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1,000	143,040	16505+16506	Discharge summary	report+report	Admission Date: [2144-1-19] Discharge Date: [2117-2-22] Date of Birth: [2074-5-6] Sex: M Service: The [Hospital 228] hospital course will be dictated from [2144-1-19] until [2144-2-13]. The remainder of the [Hospital 228] hospital course will be dictated by the team that takes over the patient's care after [2-13]. HISTORY OF PRESENT ILLNESS: Patient is a 69-year-old male with a history of diabetes mellitus type 2, hypertension, and chronic renal failure. Over the past year, the patient has had increasing lower extremity edema and recurrent leg cellulitis. The patient was recently hospitalized at [Hospital3 418] Hospital (from [1-1] until [1-19]) with complaint of weakness, chest heaviness, and shortness of breath. During his hospitalization, the patient was ruled out for a myocardial infarction, and was diuresed extensively with loss of 25 pounds. The patient complained of nausea, vomiting, and poor po intake, and underwent an EGD, gastric biopsy was concerning for amyloidosis. The patient was subsequently transferred to [Hospital1 69] for further workup. While on the Medical Service, the patient had two episodes of chest pain without electrocardiogram changes. His troponin was elevated to 1.1. On the morning following his transfer, the patient complained of nausea. He began to have episodes of hematemesis. His systolic blood pressure decreased to the 80s. The patient was administered intravenous fluids and was transferred to the MICU for further management. PAST MEDICAL HISTORY: 1. Non-insulin dependent-diabetes mellitus x15 years complicated by diabetic nephropathy. 2. Chronic renal failure. Renal biopsy in [2143-11-24] disclosed SSGS. Baseline creatinine 2.5. 3. Hypertension. 4. Paroxysmal atrial fibrillation. 5. Congestive heart failure. Echocardiogram in [2144-11-23] at [Hospital3 417] Medical Center disclosed concentric left ventricular hypertrophy, mildly decreased left ventricular function with an ejection fraction of 50-55%, RVH. 6. Erosive esophagitis and gastritis with evidence of fold thickening and nodularity of the stomach. 7. Coronary artery disease. Cardiac catheterization in [2142-12-25] disclosed a 30% lesion in the marginal branch of the left anterior descending artery, and 30% lesion in the right coronary artery. Remainder of coronaries satisfactory. 8. Cellulitis of both legs. 9. Malnutrition. 10. B12 deficiency. 11. Depression. 12. Anemia treated with iron supplementation and Epogen. 13. Plasma cell dyscrasia. Bone marrow biopsy in [2142] disclosed 10% plasma cells. 14. Prior episode of ischemic colitis diagnosed by colonoscopy [2142-4-24]. 15. History of SPEP showing three lambda-light chains and UPEP disclosing the presence of [Last Name (un) ]-[Doctor Last Name ] proteins. SOCIAL HISTORY: The patient is married. Works as an accountant. Denies use of tobacco, alcohol, and drugs. Has three children and eight grandchildren. FAMILY HISTORY: Significant for diabetes mellitus, no history of hypertension or kidney disease. MEDICATIONS: 1. Glyburide 1.25 q day. 2. Niferex 150 q day. 3. Aldactone 25 [Hospital1 ]. 4. Lasix 120 tid. 5. Aspirin 81 q day. 6. Monthly B12 injections. 7. Folate 1 q day. 8. Zaroxolyn 2.5 q day. 9. Potassium chloride 20 mEq tid. INPATIENT MEDICATIONS ON TRANSFER: 1. Famotidine 20 mg IV q12. 2. Protonix 40 mg po q12. 3. Celexa 20 q day. 4. Reglan 10 qid. 5. Carafate 1 tid. 6. Megace 400 [Hospital1 ]. 7. Aspirin 81 q day. 8. Allopurinol 100 q day. 9. Lasix 100 q day. 10. Multivitamin one q day. 11. Folate 1 mg q day. 12. Epogen 30,000 units subQ 3x a week. 13. Heparin 5,000 units subQ [Hospital1 ]. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: General: Pale elderly male appears depressed. Vital signs: Temperature 97.5, blood pressure 100/45, heart rate 63, respiratory rate 16, O2 sat is 98% on room air. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx clear. Neck: No jugular venous distention appreciated, no thyromegaly, no cervical lymphadenopathy. Heart regular, rate, and rhythm, 2/6 systolic murmur at right upper sternal border. No rubs or gallops. Lungs: Crackles bilaterally at bases. Abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, and no masses. Extremities: Dry and scaly skin changes on the lower extremities. No lower extremity edema. Neurologic: Alert and oriented times three. Cranial nerves II through XII are grossly intact. Examination is otherwise nonfocal. LABORATORY DATA: White count 11.6, hematocrit 22.8, platelets 344. Patient's baseline hematocrit is 35. Chemistries: Sodium 130, potassium 4.1, chloride 89, bicarb 30, BUN 80, creatinine 2.4, glucose 126. Calcium 8.1, magnesium 2, phosphorus 6.1. CK 20, troponin 1.1. PT 13.2, PTT 29, INR of 1.2. ELECTROCARDIOGRAM: Normal sinus rhythm at 80 beats per minute, normal intervals, normal P-R interval, left bundle branch block. CHEST X-RAY: Evidence of congestive heart failure with bilateral pleural effusions and atelectasis, cardiomegaly. As noted above, the patient was transferred to the MICU on [1-21] for treatment of gastrointestinal bleed. Patient underwent upper endoscopy on [1-20]. Large amounts of clotted blood was noted in the antrum of the stomach. The GI service decided that they would repeat the EGD when they could obtain better visualization of the stomach. HOSPITAL COURSE BY SYSTEMS: 1. Pulmonary: Patient required intubation on [1-21] for respiratory arrest due to mucus plugging. The patient underwent bronchoscopy at that time which disclosed thick purulent secretions in the left main stem bronchus. The patient was started on a course of broad-spectrum antibiotics (ceftazidime and Vancomycin) to cover nosocomial pathogens. As noted above, the patient's chest x-ray disclosed the presence of bilateral pleural effusions. The patient underwent thoracentesis on [1-22]. Laboratory data was consistent with a transudative effusion. Cytology cultures and Gram stain were negative. Due to the recurrent nature of the patient's pleural effusion, the patient required placement of bilateral chest tubes. Patient underwent pleurodesis of the left sided chest tube. During his hospitalization, the patient's chest tubes have continued to drain significant amounts of pleural fluid. In addition, the patient has required repeated bronchoscopies during his MICU stay due to recurrent purulent secretions. On [1-31], the patient was noted to have purulent secretions in the main stem bronchi and right lower lobe, consistent with a ventilator-associated pneumonia. BAL culture disclosed presence of gram-negative rods. Furthermore, on [2-6], the patient underwent bronchoscopy which disclosed moderate secretions and partial obstruction of the bronchus intermedius and left main stem bronchus. Patient eventually was changed to imipenem and then meropenem for treatment of ventilator associated pneumonia. During his hospital stay, the patient was maintained on assist-controlled ventilation over the past few days. The patient has undergone trials of pressure support ventilation with a goal to wean the patient from the ventilator. 2. GI: As noted above, the patient underwent upper endoscopy on [1-20]. Large amounts of clotted blood was noted in the antrum of the stomach. On [1-22], the patient underwent repeat upper endoscopy. Blood was noted in his stomach. In addition, the whole stomach was noted to have nodularity and erosions compatible with an infiltrated disorder. Biopsies were done and pathology disclosed no evidence of neoplasm. However, it was noted that there was deposition of acellular pale eosinophilic material with a moderate degree of staining with [Country ] red. The pathologist had included that this is an amyloid like substance, possibly light chains. Since [1-22], the patient has not had any further episodes of hematemesis. However, he has had episodes of dark stools and clots per rectum. The patient has required a total of 13 units of packed red blood cell transfusions to maintain his hematocrit greater than 30 during his hospital stay. 3. Cardiology: As noted above, the patient complained of chest pain early in his hospital stay, and was noted to have a troponin elevation to 1.1. Echocardiogram was consistent with a restrictive cardiomyopathy with a normal ejection fraction. In early [Month (only) 956], the patient began to be hypotensive. A repeat echocardiogram was done to rule out pericardial effusion causing tamponade as an etiology of the patient's hypotensive. There was no evidence of pericardial effusion on the echocardiogram. Due to concern for adrenal insufficiency, random cortisol levels were checked and the patient's cortisol level was found to be 15. He was started on a course of stress dosed steroids. Furthermore, patient was noted to be febrile and there was concern for a distributive shock. Patient has continued to demonstrate septic physiology during his hospital stay. On [1-27], dopamine was started, and the patient has required pressors for much of his MICU stay. Since [2-13], we are in the process of weaning off pressors. The patient continues to require multiple fluid boluses to maintain his blood pressure. 4. Renal: As noted above, the patient has a history of chronic renal insufficiency due to FFGS and diabetic nephropathy. The patient's renal function has deteriorated during his hospital stay. Renal service has been followed the patient and his renal decompensation was initially attributed to ATN in the setting of the patient's gastrointestinal bleed. [Country 7018] red staining of the patient's kidney biopsy from [2142] was negative for amyloidosis. During his MICU stay, the patient had declining urine output. In addition, he had episodes of hematuria requiring placement of a three-way Foley. Patient's BUN and creatinine continued to rise. A renal ultrasound did not disclose evidence of hydronephrosis. On [1-26], the patient was noted to have a two component pericardial friction rub. He was started on hemodialysis. Hemodialysis has been difficult due to the patient's hypotension. However, he requires dialysis due to his worsening metabolic acidosis. The patient will have a PermCath placed by Transplant Surgery. 5. Heme: As noted above, the patient has required a total of 13 units of packed red blood cells during his hospital stay for a maintenance of a hematocrit greater than 30. The patient's last episode of hematemesis was [1-22]. The patient is administered Epogen at hemodialysis. 6. Oncology: The Hematology/Oncology service has been following the patient. The patient meets three minor criteria for multiple myeloma, namely bone marrow biopsy with 10% plasma cells, positive UPEP, and IgM less than 50. It is believed that the patient's gastric biopsy is consistent with a light-chain gastropathy, presumably from the multiple myeloma. Chemotherapy has not been pursued during the patient's MICU stay, but it is an option for the future. 7. Infectious Disease: As noted above, patient was started on broad-spectrum antibiotics to cover nosocomial pathogens on [1-21]. During his hospital stay, multiple blood, fungal, sputum, and urine cultures have been sent to the laboratory for workup of a source of the patient's sepsis. On [2-1], the patient was noted to be positive for Clostridium difficile. He has also had gram-negative rods and gram-positive cocci in his sputum. Blood cultures have remained negative to date. CT scan of the chest and abdomen did not disclose evidence of an abscess. Currently, the patient has been followed by the Infectious Disease Service. He was treated with a seven day course of fluconazole for yeast in his sputum and urine. Patient currently remains on Flagyl for treatment of his Clostridium difficile infection and meropenem for treatment for ventilator-associated pneumonia. 8. Endocrine: Patient has a history of diabetes mellitus. He has been maintained on an insulin drip during his MICU stay. In addition, patient has been started on stress dosed steroids for treatment of adrenal insufficiency in the setting of sepsis. 9. Nutrition: The patient has very poor nutritional status with an albumin in the range of [12-25].3. He has been maintained on TPN during his hospital stay. 10. Neurology: While on the ventilator, the patient was maintained on Versed and Morphine for sedation. By [2-13], these sedatives were weaned off. The patient has been observed opening his eyes, yet currently does not respond to painful stimuli or commands. 11. Vascular: On [2-8], it was noted that the patient had modeling of his feet and ischemia of his toes. Pulses are detectable by Doppler. Vascular Surgery consult has been obtained. It appears that the patient has gangrene of his right first toe. 12. Prophylaxis: The patient has been maintained on Pepcid and Venodyne boots during his MICU stay. The remainder of the [Hospital 228] hospital course will be dictated by the medical team, who takes over his care. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Dictator Info 13504] MEDQUIST36 D: [2144-2-13] 22:31 T: [2144-2-14] 04:22 JOB#: [Job Number 46899] Admission Date: [2144-1-19] Discharge Date: [2144-2-25] Date of Birth: [2074-5-6] Sex: M Service: MICU GREEN HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old man with type 2 diabetes complicated by end-stage renal disease on hemodialysis, hypertension, and a number of chronic medical problems listed separately who is transferred on the date of admission from [Hospital3 417] Hospital after presenting with congestive heart failure. The patient reports that he was in declining state of health for approximately one year. He has had persistent problems with peripheral edema, recurrent leg cellulitis, chronic debility. On admission, he complained of shortness of breath. Serial markers ruled out myocardial infarction, however, the patient's chest x-ray at [Hospital3 417] Hospital was consistent with congestive heart failure. He underwent successful diuresis with Lasix and Zaroxolyn losing approximately 25 pounds over his hospital course. Echocardiography revealed a preserved ejection fraction, mild tricuspid and mitral regurgitation and an electrocardiogram showed a left bundle branch block and an old myocardial infarction. Patient also completed a course of oxacillin for lower extremity cellulitis. The patient complained of nausea and vomiting for one month prior to admission. He underwent esophagogastroduodenoscopy with biopsy which revealed proteinaceous infiltration of the gastric submucosa suggestive, but not confirming amyloidosis. Was transferred to the [Hospital1 69] for further evaluation. PAST MEDICAL HISTORY: 1. Type 2 diabetes complicated by end-stage renal disease. 2. Hypertension. 3. Paroxysmal atrial fibrillation. 4. Anemia secondary to renal failure. 5. Chronic lower extremity cellulitis. 6. Coronary artery disease, last cardiac catheterization was in [2142-12-25] showing a 30% lesion in the right coronary artery and a 30% lesion in the marginal branch in the left anterior descending coronary artery. 7. Vitamin B12 deficiency. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Peripheral parenteral nutrition. 2. Lexapro 10 mg daily. 3. Prevacid 30 mg twice daily. 4. Metoclopramide 10 mg 4x daily. 5. Carafate 1 mg 3x daily. 6. Megace 400 mg twice daily. 7. Furosemide 100 mg daily. 8. Aspirin 81 mg daily. 9. Allopurinol 100 mg daily. 10. Multivitamin. 11. Erythropoietin. 12. Folate 1 mg daily. SOCIAL HISTORY: Patient is an accountant. He does not consume alcohol or smoke cigarettes. VITAL SIGNS: Temperature 97.0, heart rate 88, blood pressure 130/60, and oxygen saturation of 92% on room air. Generally, the patient was a depressed appearing man sitting comfortably in no acute distress. Examination of the head, eyes, ears, nose, and throat was unremarkable. The heart examination showed a regular, rate, and rhythm, normal S1, S2, and a systolic murmur. Lungs had decreased breath sounds at the bases. Abdomen protuberant, soft, nontender, nondistended, decreased bowel sounds. Extremities showed no evidence of edema or warmth. Vascular examination showed intact peripheral pulses. LABORATORY EVALUATION: On presentation, the patient's white blood cell count was 14.3, hematocrit 34.4, platelets of 396. Chemistry panel is unremarkable. HOSPITAL COURSE: The patient was admitted to the Medicine Service initially. Repeat hematocrit showed an acute drop in his hematocrit to 25.1 attributed to bleeding after esophagogastroduodenoscopy at the outside hospital. He was transferred to the Intensive Care Unit and received a blood transfusion to restore his hematocrit to above 30. The patient had a long and complicated stay in the Medical Intensive Care Unit. 1. Hypotension: The patient was persistently hypotensive upon admission to the Intensive Care Unit requiring intermittent use of up to three pressors. Attempts to wean these medications were ultimately unsuccessful. 2. Respiratory: The patient was electively intubated three days after being transferred to the Medical Intensive Care Unit for airway protection, but was never extubated. The patient was treated with a 14 day course of meropenem for ventilator-associated pneumonia. 3. Renal: The patient was dialyzed as his chronic renal failure progressed to end-stage renal disease on this admission. The uremia ultimately cleared, and the patient was able to answer questions by nodding yes and no. After temporarily employing a femoral catheter as well as a port-a-cath, the patient was ultimately dialyzed only with a port-a-cath, however, the femoral line in addition to a right subclavian line were found to be infected with Vancomycin resistant Enterococcal species, ultimately identified as ECCM. The patient was then started on linazolid, however, his platelet count started to drop. He was switched from this [Doctor Last Name 360] to Synercid in addition to persistent thrombocytopenia. The patient also had a drop in his white blood cell count and his hematocrit. In addition, the patient had worsening hypotension ultimately requiring dopamine, Neo-Synephrine, and vasopressin. 4. Vascular: While the patient initially presented with resolution of a cellulitis, his toes became gangrenous. In addition, the patient had septic emboli in his fingertips. On [2144-2-25], the patient's hypertension worsened, 3 mg of atropine and 4 mg of Epinephrine were administered, however, chest compressions were not performed as CPR was not indicated for this patient. The patient expired at 8:12 pm. His wife, [Name (NI) 35935] and son, [Name (NI) ], were contact[Name (NI) ]. They declined an autopsy. DISCHARGE DIAGNOSES: 1. Enterococcal sepsis. 2. Anemia due to blood loss. 3. Multiple myeloma. 4. Type 2 diabetes complicated by end-stage renal disease. 5. Hypertension. DR.[Last Name (LF) ],[First Name3 (LF) ] 12-838 Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2144-2-25] 21:58 T: [2144-2-26] 04:10 JOB#: [Job Number 46900]	[ "428.0", "518.5", "578.9", "277.3", "285.1", "785.59", "038.0", "403.91", "203.00" ]	icd9cm	[ [ [] ] ]	[ "39.95", "41.31", "34.04", "31.1", "99.15", "38.95", "45.16", "96.04", "96.72", "33.24", "34.92", "00.14", "45.13", "34.91" ]	icd9pcs	[ [ [] ] ]							3042, 3372	19301, 19662						16928, 19280						5611, 13763																			3807, 5583																					13792, 15201																15722, 16047	15223, 15697	16064, 16910
77,221	100,024	31968	Discharge summary	report	Admission Date: [2170-9-19] Discharge Date: [2170-9-25] Date of Birth: [2099-5-27] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion and fatigue Major Surgical or Invasive Procedure: [2170-9-19] Coronary artery bypass graft x 4 (Left internal mammary artery to diagonal, saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: 71 year old male who presented to his PCP for [Name Initial (PRE) ] routine visit with complaints of recent onset fatigue, dyspnea on exertion, exertional throat discomfort and left arm. He denied any rest pain but reports the discomfort and dyspnea occur with minimal activities such as showering. He was found to be hypertensive and was started on Atenolol 25mg daily. His EKG was normal and he was sent for a nuclear stress test. He underwent a nuclear stress test on [2170-8-1] which revealed inferolateral ischemia and a moderate inferior, inferolateral, and posterolateral perfusion abnormality. He is now refereed for cardiac catheterization. He is now being referred to cardiac surgery for revascularization. Past Medical History: Hypertension Right rotator cuff tear Compound fracture of left arm/plated as a child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair if left arm fracture, plated Social History: Race:Caucasian Last Dental Exam:"a very long time ago", does not recall when Lives with:Wife Contact:[Name (NI) ] (wife) Phone #[Telephone/Fax (3) 74913] Occupation:self employed painter Cigarettes: Smoked no [x] Other Tobacco use:denies ETOH: stopped drinking in [12-20] Illicit drug use:denies Family History: No premature coronary artery disease Physical Exam: Pulse: 56 Resp:13 O2 sat:97/RA B/P Right:173/82 Left:164/76 Height:5'9" Weight:200 lbs General: NAD, WG, WN Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [2170-9-25] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3* MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261 [2170-9-24] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197 [2170-9-25] 06:35AM BLOOD Na-139 K-4.0 Cl-99 [2170-9-24] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139 K-4.0 Cl-98 HCO3-31 AnGap-14 [2170-9-23] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99 Brief Hospital Course: Mr. [Known lastname ] was a same day admit and on [9-19] was brought to the operating room where he underwent a Coronary artery bypass graft x4 (left internal mammary artery to the diagonal and saphenous vein grafts to the left anterior descending, obtuse marginal, and posterior descending arteries) with Dr.[First Name (STitle) ]. CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93 minutes. Please see operative report for further surgical details. Following surgery he was transferred to the CVICU intubated and sedated in critical but stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated without incident. He weaned from pressor support and beta blocker/Statin/Aspirin and diuresis was initiated. Chest tubes and epicardial pacing wires were removed per protocol. POD#1 he was transferred to the step-down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. During his postoperative course he developed atrial fibrillation and was treated with beta blockers and amiodarone. Anticoagulation was initiated with Coumadin. He developed a phlebitis from IV Amio and was placed on a course of Keflex x 7 days. This was slowly improving. His pulmonary status waxed and waned with a strong productive cough and wheezing, which improved by the time of discharge. He continued nebulizer treatments. CXR showed small bilateral pleural effusions with atelectasis, no infiltrate or density. His pulmonary status slowly improved by his day of discharge. On POD 4 he developed a tender erythematous right knee and was treated with colchicine for presumed gout. This had improved by the time of discharge and the colchicine was discontinued. On POD 6 he was afebrile, ambulating with assistance, tolerating a full po diet and his wounds were healing well. On POD 6 he was discharged to Lifecare Center of [Location 15289] in stable condition. All follow up appointments were advised. Medications on Admission: ATENOLOL 25 mg Daily ASPIRIN 325 mg daily FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg Daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily NAPROXEN SODIUM [ALEVE]PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 200 [Hospital1 ] x 1 week then 200 mg daily directed by caridologist. 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for coughing . 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: For right arm phlebitis. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 14 days. 17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): Give 4 mg on [9-26] then as directed for INR goal 2.0-2.5 for A fib. Discharge Disposition: Extended Care Facility: Life Care Center of [Location 15289] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 Past medical history: Hypertension Right rotator cuff tear Compound fracture of left arm/plated as a child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair if left arm fracture, plated Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] on [10-29] at 1:15pm, #[Telephone/Fax (1) 170] Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] on [9-25] at 2:00pm Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ]. Nikolaos Michalacos in [4-17] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Patient to be given 4 mg Coumadin on [2170-9-25] Goal INR 2.0-2.5 First draw [2170-9-26] Please arrange follow up with PCP or cardiologist prior to discharge from rehab [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2170-9-25]	[ "511.9", "414.01", "411.1", "451.82", "518.0", "996.62", "V49.60", "401.9", "E878.2", "274.01", "427.31" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.13" ]	icd9pcs	[ [ [] ] ]	7110, 7177	3095, 5096	341, 578	7488, 7714	2622, 3072	8637, 9552	1881, 1919		5367, 7087		7198, 7259		5122, 5344			7738, 8614									1934, 2603																								270, 303											606, 1332																	7281, 7467	1556, 1865
7,433	105,279	27315	Discharge summary	report	Admission Date: [2137-5-7] Discharge Date: [2137-5-29] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: Fall, ICH Major Surgical or Invasive Procedure: s/p L burr hole s/p L hemiarthroplasty History of Present Illness: The patient is an 86 yo M transferred from OSH s/p fall from standing, on ASA/Plavix/Coumadin. At OSH diagnosed with SDH and L femur fx. On arrival to [Hospital1 18], it was noted that the patient was becoming increaingly less responsive and he was intubated for airway protection. A repeat head CT demonstrated worsening SDH with midline shift. The patient received Proplex, FFP, dilantin, and mannitol. Neurosurgery was involved immediately and there was discussion with the patient's wife regarding going to the OR for evacuation of the SDH; the wife declined surgery and the patient was admitted to the T-SICU for close observation. Past Medical History: -Afib -PNA -MI -s/p [Hospital1 ] to L main and distal L main coronary artery [3-11] @ [University/College ]-Hitchcock -depression -COPD on home O2 Social History: Lives with wife in [Location (un) 3844] No tobacco/EtOH Family History: N/C Physical Exam: GEN: Elderly male, boarded and collared VS: 117/64 78 18 100% NRB Initial GCS 13 --> 6 HEENT: PERRL, lac to occiput NECK: Trachea midline COR: s1s2 RRR RESP: CTAB ABD: soft, NT, ND EXT: LLE shortened, distal pulses intact but cool skin, ABI=1 NEURO: MAE SKIN: cool, dry RECTAL: tone WNL, guaiac + Pertinent Results: [2137-5-7] 11:50PM TYPE-ART PO2-141* PCO2-39 PH-7.47* TOTAL CO2-29 BASE XS-5 [2137-5-7] 10:00PM TYPE-ART PO2-72* PCO2-45 PH-7.45 TOTAL CO2-32* BASE XS-6 [2137-5-7] 10:00PM GLUCOSE-114* LACTATE-1.8 [2137-5-7] 08:36PM GLUCOSE-135* UREA N-31* SODIUM-137 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-28 ANION GAP-15 [2137-5-7] 08:36PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-1.8 [2137-5-7] 08:36PM OSMOLAL-308 [2137-5-7] 08:36PM WBC-6.2 RBC-3.22* HGB-10.0# HCT-28.0# MCV-87 MCH-31.2 MCHC-35.8* RDW-15.4 [2137-5-7] 08:36PM PLT COUNT-137* [2137-5-7] 08:36PM PT-13.7* PTT-31.9 INR(PT)-1.2* [2137-5-7] 08:36PM FIBRINOGE-241 [2137-5-7] 08:30PM TYPE-ART PO2-304* PCO2-47* PH-7.43 TOTAL CO2-32* BASE XS-6 [2137-5-7] 05:06PM TYPE-ART O2-100 PO2-86 PCO2-38 PH-7.48* TOTAL CO2-29 BASE XS-4 AADO2-606 REQ O2-97 COMMENTS-NON-REBREA [2137-5-7] 05:04PM TYPE-[Last Name (un) ] PO2-27* PCO2-51* PH-7.41 TOTAL CO2-33* BASE XS-4 COMMENTS-GREEN TOP [2137-5-7] 05:04PM GLUCOSE-103 LACTATE-1.6 NA+-141 K+-4.1 CL--100 [2137-5-7] 05:04PM HGB-13.8* calcHCT-41 O2 SAT-50 CARBOXYHB-2 MET HGB-0 [2137-5-7] 05:04PM freeCa-1.09* [2137-5-7] 05:00PM GLUCOSE-105 UREA N-32* CREAT-1.0 SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 [2137-5-7] 05:00PM AMYLASE-47 [2137-5-7] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2137-5-7] 05:00PM URINE HOURS-RANDOM [2137-5-7] 05:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2137-5-7] 05:00PM WBC-9.0 RBC-4.27* HGB-13.8* HCT-38.1* MCV-89 MCH-32.3* MCHC-36.3* RDW-15.2 [2137-5-7] 05:00PM PLT COUNT-101* [2137-5-7] 05:00PM PT-18.2* PTT-31.4 INR(PT)-1.7* [2137-5-7] 05:00PM FIBRINOGE-331 [2137-5-7] 05:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2137-5-7] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG . CT torso: 1. Multiple large mediastinal lymph nodes. 2. Evidence of lung fibrosis with interstitial and alveolar changes, consistent with history of interstitial lung disease. 3. Acute comminuted left femoral neck fracture. . CT c-spine: IMPRESSION: No evidence of acute fracture or spondylolisthesis. Degenerative change is seen within the cervical spine. . CT head: IMPRESSION: Large left subdural hematoma with blood tracking along the falx and left tentorium. There is mass effect upon the left lateral ventricles. Rightward shift of normally midline structures with approximately 9 mm shift of the septum pellucidum concerning for subfalcine herniation. Although the ambient cisterns appear patent, they are narrowed and there is concern for impending uncal herniation. . Brief Hospital Course: The patient was admitted to the T-SICU. His mental status improved and he was extubated. Repeat CT scans of the head showed stable SDH and shift. On HD 9 a head CT showed decrease in attenuation of the frontal aspect of the left subdural hematoma, but an increase in volume of the collection. The maximal width of the subdural hematoma had increased and there was an increase in mass effect on the left brain. He returned to the T-SICU for closer monitoring and remained stable, with a waxing and [Doctor Last Name 688] mental status. On HD 14 a repeat head CT showed slight worsening of the shift and the patient was minimally responsive, not communicative. He was taken to the OR and a L burr hole was placed for evacuation of hematoma. His mental status improved from a pre-op GCS of 5 to a post-op GCS of 10. He should be continued on Dilantin with a goal level of 15 (corrected for albumin). The day prior to discharge, a head CT revealed: Compared to [5-21], [2137], there has been removal of the left intracranial drainage catheter. The left subdural hematoma has largely been evacuated with a small amount of heterogeneously dense blood products layering along the left temporal and frontal lobes. There has been no significant change in left to right subfalcine shift measuring approximately 4 mm. The appearance of the ventricles and sulci has not significantly changed and there is no evidence of hydrocephalus. There remains pneumocephalus around the burr hole site which has slightly improved. There are no new areas of hemorrhage and no evidence of infarction. The [Doctor Last Name 352]/white matter differentiation appears preserved and the basal cisterns patent. The paranasal sinuses are pneumatized and the orbits are unremarkable. IMPRESSION: Status post removal of left intracranial drainage catheter. Otherwise, stable appearance of the head. Other issues for this hospitalization included: # Cardiac: The patient was s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 2 to the L main coronary artery in [2137-3-6] at [Hospital3 27447] Center; however, due to the acute intracranial hemorrhage, Plavix was held initially during his course. It was restarted briefly after discussion between Neurosurgery and Cardiology, held for surgery, and will need to be restarted [2137-5-28] per Neurosurgery. He was restarted on ASA 81mg QD post-operatively. He has a history of atrial fibrillation and was in afib with a slow ventricular response at the time of transfer. He was hemodynamically stable, with a systolic blood pressure in the 90s which has been largely his baseline (90s-110s). # Respiratory: The patient spiked a fever and a CXR was concerning for PNA. He was started on Levaquin on [2137-5-16] (HD 10); sputum cx revealed coag + staph and Vanco was started on [2137-5-18]. # L femur fracture: The patient underwent L hemiarthroplasty and tolerated the procedure well; he has been cleared by Orthopedics to be weight-bearing as tolerated when able. He can follow up with the orthopedic surgeon, Dr. [Last Name (STitle) ] [Name (STitle) 7376], in 6 weeks. # GI: A PEG was placed on [5-17] and tube feeds were started, now at goal. . Medications on Admission: Plavix, Lisinopril, Zoloft, Detrol, Coumadin, Zocor, Lasix, ASA, Duoneb Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Phenytoin 100 mg/4 mL Suspension Sig: 200 mg PO Q12H (every 12 hours). 11. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [Hospital 66960]Healthcare Discharge Diagnosis: 1. Subdural hematoma 2. Femur fracture 3. Pneumonia 4. Atrial fibrillation 5. CAD 6. COPD Discharge Condition: Fair Discharge Instructions: As per your wife's request, you are being transferred to [Hospital3 27447] Center for continued care. Followup Instructions: * Orthopedics: Dr. [First Name (STitle) ] [Name (STitle) 7376] ([Telephone/Fax (1) 2007] in 6 weeks * Neurosurgery: Dr. [Last Name (STitle) 739] ([Telephone/Fax (1) 88] in 6 weeks if desired; otherwise you may follow up in [Location (un) 3844] if more convenient [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226]	[ "820.8", "852.21", "V45.82", "486", "414.00", "496", "E888.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "96.6", "43.11", "38.93", "01.31", "81.52" ]	icd9pcs	[ [ [] ] ]	8786, 8843	4451, 7707	270, 311	8977, 8984	1601, 4008	9138, 9557	1260, 1265		7830, 8763		8864, 8956		7733, 7807			9008, 9115									1280, 1582																								221, 232											339, 983			4017, 4428														1005, 1166	1182, 1244
7,918	141,971	28329	Discharge summary	report	Admission Date: [2152-10-13] Discharge Date: [2152-10-25] Date of Birth: [2091-12-27] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1377] Chief Complaint: Acute liver transplant rejection. Major Surgical or Invasive Procedure: Internal jugular transvenous liver biopsy. Hemodialysis per schedule. History of Present Illness: 60 year-old female status post liver transplant for Hepatitis C, ESRD secondary to MPGN, and congestive heart failure who presents directly after liver biopsy performed [10-13] for elevated liver function tests was consistent with acute rejection. The patient's prograf had been increased from 2 mg [Hospital1 ] to 3 mg [Hospital1 ] [9-26]. The patient states she has been feeling fatigue and malaise for a few weeks prior. Denied fevers, chills, or night sweats. Denied abdominal pain, nausea, vomiting, melena/BRBPR. . The patient's last liver biopsy [1-/2151] at OSH revealed grade 3 inflammation and stage 2 fibrosis. EGD done at that time showed candidal esophagitis. Colonoscopy was normal. . ROS: As above. Denied headache, rhinorrhea or congestion. Denied chest pain, shortness of breath, orthopnea, PND. No lightheadedness, dizziness. No dysuria. Denied arthralgias or myalgias. No rash. Review of systems otherwise negative in detail. Past Medical History: 1. DM2- poorly-controlled, recently started to see [Last Name (un) ], last hgbA1C = 7.7 in [9-1] 2. Status post liver transplant- on [2150-7-8] in [State 8449] for hepatitis C; on tacro/Cellcept, [10-13] biopsy with moderate acute rejection, liver biopsy [10-23] with st2-3 fibrosis, minimal inflamm., no acute rejection; followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] of Hepatology 3. Hepatitis C- diagnosed in [2135], [12-30] IV drug use, treated pre-transplant with PEG interferon/ribavarin twice which she tolerated poorly; treated with Pegasys monotherapy post transplant w/o response; last VL [10-14] 4,340,000; followed by Dr. [Last Name (STitle) 497] 4. History of Candidal esophagitis per report, with EGD [Month (only) 547] [2150] 5. ESRD- on HD T/Th/Sat, secondary to probable membranoproliferative GN, cryoglobulinemia, hypertension and calinuric toxicity 6. HTN- poorly controlled, recent admission [2075-10-13] for acute pulmonary edema requiring NIPPV in setting of BP 230s/100s 7. Diastolic dysfunction 8. EtOH in the past but now abstinent 9. Pancytopenia 10. Hyperparathyroidism 11. Chronic obstructive pulmonary disease Social History: past alcohol use, none x months-year; lives at home with friend [Name (NI) ] (HCP). Smokes 1ppd. Past IVDU. Used to work as [Location (un) ]. Family History: noncontributory Physical Exam: Vitals- T 98.0, HR 79, BP 172/98, RR 18, O2sat 96%RA, FS 240 General- chronically ill-appearing, NAD HEENT- NCAT, sclerae anicteric, moist MM, OP clear Neck- supple, no JVD Chest- R SC port Pulm- crackles at L base CV- RRR, no murmur Abd- RUQ well-healed surgical scar, liver edge palpable medially 4cm BCM, NT, ND, +BS Extrem- 1+ edema to mid calf b/l, L knee with no laxity, negative anterior and posterior drawer sign, ?effusion, TTP over patella, full ROM, no asterixis Pertinent Results: [2152-10-13] 10:37PM GLUCOSE-281* UREA N-43* CREAT-5.9# SODIUM-140 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18 [2152-10-13] 10:37PM ALT(SGPT)-95 AST(SGOT)-37 LD(LDH)-213 ALK PHOS-177* TOT BILI-0.4 [2152-10-13] 10:37PM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-6.1* MAGNESIUM-1.9 [2152-10-13] 10:37PM WBC-1.4* RBC-2.60* HGB-9.1* HCT-27.0* MCV-104* MCH-35.2* MCHC-33.9 RDW-18.7* [2152-10-13] 10:37PM PLT COUNT-91* [2152-10-13] 10:37PM PT-12.4 PTT-27.0 INR(PT)-1.1 [2152-10-13] 10:37PM GRAN CT-710* [2152-10-13] 08:40AM PLT SMR-LOW PLT COUNT-96* Brief Hospital Course: 60 year-old female with past medical history of HCV cirrhosis status post liver transplant in [2149], congestive heart failure with history of flash pulmonary edema requiring MICU transfer x2, ESRD on HD who initially presented on [10-13] with a liver biopsy consistent with acute rejection. . 1. Liver transplant with acute rejection: The patient is status post OLT [2150-7-8] in [State 8449] for Hepatitis C cirrhosis. Biopsy on admission showed moderate acute cellular rejection with central venulitis and increased portal fibrosis with early septa formation, (Stage 2). The patient received solumedrol for five days. The patient was restarted on cellcept. The patient's tacrolimus was dosed for goal trough level [5-6]. Repeat liver biopsy prior to discharge status post the above treatment showed no features of acute cellular rejection and minimal portal mononuclear inflammation, non-specific. The patient was discharged home on cellcept [Pager number ] mg twice daily and tacrolimus 3 mg twice daily. The patient will follow-up with Dr. [Last Name (STitle) 497] at the transplant center. . 2. Respiratory distress/flash pulmonary edema: Resolved prior to discharge. The patient had two episodes of flash pulmonary edema requiring transfer to the MICU. Per OSH records, the patient has a history of flash pulmonary edema secondary to poor blood pressure control and fluid overload. COPD likely contributed to the patient's respiratory distress. Cardiology was consulted and adjusted the patient's anti-hypertensive regimen as below. The patient was started on advair and nebulizer treatments as needed. The patient received hemodialysis per schedule for fluid balance. . 3. ESRD on HD: Secondary to MPGN. The patient was followed by renal throughout admission. The patient was dialyzed per schedule. The patient was continued on calcium acetate and nephrocaps. The patient underwent vein mapping for placement of an AV fistula and will be followed by transplant surgery. . 4. Hypertension: The patient was followed by cardiology during admission. The patient was briefly on nitro gtt for blood pressure control while in the MICU. The patient's anti-hypertensive regimen was modified and the patient was discharged on Metoprolol 100 mg q8h, Lisinopril 40 mg [Hospital1 ], Amlodipine 10 mg qd, Hydralazine 50 mg q6h and Imdur 30 mg qd. The patient received hemodialysis per schedule for fluid balance. . 5. Thrombocytopenia and anemia: Likely secondary to end-stage liver disease and end-stage renal disease, respectively. The patient's hematocrit and platelet count remained stable throughout hospitalization. The patient had no signs or symptoms of active bleeding during admission. . 6. Diabetes: The patient was followed by [Last Name (un) ] during admission. The patient's glipizide and metformin were held. The patient was discharged on standing Glargine 14 units at bedtime with a sliding scale provided. . 7. Coronary artery disease/congestive heart failure: The patient was followed by cardiology. The patient had no complaints of chest pain during admission. The patient's troponins remained flat around 0.06. The patient has a history of catheterization showing mild disease performed in [State 48158] for flash pulmonary edema. The patient was admitted to [Hospital6 ] [2152-9-15] with flash pulmonary edema; work-up included pharmacologic stress test which shows small, mild, reversible anterior defect. Ejection fraction 60% on echocardiogram [10-2]. The patient was continued on aspirin, beta-blocker, ACE-inhibitor, plavix, and Imdur. The patient is not on a statin given her liver function. . 8. Hepatitis C: Refractory to treatment. Stable. . Code: Full Medications on Admission: MEDS at home: Aspirin 81 mg Plavix 75 mg Prograf 3 mg [Hospital1 ] Toprol xl100 mg QD Norvasc 10 mg QD Lisinopril 20 mg [Hospital1 ] Glipizide 10 mg [Hospital1 ] Lantus insulin 12 u SC Qpm Humalog 3u SC before each meal Furosemide 160 mg [Hospital1 ] Doxazosin 2 mg [Hospital1 ] Phoslo 667 mg TID with meals Nitroglycerin 24 mg sublingually Nephrocap 1 mg daily Protonix 40 mg daily Glimepiride 4 mg QD Metolazone 5qd Mirtazapine 15 qhs Epogen 10k tiw . MEDS on transfer: 1. Plavix 75 mg qd 2. Tacrolimus 3 mg [Hospital1 ] 3. Amlodipine 10 mg qd 4. Calcium acetate 667 mg tid 5. Nephrocaps qd 6. Protonix 40 mg qd 7. Metolazone 5 mg qd 8. Mirtazapine 15 mg qhs 9. Docusate 100 mg [Hospital1 ] 10. Senna 1 tab [Hospital1 ] 11. CellCept [Pager number ] mg [Hospital1 ] 12. Nicotine patch 21 mg qd 13. Atrovent q6 hrs prn 14. Metoprolol 50 mg tid 15. Insulin 16. Lisinopril 40 mg [Hospital1 ] Discharge Medications: 1. Home Nebulizer 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Disp:180 Tablet(s) Refills:2 12. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:120 Solutions Refills:2 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). Disp:180 Solutions Refills:2 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 17. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 18. Insulin Glargine 100 unit/mL Cartridge Sig: Fourteen (14) Units Subcutaneous with dinner: Please follow insulin sliding scale. Disp:QS Units Refills:2 19. Lancets Misc Sig: One (1) Miscell. four times a day. Disp:QS QS Refills:2 20. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: 1. Acute liver transplant rejection 2. Hepatitis C cirrhosis status post liver transplant [2149] 3. Pulmonary edema, likely secondary to end-stage renal disease and hypertension . Secondary: 1. End-stage renal disease on HD from MPGN 2. Congestive heart failure, EF 45-49% 3. Hypertension 4. Type 2 diabetes 5. Pancytopenia 6. Cryoglobulinemia 7. Hyperparathyroidism 8. Chronic obstructive pulmonary disease Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, shortness of breath, chest pain, increased abdominal pain, or any other concerning symptoms. . It is very important you take your medications as prescibed. - Your tacrolimus will continue at 3 mg twice daily - You were started on cellcept [Pager number ] mg twice daily for liver rejection - Your insulin was increased to Lantus 14 units at dinner with insulin sliding scale as provided; your glipizide and glimepiride were discontinued - You were started on advair inhaler and albuterol and ipratropium nebulizers for your breathing - Your blood pressure regimen is now as follows: -- Norvasc 10 mg once daily as before -- Lisinopril 40 mg twice daily -- Metoprolol 100 mg three times daily -- Hydralazine 50 mg four times daily -- Imdur 30 mg once daily -- Your cardura and Toprol XL were discontinued -- Your lasix and metazolone were discontinued . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with transplant medicine regarding placement of an AV graft: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2152-11-6] 3:20 . Follow-up with liver: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2152-11-8] 1:00 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 673] Date/Time:[2152-11-8] 2:00 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "250.92", "996.82", "414.01", "070.54", "276.7", "585.6", "284.1", "403.01", "428.0", "789.5" ]	icd9cm	[ [ [] ] ]	[ "93.90", "39.95" ]	icd9pcs	[ [ [] ] ]	10784, 10842	3951, 7681	309, 381	11307, 11339	3333, 3928	12355, 12987	2807, 2824		8665, 10761		10863, 11286		7707, 8181			11363, 12332									2839, 3314																								236, 271											409, 1375																	1397, 2623	2639, 2791		8199, 8642
11,710	177,094	53249+53250	Discharge summary	report+report	Admission Date: [2178-2-16] Discharge Date: [2178-3-6] Service: HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman status post coronary artery bypass graft times three on [2178-1-18]. The patient was discharged to rehabilitation on [2178-1-27] and readmitted on [2178-2-1] with pneumonia. On readmission the patient was noticed to have erythema and drainage from sternal incision and this is opened and packed with normal saline wet to dry dressing changes. The patient was discharged to rehabilitation on [2178-2-4] on Levofloxacin. The patient was seen today in the clinic for increased drainage from the sternal incision. The patient also reported being treated by rehabilitation for infection in the left lower extremity saphenous vein harvest site. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease 2. Peptic ulcer disease 3. Peripheral vascular disease 4. Status post bifemoral bypass graft 5. Status post coronary artery bypass graft times three 6. Status post myocardial infarction in [2171] 7. History of recent pneumonia 8. History of ventricular tachycardia on Amiodarone 9. History of Raynaud's 10. Hypertension 11. Increased cholesterol 12. History of atrial fibrillation MEDICATIONS: Lopressor 25 mg p.o. b.i.d.; Percocet prn; Ativan prn; Niferex 150 mg p.o. b.i.d.; Duricef 500 mg p.o. b.i.d.; Pulmicort 200 mcg metered dose inhaler; Captopril 25 mg p.o. t.i.d.; Lasix 20 mg p.o. q.d.; Plavix 75 mg p.o. q.d.; Protonix 40 mg p.o. q.d.; Lipitor 10 mg p.o. q.d.; Amiodarone 400 mg p.o. q.d.; Colace 100 mg p.o. t.i.d.; Meprobamate 400 mg p.o. t.i.d.; Combivent; [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mg p.o. q.d. PHYSICAL EXAMINATION: Vital signs temperature 99.8, pulse 74, blood pressure 177/58, respirations 18, saturations 98% on 2 liters of nasal cannula. On examination the patient is anxious, tearful. Neurological, alert and oriented to person, place, +/- time, +/- situation. Regular rate and rhythm. Respiratory rate increased with breathsounds decreased at the bases. No wheezes and no consolidation. Gastrointestinal: Bowel sounds, soft, nontender and nondistended. The patient reports multiple loose bowel movements over the last day. Trace lower extremity edema. Extremities warm. Sternal incision is open at the base, approximately 1 cm by 1 cm with yellow fibrinous base visible, Vicryl suture, moderate serous cloudy drainage. The sternum with positive click and pain to palpation. Left lower extremity and ankle with erythema, yellow fibrinous, warm, tender to touch. Upper left lower extremity with dark eschar over incision. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 6067] MEDQUIST36 D: [2178-3-5] 17:38 T: [2178-3-5] 18:34 JOB#: [Job Number 109609] Admission Date: [2178-2-16] Discharge Date: [2178-3-6] Service: HOSPITAL COURSE: The patient was admitted and was started on intravenous vancomycin. The patient was seen by Plastic Surgery on [2178-2-17], who felt that the patient would likely need debridement and flap closure. The patient was taken to the operating room on [2178-2-18] for sternal wound debridement. The patient was transferred to the Unit intubated and sedated, and the wound was dressed with wet-to-dry dressing changes using one-quarter strength iodine packings. On hospital day number three, the patient was started on total parenteral nutrition. On [2178-2-20], the patient returned to the operating room for omental flap and closure of her sternal defect. On [2178-2-22], a wean to extubate was attempted. On [2178-2-24], the patient was extubated. Nitro drip was weaned to off. On [2178-2-25], the patient was reintubated due to progressive dyspnea. On [2178-2-25], the patient was started on tube feeds and the patient's total parenteral nutrition was weaned. On [2178-2-27], the patient was extubated for the second time. The patient remained in the Intensive Care Unit until [2178-3-2] for observation due to confusion. On [2178-3-2], the patient was transferred to the floor. The patient did well while on the floor, and was screened for rehabilitation. Although the patient's oral intake increased, she was still not taking enough calories by mouth to discontinue the tube feeds. Tube feeds were continued via her Dobbhoff tube. The patient was transferred to rehabilitation on [2178-3-6] on the following medications: Amiodarone 200 mg by mouth once daily, Flovent four puffs inhaled twice a day, Combivent metered dose inhaler four puffs every six hours, heparin subcutaneously 5000 units twice a day, Lipitor 10 mg by mouth once daily, Ultra-Cal at 50 cc/hour through her Dobbhoff tube, free water flushes 250 cc each shift through the Dobbhoff tube, Lopressor 25 mg by mouth twice a day, [Doctor Last Name ] ointment twice a day to her leg wound, meprobamate 400 mg by mouth three times a day, Prevacid elixir 30 mg by mouth once daily, Dulcolax suppositories one per rectum every other day, Captopril 37.5 mg by mouth three times a day, vancomycin 1 gram intravenously every 48 hours, Plavix 75 mg by mouth or per nasogastric tube once daily, vitamin C 500 mg by mouth or by nasogastric tube twice a day, Tylenol #3 one to two tablets by mouth every four to six hours as needed, albuterol metered dose inhaler every four hours as needed. DISCHARGE DIAGNOSIS: 1. Status post sternal wound debridement on [2178-2-18] 2. Status post omental and pectoral flap on [2178-2-20] DISCHARGE STATUS: In stable condition to rehabilitation. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 22557] MEDQUIST36 D: [2178-3-5] 21:25 T: [2178-3-6] 00:00 JOB#: [Job Number 109610]	[ "V45.81", "512.1", "427.1", "998.59", "496", "401.9", "412", "272.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "77.61", "38.93", "96.71", "99.15", "96.6", "83.82", "96.04" ]	icd9pcs	[ [ [] ] ]											5586, 6032			3058, 5565																									1770, 3039																					112, 808																	830, 1747
44,016	122,419	37765+58178	Discharge summary	report+addendum	Admission Date: [2152-8-31] Discharge Date: [2152-9-4] Date of Birth: [2104-8-5] Sex: M Service: CARDIOTHORACIC Allergies: Motrin / Tetracycline Attending:[First Name3 (LF) 922] Chief Complaint: Nausea and Dyspepsia Major Surgical or Invasive Procedure: 1. Aortic valve replacement with a 27-mm [Doctor Last Name ] Magna Ease bioprosthesis. 2. Replacement of ascending aorta and proximal hemiarch with a 28 mm Vascutek Dacron graft using deep hypothermic circulatory arrest. 3. Pericardial reconstruction with CorMatrix History of Present Illness: This is a 47 year old male with known cardiac murmur for several years. Recent echocardiogram showed severe aortic stenosis and dilated ascending aorta. Past medical history is notable for opiate dependence, prior intravenous drug abuse and Hepatitis C. He currently complains of intermittent nausea and dyspepsia. Cardiac workup reveals severe aortic stenosis, a bicuspid aortic valve and dilated ascending aortic aneurysm. Cardiac surgery was consulted for surgical correction. Past Medical History: Aortic Stenosis Ascending Aortic Aneurysm Obesity Chronic Hepatitis C History of intravenous drug abuse History of alcohol Abuse (no signifcant ETOH in [7-6] years) Thrombocytopenia - ?liver etiology? Anxiety Disorder, Social Phobia Depression Insomnia Chronic Back Pain, Sciatica, Lumbar Spondylosis Ventral hernia Nephrolithiasis Arthritis s/p Bilateral knee surgery s/p Gastric surgery for GI bleed Social History: Race: Caucasian Last Dental Exam: in office chart, needs dental work but cleared for surgery Lives with: Parents (divorced with 2 adult daughters) Occupation: Unemployed Tobacco: Quit smoking several wks ago after approx 1ppd x 20+ yrs ETOH: History of abuse, no signifcant ETOH in [7-6] years Family History: Mother CABG in her 60's. [Name (NI) ] brother underwent coronary stenting. Physical Exam: Admission Physical Exam: Pulse:88 Resp:16 O2 sat:98%RA B/P Right: 162/98 Left: 155/102 Height: 76inches Weight: 225lbs General: no acute distress Skin: Dry [x] intact [x] scarred area posterior right calf from burn HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no lymphadenopathy Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: cath site angioseal Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2152-9-1] 02:24AM BLOOD WBC-16.2* RBC-3.77* Hgb-11.2* Hct-32.4* MCV-86 MCH-29.6 MCHC-34.4 RDW-15.1 Plt Ct-116* [2152-8-31] 11:54AM BLOOD WBC-18.7# RBC-3.65# Hgb-10.5# Hct-31.7# MCV-87 MCH-28.8 MCHC-33.1 RDW-14.8 Plt Ct-137* [2152-8-31] 01:28PM BLOOD PT-14.9* PTT-36.5* INR(PT)-1.3* [2152-8-31] 11:54AM BLOOD PT-15.3* PTT-39.7* INR(PT)-1.3* [2152-9-1] 02:24AM BLOOD Glucose-129* UreaN-12 Creat-0.7 Na-136 K-4.2 Cl-101 HCO3-27 AnGap-12 [2152-9-3] 09:45AM BLOOD WBC-6.8 RBC-3.27* Hgb-9.6* Hct-28.0* MCV-86 MCH-29.5 MCHC-34.4 RDW-15.0 Plt Ct-88* [2152-9-3] 06:56AM BLOOD UreaN-18 Creat-0.7 Na-137 K-4.3 Cl-98 Brief Hospital Course: On [2152-8-31] Mr.[Known lastname 2479] was taken to the Operating Room and underwent aortic valve replacement with a 27-mm [Doctor Last Name ] Magna Ease bioprosthesis and replacement of ascending aorta and proximal hemiarch with a 28 mm Vascutek Dacron graft using deep hypothermic circulatory arrestand pericardial reconstruction with CorMatrix by Dr.[Last Name (STitle) 914]. Please refer to operative note for further details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated. He awoke neurologically intact and was weaned to extubation without difficulty. All lines and drains were discontinued in a timely fashion. Beta- blocker, Aspirin and a statin and diuresis were initiated. The Pain Service was consulted for recommendations for pain control because of his polysubstance abuse. He continued to progress and was transferred to the step down unit on POD#1 for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of his postoperative course was essentially uneventful. His pain was well controlled on Dilaudid and his baseline Methadone by discharge. Dr.[Last Name (STitle) 914] cleared him for discharge to home on POD# 4. All follow up appointments were advised. Medications on Admission: AMOXICILLIN - (Prescribed by Other Provider; dental prophalaxis) - Dosage uncertain METHADONE [METHADOSE] - (Prescribed by Other Provider; [Doctor First Name 48] methadone clinic [Location (un) ] RI ) - 40 mg Tablet, Soluble - [2-2] Tablet(s) by mouth once a day 110mg (from methadone clinic) ZOLPIDEM - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day bedtime Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every [4-4] hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: 1. Severe aortic stenosis. 2. Bicuspid aortic valve. 3. Ascending aortic aneurysm. 4. Chronic hepatitis C with early stage inflammation and histopathologic changes within the liver but no frank cirrhosis. Obesity Chronic Hepatitis C - ? liver disease History of IVDA(Heroin, Oxycontin) - most recent 1 month ago and currently on Methadone History of ETOH Abuse (no signifcant ETOH in [7-6] years) History of GI Bleed - 15 years ago Thrombocytopenia - ?liver etiology? Anxiety Disorder, Social Phobia Depression Insomnia Chronic Back Pain, Sciatica, Lumbar Spondylosis Ventral hernia Nephrolithiasis Pneumonia in [2149] with bilateral chest tubes placed Arthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 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.[Name (NI) 9379] office will call to arrange follow up appointment -#([Telephone/Fax (1) 170]) Cardiologist Please call to schedule appointments with your Primary Care: Dr. [Last Name (STitle) 84567] [Name (STitle) ] ([Telephone/Fax (1) 68410]) in [1-1] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2152-9-4] Name: [Known lastname 6232],[Known firstname ] G Unit No: [Numeric Identifier 13463] Admission Date: [2152-8-31] Discharge Date: [2152-9-4] Date of Birth: [2104-8-5] Sex: M Service: CARDIOTHORACIC Allergies: Motrin / Tetracycline Attending:[First Name3 (LF) 1543] Addendum: Discharge Medication Addendum: Pt was discharged on Methadone 110 mg once daily. No script was given as he will resume preoperative treatment at the [Hospital 13464] clinic. Discharge Disposition: Home With Service Facility: [Hospital1 328] VNA [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2152-9-4]	[ "305.03", "496", "746.4", "300.4", "287.4", "304.01", "V15.82", "V13.01", "780.52", "278.00", "070.54", "441.2" ]	icd9cm	[ [ [] ] ]	[ "38.45", "39.61", "37.49", "35.21" ]	icd9pcs	[ [ [] ] ]	9121, 9333	3447, 4740	307, 590	6869, 7096	2785, 3424	8020, 9098	1862, 1942		5199, 6067		6166, 6848		4766, 5176			7120, 7997									1983, 2766																								246, 269											618, 1100																	1122, 1530	1546, 1846
50,409	153,380	34576	Discharge summary	report	Admission Date: [2108-12-6] Discharge Date: [2108-12-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: # Hyperkalemia # Bradycardia # Hypoglycemia # Hypothermia # Altered mental status # Pancytopenia # Hypothyroidism # Heme + stools; probable gastritis Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] year old male with chief complaint of hyperkalemia and bradycardia. Pt with hx of HTN, DM II, probable CAD, anemia, DVT in [2100]. Admitted to [Hospital1 18] [10-22] for urosepsis. He is now at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. Routine labs yesterday showed K of 7.0. He was treated with kayexalate overnight and had BMx2 with repeat K of 6.9. He has also been bradycardic into the 40s with decreased alertness/confusion and metoprolol had been intermittently held. Renal function is stable. No change in meds. Sent to ED for more aggressive tx of hyperkalemia. In the ED he had decreased responsiveness, and his FS was found to be 26. ABG was 7.26/49/129. He got D50, FS came up to 132 and he perked up with increased alertness and able to answer questions. He was then given another 1 amp of D50 with 5 units insulin, as well as bicarb, for hyperkalemia. EKG showed no changes. BP was stable in the 120s-130s systolic and his heart rate was in the 50s to 60s. Although he had no focal signs of infection, the ED felt there was no good reason for his acidemia and since UA was pending, they empirically gave him CTX. Repeat K was 4.9, and he was admitted for further management. On admission to the floor he was again lethargic and minimally responsive. FS was 23, and he was given another amp of D50 after which his mental status improved. He was started on D5 1/2 NS at 75 cc/hr. Currently he is not complaining of any symptoms other than being tired. ROS: -Constitutional: []WNL []Weight loss [x]Fatigue/Malaise []Fever []Chills/Rigors []Nightsweats []Anorexia -Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough -Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria []Discharge []Menorrhagia -Skin: [x]WNL []Rash []Pruritus -Endocrine: [x]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [x]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [x] WNL []Seasonal Allergies Past Medical History: Diabetes Type II Hypertension Partial gastric resection with bilroth II anastomosis for bleeding peptic ulcer ([2056]) Multiple prior episodes of SBO Atrial tachycardia: recent hypotensive event from atrial tachycardia causing TIA like symptoms, no evidence of CVA on MRI. Peripheral Neuropathy Remote EtOH Circumcision ([2106]) L ankle fracture L DVT s/p filter [2100], GIB on coumadin Pernicious anemia GERD Osteoarthritis Right leg bakers cyst Social History: Widowed. No children. Active in church, sings in choir. Lives with friend from church [Name (NI) ] although recently at [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. Pt has remote former EtOH and tobacco history, recently discharged to [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ] but had been living with adopted son prior to recent admission. * DNR/DNI per HC [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (h) [Telephone/Fax (1) 79368] and (c) [Telephone/Fax (1) 79369] Physical function: Independent at baseline with dressing, toileting, and walking wtih rolling walker. [Doctor Last Name ] assists with meal preparation, housekeeping, laundry, errands. No home services. Family History: Unknown--pt is reported by friend to be the last living member of his family. Physical Exam: Physical Exam: Appearance: NAD Vitals: T: Afebrile 160/70 prior to meds - (has been SBP 130's) P70 R18 97RA Glucose 109-241 (241 is outlier; generally 110's) GEN: elderly male,pleasant, AAOx2. HEENT: eomi, MMM. RESP: CTA B. CV: RRR. 2/6 SEM RUSB. ABD: +BS. Benign. EXT: 1+ LE edema B. Pertinent Results: [2108-12-6*] 04:50PM GLUCOSE-26 UREA N-48* CREAT-1.2 SODIUM-139 POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 [2108-12-6] 04:50PM ALT(SGPT)-139* AST(SGOT)-101* CK(CPK)-878* ALK PHOS-183* [2108-12-6] 04:50PM LIPASE-11 [2108-12-6] 04:50PM cTropnT-<0.01 [2108-12-6] 04:50PM CK-MB-10 MB INDX-1.1 [2108-12-6] 04:50PM CALCIUM-8.2* PHOSPHATE-5.4# MAGNESIUM-2.5 [2108-12-6] 04:50PM WBC-4.0 RBC-2.78 HGB-8.6* HCT-25.9* MCV-93 MCH-31.1 MCHC-33.4 RDW-16.8* [2108-12-6] 04:50PM NEUTS-83.6* LYMPHS-12.4* MONOS-3.2 EOS-0.5 BASOS-0.2 [2108-12-6] 04:50PM PLT COUNT-138# [2108-12-6] 04:50PM PT-13.1 PTT-43.8 INR(PT)-1.1 EKG sinus brady at 52, nl axis, QTc466 [2108-12-9] 05:33AM BLOOD Plt Smr-LOW Plt Ct-69* [2108-12-7] 04:30PM BLOOD CK-MB-10 MB Indx-1.1 cTropnT-0.02* [2108-12-9] 02:19PM BLOOD Hapto-210* [2108-12-9] 05:33AM BLOOD TSH-5.6* [2108-12-9] 05:33AM BLOOD T4-4.1* T3-58* calcTBG-1.06 TUptake-0.94 T4Index-3.9* Free T4-0.78* [2108-12-7] 07:55AM BLOOD [Month/Day/Year ]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . CXR: 1. Right retrocardiac opacity, could represent chronic atelectasis. However, new airspace disease cannot be excluded. 2. Stable elevation of the left hemidiaphragm. . CT Head: FINDINGS: There is no acute intra- or extra-axial hemorrhage, edema, mass effect, shift of normally midline structures, or acute major vascular territorial infarction. Minimal periventricular white matter low attenuation is compatible with chronic small vessel ischemic disease. Ventricles and sulci are prominent, compatible with age-related atrophy. Visualized paranasal sinuses and mastoid air cells are normally aerated. Osseous structures are unremarkable. Atherosclerotic calcification of the right carotid artery in its cavernous portion is seen. IMPRESSION: No acute intracranial process. . . [2108-12-9] 05:33AM BLOOD WBC-2.8* RBC-2.64* Hgb-8.1* Hct-24.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.7* Plt Ct-69* [2108-12-12] 09:00AM BLOOD WBC-4.9 RBC-2.72* Hgb-8.6* Hct-25.4* MCV-93 MCH-31.4 MCHC-33.7 RDW-16.2* Plt Ct-100* [2108-12-11] 06:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Schisto-OCCASIONAL Burr-1+ Tear Dr[Last Name (STitle) 833] [Name (STitle) 24904] [2108-12-9] 02:19PM BLOOD Ret Aut-0.8* [2108-12-12] 09:00AM BLOOD Glucose-198* UreaN-22* Creat-1.2 Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 [2108-12-11] 06:45AM BLOOD calTIBC-221* VitB12-871 Folate-6.8 Ferritn-403* TRF-170* [2108-12-9] 05:33AM BLOOD TSH-5.6* [2108-12-9] 05:33AM BLOOD T4-4.1* T3-58* calcTBG-1.06 TUptake-0.94 T4Index-3.9* Free T4-0.78* . [12-9] EKG: Sinus rhythm. There is an early transition which is non-specific. Diffuse ST-T wave changes. Compared to the previous tracing the P-R interval and the Q-T interval are shorter. . . Discharge: [2108-12-15] 06:50AM BLOOD WBC-4.9 RBC-3.22* Hgb-10.1* Hct-28.6* MCV-89 MCH-31.4 MCHC-35.4* RDW-15.9* Plt Ct-124* [2108-12-15] 06:50AM BLOOD Glucose-95 UreaN-26* Creat-1.2 Na-138 K-4.1 Cl-99 HCO3-29 AnGap-14 [2108-12-14] 06:50AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9 Stool occult blood - positive . Pending: H. pylori serology; please follow up results. Brief Hospital Course: A/P: [Age over 90 ]M with HTN, DM II, probable CAD, anemia, DVT in [2100] p/w hyperkalemia and bradycardia ## Hyperkalemia: Unclear precipitant, no new meds, renal function at baseline. Treated briefly with intravenous bicarbonate. Lisinopril held. ## hypoglycemia: found to have glucose of 26 in ED for which he received D50 (x2), along with bicarb and insulin to help treat hyperkalemia. ## bradycardia: Heart rate was in 40's in ED. Hyperkalemia was treated as above, and beta-blockers were held. Heart rate subsequently improved. . ## altered mental status: likely from hypoglycemia; returned to reported previous baseline of A+Ox2, pleasant. ## hypothermia: Unclear etiology, possibly from hypoglycemia. No infection identified. All cutures remained negative, and patient remained stable off of antibiotics. ## DM2: hypoglycemic as above. Oral hypoglycemics held throughout hospitalization. Glucose remained reasonably controlled on diabetic diet. ## HTN: lisinopril was held due to presentation of hyperkalemia. Metoprolol was held due to bradycardia. Patient's blood pressure crept up through the hospitalization, and patient was restarted on Lasix with some improvement. Lasix may need titration as an outpatient. ## GERD/anemia from acute blood loss: due to pancytopenia of unclear etiology, ppi was discontinued. However, pt was later found to have decreasing HCT despite improvements in other cell counts; pt found to have +stool occult blood (no melena or gross blood). Pt was started on high dose IV ppi, and converted to high dose oral [Hospital1 ] omeprazole at discharge. Pt received additional 2 units of PRBC (total of 4 units during hospitalization), and HCT subsequently remained stable, and cell counts continued to improve. . If pt's HCT trends down in future, or continues to have +occult blood, please consider referral to [Hospital ] clinic ([Telephone/Fax (1) ]). . H. pylori serologies were sent, but pending at time of discharge. Please f/u results. . ## Pancytopenia: unclear etiology. PPi was initially discontinued due to rare incidence of marrow suppression, however this is admittedly unlikely to be the etiology. PPi resumed when found to have heme + stools. CBC was trended with nadir on [12-9] as follows: WBC 2.8 HCT 24.4 PLT 69 Hematology was consulted, however counts improved without specific intervention. # Hypothyroidism: patient was found to have a mild elevation of TSH (5.6) while in ICU. Endocrinology recommended 50 mcg IV thyroxine with transition to po75 mcg daily. Recommend recheck TFT in 4 weeks. # Acute renal failure: max Cr 1.5. Improved to 1.2 while holding ACEi and lasix. Lasix resumed on [12-12], and BUN/Cr remained stable. . ## Contact: HCP is friend [Name (NI) ] [Name (NI) ] Home: [Telephone/Fax (1) 79368] Work: [Telephone/Fax (1) 79369]. Medications on Admission: 1. Aspirin 81 mg qd 2. Atorvastatin 10 mg qd 3. Heparin 5000 Units SC tid 4. Senna 2 tabs qhs 5. Docusate Sodium 200 mg qhs 6. Acetaminophen 500 mg q6h prn 7. Omeprazole 20 mg qd 8. Glipizide 2.5 mg [Hospital1 ] 9. metoprolol 12.5mg [Hospital1 ] 10. Bisacodyl 10 mg PR qd 11. Clotrimazole 1 % Cream [Hospital1 ] 12. RISS lisinopril Discharge Medications: 1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Two Hundred (200) mg PO HS (at bedtime). 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: # Hyperkalemia # Bradycardia # Hypoglycemia # Hypothermia # Altered mental status # Pancytopenia # Hypothyroidism # Heme + stools; probable gastritis Discharge Condition: stable Discharge Instructions: Take medications as prescribed. Keep follow up appointments. Followup Instructions: Provider: [Name10 (NameIs) ] UNIT Phone:[Telephone/Fax (1) 164] Date/Time:[2109-3-20] 10:00 . PCP: [Name10 (NameIs) ] follow up on H. pylori serologies. Please follow CBC for recent pancytopenia, and H/H and stool guiacs. Consider referral to [Hospital ] clinic if stools remain Guiac positive[Telephone/Fax (1) ]). . Please schedule a follow up with your PCP within the next week; recommend checking a CBC at that time.	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24,807	139,071	9848	Discharge summary	report	Admission Date: [2145-8-14] Discharge Date: [2145-8-20] Date of Birth: [2104-11-11] Sex: F Service: [Doctor Last Name ] HISTORY OF THE PRESENT ILLNESS: This is a 40-year-old woman with past medical history of recurrent aspiration pneumonia, ho was discharged from [Hospital1 69] after admission from [8-5] to [8-11] of [2144], during which time she was treated for aspiration pneumonia with Vancomycin, Levofloxacin, and Flagyl, initially and then switched to Levofloxacin, Flagyl, which she was given as an outpatient. She returns for admission now with hypoxia and worsening shortness of breath. Per report from the rehabilitation facility, the patient's saturations on room were 80%. The patient subsequently returned to the ED. Apparently, the patient was not getting desuctioned at the facility. Per the last discharge summary, the patient was treated for a presumed aspiration pneumonia with Vancomycin, Levofloxacin, and discharged on Levofloxacin and Flagyl. She continued to produce thick, copious secretions and needed to be desuctioned. The sputum grew 3+ oropharyngeal flora, 4+ yeast, and rate gram-negative rods. Chest x-ray showed right lower opacity. Blood cultures have one out to two bottles with Staphylococcus epidermides. Additionally, the urine grew Klebsiella, but given the history of prior UTIs, it was not treated, presumably bacteria was from colonization. The patient states that she was reportedly feeling unwell at the time of discharge on the 25th. She admitted to shortness of breath, thick secretions, but no fevers, chills, nausea, vomiting, or diarrhea. She was requesting pain medications for lower back pain. She feels she has been aspirating lately. In the ED, she received IV Levofloxacin and Flagyl. PAST MEDICAL HISTORY: 1. C3-C4 spinal cord injury secondary to motor vehicle accident in [2139], now quadriplegic, with some upper extremity use. 2. Gastroesophageal reflux disease. 3. Depression. 4. Chronic adrenal insufficiency. 5. Chronic low back pain. 6. Left heel osteomyelitis. 7. Anxiety. 8. Chronic anemia. 9. Decubitus ulcers. 10. Pseudomonas under left axilla and sacral region. 11. History of recurrent aspiration pneumonia. 12. History of MRSA in sputum. ALLERGIES: The patient is allergic to PENICILLIN AND SULFA. MEDICATIONS 1. Albuterol nebulizer. 2. Atrovent nebulizer. 3. Zoloft 50 mg q.d. 4. Multivitamin. 5. Florinef 0.2 mg q.d. 6. Dulcolax suppository p.r.n. 7. Klonopin 1 mg b.i.d. 8. Tizanidine 4 mg t.i.d. 9. Zinc 220 b.i.d. 10. Lactulose 30 cc t.i.d. 11. Neurontin 900 t.i.d. 12. Iron 325 mg t.i.d. 13. Protonix 40 mg q.d. 14. Levaquin 500 mg q.d. until [8-19]. 15. Flagyl 15 mg t.i.d. [8-19]. 16. Ditropan 5 mg b.i.d. 17. Vitamin C 500 b.i.d. 18. OxyContin 30 b.i.d. 19. Ambien 5 q.h.s. 20. Oxycodone 5 mg to 10 mg q.4h. to 6h.p.r.n. PHYSICAL EXAMINATION: Examination revealed the following: Temperature 95, pulse 75, blood pressure 97/74, respiratory rate 22. Saturation 98% on 58% nonrebreather. She was alert, oriented, and tired appearing. HEENT: Pupils equal, round, and reactive to light. Extraocular muscles are intact. No lymphadenopathy. Mucous membranes dry. No JVD. Anicteric sclera. PULMONARY: Diffuse rhonchi bilaterally. CARDIOVASCULAR: S1 and S2, regular rate and rhythm. ABDOMEN: Obese, soft, positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema; 1+ pitting edema bilaterally. NEUROLOGICAL: Cranial nerves II through XII intact; quadriplegic. SKIN: Sacral decubitus ulcer left upper rib. LABORATORY DATA: Laboratory data revealed the following: 13 sodium, potassium 4.1, chloride 97, bicarbonate 31, BUN 10, creatinine 0.3, glucose 99, white count 8.9, hematocrit 36.4, glucose 183, neutrophils 83, bands 10, sputum was 10 to 25 PMNs greater than 10 epithelials. Sputum: 4+ gram-positive cocci, 4+ gram-positive rods, 3+ yeast, 3+ gram-negative rods. Blood cultures pending. Chest x-ray showed bilateral small pleural effusions, bibasilar consolidation, right greater than left. HOSPITAL COURSE: This is a 40-year-old woman with C3-C4 quadriplegia with recurrent aspiration pneumonias and new history of hypoxia. She was admitted for treatment. She was continued on antibiotics. She was started on stress-dose steroids based on her history of adrenal insufficiency. Later on the day of admission, the patient was admitted to the [Hospital Ward Name 516] Intensive Care Unit because on the floor she had oxygen saturation of approximately 92% on nonrebreather and she required frequent suctioning. She was thus admitted to the ICU for closer observation and more aggressive pulmonary toilet. She was started on Zosyn for antibiotic coverage including Vancomycin, Zosyn, and Flagyl. Thus, she was given Pseudomonal double coverage. She was continued on Hydrocortisone IV 100 q.8. and Florinef 0.2 q.d. The outpatient pain regimen was continued. She had one episode of hypotension while on the unit, which responded to fluid bolus. On [8-16], the patient was transferred to the [Hospital Ward Name 12053] Intensive Care Unit due to bed situation around the [Hospital Ward Name 516]. The patient was continued on Vancomycin, Zosyn, Flagyl, on admission to the [Hospital Ward Name 517]. She was suctioned as needed, although the requirements were minimal. The blood pressure remained normal to high from 120 to 160, with no subsequently hypotensive episodes. She did have a history of sinus bradycardia, which was continued. She was never symptomatic, although Atropine was kept at the bedside. The Plastic Surgery Team was consulted for followup. On [8-17], the patient was seen by Speech and Swallow, who recommended regular house diet, in addition to thin liquids, which should be alternated at meals. The patient should be sitting upright at 90 degrees before meals and for a minimum of 45 minutes after eating. In addition, the patient should never be lowered below a 45 degree angle, therefore, the patient should never lie flat. She needs 1:1 assist with feeding. She should be fed at a slow rate with small bites and sips. Liquids and solids should be alternated. The patient is well aware of these requirements. The patient remained afebrile. The patient had progressively lowering white count while on the [Hospital Ward Name 517] Intensive Care Unit. Aspiration precautions were ordered. The patient also had continued right lower quadrant pain. The setting was a mildly alkaline phosphatase, which trended downward by the time of admission to within normal range. She had a right upper quadrant ultrasound with no significant findings. She was stable for discharge to the floor on [8-17]. Per the Department of Plastics consultation they recommended wet-to-dry dressings and current antibiotics. On [8-18], the patient's course was complicated by an episode of mental status changes. The patient was perseverating on questions and not answering appropriately. There was no evidence of infection. LP was performed. CSF revealed no sign of infection or other process going on. In addition, head CT was obtained, which also was without acute changes. The patient's narcotics and Baclofen were held with subsequent returned to baseline mental status. The patient continued to remain stable. Cultures remained negative. Zosyn and Flagyl were removed from the antibiotic coverage and Vancomycin was continued since she had MRSA positive sputum. She remained afebrile with a decreased white count with minimal suctioning requirements. Thus, the patient was deemed stable to return back to [Doctor Last Name ] House on [8-20]. CONDITION ON DISCHARGE: Stable. The patient was discharged to [Hospital3 28354] Rehabilitation. FINAL DIAGNOSIS: 1. Recurrent aspiration pneumonia. 2. C3-C4 quadriplegia secondary to motor vehicle accident in [2139]. DISCHARGE MEDICATIONS: 1. Baclofen 5 mg PO t.i.d.. 2. Oxycodone SR 30 mg PO q.12. 3. Prednisone taper 20 mg PO q.d. times one days, 15 mg PO q.d. times three days, 10 mg PO q.d. times three days, followed by 5 mg PO q.d. continuously. 4. Acetaminophen 325 to 650 PO q.4h. to 6h.p.r.n. pain. 5. Tizanidine 4 mg PO t.i.d. 6. Heparin 5000 units subcutaneously q.12. 7. Albuterol nebs q.4h. to 6h.p.r.n. 8. Atrovent nebs q. 4h. to 6h.p.r.n. 9. Docusate 100 mg PO b.i.d. 10. Clonazepam 1 mg PO b.i.d. 11. Bisacodyl 10 mg per rectum q.h.s.p.r.n. 12. Sertraline 50 mg PO q.d. 13. Protonix 40 mg PO q.d. 14. Milk of Magnesia 30 ml q.12h.p.r.n. 15. Zolpidem 5 mg PO q.h.s.p.r.n. 16. Vitamin C 500 mg PO b.i.d. 17. Vancomycin 750 mg IV b.i.d. times 7 days. 18. Zinc 220 mg b.i.d. 19. Ferrous sulfate 325 mg PO q.d. 20. Lactulose 30 ml PO t.i.d. 21. Gabapentin 400 mg PO t.i.d. 22. Hydromorphone 0.5 to 1 mg IV subcutaneously q.3h. to 4h. p.r.n. pain. 13. .................... 0.2 mg PO q.d. 14. Oxycodone 5 mg to 10 mg PO q.4h. to 6h.p.r.n. pain. DIET RECOMMENDATIONS: Regular solids, thin liquids, alternated at meals, 1:1 assist at all meals. The patient should be slowly with small bites and sips. The patient should be bolt upright at 90 for meals and at least 45 minutes after eating, and the patient should never be allowed to lie flat. The head of the bed should be at 45 degrees or greater at all times. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Name8 (MD) 17134] MEDQUIST36 D: [2145-8-20] 11:50 T: [2145-8-20] 12:44 JOB#: [Job Number 33097]	[ "311", "507.0", "530.81", "255.4", "518.81", "707.0", "344.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]									7991, 9645					4120, 7737	7857, 7968																								2925, 4102																																						1830, 2902		7762, 7840
