLOOD PT-11.6 PTT-21.7* INR(PT)-1.0 [2144-11-3] 12:45AM BLOOD Glucose-139* UreaN-46* Creat-0.6 Na-144 K-4.0 Cl-104 HCO3-38* AnGap-6* [2144-9-26] 07:49PM BLOOD Glucose-123* UreaN-20 Creat-0.7 Na-138 K-3.5 Cl-103 HCO3-26 AnGap-13 [2144-10-12] 10:36PM BLOOD ALT-36 AST-26 LD(LDH)-338* AlkPhos-50 TotBili-0.7 [2144-10-2] 02:24AM BLOOD ALT-48* AST-141* LD(LDH)-489* AlkPhos-50 Amylase-36 TotBili-2.7* [2144-11-3] 12:45AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.4 [2144-9-28] 03:24AM BLOOD Calcium-7.4* Phos-1.4* Mg-1.5* [2144-10-4] 03:09AM BLOOD VitB12-602 Folate-6.5 [2144-10-4] 03:09AM BLOOD Ammonia-30 [2144-10-4] 03:09AM BLOOD TSH-0.58 [2144-11-3] 12:45AM BLOOD Vanco-16.4 [2144-9-29] 06:44PM BLOOD Type-ART pO2-259* pCO2-42 pH-7.35 calTCO2-24 Base XS--2 Time Taken Not Noted Log-In Date/Time: [2144-10-27] 12:24 pm PLEURAL FLUID GRAM STAIN (Final [2144-10-27]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2144-10-31]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. STAPH AUREUS COAG +. RARE GROWTH. [Female First Name (un) ] (TORULOPSIS) GLABRATA. SPARSE GROWTH. ID PERFORMED ON CORRESPONDING FUNGAL CULTURE. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Final [2144-10-31]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): [Female First Name (un) ] (TORULOPSIS) GLABRATA. [2144-10-19] 8:55 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2144-10-27] GRAM STAIN (Final [2144-10-19]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2144-10-27]): THIS IS A CORRECTED REPORT ([2144-10-25]). OROPHARYNGEAL FLORA ABSENT. BURKHOLDERIA (PSEUDOMONAS) CEPACIA. SPARSE GROWTH. TIMENTIN >64 (MCG/ML) Resistant. BURKHOLDERIA (PSEUDOMONAS) CEPACIA. SPARSE GROWTH. 2ND [Last Name (un) 68374]. TIMENTIN >64 (MCG/ML) Resistant. STAPH AUREUS COAG +. RARE GROWTH. PREVIOUSLY REPORTED AS. RARE GROWTH OROPHARYNGEAL FLORA ([2144-10-21]). 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BURKHOLDERIA (PSEUDOMONAS) CEPACIA \| BURKHOLDERIA (PSEUDOMONAS) CEPACIA \| \| STAPH AUREUS COAG + \| \| \| CEFTAZIDIME----------- =>16 R 16 I CHLORAMPHENICOL------- 16 I 16 I CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- <=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- S S <=0.12 S MEROPENEM------------- 2 S S OXACILLIN------------- <=0.25 S PENICILLIN------------ 0.25 R TRIMETHOPRIM/SULFA---- S S [10-31] IMPRESSION: No DVT involving the left upper extremity. PICC line is seen in the brachial vein [10-30] Portable upright frontal radiograph compared to [2144-10-28]. The left-sided chest tube has been removed. A left-sided PICC and a tracheostomy tube remain in place. There is no significant change in appearance of small bilateral pleural effusions, left greater than right with associated atelectasis. There is no pneumothorax. IMPRESSION: Stable bilateral pleural effusions with associated atelectasis. No pneumothorax. [10-23] TECHNIQUE AND FINDINGS: The patient was placed on the angiography table and the left arm and axilla were prepped and draped in standard sterile fashion. Under ultrasonographic guidance, the left brachial vein was cannulated with a 21-gauge needle following local administration of 1% lidocaine. Pre- and post-cannulation ultrasound hard copy images were obtained. A 0.018-inch guide wire was placed through the needle into the superior vena cava usig flouroscopic guidance. The needle was exchanged for a 4 French micropuncture sheath. The PICC line was trimmed to 46 cm. After the inner dilator was removed, the PICC line was inserted with tip ending in the mid SVC. The wire was removed and final fluoroscopic images were obtained. The dual lumen PICC line hub was flushed, heplocked, and StatLocked. There were no immediate post-procedure complications. IMPRESSION: Successful placement of a dual lumen PICC line via the left brachial vein with tip in the mid SVC. The line is ready for use. [10-5] MR spine IMPRESSION: 1. No evidence of epidural masses or hematoma. 2. No evidence of cord compression. 