27,672	184,680	30887	Discharge summary	report	Admission Date: [2179-6-8] Discharge Date: [2179-6-14] Date of Birth: [2134-4-2] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 301] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: Laprascopic roux-en-y gastric bypass. EGD with endoscopic clipping of bleeding artery at gastro-jejunal anastomosis. IVC filter placement. History of Present Illness: 45M with a history of obesity for 40 years. He has tried multiple exercise and diet programs without any sustained success. He has been extensively evaluated and medically cleared for bariatric surgery. Past Medical History: GERD, HTN, hyperlipidemia, OSA Social History: He denies alcohol and tobacco use. Family History: Non-contributory Physical Exam: Gen: no acute distress, alert and oriented CV: RRR, no murmurs Pulm: clear bilaterally Abd: obese, soft, nontender, normal bowel sounds Ext: no edema, normal strength and tone Pertinent Results: Barium swallow: post-op IMPRESSION: Moderately dilated gastric pouch with no evidence of obstruction or leak. CT scan of chest, abdomen, pelvis IMPRESSION: 1. Markedly limited examination due to respiratory motion and patient body habitus. There are equivocal filling defects noted within the right main pulmonary artery with possible extension into the right upper lobe branch. Nonocclusive emboli cannot be excluded. If high clinical suspicion, treatment is recommended, alternatively a repeat scan (if patient can provide adequate breath hold) or dedicated catheter PA angiogram may be attempted. 2. Bilateral segmental lower lobe and right middle lobe atelectasis. Scattered centrilobular ground-glass opacities predominantly within the upper lobes are nonspecific; however, infectious or inflammatory process such as aspiration pneumonitis/developing pneumonia cannot be excluded. Small amount of secretions is likely present within the upper trachea. 3. No evidence of Roux-en-Y gastric bypass leak. No evidence of obstruction with previously administered barium progressed into the large bowel. Pre-Op CBC [2179-6-8] 01:55PM BLOOD WBC-19.9* RBC-4.01* Hgb-11.9* Hct-35.4* MCV-88 MCH-29.6 MCHC-33.5 RDW-15.2 Plt Ct-425 Post-Op CBC [2179-6-10] 04:30AM BLOOD WBC-11.9* RBC-2.77* Hgb-8.0* Hct-24.0* MCV-86 MCH-28.9 MCHC-33.5 RDW-15.6* Plt Ct-226 Post-transfusion CBC [2179-6-12] 06:23AM BLOOD WBC-10.1 RBC-3.12* Hgb-9.2* Hct-27.2* MCV-87 MCH-29.6 MCHC-34.0 RDW-16.2* Plt Ct-241 ABG prior to CTA of chest [2179-6-10] 04:00PM BLOOD Type-ART pO2-53* pCO2-41 pH-7.46* calTCO2-30 Base XS-4 Brief Hospital Course: Mr. [Known lastname 73078] was admitted and underwent a laparoscopic roux-en-Y gastric bypass on [2179-6-8]. After the operation and extubation of the patient the anesthesiologist noticed blood coming out of the NG tube and the nasal trumpet. This was thought to be an upper airway bleed at first. ENT was emergently consulted and an upper airway bleed was not identified as the nasal passages were packed and blood was still coming from the oropharynx. Gastroenterology was then consulted and the patient was prepped for an emergent exploratory laparoscopy with intra-operative EGD to assess for bleeding within the GI tract. Upon exploration of the abdomen no extraluminal intra-abdominal bleed was identified. The anastomosis was tested for a leak and there was none. However, on upper endoscopy, a brisk arterial bleed was noted at the gastro-jejunal anastomosis. An endoclip was successfully placed and stopped the bleeding. The endoscope was passed down to the jejuno-jejunal anastomosis and no blood or bleeding was identified. The patient was transferred to the ICU for ventilatory support. On POD1 he was extubated without difficulty. On POD2 he passed his barium swallow as no leak or obstruction was noted. In the early afternoon he acutely desaturated down to 80% and complained of some dyspnea. An arterial blood gas was obtained and his pO2 was 54. He remained hemodynamically stable throughout this course of events. He was emergently taken to radiology for a CT angio of his chest and due to the fact that he received barium earlier in the day it was decided to scan his abdomen and pelvis to further evaluate for an anastomotic leak. There was a suspicious filling defect in his right main pulmonary artery and it was uncertain as to whether or not this was a pulmonary embolus. There was no extraluminal contrast seen in the abdomen. Due to the uncertainty of the pulmonary artery filling defect it was decided to proceed with care as if it was a pulmonary embolus. An IVC filter was placed by interventional radiology on the evening of POD2. He was started on a heparin drip for anticoagulation. His respiratory status improved on POD3 and his right groin was free from hematoma. He was able to get out of bed and into a chair and he was started on stage I bariatric diet. His hematocrit had dropped to 24, but he remained hemodynamically stable and his urine output was adequate. He was transfused with 2 units of packed RBCs. On POD 4 he was transferred out of the intensive care unit and to the floor. His saturations on room air have been stable and his diet was advanced to stage II. He continued to ambulate and his respiratory status improved. On POD 5 he was advanced to a stage III diet without complication. His hematocrit has been rechecked and it is stable at 27. He oxygen saturations are now in the high 90's on room air and he is out of bed frequently. Anticoagulation was discussed with a hematologist and it was decided that he should be treated for 6 months. He will be discharged on a Lovenox bridge and transition to coumadin with his primary care physician. [Name Initial (NameIs) ] have talked to the primary care physician's partner, Dr. [Last Name (STitle) 9037], and she is in agreement with this plan; they have the desire and capabilities to monitor his INR level. This is also the wish of the patient. Medications on Admission: Prozac 60mg Trazodone 50mg Topamax 50mg Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO every four (4) hours as needed. Disp:250 ML(s) Refills:0 2. Acetaminophen 160 mg/5 mL Solution Sig: Fifteen (15) MLs PO Q6H (every 6 hours) as needed. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. Zantac 15 mg/mL Syrup Sig: Ten (10) MLs PO twice a day for 7 days. Disp:140 MLs Refills:0 6. Zantac 15 mg/mL Syrup Sig: Ten (10) MLs PO twice a day for 23 days. Disp:460 MLs Refills:0 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 weeks. Disp:14 Capsule(s) Refills:0 8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day for 6 months. Disp:360 Capsule(s) Refills:0 9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [Hospital1 ] (2 times a day) for 4 days. Disp:8 syringe Refills:0 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day for 10 days. Disp:20 syringes Refills:0 Discharge Disposition: Home Discharge Diagnosis: Morbid obesity Discharge Condition: Good Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay in Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume all of your home medications except topamax, CRUSH ALL PILLS. You will be starting some new medications: 1. You will be given a prescription for pain medication, which may make you drowsy. Do not drive while taking pain medication. You may switch to tylenol elixir which you can buy over the counter. 2. You should begin taking a Flintstones chewable complete multivitamin. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You will be starting Lovenox injections twice a day to prevent blood clots. Follow up with your primary care physician to transition over the coumadin pills. Activity: No heavy lifting of items [8-30] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Leave white strips above your incisions in place, allow them to fall off on their own. Followup Instructions: See Dr. [Last Name (STitle) ] in his office on Wednesday [6-16] at 10am before you fly back to [Location (un) 14336]. Follow up with Dr. [Last Name (STitle) ] at your regularly scheduled appointment in [1-17] weeks. Call his office at [Telephone/Fax (1) 305] to confirm your appointment. Follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 73079], on Tuesday [6-22] at 12:45pm. She will transition you over to oral coumadin and check your INR level.	[ "998.11", "415.11", "327.23", "278.01", "V85.4", "272.4", "401.9", "518.0" ]	icd9cm	[ [ [] ] ]	[ "45.13", "38.7", "39.98", "54.21", "44.38" ]	icd9pcs	[ [ [] ] ]	7215, 7221	2654, 6051	292, 435	7280, 7287	1020, 2631	9098, 9632	791, 809		6141, 7192		7242, 7259		6077, 6118			7311, 7877									824, 1001																								238, 254								8867, 9075			463, 669									7902, 8855								691, 723	739, 775
24,573	102,522	1114	Discharge summary	report	Admission Date: [2126-2-28] Discharge Date: [2126-3-22] Date of Birth: [2070-7-15] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old male with a history of peripheral vascular disease who presented to the Medical Service with a chief complaint of claudication times one year. The patient was admitted for prehydration prior to cardiac catheterization. Previous ABIs on [2126-2-15] revealed significant bilateral superficial and femoral artery occlusion and tibial artery disease. The patient also reported some pain with walking consistent with claudication left greater then right reporting symptoms for approximately one year. The patient also noted some chest pressure with short distance walking or walking up a flight of stairs. Reports four pillow orthopnea and a history of lower extremity edema. The patient has a significant family history of coronary artery disease and a 20 pack year history of smoking. The patient denies cough, current chest discomfort, fevers or chills, nausea, vomiting, diarrhea, difficulty urinating, blood in the stool or urine. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Insulin dependent diabetes. 4. Congestive heart failure. 5. Chronic renal insufficiency. PAST SURGICAL HISTORY: Unremarkable. MEDICATIONS ON ADMISSION: 1. Lantus 40 units q.a.m. 2. Lasix 100 mg po b.i.d. 3. Elavil 25 mg po q.d. 4. Pletal 100 mg po b.i.d. 5. Lipitor 20 mg po q day. 6. Lisinopril 40 mg po q day. 7. _________ 15 mg po q day. 8. Toprol XL 25 mg po q day. 9. Aspirin 81 mg po q day. ALLERGIES: Cefepime with diaphoresis and tachycardia. SOCIAL HISTORY: The patient has a 20 pack year smoking history. No alcohol and no drugs. FAMILY HISTORY: Father with coronary artery disease. PHYSICAL EXAMINATION: The patient was afebrile and vital signs stable and in no acute distress. Alert and oriented times three. Head was normocephalic, atraumatic. No scleral icterus noted. Neck was soft and supple. No masses noted. No JVD. The patient had some carotid bruits bilaterally right greater then left. Heart was regular rate and rhythm. No murmurs. Chest was clear to auscultation bilaterally. No rhonchi or rales. Abdomen was soft, nontender, nondistended. Positive bowel sounds. Extremities was not significant for any edema. Dorsalis pedis pulses were absent and posterior tibial pulses were 2+ bilaterally. The patient was neurologically intact. HOSPITAL COURSE: The patient was admitted to the Medical Service. The patient was a 55 year-old male who was admitted to the Medical Service for prehydration prior to angio for claudication. The patient went for cardiac catheterization on [2126-3-1]. Dr. [First Name (STitle) ] attending and the patient was noted to have three vessel disease. For more details please see procedure note. Cardiac Surgery was consulted on [2126-3-2]. The patient was evaluated by Dr. [Last Name (STitle) 1537] and deemed appropriate for coronary artery bypass surgery. After undergoing the appropriate preoperative workup the patient went to the Operating Room on [2126-3-6] for coronary artery bypass graft times four, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to right coronary artery to the posterior descending coronary artery, saphenous vein graft to the obtuse marginal. For more detailed account please see operative report. The patient was transferred to the CSRU on a Dobutamine and Neo IV. Chest x-ray postoperatively was notable for a left lower lobe collapse. The patient was extubated early on postoperative day number one. In addition, on postoperative day number one the patient required one unit of packed red blood cells. Of note on postoperative day number two the patient had a creatinine of 2.8, which rose from 2.0. The Renal Service was consulted and they recommended holding diuresis with Lasix, transfusing to a hematocrit above 30 and avoiding other nephrotoxic agents. In addition they recommended keeping systolic blood pressure over 130. On [2126-3-7] the patient remained on pressors with neo-synephrine intravenously. Insulin drip was also restarted at this time. On [2126-3-10] the patient was transfused 2 units of packed red blood cells for a low urine output. The patient's renal status was worsening at this time with creatinine of 2.5 to 3 range. In addition, on this day the mediastinal chest tube was discontinued. The patient continued to have left persistent left lower collapse. On [2126-3-12] the patient was transfused 1 unit of packed red blood cells. The patient was off pressors. On [2126-3-14] the patient had a bronchoscopy, which revealed a mild tracheal malacia otherwise within normal limits. The patient also at this time was noted to have a rise in white blood cell count, so was placed on Levofloxacin. White blood cell count rose to 24. On [2126-3-15] the patient was found to have an alkaline phosphatase of greater then 1000. Right upper quadrant ultrasound was done, which showed some dilation. General Surgery Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] was consulted and the patient was monitored with expectant management. The patient was eventually transferred to the floor on [2126-3-15]. The patient continued to have left lower lobe collapse on chest x-ray. Creatinine was stable in the 2 to 2.5 range. White blood cell count was persistently high between 20 and 25,000. Liver function tests were steady decreasing and the patient's abdominal examination was benign. The patient was also noted to have some erythema at the superior pole of the sternotomy wound with minimal drainage, which improved over the course of his floor stay. On [2126-3-18] Infectious Disease was consulted and they recommended placing the patient on Vancomycin. He was placed on 1 gram q 24 hours. Over the next several days the patient's white blood cell count steadily decreased to the current discharge white blood cell count of 11. In addition, the patient was intermittently diuresed. In addition, the patient received intermittent doses of Kayexalate for a potassium level between 5 and 6. The patient continued to improve clinically on the Vancomycin. Infectious Disease recommended discharge with PICC line and intravenous Vancomycin for three weeks. On the day of discharge the patient's white blood cell count was stable at 11. The patient's creatinine had decreased to 1.8. The patient was replaced on po Lasix, however, on only 40 mg b.i.d. instead of his usual home dose of 100. The patient's ace inhibitor and [Last Name (un) ] continued to be held to be started at the discretion of his primary care physician. [Name10 (NameIs) ] patient continued to have left lower lobe collapse, however, pulmonary is recommending no intervention at this time. The patient is clinically stable. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Insulin dependent diabetes mellitus. 5. Chronic renal insufficiency. 6. Congestive heart failure. MEDICATIONS ON DISCHARGE: 1. Amitriptyline 25 mg po q.h.s. 2. Lipitor 20 mg po q.d. 3. Colace 100 mg po b.i.d. 4. Aspirin 325 mg po q day. 5. Dilaudid 2 mg one to two tabs po q 6 hours for pain. 6. Glargine insulin 20 units subq q breakfast. 7. Regular insulin sliding scale as directed. 8. Metoprolol 75 mg po b.i.d. 9. Protonix 40 mg po q day. 10. Pletal 100 mg po b.i.d. 11. Vancomycin 1 gram intravenously q day times three weeks. 12. Lasix 20 mg po b.i.d. FOLLOW UP: 1. The patient is to follow up with the Wound Care Clinic in one week. 2. Follow up with primary care physician in two to three weeks for management of intravenous antibiotics. 3. Dr. [First Name (STitle) ] from cardiology in two to three weeks. 4. Infectious disease please fax weekly laboratory results and follow up prn. 5. Dr. [Last Name (STitle) 1537] in four weeks. 6. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from General Surgery in two weeks. Please call for an appointment. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 7190] MEDQUIST36 D: [2126-3-22] 09:27 T: [2126-3-22] 09:36 JOB#: [Job Number 7191]	[ "584.5", "682.2", "428.0", "997.3", "414.01", "440.21", "250.40", "519.1", "403.91" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.72", "39.61", "99.04", "88.56", "33.23", "36.13", "37.22", "36.15" ]	icd9pcs	[ [ [] ] ]							1796, 1834	7084, 7275				7301, 7749	1376, 1687	2529, 7063										1335, 1350									7760, 8555						1857, 2511																					177, 1149																	1171, 1311	1704, 1779
55,672	126,629	35015+57966	Discharge summary	report+addendum	Admission Date: [2169-3-20] Discharge Date: [2169-4-27] Date of Birth: [2111-10-2] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 492] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: Tracheostomy placement Tracheal stent placement PICC line placement Subclavian line placement Bronchoscopy Lumbar Puncture History of Present Illness: 57-year-old woman with history of tracheobronchial malacia was transferred from [State 1727] after being found unresponsive at home on [2169-3-7]. She was found to be in acute hypercarbic and hypoxic respiratory failure and was intubated on [2169-3-7]. She was initially hypotensive, requiring fluid resuscitation and pressors for the first 24 hours. She was found to have a possible LLL pneumonia, received 10 days of moxifloxacin, as well as empiric vancomycin for the first 4 days. On [2169-3-17] she was diagnosed with a UTI, with culture pending, and was started on ceftriaxone. Also had elevated transaminases in the 6000s which gradually normalized, thought to be due to shock liver. She had [Last Name (un) ], which resolved after IVFs and was also felt to be from low blood pressures. Per OSH records, she was "ruled in" for NSTEMI--CK 368, trop (unclear if I or T) 0.54--with "limited management" given her other critical issues. The patient's hypercarbia and hypoxia quickly resolved with mechanical ventilation. Her ET tube was withdrawn over bronchoscope on [2169-3-17], but almost complete airway collapse was witnessed so she remained intubated and transferred to [Hospital1 18] for further management. She had been receiving tube feeds and these have been continued. By discharge from OSH, her labs were: WBC 15, Hct 31, plts 125, Cr 1.1; ABG 7.45/35/83. CXR on [2169-3-20] showed elevated R hemidiaphragm and bibasilar atelectasis. All cultures have been negative to date. . On arrival to [Hospital1 18], patient was awake, alert, with ET tube in but not connected to ventilator; patient was breathing room air. Her vitals were stable, and patient denied any pain. . ROS: limited as patient was intubated . Past Medical History: # tracheobronchial malacia: s/p stent placement in [2167-11-14] then removal in [2168-11-13] due to persistent secretions # obesity # GERD # avascular necrosis of the L hip s/p L hip replacement in [2161] # alcohol abuse # RUE DVT in [2167-10-14] # COPD # granulomas in L lung # s/p TAH # s/p appendectomy Social History: Ms. [Known lastname 42611] had been a regional manager at insurance company. She lived with boyfriend > 10 years. She had not been in contact with her brother in ~1 year, however, brother has visited her frequently while in the hospital and he is from [State ] area and lives at a distance. Patient has history of significant alcoholism. Unknown cigarrette smoking history as patient unable to give this history. Family History: Noncontributory Physical Exam: Admission exam: GENERAL: Middle-aged woman sitting in bed, intubated but awake, alert, able to write, in no acute distress HEENT: ET tube in place CARDIAC: RR, normal S1/S2, no m/r/g LUNG: CTAB ABDOMEN: soft, NT, ND EXT: no c/c/e . Exam at time of discharge: date [2169-4-25] Vitals: T 99.6F, BP 141/53, HR 96, RR 20 and O2 Sat 99% GEN: Awake but somnolent, not responding to commands, responds to pain HEENT: Tracheostomy in place, connected to ventilation machine CVS: RRR, s1s2 normal, no m/r/g LUNG: limited bibasilar crackles, otherwise CTA, no rhonchi ABDOMEN: soft, ND, J-tube in place and is nontender and appears clean/dry/intact EXT: pedal pulses 2+ bilaterally and no edema present Pertinent Results: Admission labs: [2169-3-20] 09:18PM WBC-13.0* RBC-3.65* HGB-9.6* HCT-29.6* MCV-81* MCH-26.3* MCHC-32.4 RDW-14.5 [2169-3-20] 09:18PM ALT(SGPT)-58* AST(SGOT)-13 CK(CPK)-39 ALK PHOS-62 TOT BILI-0.3 [2169-3-20] 09:18PM GLUCOSE-92 UREA N-25* CREAT-1.2* SODIUM-145 POTASSIUM-3.3 CHLORIDE-110* TOTAL CO2-28 ANION GAP-10 ================= IMAGING: [3-20] MR HEAD: 1. No acute intracranial pathology. There are no imaging findings to suggest anoxic brain injury or Wernicke-Korsakoff syndrome, although given that the possible anoxic brain injury event might have been a few weeks ago, imaging findings can be subtle in these cases.2. Nonspecific areas of white matter signal abnormality may reflect the sequela of chronic microangiopathy. . [2169-3-20] CXR: In comparison with the study of [2167-10-28], the respiratory tube tip lies approximately 3 cm above the carina. Retrocardiac opacification is consistent with volume loss in the left lower lobe in this patient with low lung volumes. No definite vascular congestion or acute focal pneumonia on this technically limited study. . [2169-4-2] CXR : As compared to the previous radiograph, the monitoring and support devices are in unchanged position. Tracheal wire stent is also unchanged. Minimally increasing left pleural effusion with minimal increase of left basal opacity. Small area of either atelectasis or small intrafissural effusion at the right lung base. No evidence of pneumothorax. No other relevant changes. . [2169-4-5] EEG: IMPRESSION: This is an abnormal portable EEG due to intermittent sharp waves in the L>R mid to posterior temporal regions suggestive of cortical irritability and potential for epileptogenesis. The background rhythm is slow and disorganized consistent with a moderate encephalopathy. Medications, toxic/metabolic disturbances and infections are common causes. Anoxia is also a possible etiology. If still clinically indicated, would consider 24 hour continuous EEG for further evaluation of the above findings. . [2169-4-6] UE ULtrasound: Deep venous thrombosis of the left subclavian, axillary, and basilic veins surrounding the left PICC . [2169-4-6] CTA Chest: 1. No evidence of pulmonary embolism. Bilateral lower lobe collapse with narrowing of left lower lobe and collapse of the right lower lobe bronchus. Overall findings are probably due to known tracheobronchomalacia and mucous secretion plugging. Status post tracheostomy. Slight increase in mediastinal lymphadenopathy. Mild splenomegaly. Trace free air adjacent to the gastrostomy, presumably related to recent PEG placement. . [2169-4-17] CT Abdomen IMPRESSION: 1. Cholelithiasis with no signs of cholecystitis. 2. Limited study for evaluation of mass lesion due to lack of IV contrast. However, no definite liver lesion was visualized to explain the transaminitis on the non-contrast study. 3. Splenomegaly. 4. Unchanged wedge compression deformity of the lower thoracic vertebra . [2169-4-19] CXR: CHEST, AP: Lung volumes are low, but stable. Increased linear opacities at the right lung base may represent atelectasis or consolidation. Left lower lobe atelectasis is unchanged. Tracheostomy and tracheal Y stent are in standard position. A right PICC again terminates in the right atrium. There is no pneumothorax or pleural effusion. The cardiomediastinal and hilar contours are normal. IMPRESSION: Increasing right basilar atelectasis or consolidation. . [2169-4-23] EKG - HR 80s. Baseline artifact. Sinus rhythm with first degree A-V block. Non-specific ST-T wave abnormalities. Compared to the previous tracing of no diagnostic change. No QT prolongation. . [2169-4-25] : BUN 10, Cr 0.6, Na 145, K 3.8, Cl 105, HCO3 33, Hct 28.7, Plts 256, WBC 7.4, Mg 1.9, Ca 8.3, Phos 3.2 . [2169-4-22] : AST 17, ALT 36, ALP 195 ( down from 371) , total bili .2 INR 1.3, PT 15, PTT 32 . [2169-4-19] lactate .4 [2169-4-19] H.pylori serology negative . [2169-4-18] hepatitis B panel negative MICRO DATA: [2169-4-25] C.difficile pending [2169-4-25] - Urinalysis negative [2169-4-25] - Urine culture pending [2169-4-17] - C.difficile negative [2169-4-15] - blood cultures x 2 negative [2169-4-13] - blood cultures negative [2169-4-4] - blood cultures x 2 negative [2169-3-29] -blood cultures negative [2169-3-28] -blood cultures negative [2169-4-14] 12:20 pm SPUTUM Source: Endotracheal. FINAL REPORT [2169-4-14] GRAM STAIN (Final [2169-4-14]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2169-4-14]): TEST CANCELLED, PATIENT CREDITED . [2169-3-31] BAL results - [2169-3-31] 11:00 am BRONCHIAL WASHINGS LEFT LOWER LOBE. GRAM STAIN (Final [2169-3-31]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2169-4-2]): ~3000/ML Commensal Respiratory Flora. YEAST. 10,000-100,000 ORGANISMS/ML.. ACID FAST SMEAR (Final [2169-4-1]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Final [2169-4-13]): YEAST. POTASSIUM HYDROXIDE PREPARATION (Final [2169-3-31]): TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our in-house studies if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). . [2169-4-6] 8:31 pm CSF;SPINAL FLUID Source: LP. GRAM STAIN (Final [2169-4-7]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2169-4-10]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: 57-year-old woman with history of tracheobronchial malacia was transferred from [State 1727] after being found unresponsive at home on [2169-3-7] and subsequently [Date Range 1834] intubation who has had difficulty weaning from the ventilator machine despite Y-stent placement and will need long-term weaning at rehab facility. . # Severe tracheobronchial malacia: Patient is status post Y-Stent placement [2169-3-23]. Due to inability to wean from ventilator she [Month/Day/Year 1834] tracheostomy placement [2169-4-4]. Since then, she has been able to be weaned to just a sole trach collar at night time when she sleeps due to desaturations. Thus, she has been kept on trach during daytime hours from 7am to 9pm (approximately), but is placed on pressure support at the following settings overnight : PS --> 10 cm/h2o PEEP: 5 cm/h2o FIO2: 50 %. She has tolerated this regimen for at least 1 week prior to discharge and has been doing very well with this routine. The goal is to decrease hours of pressure support to eventually have her on the trach alone x 24 hours. Per interventional pulmonology team the long term goal is also to have her recannulized, stent removed, and eventual surgery. She will be followed by interventional pulmonary for this on an ongoing basis. Full follow-up and appointments outlined below in discharge planning. Overall settings on her mechanical ventilation during daytime: CPAP w/ & w/o PS. As above, on pressure support levels at night: 10 cm/h2o PEEP: 5 cm/h2o FIO2: 50 % settings. . # Agitated Delirium: Likely related to long ICU stay coupled with anoxic brain injury and seizures. She [Month/Day/Year 1834] LP which was negative for infectious sources. She was seen by psychiatry who recommended starting haldol PRN and QHS. Agitation significantly improved. She was followed by psychiatry during her hospitalization and was recommended to be on standing and prn haldol (with EKGs checking for QTC prolongation). By disharge, her delirium was under control with haldol PO 0.5mg in AM, 0.5mg in afternoon, and 2mg QHS. She as also written for 1mg PO BID prn agitation. She was off restraints by time of discharge. She should be written for EKGs when given additional haldol doses to make sure QTC<0.5. Continue redirection over the course of the day, maintain sleep/wake cycle. . # Fevers/Ventilator Associated PNA: Only positive BAL results were for yeast in sputum per bronchial washings. Also yeast in urine. We believe this represents colonization. Given fever in setting of being on ventilator she was treated with 10 day course of Vancomycin and Cefepime which was changed to meropenem and this antibiotic regimen was finished on [4-22] and central line pulled out prior to discharge. . # Esophagitis/Gastritis/Reflux: Patient found to have coffee ground emesis [4-10]. An EGD revealed gastritis. She also had issues with reflux of bilious materials which was followed by GI. She was maintained in IV protonix and PO ranitidine [Hospital1 ]. She may still have occasional reflux/nausea of 50-100c or less (written for prn IV zofran) but is on Reglan and has GI followup for gastric motility/impedence studies. Please call [Hospital ] clinic for any concern for increased reflux to have her seen in clinic earlier (workup for this happens as outpatient). Current tubefeed schedule/levels outlined below is diet instructions and patient's J-tube site remains clean, dry and in tact and is working well. . # Concern for Anoxic Brain Injury: Patient initially found down [2169-3-7] for unknown length of time. Lumbar puncture done during this hospital course and CSF was unrevealing. Given her altered MS on this admission she [Month/Day/Year 1834] MRI which did NOT demonstrate any acute intracranial pathology. She [Month/Day/Year 1834] EEG which did show some epileptiform activity. Agitation has been well controlled with Haldol regimen as outlined in medication list. She was seen by the psychiatry service to help with adjustments in her Haldol dosing. She had been on Olanzepine briefly but did this medication had limited effects. . # Seizures: Given concern for altered MS [First Name (Titles) ] [Last Name (Titles) 1834] EEG which revealed epileptiform activity. She was loaded with dilantin and started on a maintenance dose. Her outpatient Bupropion stopped given concern for lowering sz threshold. She will need neurology follow-up as an outpatient. . # Niacin Deficiency: Found to be completely deficient of niacin which was thought to be playing a role in depressed mental status. Patient was repleted with oral niacin 100mg QID. A level following repletion is pending. . # New atrial fibrillation: Unclear etiology. Normal TSH. She was started on diltiazem which was uptitrated to 80mg QID by time of discharge. She responded to bolus doses of IV diltiazem for breakthrough ectopy but this has abated for at least 3-days prior to discharge. As noted below she is currently be anti-coagulated for DVT for lovenox. When anti-coag for DVT complete she only needs to be on ASA given CHADS 0. . # LUE DVT: Swelling was noticed so a follow-up US of LUE on [4-6] showed a deep venous thrombosis of the left subclavian, axillary, and basilic veins surrounding the left PICC. This was felt to be secondary to PICC line which was then pulled. Patient had CVL placed for better access. She was started on warfarin with lovenox bridge and she will now need a total of 3 months of anticoagulation (see course in medication section). . # Nutrition: PEG tube placed which was converted to G-J given that patient was vomiting intermittently mostly when she was coughing on secretions. She is currently at goal on her tube feeds and tube site is clean. She was followed by the GI service and will need additional outpatient follow-up as outlined above. . # COPD: On admission was taking methylprednisone IV 40mg daily that was tapered off. She is now continued on ipratropium and albuterol nebulizers. Full ventilation settings outlined above for recent respiratory failure. . # Hypernatremia: Improved with ~1.5L free water daily. Should be less of a problem now that her tube feeds have been at goal. Should be monitored at least weekly. . #Recent diarrhea: Patient has had some loose stools x 3 days which may be secondary to her tube feedings. Multiple prior C.difficile studies were negative. A repeat C.difficle sample sent prior to discharge which is now pending and will need to be followed up on. # CODE: Full Code Status / confirmed with HCP and brother ( [Name (NI) 401] ) # CONTACT: boyfriend [Name (NI) 2855] [Name (NI) ] [Telephone/Fax (1) 80054], brother [Name (NI) 401] [Name (NI) 42611] [Telephone/Fax (1) 80055] Medications on Admission: Azithromycin pantoprazole omeprazole 40 mg qday Tussionex prn cough bupropion SR 150 mg PO qday ipratropium inh lorazepam prn Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 7. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal [Hospital1 ] (2 times a day): to hemorrhoids. 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 9. Phenytoin 125 mg/5 mL Suspension Sig: 100mg PO TID (3 times a day). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Cont until INR therapeutic ([2-15]) for 48 hrs. 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: monitor INR daily. goal is [2-15]. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous [Hospital1 ] (2 times a day) as needed for thick secretions. 15. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Hold for SBP<95. 16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 17. Haloperidol 1 mg Tablet Sig: Half Tablet PO AS DIRECTED (): Haloperidol 0.5 mg PO AS DIRECTED (Morning and afternoon: 8am and 3pm) . Hold for QTC>500 . 18. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for agitation . 19. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation: patient needs daily ekg with review of HO before haldol given that day. Confirm QTC<0.5. 20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for Constipation. 21. Lidocaine (PF) 10 mg/mL (1 %) Solution Sig: 2.5 MLs Injection Q12H (every 12 hours) as needed for cough. 22. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for ng tube. 23. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 24. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 26. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 27. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: PRIMARY: Hypercarbic and Hypoxic Respiratory failure Tracheobroncheomalacia Ventilator Associated Pneumonia Deep Venous Thrombosis / upper extremity Esophagitis Gastritis Delirium Seizure Disorder Discharge Condition: Mental Status: Mental status at recent baseline, responding appropriately but unable to speak (trach in). Level of Consciousness: Awake, alert and oriented to person/place/time Activity Status: Bed-bound . DISCHARGE DIET: Tubefeeding: Start After 12:01AM; Vivonex TEN Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml q6h Goal rate:65 ml/hr Residual Check:q4h Hold feeding for residual >= :200 ml Flush w/ 250 ml water q4h Discharge Instructions: You were admitted with respiratory failure. You had a tracheal stent placed and because we could not wean you from a ventilator we had to perform a procedure called tracheostomy placement which is another opening in your airways that lead into your lungs to allow you to have assisted breathing that helps you to have appropriate oxygenation. Your course was complicated by seizures, pneumonia, deep venous thrombosis, delerium, and some mild irritation of your stomach leading to bleeding. On discharge, you have been able to tolerate the trach collar during the day and have been placed on pressure support at night which is with a ventilation machine. The goal is for you to work towards being on the trach collar 24 hours a day at rehab, which may take several weeks to months. In addition, you have a better regimen for delirium with a medication called Haldol. . You had a lab study ordered for recent diarrhea called a C.difficile stool study. You also had a urine culture that was pending at the time of your discahrge. This was communicated to your rehab facility prior to your discharge. . Based on your complicated hospital course as described above, you have been set up with neurology, pulmonary and gastroenterology appointments as an outpatient. These details are all listed below. . DISCHARGE DIET: Tubefeeding: Start After 12:01AM; Vivonex TEN Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml q6h Goal rate:65 ml/hr Residual Check:q4h Hold feeding for residual >= :200 ml Flush w/ 250 ml water q4h Followup Instructions: Provider: [Name10 (NameIs) 17853] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[Telephone/Fax (1) 3020] Date/Time:[2169-5-23] 11:30 Provider: [Name10 (NameIs) ] INTAKE,ONE [Name10 (NameIs) ] ROOMS/BAYS Date/Time:[2169-5-23] 1:30 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 5072] Date/Time:[2169-5-23] 2:00 . You have an appointment with Dr. [Last Name (STitle) ] from GI at 3pm on Wednesday [5-31] in [Hospital Ward Name 452] 1 buildling. ([Telephone/Fax (1) 2233] - call if [Doctor First Name ] acute issues arise. The plan is to followup on your reflux and do studies on your gastric motility and impedance studies. . You have a follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the neurology clinic on [4-28] at 8:30am on the [Location (un) ] of the [Hospital Ward Name 23] [Hospital Ward Name 860] building. [Telephone/Fax (1) 1690] . [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494] Completed by:[2169-4-25] Name: [Known lastname 12857],[Known firstname ] J Unit No: [Numeric Identifier 12858] Admission Date: [2169-3-20] Discharge Date: [2169-4-27] Date of Birth: [2111-10-2] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 10926] Addendum: Please note that initial discharge summary noted that she will be continued on maintenance of Dilantin for seizure control but on further discussions with neurology this medication was not felt to be needed and it was removed from her updated medication list before this list was sent to rehab facility. Patient is also no longer on Acetylcysteine medication. . Discharge Disposition: Extended Care Facility: [Hospital1 49] - [Location (un) 50] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 10927] Completed by:[2169-4-25]	[ "285.9", "518.0", "996.74", "780.39", "466.0", "519.19", "453.81", "787.91", "V43.64", "288.60", "276.0", "265.2", "491.21", "V12.51", "112.4", "427.31", "E878.1", "518.89", "293.0", "V15.88", "535.41", "278.00", "507.0", "410.71", "530.19", "V45.79", "787.22", "V46.11", "518.81", "112.2", "530.81", "V88.01", "348.1", "560.1", "303.91", "997.31", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "96.05", "45.13", "33.24", "03.31", "33.22", "97.03", "31.1", "38.93", "99.15", "96.6", "96.72", "43.11" ]	icd9pcs	[ [ [] ] ]	24233, 24446	10148, 16922	332, 457	20290, 20290	3800, 3800	22303, 24210	3048, 3065		17099, 19954		20070, 20269		16948, 17076			20749, 22280									3080, 3781				9373, 10008			10041, 10125																	276, 294											485, 2247							3817, 9336				20305, 20725						2269, 2593	2609, 3032
10,496	183,010	26417	Discharge summary	report	Admission Date: [2177-12-29] Discharge Date: [2178-1-7] Date of Birth: [2099-1-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2159] Chief Complaint: abdominal pain/nausea Major Surgical or Invasive Procedure: Intubation IR guided nephrostomy placement History of Present Illness: The patient is a 78y/o WF w/a PMH significant for HTN and afib who presented to an OSH w/ complaints of abd pain and nausea. She was found to have a R ureteral stone w/ resultant hydronephrosis and was transferred to [Hospital1 18] for ureteral stent placement. Her INR was found to be elevated when admitted and, in the course of waiting for this to normalize, the patient spiked a temperature to 105 and became hypotensive to the 70s. She was bolused w/out effect and had little response to neo so she was changed to levophed, given doses of cipro/vanco/gent and transferred to the MICU for management. . In the MICU, urology was consulted and the patient received a R nephrostomy tube. However, tube placement was complicated by renal artery puncture, afib, and increased dyspnea. She was intubated for this hypoxia and treated with lasix, metoprolol, and diltiazem. She was weaned off her pressors on [1-1] and maintained her pressure w/out additional fluid boluses. Her sedation was weaned down and she was successfully extubated shortly thereafter. UCx grew proteus and her abx were changed to levaquin alone and she remained afebrile for >24hr on this regimen. She continued to have trouble with afib and required a dilt gtt on the day prior to call-out to control this rhythm but she was transitioned to PO diltiazem and has been in NSR since this time. She was restarted on heparin prior to d/c as a bridge to therapeutic coumadin anticoagulation. Past Medical History: 1. HTN 2. A.fib on Coumadin 3. Cataract disease 4. [12-2] closed fracture of radius s/p closed reduction 5. MV, AV, TV insufficiency Social History: Single, lives with her daughter, doesn't smoke, doesn't drink, worked for bag company Family History: Brother with "heart trouble". Physical Exam: 140/66, 92, 18, 96% 2L Gen: Pleasant obese female in NAD, in wrist restraints HEENT: EOMI, PERRLA, MM dry, O/P clear Lungs: clear anteriorly CV: RRR, S1/S2 intact, 3/6 SEM at the USB Abd: S/NT/ND, obese, +BS Back: R nephrostomy tube in place and draining Ext: brace on L wrist, 2+ LE edema Neuro:CN 2-12 grossly intact, strength 5/5 bilaterally, AAO to person, place (hospital in [Location (un) 86]), and time ([2162-1-3]) Pertinent Results: CXR [2178-1-1]: Right subclavian CV line overlies proximal SVC. There is cardiomegaly and tortuosity of the thoracic aorta with small bilateral pleural effusions consistent with CHF. No pneumothorax. Overall appearances are essentially unchanged since the prior film of [2177-12-31], apart from removal of the ET tube. . CT Abd [2177-12-29]: 1) Moderate to severe right hydroureteronephrosis with two obstructing distal right ureteral stones, 8 mm and 6 mm respectively. 2) Probable obstructing 5mm right mid ureteral calculus causing mild hydroureter, though it is difficult to tell definitively if this stone is within or just medial to the right ureter on this CT without IV contrast. 3) Small bilateral pleural effusions. 4) Coronary artery calcification. . ECHO [2177-12-30]: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal LVEF>55%). 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis. 5. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Trivial mitral regurgitation is present. 6. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. . [2177-12-29] 05:49PM BLOOD WBC-36.6* RBC-4.29 Hgb-13.4 Hct-38.8 MCV-91 MCH-31.3 MCHC-34.6 RDW-13.2 Plt Ct-132* [2178-1-7] 05:17AM BLOOD WBC-11.8* RBC-3.61* Hgb-10.8* Hct-32.2* MCV-89 MCH-29.8 MCHC-33.5 RDW-13.2 Plt Ct-346 [2177-12-29] 05:49PM BLOOD PT-20.6* PTT-31.6 INR(PT)-3.0 [2178-1-7] 05:17AM BLOOD PT-15.5* PTT-75.0* INR(PT)-1.6 [2177-12-29] 05:49PM BLOOD Glucose-127* UreaN-26* Creat-1.7* Na-136 K-3.9 Cl-103 HCO3-20* AnGap-17 [2178-1-7] 05:17AM BLOOD Glucose-97 UreaN-14 Creat-1.2* Na-144 K-3.9 Cl-106 HCO3-29 AnGap-13 [2178-1-2] 03:00AM BLOOD ALT-52* AST-50* LD(LDH)-300* CK(CPK)-41 AlkPhos-280* TotBili-0.8 [2177-12-29] 05:49PM BLOOD Calcium-7.7* Phos-3.3 Mg-1.1* [2178-1-7] 05:17AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 Brief Hospital Course: A/P: 78 year old female with history of HTN, a.fib presenting with ureteral stone, hydronephrosis, and urosepsis. She originally had hypotension and a leukocytosis in the ER and was admitted to the MICU. In the MICU, urology was consulted and the patient received a R nephrostomy tube. However, tube placement was complicated by renal artery puncture, afib, and increased dyspnea. She was intubated for this hypoxia and treated with lasix, metoprolol, and diltiazem. She was weaned off her pressors on [1-1] and maintained her pressure w/out additional fluid boluses. Her sedation was weaned down and she was successfully extubated shortly thereafter. UCx grew proteus and her abx were changed to levaquin alone and she remained afebrile for >24hr on this regimen. She continued to have trouble with afib and required a dilt gtt on the day prior to call-out to control this rhythm but she was transitioned to PO diltiazem on the day of call-out. . 1. Sepsis - The patient was septic in the ER and her blood cultures eventually grew proteus. Her Bcx remained negative throughout her stay. She was treated with levaquin on the floor and will complete a 14d course at rehab. She has been afebrile since she was called out to the floor. . 2. Ureteral stone - The patient had a nephrostomy tube placed by IR to relieve her hydronephrosis. She was followed by urology during her stay and will see them again 2wk after d/c for definitive treatment of her nephrolithiasis. At this time, urology will coordinate removal of her nephrostomy tube with IR. Her nephrostomy tube was draining clear yellow urine at the time of d/c. . 3. a.fib - The patient has a history of atrial fibrillation controlled with beta blockers at home. She was treated in the MICU as above. Once on the floor, the patient had one episode of afib w/ RVR that responded immediately to IV metoprolol. Because of this, the patient's diltiazem was stopped and she was started on tid metoprolol. After this, the patient had no further problems with her rate control. She was maintained on a heparin gtt for bridge to coumadin while on the floor after this was cleared by IR and urology. She will be d/c w/out her heparin as she is trending upwards with her INR and has no MR [First Name (Titles) ] [Last Name (Titles) 65330]c heart disease. She will continue her coumadin at rehab to achieve an INR between [1-30]. . 4. delirium - The patient had troubles with agitation while in the MICU. She received prn haldol w/ little effect and improved as her infection cleared. Medications on Admission: toprol (unknown dose) coumadin 1mg qhs Discharge Medications: 1. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Outpatient Lab Work please have your INR checked at the rehab center with a goal of [1-30]. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Urosepsis Nephrolithiasis Atrial fibrillation Discharge Condition: Good Discharge Instructions: Please take your medications as directed Please keep your follow-up appointments Followup Instructions: Dr. [First Name (STitle) 28622] Attar [2178-2-3] 10:15AM [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2178-1-27] 10:40 Completed by:[2178-1-7]	[ "998.2", "584.9", "428.0", "996.39", "427.31", "397.0", "428.31", "995.92", "599.0", "E878.8", "V58.61", "038.49", "518.81", "592.1", "401.9", "785.52", "591" ]	icd9cm	[ [ [] ] ]	[ "99.07", "96.71", "55.03", "96.04", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	8470, 8556	4943, 7510	337, 382	8646, 8653	2660, 4920	8782, 9020	2163, 2194		7599, 8447		8577, 8625		7536, 7576			8677, 8759									2209, 2641																								276, 299											410, 1884																	1906, 2044	2060, 2147
27,350	183,129	49354	Discharge summary	report	Admission Date: [2133-12-23] Discharge Date: [2133-12-29] Date of Birth: [2058-4-15] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Morphine / Percocet Attending:[First Name3 (LF) 165] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: emergent LV Aneurysm Repair and CABG x1 ([12-23]) History of Present Illness: 75 yo F with known infero-basilar left ventricular aneurysm, found to have ? contained rupture at OSH. Past Medical History: PMH: CAD, s/p IMI [2132-9-25]--on cath at the time pt had RCA stent placement ([Hospital1 ]) s/p admit at [Hospital1 18] [2132-10-7]--cath at time pt had cypher DES placed OM3. Anxiety Social History: Social History: Lives with husband. [Name (NI) 1403] at [Company 20598] Museum. Denies ETOH, any hx of TOB, or illicits. Family History: Family History: No h/o CV or pulm dz. Physical Exam: HR 55 RR 20 Bp 116/60 NAD Lungs CTAB Heart RRR, no M/R/G Abdomen benign Extrem warm, no edema, no varicosities Pertinent Results: [2133-12-28] 04:20AM BLOOD WBC-9.8 RBC-3.50* Hgb-10.4* Hct-30.6* MCV-87 MCH-29.7 MCHC-34.1 RDW-14.8 Plt Ct-184 [2133-12-28] 04:20AM BLOOD Plt Ct-184 [2133-12-26] 02:16AM BLOOD PT-12.5 PTT-28.3 INR(PT)-1.1 [2133-12-28] 04:20AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-142 K-4.6 Cl-105 HCO3-31 AnGap-11 CHEST (PORTABLE AP) [2133-12-26] 1:22 PM CHEST (PORTABLE AP) Reason: evaluation for pleural fluids. [Hospital 93] MEDICAL CONDITION: 75 year old woman s/p emergent LV aneurysm repair and CABG with low hct REASON FOR THIS EXAMINATION: evaluation for pleural fluids. CHEST SINGLE VIEW ON [12-26] HISTORY: LV aneurysm repair, low hematocrit, question pleural fluid. REFERENCE EXAM: [12-25]. FINDINGS: Again seen is a moderate left pleural effusion and dense retrocardiac opacity consistent with volume loss and effusion although an underlying infectious infiltrate cannot be excluded. There is a small amount of fluid in the right major fissure. There are some patchy areas of right lower lobe volume loss as well. Again seen is a small right apical pneumothorax. Brief Hospital Course: She was transferred from [Hospital1 ] to [Hospital Ward Name 121] 6. She was taken emergently to the operating room, for ? of LV aneurysm rupture, where she underwent a CABG x 1 and LV aneurysm repair and thrombectomy. She was transferred to the ICU in stable condition on epi, neo and propofol. She was extubated on POD #1. She was transfused. She was transferred to the floor on POD #3. She did well postoperatively and was ready for discharge home on POD #5. Medications on Admission: ASA 325, Plavix 75, Lisinopril 5, Lopressor 25", protonix 40, vytorin [8-/2106] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [2-28] hours as needed. Disp:50 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Vytorin [8-/2106] 10-80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 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 BID (2 times a day) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: LV Aneurysm s/p repair and CAD s/p CABG x1 CAD s/p PCI RCA(taxus DES) and LCx(Cypher DES), HTN, dyslipidemia, dressler syndrome Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week, Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [First Name (STitle) ] 2 weeks Dr. [First Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 32255] 2 weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2133-12-29]	[ "V45.82", "414.10", "413.9", "414.8", "401.9", "272.4", "414.01", "412" ]	icd9cm	[ [ [] ] ]	[ "37.32", "39.61", "36.11" ]	icd9pcs	[ [ [] ] ]	4144, 4206	2200, 2672	311, 367	4378, 4386	1073, 1499	4700, 4944	903, 927		2806, 4121	1536, 1608	4227, 4357		2698, 2783			4410, 4677									942, 1054																								258, 273	1637, 2177										395, 499																	521, 724	756, 871
45,300	157,974	40823+40824	Discharge summary	report+report	Admission Date: [2200-7-15] Discharge Date: [2200-7-17] Date of Birth: [2139-3-28] Sex: M Service: MEDICINE Allergies: adhesive tape / tolvaptan Attending:[First Name3 (LF) 8388] Chief Complaint: Paratonsillar mass Major Surgical or Invasive Procedure: Tonsillar Mass Biopsy [2200-7-16] History of Present Illness: 61 year old male with history of NASH cirrhosis who is on the transplant list, with ascites complicated by diuretics limited due to hyponatremia, s/p TIPS on [5-14] who was recently admitted to the hospital [Date range (1) 79404] (for hypotension/anemia) presenting with peritonsillar abscess. Patient reported slight jaw pain on [7-1]. Underwent TIPS revision on [7-3] and since that time has had worsening swelling and tenderness. Went to PCP today who saw PTA and sent to ED for IV abx and likely admission. MELD score 28. No f/c. No difficutly breathing. Slight pain with swallowing. No CP/SOB. Slight nausea. No v/d. Plts of 51 on [7-3]. . In the ED, triage vitals were 97.4 106 129/79 14 100% RA Exam showed this LAbs showed CBC - 3/11/32/52, N:76%, L:11, M:8, E:2, B:2 chem 7: (Icteric) 131/3.6/95/25/7/.5/149 INR 2.7; PTT 58 Lactate 4.1 -> Received gentle IV fluids CT showed 4.2 x 3.7cm right peritonsillar lesion which is concerning for tumor, less likely infectious process in the correct clinical setting left thyroid nodule . Medications given: IV Unasyn ENT Consulted: agree with admission to medicine and they will follow -> nothing to drain likely tumor will require further workup patient was admittted for optimization prior to OR Friday Admission Vitals: On the floor, patient was feeling well, states that he has no dyspnea or dysphagia and cannot feel the mass externally, neck without pain. Past Medical History: -Decompensated Cirrhosis with ascites secondary to NASH, c/b ascites responsive to diuretics but developed hyponatremia -s/p TIPS on [5-14] for management of ascites -hyponatremia -Bilateral cataract repair. -Incisional hernia repair. -History of sigmoid resection over 20 years ago due to diverticulitis. -Diabetes, currently on metformin. -Hypertension -Hypovitmanosis D -AAA which measured 5.2 cm in [2199-5-15] Social History: He lives with his wife and youngest son. [Name (NI) ] has three sons. [Name (NI) ] was working full time at the VA in [Hospital1 1474] in the maintenance department. He quit smoking about 2 years ago, but smoked for 25 years. Previously was a social drinker, not excessive. No illicits. Family History: Negative for liver disease or liver cancer. No GI cancer in his family Physical Exam: VS: 97.8/98.3 112-120/71-79 97%RA HR 99-111 GENERAL: Well appearing in NAD. HEENT: Sclera non icteric. Periorbital jaundice. MMM. R peritonsilar mass s/p biopsy. No oozing or bleeding. Dry blood in mouth. nontender to palpation externally without appreciable neck mass CARDIAC: RRR with no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended but Soft, non-tender to palpation. No HSM or tenderness appreciated. Midline vertical scar s/p sigmoidectomy EXTREMITIES: 2+ pitting edema b/l to the knees. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis Pertinent Results: [2200-7-16] 06:30AM BLOOD WBC-3.2* RBC-3.14* Hgb-10.1* Hct-30.0* MCV-96 MCH-32.2* MCHC-33.7 RDW-19.3* Plt Ct-59* [2200-7-16] 07:20PM BLOOD WBC-2.5* RBC-2.88* Hgb-9.5* Hct-27.5* MCV-95 MCH-32.9* MCHC-34.5 RDW-19.4* Plt Ct-44* [2200-7-17] 06:40AM BLOOD WBC-2.8* RBC-2.69* Hgb-8.8* Hct-26.0* MCV-97 MCH-32.9* MCHC-34.0 RDW-19.5* Plt Ct-64* [2200-7-17] 03:25PM BLOOD Hct-30.5* [2200-7-15] 12:45PM BLOOD PT-28.8* PTT-58.1* INR(PT)-2.7* [2200-7-16] 06:30AM BLOOD PT-31.8* PTT-65.0* INR(PT)-3.1* [2200-7-16] 07:20PM BLOOD PT-24.8* PTT-47.2* INR(PT)-2.4* [2200-7-17] 06:40AM BLOOD PT-22.5* PTT-42.4* INR(PT)-2.1* [2200-7-17] 06:40AM BLOOD Ret Aut-4.8* [2200-7-15] 12:45PM BLOOD Glucose-149* UreaN-7 Creat-0.5 Na-131* K-3.6 Cl-95* HCO3-25 AnGap-15 [2200-7-16] 06:30AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-131* K-3.7 Cl-98 HCO3-27 AnGap-10 [2200-7-17] 06:40AM BLOOD Glucose-91 UreaN-7 Creat-0.4* Na-134 K-3.0* Cl-99 HCO3-27 AnGap-11 [2200-7-17] 03:25PM BLOOD Glucose-131* UreaN-7 Creat-0.5 Na-131* K-4.0 Cl-98 HCO3-28 AnGap-9 [2200-7-16] 06:30AM BLOOD ALT-25 AST-56* AlkPhos-138* TotBili-11.7* [2200-7-17] 06:40AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.6 [2200-7-15] 01:20PM BLOOD Lactate-4.1* [2200-7-15] 09:38PM BLOOD Lactate-3.3* [2200-7-16] 07:16AM BLOOD Lactate-2.6* Brief Hospital Course: 61 M with history of NASH cirrhosis, on the liver transplant list with a MELD of 28, who now p/w a new right oropharyngeal mass concerning for neoplastic process. . # R Oropharyngeal mass: Initial concern was for peritonsilar abscess. Patient was put on empiric tx with Unasyn and then seen by ENT. Per ENT, more likely a neoplastic process. He received FFP and platelets prior to a biopsy on [2200-7-16] and returned to the floor. He had some oozing in the OR, but overnight, he had no bleeding and physical exam in the morning only showed dry blood in the mouth. # Lactate 4.1: Patient with high lactate in ED. Received IV fluid hydration and antibiotics. Maintained good perfusion pressures and was afebrile. Pt continues with tachycardia HR of 110 on admission, and the concern would be for peri-tonsillar abscess causing systemic signs of inflammation. What is reassuring is that the patient does not have have leukocytosis or bandemia, hypotension or even significant pain at the site of the mass. Lactate trended down to 2.6 with minimal fluids and anti-biotics. # NASH cirrhosis, c/b recurrent ascites: s/p TIPS [5-14] and TIPS redo [2200-7-3]. He is on the liver transplant list. Last EGD in [2200-5-16] showed erosive esophagitis/duodenitis with grade 1 esophageal varices and portal gastropathy. It was recommended that he initiate pantoprazole 40mg daily but does not appear pt is taking this at home. MELD 28. Patient was continued on his bactrim prophylaxis for SBP. He was given Lactulose to prevent hepatic encephalopathy. . # Hyponatremia: Chronic, previously improved with fluid restriction. Previous usage of Tolvaptan stopped [1-16] possible cause of DIC. Spironolactone held after previous discharge. Pt on prn Lasix at home. He had increasing swelling due to the fluids he received in the ED as well as from the blood products he received. He should follow up his levels as an outpatient and use Lasix prn. Chronic Issues: # Diabetes Mellitus: controlled on metformin at home and changed to SSI while inpatient. #thrombocytopenia - likely [1-16] cirrhosis and portal hypertension. Patient required one unit of PLT prior to OR biopsy. #anemia - pt without obvious signs of bleeding but presents with HCT 5 point drop at 32.8 from 39.7 on [2200-7-3]. Recent EGD/[Last Name (un) ] showed small Gr1 varices. Hct trended down while inpatient, with small oozing after biopsy. Will need quick follow up to ensure that Hct not still trending down after discharge. Patient reticcing appropriately. Medications on Admission: 1. Clotrimazole 1 TROC PO ASDIR 2. Furosemide 20 mg PO DAILY PRN weight gain > 3 lbs, leg swelling, shortness of breath (NOT REQURING) 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Phytonadione 5 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Cyanocobalamin 500 mcg PO DAILY 7. Ascorbic Acid 500 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. lactulose 10 gram/15 mL (15 mL) Solution 15 mL by mouth twice a day titrate to [2-16] BMs daily Discharge Medications: 1. Clotrimazole 1 TROC PO ASDIR 2. Furosemide 20 mg PO AS NEEDED FOR WEIGHT GAIN >3LBS RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis 5. Cyanocobalamin 500 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Ascorbic Acid 500 mg PO DAILY 8. Lactulose 15-30 mL PO TID titrate to [2-16] BM per day Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Tonsillar Mass Secondary Diagnosis: NASH cirrhosis complicated by recurrent ascites s/p TIPS on [5-14] Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 3321], It was a pleasure taking care of you at [Hospital1 827]. You were admitted because your doctors were concerned about a mass in your throat. Initially, there was concern that this was an infection, however on CT imaging we became increasingly concerned that there was a tumor in the area. You were admitted and ENT (Otolaryngology) took you to the OR and biopsied the area. Prior to the procedure you were administered 3 units of plasma and one unit of platelets. You tolerated the procedure well and did not appear to have persistent bleeding afterwards however your blood levels came down due to some mild blood loss accompanied by the large volume of fluids and plasma products delivered. For this we transfused you 1 unit of red blood cells and we gave you lasix (medicine to get the extra water out of your system). You responded well and felt well enough to go home. The pathology results of the biopsy take 1 week to return, and so you have been set up to see Dr. [First Name (STitle) ] (from Otolaryngology) 1 week from now. She will follow up these results with you and guide further management options. No changes have been made to your home medications, however you gained 8pounds this admission due to the fluid and blood products administered. You should take your lasix 20mg by mouth daily until you return to your previous "dry" weight. Then resume weighing yourself daily and take lasix on an as needed basis for weight gain >3pounds. You should have blood drawn on Monday and sent to your PCP, [Name10 (NameIs) 3] set up by your PCP prior to admission. Followup Instructions: Name: [First Name11 (Name Pattern1) 10827] [Last Name (NamePattern1) 89193], MD Specialty: Otolaryngology When: Thursday [7-24] at 11:15am Location: [Doctor Last Name ] & [Doctor Last Name 3880] LLC Address: [Location (un) 3881], [Apartment Address(1) 3882], [Location (un) ],[Numeric Identifier 3883] Phone: [Telephone/Fax (1) 2349] Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 89194], MD Specialty: Primary Care When: Monday [7-28] at 9:30am Address: ONE PEARL ST, [Apartment Address(1) 89191], [Hospital1 ],[Numeric Identifier 9647] Phone: [Telephone/Fax (1) 89192] Department: TRANSPLANT When: WEDNESDAY [2200-7-30] at 9:20 AM With: TRANSPLANT [Hospital 1389] CLINIC [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Admission Date: [2200-7-18] Discharge Date: [2200-8-2] Date of Birth: [2139-3-28] Sex: M Service: MEDICINE Allergies: adhesive tape / tolvaptan Attending:[First Name3 (LF) 3913] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Tonsil biopsy ([7-16]) Chemotherapy port placement ([7-19]) History of Present Illness: 61 year old male with history of NASH cirrhosis who is on the transplant list, with ascites complicated by diuretics limited due to hyponatremia, s/p TIPS on [5-14] who was recently admitted to the hospital for peritonsillar mass s/p biopsy on [7-16] (discharged [7-17]), readmitted to the SICU on [2200-7-18] with oropharyngeal bleeding. He woke up the morning of admission and began coughing up small amounts of bright red blood and clots. He was discharged with a hematocrit of 30.5 the day prior and presented with a hematocrit of 31.5 (INR 2.7, plt 80), which nadired at 23.6 on [7-19]. In the SICU, he again coughed up blood and so was intubated for airway protection. An OG tube was placed which initially evacuated about 800cc of dark red blood over the first day and then progressed to bilious output therafter. ENT packed his oropharynx and he was scoped by ENT twice without signs of active bleeding. Clot was visualized consistent with recent biopsy. CTA was performed on presentation which did not show any one blood vessel feeding the mass. IR embolization was not pursued out of concern for necrosis of the tongue. Packing remained in place and patient was stabilized with 6 units PRBCs on [7-19] units of plasma over the course of the admission (mostly [Date range (1) 89195]), 2 units of platelets initially, and 16 units of cryo over the admission. Also received vitamin K 5mg x2. He remained in the ICU as his hematocrit was not appropriately bumping for days, however no active bleeding was ever seen. Per SICU resident, patient has not had melanotic stools. Packing was removed on [7-20] without signs of further bleeding. He was extubated on [7-22] and his VS remained stable with one episode of afib during his SICU course, which converted out of with IV metoprolol. Currently he is being diuesed with home lasix and additional lasix 40mg IV daily and treated with Cefepime (D1=[2200-7-21]) for enterobacter UTI, with subsequent clearing of urine. He is now being called out to the floor for continued managment. Of note, the tonsillar mass biopsy results have returned and show Nonhodgkin Lymphoma. He and his family are aware of the diagnosis and that he will not currently be listed for a liver transplant. Currently, he denies f/c, difficutly breathing. No CP/SOB. No v/d. Feels tired, but otherwise without complaints. Past Medical History: -Decompensated Cirrhosis with ascites secondary to NASH, c/b ascites responsive to diuretics but developed hyponatremia -s/p TIPS on [5-14] for management of ascites -hyponatremia -Bilateral cataract repair. -Incisional hernia repair. -History of sigmoid resection over 20 years ago due to diverticulitis. -Diabetes, currently on metformin. -Hypertension -Hypovitmanosis D -AAA which measured 5.2 cm in [2199-5-15] Social History: He lives with his wife and youngest son. [Name (NI) ] has three sons. [Name (NI) ] was working full time at the VA in [Hospital1 1474] in the maintenance department. He quit smoking about 2 years ago, but smoked for 25 years. Previously was a social drinker, not excessive. No illicits. Family History: Negative for liver disease or liver cancer. No GI cancer in his family Physical Exam: TRANSFER PHYSICAL EXAM VITALS: 98.2 120/70 78 22 94% 4L GENERAL: No acute distress, alert HEENT: OP with large right tonsilar mass. LYMPHATICS: No cervical, supraclavicular, or axillary lymphadenopathy or inguinal adenopathy appreciated. Right cervical exam limited by RIJ. HEART: regular rhythm and rate without murmur, rub, or gallop LUNGS: breathing comfortably. decreased breath sounds at the bases bilaterally ABDOMEN: distended ascitic abdomen without tenderness EXTREMITIES: warm, well perfused , 3+ edema NEURO: cranial nerves II-XII grossly intact. Strength 5/5 x4 extremities, sensation intact to light touch x4 extremities DISCHARGE PHYSICAL EXAM VS: Tm/Tc 98.5/98.4, BP 112-126/65-78, HR 89-103, RR 18, 96% on RA GENERAL: Appears well, but in NAD. HEENT: MMM. Mass noted paratonsilar with no active bleeding NECK: No JVD CARDIAC: RRR with no m/r/g LUNGS: CTA b/l no w/r/r. ABDOMEN: Distended but Soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness appreciated. Midline vertical scar s/p sigmoidectomy EXTREMITIES: [12-16]+ pitting edema b/l (much improved over past few days). Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A and O x 3 Pertinent Results: MICROBIOLOGY ============ URINE CULTURE (Final [2200-7-21]): ENTEROBACTER CLOACAE COMPLEX. (VRE) 10,000-100,000 ORGANISMS/ML. HCV VIRAL LOAD (Final [2200-7-25]): HCV-RNA NOT DETECTED. PATHOLOGY ========= SPECIMEN SUBMITTED: tonsil mass. Procedure date Tissue received Report Date Diagnosed by [2200-7-16] [2200-7-17] [2200-7-22] DR. [Last Name (STitle) ]. [Last Name (un) ]/qxn?????? DIAGNOSIS: Right tonsil mass, biopsy: Non-Hodgkin B-cell lymphoma, diffuse large B-cell type, high grade (see note). Note: Sections are of squamous mucosa with underlying dense submucosal lymphoid infiltrates with focal necrosis, hemorrhage and crush artifact. The infiltrate is diffuse and comprised of large cells with moderate amount of eosinophilic to foamy cytoplasm, round to irregular vesicular nuclei, and dispersed chromatin. A large fraction of the cells contain a single, centrally located, prominent nucleolus. There are numerous apoptotic bodies and occasional mitotic figures. Small lymphocytes are also admixed, but constitute only a minority of the cells in the sections. The overlying squamous epithelium is inflamed; however, it is without overt involvement by the previously described infiltrate. By immunohistochemistry, the lesion cells are diffusely positive for the pan-B-cell markers CD20 and co-express CD10 and BCL-6, but are negative for BCL-2 and CD30. Scattered admixed T-cells are highlighted by CD3. [Doctor Last Name 3271]-[Doctor Last Name ] virus latent membrane protein (LMP) stain is negative. By MIB-1 staining, the proliferation index is >95%. Although the proliferation fraction is extremely high and lymphoma cells lack BCL-2 staining, the morphological features do not suggest Burkitt lymphoma and are more in keeping with high grade diffuse large B-cell lymphoma. IMAGING ======= CT CHEST, ABDOMEN, AND PELVIS WITH CONTRAST ([7-25]) HISTORY: 61-year-old male with cirrhosis, awaiting liver transplant, now found to have B-cell lymphoma on the lateral aspect of the tongue, now in need of staging. STUDY: CT of the torso with contrast; MDCT images were generated through the chest, abdomen and pelvis after the uneventful IV administration of 130 cc of Omnipaque intravenous contrast. Oral contrast was also administered. Coronal and sagittal reformatted images were also generated. COMPARISON: CTA of the torso from [2200-6-22]. FINDINGS: CHEST: The visualized portion of the thyroid demonstrates a 21 x 12 mm evidence nodule in the left lobe of the thyroid and an 11 x 8 mm nodule in the right thyroid lobe, similar to prior exam (2:3,7). There is no axillary or hilar lymphadenopathy. Multiple prominent lymph nodes are seen in the mediastinum and in the paratracheal station measuring 9 mm (2:16), and 10 mm in the short axis (2:22), in the aortopulmonary window measuring 8 mm in its short axis (2:24) and in the subcarinal station measuring 16 mm in a short axis (2:28). These have progressed slightly since prior exam. The aortic arch demonstrates a common origin of the brachiocephalic and left common carotid arteries, a normal variant (2:16), a right-sided internal jugular central line tip sits in the lower SVC. Calcified coronary artery disease is present. There is no pericardial effusion. Bilateral large nonhemorrhagic effusions are present with associated atelectasis resulting in near-complete collapse of the bilateral lower lobes. The remaining aerated upper and right middle lobes demonstrate emphysematous changes without masses or nodules. Dependent edema is present in the left upper lobe (2:22). ABDOMEN: The liver again demonstrates a shrunken nodular contour compatible with cirrhosis. Hypodensity in the right lobe of the liver is not changed since prior exam and measures 10 mm (2:60); an additional hypodensity in the left lobe of the liver measures 10 mm, and is unchanged from prior exam (2:57). These previously were shown to represent cysts at MRI. A 2.0 cm (2:50) lesion in segment II anteriorly is hypodense on the delayed phase of imaging provided, and cannot be fully evaluated on a single phase examination. A TIPS is in place. The gallbladder shows no stones or wall edema. Splenomegaly is present with the spleen measuring 15.9 cm in the axial dimension. An 11 mm splenule is present just inferior to the splenic hilum (2:71). The pancreas is somewhat atrophic, but shows no masses. The adrenal glands are normal appearing bilaterally. The kidneys enhance with and excrete contrast symmetrically; bilateral hypodensities in the bilateral mid pole is too small to characterize, but likely represent cysts. The large and small bowel shows no evidence of obstruction. No lymphadenopathy or free air is present. A large amount of nonhemorrhagic ascites is seen. The aorta demonstrates aneurysmal dilatation in its infrarenal portion, measuring 5 cm in diameter in the axial plane (2:83), similar to slight increased from prior exam. Additionally, there is aneurysmal dilatation of the right common iliac artery up to 28 mm in diameter and the left common iliac artery measuring 21 mm in diameter (2:100), similar to slightly increased compared to prior exam. PELVIS: The previously described intra-abdominal ascites also tracks into the pelvis. The rectum appears unremarkable. The bladder, there is small amount of layering excreted contrast within it as well as a focus of gas in the antidependent portion, likely the result of recent catheterization, although a gas-producing infection cannot be entirely excluded. No lymphadenopathy is seen. BONES: No aggressive-appearing lytic or sclerotic lesions are present. An old right postero-lateral 8th rib fracture is present. IMPRESSION: 1. Mediastinal lymphadenopathy as described above. No abdominal or pelvic lymphadenopathy. 2. Large bilateral non-hemorrhagic pleural effusions with associated atelectasis; emphysema. 3. Cirrhotic liver with TIPS in place. 2.0 cm lesion in segment II anteriorly is hypodense on the single delayed phase image provided and cannot be fully characterized. Recommend multiphasic CT or MRI as clinically indicated. Known hepatic cysts unchanged. Splenomegaly. 4. Abdominal aortic aneurysm, 5 cm, and aneurysmal dilatation of the bilateral common iliac arteries, similar to slightly increased from prior exam. 5. Locule of gas within the bladder, likely sequelae of recent catheterization, although if no recent catheterization then infection cannot be excluded; correlate with history. CBC TREND ========= [2200-7-17] 06:40AM BLOOD WBC-2.8 RBC-2.69* Hgb-8.8* Hct-26.0* MCV-97 MCH-32.9* MCHC-34.0 RDW-19.5* Plt Ct-64* [2200-7-18] 11:45AM BLOOD WBC-3.3* RBC-3.32* Hgb-11.1# Hct-31.5 MCV-95 MCH-33.4* MCHC-35.2* RDW-19.3* Plt Ct-70* [2200-7-19] 02:01AM BLOOD WBC-3.3* RBC-2.75* Hgb-9.2* Hct-26.2* MCV-95 MCH-33.6* MCHC-35.3* RDW-19.7* Plt Ct-101* [2200-7-20] 02:58AM BLOOD WBC-3.8* RBC-3.59* Hgb-11.3* Hct-32.1* MCV-90 MCH-31.6 MCHC-35.3* RDW-19.6* Plt Ct-82* [2200-7-21] 10:49AM BLOOD WBC-5.3 RBC-3.80* Hgb-12.1* Hct-34.8* MCV-92 MCH-31.8 MCHC-34.6 RDW-20.0* Plt Ct-69* [2200-7-22] 02:18AM BLOOD WBC-4.6 RBC-3.57* Hgb-11.2* Hct-33.3* MCV-93 MCH-31.5 MCHC-33.8 RDW-19.9* Plt Ct-68* [2200-7-24] 02:45AM BLOOD WBC-4.4 RBC-3.71* Hgb-11.6* Hct-35.1* MCV-95 MCH-31.4 MCHC-33.1 RDW-19.6* Plt Ct-48* [2200-7-25] 08:30PM BLOOD WBC-3.7* RBC-3.49* Hgb-10.9* Hct-32.1* MCV-92 MCH-31.3 MCHC-34.2 RDW-19.7* Plt Ct-53* [2200-7-26] 12:00AM BLOOD WBC-3.9* RBC-3.50* Hgb-11.3* Hct-32.2* MCV-92 MCH-32.3* MCHC-35.1* RDW-19.6* Plt Ct-48* [2200-7-27] 12:00AM BLOOD WBC-5.7 RBC-3.17* Hgb-10.0* Hct-29.4* MCV-93 MCH-31.6 MCHC-34.1 RDW-19.6* Plt Ct-63* [2200-7-28] 12:00AM BLOOD WBC-7.2 RBC-3.20* Hgb-10.2* Hct-30.0* MCV-94 MCH-31.9 MCHC-34.1 RDW-20.2* Plt Ct-61* [2200-7-29] 12:00AM BLOOD WBC-8.3 RBC-3.10* Hgb-9.9* Hct-29.1* MCV-94 MCH-31.9 MCHC-33.9 RDW-20.2* Plt Ct-59* [2200-7-30] 12:00AM BLOOD WBC-6.8 RBC-3.05* Hgb-9.8* Hct-28.5* MCV-93 MCH-32.1* MCHC-34.4 RDW-20.4* Plt Ct-50* [2200-7-30] 12:00AM BLOOD Neuts-88.9* Lymphs-3.4* Monos-7.1 Eos-0.5 Baso-0 [2200-7-31] 12:00AM BLOOD WBC-6.5 RBC-3.10* Hgb-10.1* Hct-29.4* MCV-95 MCH-32.4* MCHC-34.2 RDW-20.6* Plt Ct-49* [2200-8-1] 05:29AM BLOOD WBC-5.7 RBC-3.17* Hgb-10.2* Hct-30.4* MCV-96 MCH-32.2* MCHC-33.6 RDW-21.1* Plt Ct-43* [2200-8-2] 06:38AM BLOOD WBC-5.7 RBC-2.98* Hgb-9.7* Hct-28.8* MCV-97 MCH-32.6* MCHC-33.7 RDW-20.9* Plt Ct-36* COAGS TREND =========== [2200-7-17] 06:40AM BLOOD PT-22.5* PTT-42.4* INR(PT)-2.1* [2200-7-18] 11:45AM BLOOD PT-28.2* PTT-50.4* INR(PT)-2.7* [2200-7-18] 05:00PM BLOOD PT-23.4* PTT-44.3* INR(PT)-2.2* [2200-7-19] 04:37AM BLOOD PT-21.8* PTT-37.3* INR(PT)-2.1* [2200-7-19] 04:20PM BLOOD PT-19.0* PTT-36.1 INR(PT)-1.8* [2200-7-20] 07:40AM BLOOD PT-18.3* PTT-37.6* INR(PT)-1.7* [2200-7-21] 02:40AM BLOOD PT-22.3* PTT-39.7* INR(PT)-2.1* [2200-7-21] 04:49PM BLOOD PT-23.3* PTT-41.5* INR(PT)-2.2* [2200-7-22] 09:56AM BLOOD PT-20.9* PTT-41.5* INR(PT)-2.0* [2200-7-23] 02:17PM BLOOD PT-23.6* PTT-43.9* INR(PT)-2.3* [2200-7-25] 04:55AM BLOOD PT-26.8* PTT-56.4* INR(PT)-2.6* [2200-7-25] 08:30PM BLOOD PT-24.8* PTT-48.5* INR(PT)-2.4* [2200-7-26] 12:00AM BLOOD PT-23.9* PTT-46.6* INR(PT)-2.3* [2200-7-27] 12:00AM BLOOD PT-24.3* PTT-45.4* INR(PT)-2.3* [2200-7-28] 12:00AM BLOOD PT-29.6* PTT-49.4* INR(PT)-2.9* [2200-7-30] 12:00AM BLOOD PT-30.8* PTT-55.0* INR(PT)-3.0* FIBRINOGEN TREND ================ [2200-7-18] 11:45AM BLOOD Fibrino-49* [2200-7-19] 08:01AM BLOOD Fibrino-176* [2200-7-20] 07:40AM BLOOD Fibrino-176* [2200-7-21] 04:49PM BLOOD Fibrino-136* [2200-7-22] 09:56AM BLOOD Fibrino-139* [2200-7-23] 02:17AM BLOOD Fibrino-134* [2200-7-23] 02:17PM BLOOD Fibrino-100* [2200-7-24] 02:45AM BLOOD Fibrino-103* [2200-7-25] 04:55AM BLOOD Fibrino-47# [2200-7-26] 12:00AM BLOOD Fibrino-81 [2200-7-28] 12:00AM BLOOD Fibrino-<35# [2200-7-30] 12:00AM BLOOD Fibrino-38# CHEMISTRY TREND =============== [2200-7-17] 06:40AM BLOOD Glucose-91 UreaN-7 Creat-0.4* Na-134 K-3.0* Cl-99 HCO3-27 AnGap-11 [2200-7-19] 01:42PM BLOOD Glucose-123* UreaN-14 Creat-0.4* Na-139 K-3.1* Cl-101 HCO3-27 AnGap-14 [2200-7-20] 04:40PM BLOOD Glucose-107* Na-138 K-3.2* Cl-101 [2200-7-22] 02:18AM BLOOD Glucose-106* UreaN-15 Creat-0.5 Na-141 K-3.4 Cl-104 HCO3-33* AnGap-7* [2200-7-23] 02:17AM BLOOD Glucose-99 UreaN-16 Creat-0.4* Na-142 K-3.1* Cl-105 HCO3-32 AnGap-8 [2200-7-24] 02:45AM BLOOD Glucose-102* UreaN-13 Creat-0.4* Na-141 K-3.8 Cl-102 HCO3-32 AnGap-11 [2200-7-25] 04:55AM BLOOD Glucose-108* UreaN-9 Creat-0.4* Na-135 K-3.6 Cl-99 HCO3-34* AnGap-6* [2200-7-27] 12:00AM BLOOD Glucose-201* UreaN-14 Creat-0.4* Na-133 K-3.6 Cl-96 HCO3-29 AnGap-12 [2200-7-29] 12:00AM BLOOD Glucose-214* UreaN-12 Creat-0.5 Na-129* K-4.2 Cl-93* HCO3-29 AnGap-11 [2200-7-30] 12:00AM BLOOD Glucose-164* UreaN-11 Creat-0.5 Na-131* K-3.8 Cl-94* HCO3-31 AnGap-10 [2200-7-31] 12:00AM BLOOD Glucose-156* UreaN-11 Creat-0.5 Na-131* K-3.7 Cl-92* HCO3-32 AnGap-11 [2200-8-1] 05:29AM BLOOD Glucose-153* UreaN-10 Creat-0.4* Na-130* K-3.9 Cl-94* HCO3-31 AnGap-9 [2200-8-2] 06:38AM BLOOD Glucose-162* UreaN-9 Creat-0.5 Na-128* K-3.5 Cl-91* HCO3-31 AnGap-10 LIVER PANEL TREND ================= [2200-7-18] 11:45AM BLOOD ALT-26 AST-50* AlkPhos-128 TotBili-12.3* [2200-7-19] 02:01AM BLOOD ALT-25 AST-46* AlkPhos-114 TotBili-11.5* [2200-7-20] 02:58AM BLOOD ALT-24 AST-37 AlkPhos-96 TotBili-11.7* [2200-7-21] 02:40AM BLOOD ALT-23 AST-42* AlkPhos-118 TotBili-10.1* [2200-7-22] 02:18AM BLOOD ALT-16 AST-36 AlkPhos-105 TotBili-10.4* [2200-7-23] 02:17AM BLOOD ALT-20 AST-38 AlkPhos-99 TotBili-10.1* [2200-7-23] 02:17PM BLOOD ALT-19 AST-44* LD(LDH)-348* AlkPhos-104 [2200-7-25] 04:55AM BLOOD ALT-16 AST-39 LD(LDH)-325* AlkPhos-113 TotBili-10.2* [2200-7-27] 12:00AM BLOOD ALT-19 AST-39 LD(LDH)-350* AlkPhos-133* TotBili-9.3* DirBili-3.6* IndBili-5.7 [2200-7-28] 12:00AM BLOOD ALT-22 AST-43* LD(LDH)-355* AlkPhos-130 TotBili-9.2* DirBili-3.4* IndBili-5.8 [2200-7-30] 12:00AM BLOOD ALT-29 AST-49* LD(LDH)-353* AlkPhos-133* TotBili-8.3* DirBili-3.3* IndBili-5.0 [2200-7-31] 12:00AM BLOOD ALT-30 AST-53* LD(LDH)-348* AlkPhos-138* TotBili-8.5* [2200-8-1] 05:29AM BLOOD ALT-30 AST-44* LD(LDH)-325* AlkPhos-137* TotBili-9.8* [2200-8-2] 06:38AM BLOOD ALT-29 AST-43* AlkPhos-132* TotBili-10.4* ELECTROLYTES/ALBUMIN TREND ========================== [2200-7-17] 06:40AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.6 [2200-7-20] 02:58AM BLOOD Albumin-2.9* Calcium-9.0 Phos-2.6* Mg-1.9 [2200-7-22] 02:18AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.8 Mg-1.8 [2200-7-23] 02:17AM BLOOD Albumin-3.0* Calcium-8.7 Phos-2.6* Mg-1.9 [2200-7-25] 04:55AM BLOOD Albumin-2.8* Calcium-8.6 Phos-2.8 Mg-1.6 UricAcd-1.4* [2200-7-27] 12:00AM BLOOD Albumin-3.1* Calcium-9.0 Phos-2.2* Mg-1.9 UricAcd-1.8* [2200-7-28] 12:00AM BLOOD Albumin-3.2* Calcium-9.3 Phos-3.1 Mg-1.7 UricAcd-1.8* [2200-7-29] 12:00AM BLOOD Albumin-3.3* Calcium-9.3 Phos-2.7 Mg-1.8 UricAcd-1.8* [2200-7-30] 12:00AM BLOOD Albumin-3.1* Calcium-8.8 Phos-2.9 Mg-1.7 UricAcd-1.9* Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION ================================== 61yo M with history of NASH cirrhosis and new diagnosis of Non-Hodgkin B-cell lymphoma, now off the liver transplant list, who presented one day after being discharged following peripharyngeal biopsy with hemoptysis. He was initially managed in the SICU but later called out to the floor after he was extubated and bleeding stopped. #) ACUTE ANEMIA: Patient presented with bleeding, suspected to be from recent biopsy of tonsillar mass. ENT scoped patint twice and only saw appropriately formed clot over biopsy site. He additionally is known to have grade 1 esophageal varices, which are not suspected to be the source at this time, although have not been visualized this admission. Patient was stabilized with 6 units PRBCs on [7-19] units of plasma over the course of the admission (mostly [Date range (1) 89195]), 2 units of platelets initially, and 16 units of cryo over the admission. Baseline hct ranges widely from high 20s to mid30s. Currently hct is 35.1. He has been cleared by Speech and Swallow and has been eating a soft diet for a couple days now. No signs of active bleeding. Hematocrit improved while on BMT service. #) HYPERVOLEMIA: Dry weight is 188 lbs, peaked at 229 lbs on this admission. Large pleural effusions seen on CT scan. New oxygen requirement while on BMT service with oxygen saturations in low 90s, but without dyspnea. Desaturated to 80s on exertion. Increased diuresis with spironolactone and IV lasix and patient was negative 5 liters in two days with stable/improved electrolytes and oxygen saturations. Further increased diuresis when he returned to the floor. Patients anasarca much improved with increased diuretics and on discharge, his dosage was decreased and told to have his electrolytes checked as an outpatient and his diuretics titrated by his PCP or hepatologist. #) TONSILAR NON-HODGKIN B-CELL LYMPHOMA: Currently no respiratory compromise or dysphagia. Patients lymphoma would have to be treated prior to him being considered for liver transplant. Transferred to BMT service and received rituximab and steroids. PET CT showed disease localized to tonsil, but suspicious mediastinal lymphadenopathy seen. Bone marrow biopsy deferred due to coagulopathy. Seen by rad-onc and will start XRT on [8-5] (in dispo plan.) Will also see heme/onc as outpatient to receive chemo on [8-5]. #) NASH CIRRHOSIS, c/b recurrent ascites: s/p TIPS [5-14] and TIPS redo [2200-7-3] (no intervention required at that time). He is no longer on the liver transplant list given his diagnosis of lymphoma. Last EGD in [2200-5-16] showed erosive esophagitis/duodenitis with grade 1 esophageal varices and portal gastropathy. He is currently grossly fluid overloaded (3+ edema), abdomen comfortable but with ascites. We continued his home bactrim SS Qday for SBP ppx. Lactulose titrated to 3-4BM daily to prevent hepatic encephalopathy. Possibly starting nadolol for variceal bleed prophylaxis. #) UTI: Patient does not clearly have UTI given lack of symptoms prior and negative UA. It may be that he is colonized given sputum grew same organism. Patient was started on cefepime in the unit and d/c when on the floor with repeat UA )no pyruria) and UCx to see if still growing bug. CHRONIC ISSUES ============== #) DIABETES MELLITUS: Controlled on metformin at home. Cont ISS, mointor FSBG. Hold home metformin TRANSITION ISSUES ============== #) Anarsarca: Diuresing well and kidneys fine on increased dosage of Lasix and Spironolactone. At home, he was on 20mg Lasix prn for weight gain which he rarely took. He was discharged on 20mg Lasix and Spironolactone 50mg and told to have electrolytes checked prior to his Tuesday Hem/Onc appointment. His diuretics should be changed based on his electrolytes, fluid status, and kidney status by his PCP or hepatologist. #) Cirrhosis with mass seen in liver: Patient should follow up with his hepatologist to discuss the results of the MRI to evaluate the mass seen on abdominal CT. #) B Cell Lymphoma: Patient to follow up with Hem/Onc on Tuesday [8-5] to receive chemotherapy and radiation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [Month/Year (2) 581]. 1. Clotrimazole 1 TROC PO ASDIR 2. Furosemide 20 mg PO DAILY:PRN Weight gain > 3 lbs 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. Cyanocobalamin 50 mcg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Ascorbic Acid 500 mg PO BID 8. Lactulose 15-30 mL PO TID Titrate to [2-16] BM daily Discharge Medications: 1. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes 2. Caphosol 30 mL ORAL QID:PRN pain RX Caphosol 30mL Oral four times a day Disp #1 Bottle Refills:0 3. Ciprofloxacin HCl 500 mg PO/NG Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:3 4. Diltiazem 30 mg PO BID hold for sbp<90 and hr<60 RX diltiazem HCl 30 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 5. Lactulose 30 mL PO TID 6. Lactulose 30 mL PO PRN RASS<0 Notify MD if change in mental status 7. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 8. Senna 1 TAB PO BID:PRN Constipation 9. Rifaximin 550 mg PO BID RX Xifaxan 550 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:3 10. Furosemide 20 mg PO ONCE Duration: 1 Doses Please take until appointment with physician and then readdress. RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 11. Spironolactone 50 mg PO DAILY Please take until appointment with physician and then readdress. RX spironolactone 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 12. Outpatient Lab Work Please check Basic Metabolic Profile (Electrolytes, Creatinine, BUN, glucose) and fax results to: Name: [Last Name (LF) ],[First Name3 (LF) ] L. (PCP) Address: ONE PEARL ST, [Apartment Address(1) 89191], [Hospital1 ],[Numeric Identifier 9647] Phone: [Telephone/Fax (1) 89192] Fax: [Telephone/Fax (1) 89196] Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary diagnosis- Diffuse large B-cell lymphoma End stage liver disease Coagulopathy of chronic liver disease Hypervolemia Secondary diagnosis- Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for a mass in your tonsil that was unfortunately found to be lymphoma. The biopsy of your tonsil was complicated by bleeding requiring blood products, but you were stabilized and transferred to the oncology floor. While with oncology you were treated with chemotherapy and supportive care and you improved. Because of your liver disease, you became volume overloaded, so we increased your water pills to remove excess fluid which helped your breathing. You will need to check your lab values on Tuesday, before your appointment with radiation and chemotherapy. Please follow up in liver clinic, they will be calling you to schedule an appointment. Also, please follow-up on Tuesday [8-5] for radiation therapy and another round of chemotherapy. Your primary care physician will also be calling you to schedule an appointment. Followup Instructions: Department: LIVER CENTER When: TBD, they will call you with appointment 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: RADIATION ONCOLOGY When: TUESDAY [2200-8-5] at 9 AM With: DR. [Last Name (STitle) ], MD ([Telephone/Fax (1) 8082] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: TUESDAY [2200-8-5] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3749], MD [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ],[First Name3 (LF) ] L. Address: ONE PEARL ST, [Apartment Address(1) 89191], [Hospital1 ],[Numeric Identifier 9647] Phone: [Telephone/Fax (1) 89192] Fax: [Telephone/Fax (1) 89196*]	[ "511.9", "571.5", "285.9", "286.7", "285.1", "789.59", "427.31", "E878.8", "571.8", "276.1", "V49.83", "250.00", "041.85", "276.69", "998.11", "456.1", "441.4", "572.2", "268.9", "401.9", "287.5", "202.80", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "28.11", "96.04", "38.97", "96.71", "31.42", "96.6", "99.25" ]	icd9pcs	[ [ [] ] ]	35526, 35581	29324, 33510	11379, 11449	35787, 35787	16005, 29301	36908, 37957	14649, 14721		34003, 35503		35602, 35766		33536, 33980			35938, 36885									14736, 15986																								11329, 11341											11477, 13869					8256, 8343			8219, 8235			35802, 35914			6639, 7221			13891, 14316	14332, 14633
61,569	114,157	39072	Discharge summary	report	Admission Date: [2157-2-15] Discharge Date: [2157-3-2] Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Trf from OSH with ICH - L posterior parietal IPH with mental status changes Major Surgical or Invasive Procedure: ? none History of Present Illness: [Age over 90 ]-year-old woman who presents with acute mental status change this AM. She lives at home with her son, who noticed that she was becoming increasingly agitated and was having word finding difficulties and slurring her speech this morning. She denied headache. She was alert and oriented yet did not want to go the hospital for eval. She was taken to [Hospital3 ] Emergency Department where she was found to be HTNsive initial BP unknown with Afib in RVR so pt placed on a Diltiazem gtt at 5mg/hr. HCT showed a 4x3x3 L posterior parietal lesion which was believed to be intraparenchymal bleed. She was given fos-PHT 900mg IV x1. NO report of sz-like activity and Ativan 3mg was given and she was transferred to [Hospital1 18] for further care. On reread of the CT with the [Hospital1 18] radiology staff, the lesion was believed to be tumor vs. bleed. Patient's neurologic exam was stable from the outside hospital. Past Medical History: Atrial flutter HTN Glaucoma Severe deafness s/p appendectomy Social History: Lives at home with son who reports that his mother is high functioning - normal AAOx3 able to balance her checkbook Family History: Stroke - sister at 33 y/o ICH - mother Retinal detachment - daughter Physical Exam: PE on admission: T:97 BP: 93/55 HR: 72 R 16 O2Sats 97% RA Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Thrashing, frontal beh in bed, able to follow some commands inconsistently i/e sqeeze my hand but did not let go when asked Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2mm yet sluggish on Right. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-11] throughout. No pronator drift Sensation:Withdrawal from noxious stimuli Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Pertinent Results: Labs on admission: [2157-2-15] 05:30PM BLOOD WBC-9.4 RBC-4.67 Hgb-13.0 Hct-41.2 MCV-88 MCH-27.9 MCHC-31.7 RDW-13.8 Plt Ct-253 [2157-2-15] 05:30PM BLOOD Neuts-65.3 Lymphs-29.4 Monos-4.4 Eos-0.5 Baso-0.4 [2157-2-15] 05:30PM BLOOD PT-12.6 PTT-22.4 INR(PT)-1.1 [2157-2-15] 05:30PM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-143 K-3.9 Cl-105 HCO3-29 AnGap-13 [2157-2-16] 05:00AM BLOOD ALT-13 AST-22 LD(LDH)-176 CK(CPK)-61 AlkPhos-78 TotBili-0.4 [2157-2-15] 05:30PM BLOOD cTropnT-0.01 [2157-2-15] 11:20PM BLOOD cTropnT-<0.01 [2157-2-15] 05:30PM BLOOD CK(CPK)-80 [2157-2-15] 11:20PM BLOOD CK(CPK)-82 [2157-2-16] 05:00AM BLOOD Albumin-3.6 Calcium-8.8 Phos-4.4 Mg-1.9 [2157-2-16] 05:00AM BLOOD Phenyto-13.0 Urine studies: [2157-2-16] 08:08AM URINE Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-50 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR [2157-2-16] 08:08AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Imaging: CTA [2-15]: IMPRESSION: 1. Stable hyperdense focus in the left posterior parietal lobe with surrounding edema. Differential diagnosis includes a cavernoma that has hemorrhaged, amyloid angiopathy, or an underlying neoplasm. There is no evidence of aneurysm or arteriovenous malformation. 2. No acute territorial infarction. 3. Marked central and cortical involutional changes in keeping with the patient's age of [Age over 90 ] years. 4. Diffuse microangiopathic ischemic white matter disease. 5. Moderate-severe narrowing of the M1 segment of the right middle cerebral artery with post-stenotic dilatation and adequate distal flow. No additional areas of high-grade narrowing are identified CT [2-16] IMPRESSION: Stable intraparenchymal hemorrhage in left parietal lobe, with surrounding vasogenic edema and mild mass effect. Given that the prior CTA was negative for AVM, an underlying mass and amyloid angiopathy are the major diagnostic differential considerations. Recommend MRI for further evaluation, if there are no contraindications. MR HEAD W & W/O CONTRAST Study Date of [2157-2-17] 2:05 PM IMPRESSION: Evolving subacute/acute hemorrhage in the left parietal lobe, with surrounding vasogenic edema and mild mass effect. Multiple potential causes include hypertension, AVM, cavernoma, masses, coagulopathy, trauma, and focal amyloid angiopathy. Underlying etiology cannot be excluded at thisstage. Recommend close imaging followup until hemorrhage has competely resolved. Chest Xray [2-20] IMPRESSION: 1. Compared with 02/11, there has been interval obscuration at the left lung base, raising the question of a left lower lobe collapse and/or consolidation. If clinically indicated, lateral view may help for further assessment. 2. Interval improvement in CHF findings. Minimal of any residual CHF. Brief Hospital Course: [Age over 90 ] year old woman with hypertension and atrial flutter who presented with agitation, word finding difficulties and headache, was found to have a large Left posterior parietal lobe hemorrhage at OSH and transferred to [Hospital1 18] for further evaluation. NEURO: Etiology of hemorrhage unclear: either an amyloid or cavernoma related hemorrhage or neoplasm related bleed. CTA head did not show a venous abnormality. The patient was initially admitted to NeuroICU for persistent agitation with intermittent somnolence. Dilantin was used for Seizure ppx and she was treated for 4 days after which this was discontinued give agitation, confusion and no actual seizure history. ASA 81 mg was restarted on [2-20]. Anticoagulation was not considered given that her hemorraghe was likely due to amyloid. The patient's neurologic exam at the time of discharge was limited by inattention but notable for disorientation to place and mild anomia. Right pupil was sluggish compared to left, EOMI. All limbs moved spontaneously and were antigravity. There was no pronator drift. CARDIOVASCULAR: She was treated with IV diltiazem for Afib with RVR noted at OSH but was found to be in SR on initial presentation, however, was intermittenly in atrial fibrillation while in the ICU. Upon arrival to the neurology floor, she also intermittantly had atrial fibrillation with RVR with heart rates into the 170s. She was initially started on a diltiazem drip which was then transitioned over to PO cardizem with good results. The patient was also started on metoprolol and lisinopril with good blood pressure control. GI: The patient was initially too somnolent to eat and required an NG tube. She was treated with Famotidine for GI ppx whilt the tube was in place. The NG tube was self-removed and her diet was advanced as her mental status cleared. She was cleared by speech and swallow for a regular diet. ID: Ms. [Known lastname 4702] was noted to have intermittant low grade temperatures. Urine and blood cultures were negative. Chest x-ray was concerning for a left lower lobe pneumonia. In addition, a left arm thrombophlebitis was noted. The patient was initially treated with levoquin and cephalexin but was transitioned to Unasyn on [2-23] with plans to complete an 8 day course on [3-2]. Medications on Admission: Metoprolol 25mg qday Xalatan 1 drop each eye qpm Alphagan 1drop each eye [Hospital1 ] MIV ASA 81 mg PO qday Discharge Medications: 1. Ampicillin-Sulbactam 1.5 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours): Last doses to be given on [3-2]. 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 7. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay - [Hospital1 392] Discharge Diagnosis: Left posterior parietal Intracranial hemorrhage Hypertension Atrial fibrillation/atrial flutter with rapid ventricular response, phlebitis Aspiration pneumonia Discharge Condition: Heart rate was well controlled, averaging in the 90s. Neurological examination at time of discharge was limited by inattention but noteable for disorientation to place and mild anomia. Right pupil was sluggish compared to left, EOMI. All limbs moved spontaneously and were antigravity. There was no pronator drift. Discharge Instructions: You were admitted to [Hospital1 18] with an intracranial bleed. The reason for your bleed was most like a due to a condition called amyloid angiopathy, which can occur as the brain ages. You were treated with blood pressure medications, sedating medications for your agitation and confusion. You required medications to control your heart rate due to your atrial fibrillation. Your course was complicated by an infection in your left arm (phlebitis) and a possible aspiration pneumonia. You were discharged to a rehabilitation facility. Should you experience any of the symptoms listed below or any other symptom concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Please follow with with the following appointments: PCP: [Name Initial (NameIs) 2169]: [Name10 (NameIs) ],[Name11 (NameIs) 1575] [Name Initial (NameIs) ]., on Monday, [2157-3-7] at 1pm. Please call [Telephone/Fax (1) 14655] to confirm your appointment. NEUROLOGY: Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2157-3-21] 2:00 Completed by:[2157-3-2]	[ "365.9", "427.32", "785.0", "277.39", "451.84", "389.9", "437.9", "401.9", "507.0", "438.13", "427.31", "780.09", "431" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	8861, 8941	5552, 7882	324, 332	9145, 9465	2694, 2699	10208, 10717	1545, 1616		8046, 8838		8962, 9124		7908, 8023			9489, 10185									1631, 1634																								208, 286											360, 1310	1976, 2675									2714, 5529	1836, 1960						1332, 1395	1411, 1529
17,664	134,614	4728	Discharge summary	report	Admission Date: [2167-12-27] Discharge Date: [2167-12-31] Date of Birth: [2093-3-27] Sex: F Service: MEDICINE Allergies: Codeine / Hydrochlorothiazide / Biaxin / Ciprofloxacin / Thiazides / Darvocet-N 100 / Demerol Attending:[First Name3 (LF) 5552] Chief Complaint: Dyspnea, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 74 y/o female with a h/o MMP who was recently diagnosed with non-small cell lung CA who was scheduled for cycle 2 of carboplatin/taxol (cycle 1 on [12-4]) when she presented on [2167-12-27] with worsening SOB X 2 weeks. Per patient, has had increased DOE since late [Month (only) 1096]. Usually walks one hour, but now can only walk 40 min and feels more SOB than normal. + orthopnea, no PND, no LE edema. She was seen in clinic for a scheduled visit to start second cycle of chemo on [12-28] and was found to have O2 sats of 78% with aggressive ambulation. She felt more SOB during this episode than usual, but not as badly as prior CHF exacerbations. She was sent down for imaging and CTA was negative and she went home with O2. That evening she was sipping tea and choked (has been choking on liquids since thyroid CA in [2110]'s). The next day she presented to ED with worsening SOB that was now occurring at rest but denied CP, fevers, chills, change in cough, or sputum production. In the ED, the patient's O2 sat was 93% on a NRB. CXR demonstrated RLL PNA and she was treated for a pneumonia and presumed CHF. She received ceftaz, azithromycin, lasix (680cc diuresed) and morphine. She was also started on BiPAP for presumed CHF exacerbation which helped. She was transferred to the MICU where she improved daily and the team felt that the largest contributor to acute SOB was PNA. An ECHO was obtained in setting of CABG and AVR which was unchanged from [2-26] except from increasing pulm HTN (possibly likely combination of lung CA, diphragmatic paralysis, h/o XRT when tx'd for thyroid CA). She is being tranferred to the OMED service because shy in no longer MICU level of care. She was sating high 90's on [1-24] L upon transfer. . Currently the patient's breathing is comfortable and she denies CP, palpatations. Cough is improving, nonproductive. No URI sxs. Has been eating a lower sodium diet and taking all of her medications regularly. She has had an 8 lb weight loss in 2 months d/t decreased appetite. Also had myalgias as well as numbness/tinging in toes, feet, hands, knees, calves during neulasta treatment, all currently resolved. . ROS: No fatigue, malaise, fevers, chills, N/V/abd pain/D/C/dysuria/sensory or motor loss. + nose bleed during chemo. Past Medical History: Non small cell lung CA diagnosed in [11-29] - s/p cycle 1, c/b myalgias, nausea, and decreased from taxol Coronary artery bypass graft x2 vessels [2164] Aortic valve replacement in [4-/2165], a tissue valve Chronic back pain with sciatica CHF requiring hosp x 2 ([2164], [2166]) Hypertension results in pulmonary edema Hypotension results in syncope History of right-sided pulmonary nodules Cholecystectomy TAH and BSO (unclear why) Cataract surgery Thyroid cancer ([2112], radical surgery and radiation therapy) Social History: 1 cig x 20 yrs, no ETOH, no IVDU, lives w/ husband. Family History: N/C Physical Exam: Vitals- 96.8, 110/48, 94, 20, 95% 3L General- Well appearing, breathing comfortably, eating dinner HEENT- PERRL, EOMI, MMM, no LAD Pulm- Decreased BS at L base, o/w clear CV- RRR, NL S1 and S2, faint holosystolic murmur at LLSB Abd- soft, NTND, no HSM Extrem- trace pedal edema, dry skin Neuro- CN III-XII intact, nml strength and sensation. Pertinent Results: [2167-12-27] WBC-18.2# RBC-2.94 Hgb-9.0* Hct-25.8* MCV-88 MCH-30.7 MCHC-35.0 RDW-16.0* Plt Ct-285 [2167-12-27] WBC-23.2* RBC-3.34* Hgb-10.5* Hct-29.6* MCV-89 MCH-31.4 MCHC-35.5* RDW-15.7* Plt Ct-319 [2167-12-28] WBC-11.3# RBC-3.36 Hgb-10.2* Hct-29.5* MCV-88 MCH-30.4 MCHC-34.6 RDW-16.0* Plt Ct-265 [2167-12-29] WBC-8.3 RBC-3.54* Hgb-10.6* Hct-31.3* MCV-88 MCH-30.0 MCHC-33.9 RDW-15.5 Plt Ct-274 [2167-12-29] WBC-8.6 RBC-3.38* Hgb-10.2* Hct-29.3* MCV-87 MCH-30.1 MCHC-34.7 RDW-15.6* Plt Ct-298 [2167-12-30] WBC-9.7 RBC-4.00* Hgb-11.9* Hct-34.8* MCV-87 MCH-29.7 MCHC-34.2 RDW-15.3 Plt Ct-306 [2167-12-31] WBC-6.4 RBC-3.87* Hgb-11.4* Hct-33.3* MCV-86 MCH-29.5 MCHC-34.3 RDW-15.3 Plt Ct-289 [2167-12-31] Neuts-74.2* Lymphs-13.7* Monos-6.8 Eos-5.1* Baso-0.2 [2167-12-27] Glucose-271* UreaN-20 Creat-0.9 Na-135 K-4.5 Cl-100 HCO3-25 [2167-12-31] Glucose-127* UreaN-12 Creat-0.8 Na-140 K-4.3 Cl-100 HCO3-30 [2167-12-31] proBNP-674* [2167-12-31] Calcium-9.2 Phos-3.3 Mg-2.1 . CXR [2167-12-27] Interval development of poorly defined opacities in the lungs bilaterally, most consistent with pneumonia. Acute chemotherapy reaction could have a similar appearance. . CXR [2167-12-28] Bilateral basilar infiltrates, suggesting pneumonia. . TTE [2167-12-28] The left atrium is normal in size. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The gradient increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-24]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2167-2-25], estimated pulmonary artery systolic pressure is now higher. Brief Hospital Course: 74 y/o female with a h/o MMP who was recently diagnosed with non-small cell lung CA who was scheduled for cycle 2 of carboplatin/taxol (cycle 1 on [12-4]) when she presented on [2167-12-27] with worsening SOB X 2 weeks. The following issues were addressed during this hospitalization. . 1. SOB Pt was initially admitted to the [Hospital Unit Name 153] for respiratory monitoring given her hypoxia and worsening SOB. ICU course: Initially presented with hypoxic respiratory failure. Etiology appeared to be multifactorial including possible RLL PNA, LUL mass (malignancy) and an elevated L hemidiaphragm suggestive of phrenic nerve involvement. She was started on Unasyn. Given progression of lung CA she may be O2 dependent. Her hypertension was controlled with home atenolol and cozaar. Her anemia was deemed [12-25] chronic disease and iron deficiency and she was started on iron supplementation. She continued synthroid. . OMED Floor Course Pt was transferred to OMED when stable from a respiratory standpoint. She was continued on Unasyn for presumed aspiration PNA and switched to liquid Augmentin to complete her ABx course. Pulmonary was consulted given her initial worsening of SOB and increased pulmonary HTN on TTE. The most likely etiology for the pt's presentation was an acute on chronic pulmonary process. She had described SOB since [7-28] which progressively became worse. She had a documented aspiration event which was the etiology of her acute presentation, most likely aspiration pneumonitis but was treated for aspiration PNA. The pulmonary HTN was most likely the result of her known valvular heart disease which progressed in the setting of her carcinoma. She will follow up with pulmonology upon discharge. She was discharged home on oxygen therapy. . 2. HTN Pt was maintained during most of her hospital admission on her home dose of atenolol and cozaar. After discussion with her outpatient cardiologist, he recommended metoprolol TID, no diuretic therapy (pt with h/o hypotensive episodes while on diuretic therapy) and continuing Cozaar. Medications on Admission: MEDS ON TRANSFER: Ampicillin-Sulbactam 3 gm IV Q8H Lorazepam 0.5 mg PO BID:PRN hold for RR <12 Atorvastatin 10 mg PO DAILY Metoprolol 25 mg PO TID please hold for sbp<100, hr<60 DHEA NF 25 mg Oral daily Prochlorperazine 10 mg PO Q8H:PRN nausea Estrogens Conjugated 0.3 mg PO QAM Fish Oil (Omega 3) [2160] mg PO QAM Zolpidem Tartrate 5 mg PO HS Heparin 5000 UNIT SC TID Zofran NF 2 mg/mL Injection q8H:prn Hydrocodone-Acetaminophen [11-24] TAB PO Q4-6H:PRN . MEDS AT HOME: Ambien 5 milligrams q.h.s., atenolol 31.25 mg nightly, Compazine p.r.n. Cozaar 12.5 mg in the morning, fish oil, Lortab, Lipitor 10 mg q.h.s., Synthroid 0.125 mg, Premarin 0.3 mg every morning, Ativan 0.5 mg p.r.n., and DHEA 25 mg daily, after lunch. Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Prochlorperazine 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for nausea. Tablet(s) 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. DHEA 25 mg Tablet Sig: One (1) Tablet PO daily (). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 11. Oxygen Therapy Humidifier bottle: Add humidification to oxygen. Diagnosis: Non-small cell lung cancer. 12. Oxygen therapy Liquid Oxygen: Observe for conserving device. 13. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Ten (10) mL PO twice a day for 1 weeks. Disp:qs 1 week mL Refills:0 14. Fish Oil 2 teaspoons ([2160] mg) every morning. 15. Hydrocodone-Acetaminophen 2.5-167 mg/5 mL Solution Sig: [12-26] teaspoons PO every 4-6 hours as needed for pain. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:qs 2 weeks ML(s) Refills:0 18. Cozaar 25 mg Tablet Sig: 0.5 Tablet PO once a day. 19. Oxygen Oxygen nasal cannula 1-3 liters. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Non-small cell lung cancer Pulmonary Hypertension Discharge Condition: The patient was discharged hemodynamically stable afebrile with appropriate follow up. Discharge Instructions: Please call your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] or seek medical attention in the ED if you experience any chest pain, worsening shortness of breath, nausea, vomiting, diarrhea, abdominal pain, fever, chills, inability to tolerate liquids, or any other concerning symptom. . Please take all medications as prescribed. You were started on an antibiotic to treat an aspiration pneumonia called Augmentin. Please complete this course of antibiotic as directed. You were started on a medication called metoprolol for your blood pressure. Please stop taking your Atenolol. You can resume taking your Cozaar. Please use the nystatin liquid for your mouth sores until they heal. . Please keep all follow up appointments. They are listed below. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 1694] Date/Time:[2168-1-4] 1:00 . Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2168-1-8] 8:10 . Provider: [Name10 (NameIs) 1570],[Name11 (NameIs) 2162] [Name12 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2168-1-8] 8:30 Completed by:[2168-1-6]	[ "507.0", "285.29", "428.0", "518.81", "428.33", "162.3", "V45.81", "416.8", "V10.87", "V42.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10548, 10606	5928, 8015	373, 380	10709, 10798	3741, 5905	11614, 12092	3358, 3363		8802, 10525		10627, 10688		8041, 8041			10822, 11591									3378, 3722																								317, 335											408, 2712																	2734, 3273	3289, 3342		8059, 8779
81,328	161,100	46880	Discharge summary	report	Admission Date: [2160-6-6] Discharge Date: [2160-6-15] Date of Birth: [2101-7-24] Sex: F Service: MEDICINE Allergies: Dilantin Kapseal / Penicillins Attending:[First Name3 (LF) 3984] Chief Complaint: Dyspnea, respiratory failure Major Surgical or Invasive Procedure: [2160-6-7] Thoracentesis [2160-6-9] Intubation [2160-6-9] Cardioversion History of Present Illness: 58 year old female with advanced cholangiocarcinoma, Hepatitis B/C/EtOH cirrhosis, and chronic alcohol abuse who presents from clinic with shortness of breath after a routine CT showed new right-sided pleural effusion and pulmonary infiltrates. She was diagnosed with cholangiocarcinoma in [11/2159] and has been evaluated by surgery but not deemed a surgical candidate. The attempt at giving chemotherapy has been difficult due to ongoing substance abuse and poor medical compliance. She was admitted [Date range (1) 35539] for pain control due to abdominal pain. She was on the medicine service and restarted on her home medications with improvement in her pain. She also completed a course of Keflex for cellulitis. She reports the onset of dyspnea on exertion 2 days ago that has progressively worsened. Also reports fever to 100.0 yetserday, as well as chills. Has had cough x 1 week. Also reports nausea without vomiting, and poor appetite. Has chronic abdominal pain, but feels it is worse in the last few days. Has baseline peripheral edema, but also feels this is worse in the last week. Has had regular BM, no blood in stool. Also describes chest soreness with palpation and with coughing on the right side over the last week. She was seen in clinic today and complained of shortness of breath. She had a routine staging CT this AM which showed pulmonary infiltrate and pleural effusion and is therefore being directly admitted from clinic. Review of Systems: (+) Per HPI. Has been losing weight, cannot quantify. (-) Denies headache. Denies palpitations. Denies nausea, vomiting, diarrhea, constipation, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: Cholangiocarcinoma - Ms. [Known lastname 4587] admitted on [2159-11-19] to [2159-11-23] when she presented to the emergency room with abdominal pain. While in the hospital, she underwent an abdominal ultrasound, which showed increase in size of the common bile duct, suspicious for an obstructive process. - ERCP was performed on [2159-11-20] with brushings of the common bile duct which were positive for malignant cells consistent with adenocarcinoma. She underwent abdominal MRI on [2159-11-22], which showed a segment VIII hepatic lesion which was compatible with cholangiocarcinoma. The lesion is approximately 2.0 x 1.5 cm in size. - She was evaluated for surgical resection and was deemed a surgical candidate if she could remain abstinent from alcohol consumption given the high risk of complications with liver resection in patients who are actively abusing alcohol. She has been unable to remain sober for any significant duration since that evaluation, and continues to abuse EtOH chronically. - She recieved her first cycle of gemcitabine and cisplatin [2160-4-18] PAST MEDICAL HISTORY: EtOH abuse with h/o withdrawal seizures Cirrhosis, due to HCV (genotype 1b), HBV, EtOH Cocaine abuse Chronic abdominal pain Gastritis Alcoholic pancreatitis [5-/2156] Cholelithiasis Diverticulosis Seizure disorder C5 radiculopathy - EMG [2157-4-29] showed mild chronic reinnervation in the biceps and deltoid Thoracic radiculopathy Anterolisthesis of L4 on L5, grade 1 Hypertension Asthma Polyclonal gammopathy Thrombocytopenia Depression Glaucoma Social History: Lives with boyfriend in [Name (NI) 5503], commonly stays in [Location (un) 86] with her daughter. Not employed. Longstanding chronic EtOH abuse history - initially reports she hasn't consumed EtOH since her cancer diagnosis, but then admits to drinking "an occasional wine." Thinks last drink "about a month ago." Denies other current drug use, although has had recent cocaine use per her primary oncologist. Family History: Mother had pancreatic cancer. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98.6 172/78 78 24 95%RA GENERAL: NAD, although does appear SOB with minimal exertion including sitting up and speaking in long sentences HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, patent nares, MMM, nontender supple neck CARDIAC: RRR, S1/S2, no mrg LUNG: Decreased breath sounds at the right base, diffuse wheezing throughout, crackles at left base ABDOMEN: Mildly distended with some shifting dullness, moderately tender to palpation in RUQ and some in RLQ, no rebound or guarding, positive bowel sounds M/S: Moving all extremities well, 2+ pitting edema bilaterally to the shins PULSES: 2+ DP pulses bilaterally Pertinent Results: ADMISSION LABS [2160-6-6] 01:00PM BLOOD WBC-11.7# RBC-3.62 Hgb-11.5* Hct-36.1 MCV-100* MCH-31.7 MCHC-31.8 RDW-17.5* Plt Ct-172# [2160-6-6] 01:00PM BLOOD Neuts-80.0* Lymphs-12.8* Monos-5.3 Eos-1.4 Baso-0.6 [2160-6-7] 10:45AM BLOOD PT-14.5* PTT-39.1* INR(PT)-1.4* [2160-6-6] 01:00PM BLOOD UreaN-7 Creat-0.8 Na-137 K-3.6 Cl-103 HCO3-25 AnGap-13 [2160-6-6] 01:00PM BLOOD ALT-24 AST-71* AlkPhos-248* TotBili-1.3 [2160-6-7] 07:55AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9 [2160-6-7] 10:45AM BLOOD Albumin-3.2* [2160-6-6] 01:00PM BLOOD Ethanol-24* [2160-6-9] 04:13AM BLOOD Lactate-1.4 PERTINENT LABS [2160-6-6] 01:00PM BLOOD Lipase-44 [2160-6-9] 02:48AM BLOOD proBNP-708* [2160-6-9] 02:48AM BLOOD TSH-0.17* [2160-6-9] 02:48AM BLOOD T4-11.4 T3-95 [2160-6-11] 03:02AM BLOOD ANCA-NEGATIVE B [2160-6-13] 03:59PM BLOOD HIV Ab-NEGATIVE [2160-6-11] 07:09PM BLOOD Carbamz-1.0* [2160-6-6] 01:00PM BLOOD Ethanol-24* [2160-6-11] GLOMERULAR BASEMENT MEMBRANE <1.0 (NEGATIVE) [2160-6-11] ASPERGILLUS ANTIGEN 0.1 (NEGATIVE) [2160-6-11] (1,3)-B-D-Glucans >500 pg/mL* (HIGHLY POSITIVE) [2160-6-6] CA [67]-9 7 (NEGATIVE) DISCHARGE LABS [2160-6-15] 05:23AM BLOOD WBC-26.6* RBC-2.79* Hgb-8.7* Hct-28.3* MCV-102* MCH-31.2 MCHC-30.8* RDW-19.8* Plt Ct-63* [2160-6-15] 05:23AM BLOOD Neuts-86* Bands-0 Lymphs-7* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-3* [2160-6-15] 05:23AM BLOOD PT-22.6* PTT-67.9* INR(PT)-2.2* [2160-6-15] 05:23AM BLOOD Glucose-176* UreaN-61* Creat-2.5* Na-141 K-5.0 Cl-111* HCO3-20* AnGap-15 [2160-6-15] 05:23AM BLOOD ALT-57* AST-223* LD(LDH)-715* AlkPhos-282* TotBili-1.5 [2160-6-15] 05:23AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.7* MICROBIOLOGY [2160-6-6] Blood Culture, Routine (Final [2160-6-12]): NO GROWTH. [2160-6-6] Blood Culture, Routine (Final [2160-6-12]): NO GROWTH. [2160-6-7] URINE CULTURE (Final [2160-6-8]): SKIN/GENITAL CONTAMINATION. [2160-6-7] Legionella Urinary Antigen (Final [2160-6-7]): NEGATIVE [2160-6-7] [2160-6-7] SPUTUM Source: Expectorated. GRAM STAIN (Final [2160-6-7]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [2160-6-9]): RARE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [2160-6-16]): NO LEGIONELLA ISOLATED. [2160-6-7] PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [2160-6-7]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2160-6-10]): NO GROWTH. ANAEROBIC CULTURE (Final [2160-6-13]): NO GROWTH. [2160-6-8] Blood Culture, Routine (Final [2160-6-14]): NO GROWTH. [2160-6-8] Blood Culture, Routine (Final [2160-6-14]): NO GROWTH. [2160-6-10] SPUTUM Source: Endotracheal. GRAM STAIN (Final [2160-6-10]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2160-6-12]): NO GROWTH. [2160-6-11] Blood Culture, Routine (Final [2160-6-17]): NO GROWTH. [2160-6-11] URINE CULTURE (Final [2160-6-12]): NO GROWTH. [2160-6-11] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [2160-6-11]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2160-6-13]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [2160-6-18]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2160-6-11]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2160-6-12]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2160-6-12]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [2160-6-11] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture (Final [2160-6-13]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST(Final [2160-6-13]): Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. [2160-6-12] Blood Culture, Routine (Final [2160-6-18]): NO GROWTH. [2160-6-12] Blood Culture, Routine (Final [2160-6-18]): NO GROWTH. [2160-6-12] URINE CULTURE (Final [2160-6-13]): NO GROWTH. [2160-6-12] Source: Line-R brachial PICC- purple port 2 OF 2. Blood Culture, Routine (Final [2160-6-18]): NO GROWTH. [2160-6-12] C. difficile DNA amplification assay (Final [2160-6-13]): Negative [2160-6-13] SPUTUM Source: Endotracheal. GRAM STAIN (Final [2160-6-13]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2160-6-15]): Commensal Respiratory Flora Absent. YEAST. RARE GROWTH. [2160-6-13] SEROLOGY/BLOOD, CRYPTOCOCCAL ANTIGEN (Final [2160-6-13]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. [2160-6-13] CSF;SPINAL FLUID Source: LP. CRYPTOCOCCAL ANTIGEN (Final [2160-6-13]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. [2160-6-13] CSF;SPINAL FLUID GRAM STAIN (Final [2160-6-13]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2160-6-16]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [2160-6-13] CSF;SPINAL FLUID HIV-1 Viral Load/Ultrasensitive(Final [2160-6-16]):HIV-1 RNA not detected. [2160-6-13] HBV Viral Load (Final [2160-6-17]): HBV DNA not detected. [2160-6-13] HIV-1 Viral Load/Ultrasensitive (Final [2160-6-16]):HIV-1 RNA not detected. [2160-6-13] Blood Culture, Routine (Pending): [2160-6-13] Blood Culture, Routine (Pending): [2160-6-13] URINE CULTURE (Final [2160-6-16]): YEAST. 7000 CFU/ML. [2160-6-13] Blood Culture, Routine (Pending): [2160-6-14] BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. IMAGING [2160-6-6] CT ABD & PELVIS W & W/O CONTRAST, CT CHEST W/CONTRAST: Overall progression of disease with new diffuse tumor infiltration in the right hepatic lobe with metastatic foci in the left hepatic lobe. New retroperitoneal lymph node enlargement. New bony metastases. Mild intrahepatic bile duct dilation has increased. Moderate ascites. New occlusion of the right anterior and right posterior portal veins. The left portal vein and main portal vein are patent. Moderate-to-large right pleural effusion with adjacent compressive atelectasis. Multifocal left lung pneumonia. [2160-6-9] ECG: Sinus tachycardia. The Q-T interval may be slightly short, particularly in the anterior precordial leads. Poor R wave progression. Consider prior anteroseptal myocardial infarction. Compared to the previous tracing of [2160-4-8] the rate has increased. The Q-T interval has shortened. Lateral ST segment depressions are not as prominent on the current tracing. Clinical correlation is suggested. [2160-6-9] BILAT LOWER EXT VEINS PORT: No evidence of deep vein thrombosis in either right or left lower extremity [2160-6-9] CTA CHEST W&W/O C&RECONS, NON-CORONARY: No evidence of pulmonary embolism. Alveolitis, pulmonary edema or pulmonary hemorrhage significantly progressed since [2160-6-6]. Moderate, posterior layeriing, nonhemorrhagic right pleural effusion is smaller since [2160-6-6]. [2160-6-9] CT HEAD W/O CONTRAST: No CT evidence for acute intracranial hemorrhage. [2160-6-10] TEE: 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. Left ventricular systolic function is hyperdynamic (LVEF>75%).. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild-moderate tricuspid regurgitation. IMPRESSION: No thrombus or spontaneous echo contrast in the LA/LAA/RA/RAA. Hyperdynamic biventricular systolic function. Mild aortic atheroma. [2160-6-11] EEG: This is an abnormal continuous ICU monitoring study because of severe diffuse encephalopathy. The pattern is one of a burst and burst suppression. This may be medically induced although it can also occur as a result of an anoxic event. There did appear to be epileptiform features in the left central region initially but then became bilateral and synchronous in both central regions. As the tracing progressed, the encephalopathic features appeared more prominently in that there was greater suppression of electrical activity and longer suppressive bursts. The left central region remained fairly active to the end of this study. [2160-6-14] LIVER OR GALLBLADDER US: No evidence for biliary obstruction or main portal vein thrombosis. Heterogeneous liver and perihepatic nodal masses consistent with known cholangiocarcinoma. Cholelithiasis. Gallbladder wall edema may relate to underlying liver disease/ascites. Perihepatic and right lower quadrant pockets of ascites. [2160-6-15] EEG: This is an abnormal continuous ICU monitoring study which shows a generally attenuated background with frequent generalized periodic epileptiform discharges indicative of severe encephalopathy with generalized epileptogenic potential. At times these generalized periodic discharges appeared to be higher amplitude and more frequent over the left central region. They did not evolve to form electrographic seizures and did not appear to have an obvious clinical correlate on video. Compared to the prior day's recording, there was no significant change. [2160-6-15] CHEST (PORTABLE AP): Indwelling support and monitoring devices remain in standard position. Worsening bilateral alveolar opacities likely reflect diffuse pulmonary edema; differential diagnosis includes widespread pneumonia and pulmonary hemorrhage. Increasing large right and moderate left pleural effusions. CYTOLOGY [2160-6-7] PLEURAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, macrophages and lymphocytes. [2160-6-11] BRONCHIAL WASHINGS: ATYPICAL. Rare atypical cells are present. Alveolar macrophages and numerous neutrophils. NEGATIVE FOR MALIGNANT CELLS. Alveolar macrophages, neutrophils and bronchial cells. [2160-6-13] SPINAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes and histiocytes. Brief Hospital Course: Ms. [Known lastname 4587] was a 58 year old female with cholangiocarcinoma, Hep B/C/EtOH cirrhosis, and alcohol abuse who presented from clinic with shortness of breath after a routine CT showed new right-sided pleural effusion and pulmonary infiltrates. She was initially treated with ceftriaxone and azithromycin but she became more lethargic and so was switched to vancomycin/cefepime/flagyl. She underwent a thoracentesis that removed transudative fluid, but due to increasing respiratory distress, she was sent to the MICU. During her MICU course, she initially tolerated and remained stable on BiPAP, but then demonstrated progressive clinical deterioration in respiratory status, hypoxemia and required intubation and mechanical ventilation. CT scan showed multifocal pneumonia. BAL was performed, without evidence for hemorrhage and negative for microbials pathogens. She also developed afib with RVR and was cardioverted successfully, but was continued on a heparin drip for anticoagulation, slated to continue for 1 month after cardioversion. She developed altered mental status, decreased level of consciousness despite lactulose and rifaximin for possible hepatic encephalopathy. A 20min EEG was performed which showed epileptiform activity. Neurology was consulted and she was initiated on anti-epileptic drugs, though a continuous 24hr EEG did not show overt seizure activity. CT head and LP were non-revealing. Overall, she demonstrated continued clinical decline, with persistent respiratory failure, progressive hypotension requiring vasopressor support, oliguric renal failure, and persistent coma (despite discontinuation of sedatives for seveeral days). Several extensive family meetins, updating medical status and poor prognosis. Ultimatley, decision to move to focus care on comfort as primary goal was decided, consistent with patients previously expressed wishes. THe patient quietly and peacefully expired shortly following extubation. Medications on Admission: Albuterol 0.083% nebs q6h prn wheezing/SOB Amlodipine 10mg po daily Carbamazepine 200mg po bid Citalopram 40mg po daily Fluticasone 110mcg 2 puffs [Hospital1 ] MS contin 30mg po q12h Morphine 15mg po q6h prn pain Ondansetron 8mg po q8h prn nausea Cyclobenzaprine 5mg po tid prn back pain Furosemide 20mg po daily prn LE edema Albuterol 90mcg inh q8h prn SOB/wheeze Folic acid 1mg po daily Hydroxyzine 25mg po q6h prn itching Protonix 40mg po daily Lactulose 15ml po tid Discharge Medications: The pt expired. Discharge Disposition: Expired Discharge Diagnosis: The pt expired. Discharge Condition: The pt expired. Discharge Instructions: The pt expired. Followup Instructions: The pt expired. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2160-6-19]	[ "276.7", "401.9", "789.59", "427.31", "276.0", "493.90", "285.9", "345.80", "790.7", "198.5", "276.1", "311", "348.30", "584.9", "303.90", "511.9", "155.1", "070.70", "427.32", "486", "571.2", "287.5", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.04", "03.31", "96.72", "34.91", "38.93", "93.90", "99.62", "33.24" ]	icd9pcs	[ [ [] ] ]	19353, 19362	16819, 18789	319, 405	19421, 19438	5038, 9388	19502, 19674	4322, 4353		19313, 19330		19383, 19400		18815, 19290			19462, 19479									4368, 5019				9579, 11549			12228, 16796						12173, 12195								1913, 2270			251, 281											433, 1894																	3415, 3872	3888, 4306
70,469	154,809	31316	Discharge summary	report	Admission Date: [2123-7-21] Discharge Date: [2123-8-12] Date of Birth: [2065-9-27] Sex: M Service: SURGERY Allergies: Bactrim / Ambien Attending:[First Name3 (LF) 695] Chief Complaint: Nausea, diarrhea Major Surgical or Invasive Procedure: cholangiogram angiography with stenting of hepatic artery umbilical herniorrhaphy [2123-8-4] paracentesis [2123-7-26], [2123-8-3] History of Present Illness: 57M, 20 days s/p OLT presenting with nausea and diarrhea x 2 days. He was constipated over the weekend after starting iron supplementation and took milk of magnesia and dulcolax suppositories with subsequent yellowish, liquid non-bloody diarrhea. He also endorses a single episode of emesis on the morning of admission, which was bilious but nonbloody. He was able to tolerate his oral medications thereafter. He denies fever, chills and abdominal pain. Mr. [Name13 (STitle) 4027] does report persistent dysuria, frequent small-volume urination, and a sensation of urgency for which a U/A was obtained on [7-14] and corresponding urine culture grew <10,000 colonies. He had been started on lasix at his [2123-7-14] clinic visit for lower extremity edema, which has improved significantly since that time. His JP drain was removed at that visit. Respiratory symptoms have been stable although, as recorded in his outpatient notes, Mr. [Name13 (STitle) 4027] reports a sensation of chest heaviness associated with lying down and a persistent dysphagia. He is able to sleep lying flat on one pillow, and his wife ([Name8 (MD) ] RN), reports that his oxygen saturation at home has been stable at 98%. He had been scheduled for EGD on [2123-7-22] in evaluation of his dyphagia. ROS: (+) per HPI (-) Denies pain, fevers, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, trouble with sleep, pruritis, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, hematemesis, hemoptysis, cramping, melena, BRBPR, chest pain, cough, edema Past Medical History: PMH: HCV, HCC s/p radioablation, PV thrombus (non-occlusive) Pulmonary embolism ([12-17]),HTN, Depression, Anxiety, Migraines, Cellulitis, Obesity, Left ankle fracture, Colonic polyps, L2+L3 compression fractures PSH: Kyphoplasty Social History: Lives with wife [Name (NI) ] who is a nurse. Smoked 1-1.5ppd x 25 years, quit 20 years ago. Last drink 20 yeras ago, reports moderate drinking history. H/o IVDU in the past, last use 20 years ago. On "medical retirement" from VA where he worked as a case manager. H/o incarceration for selling scheduled substances in the past Family History: Mother died of liver disease at age 60 and possibly cancer. Father died at age 80 of "old age." H/o alcoholism in the family. Physical Exam: Vitals: 98.1 87 149/91 20 98% RA GEN: A&O, comfortable and cooperative; wife at bedside [Name (NI) 4459]: mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses. Abdominal incision clean, dry, and intact with skin staples. No erythema, induration, drainage, fluctuance, or hernia. RLQ former JP sites x2 intact with sutures; no drainage, erythema, or induration. Known umbilical hernia soft and easily reducible with no skin changes. DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused Laboratory: Pending Pertinent Results: [2123-8-12] 04:50AM BLOOD WBC-6.8 RBC-3.34* Hgb-9.0* Hct-27.6* MCV-83 MCH-26.9* MCHC-32.6 RDW-18.1* Plt Ct-153 [2123-8-12] 04:50AM BLOOD PT-14.0* PTT-26.5 INR(PT)-1.3* [2123-8-12] 04:50AM BLOOD Glucose-92 UreaN-18 Creat-1.5* Na-140 K-4.8 Cl-105 HCO3-24 AnGap-16 [2123-8-12] 04:50AM BLOOD Glucose-92 UreaN-18 Creat-1.5* Na-140 K-4.8 Cl-105 HCO3-24 AnGap-16 [2123-8-12] 04:50AM BLOOD ALT-9 AST-14 AlkPhos-101 TotBili-0.5 [2123-8-12] 04:50AM BLOOD tacroFK-10.0 Brief Hospital Course: 57M s/p liver [Month/Day/Year ] [2123-7-2] (POD 20) presented with nausea and diarrhea x1 day, dysphagia, dyspnea on exertion or when lying flat, and dysuria. He was admitted to the [Month/Day/Year ] service under Dr. [Last Name (STitle) ]. Baseline labs were drawn and diet was restricted to clear liquid. Cellcept was held, stool was sent for culture and C diff. UA was WNL. An EGD was done demonstrating multiple superficial lower esophageal ulcerations above the GE junction as well as findings consistent with duodenitis. Protonix was increased to [Hospital1 ]. Remeron was started for complaints of poor appetite and depressed mood. Diarrhea resolved and stool cultures were negative. An [7-23] abdominal U/S was done which showed hepatic artery stnosis. Diagnostic hepatic angiogram demonstrating a segment of high grade stenosis of the main hepatic artery distal to the GDA with a focal associated pseudoaneurysm. Angiography and attempt to stent by IR demonstrated the critically stenotic segment of the main hepatic artery and associated pseudoaneurysm. Stents were deployed within the main hepatic artery across the area of concern, with immediate thrombosis and only minimally successful thrombolysis/thrombectomy. The stent remained partially thrombosed without good flow and patency. Anticoagulation was then started with ASA, plavix an heparin drip. He returned to IR the followig day for repeat angiography and potential re-intervention. This showed complete thrombosis of the hepatic artery stents, with unsuccessful attempts at recanalization. Additionally, there was complete thrombosis of the adjacent pseudoaneurysm. He continued on his anticoagulation and was bridged to coumadin and continued his ASA and plavix. His LFT's continued to be normal throughout this hospitalization. He was also not encephalopathic. He had edema and increased ascites after his procedure and received multiple paracentesis and was started on lasix. On [8-2], his hct dropped to 21.8 and there was concern for a retroperitoneal hematoma. A CT scan was negative for hematoma and he was transfused 2U pRBC and his hct responded appropriately. A hemolytic work up was also negative. He was taken to the OR by Dr. [First Name (STitle) ] on [8-4] for umbilical hernia repair with mesh. A JP drain was also placed at the time for his ascites requiring multiple paracentesis. He also received albumin replacements for his high JP outputs. On POD 2, the patient complained of obstipation and emesis. A KUB was done demontrating an Ileus and he was managed appropriately wth NG tube, IVF and NPO. His ileus improved, he was placed on a low sodium diet and tolerated it well. Over time, his edema improved, the JP output decreased and the executive decision was made to stop his coumadin before discharge.. He was discharged on [8-12] tolerating regular diet, having regular bowel movements, reduced JP output to 650cc, improved edema, and ambulating. He received JP teaching, went home with VNA,and was instructed to get his biweekly labs from QUEST. He continued only ASA and plavix for anticoagulation. He is to follow up with Dr. [Last Name (STitle) ] in clinic on [8-18] with his JP output recordings and to be seen in the [Hospital 73840] clinic in the near future. Medications on Admission: (confirmed with pt, wife, and medication binder on admission) amitriptyline 100', fluconazole 400', furosemide 40', lamivudine 50', mycophenolate mofetil 1000'', pantoprazole 40', pentamidine 300 inh q month, prednisone 20' (to taper to 17.5 on [7-22]), tacrolimus 2'' (last level 17), androgel 1%', valcyte 450 every other day (even days), colace (held for diarrhea), ferrous sulfate 325'' Allergies: bactrim, ambien Discharge Medications: 1. Amitriptyline 100 mg PO HS 2. Aspirin 325 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 Tablet(s) by mouth once a day Disp #30 Tablet Refills:6 4. Docusate Sodium 100 mg PO BID 5. Fluconazole 200 mg PO Q24H 6. LaMIVudine 100 mg PO DAILY RX Epivir HBV 100 mg 1 Tablet(s) by mouth once a day Disp #30 Tablet Refills:3 7. Metoprolol Tartrate 25 mg PO BID RX metoprolol tartrate 25 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 8. Mirtazapine 15 mg PO HS insomnia RX mirtazapine 15 mg 1 Tablet(s) by mouth at bedtime Disp #30 Tablet Refills:3 9. Mycophenolate Mofetil 1000 mg PO BID 10. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 11. PredniSONE 12.5 mg PO DAILY start [8-10] Tapered dose - DOWN 12. ValGANCIclovir 900 mg PO Q24H RX Valcyte 450 mg 2 Tablet(s) by mouth once a day Disp #60 Tablet Refills:3 13. OxycoDONE (Immediate Release) 5-10 mg PO Q8H:PRN Pain RX oxycodone 5 mg [2-8] Tablet(s) by mouth every eight (8) hours Disp #40 Tablet Refills:0 14. Outpatient Lab Work Stat labs twice weekly (every [Month/Day (2) 766] and Thursday)for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, PT/INR and trough prograf level. fax to [Telephone/Fax (1) 697] attention [Telephone/Fax (1) ] RN coordinator 15. Tacrolimus 2.5 mg PO Q12H Duration: 2 Doses First dose 7/4 at 6pm, Second dose [8-12] at 6 am. Please give after drawing levels Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA - [Location (un) 5087] Discharge Diagnosis: Liver [Location (un) ] Esophageal ulcers Duodenitis Hepatic artery stenosis s/p stenting c/b thrombosis of stent Umbilical hernia, s/p repair ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: please call the [Location (un) ] office [Telephone/Fax (1) 673] if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, jaundice, confusion, increased abdomimal pain, incision or JP drain site has redness/bleeding/drainage, JP drain output stops or increases greater than 1 liter per day, decreased urine output, weight increases or decreases 3 pounds in a day -Empty and record all JP drain output.Bring record of JP drain output to next appointment -Use a dry gauze around your incision -Get your blood tests drawn every [Telephone/Fax (1) ] and thursday at Quest Laboratory. -you may shower, no tub baths or swimming -change dry gauze dressing over JP drain daily and as needed YOUR COUMADIN HAS BEEN STOPPED. YOU WILL NO LONGER BE TAKING IT. YOU WILL CONTINUE ASPIRIN AND PLAVIX FOR ANTICOAGULATION. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2123-8-18] 9:00 Provider: [Name10 (NameIs) 1248],CHAIR ONE [Name10 (NameIs) 1248] ROOMS Date/Time:[2123-8-25] 11:15 Provider: [Name10 (NameIs) 1248],CHAIR FIVE [Name10 (NameIs) 1248] ROOMS Date/Time:[2123-9-29] 11:15 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709*]	[ "996.82", "531.90", "535.60", "285.9", "300.00", "789.59", "997.49", "287.5", "560.1", "553.1", "442.84", "788.1", "311", "E878.1", "530.20", "782.3", "444.89", "447.1", "278.00", "V12.55", "585.9", "E878.0", "788.5", "V15.82", "V85.37", "996.74", "403.90" ]	icd9cm	[ [ [] ] ]	[ "45.16", "00.46", "00.40", "54.91", "38.93", "99.10", "53.41", "39.50", "39.90", "88.47" ]	icd9pcs	[ [ [] ] ]	9380, 9458	4068, 7397	293, 437	9656, 9656	3562, 4045	10682, 11208	2715, 2843		7872, 9357		9479, 9635		7423, 7849			9807, 10659									2858, 3543																								236, 255											465, 2091											9671, 9783						2113, 2350	2366, 2699