3. Increased signal intensity in the conus region which is nonspecific and infarction cannot be excluded based on this appearance. 4. Increased signal intensity within the mid-lower thoracic spinal cord could be artifactual. 5. Mild disc bulge at L4-5 and left disc herniation at L5-S1 causing mild indentation on the thecal sac. [2144-9-30] TEE Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.5 cm Left Ventricle - Fractional Shortening: 0.35 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%) Aorta - Valve Level: 2.0 cm (nl <= 3.6 cm) Aorta - Ascending: 2.9 cm (nl <= 3.4 cm) Aorta - Arch: 2.4 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 5.8 cm (nl <= 2.5 cm) Aortic Valve - Peak Gradient: 8 mm Hg Mitral Valve - Peak Velocity: 2.0 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 260 msec INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the RAA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic root. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Markedly dilated descending aorta There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions: PRE-BYPASS: No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. There are focal calcifications in the aortic arch. The descending thoracic aorta is markedly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. POST-BYPASS: Preserved biventricular function, LVEF >55%. Mitral regurtiation remains mild. Aortic insufficiency remains mild. There is a prosthetic graft insitu in the descending aorta from below the left subclavian down as far distal as can be visualized (about the level of the diaphragm). Incidental note is made of mobile echogenic material within the lumen of the thoracic graft about the level of an intercostal button. This material may represent clot, suture material, or tissue from the button; surgeons notified. Brief Hospital Course: Admitted from OSH with Type aortic dissection for surgical evaluation. He underwent preoperative work up including cardiac evaluation. Blood pressure was closely closely controlled with vasoactive drips in the ICU. On [9-29] he was due to respiratory failure and bronched. [9-30] he went to the operating room for thoraco-abdominal aorta replacement with 26 mm gelweave graft. Please see operative report for further details. He was transferred back to the ICU for hemodynamic monitoring. In the first 24 hours he awoke, following commands, and moving upper extremeties. He was able to slightly move right foot and no movement left LE. He was treated with steroids, increased B/P, and continued with lumbar drain. He was extubated on [10-2]. He was alert but confused and still no improvement in LE. He underwent MR of spine and head see reports. He had episodes of intermittent Atrial fibrillation that he converted with amiodarone and started on anticoagulation. He was started on tube feeds for nutrition since he failed swallowing evaluation. He remained extubated requiring frequent pulmonary toileting with increased oxygen requirement and was reintubated on [10-12]. He also had chest tube placed at that time for left pleural effusion, and bronchoscopy. Effusion was found to be chylothorax and thoracic surgery was consulted. His tube feeds were stopped due to chylothorax and he was started on TPN. On [10-14] he was bronched and extubated but failed quickly requiring reintubation. [10-15] ID was consulted due to + cultures (see lab data) bacteremia treating with Vancomycin and Zosyn. He also went to the operating room and underwent redo left thoracotomy and drainage of left empyema, Right chest tube placement, Flexible bronchoscopy. Please see operative report for further details. He developed a rash, at which time Zosyn was discontinued and he was started on Miropenem and the rash did clear after a few days. He was restarted on tube feeds prior to chest tube removal, no further [Last Name (LF) 3564], [First Name3 (LF) ] chest tubes removed. He continues on tube feeds for nutritional support via G tube. He underwent trach and Gtube