47,687	100,265	41302	Discharge summary	report	Admission Date: [2200-11-10] Discharge Date: [2200-11-18] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Thoracentesis [2200-11-10] History of Present Illness: [Age over 90 ] year old female that was brought to the ED tonight for shortness of breath. The family noticed that the patient appeared to be quite dyspnic this AM. The shortness of breath was exacerbated by exertion. The patient has not had fever or cough. No N/V/D. no abdominal complaints. The patient denied any chest discomfort. The family has also noted cyanotic fingers and toes that are new for the patient. She denies any associated pain. In the ED the patient had a chest x-ray that was consistent with a significant left pleural effusion. A thoracentesis was performed and removed 1.5L. Post procedure chest x-ray showed improvement. The patient symptomatically improved and required lower oxygen requirements. She was found to have a lactic acidosis that improved after 1L of crystalloid. She was given IV vancomycin and cefepime for empiric antimicrobial coverage. In the ED, initial VS were: Sinus tachycardia, 108, 125/76, 29, 5L NC . On arrival to the MICU, the patient was awake and mildly confused. Patient aware of her location and self but confused to time. She was not in any acute distress. She reports that her breathing is much better than when she initially presented to the ED. Denies any current chest pain or abdominal pain. Patient is still somewhat tachypnic but appears comfortable. Past Medical History: hyperlipidemia, dementia, osteoperosis Social History: Denies any tobacco, EtOH, or recreational drug use Family History: Non-contributory Physical Exam: On admission: Vitals: T:97.3 BP:154/73 P:110 R:28 O2: 94% 4L NC General: Alert, confused to place, but does not appear to be in distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles in the left lobes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: cyanotic digits in the hands and feet, +radial pulses bilaterally, +DP/PT in left, right foot difficult to obtain Doppler pulses Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred On discharge: Vitals: 98.6 150/90 103 21 92%1L NC GEN: Frail elderly female, No acute distress. HEENT: Dry mucous membranes, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: Regular rate and rhythm, no murmurs, rubs or [Last Name (un) 549] PULM: Bibasilar crackles, diminished breath sounds at left base. Resp unlabored, no accessory muscle use. ABD: Soft, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. NEURO: A & O x 1. Moving all extremities, following commands SKIN: No ulcerations or rashes noted. Pertinent Results: On admission: [2200-11-10] 07:05PM BLOOD WBC-15.6* RBC-5.88* Hgb-16.9* Hct-52.7* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.0 Plt Ct-131* [2200-11-10] 07:05PM BLOOD Neuts-89.2* Lymphs-5.9* Monos-3.7 Eos-0.9 Baso-0.3 [2200-11-10] 07:05PM BLOOD PT-17.8* PTT-22.4 INR(PT)-1.6* [2200-11-10] 07:05PM BLOOD Glucose-394* UreaN-59* Creat-1.5* Na-138 K-5.5* Cl-95* HCO3-20* AnGap-29* [2200-11-10] 07:05PM BLOOD LD(LDH)-523* [2200-11-10] 07:05PM BLOOD proBNP-[Numeric Identifier 1199]* [2200-11-10] 07:05PM BLOOD cTropnT-0.03* [2200-11-10] 07:05PM BLOOD Calcium-9.6 Phos-6.2* Mg-2.2 [2200-11-12] 07:08AM BLOOD %HbA1c-10.8* eAG-263* [2200-11-11] 04:41AM BLOOD TSH-5.7* [2200-11-11] 08:25PM BLOOD Vanco-9.8* [2200-11-10] 07:25PM BLOOD Type-ART pO2-77* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 [2200-11-10] 07:13PM BLOOD Glucose-339* Lactate-5.3* [2200-11-11] 12:18AM BLOOD O2 Sat-95 [2200-11-11] 12:18AM BLOOD freeCa-1.10* [2200-11-11] 01:15AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2200-11-11] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG [2200-11-11] 01:15AM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE Epi-1 [2200-11-11] 01:15AM URINE CastHy-64* [2200-11-11] 01:15AM URINE Hours-RANDOM UreaN-897 Creat-159 Na-10 K-74 On discharge: [2200-11-17] 07:00AM BLOOD WBC-11.7* RBC-4.65 Hgb-13.5 Hct-42.3 MCV-91 MCH-29.0 MCHC-31.9 RDW-14.6 Plt Ct-211 [2200-11-14] 08:30AM BLOOD PT-13.2* PTT-26.7 INR(PT)-1.2* [2200-11-17] 07:00AM BLOOD Glucose-157* UreaN-11 Creat-0.6 Na-138 K-4.3 Cl-100 HCO3-26 AnGap-16 [2200-11-12] 07:08AM BLOOD proBNP-3694* [2200-11-17] 07:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7 [2200-11-16] 06:30AM BLOOD Triglyc-183* HDL-29 CHOL/HD-6.0 LDLcalc-108 [2200-11-12] 06:51AM BLOOD Lactate-1.6 Pleural Fluid: [2200-11-10] 09:37PM PLEURAL WBC-299* RBC-179* Polys-34* Lymphs-16* Monos-0 Meso-2* Macro-18* Other-30* [2200-11-10] 09:37PM PLEURAL TotProt-3.8 LD(LDH)-115 Cholest-119 GRAM STAIN (Final [2200-11-10]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2200-11-13]): NO GROWTH. ANAEROBIC CULTURE (Final [2200-11-16]): NO GROWTH. Cytology: POSITIVE FOR MALIGNANT CELLS, Consistent with metastatic adenocarcinoma. Immunohistochemical stains show that tumor cells stain positive for B72.3, [Last Name (un) ]-31 (weak) and cytokeratin 7; cells are negative for CD15 (LeuM1), cytokeratin 20, TTF-1, mammoglobin, GCDFP, ER, PR and CDX2. Immunostains for calretinin and WT-1 highlight background mesothelial cells. The immunophenotype is non-specific. Possibilities include (but are not limited to) lung, breast and gynecologic primary malignancies. Microbiology: Blood Culture, Routine (Final [2200-11-16]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [2200-11-11]): GRAM POSITIVE COCCI IN CLUSTERS URINE CULTURE (Final [2200-11-12]): NO GROWTH. Blood Culture, Routine (Final [2200-11-17]): NO GROWTH. Blood Culture, Routine (Final [2200-11-18]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2200-11-16]): Feces negative for C.difficile toxin A & B by EIA. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2200-11-18]): Feces negative for C.difficile toxin A & B by EIA. Portable CXR [2200-11-10]: IMPRESSION: Large left pleural effusion with associated lower lung atelectasis. Please note underlying pneumonia cannot be excluded. Recommend followup to resolution. Portable CXR [2200-11-10]: Previous left pleural effusion has nearly resolved following thoracentesis. No obvious pneumothorax. Heterogeneous opacification in the left lung could be residual atelectasis or reexpansion edema and should be followed. Mild interstitial abnormality and possible bronchiectasis noted in the right lung, but nothing acute. The heart is moderately enlarged. TTE [2200-11-11]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. CT chest w/o contrast [2200-11-11]: FINDINGS: Extensive calcifications of the aorta are noted. Mediastinal lymph nodes are not pathologically enlarged based on the size criteria. There is normal diameter of the pulmonary arteries. There is left lower lobe extensive consolidation associated with pleural effusion. In addition there are multiple pulmonary nodules with ill-defined margins noted throughout the lungs bilaterally. Multiple pulmonary nodules are bilateral, ranging up to 15 mm in the left upper lobe, 10.5 mm in the right upper lobe. Some of the nodules are cavitated. No definite dominant lesion is noted in the lungs, but it potentially could be obscured by extensive consolidation in the lingula and left lower lobe. Small amount of pleural effusion on the current study appears to be decreased as compared to [2200-11-10] and most likely unchanged since chest radiograph obtained after thoracocentesis. Airways are patent to the level of subsegmental bronchi bilaterally. No bone abnormalities to suggest lytic or sclerotic lesions worrisome for neoplasm or infectious process demonstrated. The imaged portion of the upper abdomen demonstrates sludge in the gallbladder and otherwise is unremarkable within the limitations of this study technique. IMPRESSION: 1. Substantial consolidation in the left lower lobe and lingula with some degree of volume loss associated currently with minimal amount of pleural effusion. Infectious etiology would be the first choice, although underlying neoplasm or vasculitis cannot be excluded. All those etiologies may potentially explain the presence of multiple ill-defined pulmonary nodules seen in both lungs as well as consolidation, correlation with clinical symptoms and tissue diagnosis is required. 2. The extensive consolidations might potentially obscure pulmonary lesions being dominant in the case of malignancy. Portable CXR [2200-11-13]: FINDINGS: Since the most recent examination, there has been interval increase in now a small-to-moderate left layering pleural effusion. There is mild improvement in ill-defined nodular opacification scattered throughout all lung fields as better characterized on recent CT. There is no evidence of pneumothorax. There is no right-sided effusion. The cardiomediastinal and hilar contours are stable, demonstrating borderline enlarged heart size. Pulmonary vascularity is not increased. IMPRESSION: 1. Mild interval increase in now small-to-moderate left layering pleural effusion since most recent examination. 2. Mild improvement in multifocal ill-defined nodular opacification, as better characterized on CT from [2200-11-11]. MRI head w and w/o contrast [2200-11-14]: FINDINGS: Diffusion images demonstrate a small area of high signal in the right occipital lobe near the midline without corresponding enhancement. Subtle T2-hyperintensity is also seen in this region. Additionally, there is a focus of hyperintensity in the left centrum semiovale, which demonstrates an area of enhancement. There are no other areas of abnormal enhancement seen. There is moderate-to-severe brain atrophy seen with prominence of temporal horns indicating temporal lobe atrophy. Mild-to-moderate changes of small vessel disease are seen. IMPRESSION: A focus of hyperintensity on diffusion images in the right occipital lobe without corresponding enhancement is too small to characterize on ADC map, but could represent a small acute infarct. An abnormality in the left centrum semiovale demonstrates T2 abnormality with subtle enhancement. Given the faint enhancement and T2 abnormality, the differential diagnosis includes a small deep white matter subacute infarct versus a metastatic lesion. A followup study in two weeks would help for further assessment. No other areas of abnormal enhancement seen. No territorial infarcts are identified. Brain atrophy is seen. Brief Hospital Course: [Age over 90 ]yo F with dementia, HL, and osteoporosis who presented with SOB and was found to have large left sided pleural effusion on CXR. #Pleural Effusion, malignant: Patient presented to the ED with shortness of breath, tachypnea and hypoxia. Chest x-ray was significant for a large left pleural effusion. Thoracentesis was performed that removed 1.5L of fluid. Analysis showed 300 WBC with 33% PMN. Light criteria negative for exudate. Gram stain was negative. Differential is broad but based on history, physical, and labs question parapneumonic effusion vs malignancy. Less likely to be CHF, PE. TTE was performed that showed EF >75%. BNP was [Numeric Identifier 1199] on admission but dramatically decreased to 3694 after thoracentesis. Patient was transitioned to ceftriaxone and azithromycin for empiric coverage for CAP and treated with 7 days of antibiotics. Repeat chest x-ray was consistent with intersitial edema and questionable consolidation in the left lower lobe. Oxygen requirements were weaned and the patient was transferred on 2L on nasal cannula. She remained mostly on room air, intermittently on 1-2L oxygen, throughout remainder of hospital course on the floor. Repeat CXRs showed slow re-accumulation of left pleural effusion. Cytology of the pleural fluid returned positive for malignant cells, showing metastatic adenocarcinoma. Interventional pulmonary continued to follow the patient on the floor. Discussion of therapeutic options for the pleural effusion was held, including possible options of chest tube drain and pleurodesis. Prior to discharge, the option of performing a repeat thoracentesis to drain remaining fluid was discussed with the family. Given the risks of the procedure, the family declined further interventions. The palliative care team was consulted for further guidance on end of life care. On [2200-11-17], family meeting was held with the palliative care team to discuss goals of care and options for care at home vs extended care facility. The family decided to home hospice and the patient was discharged on [2200-11-18] with home hospice service in place. She will need 24 hour care at home, home oxygen at home for oxygen saturation below 90%, and a wheelchair. She will also be provided with medications to help with comfort, including morphine. # Somnolence/Encephalopathy: Pt exhibited waxing and [Doctor Last Name 688] levels of somnolence during her hospital stay. Per family report, she had also been increasingly sleep at home prior to admission to hospital. Because of the likelihood of malignancy and possibility of metastatic spread, MRI of the head was pursued after discussion with the family about risks and benefits of head imaging. The MRI showed a focus of hyperintensity in right occipital lobe that could represent small acute infarct as well as abnormality in left centrum semiovale consistent with either subacute infarct vs metastatic lesion. Patient was started on a baby aspirin and will remain on her simvastatin. Her LDL was 108. #Lactic acidosis: Patient presented with a lactate of 5.3. After thoracentesis and fluid resuscitation lactate improved to 4.1. Etiology includes hypovolemia and hypoperfusion vs sepsis vs hypoxia. Patient does have an elevated WBC to 15.6 with a left shift. Patient was hemodynamically stable. Received IV vancomycin and cefepime in the ED and was transitioned to ceftriaxone/azithromycin. Lactate normalized to 1.6 prior to transfer to the floor. #Acute Kidney Injury: On admission, patient had acute elevation in her Cr from 0.8 to 1.5 with an elevated BUN to 59. Pre-renal azotemia most likely secondary to hypovolemia. Differential also includes ATN. FeNa <1%. Most likely secondary to hypovolemia. Cr improved with fluid resusciation. Cr was at baseline 0.6 by time of discharge. She was given conservative IV fluids prn for signs of volume depletion, including tachycardia to low 100s and low urine output. #Hyperglycemia/DM type 2, uncontrolled, without complications: Patient with a history of diabetes and on glimepiride at home presenting with serum glucose of 394. Patient was started on sliding scale insulin. Prior to discharge home, fingersticks remained 100s-200s without insulin. Hemoglobin A1c was 10.8. Risks and benefits of oral agents for diabetes were discussed with family. Because of the risks of hypoglycemia and her minimal po intake, the patient was not discharged on home oral hypoglycemics. #Cyanotic Digits: Patient has cyanosis of fingers and toes. Not associated with any pain. Positive radial pulses. Left DP/PT present on Doppler but was not able to be obtained on the right. Currently does not appear to be ischemic but more likely to be chronic PVD. After re-examining the patient during HD 1 morning rounds the extremity cyanosis resolved and pulses were present in all extremities. ABI showed bilateral aortoiliac and likely infrainguinal arterial occlusive disease . ABIs were 0.7 on the right and 0.6 on the left. Given overall limited life expectancy, further work-up for PVD was not pursued. # Bacteremia: Blood culture on arrival to ED [2200-11-10] grew GPCs in clusters; she was started on vancomycin empirically. Speciation returned as coag negative staph. It was felt that this one positive blood culture was most likely contaminant as pt was afebrile and with downtrending WBC. Subsequent blood cultures showed no growth. Vancomycin was discontinued after one day. #Diarrhea: Two days prior to discharge, pt developed increased frequency of loose stools. C.diff was negative x 2. She may find symptomatic relief with anti-diarrheal agents such as loperamide. She was given conservative IV fluids prn for volume depletion. She did not have diarrhea on day of discharge. #Poor po intake: Family was concerned with pt's minimal oral intake, which had been an ongoing problem prior to admission. She was seen by swallow therapist who performed a bedside evaluation and found no risk of aspiration. Although swallow therapist felt that there were no restrictions on her diet, she was kept on a soft dysphagia diet because the family requested it. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly DONEPEZIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day glimepiride 1 mg tab QD SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. Wheelchair Please provide 1 wheelchair 3. Compression stockings Provide 1 pair of compression stockings 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Hospice of the [Location (un) 1121] Discharge Diagnosis: Primary: Pleural effusion Adenocarcinoma Acute/subacute infarct Secondary: Diabetes mellitus type II Peripheral vascular disease Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with shortness of breath. You were found to have a large fluid collection around your lungs; this fluid was removed. This fluid showed cancer cells. An MRI of the head also showed a possible stroke and possibly spread of cancer to the brain. Your family met with the palliative care team and it was decided that you would go home with hospice care. The hospice team will provide your family with medications to keep you comfortable. The following medication changes were made: 1) STOP glimepride 2) START aspirin 81mg daily 3) You may continue to take simvastatin 10mg daily 4) STOP alendronate Followup Instructions: You will be cared for by a hospice team at home. Completed by:[2200-11-18]	[ "276.52", "199.1", "250.02", "584.9", "787.91", "733.00", "511.81", "783.21", "348.30", "276.2", "294.8", "272.4", "440.21", "486", "434.91" ]	icd9cm	[ [ [] ] ]	[ "34.91" ]	icd9pcs	[ [ [] ] ]	18874, 18944	12135, 18304	274, 307	19118, 19118	3228, 3228	19993, 20074	1802, 1820		18555, 18851		18965, 19097		18330, 18532			19295, 19970									1835, 1835																		4609, 12112						215, 236											335, 1656										3242, 4595	19133, 19271						1678, 1718	1734, 1786
31,049	196,616	51838	Discharge summary	report	Admission Date: [2127-5-8] Discharge Date: [2127-5-12] Date of Birth: [2050-4-3] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Nsaids Attending:[First Name3 (LF) 458] Chief Complaint: ST-elevations on EKG, concern for STEMI at OSH Major Surgical or Invasive Procedure: Cardiac Catherization History of Present Illness: 77 y/o woman with a PMhx of metastatic lung cancer with mets to bone & h/o malignant pleural effusion, who is transferred from [Hospital3 1443] Hospital for cardiac catheterization after she was found to have ST-elevations in V2-6, I and aVL. . The patient initially presented to LMH on [2127-5-3] with right hip pain. She was found to have an intertrochanteric fracture of the R hip, which was thought to be pathologic in nature. She underwent total hip replacement and ORIF on [2127-5-3], and tolerated the procedure well. Post-op, her WBC rose to 17. She was found to have pansensitive Ecoli UTI. Her Hct also dropped from low 30s to 26, for which she reportedly received PRBCs (per dtr). She was getting ready for DC to rehab, when she was noted to be tachycardic. EKG showed new ST elevations ~2mm in V2-6, I and aVL. She had no chest pain and no new SOB. She was sent for a CTA, which was negative PE, though study was slightly limited by motion. (CTA did, however, show large R pleural effusion, which is old and has been malignant on prior taps. Also seen was masslike consolidation of RUL & RML w/ adenopathy). CK was 96, MB 13, Trop 0.45, INR 1.1, Hct 31. Discussion w/ cardiology at OSH was had & decision made to transfer pt for cardiac cath b/c of concern for STEMI. Pt & family agreed to this intervention. . In the cardiac cath lab at [Hospital1 18], there were no significant coronary lesions on angio. Notably, her LV-gram showed severe anterolateral, apical, and inferoapical hypokinesis w/ LVEF 20%. She had markedly depressed cardiac index (1.8), elevated wedge (34), and moderate pulm HTN. She was given presumptive dx of Takotsubo CMP. During the cath, the patient became confused and agitated. She was transferred to the CCU for closer monitoring. Past Medical History: OUTPATIENT MEDICATIONS: Colchicine 0.6mg daily Iron 300mg TID Folic acid 1mg daily Atenolol 50mg daily Nisedapine 30mg daily ASA 81mg daily Compazine PRN . TRANSFER MEDICATIONS: Lopressor 2.5mg IV at 2pm Cipro 200mg IV BID Colchicine 0.6mg daily Colace 100mg [Hospital1 ] Lovenox 40mg daily-last dose 6pm [5-6] Iron 300mg TID Folic acid 1mg daily Lopressor 25mg tid-Last po dose was at 8am, Multivitamin Prilosec Oxycontin 20mg [Hospital1 ] Senna [Hospital1 ] Resteril qhs ASA 325mg 12noon Plavix 300mg Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. The patient lives in a two family home, where she occupies one unit and her daughter's family the other. She is independent with her ADLs at baseline. Walks her dog a few times a day. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION: VS - 96.8, 88, 136/72, 21, 100% on RA; 1L of UOP p 20mg IV lasix given in cath lab Gen: slightly anxious elderly woman. Oriented to self & family members in room; though thinks she's in [Hospital3 ]. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: JVP just below angle of jaw. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild bibasilar crackles. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: No ulcers. . Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: OSH CXR: large right pleural effusion and atelectasis, mass right upper lobe . CT scan of chest [5-7]: large right side pleural effusion, mass like consolidation in right upper lobe and portion of right mid lobe. . EKG demonstrated sinus tach, ~2mm STE in V2-6, I and aVL w/ biphasic TW I & avL. TWI V4-6. . CARDIAC CATH performed on [2127-5-6] demonstrated: 50% LMCA lesion RADIOLOGY Final Report CT HEAD W/O CONTRAST [2127-5-9] 8:56 AM CT HEAD W/O CONTRAST Reason: Please eval for SDH or e/o mets. [Hospital 93] MEDICAL CONDITION: 77 year old woman with known stage IV lung CA s/p cardiac cath. Mental status changes. REASON FOR THIS EXAMINATION: Please eval for SDH or e/o mets. CONTRAINDICATIONS for IV CONTRAST: contrast w/ cath already today HISTORY: 77-year-old female with known stage IV lung cancer status post cardiac catheterization, now with altered mental status. COMPARISON: No prior exam is available for comparison. TECHNIQUE: Contiguous axial imaging was performed through the brain without administration of IV contrast. CT HEAD: Hypodensity involving right posterior frontal subcortical white matter along the superior convexity is noted; while this may represent old ischemic change, no prior imaging is available to establish stability and this may represent edema surrounding a metastatic lesion in this patient with known stage IV lung cancer. Note is made of mild atrophic appearance, which would be more consistent with old infarct. There may also be a smaller region of hypodensity along the posterior left frontal region as well, along the superior convexity. Otherwise, there is no evidence of acute intracranial hemorrhage, shift of normally midline structures, effacement of the basal cisterns, or infarction. Punctate, likely extra-axial densities may represent sequelae from prior myelography versus vascular calcifications. Mild prominence of the ventricles and extra- axial CSF spaces is consistent with age-related involutional change. Vascular calcifications are noted along the cavernous carotid arteries. Patient is noted to have right lens replacement. The soft tissues appear unremarkable. No region of bony destruction is seen in the visualized calvarium. The visualized paranasal sinuses and mastoid air cells remain well aerated. IMPRESSION: Region of hypodensity along the posterior right frontal lobe along the superior convexity may represent old infarct, however edema due to underlying mass may also have this appearance. If no prior study is available to establish stability, MR would be recommended for further evaluation. Note is also made of a smaller region of hypodensity along the left superior convexity. No evidence of acute intracranial hemorrhage. Brief Hospital Course: . #. Cardiomyopathy: 77yo woman with progressive stage IV NSCLC, h/o CVA, HTN, hyperlipidemia, and recent R hip fx s/p replacement & ORIF who was noted to be in sinus tach at OSH, EKG showed STE, and cardiac cath was done on arrival which was notable for absence of significant CAD and presence of hypokinesis of anterolat/apex/inferoapex with severely depressed cardiac index, concerning for Takotsubo CMP. Her EF was found to be ~20%. There is a broad hypokinesis of broad territory w/o corresponding CAD with question of Takostubo CMP. Possible triggers may have been recent hip fx vs. stress of being in hospital. However unclear if true stress reaction vs possibly thromboembolic event to coronaries. Pt was started on Metoprolol, hydralazine and isordil. She was also placed on simvastatin 10mg daily and aspirin 325mg. ACEi were not given secondary to a history of medication intolerance. Her medications were titrated as her BP and HR tolerated for optimzal management of her cardiomyopathy. An ECHO was not done during her hospitilization as her EF was assessed at cath and her general goals of care were addressed given her late stage Lung Cancer. In addition anti-coagulation therapy with warfarin was not started given her known metastatic disease. A cardiology appointment will be scheduled for her at [Hospital1 18]. If she does not hear from the cardiology dept by Wed [6-13] please be sure to call [Telephone/Fax (1) 9832] and have one scheduled. . #. CAD: pt does have 50% LMCA lesion on cath. She was placed on aspirin 325, simvastatin 10mg daily and metoprolol 50 [Hospital1 ]. . # Confusion: Pt was initially agitated and confused during her cardiac catheterization. Once in the ICU and her lines removed she was re-oriented. A CT head was done which showed no hemorrage or acute event, but did show ? edema and possible mets given her lung CA. Given her known lung CA, her primary oncologist was conteacted and who felt that the finding was likley not new. THe pt will f/u with her oncologist for further assessment and f/u of this finding. No further intervention was felt acutely necessary. In addition goals of care were addressed and the patient and family wished to focus on getting pt to rehabilitation. . # Right Hip Fracture: Pathologic in nature. Pt was treated in her post-op period for pain control with oxycodone and tylenol. In addition, she was continued on Lovenox. Upon discussion with orthopedics she will need to complete a 30 day course of Lovnenox SC for prophylaxis, which will be finished [2127-5-31]. She should follow up with orthopedics on discharge. . # Pleural effusion: Pt initially had some respiratory distress. A CXR showed loculated effusion. Given her known lung CA her primary oncologist was contact[Name (NI) ]. This effusion was not felt to be new. In addition her goals of care were addressed wehich were to avoid invasive procedures at this time including a pleurx catheter. She was given symptom control with nebulizer treatments. She will follow up with her oncologist on discharge. . #. Code: DNR/DNI confirmed w/ HCP [Name (NI) ] (son) - [Telephone/Fax (1) 107360]. Medications on Admission: OUTPATIENT MEDICATIONS: Colchicine 0.6mg daily Iron 300mg TID Folic acid 1mg daily Atenolol 50mg daily Nisedapine 30mg daily ASA 81mg daily Compazine PRN . TRANSFER MEDICATIONS: Lopressor 2.5mg IV at 2pm Cipro 200mg IV BID Colchicine 0.6mg daily Colace 100mg [Hospital1 ] Lovenox 40mg daily-last dose 6pm [5-6] Iron 300mg TID Folic acid 1mg daily Lopressor 25mg tid-Last po dose was at 8am, Multivitamin Prilosec Oxycontin 20mg [Hospital1 ] Senna [Hospital1 ] Resteril qhs ASA 325mg 12noon Plavix 300mg Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary Takostubo Cardiomyopathy . Secondary Stage IV Lung Cancer Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted to the hospital and found to have an abnormality of your heart. Your heart function was felt to be depressed. The underlying cause was unclear but it is thought that this may be related to the high stress you were under after your recent surgical procedure. You underwent a cardiac cathteterization procedure for this. You were started on many new medications. Your new list of medications includes: Aspirin 325mg one tablet daily Albuterol nebulizer treatments to help with breathing Colchicine 0.6mg (you were on this at home) Docusate and Senna (for constipation as needed) Lovenox SC injections each day to complete a 30 day course; this is to help prevent clots from forming after the surgical procedure Ferrous Sulfate Folic Acid 1mg each day Hydralazine 10mg four times per day Ipratropium nebulizer breathing treatments as needed Isosorbide Dinitrate 10mg three times per day Metoprolol 50mg twice daily Oxycodone as needed for pain Simvastatin 10mg daily for cholesterol trazadone as needed for sleep . If you have any chest pain, shortness of breath, palpitations or other concerning symptoms please call your doctor or come to the emergency room. Followup Instructions: You have a follow up appointment with your primary care doctor on Thursday [5-22] at 11:30am You will need to be seen by a cardiologist. The cardiology office at [Hospital1 18] will call you at rehab with an a appointment. If you do not hear from them, please call [Telephone/Fax (1) 62].	[ "733.14", "198.5", "162.9", "599.0", "272.4", "197.2", "041.4", "429.83", "414.01", "416.8", "V12.54", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.53", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]	11721, 11793	6622, 9805	329, 353	11903, 11912	3858, 4380	13241, 13547	3039, 3121		10375, 11698	4417, 4504	11814, 11882		9831, 9831			11936, 13218									3136, 3136											9855, 9987			3158, 3839										243, 291	4533, 4927								10009, 10352		381, 2171			4936, 6598														2193, 2193	2730, 3023
22,424	136,862	30817	Discharge summary	report	Admission Date: [2152-2-29] Discharge Date: [2152-3-2] Date of Birth: [2101-8-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 30] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 35984] is a 50-year-old gentleman with a PMH significant for IVDU, chronic pain on suboxone, and hepatitis C now admitted for somnolence and concern for clonidine overdose. The patient was at CVS today waiting for his suboxone prescription. At that time, he was noted to be increasingly somnolent, and EMS was called. Per report, patient received 2 doses of intranasal narcan without improvement in mental status. . In the [Hospital1 18] ED, initial VS 64 102/63 15 96%2L nc. Serum tox screen and labs and ECG were unremarkable. The patient was somnolent, and had minimal improvement in mental status with an additional dose of 0.8 mg naloxone. Toxicology was consulted, with concern for clonidine overdose. He was noted to have a SBP in the 90-100s with a HR in the 60s, he received 4L IVF, and was admitted to the MICU for further management. . Currently, the patient is somnolent but arousable. He is complaining of chronic lower leg pain and right hand pain. He is unable to state why he is here, if he has fallen or had any recent trauma. Denies any CP/SOB, f/c/s, n/v/d, abd pain. . ROS: As above, otherwise negative. Per Mother, was admitted "a few months ago" hospitalized at [Hospital1 2177]. Past Medical History: 1. Chronic low back pain secondary to injury in [2110] - prev on methadone, most recently per report on suboxone. 2. Neuropathy 3. Pulmonary nodules which are followed at [Hospital6 14430] 4. Asthma/COPD. 5. Hepatitis C 6. Hypertension. 7. IVDU - overdose with [Hospital1 2177] MICU admission in [2147] from methadone, klonopin. Social History: Patient is currently homeless and lives in a shelter in [Hospital1 392]. His case manager is Lenelle and her number is [Telephone/Fax (1) 72946]. The nurse [First Name (Titles) ] [Last Name (Titles) 31486] his methadone is [Doctor First Name ]. Her number is [Telephone/Fax (1) 27560]. Patient is currently divorced with two adult daughters. [Name (NI) ] denies any current drug, alcohol, or tobacco use. He does admit to history of marijuana, intranasal cocaine, and intranasal heroin. He denies any current IV drug use. He began to use heroin at age 40, subsequently developed addiction and managed currently with methadone maintenance as described above. Denies any history of heavy alcohol use. Does admit to a smoking history. He smoked one pack per day x 10 years. He was tested a few months ago for HIV which was negative. Hepatitis C as mentioned above. Family History: Grandfather died of an MI in his 70s, grandmother died of liver cancer, mother with skin cancer. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 96.1 73 130/97 12 96%2L nc. Gen: Somnolent but arousable. HEENT: MM dry, OP clear. NCAT. CV: Nl S1+S2, no m/r/g. Pulm: CTAB Abd: S/NT/ND +bs Ext: No c/c/e. Right hand swollen and tender to palpation. Neuro: Not oriented. CN non-focal. symmetric 1+ patellar, biceps brachii, and brachioradialis reflexes bilaterally. No clonus. MSK: No midline cervical tenderness. PHYSICAL EXAM ON DISCHARGE: Tm 98.2, Tc 97.4, BP 124/60 (124-134/60-78), 97 (70-97), 20, 98%RA (93-98%RA) GENERAL - ungroomed, well-appearing male in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, teeth missing 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, 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 - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-6] throughout UE's, [3-7] throughout LE's, sensation grossly intact throughout, wide based gait, but able to support himself with crutches for [4-7] steps, then gait exam stopped. Pertinent Results: LABS ON ADMISSION: [2152-2-29] 11:42PM TYPE-[Last Name (un) ] PO2-37* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-1 [2152-2-29] 11:42PM LACTATE-0.9 [2152-2-29] 11:42PM O2 SAT-66 [2152-2-29] 09:45PM URINE HOURS-RANDOM [2152-2-29] 09:45PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2152-2-29] 09:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2152-2-29] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2152-2-29] 05:50PM GLUCOSE-104* UREA N-16 CREAT-1.0 SODIUM-140 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-32 ANION GAP-9 [2152-2-29] 05:50PM ALT(SGPT)-36 AST(SGOT)-29 LD(LDH)-185 CK(CPK)-102 ALK PHOS-52 TOT BILI-0.3 [2152-2-29] 05:50PM ALBUMIN-3.9 [2152-2-29] 05:50PM OSMOLAL-296 [2152-2-29] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2152-2-29] 05:50PM WBC-9.8 RBC-3.79* HGB-12.0* HCT-33.7* MCV-89 MCH-31.7 MCHC-35.6* RDW-14.2 [2152-2-29] 05:50PM NEUTS-55.9 LYMPHS-35.8 MONOS-5.0 EOS-2.4 BASOS-0.9 [2152-2-29] 05:50PM PLT COUNT-273 . CXR [2152-2-29]: Overdose and O2 requirement. Comparison is made to prior study dating back [2149-3-4]. Cardiac size is top normal. There is mild vascular congestion. There is no pneumothorax or pleural effusion. HEAD CT W/OUT CONTRAST [2152-2-29]: IMPRESSION: No acute interval change. R HAND X-RAY [2152-2-29]: HISTORY: Right hand pain and swelling. There is soft tissue swelling overlying the dorsum of the hand. Old healed boxer fracture deformity of the fifth metacarpal. There is a tiny soft tissue calcification adjacent to the distal first metacarpal of doubtful significance. No overt acute fracture and no bone destruction or joint space narrowing. Localizing history might be helpful. EKG [2152-3-1]: sinus bradycardia at HR of 52 with QTC of 476. LABS ON DISCHARGE: [2152-3-2] 07:05AM BLOOD WBC-7.7 RBC-3.54* Hgb-11.0* Hct-32.0* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.2 Plt Ct-247 [2152-3-2] 07:05AM BLOOD Glucose-83 UreaN-17 Creat-0.8 Na-139 K-4.3 Cl-106 HCO3-31 AnGap-6* [2152-3-2] 07:05AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 Brief Hospital Course: Mr. [Known lastname 35984] is a 50 year old gentleman with a PMH significant for IVDU, chronic pain on suboxone, and hepatitis C now admitted for somnolence and concern for clonidine overdose. . # OVERDOSE/AMS: Given transient hypotension and lack of compensatory tachcyardia, concern for clonidine overdose given that this is a known medication for the patient. Somnolence and small pupils would also be consistent with this toxidrome. ECG without evidence of AV nodal block, and nothing to suggest that patient had concomitent AV nodal blockade with a beta blocker or CCB. Urine tox screen positive for barbiturate with negative serum barbiturate level, which per lab is c/w barbituate use in the last 2 weeks but not more recently. Suboxone overdose also less likely as pt given naloxone with no effect. Patient was treated with IVF and airway was monitored. He was ordered for social work and addiction consults. Toxicology signed off, having no further recommendtions. Serial EKGs did not show evidence of QT prolongation beyond his baseline (obtained as QTc of 479 from [Hospital1 2177] EKG in [2149]). Outside records from pain clinic and PCP were obtained, which showed that patient has been on the same medications for months and despite occasional substance abuse (cocaine, barbituates), has been off heroin for 14 months. . # HYPOXEMIA: Patient with new supplemental oxygen requirement. ABG on room air 7.37/48/64, with A-a gradient of 25. Likely due to alveolar hypoventilation in the setting of CNS depression. Oxygenation improved as patient's mental status cleared. . # RIGHT HAND PAIN: Concerning for fracture, although no overt signs of trauma. Plain films however showed some swelling, but no fracture, which was reassuring. . # ANEMIA: Unclear baseline. Hematocrits were trended throughout admission. No overt signs or symptoms of bleeding. His HCT remained stable throughout admission, so no intervention done. Medications on Admission: Suboxone 8/2 mg, #64, 1.25 qam, 1 qpm Neurontin 800 Q6H Clonidine 0.2 Q6H Fluoxetine 40 mg QAM Discharge Medications: 1. buprenorphine-naloxone 8-2 mg Tablet, Sublingual Sig: 1.25 Tablets Sublingual QAM (once a day (in the morning)). 2. buprenorphine-naloxone 8-2 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual QPM (once a day (in the evening)). 3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours). 5. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary: Suspected clonidine overdose Secondary: chronic pain, hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname 35984], You were seen in the hospital for being found confused with low blood pressure and low heart rate. You were admitted to the ICU for monitoring. We are unsure exactly what caused this, but your blood pressure, heart rate and mental status all returned to your baseline shortly after being admitted to the hospital, and you were sent to the regular medicine service. There, you continued to do well, so we were able to send you to your pharmacy in a chair car. We recommend that you contact one of the homeless shelters our social worker gave you the information for in the future for a place to stay. We made no changes to your medications. Please continue to take your prescritpitons exactly as precribed. If you experience any confusion, dizziness or weakness please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospital admission. Followup Instructions: You have a follow-up appointment at your outpatient pain clinic on [3-28] at 11pm ([Location (un) 72947], [Location (un) 1456], [Numeric Identifier 72948]; phone [Telephone/Fax (1) 72949], fax [Telephone/Fax (1) 72950])	[ "780.09", "V60.0", "355.9", "799.02", "724.2", "518.89", "338.29", "729.5", "070.70", "493.20", "E980.4", "304.01", "285.9", "972.6", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9157, 9163	6585, 8540	309, 315	9282, 9282	4305, 4310	10421, 10669	2880, 2979		8686, 9134		9184, 9261		8566, 8663			9465, 10398									2994, 3008																3419, 4286								261, 271					6295, 6562						343, 1580										4324, 6275	9297, 9441						1602, 1955	1971, 2864
26,349	157,971	28757	Discharge summary	report	Admission Date: [2128-1-8] Discharge Date: [2128-1-9] Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[First Name3 (LF) 3326] Chief Complaint: pneumonia, sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo M with extensive cardiac history who was found in his chair unresponsive, pulseless and apneic this AM at his nursing home. CPR was initiated for approximately 1 min and the patient was reported to have a HR of 38. EMS was called and he was found to be alert and responsive on the scene with a HR of 50, systolic pressure of 70. He was placed on NRB at 15L per min with unknown O2 sat. Hypotensive in 70s. Presumed to have a pneumonia on CXR. Right IJ placed. Also found to be hyperkalemic. Given 10U regular insulin, kayexalate, amp of D50. Became hypoglycemic w/ BG of 35. Given add'l amp of D50. Past Medical History: HTN syncope MI CHF EF 15-20% CASHD CABG x 3 in [2118] sick sinus syndrome a-fib/a-flutter, previously on coumadin ventricular pacemaker in [2118], revised to dual chamber pacemaker without ACID in [2122] recurrent PNA s/p L partial pneumonectomy CRI aortic stenosis - moderate to severe 4+ TR RLE ulcer Social History: Lives at [Hospital3 16749] Home. Family History: NC Physical Exam: VS: T 95 ax BP 103/58 on levophed HR 80 and O2 sat 95% on high flow face mask. Gen: moaning and shouting, looks very uncomfortable HEENT: dry MMM Cor: difficult to appreciate hear sounds over rhonchi Pulm: rhonchi bilaterally Abd: soft NT ND Ext: WWP with 1 + dependent pedal edema, right lower extremity with dressings intact without drainage. Neuro: oriented to self and place but not date, moving all 4 extremities Pertinent Results: [2128-1-8] 09:33PM GLUCOSE-136* UREA N-55* CREAT-2.8# SODIUM-134 POTASSIUM-5.6 CHLORIDE-100 TOTAL CO2-18* ANION GAP-22* [2128-1-8] 09:33PM estGFR-Using this [2128-1-8] 09:33PM ALT(SGPT)-49* AST(SGOT)-118* CK(CPK)-150 ALK PHOS-133* AMYLASE-34 TOT BILI-1.9* [2128-1-8] 09:33PM LIPASE-13 [2128-1-8] 09:33PM CK-MB-13* MB INDX-8.7* cTropnT-0.49* [2128-1-8] 09:33PM ALBUMIN-2.9* CALCIUM-8.2* PHOSPHATE-5.3* MAGNESIUM-2.5 [2128-1-8] 09:33PM WBC-7.9 RBC-4.25* HGB-13.4* HCT-40.4 MCV-95 MCH-31.5 MCHC-33.1 RDW-20.5* [2128-1-8] 09:33PM NEUTS-87.8* BANDS-0 LYMPHS-10.1* MONOS-1.7* EOS-0.2 BASOS-0.1 [2128-1-8] 09:33PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-1+ [2128-1-8] 09:33PM PLT COUNT-215 [2128-1-8] 09:33PM PT-21.0* PTT-46.9* INR(PT)-2.0* . IMAGING: CXR with bilateral effusions, left infiltrate at base, RIJ with tip at heart border, pacer in place, cephalization . EKG: V paced, rate 80, LVH, LBBB Brief Hospital Course: the patient presented to the [Hospital Unit Name 153] in severe respiratory distress, acutre renal failure and sepsis. . After discussion of poor prognosis with his family, and the pain the patient was in, his health care proxy decided to change the goals of care to comfort measures. . He passed away on the evening of [1-9] at 9:55 pm. Medications on Admission: Captopril 12.5mg TID Zaroxalyn 2.5mg [2-10] tab PO qOD KcL 20mEQ PO BID OsCal 500mg PO TID Amiodarone 200mg PO qD Lasix 40mg PO qD Celexa 20mg PO qD Spironolactone 12.5mg PO qD MVI EC ASA 325 PO qD Lipitor 10mg PO qD Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "397.0", "276.7", "276.2", "038.9", "585.9", "584.9", "425.4", "403.90", "428.0", "427.31", "486", "V45.81", "995.92", "424.0", "V45.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3434, 3443	2816, 3163	252, 258	3494, 3503	1759, 2793	3559, 3569	1302, 1306				3464, 3473		3189, 3411			3527, 3536									1321, 1740																								195, 214											286, 893																	915, 1232	1248, 1286
3,927	133,161	26096	Discharge summary	report	Admission Date: [2197-12-17] Discharge Date: [2198-1-17] Date of Birth: [2144-12-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4219] Chief Complaint: Fever, respiratory failure Major Surgical or Invasive Procedure: endotracheal intubation, lumbar puncture, insertion of CVL History of Present Illness: 52 yo female, h/o hyperlipidemia, DM, HTN, presenting after returning from [Country 11150] with fever of unknown origin. Pt originally presented to [Hospital1 ] on [12-15] day after returning from [Country 11150]. As per their notes, she had been feeling unwell since the 2nd leg of her flight, with symptoms of fever, chills, diffuse muscular pain, HA, weakness, and rigors. Her husband, who was still in [Name (NI) 11150], had similar symptoms that were resolving. She was in a rural area in Inday, bitten by many mosquitos, and had stitches place in her left ear for a stretched piercing. She had denied diarrha, photophobia, nuchal rigidity, nausea; she had been complaining of pain in the left ear x 1 day. . At [Hospital1 ], she was found to be febrile to 103.5, hemodynamically stable with a HR=130. UA was negative, bld/urine cultures were drawn (and remain negatibe), and Hct was 40.3, plts 210, WBC=3.9. She had a mild transaminitis. EKG showed LBBB (thought to be old), and thick/thin smear was negative for parasites. LP was not performed/felt to not be clinically indicated. She was started on ceftriaxone 2 mg, and monitored. Further workup included hepatitis serologies (pending), TTE which showed severely depressed EF=25%. She had mild drop in hematocrit/plts. She did not improve and was intubated on [12-16] [2-22] hypoxic respiratory failure (?flash pulmonary edema vs. ARDS). Doxycycline was added to medication regimen, 1 dose of PO quinidine was administered. SBP dropped, and she was started on dopamine with stabilization of her BP and resumption of urine output. CT of the head was performed and was negative for any acute process. Upon the wishes of family, she was transferred for [Hospital1 18] for further care. . Upon transfer, she had a brief episode of hypotension upon transfer that responded to fluid bolus. She remains on dopamine gtt, propofol gtt, insulin gtt and is saturating adequately on AC ventilation. She was febrile to 101 on transfer. Past Medical History: PMH: 1. HTN 2. DM2 3. Hypercholesterolemia 4. Pyelo in past, pan-sensitive klebsiella, with respiratory failure requiring FM O2 (no intubation)/sepsis, at [Hospital1 112] (?ARDS)--[2191] 5. s/p CCY 6. Normal C-scope in [2197] 7. CHF: EF reportedly 35% in past (?was this in setting of urosepsis), followed by Dr. [Last Name (STitle) 32963] at [Hospital1 112] Social History: no t/e/d, recently returned from [Country 11150] as above; was there for 12 days, rural area Family History: Father with [Name2 (NI) 499] cancer Physical Exam: PE: BS: 101.0 86 (SR) 94/56 23 100% AC, FiO2=100%, TV=500, R=14, breathing at 23, PEEP=5 Gen: intubated, sedated, unresponsive HEENT: PERRL, OP clear, MMM Neck: no JVD Lungs: rhonchorous diffusely to anterior exam, no w/r CV: 2/6 SEM at LUSB Abd: soft, nt/nd, nabs Extr: no c/c/e, DP 2+ bilat Left ear: with stitches, mild erythema Lines: Right femoral, 2 x PIV; no erythematous Neuro: toes downgoing bilaterally, sedated Pertinent Results: Relevant Labs/Studies: Brief Hospital Course: 1. Fever: She initially presented to the OSH with fevers (as high as 105.0). Etiology for this was explored at length. Blood, urine cultures (including fungal and mycolytic cultures) were drawn and were persistently negative. Stool cultures were also sent and remained negative. Thick/Thin preps were prepared and were negative for parasistes x 6. Although she did receive 1 dose of quinidine and 1 dose of malarone, therapy for malaria was discontinued given low likelihood of this. LP was performed upon arrival to [Hospital1 18] and was negative for signs of infection. Hepatitis serologies were sent, BAL was sent for viral/bacterial organisms, and legionella urinary antigen was negative. Dengue fever and leptospirosis were also sent. She was started on Ceftriaxone, Vanco, Ampicillin, Azithromycin initially upon presentation to [Hospital1 18]. Ampicillin was discontinued with negative LP results. She eventually defervesced. Cause of febrile illness was likely a viral source. All antibiotics were stopped after 4-5 days given lack of a source. All serologies (leptospira, hepatitis, mycoplasma) were negative, Dengue still pending. She respiked with evidence of an infiltrate s/p failed extubation and was started on vanco/zosyn for VAP. She remained afebrile after this one temp spike and completed a 10-day course of vanc/zosyn. Patient was taken to the OR in order to get a permanent tunnelled line. Procedure was complicated by 3 degree av block and was transfer to MICU. In the MICU, after having two femoral lines and a temporal wire pacer patient spiked [2198-1-5]. Because suspition of line associated infection, she was given 1 dose of Vancomycin. 2 days after, patient was transfer to the floor. She remained having low grade fever and spiked to 101 while on the floor again. Femoral lines were removed. Pacer wire was being kept until definitive tunneled catheter was placed given previous complication. Multiple blood culrues and urine cultures were drawn and all came back negative. Patient received a second dose of vancomycin on the floor and had a red man reaction. She developed a rash. Given persistent negative results for fever source, and rash drug fever was contemplated. Temporary pacer wire was also removed on [2197-12-11]. Patient fevers decreased and remained afebrile since [2197-12-12]. On [2197-12-25],fevers returnedand felt were [2-22] to drug fever. All antibiotics were discontinued with resolution of rash and serum eosinophilia.Patients Temp. PM heardware removedas well as her Temp IF HD line on [2198-1-16]. Patient remained to have low grade temps(100.0 max) but all blood, urine, sputum, andtips cultures remained without growth. Dengue fever serologies (from [12-17] and [12-25]) were still pending at the time of discharge. Will foloow up in [Hospital ] clinic on [2197-2-12]. . 2. Hepatitis: Although AST/ALT were within normal limits at OSH, they were extremely elevated upon presentation to [Hospital1 18] (to 10,000's, AST peaked at 16,000). Alkaline phosphatase/bilirubin were within normal limits while LDH was also elevated to 8000. Liver was consulted and believed that the rise in ALT/AST was less consistent with Dengue fever and more consistent with shock liver [2-22] episode of hypotension peri-intubation at OSH (induced by sedating medications, lasix). Hepatitis, EBV, CMV serologies were sent to exclude infectious causes; all serologies were negative. Supportive care was given, and liver function improved to within normal limits. . 3. Renal Failure: Creatinine started to rise and urine output decreased upon transfer. Urine was examined and had many muddy brown casts. Urine sodium was high at 110. This was most likely consistent with ATN, given episode of hypotension described above. Due to anuria, metabolic acidosis and rising creatinine up to 10, renal made the decision to dialyze. A temporary dialysis catheter was placed, and HD was started during anuric period to manage acid/base status and volume issues. Pt's urine output started to increase however she stilled required HD. Patient was taken for a permanent tunneled HD catheter on [2198-1-6] and procedure was complicated by AV block. Patient was transfered to the Unit. Patient urine output continue improving however given pericardial rub on auscultation she still required hemodialysis. Temporary catheter was placed on [2198-1-10] by IR and removed on [2198-1-16]. She maintained excellent urine output,only requiring HD to manage a question of uremic rub. Last Dialysis was on [2198-1-14],with creatine remaining stable at 3.0. Patient will follow up in [Hospital 10701] clinic and her PCP to review her creatine. At this time, patient was instructed to not continue any nephrotoxic agents (ACE,NSAIDS) until a baseline creatine is established. . 4. Respiratory failure: This was likely hypercarbic, secondary to capillary leak/respiratory distress. She was initially maintained on assist control and weaned as tolerated. After eight days of intubation, she was extubated but failed requiring re-intubation likely secondary to volume overload, tachypnea [2-22] underlying metabolic acidosis. There may have been vocal cord edema (no cuff leak), so she was given 48 hours of Decadron. NIF was appropriate, and extubation was accomplished (after 13 days of intubation). She continued to improve and was satting well on room air on discharge. . 5. Hypotension: She was hypotensive peri-intubation period, likely from sedating medications and lasix she received. She was dopamine upon transfer here, transitioned to levophed. This was weaned after one day, and she remained hemodynamically stable. . 6. CHF/cardiomyopathy: EF on TTE at [Hospital1 18] was <20%, no vegetations, global LV HK. Records from OSH cardiologist showed that in mid-[2182], pt had a normal ejection fraction. However, when she was admitted to [Hospital6 ] in [2191] for urosepsis, she was found to have an EF of <20%. This was thought to be [2-22] an ischemic cardiomyopathy, with anterior/apical WMA, and also [2-22] sepsis. ... EF was likely depressed in the setting of inflammation/sepsis and will likely recover. CVPs in ICU were adequate in the range of [7-31]. Lopressor was restarted, and hydralazine/nitrate were added for afterload reduction. ASA was started when coagulopathy when stable. ACEI was held in-house and should be restarted when renal function normalizes. She will need follow up TTE 3-4 weeks after discharge to reassess for recovery of function. Last Echo 35% EF after her second MICU stay. Patient should get a repeat Echo as an outpatient in 1 month time. Given her renal insufficency, ACE was not initiated. -- Rhythm: She was taken to the OR for placement of a R IJ Permacath. After the procedure, she was noted to have second degree heart block, with possible runs of v tach, then brady into 40s. R IJ Permacath was removed. SBP was in the 70s, HR 50s. Her heart rate climbed to the 150s, thought to be atrial tachycardia with 3:1 heart block. Levophed was begun and uptitrated to 0.1mcg/min, without adequate recovery of BP. Epi gtt begun. DCCV attempted, with 200J, 300J x2. This was unsuccessful. BP was 140s/30s, rate in 50s. Pt was then noted to have a junctional rhythm with RBBB rather than LBBB, and appeared to have complete AV dissociation. HR in 40s-50s. Temp wire placed via right femoral vein for complete AV dissoc on [1-4]. Posterirly VVI pacer placed [1-5]. Patient back to sinus with LBBB. Temp PM was removed [2197-12-25] without complications, and remained in NSR. Her Betablocker should be restarted as an outpatient. . 7. Coagulopathy: INR was initially mildly elevated, and platelets dropped. Hematocrit dropped in this setting. Hematology was consulted and felt that this was all in the setting of sepsis. Hemolysis labs were normal, and fibrinogen remained >100. She was supported with platelets and PRBC as needed. As she improved clinically, hematologic parameters remained stable, . 8. DM: She was put on Insulin drip while in the ICU for aggressive blood sugar control. This was transitioned to SSI when extubated, taking POs. At time of discharge, patient was started on Glipizide 2.5mg po bid with excellent sugar control. . 9. Hypercholesterolemia. Lipitor was held initially given elevated transaminases. Triglycerides were elevated. She will need resumption of lipid management as an outpatient. At time of discharge, all LFT abnormalities resolved. . 10. Psych: 1 day after being transfer from the MICU (inital stay), She became extremyly withdrawn and was not talking to anybody. Psychiatry was consulted, and later that day patient started to interact again. Patient had a depresed mood and was extremely frustrated because she could not go home. After being admitted for the second time to the MICU, patient again became extremely withdrawn. Unclear dx Uremia vs. Catatonic Depression vs. ICU psychosis. Psych recommend seroquel [Hospital1 ] with good improvement. On [2197-12-28], seroquel was discontined and,as her health returned, so did hermood. At time of discharge, she was with ample social support and without need of mood stablizers. Medications on Admission: Meds at home: ASA 81 mg, ATenolol 25 mg, Moexipril 7.5 mg, Metformin 500 mg, Lipitor 40 mg Meds on Transfer: Tylenol PRN Fioricet PRN Restoril PRN Ins gtt Propofol gtt Dopamine gtt Ceftriaxone 2 gm q24 (d3) ASA 81 mg Lipitor 40 mg Protonix 40 mg Doxycycline 100 mg IV BID Quinidine PO x 1 NKDA Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home with Service Discharge Diagnosis: ARDS Sepsis CHF ARF DM2 Complete Heart Block Discharge Condition: Home in stable condition, afebrile, no oxygen requirments, ambulating without difficulty, with stable creatine. Discharge Instructions: Please take all medications as directed. Please avoid Motrin (NSAIDS) until you see your PCP. [Name10 (NameIs) ] have changed a lot of your prior medications due to your kidney disease; please see this medication list and discuss with your PCP reinitiation of your prior medications (you were on ASA 81 mg, ATenolol 25 mg, Moexipril 7.5 mg, Metformin 500 mg, Lipitor 40 mg) Followup Instructions: Please call your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) 10755] [Telephone/Fax (1) 46461] today (His office is expecting your call. We wish you to see him this friday to have your blood chemistries to be check and blood sugars. Dr. [Last Name (STitle) 10755] will arrange to have your lipid profile checked, Liver function as well as a repeat Echo of your heart in 1 months time. Your Dengue result is pending at time of discharge. Please follow up in [Hospital ] clinic: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16881], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2198-2-12] 11:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231]	[ "038.9", "250.00", "518.81", "401.9", "425.4", "426.0", "693.0", "584.5", "486", "284.8", "997.1", "428.0", "079.99", "E930.8", "570" ]	icd9cm	[ [ [] ] ]	[ "96.6", "33.24", "38.95", "00.17", "38.93", "03.31", "39.95", "99.62", "86.05", "37.78", "96.72" ]	icd9pcs	[ [ [] ] ]	13635, 13654	3565, 12876	344, 404	13743, 13857	3518, 3542	14283, 15061	3012, 3053		13223, 13612		13675, 13722		12902, 12994			13881, 14260									3068, 3499																								278, 306											432, 2471																	2493, 2881	2897, 2996		13012, 13200
11,627	181,140	2877	Discharge summary	report	Admission Date: [2119-9-18] Discharge Date: [2119-9-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7934] Chief Complaint: Abdominal Pain, bloody stools Major Surgical or Invasive Procedure: Intubation History of Present Illness: 85 y/o with abdominal pain and a fib presents with 1-2 days of abd pain and "red stools", in ED was guiac positive, HCT stable but wbc with 17%B. VSS at the time. Initial lactate was 9.2; CT scan showing ischemic bowel and splenic/renal infarcts. Family refused surgery; vascular and gen [Doctor First Name ] consulted. Past Medical History: CAD s/p MI and 3vD CHF EF 15 HTN s/p CVA with left hemiplegia PVD Type 2 DM Physical Exam: PE 102r 128/66 101 90 38 95% laying in bed, nontoxic JVP 8 decreased bs @ bases irreg irreg s mrg abd: distented and typmanitic, decreased bs, guiac + per ED no peripheral stigmata of endocarditis Pertinent Results: [2119-9-18] 09:52PM TYPE-ART TEMP-38.9 PO2-81* PCO2-25* PH-7.33* TOTAL CO2-14* BASE XS--10 INTUBATED-NOT INTUBA [2119-9-18] 09:52PM LACTATE-5.8* [2119-9-18] 09:52PM HGB-13.4 calcHCT-40 O2 SAT-95 [2119-9-18] 09:01PM LACTATE-5.4* [2119-9-18] 08:14PM LACTATE-6.5* [2119-9-18] 06:56PM LACTATE-8.1* [2119-9-18] 06:04PM LACTATE-7.1* [2119-9-18] 05:54PM LACTATE-7.1* [2119-9-18] 04:07PM LACTATE-7.7* [2119-9-18] 02:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2119-9-18] 02:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2119-9-18] 02:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2119-9-18] 02:01PM LACTATE-9.2* [2119-9-18] 12:20PM TYPE-ART COMMENTS-NOT SPECIF [2119-9-18] 12:20PM HGB-15.5 calcHCT-47 [2119-9-18] 12:10PM GLUCOSE-300* UREA N-20 CREAT-1.3* SODIUM-129* POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-19* ANION GAP-25* [2119-9-18] 12:10PM ALT(SGPT)-33 AST(SGOT)-48* LD(LDH)-319* ALK PHOS-63 AMYLASE-206* TOT BILI-1.1 [2119-9-18] 12:10PM LIPASE-43 [2119-9-18] 12:10PM CK-MB-5 cTropnT-<0.01 [2119-9-18] 12:10PM ALBUMIN-4.2 [2119-9-18] 12:10PM DIGOXIN-<0.2* [2119-9-18] 12:10PM WBC-10.1 RBC-5.06 HGB-14.6 HCT-43.5 MCV-86 MCH-28.9 MCHC-33.6 RDW-13.4 [2119-9-18] 12:10PM NEUTS-66 BANDS-17* LYMPHS-13* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2119-9-18] 12:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [2119-9-18] 12:10PM PLT COUNT-163 [2119-9-18] 12:10PM PT-15.5* PTT-29.9 INR(PT)-1.6 . [9-19] CXR IMPRESSION: 1. Endotracheal tube in satisfactory position, but cuff is slightly overdistended. Coiling of nasogastric tube as described. 2. New patchy bibasilar opacities, which may relate to atelectasis or aspiration. 3. Small left pleural effusion. . [9-18] CT Abd/Pelvis IMPRESSION: 1. Findings consistent with widespread embolic disease. 1. Likely acute thrombus within the SMA causing bowel ischemia. There is also chronic disease of the celiac and the [Female First Name (un) 899]. The origin of the celiac is completely or almost completely occluded. 3. Right renal infarct. 4. Splenic infarcts. 5. Fatty liver. 6. Decreased flow in the left portal vein of unknown etiology. It does not appear to represent blood clot. 7. Renal cysts. . Brief Hospital Course: Assessment: 85 y/o with abdominal pain and a fib presented with 1-2 days of abd pain and "red stools", in ED was guiac positive, HCT stable but wbc with 17% bands. VSS at the time. Initial lactate was 9.2; CT scan showed ischemic bowel and splenic/renal infarcts. 1. Diffuse embolic dz: poor prognosis without surgery. She was heparinized in the ED. Checked blood cx to r/o endocarditis. Continued Abx (Levo/Flagyl for gut translocation + Vanc to cover for endocarditis). We continued asa, PPI, NPO diet. Pt was seen by both vascular and general surgery teams but she refused invasive procedures. She was realtively stable until [9-19] at 7am when her BP was 77/35 and she had an O2 sat of 88%. Anesthesia was called and she was intubated. Based on >90% Mortality as determined by Vascular surgery without intervention, the family was notified and CMO measures were discussed. She was made CMO on [9-19] per family wishes once their Priest was present and she was extubated shortly thereafter. Her BP gradually declined and she expired within one hour of extubation. Medications on Admission: ASA Atenolol Lipitor Metformin Digoxin Glipizide Hydralazine HCTZ Lisinopril Nifedipine Coumadin Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "427.31", "438.20", "401.9", "289.59", "250.00", "593.81", "412", "V66.7", "557.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4755, 4764	3491, 4576	292, 305	4815, 4824	991, 3468	4880, 4890			4723, 4732		4785, 4794		4602, 4700			4848, 4857									773, 972																								223, 254											333, 658																	680, 758
27,468	153,788	51363	Discharge summary	report	Admission Date: [2195-6-18] Discharge Date: [2195-6-21] Date of Birth: [2139-5-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 562] Chief Complaint: weakness and lethargy Major Surgical or Invasive Procedure: EGD History of Present Illness: 56 yo M w/ cirrhosis, htn, hyperchol, p/w hemetemesis x2, black stools, lethargy. He reports sharp intermittent abd pain since last weeks accompanied by dark stools. On [Name (NI) 766] pt. was feeling unwell and had projectile hematemesis x 2. He continued to have black stools w/ ?red blood. His partner convinced him to seek medical attention giving his lethargy and GI bleeding. In the ED his initial VS were: 97.2, 81/43 (down to 71/36), 117, 16, 100%RA. His initial hct 15.2. He was given 4u of pRBCs and 1 unit of FFP. He also received protonix, octreotide and zosyn. His tachycardia improved and his sbp stablized to the 90's. Also, CXR was significant for right sided pneumomediastinum. Pt. was seen by thoracics and general surgery in the ED. Surgery recommended zosyn and fluconazole for prophylactic coverage. Liver fellow contact[Name (NI) ] and recommended protonix gtt and octreotide gtt. They will assess pt. re: EGD, but feel this is high risk given pneumo mediastinum. ROS: denies fevers chills, reports SOB x1 day, no chest pain, weight loss of 20lbs over the past 1 year (intentional), other Past Medical History: alcoholic cirrhosis Hypertension hypercholesterolemia Social History: retired. previously heavy etoh use ([1-4] vodka drinks/night), now continues to drink wine 1x/week. Tobacco- quit 8 years ago, prev. smoked [12-3] ppd for many years. no illicit drug use. per omr He is a retired Director of Human Resources Family History: per omr. Mother and father both had heart disease. His mother had three strokes and died of uterine cancer. His father died of a heart attack in his 40s. He also had diabetes. He has eight siblings who are all healthy. Physical Exam: VS: BP 104/59 HR 92 02sat 100% RR 16 Gen: NAD heent: MMM, non-icteric sclera. cvs: distant heart sounds, tachy, no murmurs chest: scattered bilateral rales abd: Nt/ND, soft, hypoactive BS, no detectable ascites. ext: no edema, 1+ pulses neuro: AA0x3 Brief Hospital Course: Assessment and plan: 56 yo M w/ cirrhosis p/w hematemesis and BRBPR, initial HCT of 15, now s/p 4u of pRBCs and 1u FFP. . # GI bleed: Patient initially had dark stools and BRBPR. He also had hematemesis (2 episodes on [Month/Day (2) 766] but non since). He was severely anemic on presentation with a HCT of 15 which increased to 25 with 4 units pRBCs. He was given FFP as well for a concern of coagulopathy. The patient has a history of alcoholic cirrhosis as well, with know grade 1 esophageal varices in the past. He was started on octreatide gtt and protonix gtt. He was given a total of 5 units of pRBCs in the ICU, with a stable HCT at the time of discharge from the MICU. The patient underwent EGD which showed no active bleeding source, but there was evidence of an ulcer which was thought to be likely the source of his GIB. His h.pylori was checked and was pending on day of d/c. An abdominal US was performed which showed Similar heterogeneous echogenic appearance of the liver, with somewhat increased ascites. No focal mass identified on somewhat limited evaluation. He had an episode of melena on [6-19] but this resolved and his Hct only decreased to 25 then rebounded to 27 and then to 30 on morning of d/c, this was repeated and it was 27.6, thought that the 30 represented lab error as pt. had normal stool in between the two draws. Diet was advanced per liver to full w/ salt restriction on day of d/c and pt. tolerated it well. # pneumomediastinum: initially, the patient was thought to have a pneumomediastinum. Thoracic surgery was consulted, and he was started on empiric fluc/zosyn. A CT neck was performed, which did not show any evidence of pneumomediastinum, and the antibiotics were stopped. He was only continued on ciprofloxacin since he is a cirrhotic patient with UGIB. # cirrhosis: D/c'd on aldactone. . # htn: resumed moexipril on D/C . # hyperlipidemia: REsumed statin on d/c . # code status: presumed full . Medications on Admission: Univasc Lipitor Aldactone [Doctor First Name ] Flonase Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: Total 5 days, last dose 7/22. Disp:4 Tablet(s) Refills:0 3. Univasc 15 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. [Doctor First Name ] Oral 7. Flonase Nasal Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Bleeding Duodenal Ulcer 2. Cirrhosis Secondary Diagnoses: 1. Hypertension 2. Hyperlipidemia Discharge Condition: Stable Discharge Instructions: You have been admitted to the hospital because of a GI bleed. While you were here you were transfused with blood products. Please take your medications as described in the discharge paperwork. You will be discharged on an antibiotic called Cipro, which you must take for the next 5 days to prevent an infection after the endoscopy. Please return to the ED for any dark stools, bloody vomitus, chest pain, shortness of breath or any other medical concerns. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 2392] within one week of discharge. ([Telephone/Fax (1) 798] LIVER FOLLOW UP: The liver center will call you for a follow up appointment in 6 weeks for a follow up EGD. Completed by:[2195-6-21]	[ "303.90", "571.2", "789.59", "401.9", "537.89", "532.40", "572.3", "518.1", "584.9", "285.9", "456.21", "272.0", "286.9" ]	icd9cm	[ [ [] ] ]	[ "45.13", "99.07", "99.04" ]	icd9pcs	[ [ [] ] ]	5022, 5028	2361, 4328	335, 340	5187, 5196		5702, 5824	1850, 2071		4438, 4999		5049, 5109		4354, 4415			5220, 5679									2086, 2338		5130, 5166						5835, 5957																274, 297											368, 1490																	1512, 1568	1584, 1834
76,968	150,364	37961	Discharge summary	report	Admission Date: [2179-5-6] Discharge Date: [2179-5-7] Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 5018] Chief Complaint: intraparenchymal hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: [Known firstname ] [Known lastname ] is a [Age over 90 ] year-old man who was transferred from [Hospital3 628] after being found down this morning at his nursing home. His family who are present state that he at his baseline is a very cognitively sharp person who reads the paper and does crossword puzzles frequently. This morning when care workers went to check on him his was found on the ground with some blood around his nose. He was reported to be nonresponsive and was not moving either extremity. He was taken to [Location (un) 620] where a CT showed a large IPH. He was transferred to [Hospital1 18] for neurosurgical evaluation, who felt there was no intervention and that this was a catastrophic bleed. He is not on anticoagulation or aspirin as per his son. [Name (NI) ] has a history of a resected breast malignancy and prostate cancer that was being followed. There was no history of hypertension. ROS unobtainable given intubation Past Medical History: s/p CABG s/p Pacemaker placement CHF Prostate cancer Breast cancer Hip replacement Spinal stenosis Social History: worked in life insurance and financial services, smoked during his military service. lived in [Location (un) ] [Hospital3 ] in [Location (un) 620]. Family History: non-contributory Physical Exam: Physical Exam on Admission: Vitals: 98 72 130/99 100% 5 PEEP General: intubated, nonresponsive. HEENT: ET tube Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: coarse breath sounds Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neuro: MS - intubated, sedated, does not open eyes to sternal rub. L pupil 5 mm and NR, R pupil 2mm and sluggish, + VOR, + corneals, + gag. Extensor postures the left arm to noxious, no movement of the right arm or leg, toes extensor or right and left. Physical Exam on Discharge: Expired Pertinent Results: [2179-5-6] 12:55PM GLUCOSE-163* UREA N-18 CREAT-0.8 SODIUM-141 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [2179-5-6] 12:55PM estGFR-Using this [2179-5-6] 12:55PM WBC-20.3* RBC-4.39* HGB-13.5* HCT-43.0 MCV-98 MCH-30.8 MCHC-31.5 RDW-14.1 [2179-5-6] 12:55PM NEUTS-86.2* LYMPHS-7.9* MONOS-5.4 EOS-0.4 BASOS-0.2 [2179-5-6] 12:55PM PLT COUNT-126* [2179-5-6] 12:55PM PT-11.9 PTT-25.6 INR(PT)-1.1 CT head - large left IPH 8 x 11 x 5 cm with IV blood and 2cm midline shift Brief Hospital Course: [Known firstname ] [Known lastname ] is a [Age over 90 ] yo man who suffered a large left hemispheric intraparenchymal hemorrhage and was found unresponsive at his [Hospital3 ] facility. He was not on anticoagulation and did not have hypertension. He did have a malignancy history with breast and prostate. His exam is notable for a large left pupil which wa snot reactive and a right hemiparesis. He was not responsive to sternal rub, but has intact corneals, VOR and gag. His CT showed a large left hemispheric IPH. Given his prognosis and living will which stated he did not want to live in an incapacitated state, his family opted to make him CMO. The etiology of the bleed could be metastatic or amyloid or possible hemorrhagic transformation of ischemic stroke, however it is difficult to say given the extent of the bleed. He was started on a morphine drip for comfort and admitted to the ICU. Per his family's wishes he was extubated on [2179-5-6]. He passed away peacefully at 02:42 on [5-7]. Medications on Admission: Lasix - unknown dose Metoprolol - unknown dose Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Large left intraparenchymal hemorrhage measuring 8 x 11 x 5 cm with intraventricular blood and midline shift Discharge Condition: Expired Discharge Instructions: Mr. [Known lastname ] was admitted to [Hospital1 69] on [2179-5-6] after being found unresponsive at his [Hospital3 ] facility. He was found to have a large left intraparenchymal hemorrhage with significant midline shift. Given his poor prognosis his family decided to make him CMO (comfort measures only). He was started on a morphine drip, admitted to the neuro ICU, and extubated. He passed away peacefully at 02:42 on [2179-5-7]. Followup Instructions: n/a [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023]	[ "V43.64", "348.4", "V45.01", "V10.3", "185", "428.0", "724.00", "V45.81", "342.90", "431", "V66.7" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	3962, 3971	2809, 3837	260, 266	4124, 4134	2273, 2786	4636, 4758	1586, 1604		3934, 3939		3992, 4103		3863, 3911			4158, 4613									1619, 1633																2245, 2254								193, 222											294, 1271										1647, 2217							1293, 1393	1409, 1570
71,377	156,655	9014	Discharge summary	report	Admission Date: [2193-5-22] Discharge Date: [2193-6-18] Date of Birth: [2122-3-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: coffe ground emesis Major Surgical or Invasive Procedure: Mechanical Ventilation Central Line Arterial Line Tracheostomy Endoscopy History of Present Illness: 71 year old woman african-american with hypertension, diabetes, dementia, and two prior CVA's leaving her non-verbal at baseline. She had several episodes of coffee ground emesis at her nursing facility earlier today. She was transported to the emergency department at [Hospital1 18]. Initial vitals were 99.5 126 157/79 24 100. An NG lavage was performed with 250 cc of normal saline. It initially cleared. However, prior to transfer she began having small amounts of bright red blood from the NG tube. She was started on a pantoprazole gtt. GI saw her in the ED and plan to do an endoscopy tomorrow. . Her respiratory status declined while in the ED. She was placed on a NRB briefly and then intubated. Her labs were significant for a lactate of 6.4 and WBC of 13.2. A CXR showed a retrocardiac opacity and possible right lower lobe infiltrate. An abdominal CT showed no acute pathology. She was given vancomycin and zosyn. A right IJ was placed and she was given at least 3 liters of normal saline. During the time in the ED, it was noted that her right neck appeared [Hospital1 2824]. A CT of the neck showed a hematoma around the catheter site. . Ms. [Known lastname 19784] had a recent admission in [Month (only) 547]/[2193-4-20]. She had an E coli UTI. She also had a left MCA stroke complicated by seizure. She was started on plavix following this event. Ethics was involved to discuss the code status. Ms. [Known lastname ] husband wanted her to be a full code. After extensive conversations it was decided that CPR would not be medically indicated. Her code status was changed to DNR/DNI. . On the floor, she was non-verbal, not reliably communicative, and unable to answer questions. Past Medical History: Type II Diabetes Left eye trauma and enucleation s/p right posterior cerebral artery CVA s/p left middle cerebral artery CVA Hypertension Dysphagia s/p PEG tube Dementia Depression History of clostridium difficle History of lactic acidosis E. Coli urinary tract infection complicated by septic shock [2193-3-21] Post-infarct epilepsy Social History: Lives in a nursing home. Per review of records she is separated from her husband. However, he is her healthcare proxy. Family History: Unable to obtain. Physical Exam: Vitals: T: 99.1 BP: 98/59 P: 89 O2: 100 on CMV/AS General: does not respond to commands, occasionally moans HEENT: left eye enucleation, right pupil reactive Neck: right sided IJ, increased fullness on right side Lungs: mechanical ventilatory sounds CV: Regular rate Abdomen: soft, slightly distended, bowel sounds present, PEG tube in place, no erythema surrounding Rectal: Guiac negative in ED Ext: 1+ DP/PT pulses Pertinent Results: [2193-5-22] 11:43AM BLOOD WBC-13.2# RBC-3.54 Hgb-11.4* Hct-34.4* MCV-97 MCH-32.3* MCHC-33.3 RDW-15.1 Plt Ct-384 [2193-5-23] 04:48PM BLOOD WBC-9.0 RBC-2.42* Hgb-7.6* Hct-23.1* MCV-95 MCH-31.3 MCHC-32.8 RDW-14.2 Plt Ct-237 [2193-5-24] 07:25AM BLOOD WBC-8.0 RBC-2.55* Hgb-8.1* Hct-24.4* MCV-96 MCH-31.9 MCHC-33.2 RDW-14.2 Plt Ct-257 [2193-5-24] 06:53PM BLOOD Hct-20.3* [2193-5-25] 09:57AM BLOOD Hct-25.0* [2193-5-29] 03:01AM BLOOD WBC-5.2 RBC-2.41* Hgb-8.0* Hct-22.2* MCV-92 MCH-33.2* MCHC-36.1* RDW-14.4 Plt Ct-328 [2193-5-29] 08:04PM BLOOD WBC-6.2 RBC-2.69* Hgb-8.3* Hct-24.9* MCV-92 MCH-31.0 MCHC-33.5 RDW-14.0 Plt Ct-386 [2193-6-1] 04:33AM BLOOD WBC-7.9 RBC-2.57* Hgb-8.3* Hct-23.6* MCV-92 MCH-32.4* MCHC-35.4* RDW-14.4 Plt Ct-469* [2193-6-3] 03:30AM BLOOD WBC-7.1 RBC-2.59* Hgb-7.9* Hct-23.9* MCV-92 MCH-30.3 MCHC-32.9 RDW-14.5 Plt Ct-455* [2193-6-6] 03:02AM BLOOD WBC-4.6 RBC-2.56* Hgb-7.8* Hct-23.9* MCV-93 MCH-30.5 MCHC-32.7 RDW-14.4 Plt Ct-480* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2193-6-18] 05:24 6.1 2.83* 8.4* 25.6* 91 29.7 32.8 15.7* 365 [2193-5-22] 02:00PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.021 [2193-5-22] 02:00PM URINE Blood-TR Nitrite-NEG Protein-75 Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG PHENYTOIN: NEUROPSYCHIATRIC Phenyto [2193-6-18] 05:24 15.0 . Microbiology [2193-6-6] BLOOD CULTURE Blood Culture, Routine-PENDING [2193-6-6] BLOOD CULTURE Blood Culture, Routine-PENDING [2193-6-6] URINE URINE CULTURE-PENDING [2193-6-2] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-positive [2193-6-2] URINE ANAEROBIC CULTURE-negative [2193-5-31] CATHETER TIP-IV WOUND CULTURE-negative [2193-5-27] SPUTUM GRAM STAIN-negative; RESPIRATORY CULTURE-negative [2193-5-23] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-positive [2193-5-22] BLOOD CULTURE Blood Culture, Routine-negative [2193-5-22] BLOOD CULTURE Blood Culture, Routine-negative [2193-6-14] 11:09 am SPUTUM Source: Endotracheal. FINAL REPORT [2193-6-17] GRAM STAIN (Final [2193-6-14]): >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 ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2193-6-17]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. GRAM NEGATIVE ROD #2. SPARSE GROWTH. PROTEUS SPECIES. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 16 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R . Imaging [2193-5-22] CT Head IMPRESSION: No acute intracranial pathology. Unchanged involutional changes due to multiple prior infarcts. If clinical concern for acute ischemia, MRI is more sensitive, if there is no clinical contraindication. . [2193-5-22] Chest Xray FINDINGS: An endogastric tube is noted with its side port below the GE junction. The lung volumes are low. The cardiac and mediastinal contours appear unremarkable. The hila are normal appearing bilaterally. Despite low volumes, there is no evidence of pulmonary consolidation. No pleural effusion or pneumothorax is seen. IMPRESSION: No acute cardiopulmonary process. . [2193-5-22] CT abdomen and pelvis IMPRESSION: 1. No acute pathology within the abdomen and pelvis to explain patient's symptoms. 2. Bibasilar atelectasis. 3. 3 mm right lower lobe pulmonary nodule, in the absence of risk factors does not require further followup. . [2193-5-22] CT Neck IMPRESSION: 1. Small hematoma posterior to the right internal jugular central venous line entry site, as described above with overlying edema of the right sternocleidomastoid muscle. No evidence of active extravasation. 2. Multinodular thyroid with multiple punctate calcifications; thyroid ultrasound could be performed if clinically warranted, as also recommended on prior chest CT from [2192-9-3]. . [2193-5-23] Chest Xray IMPRESSION: Increased opacities in the lower lungs, compatible with atelectasis, although differential considerations include pneumonia, at least for some of this appearance. Follow-up radiographs may be helpful if clinically indicated. . [2193-5-31] Chest Xray CHEST: The tip of the PICC line lies in the region of the junction of the SVC and right atrium. Position of the other lines and tubes is unchanged. . [2193-6-6] Chest Xray IMPRESSION: 1. Low lung volumes with increased bibasilar atelectasis. No pneumonia. 2. Probable new small right pleural effusion. [6-18]: Chest Xray FINDINGS: In comparison with the study of [6-17], there is increasing opacification at the right base medially. In view of the clinical history, this is most consistent with developing pneumonia. An area of increased opacification at the left base could represent either atelectasis related to low lung volumes or another focus of consolidation. Tracheostomy tube and central catheter remain in place. Brief Hospital Course: Ms. [Known lastname 19784] is a 71 year old woman who is non-verbal at baseline secondary to multiple CVA??????s. She presented with UGI bleed, pneumonia, sepsis. Sepsis/pneumonia: On admission Ms. [Known lastname 19784] met criteria for sepsis. The source was thought to be pulmonary. She received an eight day course of vancomycin and Zosyn. She was covered for hospital acquired pneumonia given that she is from an [Hospital 4382] facility. In addition, it was felt that the location of the pneumonia was thought to be likely an aspiration event. She improved and advanced to trach collar. Three weeks into her hospital course, her respiratory status worsened, her blood pressure dropped and her sputum culture grew pseudomonas aerugenosa sensitive to meropenem, ceftazadine and cefepine. She was given meropenem (Day 1= [6-16]) for a total 14 day course to be finished: [2193-6-29]. Her respiratory status stabalized over the course of the next few days. C. diff: Ms. [Known lastname 19784] developed diarrhea during her hospitalization, and stool C. diff positive assay. She was placed on metronidazole (Day 1 = [6-3]) to be continued until 7 days after her last antiiotic course is finished. Estimated stop date is: [7-6]. Respiratory Failure: Ms. [Known lastname 19784] was intubated shortly after arrival in the emergency department. Despite treating her pneumonia, she continued to have difficulty weaning from the vent. A trachostomy was placed on [6-5]. She tolerated intermittent trach collar but ultimately needed to go back on the ventilator with the new developed of a pseudonomas pneumonia infection (Her lated vent settings were assist control CMV, Vt 500, RR 14, PEEP 5, FiO2 40%, satting 100%). GI Bleed: Ms. [Known lastname 19784] presented with guiac positive coffee ground emesis. A non-bleeding ulcer was found on endoscopy. She required a total of one unit of pRBC's. An H. pylori antibody test was positive. She completed 10 day course of amoxicillin/ and clarithromycin. She was continued on a PPI. CVA/Seizures: Ms. [Known lastname 19784] has a history of multiple CVA's which have left her non-verbal and non responsive at baseline. Her clopidogrel was held during the hospitalization given the acute bleeding episode. She was started on aspirin following her tracheostomy. She has a history of seizures. Her phenytoin dose was increased to 400mg daily (100mg in AM, 100mg in afternoon, 200mg in at 10pm) for therapeutic effect and goal serum phenytoin level. Throughout her hosptial course she would move her lips which the team ultimately thought was unlikely seizure activity. Her phenytoin level was carefully monitored and doses adjusted appropriately. Blood Pressure: Her home metoprolol and lisinopril were held on admission given the acute issues. Her lisinopril was gradually restarted and titrated back to her home dose. Her metoprolol should be restarted as her blood pressure allows. Volume Status: During the beginning of the hospitalization, she was given several fluid boluses. She was diuresed with furosemide. Ethics: During the majority of the hospitalization, the team was unable to reach Ms. [Known lastname ] husband [Name (NI) 31223] repeated attempts by multiple personnel. Multiple messages were left. He was eventually [Name (NI) 653], but would not come to the hospital to have a meeting or see Ms. [Known lastname 19784]. A guardianship was discussed, but the patient's HCP declined. Ethics and legal were involved. Her care was impacted because it was difficult to contact the husband for consent for procedures or transfer to another facility. Medications on Admission: glargine 10 units qhs novolog sliding scale glucerna 1.2 at 80 ml/hr cranberry caps, 2 daily multivitamin famotidine 20 mg lisinopril 30 mg plavix 75 mg lipitor 40 mg mapap 325 mg metoprolol phenytoin 100 mg q8 Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours): Continue until [7-6]. 3. Insulin Lispro 100 unit/mL Solution [Month/Year (2) ]: sliding scale units Subcutaneous four times a day. 4. Lisinopril 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable [Month/Year (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month/Year (2) ]: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Chlorhexidine Gluconate 0.12 % Mouthwash [Month/Year (2) ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 9. Meropenem 500 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 13 days: last day- [6-29]. 10. Phenytoin 125 mg/5 mL Suspension [Month/Year (2) ]: One Hundred (100) mg PO BID (2 times a day): give at 8am, 4pm. 11. Phenytoin 125 mg/5 mL Suspension [Month/Year (2) ]: Two Hundred (200) mg PO every twenty-four(24) hours: give at 10pm. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: Sepsis Pneumonia- pseudomonas GI Bleed Hypertension C. Difficile Infection Diabetes Mellitus Type II Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Non-verbal. Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital with bleeding from your stomach. You also developed a pneumonia which was likely from vomiting and then aspirating some of your stomach contents. We made the following changes to your medications: We STOPPED Plavix (clopidogrel). We STARTED aspirin- 81mg daily We STOPPED metoprolol. We STARTED metronidazole (Flagyl)- please take for 7 days after completion of meropenem course (last day- [7-6]) We STARTED meropenem (day 1- [6-16])- please take for 14 days (last day- [6-29]) We STARTED lansoprazole- 30mg daily We STARTED dilantin- 100mg PO/NG [Hospital1 ] (8am, 4pm), 200mg PO/NG in evening (10pm) Followup Instructions: You will be followed by the physicians at your rehab facility. Please follow-up with your primary care physician [Last Name (NamePattern4) ] [12-22] weeks after discharge from the rehabilitation center. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2193-6-19]	[ "438.89", "294.8", "041.7", "531.40", "V44.1", "401.9", "438.11", "038.9", "250.00", "518.81", "507.0", "008.45", "276.2", "041.86", "995.92", "996.74", "997.31", "345.90" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.91", "31.1", "96.04", "45.13", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	13946, 14017	8630, 12305	335, 409	14181, 14271	3144, 8607	15025, 15394	2672, 2691		12567, 13923		14038, 14038		12331, 12544			14295, 14551									2706, 3125																				14580, 15002				276, 297											437, 2158								14057, 14160									2180, 2520	2536, 2656
62,974	176,174	42840	Discharge summary	report	Admission Date: [2140-4-17] Discharge Date: [2140-4-22] Date of Birth: [2101-4-14] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 371] Chief Complaint: Trauma: fall: left temporal bone fracture left temporal SAH / SDH left aspiration pneumonitis Major Surgical or Invasive Procedure: None History of Present Illness: 39F intoxicated who presents after falling approximately [7-17] feet and striking the back of her head. Loss of consciousness was noted and EMS was called. When EMS arrived she had evidence of emesis. Pt was moving all extremities purposefully but was reported to have agonal breathing and was bradycardia with a GCS 7. She was thus intubated in the field and medflighted to [Hospital1 18]. On arrival her exam was notable for 2 mm pupils bilaterally which were non-reactive and disconjugate with intact gag and cough reflexes. CT head revealed left temporal bone fracture and left SAH. CT chest revealed left aspiration pneumonitis. Mannitol was administered and her exam was noted to improve markedly as sedation concomitantly wore off. Per Neurosurgical evaluation, no EVD or other acute surgical intervention was required. INJURIES: -left temporal bone fracture -left SAH -left aspiration pneumonitis Past Medical History: -Hx concussion in college Social History: unknown Family History: NC Physical Exam: PHYSICAL EXAM: upon admission: [2140-4-18] Gen: intubated, sedated HEENT: Pupils: PERRL EOMs unable to assess Neck: c-collar in place, Supple. Lungs: Diminished on left, CTA on right Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: sedated Orientation: unable to assess Language: intubated Physical examination upon discharge: [2140-4-22] Vital signs: t=97.6, hr=60, rr=18, oxygen saturation 100% General: Resting comfortably in bed, NAD CV: Ns1, s2, -s3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXT: + dp bil. no ankle edema bil., no calf tenderness NEURO: alert and oriented x 3, speech clear, no tremors, full EOM's, + hearing right > left, muscle st. upper ext. +5/+5 bil., lower ext. +5/+5 bil., tongue midline, no decreaseed sensation face, Pertinent Results: [2140-4-20] 05:30AM BLOOD WBC-8.8 RBC-3.34* Hgb-10.9* Hct-31.1* MCV-93 MCH-32.6* MCHC-35.0 RDW-12.4 Plt Ct-163 [2140-4-19] 12:46AM BLOOD WBC-15.4* RBC-3.64* Hgb-12.1 Hct-33.1* MCV-91 MCH-33.2* MCHC-36.5* RDW-12.6 Plt Ct-198 [2140-4-18] 01:43AM BLOOD WBC-14.8# RBC-3.89 Hgb-12.9 Hct-34.8* MCV-89 MCH-33.1* MCHC-37.0* RDW-12.2 Plt Ct-243 [2140-4-20] 05:30AM BLOOD Plt Ct-163 [2140-4-19] 12:46AM BLOOD Plt Ct-198 [2140-4-19] 12:46AM BLOOD PT-12.8* PTT-25.8 INR(PT)-1.2* [2140-4-20] 05:30AM BLOOD Glucose-95 UreaN-6 Creat-0.3* Na-140 K-3.7 Cl-104 HCO3-21* AnGap-19 [2140-4-19] 12:14PM BLOOD Glucose-122* UreaN-7 Creat-0.4 Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 [2140-4-19] 06:05AM BLOOD Na-140 K-3.8 Cl-107 [2140-4-19] 12:46AM BLOOD ALT-83* AST-85* AlkPhos-69 TotBili-1.0 [2140-4-18] 07:33AM BLOOD ALT-124* AST-192* AlkPhos-82 TotBili-0.7 [2140-4-18] 06:36AM BLOOD ALT-128* AST-208* AlkPhos-82 TotBili-0.6 [2140-4-17] 08:50PM BLOOD Lipase-64* [2140-4-18] 02:58PM BLOOD cTropnT-<0.01 [2140-4-20] 05:30AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.9 [2140-4-19] 12:14PM BLOOD Calcium-7.8* Phos-2.1* Mg-2.1 [2140-4-19] 12:14PM BLOOD Osmolal-285 [2140-4-18] 02:58PM BLOOD Phenyto-19.8 [2140-4-17] 08:50PM BLOOD ASA-NEG Ethanol-262* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2140-4-18] 02:07AM BLOOD Type-ART pO2-244* pCO2-33* pH-7.39 calTCO2-21 Base XS--3 [2140-4-17] 09:01PM BLOOD freeCa-0.87* [2140-4-17]: chest x-ray: IMPRESSION: 1. Diffuse left lung opacity likely reflecting a mixture of aspiration pneumonitis, asymmetric edema, and /or pneumonia. 2. ET tube terminating 7 cm above the carina. [2140-4-17]: head cat scan: IMPRESSION: Small left temporal subarachnoid hematoma and small left cerebral subdural hematoma. Generalized loss of cerebral sulcal markings raises the suspicion for mild cerebral edema. No signs of herniation. Non-displaced left temporal bone fracture. [2140-4-17]: cat scan of the abdomen: IMPRESSION: 1. Left lung consolidation is concerning for a combination of aspiration pneumonitis and associated edema, atelectasis. 2. Markedly distended urinary bladder. [2140-4-17]: cat scan of the c-spine: IMPRESSION: 1. No acute fracture or traumatic malalignment of the cervical spine. 2. Severe left apical lung consolidation, likely reflecting aspiration - better assessed on concurrent CT torso. [2140-4-18]: cat scan of the head: IMPRESSION: 1. New hyperdense blood products seen along the left tentorial leaflet, right vertex, right aspect of the falx, and within the left frontal lobe. 2. Slightly increased blood products neighboring the focal left temporal bone fracture. Small amount of subarachnoid blood in the interpeduncular cistern. 3. No new mass effect. [2140-4-18]: chest x-ray: Cardiomediastinal contours are normal. There are low lung volumes, increasing opacities in the lower lobes are partially due to increasing atelectasis. There is continuous improvement of left upper lobe opacities, now almost completely resolved. There is no pneumothorax or pleural effusion [2140-4-21]: CTA head: IMPRESSION: 1. Increase in left frontal and temporal lobe hemorrhagic contusions. Mass effect of subjacent sulci and left lateral ventricle but no midline shift. 2. No evidence of dissection on CTA of the head. [2140-4-21]: CT tempora bone (orbits, sinuses): There is a fracture in the squamous portion of the temporal bone extending into the air cells. There is no extension of the fracture into the carotid canal. There is fluid (blood) in the middle ear cavity but the ossicles without evidence of injury. There is also fluid in the mastoid air cells. Brief Hospital Course: 39 year old female who fell backwards, hitting head on concrete with + LOC. She was intubated in the field related to agonal breathing and bracycardia. Upon admission, she underwent a cat scan of the head which showed a left temporal bone fracture, left temporal sub-arachnoid and sub-dural hematoma. On arrival her exam was notable for 2 mm pupils bilaterally which were non-reactive and disconjugate with intact gag and cough reflexes. She was given mannitol and lasix and her neurological status slowly improved. She continued on hourly neuro exams. Neurosurgery was consulted and recommended neurological monitoring in the intensive care unit and continuation of mannitol. She was sedated with propofol and fentanyl and started on dilantin. Repeat head cat scan on HD # 2 demonstrated a small new contusion in the left frontal region as well as a small increase in the bleed with no midline shift. On chest x-ray she was found to have a left lung consolidation concerning for a combination of aspiration pneumonitis. On HD #2 she was extubated and started on clear liquids. Her c-spine showed no acute fracture or traumatic mal-alignment of the cervical spine and her cervical collar was removed. Chest x-ray shows an improvment in the left upper lobe opacities and she continued with pulmonary toilet. She was transferred to the surgical floor on HD #3. Her vital signs are stable and she is afebrile. Her hematocrit is 31. She has reported pain in left ear and a headache. Her pain medication has been changed to codeine. ENT was consulted on HD #5 regarding her left temporal bone fracture and to address her left ear pain. She underwent a cat scan of the head which showed an increase in the temporal lobe contusion. Neurosurgery was consulted and no intervention warrented. She also underwent a cat scan of the temporal bone fracture and was found to have no extension of the fracture into the carotid canal. Fluid (blood) in the middle ear cavity was reported but there was no evidence of injury to the ossicles. Fluid was also seen in the mastoid air cells. Her vital signs are stable and she has been afebrile. She was reporting a headache along with decreased hearing in the left ear. She was started on fioricet which seemed to decrease the headache and alleviate the nausea. She is slowly progressing to a regular diet. She has ambulated with the assistance of physical therapy who evaluated her and made recommendations for discharge with 24 hour supervision. Her family was able to provide her with this care. She was also seen by the social worker who has provided her and her family with additional support. She has an out-pt audiogram scheduled on [4-25] with Dr. [Last Name (STitle) 3878]. Medications on Admission: None Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 4. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 8H (Every 8 Hours) for 2 days: last dose 3/18. Disp:12 Tablet, Chewable(s) Refills:0 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:40 Tablet(s) Refills:0 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [2-8] Tablets PO Q6H (every 6 hours) as needed for headache: maximum 6 tablets daily. Disp:25 Tablet(s) Refills:0 8. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses. Discharge Disposition: Home Discharge Diagnosis: s/p fall: Injuries: 1. Left temporal bone fracture 2. Left subarachnoid hemorrhage 3. Left subdural hematoma 4. Left aspiration pneumonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after suffering a fall. You sustained an injury to your brain and a fracture in a bone in your skull. You are recovering well and are now being discharged home with the following 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 have been prescribed Dilantin (Phenytoin) for anti-seizure medicine. Take this medication as presribed for 4 more days until the prescription is complete. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: New onest of tremors or seizures. Any confusion, lethargy or changes in mental status. Any visual changes Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 33239] When: Wednesday [2140-4-27] at 1:45 PM Location: FAMILY MEDICAL ASSOCIATES Address: [State 92518], [Location (un) ],[Numeric Identifier 45899] Phone: [Telephone/Fax (1) 79431] Department: RADIOLOGY When: TUESDAY [2140-5-31] at 1:30 PM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: NEUROSURGERY When: TUESDAY [2140-5-31] at 2:15 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 9151], MD [Telephone/Fax (1) 1669] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2140-5-3] at 10:15 AM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853] in ACUTE CARE CLINIC Phone: [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2140-5-5] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage You have an appointment for an Audiogram on [2140-4-25] with Dr. [Last Name (STitle) 3878] at [Location (un) 92519],( the KINKO-[Company ] building) [Location (un) 55], Mass. Your appointment is scheduled for 11:15 am. Please arrive at 10:45am. The telepone number is #[Telephone/Fax (1) 2349]. Completed by:[2140-4-22]	[ "800.26", "305.00", "427.89", "389.9", "388.71", "780.09", "389.15", "507.0", "385.89", "E880.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	9846, 9852	6054, 8796	399, 406	10037, 10037	2302, 6031	11481, 13417	1441, 1445		8851, 9823		9873, 10016		8822, 8828			10188, 11458									1475, 1477																								263, 361										1847, 2283	434, 1351										1491, 1735	10052, 10164						1373, 1400	1416, 1425
11,638	155,878	15383	Discharge summary	report	Admission Date: [2180-1-12] Discharge Date: [2180-1-21] Date of Birth: [2108-5-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: total body overload Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo F w/ CAD, ischemic [Last Name (NamePattern1) 7921] (EF 10%) s/p [Hospital1 ]-V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU ([11-5]) for CHF exacerbation c/b C.diff infection and on [12-3] for septic joint washout c/b failure to extubate [1-18] CHF exacerbation, who is now being admitted from [Hospital 1902] clinic with total body fluid overload. . Ms. [Known lastname ] is a resident at NE [Hospital1 ] where she is convalescing from a polyarticular MRSA septic arthritis. She has NYHA IV CHF at baseline but over the last 4 days has developed 4+ LE edema and ascites where there was previously none. She was presented with the choice to pursue cardiac transplantation more than 12 years ago when given the diagnosis of end-stage CHF. She opted against that. . Per her recent visit note at [Hospital ] clinic, she continues to have L shoulder pain, though significantly improved from a few weks ago. She continues to work with PT to improve her ROM. She has no pain at her R 3rd MCP, though has difficulty extending her finger at that joint. She continues to have mild pain and significant weakness at her L hip, though improved since hospital discharge. She has had no F/C/NS, and no problems with her midline. She has had progression of a sacral decub, which gives her the majority of her pain. There has not been concern on the part of her rehab for superinfection, and it is being treated with local wound care and frequent turning. Her sister is hoping to transfer her to [Hospital1 599] within the next several days. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in [2164], Occluded RCA/no intervention -PACING/ICD: Ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD and atrial fibrillation 3. H/o PE secondary to DVT s/p IVC filter on Coumadin 4. PVD 5. Small VSD 6. Hypothyroidism 7. CKD 8. Osteoarthritis Social History: -Tobacco history: 20 pack year history, however she quit 30 yrs ago -ETOH: Denies -Illicit drugs: Denies Pt lives alone but currently resides at [Hospital 599] rehab. She is not married. She has many siblings and family members involved in her care. Her health care proxy is her niece [Name (NI) 698] [Name (NI) ] ____, who is a nurse. Family History: Mother had MI at age 50, maternal uncle died of MI in his 50's. No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: Temp 95.4 BP 82/53 (82-109/58-76) HR 70's RR 14 Sp02 100%RA GENERAL: Elderly female, Cachectic, NAD, Pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP to angle of jaw in recumbant position CARDIAC: Irreg/Reg, normal S1, S2. II/VI systolic murmur best at apex. PMI is laterally displaces LUNGS: CTAB, no wheezes, crackles or ronchi (anteriorly) ABDOMEN: Soft, NT, +ascites, +fluid wave EXTREMITIES: 3+ Pitting edema to thighs bilaterally, dopplerable pedal pulses, right MCP joint with healing incision site, hands tremble arrhythmically when held in air SKIN: At least Stage 3 Sacral decub Pertinent Results: CXR [2180-1-12]: IMPRESSION: 1. High lying right PICC line, terminating in the region of the right subclavian vein. Recommend repositioning or removal. 2. Persistent severe cardiomegaly. 3. Small left pleural effusion with overlying atelectasis. 4. Mild blunting of the right costophrenic angle, may be due to a trace effusion and/or thickening. CHEST (PORTABLE AP) Study Date of [2180-1-13] 7:49 AM AP UPRIGHT CHEST RADIOGRAPH: Marked cardiomegaly is stable. A right internal jugular catheter with its tip in the low SVC, a right-sided venous catheter with its tip in the subclavian vein and left-sided AICD with its leads overlying the right atrium and right ventricle are unchanged. Small bilateral effusions are stable. There is slight increase in vascular engorgement since [93] hours prior. There is no consolidation or pneumothorax. IMPRESSION: Mild increase in vascular engorgement, otherwise no change since [81] hours prior. [2180-1-12] 01:15PM BLOOD WBC-5.7 RBC-3.59* Hgb-11.5* Hct-36.0 MCV-100* MCH-32.0 MCHC-31.8 RDW-19.1* Plt Ct-195 [2180-1-12] 01:15PM BLOOD Neuts-86.1* Lymphs-11.0* Monos-2.2 Eos-0.3 Baso-0.4 [2180-1-12] 01:15PM BLOOD PT-16.3* PTT-29.5 INR(PT)-1.4* [2180-1-12] 01:15PM BLOOD Glucose-95 UreaN-46* Creat-1.3* Na-135 K-4.6 Cl-96 HCO3-24 AnGap-20 [2180-1-12] 01:15PM BLOOD CK(CPK)-22* [2180-1-12] 01:15PM BLOOD cTropnT-0.06* [2180-1-12] 01:15PM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3 [2180-1-13] 05:43AM BLOOD Vanco-18.7 [2180-1-12] 01:26PM BLOOD Lactate-1.7 K-4.5 Brief Hospital Course: 71 yo F w/ CAD, ischemic [Month/Day/Year 7921] (EF 10%) s/p [Hospital1 ]-V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU ([11-5]) for CHF exacerbation c/b C.diff infection and on [12-3] for septic joint washout c/b failure to extubate [1-18] CHF exacerbation, who was admitted from [Hospital 1902] clinic with total body fluid overload. . # Acute on Chronic Systolic Heart Failure: Patient has endstage systolic heart failure [1-18] ischemic [Last Name (LF) 7921], [First Name3 (LF) ] 10%, s/p BiV ICD ([Company 1543] Concerto C154DWK) [12-24] with EF 10%, presenting with significant fluid overload. She was diuresed 9L of fluid during her stay in the CCU with symptomatic improvement. Her blood pressure and forward cardiac flow were maintained initially with neosynephrine, then with a milrinone drip for two days. After a trial of stopping the milrinone drip, systolic blood pressures dropped from 90s to 70s, so milrinone was restarted for one more day. Milrinone was again stopped after the primary goal of care became comfort measures only. Patient had been made aware of her endstage condition by her primary cardiologist, Dr. [First Name (STitle) 437], during past hospitalizations; on presentation at this admission, her long term goals were comfort. Her ICD was turned off during her stay in the CCU. The primary CCU team and Dr. [First Name (STitle) 437] held a family meeting, at which the goals of care were made clear to be comfort measures only. Palliative Care was also consulted to help with the transition to comfort measures. After milrinone was discontinued the second time, patient's blood pressures were maintained in the 90s systolic. The patient should not be hospitalized further for congestive heart failure. Her anticoagulation was stopped, and she will remain on po antibiotics for her septic joints to prevent pain associated with worsening infection which would cause further pain. Her pain medications may be uptitrated as necessary. She is maintained currently on 20mg torsemide once daily. If she develops shortness of breath, she may be given morphine for comfort. . # Septic Joints: Patient with history +staph aureus in left shoulder treated by washout and vancomycin, 4 weeks of monotherapy by the time of this admission. She has had no positive blood cultures since before [2179-11-25]. Her pain was controled on ultram, standing tylenol, and long-acting morphine. On [2180-1-20], the vancomycin course finished, and she was switched to oral doxycycline for indefinite prophylaxis. . # Sacral Decubitus Ulcer: Patient has unstageable decubitus ulcer, which she had prior to admission. Her pain is being controlled with standing ultram, standing tylenol, MS Contin, and immediate release morphine. Her pain worsens significantly when moved. These pain medications may be uptitrated as necessary. . # Hx of CAD: Patient has right dominant system, hx of mild instent re-stenois of the LAD BM stent and occluded RCA. Patient's blood pressures could not tolerate beta blocker, and beta blocker was discontinued after she was made comfort measures only. . # Hx Atrial Fibrillation: Patient with h/o atrial fibrillation, s/p BiV ICD ([Company 1543] Concerto C154DWK) [12-24], on coumadin. Her amiodarone and metoprolol have been stopped, but she has been continued on her digoxin. Her coumadin has been stopped as well so that she will not have to get frequent blood draws to follow INR. . # Hx of DVT/PE: Patient has hx of DVT/PE and was on coumadin with [Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter in place. Her coumadin was stopped after she was made comfort measures only in order to prevent frequent INR draws. . # Hypothyroidism: Levothyroxine was discontinued after patient was made comfort measures only. . # Gout: Allopurinol was discontinued after patient was made comfort measures only. . # ACCESS: Patient had Right midline, Right IJ central line, and Left EJ during this hospitalization, which were removed prior to discharge. . # PROPHYLAXIS: on coumadin . # CODE: DNR/DNI, made Comfort Measures Only GOALS OF CARE: Patient should not be hospitalized further for heart failure. Her pain should be kept under control by uptitrating the morphine as needed. She is now on comfort measures. She will continue on the medications as listed. Medications on Admission: #. Aspirin 81 mg Tablet daily #. Allopurinol 100 mg daily #. Amiodarone 200 mg daily #. Levothyroxine 150 mcg daily #. Digoxin 62.5 mcg qOD #. Simvastatin 20 mg daily #. Nexium 40 mg daily #. Metoprolol SR 25 daily #. Warfarin 2 mg daily #. Torsemide 20 mg [Hospital1 ] #. Lasix 20mg daily #. Tylenol 975 mg q8 #. Ultram 50 mg QID # Vancomycin 500 mg q24 # MVI w/Minerals # Zinc 200mg Daily # Vitamin C 500 mg [Hospital1 ] Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO every 2 hours as needed for mild pain. 2. Morphine 10 mg/5 mL Solution Sig: Ten (10) mg PO every 2 hours as needed for moderate pain. 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for dry skin. 5. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 hours as needed for severe pain or respiratory distress: For terminal care, may give sublingual if needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever or pain. 8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for itching. 10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): to be given indefinitely. Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Systolic Heart Failure Secondary Diagnoses: Septic Arthritis Sacral Decubitus Ulcer Urinary Tract Infection Discharge Condition: Stable. Alert and oriented x3 Activity Status:Out of Bed with assistance to chair or wheelchair Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the hospital because you were fluid overloaded, having an exacerbation of your heart failure. You were given medicines to urinate out a significant amount of fluid which helped your breathing. You were also given more pain medications to help control the pain in your joints and from your pressure ulcer. You were found to have a urinary tract infection, for which you were also treated with antibiotics. After discussion with Dr. [First Name (STitle) 437], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and our Palliative care team, you have chosen to be treated with comfort measures only. You will continue on your torsemide and digoxin to help your heart work better but most of your other scheduled medicines have been discontinued. You will get morphine as needed for pain and trouble breathing and it was decided that you would not return to [Hospital1 18] for aggressive treatment of your heart disease. The following changes were made to your medications: 1. We have discontinued Allopurinol, amiodarone, aspirin, levothyroxine, Lisinopril, Metoprolol, omeprazole, simvastatin, tramadol and warfarin. 2. Vancomycin course was finished, you were started on doxycycline pills to prevent the MRSA from coming back. 3. We changed the oxycodone to morphine long and short acting. . Pt is DNR/DNI as per attending Dr. [First Name (STitle) 437] Followup Instructions: none	[ "414.01", "428.0", "428.23", "403.90", "711.01", "V45.82", "707.03", "V53.39", "V12.51", "244.9", "599.0", "414.8", "707.23", "274.9", "585.9", "427.31", "745.4" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11337, 11451	5214, 9690	343, 349	11640, 11781	3645, 5191	13301, 13309	2819, 2989		10172, 11314		11472, 11472		9716, 10149			11840, 13278									3004, 3626		11553, 11619	2117, 2435																					284, 305											377, 2023								11491, 11532			11795, 11816						2045, 2097	2451, 2803
83,349	108,420	9631	Discharge summary	report	Admission Date: [2165-8-25] Discharge Date: [2165-8-29] Date of Birth: [2083-11-24] Sex: F Service: MEDICINE Allergies: Penicillins / Xeloda Attending:[First Name3 (LF) 4057] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Left sided pleurex catheter placement with IP History of Present Illness: History of Present Illness: Mrs. [Known lastname ] is an 81F with hx of metastatic breast cancer and recurrent left malignant hydrothorax who presents with increasing dyspnea over a week. The pt states that she has had progressive dyspnea for the past week, walking around the house has become more difficult, and it has become even worse over the last 2 days prior to admission to the point that she is now dyspneic with speaking. Per her daughter, she came to visit this morning and was concerned about her SOB. She endorses minimal coughing, not productive of sputum. She denies chest pain, pressure, fever or chills. She denies lightheadedness, dizziness, throat swelling, pleuritic CP, new medications. She denies orthopnea but does use 2 pillows with sleep. Of note, the pt was diagnosed with malignant L pleural effusion in [5-4]. She's had three thoracenteses ([5-13], [8-1], [8-6]). Prior to these procedures she states she has felt similarly dyspneic. . On the floor, the pt was 96.6 126/67 81 RR33 100%2L. She continued to endorse dyspnea but denies any pain. Because of her tachypnea, she was transferred to the ICU where she underwent pleurex drain placement. The procedure was only complicated by mild hypotension with SBP 70s which improved to 130s with less than 1 liter of IVF, then she was hypertensive to 170s. On transfer to the floor, she felt her breathing was stable and very well. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: -metastatic breast cancer: first breast cancer at the age of 57 in [2140]; that was an ER positive breast cancer treated with lumpectomy and radiation at [Hospital1 107] [Doctor Last Name ]-Kettering Cancer Center. She only took tamoxifen for two years. Then in [4-/2160], she developed a left breast cancer, which was a triple negative breast cancer, 1.1 cm in size, grade 3 with six positive lymph nodes. She was treated with lumpectomy and radiation, but refused chemotherapy. . -L sided malignant pleural effusion: s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 576] x3. tapped and found to have malignant cells that were ER negative, adenocarcinoma consistent with her breast cancer. . -Hypothyroidism [2154] -Hyperlipidemia - [2154] -Depression per daughter - [2163] -Clavicle fxr - [2151] -Thoracic aneurysm (approx 5 cm) - [2159] -Hypertension - [2154] -Seasonal allergies - childhood -Melanoma on face: removed, never recurred - [2152] . PSH -R breast lumpectomy and node dissection - [2140] -L breast lumpectomy and node dissection - [2159] -Thoracentesis - [2165-5-13], [2165-8-1], [2165-8-6] Social History: Lives alone, widowed. Originally from Poland. Emigrated to [Location (un) 7349] in [2100] and lived there until 7 years ago when she moved to [Location (un) 86] to be closer to her 2 daughters who are very active in her care. Has 4 grandchildren. Occupation: retired bookkeeper Smoking history: never Alcohol: never Family History: breast cancer Physical Exam: Admission Exam: . Physical Exam: T 97.1 bp 120/80 HR 78 RR 22 SaO2 992L General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds in lower [11-26] left lung, normal effort, no wheezes Chest : L pleurex in place with dressings c/d/i, non-tender CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Skin: diffuse erythematous rash lesions, no excoriations Ext: no edema Neuro: no focal deficits Psych: pleasant, cooperative . Discharge Exam: . Physical Exam: 97.6, 106/56, 68, 20, 98% 2L NC General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: increased effort. Sound clear bilaterally. SOB with speaking Chest : L pleurex in place with dressings c/d/i, non-tender CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Skin: diffuse erythematous rash lesions, no excoriations Ext: no edema Neuro: no focal deficits Psych: pleasant, cooperative Pertinent Results: Admission Labs: [2165-8-25] 10:30PM TYPE-ART PO2-99 PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-1 [2165-8-25] 10:30PM LACTATE-2.3* NA+-125* K+-3.7 [2165-8-25] 10:30PM freeCa-1.14 [2165-8-25] 06:45PM URINE HOURS-RANDOM UREA N-240 CREAT-37 SODIUM-37 POTASSIUM-9 CHLORIDE-33 TOTAL CO2-LESS THAN [2165-8-25] 06:45PM URINE HOURS-RANDOM [2165-8-25] 06:45PM URINE OSMOLAL-201 [2165-8-25] 06:45PM URINE GR HOLD-HOLD [2165-8-25] 06:45PM PT-11.7 PTT-21.7* INR(PT)-1.0 [2165-8-25] 06:45PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.004 [2165-8-25] 06:45PM URINE BLOOD-TR NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [2165-8-25] 06:45PM URINE RBC-1 WBC-11* BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-<1 [2165-8-25] 06:45PM URINE CA OXAL-RARE [2165-8-25] 05:13PM K+-4.3 [2165-8-25] 05:05PM GLUCOSE-116* UREA N-13 CREAT-0.8 SODIUM-124* POTASSIUM-6.1* CHLORIDE-90* TOTAL CO2-22 ANION GAP-18 [2165-8-25] 05:05PM estGFR-Using this [2165-8-25] 05:05PM cTropnT-<0.01 [2165-8-25] 05:05PM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.9 [2165-8-25] 05:05PM OSMOLAL-260* [2165-8-25] 05:05PM TSH-8.2* [2165-8-25] 05:05PM FREE T4-1.3 [2165-8-25] 05:05PM WBC-5.4 RBC-3.88* HGB-11.7* HCT-35.1* MCV-90 MCH-30.2 MCHC-33.4 RDW-14.4 [2165-8-25] 05:05PM NEUTS-74.4* LYMPHS-16.4* MONOS-5.9 EOS-2.8 BASOS-0.4 [2165-8-25] 05:05PM PLT COUNT-359 . CXR [2165-8-25]: FINDINGS: Consistent with the given history, there has been interval development of bilateral pleural effusions left much larger than right. There is diffuse engorgement of the vascular pedicle and indistinctness of the cephalized vascular flow. Findings suggest superimposed volume overload in addition to the bilateral pleural effusions. The aorta remains markedly tortuous though incompletely evaluated given the large left effusion. Calcified plaque is seen at the arch. Cardiac silhouette size is difficult to assess but is presumed stable and remaining enlarged. Clips are present in both axillary regions. Deformities of multiple left posterolateral ribs are stable. IMPRESSION: Interval development of bilateral pleural effusions left much larger than right. There is superimposed pulmonary edema as well. . CXR [8-28] FINDINGS: In comparison with the study of [8-26], the left Pleurx catheter remains in place and there is no evidence of pneumothorax or recurrent effusions. Small right effusion persists. Continued prominence of indistinct pulmonary vessels, consistent with some elevation in pulmonary venous pressure. Enlargement of the cardiac silhouette with tortuosity of the aorta persists, as well as multiple surgical clips in the axillary regions bilaterally. . Discharge Labs: . [2165-8-29] 06:35AM BLOOD WBC-6.6 RBC-3.32* Hgb-10.5* Hct-31.1* MCV-94 MCH-31.7 MCHC-33.9 RDW-14.2 Plt Ct-265 [2165-8-25] 05:05PM BLOOD Neuts-74.4* Lymphs-16.4* Monos-5.9 Eos-2.8 Baso-0.4 [2165-8-29] 06:35AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-126* K-4.7 Cl-94* HCO3-25 AnGap-12 [2165-8-29] 06:35AM BLOOD ALT-5 AST-13 AlkPhos-55 TotBili-0.5 [2165-8-29] 06:35AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.7 [2165-8-28] 05:58PM URINE Osmolal-587 [2165-8-28] 05:58PM URINE Hours-RANDOM UreaN-633 Creat-214 Na-73 K-53 Cl-88 Brief Hospital Course: 81F with hx of metastatic breast cancer and recurrent left malignant hydrothorax who presented with increasing dyspnea over a week, found to have increased bilateral pleural effusions on the left. . # Dyspnea: Patient presented with dyspnea, tachypnea, and mild hypoxia consistent with increasing malignant hydrothorax. The patient had a pleurex catheter placed on [8-26]. We monitored her for signs of infection. The patient's symptoms improved; however, she remained SOB with ambulation throughout her stay. . # Hyponatremia: On admission, we found her initial Serum Na to be 125. We followed her urinary electrolytes along with her serum sodium. We deemed her results to indicate SIADH. We placed her on fluid restrictions, however, noticed that she was taking minimal fluids as is. We monitored her sodium and it remained stable around 125. . # UTI - The patient was found to have E Coli growing in her urine. She was treated with a course of ciprofloxacin. . Oncology - Breast cancer s/p lumpectomy and node dissection on each breast on 2 different occasions. The patient refused any chemotherapy. . # HTN: Patient stable on home medications. . # Hyperlipidemia: stable on home medications. . # Hypothyroid: Patient's TSH was found to be high. Her levothyroxin dose was increased. Medications on Admission: LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Capsule - 1 Capsule(s) by mouth Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: pre-medicate prior to draining pleurX catheter. 5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: PRIMARY: 1. recurrent left sided malignant hydrothorax 2. metastatic breast cancer Secondary: 1. Urinary Tract Infection 2. Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the hospital for dyspnea. You underwent pleurex catheter placement on the left side for your fluid accumulation around the lungs. MEDICATION CHANGES: - INCREASE levothyroxine to 112 mcg. - START oxycodone as needed for pain Followup Instructions: Provider: [Doctor Last Name 24141], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2165-8-30] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4285], [MD Number(3) 1240]:[Telephone/Fax (1) 22] Date/Time:[2165-9-4] 9:30 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2165-9-4] 9:30 Completed by:[2165-8-30]	[ "197.2", "272.4", "458.29", "V10.3", "244.9", "401.9", "511.81", "599.0", "041.49", "253.6" ]	icd9cm	[ [ [] ] ]	[ "34.04" ]	icd9pcs	[ [ [] ] ]	10898, 10992	8522, 9817	290, 338	11174, 11174	5139, 5139	11661, 12084	3786, 3801		10345, 10875		11013, 11153		9843, 10322			11357, 11542		7953, 8499							4518, 5120					4500, 4502																1815, 2214		11562, 11638	243, 252											394, 1796							5155, 7937				11189, 11333						2236, 3423	3439, 3770
48,464	149,197	1478	Discharge summary	report	Admission Date: [2115-9-16] Discharge Date: [2115-10-1] Date of Birth: [2041-4-12] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3227] Chief Complaint: [2041]0 ft. Major Surgical or Invasive Procedure: [2115-9-16] Intracranial Pressure Monitor [2115-9-25] Tracheostomy [2115-9-25] PEG placement [2115-9-25] IVC Filter History of Present Illness: 75-y.o. male fell 10 ft, struck head against concrete, unclear LOC, but was found awake and combative at scene. He was intubated in the ED. Past Medical History: hernia repair, appendectomy, hypercholesterolemia, HTN, CABG x 4 Social History: Lives with wife at home. No tobacco, occas ETOH, no drugs Family History: non-contributory Physical Exam: BP: 124/66 HR: 55 R 14 O2Sats 100% Intubated and sedated. HEENT: Blood noted from R ear, no clear fluid visualized. Pupils: 1mm and sluggishly reactive Neck: C collar in place Extrem: Warm and well-perfused. Neuro: Mental status: Intubated. Not following commands. Moving upper extremities spontaneously. Withdraws lower extremities to noxious. Face appears symetric. Large left peri-orbital echymosis and swelling noted. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. Toes downgoing bilaterally PHYSICAL EXAM UPON DISCHARGE: awakens to light stimulation alert to self pupils- 4mm reactive b/l tolerating PMV MAE's symetrically, antigravity following simple commands Pertinent Results: [2115-9-16] 01:00PM WBC-11.3* RBC-3.54* HGB-10.8* HCT-31.5* MCV-89 MCH-30.4 MCHC-34.2 RDW-14.7 [2115-9-16] 01:00PM PLT COUNT-152 [2115-9-16] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2115-9-16] 01:16PM GLUCOSE-135* LACTATE-3.1* NA+-136 K+-6.2* CL--103 TCO2-25 [2115-9-16] 05:27PM GLUCOSE-150* UREA N-14 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-9 [2115-9-16] CT head showed: 1. Subdural and subarachnoid hemorrhages. Parenchymal contusions. 2. Right petrous bone, right occipital bone, and left orbital roof fracture. 3. Left lamina papyracea appears distorted, age indeterminate. [2115-9-16] CT face showed preliminarily: Fracture of right petrous bone. Left orbital roof fracture. Bilateral extraconal hematoma with no definite evidence of fracture of right orbital roof. [2115-9-16] CT C-spine showed preliminarily: No acute fx. [2115-9-16] CT abdomen/pelvis showed preliminarily: No acute abdominal process. B/l basilar atelectases. [2115-9-17] CT Head: IMPRESSION: 1. Increased intraparenchymal air in the region of the previously seen right temporal hemorrhagic contusion, most likely due to extension from right temporal bone fracture. 2. Stable-appearing subarachnoid hemorrhage and subdural hematomas. 3. Stable appearance of the anterior temporal and left inferior frontal hemorrhagic contusions with associated mass effect and mild rightward midline shift which appears unchanged. 4. Stable appearance of the recently placed ICP bolt CT HEAD [2115-9-20] No significant change in the extensive bihemispheric subarachnoid, subdural, parenchymal, and intraventricular hemorrhage, as described above. Persistent rightward shift of the midline structures, stable. No new focus of hemorrhage identified. CT Head [9-22] Status post right frontal ICP bolt removal with little change in extensive intracranial hemorrhage and stable associated subfalcine herniation. No new hemorrhage identified. [9-26] LENI's No DVT [9-27] EEG: IMPRESSION: This in an abnormal extended routine EEG due to the presence of a discontinuous and unreactive background of mixed alpha and theta frequency observed throughout the recording. This pattern is most consistent with a moderate to severe diffuse encephalopathy most commonly seen with medication effect, metabolic disturbance, or infection. However, given the patient's clinical history, this pattern could also be consistent with diffuse axonal injury. Furthermore, the continuously attenuated activity over the entire left hemisphere is suggestive of a diffuse underlying structural lesion, most commonly a subdural collection. Finally, there is continuous frontally-predominant delta slowing observed over the right hemisphere with frequent right fronto-central sharp and slow wave activity. This pattern suggests an underlying structural defect, with a focus in the right fronto-central region, with high epileptogenic potential. There were no electrographic seizures seen. Brief Hospital Course: On [2115-9-16], the patient was admitted to the TSICU on acute care surgery. Multiple craniofacial fractures and intracranial injuries were found. Plastic surgery was consulted for the left orbital roof fracture, which did not require emergent or urgent operation. Neurosurgery was consulted for intracranial injuries and performed... On [2115-9-17], the patient was transferred to the neurosurgery service. His exam remained unchanged, and his BOLT remained in place with ICP readings in the teens. A repeat Head CT was stable. There were no acute events. On subsequent days, the patient was maintained on hyperosmolar therapy titrated to ICP readings. By [9-21], the ICPs began to normalize and the patient was weaned off the hyperosmolar therapy. On [9-22] the Bolt monitor was pulled, as his ICPs consistently remained in the low teens. The patient's exam remained unchanged. He developed thick secretions in the afternoon and morning of [9-23], and therefore a bronchoscopy was performed. A BAl was sent, and it was positive for Serretia bactiera. The patient was started on Levaquin for PNA. On [9-25], the patient went to the operating room for a tracheostomy, PEG tube, and IVC filter placement. He tolerated the procedure well, and was restarted on his SQ Heparin. On [9-26] he was on CPAP on the vent and was opening his eyes spontaneously. LENI's were obtained which showed no DVT and EEG leads were placed by neurology. On [9-27] attempts to wean him off the vent continued and he was on CPAP for the majority of the day. His exam was slightly improved as well as he was opening his eyes spontaneously and following simple commands. In the afternoon he successfully remained off the vent and continued overnight without complication. In subsequent days, He became brighter on exam however required bilateral upper extremity restraints as his mental status improved and he was agitated trying to get out of bed. Pt was seen by Speech and Swallow therapy, who trialed him on a passey muir valve. He tolerated this well without desaturation. His restraints were removed on the morning of [9-30] with plan for discharge to rehab on [10-1]. Pt remained stable overnight into [10-1] without agitation or need for restraints. He was again seen by the speech/swallow therapist who recommended advancing him to nectar thick liquids, pureed solids and ensure puddings. He continued to tolerate the PMV. He was cleared for discharge to rehab at this time. Medications on Admission: none known Discharge Medications: 1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for irritation. 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 3. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for hypertension. 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash/itch. 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Subarachnoid hemorrhage Left frontal Contusion Left frontal Subdural hematoma Fracute of right petrous bone. Left orbital roof fracture. Fracture right occipital and temporal bones Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, permission to take these will be discussed at your follow-up appointment ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ?????? Please call ([Telephone/Fax (1) 7767] to schedule an audiogram and follow up appointment with Dr. [First Name (STitle) ] from Otolaryngology. Follow up appointment should be 4-6 weeks from discharge. ?????? Please call [Telephone/Fax (1) 253] to make a follow up appointment at the eye clinic in [3-12] weeks. Completed by:[2115-10-1]	[ "E881.0", "V45.81", "801.21", "V49.87", "276.7", "518.0", "372.72", "801.11", "873.0", "300.00", "692.9", "518.5", "511.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "43.11", "38.91", "38.93", "01.10", "31.1", "38.7", "96.72", "96.6", "96.04", "33.23" ]	icd9pcs	[ [ [] ] ]	8714, 8797	4734, 7255	335, 469	9022, 9022	1645, 2719	10444, 11105	818, 836		7316, 8691		8818, 9001		7281, 7293			9199, 10421									851, 1077																								280, 297							1483, 1626				497, 639	1302, 1453		2728, 4711								9037, 9175						661, 727	743, 802
43,439	119,445	4435	Discharge summary	report	Admission Date: [2188-12-18] Discharge Date: [2188-12-20] Date of Birth: [2123-6-24] Sex: M Service: SURGERY Allergies: Clotrimazole / Augmentin / IV Dye, Iodine Containing Contrast Media Attending:[First Name3 (LF) 2836] Chief Complaint: abdominal wall abscess Major Surgical or Invasive Procedure: [2188-12-18]: I&D abscess cavity of abdominal wall. See Dr[Name (NI) 5067] operative report for further details. History of Present Illness: Mr. [Known lastname ] is a 65-year-old man with a complex past medical history and multiple abdominal operations, including fundoplication c/b splenic injury and splenectomy, ventral hernia repair complicated by chronic pancreatitis and intra-abdominal abscesses, cutaneous fistulas, VRE bacteremia ([5-17]), with history of intra-abdominal MRSA abscesses currently being treated with vancomycin. He also has a chronically draining biliary fistula from a prior right subcostal drain insertion site, followed by Dr. [Last Name (STitle) 468]. He presented [2188-12-18] with an enlarging mass over the inferior aspect of his prior midline abdominal incision for the past 2-3 weeks. He has noticed increasing erythema over the overlying skin, and it has become painful and has increased in size over the last 2 days. He denies fever, chills, nausea, vomiting, changes in appetite, diarrhea, constipation, hematochezia, melena. He last had a bowel movement earlier this afternoon which was unremarkable. He thinks he has passed flatus that afternoon but is uncertain. Past Medical History: 1. Multiple polymicrobial fluid collections, status post multiple drain procedures over the past several years. Most recently MRSA in new L flank abscess in [2188-6-6], past h/o psoas abscess, retroperitoneal abscess, enterocutaneous fistula. 2. Ventral hernia repair complicated by severe pancreatitis, leading to a nearly yearlong hospitalization starting [2185-4-7] at [Hospital6 10353] and at the [Hospital1 2177] to rehabilitation ending [2186-1-8]. 3. Pancreatic mass per GI notes. Endoscopic ultrasound performed twice, most recently [2187-1-8] showing 2 x 3 cm ill-defined mass to the pancreas. FNA was performed. No malignancy was found. 4. CAD status post MI [2185] 5. Diverticulosis. 6. Anxiety. 7. Hypothyroidism. 8. Hypertension. 9. Lower extremity DVT status post IVC filter ([2185] or [2186]) 10. Portal vein thrombosis. 11. Status post fundoplication 16 plus years ago complicated by splenic injury requiring splenectomy. 12. BPH. 13. Vitamin D deficiency. 14. Abnormal LFTs intermittently, most recently thought due to Augmentin. 15. Gynecomastia. 16. Cirrhosis - dx in [2186] Social History: Lives in [Location (un) 7913] with [Doctor First Name 1258] his wife. [Name (NI) ] is unemployed. - Tobacco: smoked <1 PPD for 1 year in the past - Alcohol: denies - Illicits: denies Family History: Denies any known family history. Physical Exam: On Admission: Vitals: 99.2 110/76 80 17 99%RA Gen: A&Ox3, some agitation on physical exam HEENT: anicteric sclera, dry mucous membranes CV: RRR, S1/S2 nl, no MRG Lungs: CTAB Abd: Distended. Tympanic. 10x10 cm mass protruding from inferior aspect of prior midline surgical scar, inferior and lateral to umbilicus, which is very tender to palpation, and non-reducible [1-8] tenderness. Extensive erythema overlying mass, with no induration. No rebound tenderness, no guarding, extensive collateral veins visible. Fistula on right flank draining bilious fluid Rectal: No masses. No stool in vault. Guaiac postive on exam. Ext: Warm, well perfused Pertinent Results: [2188-12-20] 12:04AM [Month/Day/Year 3143] WBC-9.1 RBC-3.33* Hgb-9.4# Hct-29.5 MCV-89 MCH-28.3 MCHC-32.0 RDW-15.2 Plt Ct-553* [2188-12-20] 12:04AM [Month/Day/Year 3143] PT-15.3* PTT-33.4 INR(PT)-1.4* [2188-12-20] 12:04AM [Month/Day/Year 3143] Glucose-84 UreaN-13 Creat-0.7 Na-141 K-3.8 Cl-114* HCO3-21* AnGap-10 [2188-12-18] 06:15PM [Year/Month/Day 3143] ALT-17 AST-32 AlkPhos-336* TotBili-0.6 [2188-12-20] 12:04AM [Month/Day/Year 3143] Calcium-7.5* Phos-3.4 Mg-1.6 Brief Hospital Course: Mr. [Known lastname ] was admitted to the Surgical Service for operative treatment of his abdominal wall abscess. On [2188-12-18], he underwent operative incision and drainage of the abscess. Please see Dr[Name (NI) 5067] operative note for further details. From the OR he was taken to the floor, on broad spectrum antibiotics, IV fluids, with a foley catheter. He was hemodynamically stable initially then had an episode of hypotension and altered mental status on POD 1 so was transferred to the ICU. On his second day in the ICU, he was seen by his PCP Dr [Last Name (STitle) ] who discussed at length with the patient and his health care proxy about return to [Name (NI) ] House for hospice care. He was deemed appropriate for this transition of care so was discharged directly from the ICU to [Name (NI) ] House the evening of hospital day 3. CV: He remained persistently mildly hypotensive (SBP mid-80's) throughout his stay; vital signs were routinely monitored. PULM: He remained stable from a pulmonary standpoint; vital signs were routinely monitored. He was on 2L NC oxygent at time of discharge GI/GU/FEN: Post-operatively, he was made NPO with IV fluids. Diet was advanced POD 2 to regular, though he showed litte interest in eating meals Wound: He has an open abdominal wound at the site of the abscess that was being packed with wet to dry gauze twice daily. The first few dressings showed dark green/brown fluid which had improved to serosanguinous drainage by discharge. Prophylaxis: He received subcutaneous heparin and venodyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, he was doing well, afebrile with stable vital signs. He was tolerating a regular diet and pain was well controlled. He received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Nepro 240ml PO daily at lunchtime; Vancomycin 1g IV q36hrs; aspirin 81mg PO qday; Furosemide 10mg PO qday; Multivitamin PO qday; Pantoprazole 40mg PO qday; Nephro caps 1 tab PO qday; Zinc sulfate 220mg PO qday; Omeprazole 20mg PO qday; Levothyroxine 125mcg PO qday; Sevelamer 1600mg PO TID with meals; Pancrelipase 24,000units PO TID with meals; Oxycodone 10mg PO q8hrs; Colace 100mg PO BID; Magnesium oxide 400mg PO q12hrs; Dilaudid 2mg PO q4hrs PRN pain; Quetiapine 25mg PO BID; Mirtazapine 15mg PO qhs; Ciprofloxacin 500mg PO BID Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. Discharge Disposition: Extended Care Facility: [Name (NI) ] house Discharge Diagnosis: abdominal wall abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged back to The [Name (NI) ] House. Please refer to your primary provider: [Name10 (NameIs) ] [Last Name (STitle) ] [Name (STitle) ], MD for medical concerns. Regarding your recent surgery, please notify your care provider if you experience: New chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. Vomiting and cannot keep down fluids or your medications. Dehydration due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. [Name (STitle) ] or dark/black material when you vomit or have a bowel movement. Burning when you urinate, [Name (STitle) ] in your urine, or urinary discharge. Your pain doesn't improve in [7-19] hours or is not gone within 24 hours. Call or return immediately if your pain becomes severe, changes location or moves to your chest or back. Shaking chills or fever greater than 101.5F or 38C. An acute change in your symptoms, or new symptoms that concern you. Increased pain, swelling, redness, or drainage from any incisions you may have. Any of the warning signs listed below. Followup Instructions: You do not need to follow up with Dr [First Name (STitle) ], your surgeon at [Hospital1 18]. If you do wish to schedule a follow-up visit, you may contact her office at ([Telephone/Fax (1) 8105*].	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74,549	146,565	41368	Discharge summary	report	Admission Date: [2106-2-21] Discharge Date: [2106-2-25] Date of Birth: [2034-8-28] Sex: M Service: MEDICINE Allergies: Vicodin / Shellfish Attending:[First Name3 (LF) 613] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname ] is a 71yo male who fell ~20 feet to ground on [2106-1-18] while shoveling snow off a roof, likely sustained single rib fx and L1 fx at time, and had been doing well until 3 days ago when he developed SOB with exertion. About one month ago, pt fell ~20 ft when the ladder he was standing on collapsed around him. Reports hitting his head at time, with + LOC. Also reports ladder folding around his abdomen. At OSH, had CT head and C-spine without contrast, which showed no acute intracranial process and no acute fracture or dislocation of cervical spine. Had been doing well since that time, with intermittent abdominal pain but no back pain. Then about 3 days PTA, began to develop dyspnea on exertion. Presented to PCP, [Name10 (NameIs) 1023] referred patient for CT abd/pelvis given concern that patient may have sustained further injury during recent fall. Report notes L1 vertebral fx of indeterminate age, though new since 6/[2104]. Patient also noted to have patchy opacity R lung, c/w possible PNA. Started on azithromycin for planned 5 day course. Over the next two days, developed progressively worsening dyspnea to the point where he could not walk. Wife brought him to ED at OSH for further evaluation. Denies any CP during this time. . At [Hospital6 19155] ED, was tachycardic to 120s, tachypneic in 30s, and hypoxic to 60s on room air. Sat came up to 98% on NRB. ABG on 12L O2 NRB (FiO2 100%): 7.43/39/82/25.9. WBC 14.5. Had CTA chest which revealed bilateral segmental and subsegmental PEs, as well as bilateral lower lobe infarction. Received heparin bolus, and was started on heparin gtt (guiac neg). Transferred to [Hospital1 18] for possible lysis. . On arrival to [Hospital1 18], patient satting well on NRB. VS: 96.3 120 123/73 34 98% on NRB (10L O2). Per report lungs clear on exam, abdomen benign, and lower extremities w/o edema. PTT therapeutic at 63. Had bedside echo which showed RV dilitation, intraventricular septal bowing. Given patient hemodynamically stable, he did not receive lysis. Just prior to transfer to MICU, VS: 111, 116/69 22 97% on 8L NRB. . On arrival to MICU, patient satting in high 90s on NRB, and quickly weaned to 6L NC with sat maintained in mid-high 90s. Patient still tachy to 120s. Reports significant improvement in SOB with supplemental O2. Denies any CP at present, though does have discomfort when coughing. Intermittent dry cough; no hemoptysis. . ROS: Positive as per HPI. Also notable for ~10 pound weight loss over past month, decreased appetite. Had colonoscopy ~1 year ago with single polyp removed per patient's report. Felt warm/diaphoretic last night. Chronic constipation. Denies any HA, dizziness, chest pain, palpitations, abdominal pain, N/V/D, blood in stool, dysuria, myalgias, arthralgias, easy bruising, bleeding, or rashes. Past Medical History: HTN Hand tremor HLD s/p hernia repair s/p knee surgery Social History: Married, lives with wife. [Name (NI) ] 5 children. Denies any tobacco or illicit drug use. Rare EtOH, about one drink every 3 months. Family History: Mother may have had history of blood clot. No family history of bleeding disorders. Physical Exam: ADMISSION EXAM: VS: 96.7 114 121/70 28 95% 6L NC GEN: awake, alert, oriented, essential tremor of head and left hand, able to speak in full sentences, NAD HEENT: PERRL, EOMI, sclera anicteric, MMM, OP clear NECK: supple, prominent neck veins with JVD to just below earlobe CV: tachycardic, regular, normal S1 S2, S4 heard over RV, no rubs or murmurs LUNGS: occasional rales at left base, otherwise CTAB, no wheezes ABD: bowel sounds present, soft, NT, ND, no organomegaly, no guarding or rebound tenderness EXT: warm, radial pulses 2+ bilaterally, DP/PT pulses 1+ bilaterally, no lower extremity edema NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 in all four extremities proximally and distally PSYCH: calm, appropriate SKIN: no rashes or lesions noted . Discharge exam: Vitals: T: 99/96.6 BP: 115-149/68-88 P: 76-93 R: 18 O2: 97% on 2L General: Alert, oriented, no acute distress; tremor of head and upper arms. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Mild crackles at bases bilaterally; moving air well at apices. CV: S1, S2, likely S4. no murmurs auscultated Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no calf tenderness or swelling, [Last Name (un) 5813] sign negative. Neuro: CNs [2-20] grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [2106-2-21] 08:00PM BLOOD WBC-12.4* RBC-4.54* Hgb-14.3 Hct-41.5 MCV-92 MCH-31.6 MCHC-34.6 RDW-12.6 Plt Ct-341 [2106-2-21] 08:00PM BLOOD Neuts-86.3* Lymphs-10.0* Monos-3.2 Eos-0.3 Baso-0.2 [2106-2-21] 08:00PM BLOOD PT-14.7* PTT-63.2* INR(PT)-1.3* [2106-2-21] 08:00PM BLOOD Glucose-136* UreaN-27* Creat-1.1 Na-137 K-5.2* Cl-100 HCO3-24 AnGap-18 [2106-2-21] 08:00PM BLOOD proBNP-7355* [2106-2-21] 08:00PM BLOOD cTropnT-0.19* [2106-2-21] 08:04PM BLOOD Glucose-128* K-5.2 Discharge labs: [2106-2-25] 06:30AM BLOOD WBC-6.7 RBC-3.92* Hgb-12.0* Hct-35.6* MCV-91 MCH-30.6 MCHC-33.6 RDW-12.7 Plt Ct-303 [2106-2-25] 06:30AM BLOOD PT-25.8* PTT-127.3* INR(PT)-2.5* [2106-2-25] 06:30AM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-142 K-3.9 Cl-107 HCO3-25 AnGap-14 [2106-2-25] 06:30AM BLOOD CK(CPK)-48 [2106-2-25] 06:30AM BLOOD CK-MB-3 cTropnT-0.01 [2106-2-25] 06:30AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 . IMAGING: TTE [2106-2-22]: IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Mitral valve prolapse with moderate mitral regurgitation. Dilated ascending aorta. . LENIs [2106-2-22]: IMPRESSION: Deep vein thrombosis seen in two of the calf veins of the right leg (one posterior tibial vein and one peroneal vein). A nonocclusive thrombus is seen in the right popliteal vein. No DVT seen in the left leg. . CT Head w/o Contrast [2106-1-18] ([Hospital6 19155]): No acute intracranial process. Soft tissue swelling over high right parietal convexity. . CT C-Spine w/o Contrast [2106-1-18] ([Hospital6 19155]): Multilevel degenerative changes, most prominent at levels of C4-C5 and C5-C6. . CT ABD/PELVIS [2106-2-19] ([Hospital6 19155]): Compression deformity involving L1 superior endplate; which is new compared to [2105-6-5], but remains age indeterminate. The frature line extends into the right pedicle, but not the right pedicle. There is no retropulsion of bone fragments into the spinal canal. There is approximately 20% vertebral body height loss. Further eval with MRI recommended. Patchy opacifications at right lung, c/w PNA. Small fluid density left pleural effusion, with compressive atalecatsis. No acute intraabdominal pathology. . CTA CHEST (OSH) [2106-2-21]: bilateral large pulmonary emboli . Brief Hospital Course: 71yo male s/p fall ~1 month ago at which time he likely sustained rib fracture and L1 fracture, with progressively worsening dyspnea on extertion over past several days, bilateral PEs noted on CTA chest at OSH, and evidence of RV strain, who is transferred to [Hospital1 18] MICU for further management and possible lysis. . #. Bilateral Submassive PEs: Patient presented with dyspnea, tachycardia, tachypnea, hypoxemia, CTA chest findings of bilateral PEs, and evidence of RV strain. Given RV strain, elevated trop of 0.19, and elevated BNP of 7355, patient at overall increased mortality risk. Was hemodynamically stable on arrival to ICU; there were no indications for urgent/emergent thrombolysis. PTT was therapeutic on heparin gtt, and dyspnea had significantly improved with supplemental oxygen. Etiology of PEs unclear, though may be related to recent trauma. Approximate 10 pound weight loss concerning for possible underlying malignancy, which could also explain hypercoaguable state. Patient continued on heparin gtt, and monitored on telemetry overnight. Given concern for hypovolemia given LV underfilling on bedside echo, patient challeneged with 500cc bolus NS x2, with subsequent improvement in HR from 120s to 90s. BP remained stable. The following day, patient had TTE which demonstrated right ventricular cavity enlargement with free wall hypokinesis. Also had bilateral LENIs which revealed DVT in two of the calf veins of the right leg (one posterior tibial vein and one peroneal vein), as well as a nonocclusive thrombus in the right popliteal vein. Patient started on warfarin for long-term anticoagulation. Given hemodynamic stability, was transferred to medicine floor. . On the medicine floor, he remained hemodynamically stable and was put on Coumadin. His heparin gtt was stopped the day of discharge. He was discharged with a therapeutic INR of 2.5 on Warfarin 2.5mg daily. He was satting well on 3L NC on discharge. . #. Hypertension: Normotensive on arrival. His metoprolol was held this admission and he remained normotensive. This can be restarted if clinically indicated as an outpatient. . #. HLD: Continued home regimen simvastatin 40mg QHS. . #. Tremor: Held primidone as patient was not using. . TRANSITIONAL CARE ISSUES: -was full code during this admission -will need INR checks by his PCP on discharge from rehab Medications on Admission: Simvastatin 40mg QHS Metoprolol tartrate 25mg PO daily Primidone (Mysoline) 150mg PO BID Vitamin A 1000 units PO daily Azithromycin 250mg PO daily (started [2-19], did not take dose [2-21]) Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. primidone 50 mg Tablet Sig: Three (3) Tablet PO twice a day. 3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57850] Healthcare Center - [Location (un) ] Discharge Diagnosis: Pulmonary emboli Deep vein thrombosis of right leg Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], . It was a pleasure participating in your care at [Hospital1 771]. . You were admitted to [Hospital1 ] because you had pulmonary emboli, which are blood clots in your lungs. Your pulmonary emboli made it difficult for you to breathe and increased the work that your heart does. Surgery to remove the clots were considered, but it was decided instead to treat you medically with medications that can help prevent further clots from forming. Ultrasound of your leg showed that veins in your right leg still had some clots. These leg clots may have been the source of your pulmonary emboli. Again, the blood thinner you have been started on will help to prevent further such clots from forming. . You will go to a rehabilitation center to get stronger and decrease your reliance on oxygen. When you are ready to go home, you will need to get in touch with your Primary Care Physician. [Name10 (NameIs) ] will need regular checks of your blood to make sure the blood thinner, warfarin, is at the correct dose. START warfarin. STOP metoprolol. Continue primodone if you want. You mentioned that it did not seem to help you, so you did not receive it while in the hospital. Followup Instructions: Please follow up with your primary care physician following your stay at rehabilitation. You will need close follow-up and monitoring of your anticoagulation (blood thinning) medications and its levels in your blood. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "415.19", "V58.61", "401.9", "785.0", "805.4", "453.42", "807.01", "276.52", "783.21", "272.4", "E929.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10155, 10293	7315, 9568	287, 295	10388, 10388	4915, 4915	11771, 12112	3450, 3535		9937, 10132		10314, 10367		9715, 9914			10539, 11748		5443, 7292							3550, 4311					4327, 4896																			240, 249			9594, 9689								323, 3200							4931, 5427				10403, 10515						3222, 3278	3294, 3434
12,837	141,301	15296	Discharge summary	report	Admission Date: [2123-4-5] Discharge Date: [2123-4-19] Date of Birth: [2067-1-6] Sex: F Service: MEDICINE Allergies: Tape / Provera / Antibiotic / Verapamil / Heparin Agents Attending:[First Name3 (LF) 2145] Chief Complaint: admitted for charcot joint reconstruction Major Surgical or Invasive Procedure: surgical reconstruction/repair of charcot joint History of Present Illness: 56yo F with a hx of unclear bleeding diathesis, as well as diastolic CHF and DM complicated by charcot foot deformity was admitted on [2123-4-5] and underwent reconstruction of L charcot foot on [2123-4-10]. The delay between the time of admission and OR was secondary to swelling of the LLE believed to be secondary to her Charcot deformity. She was intubated for the OR on [4-10] for a total of 5 hours. At the recommendation of the heme/onc service, the pt was given ddAVP 30mcg/kg IV prior to OR for her bleeding diathesis. During the op, the pt was given 2units PRBCs and 3 liters of LR with a significant amount of blood loss intraoperatively per the podiatry resident est. 750 cc + and urine output of 400cc/5 hours intra-operatively (for net of positive of over 3.5 liters positive). Post op, the patient complained of left sided upper anterior chest pain without radiation which was reproducible with palpation and felt to be secondary to a device placed in the exact location of her pain used to prop her during the procedure. She was given morphine with relief of pain. At the time, her HR was 70, BP: 160/60, SaO2: 100% (but unclear amount of supplemental oxygen, RN nursing notes her SaO2 to be 98% on 3L at time of acceptance from PACU). Her CV exam was RRR, S1, S2, no m/r/g and lung exam was CTA bilaterally. No JVP or LE edema was mentioned on exam. Subsequently the pt was given lasix 40mg IV x1 over night for her positive fluid status. A CXR was obtained at that time which confirmed pulmonary edema on [2123-4-10]. Past Medical History: 1. CHF (Diastolic pMIBI [3-20] Mild [Last Name (LF) ], [First Name3 (LF) ]=57%) 2. Aortic Valve Insufficiency 3. Bleeding diathesis with neg prior workup which has previously responded to ddAVP. Pt is followed by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] of Heme/Onc 4. OSA on bipap at home 5. Insulin Dependent DM complicated by Charcot foot and peripheral neuropathy. 6. PVD with multiple foot ulcers 7. Hashimoto's Thyroiditis 8. Asthma 9. Anemia 10. IBS 11. Hepatitis C 12. MRSA in past 13. Cataracts 14. Macular degeneration 15. Osteoarthritis 16. Bladder spasms 17. Stress urinary incontinence 18. Fibromyalgia 19. Anxiety 20. Major Depression 21. s/p tonsilletcomy and adenoidectomy 22. s/p c-section with significant post partum bleeding 23. s/p bladder suspension complicated by post op bleeding 24. s/p hernia repair Social History: Married. Lives with husband. Daughter is HCP. Family History: Non-contributory. Physical Exam: Tc=101.8 P= 86 BP=108/48 RR=20 88-100% on nasal BIPAP . GEN: Initially, mild-moderate respiratory distress with accessory SCM use bilaterally, AOX2 (thought she was at [Hospital 107] Hospital in [Hospital1 1559], MA) HEENT: 12 cm JVP, nasal BIPAP, PERRLA CV: RRR, S1, S2 Chest: Bilateral diffuse rhonchi with mild expiratory wheezes Abd: NT, ND +BS Ext: LLE in tight ACE wrap s/p left charcot reconstruction Pertinent Results: Foot and ankle films [4-5]: Extensive neuropathic changes with paraspinous of the foot and extensive soft tissue swelling. . ECG [2123-4-6]: NSR at 70, left [Hospital1 ] axis, Q in III, no ST changes, TW flatteningn in L, TWI in V2 to v3, poor R wave progression. . CT lower extrem [4-6]: Extensive Charcot changes throughout the left hindfoot, with rocker- bottom deformity, without significant change from the radiograph dated [2123-2-25], and [2123-4-5]. . Left LENI [4-6]: No evidence of DVT within the left lower extremity from the popliteal vein through the common femoral vein. . [4-10] CXR: Lung volumes are lower today and borderline pulmonary edema is new. Moderate cardiomegaly is stable. What is most noteworthy is interval widening of the mediastinum, particularly in the right lower paratracheal region. Since there is no contralateral tracheal shift to suggest the mass effect generally seen from hematoma. I suspect this is due to vascular overload alone. I suggest careful followup following diuresis to exclude conditions such as aortic dissection and if central venous line was placed or attempted in the interim, mediastinal hematoma. The esophagus is distended with air above the level of the carina and could be the cause of pain. . ECG [2123-4-10]: NSR at 80, leftward axis, Q in III, no ST changes, TW flattening in III, TWI in V2 to v4, poor R wave progression. . [4-11] CXR: Lung volumes remain low, but pulmonary vascular congestion has improved since [4-10]. Mediastinal veins remain dilated. The heart is moderately enlarged. There is no appreciable pleural effusion or indication of pneumothorax. . [4-12] Foot and ankle films: Limited secondary to overlying cast. The patient is status post subtalar and first ray fusion as described above. . [4-17] CXR: Upper lungs are clear. Mild cardiomegaly is stable. Consolidation at the left lung base has worsened since [4-10], stable since [4-12], and less pronounced opacification at the right lung base has worsened since [4-12]. Findings are consistent with atelectasis but pneumonia cannot be excluded. There is no pleural effusion or pneumothorax. . [4-18] CXR: 1. Slight interval improvement in left lower lobe consolidation. 2. Improvement in opacity at the right lung base which may partly be due to differences in patient rotation. Brief Hospital Course: The patient was initially admitted to the Podiatry service: PODIATRY COURSE POD #1, the pt was found to have a low grade temp of 100.4 with HR: 76, BP: 112/60 and RR: 20 with SaO2: 97% on 3L. Her lung exam was significant for crackles at bases bilaterally. Her ins/outs were as follows: IVF: 380 and PO: 240 for total of: 630 and Outs: 1350. She was given another dose of ddAVP 30mg IV x1 as well as lasix 60mg IV x1. During the course of the day, she did not diurese appropriately, and continued to have crackles at her bases bilaterally resulting in another dose of lasix 120mg IV x1 at noon. On [2123-4-11], despite diuresis with lasix, her urine output remained low at 40 cc/hr. Her creatinine rose from 0.9 to 1.2. As this did not result in much improvement a med consult was called for evaluation for diuresis. Medical consult recommended transfer to medicine on [4-11] but at the time of evaluation, she was felt to be in respiratory distress. The MICU was called for further evaluation. An ABG and stat CXR were obtained at that time around 4 pm. Initial ABG on BIPAP with O2 sats of 94% was: 7.43/46/32/53 on BIPAP, sat 94%. Repeat ABG [11-16] an hour later on the same settings of BIPAP was as follows: 7.45/42/30/68, lactate 1.1 CXR on [2123-4-11] was consistent with pulmonary edema. MICU COURSE The patient was then transferred to the MICU for further evaluation. Her O2 sats dropped to 88% and her nasal BIPAP was tightened and readjusted. An ABG with O2 sats of 88% was improved at: 7.53/33/198/28/198 Her O2 sat rose with adjustment of her BIPAP to 100%. The patient was given 5 mg metolaxone and 60 mg IV lasix in the MICU and put out 190 cc of urine. She diuresed well overnight and was 1.5 L negative during her 18 hours in the MICU. In the morning her hematocrit had continued to slowly trend down to 24, and she received 1 U PRBC followed by lasix and metolazone. She was called out to the floor the morning after arrival in the MICU. FLOOR COURSE ... On the floor, the patient was diuresed with further improvement in her oxygenation. Once she was at her baseline in terms of pulmonary status, her home regimen of PO lasix was restarted. Her blood pressure was well-controlled. Following her transfusion of PRBC in the MICU, her hematocrit remained stable and began to improve. Vancomycin and unasyn were continued post-op and discontinued on discharge. The podiatry service continued to follow the patient, and they discontinued her JP drain and placed a bivalve cast prior to discharge. She will follow up with podiatry 2 weeks after discharge. The patient will continue to be followed by [Date Range 1978] as an outpatient, and the need for ddAVP should be discussed carefully in the future given that the patient developed volume load and CHF after receiving ddAVP peri-op on this admission. Medications on Admission: 1. Atenolol 50mg QPM 2. Diovan 80mg QAM 3. Lasix 100mg [Hospital1 ] 4. Lantus 80unts QPM with HISS 5. Levoxyl 0.175mcg QAM 6. ddAVP NS PRN 7. Singulair 10mg QAM 8. Combivent IH PRN 9. Ciproflaxacin 500mg [Hospital1 ] ([2123-3-29] -) 10. Clindamycin 300mg TID ([2123-3-29] - ) 11. Ditropan XL 10mg QAM 12. Effexor 150mg QAM 13. Flexeril 10mg TID/PRN 14. Amitriptyline 150mg QHS 15. Neurontin 600mg [Hospital1 ] 16. Nexium 40mg QAM 17. Niferex capsule 1-2 times daily 18. Potassium 10-20mg QPM 19. Ultram 100mg PRN 20. Xanax 0.5mg QHS and PRN 21. Mireda IUD with Progesterone Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for anxiety. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 7. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 8. Oxybutynin Chloride 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO qd (): Please hold until patient urinating well after foley has been removed. 9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 11. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [11-16] Puffs Inhalation Q6H (every 6 hours) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q4-8H () as needed. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 21. Calcium Carbonate 500 mg/5 mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. 22. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 23. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [2-18] hours as needed for nausea. 24. Foley removal Please discontinue foley when patient arrives at rehab Discharge Disposition: Extended Care Facility: Masonic Home Discharge Diagnosis: Primary Diagnoses: Charcot joint s/p surgical reconstruction diastolic congestive heart failure bleeding diathesis with prior negative workup anemia, secondary to blood loss . Secondary Diagnoses: diabetes mellitus peripheral vascular disease depression Discharge Condition: good Discharge Instructions: If you experience fever, chills, shortness of breath, or worsening pain, redness, or drainage from your surgical site, please call your doctor or return to the emergency room for evaluation. . Please take all medications as prescribed. . Please attend all follow up appointments. Followup Instructions: You should make an appointment to follow up with Dr. [Last Name (STitle) 44484] of Podiatric Surgery within 2 weeks after discharge from the hospital. You can call [Telephone/Fax (1) 543] for an appointment. . You also have the following appointments already scheduled: Provider: [Name10 (NameIs) 7801],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]/ONCOLOGY-CC9 Date/Time:[2123-6-21] 10:00 Provider: [Name10 (NameIs) 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D. Phone:[Telephone/Fax (1) 1989] Date/Time:[2123-8-20] 11:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2123-4-19]	[ "735.0", "287.9", "713.5", "584.9", "707.15", "518.5", "786.59", "285.1", "428.31", "250.60", "278.00", "V58.67", "070.70" ]	icd9cm	[ [ [] ] ]	[ "83.85", "81.14", "93.90", "77.58", "77.59", "81.12" ]	icd9pcs	[ [ [] ] ]	11586, 11625	5874, 8745	357, 407	11923, 11930	3465, 5851	12258, 13016	2994, 3013		9390, 11563		11646, 11822		8771, 9367			11954, 12235									3028, 3446		11843, 11902																						276, 319											435, 1991																	2013, 2913	2929, 2978