placement due to respiratory failure on [10-27]. Please see operative report for further details. He has continued to progress working with physical therapy and has been able to tolerate trach collar during the day. He was ready and discharged to rehab on POD 34. Medications on Admission: HCTZ 25, Atenolol 100mg', prilosec, methyldopa 250mg qam, 500mg qpm, Kdur 10meq', ASA 81mg' Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback [Month/Day (1) ]: One (1) Gm Intravenous Q 24H (Every 24 Hours): continue until [2144-11-25], then should start Doxyclycline 100 mg daily for lifelong suppression. 2. Aspirin 81 mg Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 150 mg/15 mL Liquid [Month/Day/Year ]: Ten (10) ml PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution [Month/Day/Year ]: sliding scale Injection AC and HS: SQ. 5. Bisacodyl 10 mg Suppository [Month/Day/Year ]: One (1) Suppository Rectal QOD (). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: 5000 (5000) units SQ Injection TID (3 times a day). 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation Q4H (every 4 hours). 9. Fluticasone 110 mcg/Actuation Aerosol [Last Name (STitle) ]: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 10. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Hospital1 ]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 12. Lorazepam 0.5 mg Tablet [Hospital1 ]: 0.5 Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Hospital1 ]: Two (2) ML Intravenous DAILY (Daily) as needed. 14. Ascorbic Acid 90 mg/mL Drops [Hospital1 ]: Five Hundred (500) mg PO DAILY (Daily). 15. Ferrous Sulfate 300 mg/5 mL Liquid [Hospital1 ]: Five (5) ml PO DAILY (Daily). 16. Citalopram 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 17. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: Three (3) Tablet PO BID (2 times a day). 18. Lantus 100 unit/mL Solution [Hospital1 ]: Twelve (12) units Subcutaneous qam . 19. Lasix 20 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day. 20. Potassium Chloride 20 mEq Packet [Hospital1 ]: One (1) PO twice a day: with lasix. Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Hospital Discharge Diagnosis: Type B aortic dissection s/p repair Chylothorax Respiratory Failure MSSA Bacteremia - tx vancomycin MSSA Buetholderis Pneumonia -tx meropenem Enterococcal Empyema - tx vancomycin PMH: BPH GERD left shoulder bursitis s/p Appy s/p hernia Discharge Condition: good Discharge Instructions: Please make all follow up appointments Continue antibiotic treatment for life Any questions please call [Last Name (NamePattern4) 2138]p Instructions: Dr [Last Name (Prefixes) ] after discharge from rehab ([Telephone/Fax (1) 170]) please call for appointment Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] in [Hospital ] clinic upon discharge from rehab ([Telephone/Fax (1) 10], please call for appt. Please have Vanco trough,CBC w/Diff, BUN/Cr, AST/ALT Qweek and fax results to [Telephone/Fax (1) 1353] Attn Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] Dr [Last Name (STitle) ] after discahrge from rehab ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) ] after discahrge from rehab ([Telephone/Fax (1) 2625]) please call for appointment Completed by:[2144-11-4*]	[ "790.7", "457.8", "482.1", "998.2", "276.0", "510.9", "348.31", "401.9", "997.09", "E930.0", "998.32", "344.1", "441.03", "336.1", "518.5", "482.41", "511.9", "693.0", "707.03", "041.04", "427.31" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.45", "96.72", "33.43", "43.11", "34.09", "33.24", "38.93", "31.1", "96.04", "99.15", "03.31", "88.72", "86.22", "39.61", "96.05", "38.44", "39.59" ]	icd9pcs	[ [ [] ] ]	16107, 16168	11295, 13776	298, 741	16448, 16455	1723, 4122		1240, 1244		13918, 16084		16189, 16427		13802, 13895			16479, 16584					16635, 17373					1259, 1704									4158, 11272																					248, 260																769, 990																		1012, 1140	1156, 1224

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