62,741	191,275	28760	Discharge summary	report	Admission Date: [2132-8-24] Discharge Date: [2132-9-16] Date of Birth: [2082-12-6] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Increasing headache Major Surgical or Invasive Procedure: angiogram with coiling History of Present Illness: HISTORY OF THE PRESENT ILLNESS: Ms. [Known lastname 69503] is a 49 year old woman with metastatic breast cancer to bone, liver, lung, and brain. Patient was diagnosed with triple negative breast cancer in [2128], and was found to have metastatic disease in [Month (only) ] of [2131]. She has undergone chemo, most recently with Taxol and Avastin. She also underwent whole brain XRT. She is followed in oncology clinic here with Dr. [Last Name (STitle) 19]. Importantly, she had a PE in [Month (only) 404] of this year and was placed on Lovenox 100mg daily. Per a note by Dr. [Last Name (STitle) 19], she was slated to come off of this, and it seems that this was stopped on [2132-8-12] (a fact which her husband confirms). [Name2 (NI) ] last brain imaging here was done in [2132-3-24] and showed significant interval decrease in size of the enhancing metastatic lesion within the right frontal lobe, as well as diminished associated vasogenic edema. Today she presented to an outside hospital in NH with increasing HA. Per husband, at approximately 2pm on [8-23] she began to complain of severe bitemporal HA and nausea and vomiting. The patient presented to the [State 20192] Center at 9:23pm. We were contact[Name (NI) ] by them stating that they wished to transfer her here because a head CT showed "hemorrhagic conversion of a prior known met." By their report she was fully awake and talking. Patient was given 4mg of MSO4 and a total of 5mg of dilaudid. Per her husband, after the last dose of this she became poorly responsive. Per [Location (un) ] team, they arrived to transfer the patient, only to find her encephalopathic and satting in the 50's. They decided to intubate her prior to flight. Prior to intubation she transiently became alert and talkative. She received 8mg of vecuronium and ativan for intubation and was brought to the [Hospital1 18] ED and arrived here at approximately 1:15a.m. on [8-24] intubated and sedated. We reviewed head CT at OSH and that done here upon arrival. Both show diffuse SAH, with seemingly thicker clot in the medial frontal region. Of note, labs at OSH notable for platelets of 139(coags not done). Past Medical History: -- breast CA, see above -- diet controlled DM -- HTN -- COPD (asthma and bronchitis) -- s/p hysterectomy in [2124] for menorrhagia -- h/o lithotripsy for kidney stone in [2112] Social History: -- accompanied by husband -- two daughters in college -- She does not smoke cigarettes or drink alcohol. Family History: Her mother had coronary artery disease and lung problems. [Name (NI) ] father died of esophageal cancer. She has a brother who is healthy. She has 8 children; she had 2 sets of twins, and one of the youngest twins died in a miscarriage. A first cousin has breast cancer. Physical Exam: VS: Afeb BP 102/67 HR 90 RR17 100% RA GENERAL: LUNGS: CTAB, no wheezing/rhonchi/rales, no crackles CV: RRR, no murmurs/gallops/rubs, no JVD ABD: + BS, soft, non-distended, non-tender, no HSM EXTREMITIES: no erythema, WWP NEUROLOGICAL: (EXAM DONE ON PROPOFOL with possibility of lingering vecuronium) Intubated and Sedated. Pupils 2.5 to 1.5mm bilaterally. No BTT. No corneals. Trace Doll's. Face symmeteric. +gag. No movement to deep nailbed pressure. DTRs 3+ throughout with toes upgoing bilaterally. Exam on Discharge: Neurologically intact Pertinent Results: LABS: PT 12.9, INR 1.1 platelets 113 CT/CTA head IMPRESSION: 1. Extensive subarachnoid hemorrhage as described above along with a small focus of possible parenchymal hemorrhage in the right frontal parasagittal location. 2. 6 x 4 mm lobulated aneurysm, at the confluence of the anterior communicating artery and the A2 segments of anterior cerebral arteries, posisbly ruptured given the extent of acute intracranial hemorrhage. 3. Slight focal prominence of the M2 branch of the right middle cerebral artery. Please see further details on the conventional angiogram, performed subsequently which better demonstrated the aneurysm. 4. Subcm focal lucent lesion in the right frontal bone- correlate with bone scan. [2132-9-15] FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. There is normal flow, compression and augmentation seen in all the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. [2132-9-1] CT perfusion IMPRESSION: 1. Findings compatible with right frontal lobe infarction, possibly due to right ACA A1 segment vasospasm as evidenced by diminutive caliber on CTA. 2. Anterior communicating aneurysm clip in place with limited evaluation of residual patency. Interval decrease in amount of subarachnoid hemorrhage with residual blood product in the inferior left frontal region. 3. Punctate left frontal hyperdensity may represent a treated metastatic lesion. Additional intracerebral metastases are better demonstrated on prior MRI from [2131-10-25]. 1. Unchanged minimal luminal narrowing of the right A1 segment. There is no definite vasospasm. 2. Intra-arterial slow hand infusion of 5 mg of verapamil in each of the left internal carotid artery, right internal carotid artery and left vertebral artery. [2132-9-7] CT perfusion IMPRESSION: 1. No evidence of new intracranial arterial stenosis to suggest vasospasm. 2. No new territorial infarction. No evidence of new hemorrhage. The left hemispheric infarcts demonstrated on the DWI sequence of the recent MRI are not well appreciated on this study. 3. Expected evolution of the paramedian right frontal lobar infarct which now shows minimal volume loss. Brief Hospital Course: Patient presented on [2132-8-24] to an OSH with complaints of worsening headache. Imaging was done in the emergency department of the OSH which showed that she had diffuse SAH the OSH transfered her to [Hospital1 18] for further care. whne she arrived in our ED she was intubated and sedated. Upon arrival at [Hospital1 18] CTA of the head was done which showed that she had an Anterior communicating artery aneurysm which had ruptured. She underwent coiling of the aneurysm x 2, she recevied an intravenous fluid bolus of 500 cc for a systolic blood pressure in the 80's. Her urine output was also borderline oliguric with an average hourly output of 30cc/hr. She had RUE weakness both before and after angio. She was started on Nimodopine and as a result of her hypotension her dosage was changed from 60mg Q4hours to 30mg Q2hours. Also on [8-24] a 24hour EEG was ordered for monitoring and Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 69504] was notified. On [8-25] she continued to remain in the ICU for vasospasm watch. On [8-26] she was noted to continue to have low systolic blood pressures in the 90's. Dr. [Last Name (STitle) 739] was made aware and it was determined that if she was asymptomatic then her SBP could be liberalized. On [8-27] she remained stable in the ICU and her motor strength was full. She complained of headaches in the afternoon ad was started on firoicet. She did not require the firoicet overnight on [8-27] into [8-28] and stated that her headaches were imrpoved. In the afternoon of [8-28] she had a moderate headache for which Fioricet was given and provided relief of symptoms. On exam the morning of 8.6 she was stable and her exam was nonfocal. The plan going forward was discussed with her and she was able to verbalize her understanding. She remained stable in the ICU over the weekend of [8-30] and [8-31] with no issues. On [9-1] she was noted to be bradycardic and hypotensive, pacers were put on standby and she received a CTA/P instead of a cerebral angiogram. The CTA/P was stable and however it showed a right frontal hypodensity which was old and seen on [8-24]. Also on [9-1] EEG showed slowing on the right. She complained of back pain which had worsened but no images were obtained. Her nimodopine was held for the bradycardia and her EEG continued to show frontal slowing. The decision was made to not press her blood pressures as she was clinically stable. On [9-3] her exam remained stable in the morning and she underwent a cerebral angiogram which showed no definitive spasm but verapamil was given. Following the angiogram her exam was altered and she was perseverative. She had an MRI of the Brain and L/S spine on the afternoon of [9-3] which showed a small left frontal infarct and a L5-S1 herniated disc abutting the descending S1 nerve root. Also on [9-3] she was evaluated by neuro-oncology for thoracic mets that were seen on MRI on [2131-12-24]. They recommended that the SAH be treated first and then to get repeat MRI of the thoracic spine to evaluate the metastasis further. They also recommended MRI fo the Brain and Lumbar spine which she received. On [9-4] her blood pressure was liberalized to >160 systolic on neosynephrine and levophed. her exam was not notably improved. In dicussions in EEG conference it was noted that one of her coils might be compression the anterior cerebral arterys. On the morning of [9-5] her exam was much improved and she was at her baseline. Her blood pressure was liberalized again to only treat for SBP<140. Also her Nimodopine was divided so that it was deleivered 30mg q2hours instead of 60mg q4hours to aid in achieving her blood pressure goals. On [9-6] she was noted to have tachycardia while on levophed and as a result it was stopped. the tachycardia soon resolved and her blood presure management agents were changed. On mornign rounds on [9-7] she was noted to have difficulty remembering the day of the month. otherwise her exam was unchanged however a CTA of the head was obtained which was stable from previous studies. A CXR was obtained which showed that she had pulmonary vascular overload and her IV fluids were stopped. On the morning of [9-8] her exam remained the same and her blood pressure goal was liberalized to only treat for <120 systolic overnight. On the morning of [9-9] her exam continued to be stable and we allowed her blood pressure to liberalize as long as her clinical exam did not worsen. She was transferred to the floor. She was started on Cipro and a foley catheter was replaced for a UTI on [9-15] after it was noted that she was continuously having Post void residuals in excess of 400 CCs. Medications on Admission: unknown Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Subarachnoid aneurysm from ruptured aneurysm SVT Left thalamic infarct left subacute centrum semiovale infarct Urinary retention Urinary Tract Infection cerebral vasopsasm Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. 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. ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) ?????? 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 Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in one month Call [Telephone/Fax (1) 1669] for an appointment. You will need an MRI/MRA prior to your visit, this will be arranged by our office at the time of your visit. Please Call Dr.[Name (NI) 5327] office for a follow up appointment and to set up your next Chemo therapy treatment: [Telephone/Fax (1) 8630]. Completed by:[2132-9-16]	[ "V15.3", "427.0", "198.3", "493.20", "250.00", "401.9", "V10.3", "V87.41", "V13.01", "599.0", "722.10", "197.7", "788.20", "198.5", "430", "V12.51", "433.91", "197.0" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.72", "38.91" ]	icd9pcs	[ [ [] ] ]	10941, 10988	6093, 10883	337, 362	11204, 11204	3810, 6070	12043, 12454	2953, 3229				11009, 11183		10909, 10918			11314, 12020									3244, 3749																								278, 299											390, 2606		3768, 3791									11219, 11290						2628, 2814	2830, 2937
29,055	151,132	1389	Discharge summary	report	Admission Date: [2119-10-4] Discharge Date: [2119-10-12] Date of Birth: [2063-1-8] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 668] Chief Complaint: HCC now here for liver transplant Major Surgical or Invasive Procedure: [2119-10-4]: Orthotopic liver transplant History of Present Illness: 56 years old Hep C virus infection with cirrhosis, portal hypertension and esophageal varices s/p banding, non-occlusive portal vein thrombosis and hepatocellular carcinoma s/p radiofrecuency ablation of hepatoma of segment VI ([2118-6-5]). Patient was listed for liver transplantation at [Hospital1 18]. He has been doing fine, able to work full time as a research nurse. . ROS: No fever, chills, SOB, chest pain, abdominal pain, diarrhea or constipation. Past Medical History: # HCV genotype I --portal hypertension --esophageal varices, grade II, s/p banding x2, s/p Sodium Morrhuate injections for hemostasis [2117-12-16] --splenomegaly --noncavernomatous portal vein thrombus --small nodule (ddx degenerative nodular or hepatocellular carcinoma) . # h/o Hemopneumothorax # h/o L arm compound fracture # s/p R knee surgery # s/p R inguinal hernia repair [2116] Social History: # Personal: Lives alone # Professional: Nurse in a medical device company. # Substance use: No current tobacco and alcohol. Last alcoholic drink [2115-1-5]. Family History: Father had [Name2 (NI) 499] cancer, possibly metastasis from the lung. Mother is deceased at age [Age over 90 ], had a history of coronary artery disease, died of PE. No family history of liver disease. Physical Exam: : 98.5 HR: 52 bpm BP: 101/ 51 RR 18 Sat 97 RA . HEENT : WNL Neck: supple, no bruits Cardiac: RRR Lungs: CTA ABD: NBS, soft, no tender, no distended, splenomegaly, no rebound. Surgical incision left groin area, well healed. EXT: well perfused, bilateral DP/PT Pertinent Results: On Admission: [2119-10-3] WBC-2.0* RBC-3.60* Hgb-12.2* Hct-35.6* MCV-99* MCH-34.0* MCHC-34.4 RDW-14.7 Plt Ct-64* PT-15.7* PTT-31.9 INR(PT)-1.4* Glucose-86 UreaN-12 Creat-0.5 Na-140 K-4.1 Cl-107 HCO3-26 AnGap-11 ALT-129* AST-168* AlkPhos-69 TotBili-1.8* Albumin-3.2* Calcium-8.9 Phos-3.0 Mg-1.5* On Discharge [2119-10-12] WBC-5.2# RBC-4.40* Hgb-13.0* Hct-38.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-16.7* Plt Ct-54# Glucose-88 UreaN-24 Creat-0.8 Na-136 K-4.3 Cl-101 HCO3-31 AnGap-8 ALT-180* AST-34 AlkPhos-72 TotBili-2.0* Albumin-2.9* Calcium-8.3* Phos-2.9 Mg-1.4* tacroFK-7.2 Brief Hospital Course: 56 y/o male s/p RFA for HCC is admitted for orthotopic liver transplant with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. He received routine induction immunosuppression. At the time of surgery he was noted to have portal vein thrombus, The lumen appeared to be completely thrombosed. When the clamps came off there was no blood flow through the portal vein. An extensive embolectomy was performed removing an extensive amount of fresh and old clot from the portal vein and eventually we were able to establish portal venous inflow. During the surgery, he received Three units packed cells 6 units of FFP, 2 of platelets, 500 of albumin, 7 liters of crystalloid. In the immediate post op period in the SICU he received and additional 4 units RBCs, 2 more of platelets and one of cryo. Liver ultrasound revealed Large hematoma about the right lobe of the transplanted liver, thought to be subcapsular and with probable additional subdiaphragmatic component. He had bruising along the left hip and flank as well which was resolving over the hospital course. His heparin was held, and then restarted POD 4. His platelets were noted to fall again into the 30's, so a HIT was sent which was negative. He will receive coagulation to start as an outpatient for this portal vein thrombus, but it was determined he should wait awhile longer before initiation of this therapy. He was otherwise doing well. Eating, ambulating and had return of bowel function. He had an infiltrate on a right arm PIV which was continued to be dressed and was starting to heal. Medications on Admission: Cefaxin 600 [Hospital1 ] Nadolol 40 mg. daily Omeprazole 40 mg. daily Spironolactone 100 mg. daily Vitamin C 500 mg. daily citalopram 10 mg qd Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for gerd. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 12. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 13. Outpatient Lab Work Outpatient labs [2119-10-14] at [Hospital Ward Name 1826] 7 Lab CBC, Chem 7, Ca, Phos, Mg, AST, ALT, Alk Phos, T Bili, trough prograf Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: HCC now s/p liver transplant. Hepatitis C and hepatoma with portal vein thrombus. Discharge Condition: Stable/Good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding. You may shower, pat incision dry. Replace drain sponges daily or after showering Drain and record drain output twice daily and more often as necessary. Bring copy with you to clinic. Call if the drainage increases greatly, turns bloody in appearance or develops a foul odor. Place new drain sponge daily. No driving if taking narcotic pain medication Dressing change to right arm daily No heavy lifting Followup Instructions: BED 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2119-10-14] 8:00 : Labwork. PLease do not take prograf until after lab is drawn . [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2119-10-19] 3:20 CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2119-10-24] 9:15 Completed by:[2119-10-12]	[ "572.3", "571.5", "998.12", "070.70", "E878.0", "E932.0", "287.5", "155.0", "452", "456.21", "790.29" ]	icd9cm	[ [ [] ] ]	[ "50.59", "38.07", "00.93" ]	icd9pcs	[ [ [] ] ]	5617, 5675	2576, 4152	304, 351	5801, 5815	1974, 1974	6494, 6880	1460, 1673		4350, 5594		5696, 5780		4178, 4327			5839, 6471									1689, 1955																								231, 266											379, 847										1988, 2553							869, 1264	1280, 1444
25,555	152,713	30047	Discharge summary	report	Admission Date: [2183-1-31] Discharge Date: [2183-2-11] Date of Birth: [2160-3-2] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: PICC History of Present Illness: This is a 22 year old male who was transferred from an OSH with pancreatitis and possible evolving cyst. He was binge drinking over the weekend [Date range (1) 71671] and he presented with abdominal pain. He complained of nausea and vomitting. He has a history of alcohol abuse. He reports drinking 6-12 beers daily for the past 2 years. Past Medical History: None Social History: tob 1pk/day, etoh 6-12pk/d, denies ilicits Physical Exam: MS/NEURO: A/O x 2, confusion at times, wanting to get out of bed. HEENT: PERRLA, EOMI CVS: Regular tachycardia Resp: CTA-B Abd: diffusely tender to palpation, especially to epigastric. +BS Ext: +2 pulses bilat. Pertinent Results: [2183-2-9] 05:52AM BLOOD WBC-18.0* RBC-3.22* Hgb-10.3* Hct-30.0* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.9 Plt Ct-721* [2183-2-10] 07:36AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-134 K-4.3 Cl-99 HCO3-28 AnGap-11 [2183-2-9] 05:52AM BLOOD ALT-55* AST-39 AlkPhos-96 Amylase-82 TotBili-0.5 [2183-1-31] 10:44PM BLOOD ALT-40 AST-35 AlkPhos-60 Amylase-328* TotBili-1.6* [2183-2-9] 05:52AM BLOOD Lipase-86* [2183-2-10] 07:36AM BLOOD Calcium-9.3 Phos-5.0* Mg-2.4 [2183-2-7] 04:43AM BLOOD Triglyc-99 CHEST (PORTABLE AP) [2183-2-1] 12:11 AM IMPRESSION: Left lower lobe collapse and/or consolidation in the setting of low inspiratory volumes. Small left effusion. NG tube coiled in stomach. Brief Hospital Course: He was admitted to the TICU for worsening pancreatitis complicated by pseudocyst. Neuro: He was confused and restless on admission. He was ordered for CIWA scale and Ativan for agitation and withdrawal with good effect. The Ativan was weaned during this hospitalization and his mental status cleared. . CV: He was tachycardic. He was receiving fluid resuscitation and required several IV fluid boluses for hypovolemia. He was having fevers, up to 102.4, and his WBC rose to 20 on HD 3, as expected due to the pancreatitis. He was not receiving antibiotics. Eventually, we caught up with his fluid resuscitation. His WBC slowly was trending down and the fevers resolved. Resp: He was having respiratory alkalosis with primary hyperventilation. His RR was 30-50. He was oxygenating well and was monitored for any signs of respiratory failure. Intubation was avoided. GI/Abd: He was NPO with an NGT in place due to nausea and dry heaving. His abdomen was distended and he had absent bowel sounds. His stomach was decompressed with the NGT in place. He reported a large liquid stool on HD 1. The NGT was self D/C'd on HD 3 and was not replaced at this time. His abdomen continued to be distended and gradually improved. . FEN: He was NPO, with IVF. He was started on TPN and this was increased to goal. He was started on sips on HD 8, and slowly his diet was advanced to regular. He was tolerating a regular diet at time of discharge. . He was transferred to the floor on [2-5], HD 6, and continued to recover and improve. Neuro: He continued to have some confusion, such as disconnecting his IV and wanted to leave the hospital. He was able to carry on normal conversations. [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] was called and spoke with the patient regarding EtOH abuse. He agreed to EtOH support group or rehab. Abd: His abd was much less tender, and still distended and tympanic. Once back on a diet, he did not complain of worsening abdominal pain and the distention resolved. IV: A PICC line was placed on [2182-2-5] and he was started on TPN. The PICC was D/C'd prior to discharge. Labs: His LFT's, Amylase and Lipase continued to trend down over his hospitalization. At time of discharge Amylase 68, Lipase 66, and Total Bili 0.4. Addictions/Social Work: He was seen by [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] and they discussed EtOH abuse. He was given information about different support groups/meetings. He stated that he will not drink alcohol. Medications on Admission: None Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:2 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 2 weeks. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Pancreatitis Pancreatic Pseudocyst Mental Status Change Hypovolemia Discharge Condition: good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please resume all of your regular medications and take any new meds as ordered. . Continue to ambulate several times per day. . Avoid All Alcohol . Eat several small meals throughout the day. Adhere to a low fat diet. Maintain your hydration. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call ([Telephone/Fax (1) 15807] to schedule an appointment. You will need a CT prior to this appointment. Call to arrange this. Please follow-up with Dr. [Last Name (STitle) 174] (Pancreatologist) in [1-18] weeks. Call ([Telephone/Fax (1) 22346] to schedule an appointment. [Hospital1 1680] Counseling - [Location (un) 246] [Telephone/Fax (1) 71672]. Call for supportive services for alcohol Absteinance Completed by:[2183-2-11]	[ "305.1", "276.52", "291.81", "276.4", "577.0", "305.01", "577.2" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	4760, 4766	1772, 4314	325, 332	4878, 4885	1039, 1749	5317, 5844			4369, 4737		4787, 4857		4340, 4346			4909, 5294									807, 1020																								273, 287											360, 704																	726, 732	748, 792
7,339	195,303	48440	Discharge summary	report	Admission Date: [2162-3-8] Discharge Date: [2162-3-11] Date of Birth: [2097-7-18] Sex: M Service: MEDICINE Allergies: Pine Tar Attending:[First Name3 (LF) 30] Chief Complaint: transferred from OSH for sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 64yoM with h/o CAD, hemochromatosis, pulmonary fibrosis on chronic steroids and intermittent home oxygen, transferred from OSH with sepsis and pneumonia. Patient initially presented to [Hospital3 ] ED [2162-3-6] with complaint of fever to 103 and rigors. Prior to that he had been ill for about a month with productive cough and congestion. Initial vitals included T 103.9, BP 98/56. In the ED, SBP dropped from 90s to 70s. He was bolused 1L NS and started on dopamine by peripheral iv. His urinalysis was consistent with infection, and he received doses of levofloxacin and vancomycin to cover UTI and possibility of pneumonia given h/o pulmonary fibrosis. He was also treated with hydrocortisone 100mg iv Q8hr given h/o chronic steroid use and risk of adrenal insufficiency. An abdominal u/s was performed to evaluate for ascites and revealed a cirrhotic liver, splenomegaly, and ascites. . In the MICU, the dopamine drip was weaned off and pt's blood pressure remained stable. His stress dose steroids were also weaned once he was off pressors. Vancomycin was stopped and levaquin was continued for pneumonia. Hematology was consulted given his pancytpoenia. An ECHO was done to evaluate for cardiomyopathy given pt's hx of hemochromatosis. . This morning, he states that he feels much improved. He endorses only some sore throat which he attributes to oxygen. On review of systems, he states that he has had a 37 lb weight loss over the last six months coincident with tapering of his prednisone. He denies any recent headache, vision changes, chest pain, palpitations, orthopnea, PND, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria, BRBPR, melana, arthralgias or skin rash. Past Medical History: * Hemochromatosis - diagnosed 2yrs ago, treated with every other month phlebotomy * Cirrhosis due to hemochromatosis and ?EtOH cirrhosis * h/o EtOH abuse, no h/o withdrawals, now rare use * Hypertension * Coronary artery disease * Pulmonary fibrosis - diagnosed 3yrs ago, on chronic steroids and intermittent home oxygen (for the past 6 months) * Asthma?? * Hyperlipidemia * Psoriatic arthritis * s/p right rotator cough injury . All: pine Social History: married, retired but has been consulting as office manager EtOH: rare use currently, h/o abuse Tob: h/o 20-30 pack-yr, quit 20yrs ago Family History: sister died of lung ca at age 60, brother with DM, sister with hemachromatosis Physical Exam: PE upon transfer from MICU: T 97.7, HR 86, BP 104/68, RR 20, 93-97% on 2L GEN: comfortable, NAD HEENT: PERRL, anicteric, MMM Neck: supple, no LAD, JVP not appreciated CV: RRR, 2/6 systolic murmur at apex, nl S1S2 Lungs: fine crackles LLL, end expiratory wheezes throughout Abd: +BS, obese, soft, NT Ext: no edema, + venous stasis changes, 2+ radial and DPs bilaterally Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout, sensation intact to touch Pertinent Results: [2162-3-8] 04:46PM PT-15.4* PTT-31.0 INR(PT)-1.4* [2162-3-8] 04:46PM PLT SMR-VERY LOW PLT COUNT-66* [2162-3-8] 04:46PM WBC-2.3* RBC-3.02* HGB-9.6* HCT-27.9* MCV-92 MCH-31.9 MCHC-34.5 RDW-15.6* [2162-3-8] 04:46PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-1.5* MAGNESIUM-2.1 [2162-3-8] 04:46PM CK-MB-2 cTropnT-<0.01 [2162-3-8] 04:46PM ALT(SGPT)-28 AST(SGOT)-41* LD(LDH)-227 CK(CPK)-145 ALK PHOS-111 AMYLASE-232* TOT BILI-0.8 [2162-3-8] 04:46PM GLUCOSE-243* UREA N-17 CREAT-1.1 SODIUM-136 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-17* ANION GAP-14 [2162-3-8] 04:47PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[4-12] [2162-3-8] 04:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [2162-3-8] 04:47PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 . IMAGING: [2162-3-8] CXR: 1. Interstitial opacity within the left lower lobe is concerning for pneumonia. 2. Left upper lung opacity appears more prominent than on prior exam, likley related to technique. If clinically indicated, chest CT could be recommended for further evaluation. . [2162-3-9] ECHO: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: Mr. [Known lastname 4469] is a 64 year old male with a PMH significant for CAD, hemachromatosis and pulmonary fibrosis (on chronic prednisone therapy) who was transferred from an OSH with sepsis. . Given presentation and history, the patient was thought to have sepsis secondary to pneumonia. He was initially treated with broad spectrum antibiotics, stress-dose steroids, IVF and pressors. He was eventually weaned from pressors and remained hemodynamically stable. He was transitioned to levofloxacin to complete a 10 day course of antibiotics. Steroids were tapered to his home dose for pulmonary fibrosis. . The patient was pancytopenic on admission. His platelet count had dropped from 99 to 61, WBC 8.6 to 3.2 and Hct 32 to 27 at the OSH. A peripheral smear, iron studies and B12/folate were unremarkable. Hematology was consulted and felt that the anemia was due to chronic phlebotomy for hemochromatosis. Leukopenia may have been secondary to infection given that it dropped suddenly in setting of sepsis. Thrombocytopenia was likely due to chronic liver disease and sepsis. HIT was not likely given that patient has chronic thrombocytopenia and the platelet count did not drop to [2-9] of what is was originally. The patient takes Arava for psoriatic arthritis. This was held given the concern for immunosuppresion. It may be restarted as an outpatient as indicated. . Aspirin and statin were continued for CAD. Beta-blocker and [Last Name (un) ] were initially held and restarted when he was weaned from pressors and deemed hemodynamically stable. . Of note, a lung nodule was identified on PA and lateral CXR. Outpatient chest CT was recommended for follow up. In addition, his INR was elevated and may be related to impaired synthetic function of the liver given a history of hemachromatosis and cirrhosis. Outpatient GI follow up was recommended. . Inhalers were continued for asthma. Lasix and spironolactone were restarted for cirrhosis when the patient stabilized. Atorvastatin was continued per home regimen. . FULL CODE Medications on Admission: 1. Albuterol-Ipratropium 2 PUFF IH Q6H 2. Arava 20 mg qMWF 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY 5. Avapro 300mg qD 6. Furosemide 40 mg PO DAILY hold for SBP<90 7. Glucosamine/chondroitin 500/400mg 2tabs qD 8. Loratidine 10mg daily 9. Metoprolol XL (Toprol XL) 25 mg PO DAILY Hold for SBP <90, HR <55 10. PredniSONE 10 mg PO DAILY 11. Qvar 80mcg qD 12. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [6-17] MLs PO Q6H (every 6 hours) as needed for cough. Disp:1 bottle Refills:0 6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 4 days. Disp:12 Tablet(s) Refills:0 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day. 12. Qvar 80 mcg/Actuation Aerosol Sig: One (1) Inhalation once a day. 13. Glucosamine-Chondroitin 500-400 mg Capsule Sig: Two (2) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Left Lower Lung Pneumonia. 2. Sepsis/Shock. 3. Pancytopenia NOS. 4. Elevated Troponin NOS - likely secondary to sepsis. Secondary: 1. Hemochromatosis. 2. Cirrhosis. 3. Prior ETOH Abuse. 4. Hypertension. 5. False Positive ETT-MIBI, Negative Catheterization. 6. Idiopathic Pulmonary Fibrosis - dx [2159], on steroid taper. 7. Reactive Airway Disease. 8. Hyperlipidemia. 9. Psoriatic Arthritis. 10. Right Rotator Cuff Injury. Discharge Condition: Good. Afebrile. Tolerating PO. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital because you have pneumonia. You were treated with antibiotics. You should take antibiotics for a total of 10 days. Please return to the emergency room or call your doctor if you experience any of the following symptoms: fever > 101.5, shaking chills, worsening cough, severe pain, intractable nausea or vomiting or any other concerning symptoms. . Please take all medications as prescribed. You should not take your Arava until you see your PCP. . Please follow up with your PCP in the next 2 weeks. Followup Instructions: 1. Left upper lung opacity appears more prominent than on prior exam. CT recommended for further evaluation. 2. Follow-up pancytopenia. 3. Consider osteoporosis prophylaxis - Vitamin D/Bisphosphonate. 4. Arava was held out of concern as contributer to pancytopenia, restart as outpatient.	[ "571.5", "515", "785.52", "696.0", "410.71", "038.9", "493.90", "275.0", "284.1", "486", "995.92" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8900, 8906	5258, 7309	298, 305	9403, 9467	3234, 5235	10049, 10348	2667, 2747		7762, 8877		8927, 9382		7335, 7739			9491, 10026									2762, 3215																								227, 260											333, 2037																	2059, 2500	2516, 2651
55,682	114,187	50203	Discharge summary	report	Admission Date: [2174-10-17] Discharge Date: [2174-10-22] Date of Birth: [2096-1-15] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Headache and confusion. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Name13 (STitle) 7518] is a 78 yo right handed man who presents for evaluation of confusion. The history is given both by the patient and his daughter. Apparently, the patient lives predominantly alone. His daughter recalls speaking to him on Saturday and he appeared to be his typical self. This morning, around 9am she received a phone call from her father- he was asking for the phone number to his office, something he should know very well. She became concerned and he told her that he was not feeling well and was lying in bed (also unlike him). They hung up the phone and just minutes later, he called back, again asking the same questions and without recalling that he had just spoken to her. This prompted his daughter to go to his home where she found things in disarray- he had apparently soiled himself as well as vomited on the floor as well as a nose bleed and had no cleaned it up. She is not sure how long things had been like that. The patient refused to go to the ED and requested calling his PCP [Name Initial (PRE) ]. Upon hearing this, the PCP rightfully referred the pt to the ED. On arrival to the ED, the patient was noted to be extremely hypoxic (O2 sat 65% off oxygen). ABG at the time showed mild bicarb retention and normal COhb. EKG was notable for PACs. A head CT was obtained which identifed a large intraventricular bleed in the left caudate, extending into the ventricular system. Neurosurgery was consulted but felt there was no issued for an acute intervention. His sats quickly correctly and neurology was consulted. Mr. [First Name (Titles) 104720] [Last Name (Titles) 104721] feeling "Plunky" that last few hours but he cannot give a further description of his overall well being other than feeling fatigued. His daughter feels his fatigue predates his presentation, stating he has been a bit more quiet and down over the past few weeks than he typically is. He denies any recent head injuries or falls. He reports a mild headache (0.5/10) which is a central pressure and which appears to be resolving. On further neurologic review of systems, the patient denied loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech. Denied focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denied difficulty with gait. On general review of systems, the patient denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: - Sleep Apnea, on CPAP - Emphysema (baseline O2 84% on RA. Goal ~88 RA) - "Leaky Valve", per most recent ECHO, multiple valve disease with mild regurge from mitral, aortic and tricuspid valves. - Nephrolithiasis - Spinal Stenosis (lumbar) - GI Bleed/BRBPR, no off ASA - s/p Cataract [Doctor First Name ] (bilaterally) - s/p resection of skin lesion on his head. - s/p B/L knee replacements - s/p cholecystectomy - s/p appendectomy - s/p tonsillectomy Social History: Semi retired- works in real estate part time. Lives alone but son comes and stays with him 3 days per week. He spends a good amount of time at [Location (un) ]. He has 4 children, 2 of which are in the area. Remote smoking history of 2ppx, quit 30 years ago. No alcohol in years, no drugs. Family History: Gm HYPERTENSION, LIVER DISORDER (SECONDARY TO DAILY ACETAMINOPHEN Father- diabetes type I, ? bone ca? Physical Exam: Exam changes during the admission: Patient remained afebrile. Was hypertensive briefly, particularly on exertion, until antihypertensives added to 170s at maximum. His oxygen saturation was typically low, often in 80's - he appears to have habituated to this, with some polycythemia and no symptoms. His neurologic examination is essentially normal now, with some confusion in the evening on two nights. His family judge that he is approaching his cognitive baseline. T 99.3 BP 162/85 (prepeat 115/70) HR 94 RR 92 O2% 4L General: Awake, cooperative, NAD. Head and Neck: no cranial abnormalities, no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: irregular rate (PV/PAcs on tele). [1-29] diffuse murmur. Abdomen: soft, non-tender, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to hospital, "[2174-10-27])". Able to relate history with some difficulty and amnestic regarding some of the events of the last 2 days; confabulates. Attentive (DOW backwards 23 seconds). Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. There was no evidence of apraxia or neglect, calculations intact. Registered [2-23] after 4 tries; and recalled 0/3 at 5 minutes. -Cranial Nerves: I: Olfaction not tested. II: PERRL irregularly shaped, 3 to 2mm and sluggish, b/l lens replacements, + red reflex. Visual fields full on bedside testing with red pin. Unable to view fundus III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: decreased hearing on right compared to left ear to finger rub. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and sternocleidomastoid bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No rigidity. No adventitious movements, such as tremors, noted. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, decreased pinprick and temperature sensation in bilateral feet to ankles. Also decreased vibratory sense on right to shin and left to ankle. Impaired proprioception to fine movements at the toes bilaterally. No extinction to double simultaneous stimuli. -Deep tendon reflexes: [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 2 1 1 1 1 R 2 1 1 1 1 Plantar response was flexor bilaterally. -Coordination: Mild bilateral intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: initially deferred Pertinent Results: [2174-10-17] 12:00PM BLOOD WBC-11.6* RBC-5.58 Hgb-18.6* Hct-58.1* MCV-104* MCH-33.2* MCHC-32.0 RDW-14.1 Plt Ct-229 [2174-10-21] 05:45AM BLOOD WBC-15.2* RBC-5.75 Hgb-19.6* Hct-58.5* MCV-102* MCH-34.1* MCHC-33.5 RDW-14.2 Plt Ct-223 [2174-10-17] 12:00PM BLOOD Neuts-80.3* Lymphs-12.0* Monos-5.2 Eos-0.8 Baso-1.7 [2174-10-17] 12:00PM BLOOD PT-14.0* PTT-28.8 INR(PT)-1.2* [2174-10-21] 05:45AM BLOOD PT-16.1* PTT-29.4 INR(PT)-1.4* [2174-10-21] 05:45AM BLOOD Ret Aut-2.0 [2174-10-17] 12:00PM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139 K-4.1 Cl-102 HCO3-27 AnGap-14 [2174-10-20] 05:50AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-140 K-4.3 Cl-102 HCO3-31 AnGap-11 [2174-10-18] 02:51AM BLOOD ALT-40 AST-31 LD(LDH)-196 CK(CPK)-97 AlkPhos-63 TotBili-1.4 [2174-10-18] 02:51AM BLOOD CK-MB-5 cTropnT-<0.01 [2174-10-17] 12:00PM BLOOD Calcium-9.4 Phos-2.3* Mg-1.9 [2174-10-20] 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0 [2174-10-21] 05:45AM BLOOD UricAcd-4.1 [2174-10-17] 04:35PM BLOOD %HbA1c-6.0* eAG-126* [2174-10-18] 02:51AM BLOOD Triglyc-101 HDL-37 CHOL/HD-3.7 LDLcalc-79 [2174-10-17] 12:11PM BLOOD Type-[Last Name (un) ] O2 Flow-4 pO2-55* pCO2-45 pH-7.40 calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2174-10-17] 12:11PM BLOOD Lactate-1.8 [2174-10-21] 12:40PM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA BASED-PND [2174-10-21] 12:40PM BLOOD ERYTHROPOIETIN-PND EKG Sinus rhythm and frequent atrial ectopy. Left atrial abnormality. Right ventricular conduction delay. Compared to the previous tracing of [2172-5-16] the axis is indeterminate. There are new repolarization abnormalities in leads V1-V4 and increase in rate which may represent anterior myocardial ischemia. Followup and clinical correlation are suggested. Rate PR QRS QT/QTc P QRS T 85 148 96 350/393 51 0 4 CT Head [2174-10-17] FINDINGS: There is a large intraventricular hemorrhage which appears to be extending from a small focus of intraparenchymal hemorrhage within the left caudate (2:12). There is no evidence of obstructive hydrocephalus. There are no other foci of hemorrhage, major vascular territorial infarction, edema or shift of normally midline structures. There are no fractures or soft tissue injuries. The visualized sinuses and mastoid air cells are well pneumatized. IMPRESSION: Intraventricular hemorrhage likely from ventricular extension of left caudate hemorrhage. No obstructive hydrocephalus. Addendum: Upon further review, there is bihemispheric subarachnoid hemorrhage manifested as subtle hyperdensity within the sulci most conspicuous along the cerebral vertex on the right. CT Head [2174-10-19] FINDINGS: Again identified is diffuse bilateral subarachnoid hemorrhage, not significantly changed in size and distribution. There is intraventricular hemorrhage with increased ventricular size concerning for early obstructive hydrocephalus. In particular, the third ventricle now measures 14 mm (2, 13), previously measuring 11 mm. There is also increased dilatation of the temporal horns bilaterally. There has been slight redistribution of the intraventricular hemorrhage with blood now identified in right occipital [Doctor Last Name 534] (2, 17) and resolved from the right frontal [Doctor Last Name 534]. The previously identified hemorrhage within the third ventricle has resolved. The hemorrhage within the left ventricular system is stable in configuration. Small amount of hemorrhage within the fourth ventricle is now present within the bilateral foramen of Luschka. There is no new hemorrhage identified. There is no shift of normally midline structures or acute major vascular territorial infarction. There is normal [Doctor Last Name 352]-white matter differentiation. No evidence of acute fracture. The visualized paranasal sinuses are unremarkable. IMPRESSION: 1. Intraventricular hemorrhage with increased dilatation of the ventricular system concerning for early obstructive hydrocephalus. 2. Extensive subarachnoid hemorrhage, unchanged. No new hemorrhage identified. CT Head [2174-10-21] Ventricular size reduced by comparison on [2174-10-19] MRA/MRI Head [2174-10-17] TECHNIQUE: Sagittal T1-weighted and axial T1-weighted, T2-weighted, FLAIR, gradient echo, and diffusion-weighted images of the head were obtained. Three-dimensional time-of-flight MRA of the head and two-dimensional time-of-flight MRV of the head were obtained, with a three-dimensional maximal intensity projection images. Two-dimensional time-of-flight MRA of the neck was obtained, with three-dimensional maximal intensity projection reformatted images. During intravenous gadolinium administration, dynamic coronal VIBE imaging of neck was performed. Following intravenous gadolinium administration, multiplanar T1-weighted images of the head were obtained. FINDINGS: HEAD MRI: There is a small focus of blood in the left caudothalamic groove. There is a large amount of blood within the left lateral ventricle, third ventricle and fourth ventricle, as well as a small amount of blood in the frontal and occipital horns of the right lateral ventricle. The septum pellucidum is shifted to the right. These findings are unchanged. There is high signal on FLAIR images and low signal on gradient echo images in the hemispheric sulci bilaterally, corresponding to the subarachnoid hemorrhage seen on the preceding CT scan. There is no evidence of an enhancing mass or abnormal blood vessels. Multiple small foci of high T2 signal in the supratentorial white matter and pons, probably represent chronic microvascular infarcts, given the patient's age. HEAD MRV: Flow is visualized in the major dural sinuses without evidence of thrombosis. HEAD MRA: The study is limited by motion artifacts. The intracranial right vertebral artery is hypoplastic, better visualized on the concurrent neck MRA with gadolinium. There is no evidence of a hemodynamically significant arterial stenosis or intracranial aneurysm. This study does not cover the entire head as it is targeted for evaluation of the circle of [Location (un) 431], but no evidence of an arteriovenous malformation is seen within the area of coverage. NECK MRA: The gadolinium-enhanced dynamic neck MRA is slightly limited due to suboptimal injection timing. However, no hemodynamically significant stenosis is seen in the cervical carotid or vertebral arteries. IMPRESSION: 1. Extensive intraventricular hemorrhage, bilateral subarachnoid hemorrhage, and a small parenchymal hemorrhage in the left caudothalamic groove, as seen on the preceding CT scan. 2. No evidence of an intracranial mass. 3. No evidence of venous sinus thrombosis. 4. Slightly limited MRAs of the head and neck. No evidence of an intracranial aneurysm. No evidence of an intracranial malformation within the area of coverage, though the entire head is not covered by the MRA. Brief Hospital Course: Intraventricular Hemorrhage Typical causes of intraventricular hemorrhage include dissection into the ventricle from periventricular strucutres, particulary after hypertension hemorrhage into striatum. Other possibilities include periventricular neoplasm with necrosis and bleeding, aterovenous malformation, arising from choroid. In this case, a small amount of disrupted tissue adjacent to the left lateral ventricle, next to the head of the causeal is seen - we think that blood likely dissected into the ventricle from this possible hypertensive lesion. We will need to repeat MRI of the head in about six weeks to reevaluate for an underlying lesion at this site. Again the hypertensive hypothesis seem somewhat odd given quite reasonable blood pressure values while here. We started antihypertensive agents, as listed below. We will see him in clinic for follow-up after repeat MRI. Systemic Hypertension Not very elevated. Response to exercise/exertion brought to 170s while here, but was typically from 110s to 140s at rest. We added agents as listed below. Chronic Obstructive Pulmonary Disease Patient has previously refused day-time oxygen therapy and tolerates a very low oxygen saturation in the 80s. This hypoxemia, perhaps along with sleep apnea, has resulted in pulmonary hypertension, possibly worsening his respiratory status. He has actually been symptom free, however. Hypoxemia is also the likely cause of his polycythemia. Pulmonary Hypertension Likely secondary to COPD and hypoxia, perhaps with a contribution from OSA. Obstructive Sleep Apnea The patient used BiPAP while an inpatient. Polycythemia Was seen by Hematology while here, who recommended no phlebotomy at this time. JAK2 mutation and EPO level were pending at the time of discharge, but it seems more likely attributable to hypoxemia. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 6-8 hours as needed for shortness of breath FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhaled twice a day rinse after use OXYGEN - - 4L via nasal cannula use 24/7 Please provide liquid oxygen system. Saturation 83% on RA, 86-88% on 4LNC. Diagnosis COPD. Please call patient when oxygen is available as he would li TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled once a day Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once daily MULTIVITAMIN - (OTC) - Capsule - Capsule(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 8. multivitamin with minerals Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO twice a day. 10. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Intracerebral hemorrhage with intraventricular extension Secondary Chronic obstructive pulmonary disease/emphysema Obstructive sleep apnea Pulmonary hypertension Systemic hypertension Polycythemia, likely secondary to hypoxemia (from chronic obstructive pulmonary disease and, to a lesser extent, pulmonary hypertension) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital after having a hemorrhage in your brain, which erupted into the ventricles (fluid filled spaces inside the brain). This blocked your ventricular system, leading to the build-up of some fluid in your brain. Given this, you needed close monitoring. You recovered quickly and well from this event. Repeat imaging demonstrated that your ventricular system was again draining, so we thought that you were safe to go to rehabilitation. Please take your medications as written below and as specified by rehabilitation at your discharge from there. You will need to follow-up with our stroke team after discharge, as detailed below. Followup Instructions: Please see our stroke team as follows: Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 2574] Date/Time:[2174-12-7] 1:30 Prior to this appointment, you will need a repeat CT then MRI of your brain (imaging). The CT will need to be in two weeks (about [2174-11-6]), then the MRI in six weeks. Please call to schedule a time - the order is in, but the exact time is not booked. You can have this done in the week prior to the appointment, i.e. in the week [11-29] to [12-6]. Please call [Telephone/Fax (1) 327]. Please make an appointment to see your primary care doctor - make this appointment to see your doctor a few days after discharge - please see your doctor within a week. [Last Name (LF) ],[First Name3 (LF) ] D. [Telephone/Fax (1) 3329] We also note other appointments in our system: Provider: [Name10 (NameIs) ] [Last Name (STitle) ] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2174-11-29] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2308], MD Phone:[Telephone/Fax (1) 3965] Date/Time:[2175-3-30] 7:30	[ "327.23", "724.02", "V43.65", "331.4", "397.0", "401.9", "396.3", "289.0", "V45.79", "416.8", "431", "V15.82", "799.02", "V13.01", "492.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	17990, 18056	14311, 16139	350, 358	18429, 18429	7355, 14288	19285, 20498	4018, 4121		17040, 17967		18077, 18408		16165, 17017			18611, 19262							5773, 7336		4136, 5164																								287, 312											386, 3207											18444, 18587						3229, 3687	3703, 4002
55,992	110,891	2809	Discharge summary	report	Admission Date: [2153-7-29] Discharge Date: [2153-8-1] Date of Birth: [2074-11-10] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 78 y/o F with h/o atrial fibrillation on coumadin and h/o of GIST s/p excision and partial gastrectomy in [2143] who later developed local recurrence and omental metastasis s/p resection of omental mass in [3-/2153] and now presents today with 3 day history of dull epigastric abdominal pain. Pt had CT scan at OSH showing intraperitoneal bleeding and pt was subsequently transferred to [Hospital1 18] for further management. At OSH, pt had BP in 90s, hct 23.5 and inr 4.0. Pt denies fevers, chills, nausea/vomiting, or diarrhea Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - . Paroxysmal Atrial Fibrillation on coumadin - . Heart Failure with preserved EF -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: . 1. CVA in [2136] 2. TIA in [2138] 3. Hypertension 4. Hypothyroidism 5. Abdominal mass - GIST (diagnosed [2143]) s/p surgery, on Gleevec therapy, follows Dr. [Last Name (STitle) 13754] in Heme/Onc. . PAST ONCOLOGIC HISTORY: - Mrs. [Known lastname 13755] initially presented [2143-9-2] with abdominal pain. At that time, she was found to have a large mass in her abdomen. - On [2143-9-6], she underwent an incomplete resection of this tumor. It was found to be increasing in size and she was treated on Gleevec from [1-/2145] to 12/[2146]. At that time, she stopped it as she was having some side effects from this therapy, most notably severe cramping. On the Gleevec, her tumor had decreased in size. However, the mass grew while she was off the Gleevec and she was restarted on it again in 07/[2149]. She was restarted at 200mg daily to avoid issues with cramping. - On [2151-6-29] she had a CT scan which showed new liver lesions which were concerning. An ultrasound was obtained [2151-7-13] which showed these lesions and raised concern for metastatic disease. - She was increased from Gleevec 200mg daily to 400mg daily on [2151-9-8]. - She had stable CT scans and the liver lesions were determined to be cysts, she was decreased from 400mg daily to 200mg daily due to nausea on [2152-4-5]. -CT scan [10/2152] there was increase in size of a right upper mesenteric nodule with no other enlarging disease. Her case was discussed previously and surgery is an option. At this time she is interested in trying 400mg Gleevec to see if this controls/shrinks this mass. If the mass continues to enlarge she would consider surgery. Social History: Lives alone. Has 2 daughters. Moved from [Country ] in [2137]. Has grandchildren who visit her. -Tobacco history: negative -ETOH: negative -Illicit drugs: negative Family History: No family history of cancer, lung disease or heart disease. + for DM. Physical Exam: T 98 P 70 BP 112/64 R 20 SaO2 98% RA Gen: no acute distress heent: no scleral icterus neck: supple Lungs: clear heart: regular rate and rhythm abd: soft,no tender, nondistended, no guarding, nonrigid Extrem: no edema Pertinent Results: [2153-7-29] 03:20PM BLOOD WBC-5.9 RBC-2.63# Hgb-7.8# Hct-23.5# MCV-90 MCH-29.9 MCHC-33.4 RDW-16.6 Plt Ct-215 [2153-7-29] 03:20PM BLOOD Plt Ct-215 [2153-7-29] 03:33PM BLOOD Hgb-8.1* calcHCT-24 [2153-7-30] 02:30AM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-143 K-3.6 Cl-106 HCO3-27 AnGap-14 [2153-7-30] 02:30AM BLOOD WBC-5.6 RBC-3.03* Hgb-9.1* Hct-26.8* MCV-89 MCH-30.0 MCHC-33.8 RDW-17.1* Plt Ct-214 [2153-7-30] 06:02AM BLOOD Hct-27.4* [2153-7-31] 03:57AM BLOOD WBC-5.4 RBC-3.42* Hgb-9.9* Hct-29.8* MCV-87 MCH-29.0 MCHC-33.3 RDW-16.9* Plt Ct-206 [2153-7-31] 11:52AM BLOOD Hct-25.1* [2153-7-31] 04:10PM BLOOD Hct-28.8* [2153-8-1] 06:35AM BLOOD WBC-4.6 RBC-3.35* Hgb-10.0* Hct-30.2* MCV-90 MCH-30.0 MCHC-33.3 RDW-16.8* Plt Ct-252 Brief Hospital Course: 78 years old female with dx of GIST tumor, anticoagulated for Afib admitted wth intraabdominal bleeding on [7-29] Patient was admitted to SICU. Transfused 2u PRBC and 1u FFP. Neurologic: - Intact, mentating well. Continue to follow - Adequate pain control with dilaudid IV PRN Then switched to Po pain medication. Cardiovascular: - Clinically stable - Maintain SBP>90, Continous monitoring showed heart rate control. - continue to follow Hct and coags Pulmonary: - Clinically stable, breathing room air - No respiratory distress. Gastrointestinal / Abdomen: - GIST tumor s/p multiple resections with blood collection in abdomen - No surgical intervention at this time unless change in clinical picture Nutrition: - NPO during HD 1 and 2. The restarted on Clears on HD3 advanced to regular cardiac healthy diet on HD4. Patient tolerate the diet, no abdominal pain or distention. Renal: - Stable. Urine out up was monitored with foley. On HD 4 foley was d/c and patient voided. Hematology: - Anemia secondary to likely bleeding in abdomen - INR 4.0, 2uFFP and 10mg vit K was given on [7-29] - Transfused 2uPRBC, and follow Hct which remined stable for the rest of her hospitalization. Endocrine: Insuline SS, f/u blood sugars DVT profilaxis with pneumatic boots Medications on Admission: Coumadin 4 mg Mon Coumadin 3 mg TueWedFriSatSun Coumadin 5 mg [Last Name (un) ] Metoprolol 25 mg daily amiodarone 200 mg daily levothyroxine 200 mcg daily istalol 0.5% 1 drop each eye [Hospital1 ] lumigan 0.03% 1 drop each eye daily furosemide 80 mg daily gleevec 200 mg daily CaCO3 650 mg [Hospital1 ] cholecalciferol 1000 units daily januvia 100 mg daily Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lumigan 0.03 % Drops Sig: One (1) Ophthalmic once a day: 1 drop. 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 7. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: History of Atrial Fibrilation on coumadin presents with intraperitoneal bleeding from GIST tumors in setting of anticoagulation Heart Failure with preserved EF Diabetes Mellitus Hypercholesterolemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please schedule an appointment with your PCP within [Name Initial (PRE) ] week to restart medications (Coumadin and Gleevec) and f/u INR. 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 10lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: PLease schedule a follow up appointment with Dr. [Last Name (STitle) ]. Phone number: ([Telephone/Fax (1) 1483] Please schedule an appointment with PCP within [Name Initial (PRE) ] week. Provider: [Name10 (NameIs) ] DENSITY TESTING Phone:[Telephone/Fax (1) 4586] Date/Time:[2153-8-3] 1:00 Provider: [Name10 (NameIs) 3150],[Name11 (NameIs) ] MD Phone:[Telephone/Fax (1) 11133] Date/Time:[2153-8-24] 3:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2153-10-31] 11:20 Completed by:[2153-8-1]	[ "V45.89", "V12.54", "401.9", "171.5", "V10.05", "250.00", "428.0", "244.9", "568.81", "V58.69", "272.0", "E934.2", "427.31", "V58.61", "294.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6479, 6485	4239, 5511	318, 325	6742, 6742	3442, 4216	7781, 8402	3113, 3184		5932, 6456		6506, 6721		5537, 5909			6893, 7758									3199, 3423			1011, 1172																					264, 280											353, 904											6757, 6869		1203, 2905				926, 988	2921, 3097
8,827	193,335	13746	Discharge summary	report	Admission Date: [2144-8-18] Discharge Date: [2144-9-3] Date of Birth: [2079-3-18] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Clindamycin / Levaquin / Bactrim / Biaxin / Keflex / Aggrastat / Reopro / Sotalol / Starlix / Verapamil / Amiodarone / Lantus Attending:[First Name3 (LF) 1283] Chief Complaint: DOE Major Surgical or Invasive Procedure: [2144-8-18] Mitral Valve Replacement (27mm [Last Name (un) 3843] [Doctor Last Name ] pericardial valve) History of Present Illness: 65 year old patient with previous cardiac history of coronary artery disease with multiple stent placements, presented with increasing shortness of breath and was found to have severe mitral regurgitation and was electively admitted for mitral valve replacement. The preoperative transesophageal echo demonstrated mitral regurgitation secondary to A2 prolapse and the retracted posterior leaflets. Past Medical History: 1. CAD s/p RCA stent [9-27] 2. s/p pacer placement in [2142] at [Hospital1 336] 3. Congestive heart failure [2144-3-15] echo: EF40%, severe MR, mild concentric LVH with mild LV dilatation , infero-apical hypokinesis and apical akinesis, severe pulm HTN, 4. HTN 5. DM2 with retinopathy 6. MR 7. Hyperlipidemia 8. Cellulitis in [12-27] 9. PVD 10. TIAs 11. SVT 12. Atrial Fibrillation Social History: lives with family in Framigham, no smoke/EtOH, use to work now at home Family History: brother with MI in 50s Physical Exam: Vitals: T: afebrile P: 76 R: 24 BP: 179/81 General: Awake, alert, NAD. Obese HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lung sounds decreased at bases Cardiac: irregularly irregular, S1S2, II/VI HSM at LLSB Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. round 5cmx5cm epigastric lump. Obese. Extremities: 1+ LE pitting edema bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Left heal ulcer. Pertinent Results: [2144-9-3] 05:18AM BLOOD WBC-9.2 RBC-3.13* Hgb-9.2* Hct-28.3* MCV-90 MCH-29.4 MCHC-32.5 RDW-15.1 Plt Ct-227 [2144-9-3] 05:18AM BLOOD Glucose-145* UreaN-31* Creat-1.3* Na-144 K-4.0 Cl-105 HCO3-31 AnGap-12 [2144-8-24] 01:31AM BLOOD ALT-9 AST-16 LD(LDH)-350* AlkPhos-75 Amylase-170* TotBili-2.2* [2144-8-30] 04:45PM BLOOD Glucose-214* K-4.2 [2144-8-28] CXR The right subclavian catheter terminates in the superior vena cava. The cardiac pacemaker is in good position with the leads projecting over the right atrium and the right ventricle. There is a prosthetic valve noted. Patient is status post median sternotomy with normal alignment of the sternal sutures. The cardiomediastinal is enlarged, however stable. The lung volumes are low. There is persistent right bibasilar atelectasis and left lower lobe atelactasis/consolidation. Small bilateral effusions persist. No pneumothorax. Patchy opacity in the left upper lobe consistent with aspiration. [2144-9-1] Upper Ext U/S No evidence of acute right upper limb DVT. [2144-9-2] Lower EXT U/S No evidence of right or left lower limb DVT [2144-9-1] Head CT There is no acute intracranial hemorrhage. No mass effect is seen. No shift of normally limited structures is noted. The surrounding osseous and soft tissue structures are unremarkable. No evidence of acute infarction visible on CT is noted. [Last Name (NamePattern4) 4125]ospital Course: Mrs. [Known lastname 12740] was admitted to the [Hospital1 18] on [2144-8-18] for surgical management of her mitral valve disease. She was taken directly to the operating room where she underwent a mitral valve replacement utilizing a 27mm [Last Name (un) ] [Doctor Last Name ] pericardial tissue valve. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. The electrophysiology service was consulted to adjust her permenant pacemaker settings as her epicardial atrial wire was not capturing. On postoperative day one, her plavix was resumed for her coronary stents. She was transfused for a low hematocrit. She remained intubated as she still required inotropes. A steroid tapor was started. A heparin induced throbocytopenia assay was sent given her low platelet count however this returned negative and her thrombocytopenia resolved. Tube feeds were given while she was intubated to maintain her nutritional support. The wound care service was consulted and followed her for blisters on the lumbar region of her back and her foot ulcer. She deeloped low grade temperatures and a sputum culture was sugestive of pneumonia. Zosyn was subsequently started. On postoperative day seven, Mrs. [Known lastname 12740] awoke neurologically intact and was extubated. Diuresis was continued for peripheral edema. A swallowing evaluation was performed which showed Mrs. [Known lastname 12740] to be swallowing appropriately and her diet was advanced as tolerated. The physical and occupational therapy services were consulted for assistance with her postoperative strength and mobility. The electrophysiology service continued to make adjustments to her pacemaker as she had an episode of nonsustained ventricular tachycardia. On postoperative day thirteen, Mrs. [Known lastname 12740] was transferred to the cardiac surgical step down unit for further recovery. The jolsin diabetes service was consulted for assistance with her diabetes management. A neurology consult was obtained for right hand weakness and the sensation of a transiet ischemic attack. A head CT was ngative however anticoagulation with heparin as a bridge to coumadin was recommended for paroxysmal atrial fibrillation in addition to her aspirn and plavix. A lower and upper extremity ultrasound was performed which ruled out any venous thombosis. A urinalysis was sent due to incontinence which was negative. Mrs. [Known lastname 12740] continued to make steady progress and was discharged to rehabilitation on postoperative day sixteen. She will follow-up with Dr. [Last Name (Prefixes) ], her cardiologist, her primary care physician, [Name10 (NameIs) ] electrophysiology service and the neurology service as an outpatient. Medications on Admission: Plavix 75mg daily Aspirin 81mg daily Protonix 40mg daily Lopressor 100mg twice daily Lasix 60mg twice daily Allopurinol 400mg daily Colchicine 0.6mg daily Atacand 16mg twice daily Glyburide 5mg daily Lipitor 80mg daily Humulin 70/30 Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Tablet, Delayed Release (E.C.)(s) 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Candesartan Cilexetil 4 mg Tablet Sig: Two (2) Tablet PO qd (). 5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for Stop [2144-9-5] days: stop [2144-9-5]. 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. DiphenhydrAMINE HCl 12.5 mg IV Q6H:PRN premedicate for Zosyn d/c after LD [9-5] of zosyn 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Humalog 100 unit/mL Solution Sig: See sliding scale Units Subcutaneous QAC and HS: Sliding scale. 17. Humulin N 100 unit/mL Suspension Sig: 18 Units Units Subcutaneous QAM. 18. Humulin N 100 unit/mL Suspension Sig: Eight (8) Units Subcutaneous QPM. 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 20. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 700 Units Units Intravenous ASDIR (AS DIRECTED): For goal PTT 50-60. D/C when INR 2.0. Units 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO once a day: Please adjust for an INR between 2.0-2.5 for PAF. Please draw daily PT/INR's. 23. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: TIA's, CHF, CAD, Hyperlipidemia, HTN, Obesity, PAF, GERD, Gout, Asthma, ARF, CRI, PPM, S/P MVR. Discharge Condition: Good Discharge Instructions: 1) Please monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Monitor vital signs. Report any fever greater then 100.5. 3) No lifting greater then 10 pounds for 10 weeks. No driving for 4 weeks. 4) Do not apply lotions, creams or powders to wound until it has healed. 5) Report any weight gain of more the 2 pounds in 24 hours. 6) Continue Heparin until INR 2.0, then discontinue. Dose coumadin daily for an INR of 2.0-2.5. Discharge dose is 3mg. Please draw daily PT/INR to dose coumadin accordingly. Dr. [First Name (STitle) 4640] will monitor coumadin as an outpatient. Discontinue the peripheral IV when the the heparin is turned off. 7) Take zosyn until [2144-9-5] and then stop. Take with IV benadryl as ordered. Stop benadryl when zoysn stopped. Discontinue the subclavian line when zoysn is off. 8) Call with any questions or concerns. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. Call ([Telephone/Fax (1) 1504] for appointment. Follow-up with Dr. [First Name (STitle) 4640] (PCP) in 2 weeks. Call ([Telephone/Fax (1) 41363] Follow-up with cardiologist Dr. [Last Name (STitle) 41364] in 2 weeks. Call for appointment. Follow-up with electrophysiology service as instructed. Dr. [Last Name (STitle) ]. Please call for appointment. Follow-up with neurology service in [2-27] months or as needed. [Telephone/Fax (1) 41365] Follow-up with the [Last Name (un) ] diabetes service as instructed or as needed. Completed by:[2144-9-3]	[ "278.00", "440.21", "424.0", "428.0", "518.5", "507.0", "250.60", "707.14", "V58.67", "729.89", "997.09", "412", "427.31", "401.9", "287.5", "V53.31", "357.2", "V12.59", "458.29", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "35.23", "96.72", "96.6", "88.72", "99.04", "39.61" ]	icd9pcs	[ [ [] ] ]	9019, 9164		409, 527	9303, 9309	2117, 3502		1486, 1510		6607, 8996		9185, 9282		6350, 6584			9333, 10227			10278, 10920						1525, 2098															3553, 6324									366, 371											555, 955																	977, 1381	1397, 1470
61,078	119,671	39673	Discharge summary	report	Admission Date: [2130-7-14] Discharge Date: [2130-7-27] Date of Birth: [2085-9-4] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[First Name3 (LF) 78] Chief Complaint: OSH transfer for SAH Major Surgical or Invasive Procedure: Angiogram with coiling of L MCA [2130-6-14] History of Present Illness: 44y F with SAH. Found down at home (exact sequence of events unknown at this point) and taken to OSH. Intubated on arrival due to agitation/confusion/combativeness and ?hypoxia (by report), then on NCHCT was found to have sylvian, sulcal and prominent cisternal SAH. Also, CXR showed ?noncardiogenic (multifocal) pulmonary edema vs. multifocal PNA and CT-C-spine (degraded at C7-T2 by motion artifact) did not reveal a fracture, bony lesion or misalignment. By report, she was hyperglycemic to the 300s with pH 7.3x? and a Utox was +MJ and +benzos (Rx for Ativan and Klonopin per report), otherwise negative Utox. She was flown here to [Hospital1 18] ED from the OSH for neurosurgical management, due to her grade IV-V SAH (year old female who coplains of SAH. She was reportedly difficult to oxygenate, requiring high PEEP and FiO2, and a large amount of pink frothy sputum was suctioned from her ETT on arrival. Fentanyl and Versed were stopped on arrival for neuro exam, on which she followed commands ([Last Name (un) 87444] [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]) and moved all four extremities. Eyes were fixed midline (no tracking) and pupils were equal and reactive. Vecuronium was given due to agitation and difficulty oxygenating the patient with lots of secretions / pulmonary edema. Past Medical History: h/o EtOH abuse "in [2125]" h/o PSA h/o depression/psych/?schizoaffective (pt takes Seroquel per report) Social History: unknown; apparently a son and a daughter were here to give consent for [Name (NI) 10788]/coiling, but I have not been able to speak with them at this point. Family History: unknown Physical Exam: BP: 102/75 HR: 118 RR: 16 100% on vent Gen: sedated (just turned off), intuabted. HEENT: Pupils: 4-->2 and equal EOMs fixed midline. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Follows simple commands. Otherwise non-reactive. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light 4-->3 III, IV, VI: Does not track. No nystagmus, fixed midline gaze. V, VII: VIII: Hearing intact to voice. (follows simple commands) IX, X: +cough/gag [Doctor First Name 81]: XII: Can protrude tongue adj to ETT. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moves all extremities. Sensation, coordination, gait: Unable to assess. Toes downgoing bilaterally DISCHARGE EXAM: As above. Neurologically intact. Pertinent Results: CTA HEAD W&W/O C & RECONS [2130-7-14] 1. Subarachnoid hemorrhage with small bilateral intraventricular hemorrhage. 2. 5-mm aneurysm arising at the bifurcation of the left middle cerebral artery. 3. Mild dilatation of the temporal horns of the lateral ventricles, suggesting evolving hydrocephalus. CT C-SPINE W/O CONTRAST [2130-7-15] 1. No evidence of fractures or alignment abnormalities. 2. Partially imaged extensive [Hospital1 ]-apical consolidations. CT HEAD W/O CONTRAST [2130-7-15] . Diffuse subarachnoid hemorrhage, with slightly increased intraventricular component, which could represent redistribution.Mild ventriculomegaly. 2. Unchanged mild dilation of the occipital [Doctor Last Name 534] of the left lateral ventricle without significant hydrocephalus. Mild cerebral edema with effacement of perimesencephalic cistern without frank downward transtentorial herniation, attention on followup is recommended. CTA Head [7-19]: IMPRESSION: 1. No evidence of vasospasm. 2. Interval coiling of left MCA aneurysm. 3. Near-complete resolution of subarachnoid hemorrhage and intraventricular blood [7-21] CTA: IMPRESSION: Minimal nonocclusive vasospasm of the anterior circulation. No evidence of infarct. No new hemorrhage. [7-24] CTA: IMPRESSION: 1. No evidence of acute intracranial abnormalities. 2. Smooth mild narrowing of the proximal M1 segment of the left middle cerebral artery, and mild vasospasm of the anterior cerebral and middle cerebral arteries, which are similar to [2130-7-21], but new compared to [2130-7-14]. [7-26] Head CT: Left MCA aneurysm coil. No acute intracranial findings Brief Hospital Course: 44 y/o F found down at home was sent to OSH. She was intubated on arrival for aggitation. Head CT showed SAH and patient was then transferred to [Hospital1 18] for further neurosurgical workup. Upon arrival to [Hospital1 18], patient had a CTA which revealed a 6mm L MCA aneurysm. On [2130-7-15], patient was taken to angiogram and her aneurysm was coiled successfully. She was then transferred to the ICU to be monitored for vasospasm. She remained intubated d/t increase in secretions. Off propofol, patient was appropriate, following commands and moving all extremities. Post operative head CT stable. On [7-17], patient was extubated and SBP range was increased to 120-160. She continued to be nonfocal upon examination, but reported a severe headache. The decision was made to repeat the CTA on [7-19] - this revealed near complete resolution of SAH, as well as no evidence of vasospasm. Her dilantin level was noted to be 1.3, so therefore a 1gm bolus was given. She remained in the ICU on [7-20], with a much improved headache. On [7-21] the patient was very agitated requiring haldol, IVF was increased. A CTA was performed revealing mild vasospasm. no intervention was performed at this time. Psychiatry consult was obtained for assistance with medications and discharge planning. She was started on adderall. [7-22] pt neurologically improved. cont to be followed by psychiatry. u/a negative, dilantin bolused for level of 5.2 [7-23] stable. no changes. [7-24] pt c/o h/a, CTA obtained which was negative for vasospasm. [7-25] pressors were weaned off, dilantin discontinued and fluids were decreased in the setting of a stable exam. A CTA revealed no evidence of vasospasm. She was transferred to the floor. [7-26] Pt agitated but stable neurologically. h/a overnight therefore a CT was obtained which was stable. IVF was discontinued. TLC was removed. Psychiatry cont to follow. Psychiatry determiend that the patient was safe to go home as long as she knew the risks involved, and that she had appropriate supervision from family. She was seen again by physical therapy who determined that she was safe to go home. She was discharged to home on [2130-7-27]. Medications on Admission: Seroquel Trazodone Ativan Klonopin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Nimodipine 30 mg Capsule Sig: One (1) Capsule PO Q2H (every 2 hours) as needed for vasospasm. 8. Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO daily (). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [12-3] Tablets PO Q4H (every 4 hours) as needed for headache. Disp:60 Tablet(s) Refills:0 12. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: [12-3] Caps PO Q4H (every 4 hours) as needed for h/a. Disp:60 Cap(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: L MCA aneurysm SAH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in 4 weeks with a MRI/MRA of the head. An appointment can be made by calling [Telephone/Fax (1) 1669] Completed by:[2130-7-27*]	[ "331.4", "295.30", "430", "250.00", "518.81", "296.80", "786.2", "314.01", "305.90", "287.5", "458.29", "041.11" ]	icd9cm	[ [ [] ] ]	[ "88.41", "96.71", "38.91", "39.72", "38.93" ]	icd9pcs	[ [ [] ] ]	8198, 8204	4591, 6819	294, 344	8267, 8267	2908, 4502	10329, 10520	2024, 2033		6905, 8175		8225, 8246		6845, 6882			8418, 9387	9413, 10306								2048, 2304					2854, 2889																			234, 256											372, 1697	2385, 2838					4511, 4568					8282, 8394						1719, 1829	1845, 2008
9,363	174,876	52327	Discharge summary	report	Admission Date: [2155-10-27] Discharge Date: [2155-11-2] Date of Birth: [2091-10-21] Sex: F Service: HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 101878] is a 63-year-old female with a past medical history significant for Methicillin-resistant Staphylococcus aureus pneumonia, end-stage renal disease secondary to Lithium toxicity, papillary thyroid cancer status post tracheostomy complicated by vocal cord paralysis, and Crohn's disease who was admitted to the Emergency Department on [2155-10-27] with hypotension and fever after dialysis. This is the third week in a row that this has happened. She has been worked up for bacteremia in the past, and so far only one of many blood cultures grew out Stenotrophomonas. She has been on intravenous vancomycin and more recently gentamicin for this blood culture. A recent TEE on [2155-10-21] was without vegetation, and patient had an ejection fraction of 55%. REVIEW OF SYSTEMS: Patient denies cough, night sweats, or sick contacts. She also denied nausea, abdominal pain, vomiting, dysuria, hematuria, chest pain, or shortness of breath. Her only other complaint was of hand/arm pain, which is a chronic issue. PAST MEDICAL HISTORY: 1. Methicillin-resistant Staphylococcus aureus of the left lower lobe diagnosed 11/[2152]. MRSA screen in [2154] was positive. 2. End-stage renal disease on hemodialysis for 11 years. 3. Papillary thyroid cancer status post tracheostomy that was complicated by vocal cord paralysis. 4. Intention tremor secondary to Lithium. 5. Osteoporosis. 6. Crohn's disease status post ileostomy with history of chronic diarrhea. History of perineal abscess status post colectomy and a history of perineal abscesses. 7. Basal cell carcinoma of the right lower extremity. 8. History of recurrent right upper extremity AV graft thromboses and pseudo aneurysm formation. 9. History of upper GI bleed secondary to NSAIDs. 10. Hypothyroidism. MEDICATIONS ON ADMISSION: 1. Remeron 45 mg p.o. q. h.s. 2. Ambien 5 mg p.o. q. h.s. 3. Digoxin 0.125 mg p.o. q.o.d. 4. Synthroid 0.125 mg q.d. 5. Nephrocaps one q. Tuesday through Saturday, [Year (4 digits) 1017]. 6. Protonix 40 mg p.o. q. day. 7. Premarin 0.625 mg p.o. q. Tuesday, Thursday, Saturday, [Year (4 digits) 1017]. 8. Oxycodone 10 mg q. Monday, Wednesday, [Year (4 digits) 2974] with dialysis. 9. Oxycodone 10 mg q. 4 hours p.r.n. 10. Remegel 800 mg t.i.d. 11. Atrovent b.i.d. 12. Salmeterol q.d. 13. Phos-Lo 667 mg b.i.d. Tuesday, Thursday, [Last Name (LF) 2974], [First Name3 (LF) 1017]. 14. Humibid two b.i.d. 15. Mucinex 600 b.i.d. 16. Heparin subcutaneously. 17. Lithium 700 mg with hemodialysis. 18. Fentanyl patch 125 mg q. 72 hours. 19. Elavil 75 mg q. h.s. 20. Mirtazapine 30 mg p.o. q. h.s. 21. Loperamide p.r.n. 22. Maprotiline 125 mg q. Tuesday, Thursday, Saturday, [First Name3 (LF) 1017]. PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.1 F, blood pressure 91/53, pulse 78, respirations 17, satting 100 brisk sound and a high flow trach mask. Generally, patient is in no acute distress. She is alert and oriented times three. Patient has no voice but is able to clearly mouth words. Neck: Trachea in place with thick white secretions. HEENT: Pupils equal, round, reactive to light. Extraocular movements intact. Heart sounds are normal. Lungs are clear. Abdomen is diffusely tender; no rebound or guarding; no bowel sounds. Extremities: No edema; with good pulses. SIGNIFICANT LABORATORY DATA ON ADMISSION: White blood cell count with 94% neutrophils and 0% bands, hematocrit 34.6. Chemistries are within normal limits aside from the creatinine of 3.8 based on creatinine and BUN between 5 and 8. Lactate is 2.20. SUMMARY OF HOSPITAL COURSE: 1. Line sepsis: Patient was initially admitted to the Medical Intensive Care Unit secondary to her hypotension and concern about sepsis. She was stabilized with fluids and was transferred to the floor the next morning. She has been hemodynamically stable since. Blood cultures this hospitalization were drawn daily and are still negative to date. However, she was started empirically on vancomycin and gentamicin which were dosed at dialysis. Since this is the third week this has happened, she was suspected to have a line infection from her Perm-A-Cath. When this was removed and cultured, it grew out Stenotrophomonas sensitive to Bactrim. Vancomycin and gentamicin were discontinued and Bactrim started on [2155-11-1]. Patient was afebrile after the first day, and her white blood cell count came down nicely. She needs to continue taking Bactrim to be dosed at dialysis for the next two weeks. 2. End-stage renal disease: Patient continued to have dialysis while an inpatient. As her Perm-A-Cath was removed, a temporary catheter was placed in her groin for dialysis use only. This was removed the day of discharge. Another Perm-A-Cath was placed during this admission and is working fine. 3. Chronic hand pain: This is a big issue with this patient and is causing her to lose function of her hand. She is to follow up in Pain Clinic on Tuesday, [2155-11-4]. She is to continue to receive Fentanyl patch and Oxycodone p.r.n. and also before dialysis as dialysis exacerbates her pain. 4. Bipolar disorder: Patient is to continue on her meds which she was on prior to admission. The dosing of the medication maprotiline was questioned, however, and this needs to be readdressed by her primary doctor. In the meantime it has been discontinued. 5. Trach and ostomy care: Continue as before admission. No issues, needs, regards during this admission. DISCHARGE DIAGNOSES: 1. Bacteremia from line infection. 2. Chronic renal failure. 3. Chronic hand/arm pain. DISCHARGE MEDICATIONS: 1. Heparin 5000 units subcutaneous q. 8 hours. 2. Oxycodone 15 mg p.o. Monday, Wednesday, and [Year (4 digits) 2974] prior to hemodialysis. 3. Atrovent two puffs b.i.d. 4. Salmeterol 50 mcg, one inhalation q. day. 5. PhosLo 667, one tablet, b.i.d. Tuesday, Thursday, Saturday, [Year (4 digits) 1017]. 6. Dextromethrophan-guaifenesin 5 to 10 ml q. 6 hours as needed. 7. Ambien 5 mg p.o. q. h.s. 8. Amitriptyline 75 mg p.o. q. h.s. 9. Loperamide one p.o. q. 8 hours p.r.n. 10. Oxycodone 10 mg p.o. q. 3 hours p.r.n. 11. Estrogen 0.625 mg, one, p.o. q. Tuesday, Thursday, Saturday, [Year (4 digits) 1017]. 12. Protonix 40 mg, one, p.o. q. day. 13. Multivitamin, one, p.o. q. Tuesday, Thursday, Saturday, [Year (4 digits) 1017]. 14. Synthroid 125 mcg, one, p.o. q.d. 15. Digoxin 0.125 mg, one, p.o. q.o.d. 16. Mirtazapine 45 mg, one, p.o. q.h.s. 17. Lithium 600 mg three times a week following hemodialysis. 18. Tylenol p.r.n. 19. Simethicone p.r.n. 20. Fentanyl 125 mcg per hour; change every 72 hours. 21. Sevelamer 1600 mg t.i.d. DISCHARGE INSTRUCTIONS: 1. Patient is to follow up with Pain Management on [2155-11-4] at 10:30 a.m. 2. She is also to follow up with Dr. [Last Name (STitle) 217] [2155-11-18] at 11 a.m. 3. She is also to follow up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], her primary doctor, within the next week. She needs to call to make this appointment. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To [Hospital3 2558]. DR.[First Name (STitle) ],[First Name3 (LF) 275] 11-498 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2155-11-2] 12:13 T: [2155-11-3] 22:01 JOB#: [Job Number 108190]	[ "038.9", "996.62", "V44.2", "244.9", "296.7", "585", "555.9", "V44.0", "193" ]	icd9cm	[ [ [] ] ]	[ "86.05", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]				7295, 7584				5714, 5805	5828, 6883				2008, 2952			6907, 7273																			3803, 5693											979, 1215														158, 959										3566, 3775							1237, 1982
15,433	163,720	20242	Discharge summary	report	Admission Date: [2123-10-13] Discharge Date: [2123-10-15] Date of Birth: [2045-1-2] Sex: M Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 78 year old gentleman with a history of previous strokes in [2118] and in [2122-11-1], who was admitted to [Hospital1 190] as a transfer from [Hospital ] Hospital emergency room after a fall. His history dates back to [2118] when he had an episode of slurred speech and clumsiness with his right hand, leading him to write sloppily. These deficits lasted for about six weeks or so. He did well until about [2122-11-1] when he experienced the acute onset of hemiparesis and facial droop on the left and he was treated at [Hospital ] Hospital. He was briefly put on Coumadin and then discontinued after some complications with GI bleeding. He had a complicated post stroke course and ended up receiving a tracheostomy and a PEG tube for feeding, which were both removed in [Month (only) 547] and [2123-4-1] respectively. He had been at a rehab facility until [2123-7-2]. He was living at home in [Location (un) 13011] with his 24 hour caregivers. [Name (NI) ] falls a lot, according to his wife, but this is not different since before the stroke in [Month (only) 1096], according to her. He has not had any episodes of seizure like activity, abrupt changes in mood, personality or speaking difficulties. He had recently visited his cardiologist, Dr. [Last Name (STitle) ], at [Hospital ] Hospital about six weeks prior to admission and it was decided at that time that he should be put back on Coumadin for his history of atrial fibrillation. On the Monday before admission the patient fell out of his wheelchair, hitting his left hip and head. He did well until Tuesday morning when he was noted to have a headache as well as some nausea and vomiting. His caregiver had called an ambulance and called his wife who was working in [Name (NI) 86]. By the time she got home, he had already shooed away the EMTs. The next morning she called EMTs again because he was confused and she thought this was a gradual change over that morning. He was speaking with words that made sense by themselves, but were put together in incorrect sentences. She has not noted any personality changes or abrupt changes in mood. He was brought to [Hospital ] Hospital E.D. and subarachnoid blood was noted in addition to temporal lobe contusion. He was transferred for further management. He was thought to be speaking fluently, but incoherently on exam. Repeat CT showed a subdural hematoma after he came to [Hospital1 69]. He was given five units of FFP, platelets and 10 mg of vitamin K to reverse his INR which was found to be 1.87 at [Hospital ] Hospital E.D. He was placed on a Nipride drip for blood pressure control to systolic blood pressure of less than 140 and he gradually improved in the ICU until the morning of transfer to the neurology service. His wife came in on the morning of transfer from the ICU to the neuro floor and noticed a dramatic change, much more like his usual self. The weakness was not different than from before his fall, according to his wife. PAST MEDICAL HISTORY: CAD status post MI and CABG in [2106]. Right sided heart rate. History of GI bleed. Status post cholecystectomy. Status post hemicolectomy status post diverticulitis. Ventral hernia and history of small bowel obstruction. Diabetes. Hypertension. Stroke in [2118] and [2121] as described above. Atrial fibrillation. MEDICATIONS: Medications at home include Coumadin 5 mg p.o. q.d. except Wednesday 7.5 mg p.o. q.d., Protonix 40 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., aspirin 81 mg p.o. q.d., Lipitor 10 mg p.o. q.d. Medications on transfer from the SICU include docusate, subcu heparin, Protonix 40 mg p.o. q.d., atorvastatin 10 mg p.o. q.d., regular insulin sliding scale, phenytoin 100 mg IV t.i.d., metoprolol 25 mg p.o. b.i.d., ondansetron p.r.n. nausea, Tylenol p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Habits not obtained at this time. The patient lives in [Location 13011] with his wife and has 24 hour caregivers. [Name (NI) ] speaks English, [Doctor First Name 533], French, Norwegian and [Country ]. He was a former Norwegian freedom fighter in World War II. FAMILY HISTORY: Not obtained. PHYSICAL EXAMINATION: Temperature 100.6, heart rate 78, respiratory rate 29, O2 sat 96 percent in room air. In general, he was a well appearing, elderly man in no apparent distress. HEENT revealed dry mucous membranes. Lungs revealed some coarse upper airway breath sounds. Cardiovascular exam revealed regular rate and rhythm without murmurs, gallops or rubs. Abdomen was soft and nontender. Extremities showed Multi Podus boot on the left. Neck movements were full and not painful to palpation in the paraspinal soft tissues. On mental status the patient was alert and recalled two objects at three minutes which increased to three out of three with cues. He had good knowledge for current events. He was able to say that [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2450] is the son of [Name (NI) ] [Name (NI) 2450]. Language was intact in naming, repetition and comprehension. There was no apraxia or agnosia. There was no left/right agnosia. Cranial nerves visual acuity was intact. Visual fields were full. Optic disks were difficult to visualize due to myotic pupils 2 mm. Pupil size on the right was about 2 1/2 mm and on the left roughly 3 [12-3]. Eye movements were normal. Pupils reacted normally to light. Sensation on the face was intact to light touch and pin. There was a facial droop on the left. Hearing was intact to finger rub. There was no nystagmus. Palate elevated in the midline. Tongue protruded slightly left of the midline and is normal in appearance. Sternocleidomastoid muscles were strong bilaterally. Speech was slightly slurred, according to his family, who were present. Motor had increased tone in the left upper extremity. There was 3/5 strength on the left side. The right side was [4-5] in the upper and lower extremities. There were no adventitious movements. Coordination there was no ataxia. Finger/nose test and heel/shin test were performed accurately on the right. Deep tendon reflexes were all present, but brisker on the left throughout. Plantar responses were flexor on the right and extensor on the left. Sensation was intact to light touch, pin, temperature and joint position of the extremities and the trunk. Gait and stairs were deferred. IMAGING STUDIES: CT of the head showed a small left temporal subdural hematoma that extended along the superior margin of the left tentorium. There was a small hemorrhagic contusion within the left inferior lateral temporal lobe. There was a small subarachnoid hemorrhage adjacent to the contusion. The inferior left temporal lobe was slightly edematous compared with the right. There was no shift in midline structures. There was no hydrocephalus. There was no evidence of fracture. MRI of the head showed no diffusion restriction. There was susceptibility artifact in the vicinity of the temporal bone, but otherwise no other susceptibility artifact apart from where it was expected near the contusion. Motion artifact was present on the MRA. HOSPITAL COURSE: The patient was transferred from the ICU to neurology and did well. He was initially loaded on Dilantin while in the ICU for concern of seizure resulting in the inability to speak. He was continued on Dilantin 300 mg p.o. q.d. and tolerated this well. He was ruled out for MI. We also held aspirin and Coumadin to let the bleed subside. He had hip films and a chest x-ray which showed no evidence of pelvic or hip fracture in the setting of no hip pain. Chest x-ray also did not show any heart failure or pneumonia. The patient was cleared by P.T./O.T. for home with services and he was referred back to VNA. DISCHARGE DIAGNOSES: 1. Subdural hematoma with left temporal brain contusion. 2. Diabetes. 3. Hypertension. 4. Hyperlipidemia. 5. History of coronary artery disease status post myocardial infarction and coronary artery bypass graft in [2106]. 6. Right sided heart failure. 7. History of gastrointestinal bleed. 8. Status post cholecystectomy. 9. Hemicolectomy status post diverticulitis. 10. Ventral hernia and history of small bowel obstruction. 11. Stroke in [2118] which sounded lacunar and also in [2122-11-1] as described previously. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg p.o. q.d. 2. Metoprolol 25 mg p.o. b.i.d. 3. Dilantin 300 mg p.o. q.d. 4. Pantoprazole 40 mg p.o. q.d. FOLLOWUP: The patient is to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in two months' time in the stroke clinic. He was also referred back to his cardiologist and primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with services. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 5930] [Last Name (NamePattern1) ], M.D. [MD Number(1) 6125] Dictated By:[Name8 (MD) 4064] MEDQUIST36 D: [2123-10-27] 16:17 T: [2123-10-29] 20:14 JOB#: [Job Number 54357]	[ "852.21", "401.9", "272.0", "851.41", "428.0", "414.01", "250.00", "E884.3", "427.31" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							4419, 4434	8100, 8640	8663, 9125					7462, 8079																									4457, 6690																					168, 3241																	3264, 4104	4121, 4402	9150, 9500			6708, 7444
41,326	120,490	14007	Discharge summary	report	Admission Date: [2132-4-15] Discharge Date: [2132-4-17] Date of Birth: [2046-12-22] Sex: M Service: NEUROSURGERY Allergies: Haldol Attending:[First Name3 (LF) 78] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: R [Hospital ] transfer from OSH HPI: Pt is an 85m with history of severe dementia who was transfering with the help of family yesterday and he fell and hit his head. The son states he had no change in his mentation and continued to move everything and eat as he normally does. He is on coumadin for AFib and the sister is a NP who recommended who go to the hospital to get checked out since he hit his head. OSH CT Head showed a right sided SDH with no midline shift or hydrocephalus. He was given FFP and Vitamin K for an INR of 1.8 and transferred to [Hospital1 18] for further care. Per report CT C spine was negative and he collar was removed at outside facility. Past Medical History: # IDDM # a-fib on coumadin # HTN # mild aortic stenosis # CVA in past # history of old small, reportedly lacunar infarcts # ETOH abuse Social History: Demented. Lives with son who provides 24 hour care Family History: NC Physical Exam: T: 98.3 BP:140 /66 HR: 64 R 16 O2Sats 99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA 2-1mm Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and eyes open. Does not follow commands. Is non verbal with only moaning. Will move all extremities spontaneously and symetrically. Sensation intact in all extremities. Pertinent Results: CT head: [2132-4-16]: IMPRESSION: No significant change in the relatively thin acute subdural hematoma layering over the right cerebral convexity, extending into that middle cranial fossa. There has been no increase in mass effect and no new hemorrhage is seen. Brief Hospital Course: Mr. [Known lastname 22484] was admitted to the Neurosurgical service for evaluation and observation. He was given a few doses of Vitamin K to reverse his Coumadin. A repeat CT of the head was performed which showed no significant change to his SDH. His Coumadin and ASA were held. He is scheduled for repeat CT head in 3 weeks with follow up with Dr [First Name (STitle) ] thereafter. At that moment they will discuss options for restarting Coumadin/ ASA. There was no change to mental/physical status per primary care givers report. Medications on Admission: Pravastatin, Celexa, Trazodone, Coumadin, Seroquel, Lantus, Lopressor, Diovan Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Lantus: per prvious home dose 7. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO QDAY 8. Lopressor per home dose 9. Diovan per home dose Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary: Stable traumatic Right SDH Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were observed at [Hospital1 18] after suffering a mechanical fall on [2132-4-14]. You were seen at an OSH where a CT scan showed a right sided subdural bleed and you were then transfered here for further care. You had no change to your mental status or to your physical exam per your care giver. You had a repeat CT head which demonstrated a stable bleed. Your aspirin and coumadin were held. You are asked to continue to hold your aspirin and coumadin but continue with the rest of your medications. We will repeat a head CT in 3 weeks then discuss the options for restarting your Coumadin and aspirin. You should follow up with your primary care provider as well to discuss these options. Followup Instructions: Neurosurgery: Dr [First Name (STitle) ], A. Date/Time:[2132-5-8] at 10:00 am in the [Last Name (un) 2577] Bldg [Location (un) 470] Neurosurgery. You will have a CT head done prior to your appointment. The CT scan will be done in the clinical center [Location (un) 470] at 9 a.m. on [2132-5-8] Please arrive at least 30 minutes prior to your appointment. The CT head has been Ordered for [2132-5-8] Please call [Telephone/Fax (1) 327](#1) to ensure date and time. Please make a follow up appointment with your PCP after your appointment with Dr [First Name (STitle) ]. [Last Name (LF) ],[First Name3 (LF) ] J. Location: [Location (un) ] CARDIOLOGY Address: [Location (un) ]. [Apartment Address(1) 41824], [Location (un) ],[Numeric Identifier 28669] Phone: [Telephone/Fax (1) 9219] Completed by:[2132-4-17]	[ "V58.67", "438.82", "E884.2", "441.4", "873.0", "311", "414.01", "707.23", "427.31", "438.13", "707.03", "401.9", "787.22", "250.00", "790.92", "E934.2", "852.21", "294.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3173, 3244	1915, 2460	275, 281	3324, 3324	1624, 1624	4187, 5068	1231, 1235		2590, 3150		3265, 3303		2487, 2567			3460, 4164									1250, 1413																								231, 237											309, 988			1633, 1892								3339, 3436						1010, 1147	1163, 1215
5,274	117,739	14184	Discharge summary	report	Admission Date: [2159-6-8] Discharge Date: [2159-6-10] Service: [Hospital Unit Name 196] CHIEF COMPLAINT: Unstable angina/chest pain HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 42205] is an 85-year-old man with a history of hypertension, diabetes mellitus, and peripheral vascular disease. He was in his usual state of health until several weeks ago when he started to experience chest discomfort with exertion. The episodes resolved with rest and the patient did not seek medical attention. The day prior to admission, however, the patient experienced worsening midsternal chest pain [10-24] while picking up the trash. The symptoms were not associated with shortness of breath, nausea, or diaphoresis. The symptoms resolved after five minutes. The patient remained pain free until this morning of admission when the patient again experienced 4/10 chest pain with minimal exertion walking, and presented to [Hospital3 1443] Hospital, where he was given aspirin, Lopressor, Heparin, nitroglycerin paste with relief of symptoms. Electrocardiogram showed anterior ST-T wave changes, right bundle branch block, biphasic T wave in V1 through V4. First set of enzymes and troponin were negative. Patient was transferred to [Hospital1 69] for cardiac catheterization. In the catheterization laboratory, the patient was found to have three vessel coronary artery disease: left anterior descending artery with 50% stenosis at D1, the small D1 with 80% stenosis, ostial 50% left circumflex with 90% tubular lesion in the OM1, and right coronary artery totally occluded with antegrade collateral flow. No left ventriculogram was performed. The 90% lesion in the OM-1 was successfully stented with a 2.5 X 15 mm BioDivysio stent. Pressure wire evaluation of the LAD yielded a FFR of 0.81, indicating no limitation to flow. The patient experienced Mobitz-II rhythm with adenosine during the pressure wire study, but this resolved upon cessation of the drug. At the conclusion of the procedure, the patient was pain free and hemodynamically stable. Coronary artery disease risk factors: ? Cholesterol, hypertension, diabetes mellitus, negative family history, negative tobacco. PAST MEDICAL HISTORY: 1. Peripheral vascular disease, S/P AAA repair. 2. Hypertension. 3. Prostate cancer recently started radiation treatment. PAST SURGICAL HISTORY: 1. Abdominal aortic aneurysm repair. 2. Status post appendectomy. 3. Cataract surgery. ALLERGIES: No known drug allergies. MEDICATIONS: The patient is unable to recall medications. Daughter is to bring in medication list in from; per outside hospital records: 1. Aspirin 325 mg po q day. 2. Proscar 5 mg po q day. 3. Hytrin 2 mg po q day. 4. Klonopin 0.1 mg po, ? dosing. 5. Lopressor 25 mg po bid. 6. Plavix 300 mg po given at outside hospital x1. SOCIAL HISTORY: Lives with wife who has [Name (NI) 2481] disease. Wife goes to daycare. Their three children assist with care seven days a week, is a nonsmoker. REVIEW OF SYSTEMS: Negative transient ischemic attack, negative cerebrovascular accident, negative myocardial infarction, negative claudication, negative gastrointestinal bleeding. INITIAL LABORATORY STUDIES: White blood cell count is 6.5, hematocrit 41.6, platelets 245. Chem-7: Sodium 144, potassium 4.1, chloride 107, bicarb 22, BUN 29, creatinine 1.5, which is his baseline, and glucose 161. PHYSICAL EXAMINATION: General: Well-developed and well-nourished male lying on stretcher in no apparent distress, looks younger than stated age. Vital signs: Heart rate 66, blood pressure 131/80, sat 99%. Neck without bruits. Lungs clear anteriorly. Heart: Normal S1, S2, regular, rate, and rhythm, no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, mildly distended. Right groin with arterial sheath in situ, no hematoma, no ooze, and no flank tenderness. Dorsalis pedis and posterior tibial pulses intact bilaterally. Extremities are warm. No edema. He was on an Integrilin drip. ASSESSMENT: This is an 85-year-old male with coronary artery disease, peripheral vascular disease, hypertension, diabetes mellitus, status post OM-1 stent placement. HOSPITAL COURSE: Cardiovascular: Patient remained hemodynamically stable while on the floor without Telemetry events until the time of sheath pull. At the time of sheath pull, the patient shortly afterwards developed hypotension with a systolic blood pressure down to the 70s/30s and bradycardia with a heart rate in the 30s. The patient was given intravenous fluids and 2 mg of atropine (through what was actually an infiltrated IV). The patient subsequently became notably more somnolent. Although he was easily arousable and had a nonfocal examination, he fell asleep easily (unlike before sheath removal). The mental status changes were attributed to the excessive atropine given essentially subcutaneously. He was transferred for the CCU for observation, where he remained stable wit a blood pressure of 126/66 with a heart rate of 80. The patient was monitored in the Intensive Care Unit for approximately five hours, and then was transferred back to the [Hospital Unit Name 196] service for further observation. The patient remained hemodynamically stable on the [Hospital Unit Name 196] service throughout the rest of his hospital course with no Telemetry events. The patient did not experience any more chest pain or shortness of breath at any time. The patient had no recollection of the episode which was deemed vasovagal episode. Followup laboratories were checked: Patient's CK was 110, MB 5. CK was down from prior CK of 127. ALT 18, AST 18. Chem-7 unremarkable. Hematocrit 34.4 postprocedure and stable. Total cholesterol 208, triglycerides 184, HDL 42, LDL 124, for which atorvastatin was begun. Admission TnI was 6.3, consistent with a small non-ST elevation MI with normal MB. Patient had an uneventful day of observation after vasovagal episode, and was felt to be stable for discharge by the next day. The patient's heart rate and blood pressure were stable at all times after transfer from the CCU. Groin showed no evidence of bleeding or hematoma, was soft, and there was no bruit. DISCHARGE DIAGNOSES: 1. Coronary artery disease with non-ST elevation myocardial infarction (marker-positive unstable angina), now S/P stent placement in OM-1. 2. Vasovagal episode upon sheath pull complicated by somnolence. 3. Peripheral vascular disease. 4. Hypertension. 5. Diabetes mellitus. 6. Chronic renal insufficiency with creatinine of 1.5. Of note, creatinine was stable at 1.5 throughout his hospital course, and discharge creatinine was 1.3. 7. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. Nitroglycerin 0.3 mg tablets sublingually prn. 2. Finasteride 5 mg po q day. 3. Terazosin 2 mg po hs. 4. Metoprolol 25 mg po bid. 5. Aspirin 325 mg po q day (maintain 325 mg daily X 1 month mininum, then consider 81 mg daily) 6. Plavix 75 mg po q day x 9 months. 7. Lipitor 10 mg po q day. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. FOLLOW-UP INSTRUCTIONS: The patient is to followup with his cardiologist Dr. [Last Name (STitle) ] at [Hospital3 1443] Hospital in two weeks, and instructed if he is to have any chest pain, dizziness, loss of consciousness, difficulty breathing, to call his doctor or come to the Emergency Room. [Doctor First Name ] [Name8 (MD) 20141], M.D. [MD Number(1) 7100] Dictated By:[Name8 (MD) 6867] MEDQUIST36 D: [2159-6-10] 11:35 T: [2159-6-14] 08:33 JOB#: [Job Number 42206]	[ "250.00", "411.1", "426.12", "185", "997.1", "401.9", "414.01", "458.2" ]	icd9cm	[ [ [] ] ]	[ "36.06", "36.01", "37.22", "88.56", "99.20" ]	icd9pcs	[ [ [] ] ]				7051, 7087				6251, 6712	6735, 7029					4215, 6230										2391, 2845															3438, 4197							3033, 3415			129, 157											186, 2223															7112, 7632		2245, 2368	2862, 3013
56,468	187,437	37808	Discharge summary	report	Admission Date: [2161-9-30] Discharge Date: [2161-10-14] Date of Birth: [2085-9-8] Sex: F Service: NEUROLOGY Allergies: Robaxin Attending:[First Name3 (LF) 2569] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: PER ADMITTING RESIDENT: 76 year-old female with unknown past medical history found down at the bottom of approximately 10 steps. In the [Last Name (LF) ], [First Name3 (LF) ] report has been non-verbal and intermittently following commands with upper extremities only. She has moved all extremities spontaneously and per nursing report did say a few words. After her CT scan in the emergency room, she had a witnessed seizure, which stopped before Ativan was given. Per social work via witnesses, she was walking up stairs in a church, gazed-up and fell posteriorly. She has a husband, who social work has called without success to contact, however, has left a message. Past Medical History: Per h/o from outside hospital, HTN, GERD, EndoCA-TAH-BSO Social History: Unknown at this time Family History: Unknown at this time Physical Exam: ON ADMISSION: O: T: BP: 155/85 HR: 87 RR: 26 O2Sats: 95% room air Gen: NAD, lethargic HEENT: EOMs unable to be assessed Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam intermittently, non-verbal. Orientation: Unable to be assessed. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2-3mm bilaterally. III, IV, VI: Not able to assess, right lateral gaze. V, VII: Not able to assess. VIII: Hearing intact to voice. IX, X: Not able to assess. [Doctor First Name 81]: Not able to assess.. XII: Not able to assess.. Motor: Not able to assess Sensation: Not able to assess. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ Exam at time of discharge: ON ADMISSION: O: T: BP: 155/85 HR: 87 RR: 26 O2Sats: 95% room air Gen: NAD, lethargic HEENT: EOMs unable to be assessed Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam intermittently, non-verbal. Orientation: Unable to be assessed. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2-3mm bilaterally. III, IV, VI: Not able to assess, right lateral gaze. V, VII: Not able to assess. VIII: Hearing intact to voice. IX, X: Not able to assess. [Doctor First Name 81]: Not able to assess.. XII: Not able to assess.. Motor: Not able to assess Sensation: Not able to assess. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ Exam at time of discharge: O: T: BP: 155/85 HR: 87 RR: 26 O2Sats: 95% room air Gen: NAD, lethargic HEENT: EOMs unable to be assessed Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam intermittently, non-verbal. Orientation: Unable to be assessed. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 2-3mm bilaterally. III, IV, VI: Not able to assess, right lateral gaze. V, VII: Not able to assess. VIII: Hearing intact to voice. IX, X: Not able to assess. [Doctor First Name 81]: Not able to assess.. XII: Not able to assess.. Motor: Not able to assess Sensation: Not able to assess. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+ Exam at time of discharge: T:98.9 tmax BP: 133-159/80s HR: 70s-90 RR: 18-22 O2Sats: 98% room air Gen: NAD, in bed, unsettled, moving around in bed. HEENT: supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT/ND, PEG in place, mild tenderness peri-PEG, no erythema Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, oriented to place, self and [2161-3-11]. Inattentive, incooperative with exam. Intact repetition, naming. Cranial Nerves: VFF intact to threat. Pupils equally round and reactive to light, to 4-2mm bilaterally. EOMi, no nystagmus, face symmetric. shoulder shrug intact, tongue midline. Motor: Moves all extremities antigravity, does not follow commands reproducibly, at least 4+ at triceps and bicepts. [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] antigravity for > 5 seconds. Sensation: Not able to assess. Reflexes: Brisk in patella b/l, otherwise 2+ in UEs. Gait: not assessed. Pertinent Results: Admission Labs: . WBC-7.8 RBC-4.39 HGB-13.6 HCT-39.8 MCV-91 MCH-31.0 MCHC-34.2 RDW-14.3 GLUCOSE-165* UREA N-18 CREAT-0.9 SODIUM-139 POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-29 ANION GAP-14 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.5 LEUK-NEG URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . IMAGING . CT Head without Contrast ([2161-9-29]): IMPRESSION: Right frontotemporal subdural and subarachnoid hemorrhage with 5 mm of right to left midline shift. Subarachnoid hemorrhage extends into the basilar cisterns and fourth ventricle. 3-mm focus of probable extraaxial hemorrhage in the left occipital region adjacent to skull base fracture. . Large left parietooccipital skull fracture extending anteriorly to the left aspect of the clivus. . Air-fluid level in the sphenoid sinus with air noted in the bilateral cavernous sinus and right middle temporal fossa. These findings are very suspicious for a nondisplaced fracture of the sphenoid sinus although no discrete fracture is visualized. . Fluid in the left middle ear cavity and mastoid air cells with possible longitudinal fracture through the left temporal bone. A dedicated CT temporal bone is recommended for further characterization. . Large left parietooccipital subgaleal hematoma. . Marked rotation of C1 on C2, which may be positional in nature. However, rotary subluxation cannot be excluded. . MR C/T/L spine: IMPRESSION: 1. No acute fracture, cord compression, or cord signal abnormality is identified. Findings of a chronic wedge deformity of L1. 2. Fluid-fluid layer within the inferior thecal sac likely due to subarachnoid hemorrhage from the brain.. . CXR [10-1] FINDINGS: The lung volumes are low. In the retrocardiac lung areas and at the right lung bases, minimal interstitial thickening suggesting potential chronic airways disease is seen. Moderate scoliosis leads to asymmetry of the rib cage. Borderline size of the cardiac silhouette, no evidence of overhydration. Minimal left-sided pleural effusion. No focal parenchymal opacity suggesting pneumonia, normal appearance of the mediastinum. MR head [10-2] IMPRESSION: 1. Acute left cerebellar infarct with small amount of blood products. 2. Extensive parenchymal contusions and subarachnoid hemorrhage as seen on the previous CT examinations. 3. Small vessel disease. 4. Mild enhancement surrounding the right temporal contusion appears secondary to loss of blood brain barrier from trauma. However, follow up should be obtained. CTA head and neck: IMPRESSION: 1. Multiple areas of intraparenchymal, subarachnoid, subdural, intraventricular hemorrhage, unchanged in appearance from prior CT examination. 2. No evidence of new hemorrhage or mass effect. 3. The carotid and vertebral arteries and their major branches are patent with no evidence of stenoses or dissection. There is no evidence of aneurysm formation. KUB [10-13] IMPRESSION: No evidence of free air. Mild-to-moderate dilatation of large and small bowel without evidence of bowel obstruction CTA of chest [10-5] IMPRESSION: 1. No pulmonary embolus. No aortic dissection. 2. Moderate hiatal hernia. 3. Mild hyperplasia of the left adrenal gland. 4. Pulmonary nodules up to 5mm in size. Per the [Last Name (un) 8773] Society Guidelines, recommend followup chest CT at six months if high risk (for example smoking history or history of malignancy) or 12 months if low risk. ECHO [10-5] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy 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 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No definite structural cardiac source of embolism identified. Labs at time of discharge: 139 105 16 82 -------------[ 4.5 24 0.7 Ca: 8.9 Mg: 2.2 P: 3.5 CBC 9.5/11.7/36/441 ENZYMES & BILIRUBIN ALT AST LDH AlkPhos TotBili [2161-10-8] 06:30AM 64* 37 280* 51 0.2 [2161-10-6] 10:30AM 80* 72* 474* 61 0.5 Microbiology: [2161-10-9] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2161-10-9] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [2161-10-8] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL INPATIENT [2161-10-7] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2161-10-7] URINE URINE CULTURE-FINAL INPATIENT [2161-10-6] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B - Positive [2161-10-6] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2161-10-5] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2161-10-5] URINE URINE CULTURE-FINAL INPATIENT [2161-10-2] URINE URINE CULTURE-FINAL INPATIENT [2161-9-30] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2161-9-29] URINE URINE CULTURE-FINAL INPATIENT Brief Hospital Course: This is a 76 y/o woman who was initially admitted to the neurosurgery service from the [Hospital1 18] ED. She reported looked up while climbing upstairs at her church, lost her balance and retropulsed landing on her back and hitting the posterior aspect of her head. It was reported that she was initally awake and alert at presentation but became more lethargic en route to [Hospital1 18]. She was found to have a GCS of 6 in ED. CT imaging revealed a right frontotemporal subdural and subarachnoid hemorrhage with 5 mm of right to left midline shift. Subarachnoid hemorrhage extends into the basilar cisterns and fourth ventricle. 3-mm focus of probable extraaxial hemorrhage in the left occipital region adjacent to skull base fracture. There was a large left parietooccipital skull fracture extending anteriorly to the left aspect of the clivus. There was the concern of increased ICP and the possibility of placing a bolt was entertained. Once imaging was obtained, Dr. [First Name (STitle) ] (neurosurgery attending) reassessed the patient and felt this measure was not required. She suffered a generalized tonic clonic seizure at 18:40 on [9-30] for approximately 90 seconds. She then received lorazepam 2 mg twice. Eventually, she seized again at 19:30 for less than one minute. This seizure activity was characterized by b/l forehead and left hand twitching. She received ativan 1 mg iv was loaded with Dilantin. She was admitted to the SICU. She was on spine precautions. Serial CT scans showed no increase in ventricular size or hemorrhage. CT imaging from [9-30] pm was reported with left cerebellar hypodensity. An MRI was ordered on [2161-10-1]. Spine MRi imaging was reviewed with Dr. [Last Name (STitle) ]. She has some old compression deeformities but no sign of acute fracture. Her TLS spine was cleared on [2161-10-1]. She was chnaged to a soft collar. This will be maintained until she can reliably report on potential neck pain. She was transfered to the neurology service on [2161-10-1]. While on neurology service: - Intracranial Hemorrhage. Patient was noted to have areas of hemorrhage within the right anterior and inferior temporal lobes with surrounding edema, narrowing of the right perimesencephalic cistern as well as subdural hemorrhage adjacent to the right occipital lobe extending to the midline. In addition, there were: subdural hemorrhage tracking along the posterior falx, scattered hyperdense subarachnoid hemorrhages within the bilateral frontal and parietal lobes and collections of blood within the dependent portions of the lateral ventricles as well as the fourth ventricle. These collections remained stable through imaging with mild increase in edema around the temporal bleed during the [10-2] and [10-5] CT head images. These were deemed to be traumatic. No evidence of aneurysm was seen on CTA head. Patient was maintained on hydralazine prn and captorpil standing for SBP control of 140-160 (due to cocurrent stroke, see below (It was later discovered that patient had bronchospasm due to AcEI, she was switched to norvasc). Due to altered mental status, she received two days of mannitol on [10-4] and [10-5]. She was treated with Keppra 750mg [Hospital1 ] for Sz prophylaxis, given seizure in the ED. AMS was felt to be due ICH, C.Diff coilitis and UTI. Upon treatment of the above, her mental status improved significantly, she became alert, oriented to self and place and responding appropriately. Due to oropharyngeal dysfunction/incoordination, patient was unable to swallow safely, and thus underwent PEG placement on [2161-10-9]. TF were restarted on [10-10]. Follow up imaging and HCT showed normal placement and stable HCT of 36 at time of discharge. She will require follow up with neurology clinic and head CT to be completed on an as needed basis. - L cerebellar stroke. Noted on evaluation with CT head. MRI confirmed an acute L cerebellar infarct with small amount of blood products per-infarct. This may have been the cause of her fall. She was started on ASA 81mg. SBP control was maintained as above to balance with goals of ICH. CTA neck was unrevealing for a source of embolism, as was the echocardiogram. A1C was 5.7. Fasting Lipids were not peformed and should be obtained in a less acute setting. Statin therapy should be started as guided by lipid status. - Altered mental status. Patient was encephalopathic, somnlolent w/ waxing and [Doctor Last Name 688] alertness, at times requiring a sternal rub to awaken, other times with eyes open and following one step commands. She underwen a routing EEG showing no sz activity, but encephalopathy. She underwent an infectious work up revealing a negative UA, CXR, and BCx. There were no electrolyte abnormalities that could account for her altered mental status. She finally developed C.Diff coilitis and was started on Flagyl on [10-6] for total of 14 days. In addition, she was noted to have a UTI and started on Bactrim DS on [10-7] for a total of a 10 day course. Finally, she was noted to have one of eight blood cultures positive for coag. neg. staph, which was felt to be a contaminant and was not treated. Patient remained afebrile and HD stable. Although patient became more alert, awake and interactive, she remained disoriented to time and at times agitated, requiring an abodminal binder for protection of her PEG. She was not treated with antipsychotics, as it was imperative to monitor her mental state. - Tachypnea. On [2161-10-5] patient developed tachypnea, tachycardia to 30s and 110s respectively. There was no evidence of CHF or PNA clinically or on imaging. ABG showed acute respiratory alkalosis. CTA of chest showed no PE, a moderate hiatal hernia, mild hyperplasia of the left adrenal gland and pumonary nodules up to 5mm in size, per the [Last Name (un) 8773] Society Guidelines, recommended followup chest CT at six months. Tachypnea resolved within 2 days and was felt to be due to bronchoconstriction due to ACE-I use, which was changed to norvasc. - Lower and upper extremity spasticity. This was initially felt to be due to cervical spine disease and possible myelopathy. Her C/T/L spine MRI revealed mild spondyloarthropathy, no fracture, cord compression, or cord signal abnormality or ligamentous injury. There was a chronic wedge deformity of L1. Her B12, A1C and Folate were wnl. - Mild transaminitis. Noted during encephalopathy evaluation. These were elevated to < 100 each and trended down. She will require further trending and outpatient evaluation if these persist. Medications on Admission: unknown Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: Basilar skull fracture; intraparenchymal, subdural, subarachnoid hemorrhages; Left cerebellar stroke; C.Difficile coilitis; urinary tract infection; Encephalopathy Secondary: Hypertension Discharge Condition: Stable. T:98.9 tmax BP: 133-159/80s HR: 70s-90 RR: 18-22 O2Sats: 98% room air Gen: NAD, in bed, unsettled, moving around in bed. HEENT: supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT/ND, PEG in place, mild tenderness peri-PEG, no erythema Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, oriented to place, self and [2161-3-11]. Inattentive, incooperative with exam. Intact repetition, naming. Cranial Nerves: VFF intact to threat. Pupils equally round and reactive to light, to 4-2mm bilaterally. EOMi, no nystagmus, face symmetric. shoulder shrug intact, tongue midline. Motor: Moves all extremities antigravity, does not follow commands reproducibly, at least 4+ at triceps and bicepts. [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] antigravity for > 5 seconds. Sensation: Not able to assess. Reflexes: Brisk in patella b/l, otherwise 2+ in UEs. Gait: not assessed. Discharge Instructions: You were admitted to [Hospital1 18] after a fall which had caused you to have multiple fractures in your skull (non displaced, not requiring neurosurgery) as well as multiple bleed in your head. Your course was complicated by coilitis (colon infection) and urinary tract infection, for which you were treated with antibiotics. Because of your head trauma and bleeds, you will may have neurological deficits, including left arm and leg weakness, difficulty with maintaining concentration and others. You required rehabiliation and thus were discharged from the hospital to the rehabilitation center. There were multiple medication changes made to your regimen, please continue to take the prescribed medications, as this may be altered while you are at rehabilitation. You were discharged in stable condition, yet with impaired attention, confusion and motor deficits. See below. Should you develop any further weakness, changes in vision, difficulties with balance, fever, chills, shortness of breath, chest pain or any other symptom concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Please follow up with the following appointments: Please follow up with your primary care doctor, Dr. [Last Name (STitle) ],[First Name3 (LF) ] C. please call [Telephone/Fax (1) 8927] to set up a follow up appointment. Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2161-11-17] 3:30 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2161-10-14]	[ "V10.42", "530.81", "V45.89", "780.39", "348.30", "786.06", "E947.8", "800.26", "401.9", "873.0", "801.26", "E880.9", "008.45", "790.4", "721.1", "518.89", "599.0", "553.3" ]	icd9cm	[ [ [] ] ]	[ "86.59", "96.6", "99.05", "43.11", "88.72" ]	icd9pcs	[ [ [] ] ]	16930, 17000	10211, 16872	278, 284	17241, 17545	4591, 4591	19349, 19881	1133, 1156				17021, 17220		16898, 16907			18209, 19326									1171, 1171																								230, 240											312, 997	17706, 18185						4607, 10188			2012, 2239	17560, 17690						1019, 1078	1094, 1117
22,615	138,547	7	Discharge summary	report	Admission Date: [2199-1-22] Discharge Date: [2199-2-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: hypernatremia, unresponsiveness Major Surgical or Invasive Procedure: PEG/trach History of Present Illness: [Age over 90 ]yo F with history of dementia, diabetes mellitus, hypertension, CVA Russian speaking woman who was found unresponsive at [Hospital 100] Rehab. On [2199-1-21], she was noted to have difficulty in swallowing. She was placed on NC for 88%RA. On morning of [2199-1-22], she desaturated to low 90s on 5 L. She was then noted to be unresponsive with left eye sluggish, right faical droop, right arm flaccid, mottled right extremities and vitals 118/68, P104, RR40 T 99.8 and 90% on 5L. In ED, patient found to be hypernatremic and recieved 2L of NS. CXR was concerning for RLL PNA and she was started on levo/flagyl. She was also reported to be more lethargic in the past 1-2 weeks. Per PCP, [Name10 (NameIs) ] baseline 1 week ago, she has been sitting up in the chair, pleasantly demented but interactive. Past Medical History: 1. [2198-11-16] PRIF of left distal femur fracture with [Last Name (un) 101] plate(require 4 person lift, followed by ortho clinic) 2. [8-21]:ORIF of right intreathrochanteric hip fracture 3. osteoporosis 4. CVA in [2189] 5. hypertension 6. dementia 7. diabetes mellitus-diet controlled 8. h/o meningioma 9. history of falls 10. cataracts Dementia DM hypertension CVA Social History: TOB-deniesETOH-denies Family History: lives at [Hospital3 102] Physical Exam: T97.3 P88 BP112/32 NSRon NRB 100% Gen-elderly woman, NAD, pale and lethargic neuro-arousable, groans in response to pain, non-conversational, cannot assess orientation, cannot assess other neuro exam CV-faint heart sounds, RRR resp-rhonchi diffusely, no crackles, no accessory muscle use [Last Name (un) 103]-no BS, soft, NT/ND, no HSM skin-stage 2 decubitus ulcer at coccyx region Pertinent Results: CT head [2199-1-22]: No evidence of acute intracranial hemorrhage or major cortical territorial infarction. CXR [2199-1-22]: : New right lower lobe confluent opacity which may represent a developing area of pneumonia. Differential diagnosis includes aspiration and atelectasis. Dedicated PA and lateral chest radiograph is suggested for more complete characterization when the patient's condition permits. no contrast head CT [2199-1-28] FINDINGS: There has been interval development of an area of decreased attenuation at the left basal ganglia and periventricular white matter in the distribution of the left lenticulostriate artery consistent with a subacute infarct. There is associated swelling with mass effect on the left lateral ventricle. There is no shift of normally midline structures. Additional areas of hypodensity in the periventricular white matter and right centrum semiovale are unchanged and consistent with old infarctions. Two calcified meningiomas are again seen arising at the left frontal dura and anterior olfactory groove. They are unchanged from prior study. No intracranial hemorrhage was identified. Surrounding osseous and soft-tissue structures are unremarkable. IMPRESSION: Subacute left lenticulostriate infarction which was not present on head CT of [2199-1-22] echo [2199-1-28]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is a severe resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is probably mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is a significant left ventricular inflow gradient which may be due to mitral annular calcification and mitral valve calcification. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. LENI [2199-1-24]: No evidence of thrombus within the right upper extremity [2199-2-6] 05:00AM BLOOD WBC-5.9 RBC-2.79* Hgb-7.9* Hct-25.0* MCV-90 MCH-28.2 MCHC-31.4 RDW-16.7* Plt Ct-451* [2199-2-5] 04:03AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.4* Hct-26.7* MCV-91 MCH-28.7 MCHC-31.7 RDW-18.0* Plt Ct-508* [2199-2-4] 04:40AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-24.6* MCV-88 MCH-27.9 MCHC-31.7 RDW-16.6* Plt Ct-477* [2199-2-3] 05:00AM BLOOD WBC-15.5* RBC-2.97* Hgb-8.5* Hct-26.7* MCV-90 MCH-28.6 MCHC-31.8 RDW-17.4* Plt Ct-578* [2199-2-2] 04:42AM BLOOD WBC-18.8* RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.5* Plt Ct-590* [2199-2-1] 04:10AM BLOOD WBC-14.4* RBC-3.40* Hgb-9.5* Hct-30.5* MCV-90 MCH-28.0 MCHC-31.2 RDW-15.2 Plt Ct-499* [2199-1-31] 04:19AM BLOOD WBC-11.6* RBC-3.31* Hgb-9.4* Hct-28.7* MCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-427 [2199-1-30] 03:45AM BLOOD WBC-9.7 RBC-3.31* Hgb-9.7* Hct-29.2* MCV-88 MCH-29.3 MCHC-33.2 RDW-15.9* Plt Ct-363 [2199-1-29] 05:43AM BLOOD WBC-12.2* RBC-3.21* Hgb-9.2* Hct-28.0* MCV-87 MCH-28.6 MCHC-32.7 RDW-14.7 Plt Ct-315# [2199-1-28] 02:53AM BLOOD WBC-9.1 RBC-2.97* Hgb-8.7* Hct-26.3* MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-201 [2199-1-27] 03:56AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.1* Hct-27.5* MCV-88 MCH-29.0 MCHC-33.1 RDW-15.1 Plt Ct-200 [2199-1-26] 03:22AM BLOOD WBC-13.6* RBC-3.18* Hgb-9.2* Hct-28.5* MCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-214 [2199-1-25] 04:57AM BLOOD WBC-15.7* RBC-3.55* Hgb-9.9* Hct-32.1* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.0 Plt Ct-277 [2199-1-24] 04:58AM BLOOD WBC-10.9 RBC-3.65* Hgb-10.8* Hct-34.9* MCV-95 MCH-29.5 MCHC-30.9* RDW-14.8 Plt Ct-209 [2199-1-23] 02:10PM BLOOD WBC-11.5* RBC-3.76* Hgb-10.9* Hct-35.4* MCV-94 MCH-29.1 MCHC-30.9* RDW-14.9 Plt Ct-201 [2199-1-22] 10:00AM BLOOD WBC-13.5* RBC-4.20 Hgb-12.2 Hct-39.6 MCV-94 MCH-29.1 MCHC-30.9* RDW-14.2 Plt Ct-251 [2199-1-22] 10:00AM BLOOD Neuts-57 Bands-32* Lymphs-7* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2199-1-22] 04:07PM BLOOD PT-14.4* PTT-24.3 INR(PT)-1.3 [2199-2-6] 05:00AM BLOOD Glucose-91 UreaN-14 Creat-0.3* Na-139 K-4.3 Cl-110* HCO3-26 AnGap-7* [2199-2-5] 04:03AM BLOOD Glucose-103 UreaN-15 Creat-0.4 Na-139 K-4.5 Cl-109* HCO3-25 AnGap-10 [2199-2-4] 04:40AM BLOOD Glucose-116* UreaN-17 Creat-0.5 Na-140 K-3.7 Cl-110* HCO3-24 AnGap-10 [2199-2-3] 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.5 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 [2199-2-2] 03:21PM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-141 K-4.8 Cl-111* HCO3-25 AnGap-10 [2199-2-2] 04:42AM BLOOD Glucose-110* UreaN-16 Creat-0.5 Na-137 K-4.2 Cl-108 HCO3-27 AnGap-6* [2199-2-1] 04:10AM BLOOD Glucose-108* UreaN-10 Creat-0.4 Na-140 K-4.2 Cl-108 HCO3-24 AnGap-12 [2199-1-31] 04:19AM BLOOD Glucose-97 UreaN-12 Creat-0.5 Na-140 K-3.9 Cl-109* HCO3-26 AnGap-9 [2199-1-30] 07:35PM BLOOD Glucose-62* UreaN-12 Creat-0.4 Na-141 K-4.0 Cl-110* HCO3-26 AnGap-9 [2199-1-30] 03:45AM BLOOD Glucose-49* UreaN-14 Creat-0.4 Na-140 K-3.5 Cl-111* HCO3-23 AnGap-10 [2199-1-29] 05:43AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-140 K-3.9 Cl-111* HCO3-21* AnGap-12 [2199-1-28] 02:53AM BLOOD Glucose-81 UreaN-22* Creat-0.5 Na-140 K-3.7 Cl-114* HCO3-21* AnGap-9 [2199-1-27] 12:15AM BLOOD K-4.2 [2199-1-26] 06:03PM BLOOD Glucose-76 UreaN-21* Creat-0.5 Na-143 K-3.5 Cl-117* HCO3-20* AnGap-10 [2199-1-26] 03:22AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-147* K-3.5 Cl-120* HCO3-21* AnGap-10 [2199-1-25] 05:52PM BLOOD K-4.2 [2199-1-25] 04:57AM BLOOD Glucose-193* UreaN-34* Creat-0.8 Na-143 K-3.5 Cl-115* HCO3-18* AnGap-14 [2199-1-24] 08:29PM BLOOD Glucose-140* UreaN-38* Creat-0.8 Na-144 K-4.0 Cl-114* HCO3-19* AnGap-15 [2199-1-24] 12:57AM BLOOD Glucose-109* UreaN-42* Creat-0.7 Na-153* K-4.0 Cl-123* HCO3-24 AnGap-10 [2199-1-23] 08:59PM BLOOD Glucose-161* UreaN-42* Creat-0.7 Na-156* K-4.1 Cl-124* HCO3-25 AnGap-11 [2199-1-23] 02:10PM BLOOD Glucose-92 UreaN-47* Creat-0.8 Na-163* K-4.5 Cl-130* HCO3-28 AnGap-10 [2199-1-23] 04:08AM BLOOD Glucose-235* UreaN-53* Creat-1.0 Na-168* K-4.3 Cl-130* HCO3-31* AnGap-11 [2199-1-22] 11:54PM BLOOD Glucose-61* UreaN-56* Creat-1.0 Na-169* K-3.2* Cl-132* HCO3-32* AnGap-8 [2199-1-22] 08:58PM BLOOD Glucose-184* UreaN-55* Creat-1.1 Na-170* K-3.1* Cl-131* HCO3-30* AnGap-12 [2199-1-22] 04:07PM BLOOD Glucose-399* UreaN-55* Creat-1.1 Na-167* K-4.0 Cl-131* HCO3-30* AnGap-10 [2199-1-22] 10:00AM BLOOD Glucose-427* UreaN-53* Creat-1.2* Na-167* K-4.1 Cl-127* HCO3-29 AnGap-15 [2199-2-2] 09:10PM BLOOD CK(CPK)-94 [2199-2-2] 03:21PM BLOOD CK(CPK)-80 [2199-1-24] 04:58AM BLOOD CK(CPK)-151* [2199-1-23] 08:59PM BLOOD CK(CPK)-176* [2199-1-23] 02:10PM BLOOD CK(CPK)-214* [2199-1-22] 04:07PM BLOOD CK(CPK)-206* [2199-1-22] 10:00AM BLOOD ALT-11 AST-15 LD(LDH)-227 CK(CPK)-205* AlkPhos-119* TotBili-0.4 [2199-2-2] 09:10PM BLOOD CK-MB-6 cTropnT-0.04* [2199-2-2] 03:21PM BLOOD CK-MB-8 cTropnT-0.06* [2199-1-24] 04:58AM BLOOD CK-MB-4 cTropnT-0.04* [2199-1-23] 08:59PM BLOOD CK-MB-4 cTropnT-0.06* [2199-1-23] 02:10PM BLOOD CK-MB-4 cTropnT-0.08* [2199-2-5] 04:03AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 [2199-2-4] 04:40AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7 [2199-2-3] 05:00AM BLOOD Calcium-7.9* Phos-2.5# Mg-2.0 [2199-2-2] 03:21PM BLOOD Calcium-8.1 Phos-5.2* Mg-2.3 [2199-2-1] 04:10AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9 [2199-1-31] 04:19AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7 [2199-1-22] 04:07PM BLOOD Osmolal-369* [2199-1-25] 01:43PM BLOOD Cortsol-29.3* [2199-1-25] 01:04PM BLOOD Cortsol-25.1* [2199-1-25] 12:15PM BLOOD Cortsol-18.4 [2199-2-6] 05:16AM BLOOD Type-ART pO2-111* pCO2-38 pH-7.43 calHCO3-26 Base XS-0 [2199-2-5] 04:53PM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-88 pCO2-34* pH-7.45 calHCO3-24 Base XS-0 Intubat-INTUBATED [2199-2-4] 07:09PM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-40 pO2-80* pCO2-32* pH-7.47* calHCO3-24 Base XS-0 Intubat-INTUBATED [2199-2-4] 10:40AM BLOOD Type-ART Temp-35.0 Rates-/20 PEEP-5 FiO2-40 pO2-65* pCO2-30* pH-7.47* calHCO3-22 Base XS-0 Intubat-INTUBATED [2199-2-4] 04:54AM BLOOD Type-ART Temp-37.4 Rates-/14 Tidal V-400 PEEP-5 FiO2-40 pO2-67* pCO2-32* pH-7.49* calHCO3-25 Base XS-1 Intubat-INTUBATED [2199-2-3] 10:19PM BLOOD Type-ART Temp-37.2 pO2-65* pCO2-30* pH-7.50* calHCO3-24 Base XS-0 [2199-2-3] 03:48PM BLOOD Type-ART Temp-37.3 Rates-/20 Tidal V-330 PEEP-5 FiO2-40 pO2-97 pCO2-32* pH-7.48* calHCO3-25 Base XS-0 Intubat-INTUBATED Comment-PS 10 [2199-2-3] 01:10PM BLOOD Type-ART Temp-36.6 Rates-/12 Tidal V-500 PEEP-5 FiO2-40 pO2-108* pCO2-28* pH-7.54* calHCO3-25 Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU [2199-2-2] 08:08PM BLOOD Type-ART Temp-38.0 Rates-16/ Tidal V-500 PEEP-5 FiO2-60 pO2-78* pCO2-30* pH-7.45 calHCO3-21 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2199-2-2] 04:50PM BLOOD Type-ART Temp-36.1 Rates-20/0 Tidal V-500 PEEP-8 FiO2-60 pO2-83* pCO2-31* pH-7.45 calHCO3-22 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2199-1-24] 03:29PM BLOOD Type-ART Temp-36.2 O2 Flow-6 pO2-72* pCO2-33* pH-7.40 calHCO3-21 Base XS--2 Intubat-NOT INTUBA [2199-1-22] 04:11PM BLOOD Type-ART pO2-128* pCO2-48* pH-7.37 calHCO3-29 Base XS-2 Intubat-NOT INTUBA [2199-1-22] 10:04AM BLOOD Type-ART Temp-37.9 pO2-65* pCO2-45 pH-7.45 calHCO3-32* Base XS-6 [2199-2-2] 03:38PM BLOOD Lactate-1.5 [2199-1-24] 04:32PM BLOOD Lactate-3.0* [2199-1-22] 10:04AM BLOOD Lactate-3.0* [2199-2-2] 04:48PM BLOOD O2 Sat-69 [2199-2-6] 05:16AM BLOOD freeCa-1.19 Brief Hospital Course: Patient was admitted with hypernatremia and acute mental status changes and right sided paralysis. Her corrected sodium on admission was about 170s and her free water deficit was 5.5L. She was volume repleted with normal saline. She also recieved D51/4 NS for free water repletion initially and this was changed to free water boluses through nasogastric tube. Her sodium gradually trended down with free water repletion. She also was in pre-renal renal failure and her creatinine trended down with hydration. With regards to the acute mental changes, this is partially explained by the hypernatrmic state. However, she was also noted by the nursing home to have right sided weakness. CT head was performed on admission which was negative for stoke. Neurology was consulted and found that she has a MCA territory stroke by exam. A repeat CT head was performed on [1-28] which showed watershed infarct. TTE which was also obtained did not reveal any thrombus.Per neurology recommendation, all her hypertensive medication has been discontinued and she was started on aspirin. Chest XRay on admission was concerning for right lower lobe pneumonia. Her sputum culture grew MSSA for which she was on oxacillin. Levofloxacin was also started for community acquired pneumonia. Nasal aspirate was sent for influenza and was negative. She was intubated on [2199-1-24] for increased respiratory effort. Her resporatory decompensation was likely from aspiration pneumonia. She was extubated on [2199-1-31] when her lungs mechanic improved. However, given her depressed mental status and stroke, she was not able to clear her secretions well. SHe was intubated again on [2-2] after unsuccessful attempt to maintain her oxygen saturation with high flow mask. She recieved tracheostomy and G tube and tolerated well post procedure. Her nutrition status was maintained by tubefeeds and insulin sliding scale and NPH kept her glucose within range. Her blood pressure was initially low on admission. This responded well to hydration and brief use of levophed. Her [Last Name (un) 104] stimulation test was responsive. Admission EKG showed ST depression in V2-V3 and it was unsure if this is old. She had slightly elevated troponin, likely from acute renal failure which eventually trending down. Plastic surgery was consulted for decubitus ulcer. No debridement was indicated and their recommendation was to maxmize nutrition, wet to dry dressing and tight glucose control. She remained on sc heparin, lansoprazole, pneumoboots and bowel regimen as part of her porphylaxis. She had picc line placed upon discharge THere had been multiple discussion with her daughter, which is her health care proxy regarding code status. It was felt by the medical team that her condition will not likely improve despite optimal medical treatment. However, due to religious reasons, her family remained steadfast that everything should be done. However, her family agrees that should she go into cardiac arrest, there should be no chest compression or defibrillation. Medications on Admission: coumadin-d/c [2199-1-10] ASA 81 QD Calcium/vit D [Hospital1 ] enalapril 1.25 QD metorpolol 12.5 [Hospital1 ] sorbitol 30ml QD tylenol NKDA Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 15. Insulin NPH Human Recomb Subcutaneous 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: 1. MRSA pneumonia 2. hypernatremia 3. acute renal failure 4. Left MCA territory watershed infarct 5. decubitus ulcer Discharge Condition: stable Discharge Instructions: You will be discharged to rehabilitation center. Please let the medical staff knows if you have any concerns at all. Followup Instructions: Your care will be transferred to the rehabilitation center. Completed by:[2199-2-12]	[ "250.00", "707.03", "438.20", "518.84", "507.0", "733.00", "276.5", "276.0", "V09.0", "401.9", "482.41", "294.8", "584.9", "428.0", "434.91", "707.06", "707.14" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "99.04", "43.11", "00.17", "86.28", "31.1", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	16770, 16841	12098, 15163	292, 303	17002, 17010	2082, 12075	17176, 17267	1630, 1660		15365, 16747		16862, 16981		15189, 15342			17034, 17153									1675, 2063																								221, 254											331, 1167																	1189, 1575	1591, 1614
14,825	107,378	23666	Discharge summary	report	Admission Date: [2178-4-14] Discharge Date: [2178-4-22] Date of Birth: [2119-12-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest discomfort and exertional dyspnea Major Surgical or Invasive Procedure: CABGx4(LIMA->LAD, SVG->PDA, OM2, Diag) [2178-4-15] CAZrdiac Catheterization [2178-4-14] History of Present Illness: Mr. [Known lastname 60510] is a splendid 58 year old gentleman who has recently developed chest discomfort and dyspnea on exertion. He is normally able to exercise for 40 minutes or longer without difficulty. Since [Month (only) 956], he describes 2/10 chest pain and an overall sensation that something is wrong with exercise. He was seen at [Hospital3 3583] on [2178-4-13] where a troponin was positive and EKG changes were noted. Nitroglycerin was given with relief. He was subsequently transferred to [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] Medical center for a cardiac catheterization. Past Medical History: S/P Hernia Repair Nephrolithiasis Social History: Denies smoking cigarettes. Former pipe smoker and occassional cigars. No illicit drug use. Occassional beer or wine. Lives with wife at home. Family History: Non Contributory Physical Exam: VITALS: 57 SB, BP: 150/74 NEURO: Alert, no focal deficits, PERRL, Stregth equal bilaterally CARDIAC: RRR, no murmur LUNGS: Scattered rales at bases ABDOMEN: normoactive bowel sounds, nontender, nondistended EXTREMITIES: warm, well perfused, no edema, no varicosities noted PULSES: 2+ throughout No bruits Pertinent Results: [2178-4-14] 03:49PM PT-14.6* PTT-113* INR(PT)-1.4 [2178-4-14] 03:49PM WBC-4.5 RBC-5.23 HGB-15.9 HCT-45.6 MCV-87 MCH-30.5 MCHC-34.9 RDW-12.7 [2178-4-14] 03:49PM ALT(SGPT)-29 AST(SGOT)-24 CK(CPK)-73 ALK PHOS-86 AMYLASE-55 TOT BILI-0.8 [2178-4-14] 03:49PM GLUCOSE-111* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [2178-4-14] CXR No acute cardiopulmonary process. [2178-4-14] ECG Sinus bradycardia. Borderline prolonged QTc interval. Left ventricular hypertrophy with ST-T wave abnormalities. The anterolateral ST-T wave changes suggest in part, ischemia. Clinical correlation is suggested. No previous tracing available for comparison. [2178-4-15] ECG Baseline artifact. Probable sinus rhythm, although baseline artifact makes assessment difficult. Left ventricular hypertrophy with ST-T wave abnormalities. The anterolateral T wave changes suggest in part, ischemia. Clinical correlation is suggested. Since the previous tracing of [2178-4-15] baseline artifact makes comparison difficult. [2178-4-14] Cardiac Catheterization 1. Three vessel coronary artery disease. 2. Moderate and regional systolic ventricular dysfunction. 3. Mild left ventricular diastolic dysfunction. 4. Successful stenting of the proximal LAD with a Drug Eluting Stent. Brief Hospital Course: Mr. [Known lastname 60510] was admitted to the [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] Medical Center on [2178-4-13]. He underwent a cardiac catheterization which revealed an occluded left anterior descending artery with distal 90% disease, an 80% stenosed circumflex artery, an 80% stenosed posterior descending artery and an ejection fraction of 35%. The proximal left anterior descending artery was stented with success. Plavix and heparin were started. Due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [Known lastname 60510] was worked-up in the usual preoperative manner. On [2178-4-15], Mr. [Known lastname 60510] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. His chest tube output was noted to be high and Mr. [Known lastname 60510] was returned to the operating room. Bleeding was found coming from a side branch of the vein graft. Hemostasis was achieved and Mr. [Known lastname 60510] was returned to the intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 60510] [Last Name (Titles) 5058] neurologically intact and was extubated. Beta blockade was resumed and titrated for optimal heart rate and blood pressure control. Plavix was resumed. Later on postoperative day one, Mr. [Known lastname 60510] was transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His chest tubes and pacing wires were removed per protocol. A small amount of serous drainage was noted from the inferior aspect of Mr. [Known lastname 60511] sternotomy. Betadine occlusive dressings were applied and Keflex was started prophylactically. Mr. [Known lastname 60510] continued to make steady progress and was discharged to his home on postoperative day seven. He will return in 1 week for evaluation of his sternal wound. Mr. [Known lastname 60510] will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Norvasc 5mg daily [Doctor First Name ] PRN Aspirin occassionally Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. Disp:120 Tablet(s) Refills:0 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. Disp:50 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:40 Capsule(s) Refills:0 10. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Coronary artery disease. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 30224] [Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 911] for 2-3 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Come to [Hospital Ward Name 121] 2 between 10AM and 4PM on Fri., [4-24] for wound check. Completed by:[2178-4-22]	[ "410.71", "414.01", "V13.01", "401.9", "998.11" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.13", "36.01", "88.53", "99.04", "37.22", "39.61", "34.03", "88.56", "36.07" ]	icd9pcs	[ [ [] ] ]	6865, 6899	3105, 5488	362, 459	6968, 6975	1749, 3082	7218, 7583	1391, 1409		5607, 6842		6920, 6947		5514, 5584			6999, 7195									1424, 1730																								283, 324											487, 1159																	1181, 1216	1232, 1375
15,046	144,046	50751	Discharge summary	report	Admission Date: [2195-5-17] Discharge Date: [2195-5-25] Date of Birth: [2124-2-1] Sex: F Service: MEDICINE Allergies: Tetracycline Analogues / Zinc / Optiray 350 Attending:[First Name3 (LF) 1253] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: G-J tube unclogging History of Present Illness: 71 year old female with COPD, chronic aspiration pneumonia (Pseudomonas, MRSA) requiring intubation in past, recent admits for aspiration pneumonia, presenting from home with fever, productive cough with yellow sputum x 2 days, hypoxia to 75% on home 2L NC, improved with 4L NC. Patient's caretaker notes that yesterday, patient had some mild dyspnea and intermittent fevers, as well as continued productive cough. Patient is on [2-5] L O2 at baseline. Fever was reportedly up to 102.4 F on the night prior to admission and 100 F rectally this morning at home after Tylenol. There is no report of headache and neck stiffness. Caregiver reports that patient is confused and can't find words easily when she spikes a fever. Patient has a J-tube in place for feeding due to aspiration risk. The patient's caretaker notes that there has been some increased purulent drainage from the J-tube site over the last few days. . In the ED, initial VS were: 88 133/63 10 93% NRB. Patient was noted to be acutely dyspneic with a productive cough. She was answering questions appropriately but noted to be somewhat somnolent. Rectal temperature was noted to be 100F. EKG shows SR@80, normal axis. Portable CXR showed moderate pulmonary edema, patchy bilateral infiltrates, stable elevation of L hemidiaphragm, as well as worsening consolidation in the left lower lobe. Lactate was elevated to 3.0, and WBC elevated to 18.3. She was given a dose of ceftriaxone and levofloxacin for pneumonia as well as metronidazole because of possibility of aspiration. She was also given a dose of 125mg IV methylprednisolone for COPD exacerbation and combivent nebs. Vitals in ED prior to transfer are as follows: 101.4F (Rectal) 98 131/68 20 93-96% on 4L NC. . On admission to ICU, patient is not reporting dyspnea. Her caretaker states that she is mildly confused, in conjunction with when she spikes a fever. . Review of sytems: (+) Per HPI (-) Per caretaker, [Date Range ] fever, chills. [Date Range 4273] headache, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Past Medical History: 1. Castleman's disease: unicentric. Found incidentally on splenectomy done for "splenic pain" around [2176]. Has had lymph nodes sampled in past to r/o lymphoma but all have shown reactive lymph tissue only. Followed by Dr. [Last Name (STitle) 410]. (Heme/Onc) 2. anaplastic thyroid cancer s/p radical neck dissection, at age 15 3. Esophageal webs and esophageal dysmotility. Has had numerous esophageal dilatations. 4. Recurrent aspiration pneumonias sputum Cx growing Pseudomonas, MRSA 5. Chronic pulmonary disease 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Hx Bipolar d/o 8. GERD 9. Osteoporosis: has broken both hips, left in [11-7], right with failed ORIF and redo at [Hospital1 2025] 10. Hx zoster 11. Hx depression, chronic pain 12. HTN 13. Parkinson's disease Social History: Retired social worker. [Name (NI) 6934] with walker and assistance at baseline. No Etoh, [Name (NI) ], drugs. Lives at home w/ 24 hour health aid. POA = [Name (NI) ] [Name (NI) 105568] (attorney) [Telephone/Fax (1) 105579]. Unclear if he is also her HCP. Family History: 1. Father: HTN, DM, depression, died MI, age 59. 2. Mother: HTN, hypercholesterolemia, died MI, age 82. 3. Sister: HTN Physical Exam: Admission: Vitals: T: 100.5 BP: 115/75 P: 89 R: 21 O2: 92%RA General: Alert, oriented x 2 (not to date), no acute distress, but appears mildly uncomfortable, answers some questions appropriately, otehr times does not complete answers HEENT: Sclera anicteric, MM dry, oropharynx clear with no lesions noted Neck: supple, JVP not elevated, no LAD Lungs: Coarse rhonchi noted bilaterally, worse at bases and R>L, no wheezes, no accessory muscle use CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, J-tube in place with erythema surrounding insertion site and purulent drainage from old J-tube insertion site, tender to palpation around area, bowel sounds hypoactive, no rebound tenderness or guarding, no organomegaly GU: Foley catheter in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge: VS afebrile 132/68 p71 R18 91% 2L Cachectic. Non-toxic. Speaking full sentences. Improved BS, generally clear. Good AE. Pertinent Results: CXR [5-18] Continued moderate pulmonary edema, with possible superimposed infection at the lung bases TTE [5-18] The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([1-4]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild-moderate mitral regurgitation with normal valve morphology. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [2190-5-4], the severity of mitral regurgitation has increased. CLINICAL IMPLICATIONS: Based on [2191] 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. . CXR [5-18]- Tip of the new left PIC line ends in the upper SVC. A component of interstitial edema has cleared from the right lung, revealing pulmonary fibrosis. Similar improvement at the left lung base could be due to resolving pneumonia or atelectasis. Heart size is normal. No pneumothorax. Pleural effusion is small if any. . Abdominal u/s- FINDINGS: The abdominal wall and underlying soft tissues show normal echogenicity. There is no focal fluid collection seen. The balloon of the MIC G-tube appears well inflated lying under the gastric wall. IMPRESSION: No focal abdominal wall fluid collection or abscess seen. . KUB [5-21]-IMPRESSION: Gastrojejunostomy tube in similar position compared to prior with tip likely within the proximal jejunum. . CHEST (PORTABLE AP) Study Date of [2195-5-22] There are low lung volumes with interval improvement of interstitial edema from prior study of [2195-5-18]. Pulmonary fibrosis is again noted. Mild bibasilar opacity is similar from prior study, and may be due to atelectasis and/or pneumonia. The cardiomediastinal and hilar contours are stable. . [2195-5-23] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-Negative [2195-5-19] URINE CULTURE-Negative [2195-5-19] Blood Culture, Routine-Negative [2195-5-18] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-Contaminated [2195-5-18] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-Contaminated [2195-5-17] 3MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} [2195-5-17] URINE Legionella Urinary Antigen -Negative [2195-5-17] URINE CULTURE-Negative [2195-5-17] Blood Culture, Routine-Negative [2195-5-17] Blood Culture, Routine-Negative . U/A negative x 2 . Most recent labs: 10.6\ 9.9 /368 / 30.5 \ . 139 \| 102 \| 15 / 130 4.7 \| 33 \| 1 \ Brief Hospital Course: IMPRESSION/PLAN: Pt sis a 71 y.o female with h.o Castleman's disease, h.o anaplastic thyroid cancer, recurrent aspiration PNA (h.o pseudomonas and MRSA), COPD, bipolar disorder, Parkinson's who initially presented to ICU with tachypnea found to have HAP and probable EC fistula. . #FEVER, ASPIRATION PNEUMONIA/hypoxia: based on CXR, history of aspiration PNA, prior PNA with MRSA/pseudomonas. Pt placed on vanco/zosyn/levoflox for 8 day course, levoflox for 5 day course. Sputum sample x2 contaminated. Pt was given nebs and placed on aspiration precautions. Prior S+S has recommended strict NPO given full code status. However, pt has been non-compliant at home. Pt initally given steroids in ED for concern of possible COPD flare, but these were discontinued in the ICU. CHF considered, but BNP normal and echo not suggestive of CHF. Pt finished her 8 day course of vanco/zosyn during hospitalization as well as her 5 day levoflox course. She was stable on 2L NC Oxygen at the time of discharge. . # Goals of care Palliative care was consulted, as during the hospitalization pt indicated that she was tired of aggressive medical care and she wanted to be home and focus on her quality of life. During the Palliative Care consult, pt remained very inconsistent with her wishes which included staying home to be comfortable and without aggressive care, but then went on to say that ICU care would be ok up to 3 weeks. Given the inconsistencies, and the nature of the conversation, she remains a full code at this time. However, patient would likely benefit from ongoing goals of care conversations, and recommended Hospice consultation as an outpatient. The Palliative Care service will update her health care proxy on their conversation. . #CELLULITIS, Probable ENTEROCUTANEOUS FISTULA: Possible cellulitis surrounding old G tube site which is likely a enterocutaneous fistula. Soft tissue ultrasound was performed which did not show an abscess. Wound care was consulted who recommended 1. Pressure Redistribution - Atmos Air 2. Gently cleanse peritubular skin with Aloe Vesta foam cleanser. Pat dry. 3. Apply Miconazole powder to peritubular wet weepy skin; sprinkle powder over inflamed tissue, rub in, and dust off. Apply Critic aid antifungal skin barrier ointment over treated tissue. 4. Make slit with scissors in small Soft sorb dressing, to fit around G/T tube bumper. 5. Window dressing with Medipore tape. 6. Change [Hospital1 ]. IR was consulted who evaluated the patient and stated that her fistula actually appears better and appears to be healing well from prior evaluation. IR feels that pt's noncompliance with NPO status is what has lead to delayed healing and resultant chemical irritation on the abdomen. IR also had to unclogged the GJ tube and this was done at the bedside. KUB showed GJ tube to be in appropriate position. Pt should remain NPO at home in order to faciliate healing. If fistula site continues to be become an issue, then pt should be reevaluated by her surgeon, Dr. [Last Name (STitle) ]. During the hospitalization, the site appeared to clinically improve with improved erythema. . # Chronic pain Pt was maintained on her home regimen with Fentanyl patch 125 mcg, and prn oral dilaudid. At the time of discharge, pt indicated that she would like to have her pain regimen changed, as she does not feel that the patch is working for her. Given her severe cachexia, transitioning her off of the fentanyl patch does seem reasonable, as absorption may be impaired by her lack of body fat. Instead I would consider a long-acting oral opiate, such as MSContin, with shorter acting [Doctor Last Name 360] (such as MSIR) for breakthrough. However, given that these concerns were raised at the time of discharge, I will defer changes to her chronic regimen to outpatient follow up. Otherwise, continued home lamictal and neurontin. . #PARKINSON'S DISEASE: continued home meds. PT consulted during the admission. . #ACUTE KIDNEY INJURY: baseline Cr normal. Cr on admission 1.4, improved with initial hydration. . #metabolic alkalosis-thought to be compensatory due to chronic CO2 retention/resp acidosis. . #leukocytosis-pt with intermittent leukocytosis during admission. Has known aspiration pneumonia that is clinically improving. Prior UCX negative. Stool was negative for c-diff. . #normocytic anemia-chronic. HCT remained stable. . #h.o anaplastic thyroid cancer in youth-continued levothyroxine . #Depression-no signs of SI, continued home meds, seroquel, lexapro . . #precautions-MRSA/aspiration . Communication: patient, HCP is [Name (NI) ] [Name (NI) ] at law firm [Name (NI) 2795] [Last Name (NamePattern1) 30370] [Last Name (un) 73762], lawyer ([Telephone/Fax (1) 105569]) FULL CODE . #dispo-pending improvement in PNA and wound care/IR eval of abdomen . FULL CODE Communication: patient, HCP is [Name (NI) ] [Name (NI) ] at law firm [Name (NI) 2795] [Last Name (NamePattern1) 30370] [Last Name (un) 73762], lawyer ([Telephone/Fax (1) 105569]) Medications on Admission: Carbidopa-levodopa 25-100 mg PO QID Escitalopram 20 mg PO daily Fentanyl 100 mcg/hr patch 1 patch x 2 q72h PRN pain Gabapentin 300 mg PO QHS Hydromorphone 2 mg PO q4h PRN pain Lamotrigine 100 mg PO daily Levothyroxine 75 mcg PO daily Lorazepam 1 mg PO QAM, 2 mg PO QPM Ondanesetron 4 mg PO q8h PRN nausea Primidone 25 mg PO daily Quetiapine 200 mg PO QHS Kayexalate PRN Albuterol sulfate 2.5 mg/3 ml neb q6h PRN SOB Esopmeprazole 20 mg PO daily Senna 8.6 mg PO BID Docusate 50 mg/5 ml 100 mg PO BID Polyethylene glycol 17 gram powder daily PRN constipation Cholecalciferol 800 units PO daily Calcium carbonate 200 (500 mg) PO BID Polyvinyl alchohol-povidone 1.4-0.6% 1-2 drops ophthalmic PRN dry eyes Discharge Medications: 1. carbidopa-levodopa 25-100 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO QID (4 times a day). 2. escitalopram 10 mg Tablet [Telephone/Fax (1) ]: Two (2) Tablet PO DAILY (Daily). 3. fentanyl 100 mcg/hr Patch 72 hr [Telephone/Fax (1) ]: One (1) Transdermal Q72H (every 72 hours). 4. gabapentin 300 mg Capsule [Telephone/Fax (1) ]: One (1) Capsule PO HS (at bedtime). 5. hydromorphone 2 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. lamotrigine 100 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 75 mcg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 8. lorazepam 1 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO QAM (once a day (in the morning)). 9. lorazepam 1 mg Tablet [Telephone/Fax (1) ]: 1-2 Tablets PO QPM (once a day (in the evening)). 10. ondansetron 4 mg Tablet, Rapid Dissolve [Telephone/Fax (1) ]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea . 11. primidone 50 mg Tablet [Telephone/Fax (1) ]: 0.5 Tablet PO DAILY (Daily). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Telephone/Fax (1) ]: One (1) Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 13. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) [Telephone/Fax (1) ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. senna 8.6 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 15. docusate sodium 50 mg/5 mL Liquid [Telephone/Fax (1) ]: Two (2) PO BID (2 times a day). 16. cholecalciferol (vitamin D3) 400 unit Tablet [Telephone/Fax (1) ]: Two (2) Tablet PO DAILY (Daily). 17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [Telephone/Fax (1) ]: One (1) Tablet, Chewable PO twice a day: Do NOT take at same time as other medications. Take at least 2 hours away from other medications. 18. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [Telephone/Fax (1) ]: [1-4] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 19. miconazole nitrate 2 % Powder [Month/Day (2) ]: One (1) Appl Topical QID (4 times a day) as needed for G tube site. Disp:qs qs Refills:0 20. fentanyl 25 mcg/hr Patch 72 hr [Month/Day (2) ]: One (1) patch Transdermal every seventy-two (72) hours. 21. quetiapine 200 mg Tablet [Month/Day (2) ]: One (1) Tablet PO at bedtime. 22. Miralax 17 gram/dose Powder [Month/Day (2) ]: One (1) packet PO once a day as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: aspiration/hospital acquired pneumonia abdominal skin irritation/rash G-J tube malfunction . Secondary: parkinsons disease GERD HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with shortness of breath and coughing due to aspiration pneumonia. You initially were admitted to the ICU and started on IV antibiotics. Your symptoms improved. In addition, you reported abdominal pain and leaking around your feeding tube. You had an ultrasound that did not show an abscess. You were evaluated by the interventional [Hospital ] team and wound care team as well. In order to continue the healing process of your abdominal fistula, it is important that you have nothing to eat or drink by mouth. . Medication changes: none . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 8741] Location: [Hospital ] MEDICAL GROUP Address: [State ], STE#305, [Location (un) ],[Numeric Identifier 588] Phone: [Telephone/Fax (1) 82179] Appt: Thursday, [5-28] at 10am	[ "311", "569.81", "785.6", "285.9", "332.0", "338.29", "733.00", "530.81", "584.9", "401.9", "507.0", "424.0", "491.21", "536.42", "V15.81", "V85.0", "V10.87", "682.2", "E878.3", "799.4", "276.3" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.97" ]	icd9pcs	[ [ [] ] ]	16584, 16642	8162, 13234	325, 347	16818, 16818	4881, 6056	17676, 17929	3720, 3841		13986, 16561		16663, 16797		13260, 13963			16996, 17532									3856, 4862						6079, 8139																	17552, 17653	264, 287						2299, 2582					375, 2281											16833, 16972						2604, 3411	3427, 3704
3,654	138,803	23481	Discharge summary	report	Admission Date: [2104-11-8] Discharge Date: [2104-12-23] Date of Birth: [2060-8-15] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old male with one month of complaints of [8-31] headache after a cold that has not resolved but the headache has persisted. The patient complains of mild neck stiffness, denies any visual changes, nausea, vomiting, chest pain, shortness of breath. The patient denies any trauma. The patient went to an outside hospital where a lumbar puncture and CT were done. The lumbar puncture was 34 to 750 red cells in tube number one and 28,500 in tube number four, with no white cells and a protein count of 217. Head CT at the outside hospital, there is a question of a suprasellar subarachnoid hemorrhage. The patient was sent to [Hospital1 69] for further work-up. The patient has a negative past medical history and past surgical history. No known allergies. PHYSICAL EXAMINATION: His temperature is 99.4 degrees. Heart rate 76. Blood pressure 135/79. Respiratory rate 14. Saturations 97 percent on room air. The patient is a well- developed, well-nourished, sleepy but arousable gentleman in no acute distress. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Pupils 4 down to 2 mm and briskly reactive. Speech is fluent and appropriate. Repetition and naming intact. Face is symmetric. Tongue midline with no drift. His strength is 5 out of 5 in all muscle groups. His sensation is grossly intact. His reflexes are 2 plus throughout except for the ankles which are 1 plus bilaterally. His toes are downgoing. He has no dysmetria on the right, mild on the left. He has a positive Romberg with normal gait. He was admitted. Head CT shows hyperdenisty in the right suprasellar cistern with possible subarachnoid hemorrhage. The patient was admitted to the Intensive Care Unit, had a CTA with evidence of a right PICA aneurysm. He was admitted to the Intensive Care Unit for close neurological observation. He had an angiogram done which showed right PICA aneurysm which was coiled. The patient also had diffuse vasospasm and was then post angiogram sent back to the Intensive Care Unit for close neurological observation. Postoperatively, he was extubated, awake, alert and oriented times three. Pupils equal, round and reactive to light. Extraocular muscles full. No diplopia. Strength was [3-26] in all muscle groups. He had positive pedal pulses and his groin site was clean, dry and intact with no evidence of hematoma. The patient had a vent drain placed at the time of admission. Vital signs remained stable. He, on [2104-11-10], was awake, alert, oriented times three, moving all extremities with good strength. His sodium level was low and he was being repleted with 3 percent saline. His vital signs and labs were otherwise within normal limits. The patient had a repeat head CT on [2104-11-12] which showed a stroke on the right side of the head of the caudate consistent with obstruction of the artery of Heubner, most likely representing vasospasm. The patient was taken to angio on [2104-11-12] after CT showed stroke. He was found to have severe vasospasm. The patient was transferred back to the Intensive Care Unit and his blood pressure was kept in the 170 to 190 range. CVP in the 10 to 12 range. The patient was receiving intravenous fluid boluses, albumin as needed, and continued on a 3 percent saline drip trying to keep his sodium above 130. Infectious Disease was consulted on [2104-11-12] due to the persistent fevers of 101 degrees. The patient's cultures to date had been negative. They did not recommend any specific antibiotic coverage to be started at that point. The patient was on prophylaxis for his vent drain. Infectious Disease continued to follow the patient. The patient continued to spike temperatures to 101.2 degrees. Infectious Disease felt that it could be drug fever and recommended changing Dilantin to another [Doctor Last Name 360]. On the 26th the patient had repeat head CT which showed no change. The patient had a carotid ultrasound which was negative and had a chest x-ray after placement of a subclavian line. On [2104-11-18], the patient went back to angio which showed improved angiographic evidence of spasm. The patient's blood pressure was then wanted to be kept in the 150 to 180 range and his CVP in the 8 to 10 range. Post angio, his vital signs were stable. He was afebrile. He was awake, alert and oriented times three. He had no hematoma in his groin. His pulses were palpable. On [2104-11-22], the patient had been having his drain raised and on [2104-11-22], had a repeat head CT which showed increase in ventricular size. The drain was therefore placed back down at 12 cm. He spiked on [2104-11-23] to 103.8 degrees. CSF was sent and it came back positive for gram positive cocci. Infectious Disease recommended vancomycin and Ceptaz and repeat cultures and also possibly starting intrathecal vancomycin. Pathology was consulted due to his persistently low Dilantin levels and need for several episodes of re-bolusing. Neurology recommended starting Keppra and weaning Dilantin which was done. The patient was neurologically intact, awake, alert and oriented times three. He did have an episode on [2104-11-24] of having left-sided weakness and somnolence. Repeat head CT showed no evidence of new stroke and post CT the patient was more awake and following commands and moving both right and left sides. The patient also had an electroencephalogram which showed no evidence of seizure activity and continued to be followed by Infectious Disease for a CSF infection. He also had a transthoracic echocardiogram which showed no evidence of vegetation in the heart valves and no clots. The patient was neurologically stable and transferred to the Step-Down unit on [2104-11-29]. His stay on the floor was complicated by a continued CSF infection for which he was treated with vancomycin for two to three weeks. He also developed a pulmonary embolism on [2104-12-1] and was started on intravenous heparin. He remained on intravenous heparin until he was taken to the Operating Room on [2104-12-19] when he had a VP shunt placed. Heparin was discontinued prior to the Operating Room and the patient was started on Lovenox postoperatively two to three days after surgery. He remained neurologically intact, awake, alert and oriented times three, moving all extremities with no drift. He was seen by Physical Therapy and Occupational Therapy and found to be safe for discharge to home on [2104-12-23]. Medications at the time of discharge include Lovenox 70 mg subcutaneously twice a day, Foltx 1 gm p.o. three times a day, Percocet 1 to 2 tabs p.o. q.4h. p.r.n., ferrous sulfate 325 p.o. once a day, Colace 100 mg p.o. twice a day, Keppra 1000 mg p.o. twice a day, Pantoprazole 40 mg p.o. q.24h. The patient's condition was stable at the time of discharge. He will follow-up with Dr. [Last Name (STitle) 1132] in two weeks. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2104-12-22] 12:14:33 T: [2104-12-22] 13:29:22 Job#: [Job Number 60151]	[ "331.3", "276.1", "320.3", "453.42", "790.7", "285.9", "430", "434.91", "415.19", "293.0", "342.90", "996.63" ]	icd9cm	[ [ [] ] ]	[ "39.72", "88.41", "99.29", "88.43", "38.93", "38.7", "02.2", "02.34", "03.31", "99.04", "38.91" ]	icd9pcs	[ [ [] ] ]																																							984, 7408																					166, 961
171	153,112	19052	Discharge summary	report	Admission Date: [2197-7-15] Discharge Date: [2197-8-7] Date of Birth: [2135-7-23] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6169] Chief Complaint: facial swelling Major Surgical or Invasive Procedure: [7-15]:Portacath removal from L chest by IR. [7-15]:IR venogram of SVC with direct clot lysis by TPA. [7-18]:Repeat venogram and additional clot lysis by TPA. [7-20]:Final venogram and placement of SVC stent. History of Present Illness: Mr. [Known firstname 25368] [Known lastname 39602] is a 61-year- old gentleman with a history of plasmacytoma/multiple myeloma. The patient is status post autologous bone marrow transplant on [2195-9-28] for treatment of his disease (done at [Hospital1 336] with Dr. [First Name (STitle) 1557]. Since then has been fairly well, without major signs/symptoms of his underlying disease. Pt states that in the last 10 days he just has not felt like himself. He has been extremely fatigued with very little appetite. Pt reports a weight loss of ~ 8 lbs and he states that it has been a chore to do his daily activities. At approximately 9:00 pm on [7-14] pt's wife noticed that his appearance looked different, swollen. He thought it might be a bug bite and he went to sleep on the couch. He got up at 5:00 am and felt sob. His facial swelling was not improved and he went to the ED at [Hospital6 33]. At [Hospital3 ], pt was noticed to have redness and veins bulging from neck and forehead. VS - 97.3 P 93 RR 16 BP 112/73. CXR did not show a mediastinal mass. Due to concerns of SVC thrombosis and pt s/p transplant w/ Dr. [First Name (STitle) 1557], he was transferred to [Hospital1 18]. At [Hospital1 18], pt taken to IR where he had a mechanical thrombectomy, clot lysis w/ TPA, and stenting of vessels. Portacath was also removed. Past Medical History: MM diagnosed [4-1] s/p autologous BMT [9-2] multiple fracture of r. humerus with hardware (hinge). s/p removal of rod from R humerus Social History: Pt is a former truck driver, lives at home with his wife. Family History: Grandfather skin cancer Mother skin cancer Father CAD Physical Exam: VS 98.3 155/74 81 15 97 RA GEN lying in bed comfortable NAD SKIN facial erythema HEENT PEERL, EOMI, MMM, prominent forehead and neck veins, neck supple CV RRR no m/r/g CHEST: L chest portacath site draining blood bandaged, CTA b/l ABD soft NT ND + BS - HSM EXT warm no c/c/e NEURO A & O x 3 Pertinent Results: SVC GRAM 1) Thrombosis of the superior vena cava and proximal portions of the right subclavian and internal jugular veins. The patient has received 10 mg of TPA directly into the thrombus at the time of the procedure and is now receiving 1 mg per hour of TPA via infusion catheter into the thrombosis. This will be stopped 12 hours from now and then normal saline will be infused through the catheter at a rate of 30 cc per hour to keep the catheter open. The patient is also on a Heparin drip at 200 units per hour peripherally which will be continued. 2) The patient will be reevaluated with a venogram on [2197-7-17] to evaluate clot burden at that time. 3) Status post removal of the patient's left portocath. --- CT [7-15] IMPRESSION: Bypass of superior vena cava by intravenous contrast with filling of multiple venous collaterals consistent with SVC thrombosis. No significant lymphadenopathy identified --- VQ SCAN IMPRESSION: No evidence of pulmonary embolism. --- ECHO Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. No evidence of endocarditis seen. --- Tagged WBC SCAN IMPRESSION: 1) No definite evidence of an infectious source. 2) Resolving small emboli of clumped tracer material --- CT ABDOMEN/CHEST IMPRESSION: 1. Left anterior chest wall cystic lesion. This may be postoperative in nature, representing a hematoma/seroma. An infected collection cannot be ruled out. 2. Small bilateral pleural effusions, new since the prior study. 3. Left upper lobe pulmonary nodule, stable from [2197-3-10]. 4. Stable osseous lytic/sclerotic lesion. 5. No hydronephrosis. --- CXR [8-1] IMPRESSION: Bilateral pleural effusions again seen, with slight interval worsening. No other interval change. --- Brief Hospital Course: A/P 61 yo male with multiple myeloma w/ fractures of humerus and vertebrae status post BMT admitted for SVC thrombosis at portacath s/p thrombectomy and clot lysis w/ TPN. The following issues were addressed during this admission: 1. SVC thrombosis: His portacath was thought to be the nydus for clot formation as a result of hypercoagulability secondary to underlying malignancy. He was initially taken for direct clot lysis with tissue plasminogen activator by IR. He was sent back to the ICU with a tPA infusion and heparin. He also had his portacath removed. However, while receiving tPA, he began bleeding from the port removal site which was eventually controlled with a pressure dressing. He was brought back 2 days later for additional direct tPA to remaining clot. Again, he was placed on a tPA infusion. Finally, several days later, he was again taken for a venogram and had a stent place in his SVC. He had a narrowed section that was felt to have contributed to his formation of clot. The stent was placed effectively. Of note, he had residual clot seen in the left brachiocephalic vein and the right internal jugular vein. He was then sent out on heparin and continued on this. He was switched to Lovenox and his heparin gtt was stopped. He was then started on coumadin and brought to therapeutic levels, at which point the Lovenox was stopped. He remained stable, with no additional thrombus or signs of SVC blockage. 2. Multiple Myeloma: Patient presented with complaints of back pain, fatigue, and weight loss over the 2 weeks prior to admission. This was concerning for relapse of myeloma. Total protein was also elevated on lab values. Serum protein electropheresis sent on hospital day two demonstrated a single band with 20% of his total protein present, which represented an IgG level of 2463mg/dL. Likewise, urine protein electropheresis identified a band containing 70% of the total urine protein and revealed the presence of Bence-[Doctor Last Name ] proteins. Repeat SPEP 10 days later demonstrated an increase in the representation of IgG in total serum protein to 25%, 1968mg/dL, which was concerning for further evidence of relapse. 3. FUO: On the day before his SVC stent was placed Mr [Known lastname 39602] had a fever to 101. He then proceeded to have daily fevers of varying magnitude for much of the remainder of his course. On the day of his stent, he was 101 again, then had a 102.3 fever the following day. At this point, he was started on vancomycin, and defervessed for approx 72 hours. All of his blood cultures were negative, and the vancomycin was stopped. He proceeded to have a return of his fever 13 hours after his last dose. The fevers then recurred daily, and on some days occured for the majority of the day. They seemed to worsen in length and intensity as his course progressed. After 2 days of febrility, the vancomycin was restarted. However, he did not defervese. It was continued nonetheless to protect his stent and arm hardware from contamination. Multiple blood cultures were obtained but were perpetually negative. At this point, he had a VQ scan to rule out PE, as he did have clot remaining in his body, but it was negative. He then had a chest CT and abdominal CT which were unrevealing. An echo showed no endocarditis. He then had a tagged WBC scan which showed no source of infection. Other possibilities included drug fever and tumor fever. Myeloma is not known to cause fever, and especially not fevers to the 103s as he was exhibiting. His medication list was reviewed and nothing known to cause fever was found. Vanco was considered, but he hadthe fevers before going on this drug. He did have one episode of itchy rash that resolved with Benadryl and a 5% incidence of eos of his diff. This did not recur, and was unexplained. His portacath removal site was considered as a source and eventual I&D revealed no evidence of infection. During this process, ID was consulted, and Levaquin and Ceftazidime were both added for broader coverage of possible pathogens. At this point, there was still no culture growth and no known source of infection, although patient did begin to have occasional episodes of diarrhea, which was ultimately found to be positive for Clostridium difficile. Patient was treated with metronidazole. Therefore, given the absence of any obvious symptoms or signs of infection or morbidity as a result of the etiology of the fever, all antibiotics were stopped (except for metronidazole), and patient continued to do well with only acetaminophen for treatment of fever. Patient was ultimately discharged with occasional episodes that were not otherwise symptomatic. 4. Anemia: Mr [Known lastname 39602] initially presented with a Hct of 31 on admission. This slowly trended down, and he was transfused 2 units PRBCs. He had a good response, but then drifted down again and was given another 2 units. A source of bleeding was not identified. His stools were initially guaiac negative, he had no hematuria, hemptysis, or obvious bleeding source. We also had an abdominal and chest CT which did not show bleeding. Hemolysis labs were sent and negative. Iron studies and B12/folate were also normal and unrevealing. Despite these results, patient continued to require infrequent blood transfusions for support. Given the lack of evidence for hemolysis or loss of red blood cells, the low blood count was concerning as further evidence of myeloma relapse with marrow infiltration. 5. Renal failure: Following initial procedures performed by Interventional Radiology, patient's serum creatinine began to trend upwards. Despite aggressive hydration, serum creatinine continued to increase. Therefore, it was thought that patient's renal insufficiency was likely a result of multiple rounds of contrast dye insult during initial hospital course. Although urine output continued to be adequate, patient's serum creatinine stabilized at ~1.6 (baseline had been 0.7 on admission), which was concerning for an irreversible contrast nephropathy in the setting of likely relapse of myeloma and Bence [Doctor Last Name ] proteinuria. Despite the above issues, at the time of discharge, Mr. [Known lastname 39602] claimed that he felt "the best I've felt in years", and given the stabilization of acute issues, it was felt that patient was clinically stable for discharge. At the time of discharge, patient was continuing to have occasional fevers, but had no signs or symptoms of infection. Patient was discharged with a course of metronidazole to eradiacte Clostridium difficile. Patient was to return to clinic for follow up of possible myeloma relapse. Medications on Admission: Zometa Discharge Medications: 1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 2. Epogen 10,000 unit/mL Solution Sig: One (1) injection sc Injection every M/W/F. Disp:12 doses Refills:2 3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Clostridium difficile colitis SVC syndrome Plasmacytoma Anemia s/p tPA lysis of SVC clot Discharge Condition: good Discharge Instructions: The only medications you're going out on are coumadin and epo. You will also get 10 more days of flagyl. Please call your the BMT doctor on call at [Telephone/Fax (1) 8717] (ask them to page the BMT doctor on call) or return to the hospital if you experience a fever above 100.4, or have abdominal pain, chest pain, shortness of breath, dizziness, or a recurrence of your face and neck swelling. Followup Instructions: Please call Dr. [First Name (STitle) 1557] and make an appointment to followup within 7-10 days.	[ "203.01", "453.8", "211.3", "285.9", "459.2", "996.74", "584.9", "E878.1", "V42.81" ]	icd9cm	[ [ [] ] ]	[ "99.10", "88.51", "45.13", "96.6", "39.90", "45.42", "39.50" ]	icd9pcs	[ [ [] ] ]	11748, 11754	4655, 11354	326, 553	11887, 11893	2619, 4632	12342, 12446	2228, 2284		11411, 11725		11775, 11866		11380, 11388			11917, 12319									2299, 2600																								271, 288											581, 1972																	1994, 2137	2153, 2212
23,037	194,681	15460+56652	Discharge summary	report+addendum	Admission Date: [2190-12-14] Discharge Date: [2190-12-23] Date of Birth: [2141-1-8] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old male with a past medical history of hypercholesterolemia and borderline hypertension never treated with medication who presented to an outside hospital in Exedur, [Location (un) 3844] complaining of severe back pain, chest pain, nausea and vomiting. The patient was found to have an elevated blood pressure of 200/100 and inconclusive chest x-ray with a questionable widened mediastinum. The patient was transferred to [Hospital1 69] for further evaluation and for possible aortic dissection. A CAT confirmed the presence of a thoracic aortic dissection. The patient was started on Esmolol and Nitroprusside drips. An MRA was also performed, which showed the aortic dissection starting just distal to the left subclavian and extending down to the bilateral iliacs. The patient was transferred to the Coronary Care Unit for treatment. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Borderline hypertension never treated. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Lipitor, Flonase. SOCIAL HISTORY: No smoking, several drinks per day. PHYSICAL EXAMINATION: Pulse in the 80s. Blood pressure 160s/80s. General, in acute distress, uncomfortable and struggling. HEENT supple. Pupils are equal, round and reactive to light. Cardiovascular regular rate and rhythm. Normal S1 and S2. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Decreased bowel sounds. Extremities pulses 2+, dorsalis pedis pulse, posterior tibial pulse, radial, femoral and carotids. INITIAL LABORATORIES: White blood cell count of 18.7, hematocrit 46.5, platelets 291, 78% neutrophils, 3 bands, 10 lymphocytes. Chem 7 was sodium 142, potassium 2.6, chloride 104, bicarb 21, BUN 14, creatinine .8, glucose 189, anion gap of 17. Magnesium was 1.8, INR 1.0, AST 65, ALT 77, alkaline phosphatase 99, T bilirubin .3, amylase 66, CK 170, MB 3. Urinalysis was clear. Arterial blood gas performed was pH 7.21, carbon dioxide of 47 and oxygen of 224. Lactate level was 8.4. CTA showed thoracic aortic dissection from take off of left subclavian to the both common iliac arteries, avulsed origin of the ciliac SMA and [Female First Name (un) 899]. MRI was consistent with CTA. TE was performed and showed no involvement of the ascending aorta and a aortic dissection in the descending aorta. INITIAL ASSESSMENT: The patient is a 50 year-old male found to have a thoracic aortic dissection with wide involvement and hypertension with systolic blood pressure in the 200s. HOSPITAL COURSE: 1. Cardiovascular,thoracic aortic dissection: The patient was started on an aggressive blood control management with goal MAT on 65 to 75. The patient was initially placed on Esmolol drip and nitroprusside drip. This was changed to Labetalol drip along with Nipride with moderately good control of blood pressure. Throughout the hospital course the patient was gradually transitioned to po blood pressure medication and gradually weaned off his blood pressure drips to the final discharge medications. Initially general surgery and vascular surgery teams were consulted. Both teams thought that the patient did not require surgery at the time of presentation. The patient was taken for a mesenteric angiogram, which showed good filling of the blood vessels. The patient had a fenestration performed by Vascular surgery. The vascular surgery team felt that the elevated lactate was secondary to mesenteric ischemia. Lactate levels were followed as well as chemistries quite closely initially q two hours and then q four hours and then b.i.d., which revealed a gradual decrease of the lactate to normal levels. The patient did not require surgery for his aortic dissection nor a step for his aortic dissection. The patient is to be followed up by vascular surgery for future aortic dissection management. 2. Pulmonary: The patient was initially intubated for his TEE and left intubated afterwards. Due to his abnormal blood gas the patient was hyperventilated to rectify his blood pH. The patient was able to be extubated two days after intubation with some initial confusion, which gradually cleared to a normal mental status. 3. Abdomen: There was a concern for mesenteric ischemia from the beginning due to the elevated white blood cell count and the elevated lactic acid. The patient had a esophagogastroduodenoscopy performed by the gastrointestinal team while he was intubated, which showed multiple stress ulcers in the stomach as well as the duodenum, which was consistent with his heme positive stools and gradually falling hematocrit. The patient was started on Protonix 40 mg intravenous b.i.d. for his gastrointestinal bleeding. Hematocrits were followed. The patient did require a blood transfusion after which hematocrits did stop rising day by day until normal levels. The patient did not require any further gastrointestinal intervention and was able to tolerate a regular diet by the day of discharge. 4. Fluids, electrolytes and nutrition: The patient was initially kept NPO in the beginning of his hospital course. The patient was placed on total parenteral nutrition for two days and then was started on a soft diet and then was able to tolerate a full diet. The patient had laboratories drawn serially for electrolytes and initially had a high potassium, which corrected into the normal range. Magnesium and other electrolytes were replaced prn. Overall, the patient was able to tolerate his fenestration, his extubation and his low hematocrit and transfusion quite well and was able to walk with physical therapy, eat a full diet and have normotensive pressures by the day of discharge. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po q day. 2. Enteric coated aspirin 325 mg po q day. 3. Zestril 40 mg po b.i.d. 4. Hydrochlorothiazide 25 mg po q day. 5. Labetalol 1200 mg po b.i.d. 6. Norvasc 10 mg po q.d. 7. [Doctor First Name ] 60 mg po b.i.d. 8. Protonix 40 mg po b.i.d. DISCHARGE DIAGNOSES: 1. Aortic dissection type B. 2. Hypertension. DISCHARGE STATUS: The patient is to follow up with Vascular Surgery in one month to have a repeat CTA prior to a vascular surgery appointment at which point he will be evaluated for stent placement or further medical management. The patient is also to follow up with cardiology Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and to follow up with new primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) ] myself at [Company 191] for blood pressure management. The patient will be discharged home with VNA Services. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Doctor First Name 6677] MEDQUIST36 D: [2190-12-22] 10:32 T: [2190-12-22] 11:41 JOB#: [Job Number ] Name: [Known lastname 5318], [Known firstname ] Unit No: [Numeric Identifier 8229] Admission Date: [2190-12-14] Discharge Date: [2190-12-25] Date of Birth: [2141-1-8] Sex: M Service: This is a discharge summary addendum from the hospital course from [2190-12-23] to [2190-12-25], the patient's eventual date of discharge. HOSPITAL COURSE FOR THIS PERIOD: The patient had an uneventful hospital course. The patient was afebrile and kept in the hospital due to methicillin-resistant Staphylococcus aureus positive triple lumen catheter tip. Infectious Disease consult was obtained. Infectious Disease recommended imaging of the abdomen by CT scan to look for the nidus of infection. Patient was already on Vancomycin IV via PICC line and was scheduled to receive four weeks of Vancomycin. After discharge from the hospital, the patient eventually became frustrated by delays in discharge and recusted to sign out against medical advice, which he did. DISCHARGE MEDICATIONS: Same as the discharge medications noted in the previous discharge summary. 1. Plavix 75 mg po q day. 2. Enteric coated aspirin 325 mg po q day. 3. Zestril 40 mg po bid. 4. Hydrochlorothiazide 25 mg po q day. 5. Labetalol 1200 mg po bid. 6. Norvasc 10 mg po q day. 7. [Doctor First Name 1866] 60 mg po bid. 8. Protonix 40 mg po bid. DISCHARGE DIAGNOSES: Same as previous. 1. Aortic dissection type B. 2. Hypertension. 3. Methicillin-resistant Staphylococcus aureus positive catheter tip, however, negative blood cultures. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is discharged to home. FOLLOWUP: Follow up with Vascular Surgery in one month. Repeat CTA prior to Vascular Surgery appointment. The patient is also to followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of Cardiology and myself, [Doctor First Name ] Mark, the new PCP at [Name9 (PRE) 112] for blood pressure management. The patient is discharged home with VNA services, Vancomycin IV through a PICC line for four weeks, last day of Vancomycin on [2191-1-23]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4474], M.D. [MD Number(1) 4475] Dictated By:[Name8 (MD) 4796] MEDQUIST36 D: [2191-1-11] 14:42 T: [2191-1-12] 04:03 JOB#: [Job Number ]	[ "557.1", "441.01", "996.62", "531.40", "401.9", "507.0", "272.0" ]	icd9cm	[ [ [] ] ]	[ "33.22", "38.93", "96.71", "39.54", "45.13", "89.64", "88.42", "99.15", "96.04" ]	icd9pcs	[ [ [] ] ]				8707, 9513				8515, 8685	8155, 8493					2731, 5866							1193, 1212																		1289, 2713																					162, 1040																	1063, 1171	1229, 1266
17,434	115,244	9810	Discharge summary	report	Admission Date: [2168-4-18] Discharge Date: [2168-4-21] Date of Birth: [2109-10-13] Sex: M Service: Medicine CHIEF COMPLAINT: Presyncope. HISTORY OF PRESENT ILLNESS: This is a 58-year-old male who presented with a one-week history of fatigue, lightheadedness, and black tarry stools with occasional bright red blood per rectum. The patient is status post a bicycle accident in the summer of [2166] and has been taking ibuprofen 400 mg q. 4-6 hours for approximately one month. He also reports band-like chest pain radiating from his back consistent with his history of chronic back pain. He also has increased chest pain with deep breaths and with movement but denies shortness of breath, nausea, vomiting or significant diaphoresis. Other review of systems is noncontributory. PAST MEDICAL HISTORY: 1. Status post bicycle accident in summer [2166] resulting in chronic lower back pain and history of herniated disk. 2. Hyperplastic polyp on colonoscopy [11-7]. 3. History of rheumatic fever. 4. Obstructive sleep apnea. 5. Childhood polio. 6. Status post tonsillectomy. MEDICATIONS ON ADMISSION: 1. Neurontin (patient self-discontinued secondary to sedative side effects). 2. Ibuprofen 400 mg q. 4-6 hours p.r.n. 3. Prozac 20 mg p.o. q.d. 4. Flonase. 5. Omega oils. ALLERGIES: Sulfa. SOCIAL HISTORY: The patient is married and is a former executive. He denies the use of tobacco. He occasionally drinks alcohol. He does not use drugs. FAMILY HISTORY: Mother has a history of coronary artery disease and Addison's disease. Father has a history of valvular heart disease. PHYSICAL EXAMINATION: Temperature 98, pulse 82, blood pressure 105/66, respiratory rate 18 and 100% on room air. The patient was a pleasant, well-developed, well-nourished male in no acute distress. His HEENT examination was normal except for dry mucous membranes. His neck was supple with 7 cm of jugular venous pressure. His chest was clear to auscultation bilaterally. He had a regular rate and rhythm with a systolic murmur. His abdomen was soft and nondistended with mild epigastric tenderness and normal active bowel sounds. The patient had black stools that were guaiac positive. His extremities showed no pedal edema. Pulses were +2 bilaterally. Neurological examination was grossly intact. The patient was alert and oriented x 3. Nasogastric lavage was deferred as EGD was to be done. LABORATORY DATA: Hematocrit was 24.3. The remainder of the patient's complete blood count, chem-10 and basic coagulation studies were within normal limits. EKG: On admission the patient was in normal sinus rhythm with a rate of 76, normal axis and intervals and no ischemic changes. Chest x-ray showed no infiltrates or interstitial edema. HOSPITAL COURSE: 1. Upper GI bleed: EGD performed on [2168-4-18] revealed a normal EGD to the second part of the duodenum. In the second part of the duodenum a fresh clot located between the duodenal bulb and the ampulla was noted. After washings there was fresh bleeding that completely obscured visualization. Despite multiple attempts of washings, therapeutic cautery was impossible with EGD. Given the brisk bleeding, an emergent artery embolization was needed. Interventional radiology performed an embolization of the gastroduodenal artery and noted a pseudoaneurysm at the entrance into the duodenum. This was performed on [2168-4-18]. The patient's hematocrit reached a nadir of 13.9 on [2168-4-18] and required six units of packed red blood cells for resuscitation. Following the embolization described above the patient was hemodynamically stable and hematocrit remained stable at approximately 28. The patient's diet was advanced slowly 48 hours following the procedure without complications. Serial examinations were performed to evaluate for ischemic colitis which revealed a completely benign abdomen. Gastroenterology followed the patient during the course of admission and made several recommendations to decrease future risks of GI bleeding, including Protonix b.i.d. for at least two weeks and then continued q.d. thereafter, avoidance of non-steroidal anti-inflammatory drugs and Omega oils, avoidance of alcohol and avoidance of coffee. Prior to discharge, a repeat endoscopy was done to reevaluate the region of active bleeding. This was performed on [2168-4-21] and revealed a shallow ulcer in the second part of the duodenum. Per gastroenterology, this region is stable and the patient does not require further follow up from their department unless there are signs of recurrent bleeding, such as presyncope, bloody stools, melena, or hemodynamically instability. Helicobacter pylori was negative. 2. Chest pain: The patient had the band-like chest pain on presentation that was typical of his chronic pain. The patient was ruled out for myocardial infarction. He had a normal EKG. Pain resolved with treatment of upper GI bleed and with Ultram. 3. Back pain: The patient was initiated on a treatment plan with Ultram as an alternative to ibuprofen for chronic back pain. The patient states that he gained adequate relief with this regimen and did not find any significant side effects in the first few days to use. He will be discharged with a prescription for Ultram. Tylenol may also be used. DISCHARGE DIAGNOSES: 1. Upper GI bleed. 2. Anemia secondary to blood loss status post six units of packed red blood cells. 3. Melena. 4. Chest pain, not otherwise specified. FOLLOW UP: The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 216], in one week. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. b.i.d. 2. Tramadol 50 mg p.o. q. 4-6 hours p.r.n. 3. Prozac 20 mg p.o. q.d. PENDING STUDIES: None. CONDITION ON DISCHARGE: The patient is stable hemodynamically. His hematocrit is approximately 28. He is tolerating a regular diet. He has no gross blood or melena in the stool. He has no abdominal pain, nausea or vomiting. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Last Name (NamePattern1) 6458] MEDQUIST36 D: [2168-4-21] 14:58 T: [2168-4-25] 09:09 JOB#: [Job Number 33027] cc:[Name8 (MD) 33028]	[ "E935.9", "786.50", "280.0", "442.84", "532.40" ]	icd9cm	[ [ [] ] ]	[ "99.29", "88.47", "45.13" ]	icd9pcs	[ [ [] ] ]							1521, 1642	5377, 5531	5704, 5829				1153, 1348	2812, 5356																			5543, 5681						1665, 2794										156, 169											198, 818																	841, 1126	1365, 1504	5854, 6396
10,670	143,421	19358	Discharge summary	report	Admission Date: [2108-2-5] Discharge Date: [2108-2-12] Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 27-year-old man who developed a generalized seizure, less than 2 minutes, followed by a frontal headache. He was admitted to [Hospital6 52666] Center complaining of nausea and vomiting and positive neck pain with diaphoresis. Blood pressure on arrival to [Hospital6 22197] Center was 197/118, heart rate 114, and temperature 98.3 degrees. He was in atrial fibrillation. He converted to sinus rhythm with Cardizem. The patient received Ativan and Dilantin IV push and nimodipine. His CT at the outside hospital showed diffuse subarachnoid hemorrhage with blood in the fourth ventricle and hydrocephalus. On [2108-2-4], he was transferred to [Hospital 14852] Neuro SICU, where blood pressure was maintained at less than 130 on Nipride and angiography found a [Doctor Last Name ] aneurysm at the proximal left PCA, about 3 mm in size. The patient was transferred to [Hospital1 190] on [2108-2-5] for possible coiling. PAST MEDICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS: None at home. SOCIAL HISTORY: Two beers per day. The patient had a paternal grandfather who passed away approximately 2 years prior with a ruptured aneurysm. PHYSICAL EXAMINATION: Temperature 98.4 degrees, pulse 60, blood pressure 131/61 on Nipride, respiratory rate 15, and saturation 95 percent on room air. He appeared in no acute distress. Lungs were clear bilaterally. He had a regular rate and rhythm; S1, S2, systolic; grade 2 systolic murmur. His abdomen was soft, nontender. His cranial nerves II through XII were intact bilaterally. Pupils were 3 mm to 2 mm bilaterally. Motor, no pronator drift. Motor strength was [6-6] in all extremities. Sensory was grossly intact. Reflexes were 2 plus throughout. Finger-to-nose was also intact. HOSPITAL COURSE: The patient was admitted by Dr. [Last Name (STitle) 1132], Neurosurgery Service for an angiography with possible coiling. He was placed on every 1 hour on neuro checks, nimodipine 60 mg every 4 hours. Systolic blood pressure was kept less than 130 using Nipride. He was on Dilantin, Protonix, Colace, and Senna for prophylaxis. He was kept NPO and was given an IV of normal saline at 75 cc an hour. He received Decadron 4 mg every 6 hours. His INR was kept less than 1.3 and was given morphine for pain. The patient underwent a cerebral angiogram on [2108-2-5]. On [2108-2-5], he went to the Neuroangiography Suite where he was found to have a 2.5- to 3-mm basilar trunk aneurysm located between the left posterior cerebral artery and the superior cerebellar artery, status post GDC coiling embolization via endovascular approach with GDC coils. The procedure was without complications; the procedure was completed at approximately 2230 hours. On [2108-2-6], it was noted at 1.30 in the morning that the patient became agitated and his O2 saturations were in 80 percent range. Blood pressure was 160/80, pulse 53, and temperature 97.8. He was moving all extremities. He immediately was intubated and sedated. An EKG was within normal limits. Chest x-ray showed no collapse, slight fluid overload. CT of his head was done and a CTA was completed to rule out a PE. Despite the rapid intubation he sustained an episode of severe hypoxemia with a pO2 in the 50's range which did not rapdily respond to ventilation. His cardiac enzymes were all negative. Chest x-ray showed pulmonary edema. CT of the head showed dilated ventricles with no new blood. In light of his chest x-ray findings and new mental status changes, decision was made to obtain a chest CT without contrast. CT of the chest finding was consistent with pulmonry edema. The patient had an immediate central line with Swan-Ganz catheter placed for hemodynamic monitoring. He also had a ventriculostomy drain placed without complications. On [2108-2-6] in the morning on rounds, the patient's temperature was 99.3, heart rate 53, blood pressure 144/54, and respirations 12. Gas 7.44, 33, 178, 23, 0. White count was 16.7, hematocrit 36.3, and platelets 215. Troponin was less than 0.01 and MB was 1. Sodium 140, potassium 3.7, chloride 109, 23 for bicarbonate, 8 for BUN, and 0.6 for creatinine. His pupils were 1.5 mm and trace reactive bilaterally. He localized on his upper extremities. He withdrew his lower extremities. The drain was kept at 12 above the tragus. His blood pressure was kept less than 150. PCO2 was kept 35-40, and he had an MRI later on [2108-2-6], which showed increased diffusion present in the globus pallidus region bilaterally in both caudate nuclei, the right and left posterolateral thalamus and medial temporal bones on both sides demonstrating increased diffusion. These findings were felt to be consistent with global anoxic episode. Blood was present in the lateral ventricles. There was a drainage catheter. The ventriculostomy drain was in place. At 5 p.m. on [2108-2-6], he had a diagnostic cerebral angiogram, which showed no evidence of significant change in the appearance of the treated aneurysm with no recanalization or regrowth and no evidence of thrombotic involvement in the basilar arteries or its branches. Postoperative check at approximately 7:45 on [2108-2-6] showed that he still had no response to voice. Pupils bilaterally were equal and reactive. He seemed to localize briskly better on his left upper extremity than his right. An EEG showed encephalopathy with some burst suppression. He was kept off sedatives at that time. Neurology also saw the patient on [2108-2-6] and recommended an infectious workup, a TTE to look for LV dysfunction and wall motion abnormalities. They recommended to continue to cycle his cardiac enzymes and to repeat his DWI in 24 hours to look for any anoxic injury. Neurology felt that the coma was secondary to diffuse cortical hemispheric insult. At the time of examination, brainstem reflexes were largely intact and thus it was likely that the coma was due to diffuse cortical dysfunction; however, the extent of cerebral edema, tight cisterns made herniation in the brainstem dysfunction a possibility. They recommended if it should worsen or his ventricular drain should fail, that the cause that his diffuse cortical injury most likely was anoxic in nature since the symptoms acutely followed a hypoxic event. Another thought was that the patient suffered from alcohol abuse and perhaps that a Wernicke encephalopathy was possible. They also recommended a close ICP monitoring as already was being done and optimal cerebral perfusion with systolic blood pressure greater than 140, head of bed at 30 degrees, and calcium channel agonist to prophylax against vasospasm, which had already been started. On [2108-2-7], his T-max was 100.7, pulse was 72, blood pressure 169/76, PA pressure 42/20, and wedge pressure 15. He was receiving Nipride and propofol. He was on assist control. He would open his eyes to stimulation. His pupils were 1.5 mm and trace reactive. He localized briskly bilateral upper extremities and withdrew bilaterally in his lower extremities. His blood pressure was kept less than 150 using labetalol and Nipride as needed. PCO2 was kept 35-40. The drain was at 10 cm of water. He was receiving mannitol 15 mg IV every 4 hours. His total IV fluids were kept at 100 cc an hour. His serum osmols and sodium and arterial gases were monitored closely. On [2108-2-7], he had a repeat head CT, which showed interval loss of [Doctor Last Name 352] and white matter differentiation in the cerebrum. In the interval since the prior studies, the findings were consistent with anoxic brain injury. There was no interval change in the areas of hypoattenuation within the globus pallidus bilaterally and no interval change in the extent of the subarachnoid hemorrhage blood within the lateral ventricles. On [2108-2-8], T-max was 100.9, blood pressure 126/54, PAP pressure 32/13, wedge of 8, and ICP was in the range 9-23. He was sedated and intubated at that time. His pupils were 2 to 1.5 mm bilaterally. His right upper extremity and left upper extremity had slight flexion in an attempt to localize. Gas was 7.46, 36, 154, 26, 2. He essentially was moving all 4 extremities under sedation. Systolic blood pressure was less than 150. He was receiving mannitol 25 mg every 4 hours as needed for ICPs greater than 20. His head CT continued to show global anoxic injury. His drain had been lowered to 5 in order to maintain ICPs less than 20. PCO2 was kept 35-40. On [2108-2-8], a CTA was performed that showed a dense opacification predominantly involving the right lower lobe with patchy opacifications in the lower lobe and right upper lobe. Overall improvement in the atelectasis changes dependently; however, mass effect from the right lower lobe consolidated major fissure concerning for development of pneumonia. There was no evidence of pulmonary embolus. He also had an MRI of the brain and MRA completed, which showed mild changes in vasospasm suspected involving the M1 segment of the left MCA and to a lesser degree the cavernous portion of both ICAs. There was nonvisualization of the left proximal T1 segment of the PCA, which could be due to recent surgery and coiling and the presence of blood was also in the pre-pontine cistern, significant collapse of the right lateral ventricle which could be related to over shunting. Adjustment of the ventricle catheter was suggested; extensive subarachnoid intraventricular hemorrhage with partial resolution. There were areas of restricted diffusion, which partially resolved left in the basal ganglia along the globus pallidus caudate, most likely related to anoxic injury. On [2108-2-9], the patient was examined on propofol. Systolic blood pressures were maintained. The patient was not examined due to the amount of sedation. Blood pressures were kept in the 160-170 range. An EEG on [2108-2-6] showed diffuse generalized slowing with delta slowing burst with moderate to severe encephalopathy. Cultures, CSF showed no growth to date. Blood cultures continued to be pending as of [2108-2-9]. Sputum cultures had no growth and urine cultures also had no growth. At 10:30 in the morning on [2108-2-9], the patient continued to have ICP increases despite receiving extra mannitol and being in a phenobarbital coma. He was given a total of 25 g of mannitol over the last hour and the phenobarbital was at 3.5. A stat head CT was done, which showed no evidence of new hemorrhage; however, there was evolution of the infarction at the basal ganglia, hippocampus, corpus callosum and cerebral peduncles as well as the posterior temporal lobes and occipital lobes bilaterally. There was global swelling to suggest supratentorial hypoxic injury and infarction. A bedside EEG was competed, which the report on [2108-2-10] shows throughout the recording of presence of low voltage; low frequency in the background was observed. There were no bursts of normal activity, no focal or epileptiform features seen, no testing or reactivity done. The bedside portable EKG was done over the course of 24 hours, intermittently recording was turned off and on. Overall, it was noted to be a marked abnormal EKG with suppressed activity and severely low voltage and frequency indicative of a severe encephalopathy. On [2108-2-10], the patient was started on TPN for nutrition. He was taken off his tube feedings due to possible need to go to OR, and he was started on TPN. On [2108-2-10], the patient had a sudden drop in his O2 saturations with no improvement despite manual bagging and suctioning. O2 saturations continued to be in 50 percent with good tracing. Blood pressures decreased to amounts of 50s. No breath sounds were detected on the right and the patient received emergency right chest tube and was placed under sterile procedures. Chest showed good placement with marked volume on the right. A Pulmonary Medicine consult was obtained at that point, which they felt the patient had known intermittent hypoxia of unknown etiology and that he had right lower lobe air space disease on CT and shunting. They recommended antibiotics, protective ventilation, and diuresis. On [2108-2-10], Dr. [Last Name (STitle) 1132] spoke with the patient's mother and explained that the CT had showed loss of white matter differentiation and extensive infarct and consistently elevated ICP, and the patient was not improving given therapy. Also on [2108-2-10], he had an echocardiogram to question right ventricular function. Suboptimal image quality showed preliminary [Location (un) 1131] of no right ventricular dilation. On [2108-2-11], the patient had another episode of hypoxia and ongoing elevation of the ICP. At that time, they felt that he had a right-to-left shunt, either intracardiac or intrapulmonary. His desaturations did improve with oxygenation and at that time, TEE did not show any right-to- left shunting as done the previous day. His ICPs remained persistently elevated in the 20s, CPP was greater than 70. Dr. [Last Name (STitle) 1132] again discussed with the family the poor prognosis of the patient. On [2108-2-11] at 5:45, Dr. [Last Name (STitle) 1132] met with the patient's mother, uncle, grandmother and sisters and explained the grave diagnosis, answered all their questions and explained the fatal state of the patient and that he probably would be in a persistent vegetative state. On [2108-2-11] at 11 p.m., the family decided to discontinue care and to make the patient as comfortable as possible. On [2108-2-12] at 2:43 a.m., the patient passed away. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 23079] MEDQUIST36 D: [2108-7-19] 14:13:41 T: [2108-7-20] 07:48:57 Job#: [Job Number 52667]	[ "486", "E849.7", "780.01", "348.5", "348.1", "518.4", "E878.1", "430", "780.39" ]	icd9cm	[ [ [] ] ]	[ "02.2", "96.04", "96.72", "01.02", "39.72", "38.93", "38.91", "88.41", "88.91", "89.64", "34.04", "96.6" ]	icd9pcs	[ [ [] ] ]														1992, 14159																									1395, 1974																					167, 1128																	1151, 1225	1242, 1372
43,991	111,406	39559	Discharge summary	report	Admission Date: [2129-11-11] Discharge Date: [2129-11-12] Date of Birth: [2069-1-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This 60 year old male is s/p CABG [2129-10-24]. He was discharged to home on [10-28] and presented to the ED on [11-5] with shortness of breath. He was admitted and was diuresed for fluid overload. He was discharged on [11-7] and had been doing well at home. On the day of admission he felt short of breath when he lay down and came to the ED. Past Medical History: Paroxysmal Atrial Fibrilation Mitral Valve Prolapse Hypertension h/o remote Gastric ulcer Depression h/o deep vein thromboplebitis hyperlipidemia s/p CABGx4 [2129-10-24] Social History: -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Maternal grandfather with lung cancer. Paternal grandmother with GI cancer. Mother with breast cancer, died at age 62. Has 1 brother who is healthy. Physical Exam: Pulse: 86 Resp: 16 O2 sat: 98%RA B/P 108/67 General: Skin: Dry [x] intact [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] 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 Pertinent Results: [2129-11-12] 03:15AM BLOOD WBC-4.9 RBC-3.40* Hgb-10.4* Hct-32.0* MCV-94 MCH-30.6 MCHC-32.5 RDW-13.1 Plt Ct-677* [2129-11-12] 03:15AM BLOOD Glucose-125* UreaN-28* Creat-1.4* Na-137 K-4.5 Cl-99 HCO3-29 AnGap-14 [2129-11-11] 04:55PM BLOOD proBNP-1851* [Known lastname ],[Known firstname ] [Age over 90 87342] M 60 [2069-1-27] Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2129-11-11] 9:20 PM [Last Name (LF) ],[First Name3 (LF) ] EU [2129-11-11] 9:20 PM CTA CHEST W&W/O C&RECONS, NON- Clip # [Clip Number (Radiology) 87343] Reason: Eval PE Contrast: OPTIRAY Amt: 100 [Hospital 93] MEDICAL CONDITION: 60 year old man with dyspnea, recent CABG REASON FOR THIS EXAMINATION: Eval PE CONTRAINDICATIONS FOR IV CONTRAST: None. Preliminary Report !! WET READ !! Right greater than left moderate pleural effusions. DR. [First Name8 (NamePattern2) ] [Name (STitle) 28398] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2483] [Known lastname ],[Known firstname ] [Age over 90 87342] M 60 [2069-1-27] Radiology Report CHEST (PA & LAT) Study Date of [2129-11-11] 5:56 PM [Last Name (LF) ],[First Name3 (LF) ] EU [2129-11-11] 5:56 PM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 87344] Reason: Evala cute process Final Report INDICATION: 60-year-old man, status post CABG with dyspnea. COMPARISON: Chest radiograph from [2129-11-5]. TWO VIEWS OF THE CHEST: There is improvement in left lower lobe atelectasis with persistent small left pleural effusion; underlying consolidation not excluded. A small right pleural effusion is now present. Sternal wires are intact. The remaining lung parenchyma appears clear. The cardiomediastinal silhouette and hilar contours are normal. IMPRESSION: Improvement in left lower lobe atelectasis with persistent small to moderate left pleural effusion; underlying consolidation not excluded. Small right pleural effusion is now present. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Name (STitle) 28398] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2483] Brief Hospital Course: The patient underwent CTA of chest to rule out pulmonary embolism and it was found to be negative. He had small bilateral effusions, and was admitted for observation and an echo. He had an echo the following morning which revealed no significant pericardial effusion. His shortness of breath resolved, his oxygen was saturated 96% on room air. He was discharged to home with VNA follow-up. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) as needed for cad. 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for cholesterol. 5. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 6. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain. 7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day) as needed for cad. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Paroxysmal Atrial Fibrillation Mitral Valve Prolapse Hypertension h/o remote Gastric ulcer Depression s/p Coronary artery bypass graft x4 with left internal mammary artery to left anterior descending artery and saphenous vein graft to diagonal artery and saphenous vein sequential graft to ramus and obtuse marginal arteries [2129-10-24]. h/o deep vein thromboplebitis hyperlipidemia Discharge Condition: Good. Pt. ambulating well and pain controlled with Percocet, Ultram, and Motrin. Discharge Instructions: Follow previous discharge instructions from [2129-10-28], [2129-11-7]. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2129-11-28] 1:15 Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2129-11-24] at 8:10 pm Completed by:[2129-11-12]	[ "272.4", "V12.71", "V12.52", "427.31", "424.0", "311", "V45.81", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5974, 6023	3986, 4381	343, 350	6455, 6539	1644, 2292	6666, 6950	1036, 1300		5202, 5951	2332, 2374	6044, 6434		4407, 5179			6563, 6643									1315, 1625																								284, 305	2406, 3963										378, 743																	765, 940	956, 1020
2,423	133,965	21247+57232	Discharge summary	report+addendum	Admission Date: [2132-4-28] Discharge Date: [2132-5-7] Date of Birth: [2054-11-21] Sex: M Service: VSU CHIEF COMPLAINT: Right foot ulceration. HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with known type 2 diabetes, insulin-dependent. He is status post toe amputation in [1-/2132] secondary to ingrown toenail resulting in an infected ulceration which has not healed. The patient underwent arteriogram two weeks ago at St. [Hospital1 107] in [Hospital1 487]. The patient is now referred to Dr. [Last Name (STitle) ]. He was seen in the office. Films were reviewed. The patient was admitted and underwent diagnostic arteriogram and returns now for elective revascularization. The patient now returns for revascularization. He denies any interval changes since last seen. PAST MEDICAL HISTORY: Atrial fibrillation, type 2 diabetes since age 66 with neuropathy, hypertension, hypercholesterolemia, osteoarthritis, chronic renal insufficiency, history of urinary tract infections, macular degeneration. PAST SURGICAL HISTORY: Total left hip repair in [2115], a redo total hip in [2123], a right third toe amputation in [1-/2132]. [Hospital1 107] in [Hospital1 189]. MEDICATIONS ON ADMISSION: 1. Coumadin 5 mg Monday, Wednesday and Friday, alternating with 2.5 mg on other days. 2. Hydrochlorothiazide 25 mg q d. 3. Diovan 80 mg q d. 4. Zetia 10 mg q d. 5. Lente insulin 20 units q a.m., six units at h.s. 6. Multivitamin tablet. ALLERGIES: The patient denies any known drug allergies, although he has had elevated liver function tests with Pravachol. SOCIAL HISTORY: The patient is married and lives with his wife. [Name (NI) ] uses a cane for ambulation. He has a brother that has an abdominal aortic aneurysm. He is a nonsmoker and nondrinker. REVIEW OF SYMPTOMS: Unremarkable for orthopnea, paroxysmal nocturnal dyspnea or chest pain. PHYSICAL EXAMINATION: Vital signs: 97.3, 88, 16, O2 saturation of 99 percent on room air, blood pressure 120/70. General appearance: Alert, cooperative white male in no acute distress. HEENT: Unremarkable. Carotids are palpable without bruits. Pulse examination shows 2+ radial pulses bilaterally, abdominal aorta is not prominent, femoral pulses are 2+ bilaterally. On the right, the popliteal is nonpalpable. The dorsalis pedis and posterior tibial are Dopplerable signals only. On the left, the popliteal is 2+, the dorsalis pedis and posterior tibial artery Dopplerable signals only. Chest: The lungs are clear to auscultation. The heart is irregular regular rhythm. Abdominal examination is benign. Bone/joint examination shows arthritic changes of the hands, no ankle edema. The right foot is rugous cool with gangrenous changes of the third toe amputation site with a lateral fifth metatarsal head shallow ulcer, which is tender to palpation. Neurological examination was unremarkable. LABORATORY DATA: Preoperatively, CBC white blood cell count was 8.5, hematocrit 36.4, platelets 133,000, BUN 32, creatinine 1.2, potassium 4.8. Urinalysis was negative. Chest x-ray showed no active cardiopulmonary disease. Electrocardiogram was atrial fibrillation with a V-rate of 78. Vein mappings were obtained, which showed patent right greater saphenous vein. HOSPITAL COURSE: The patient was started on antibiotics and intravenous hydration for anticipated surgery on [2132-4-29]. He underwent a right below knee popliteal to dorsalis pedis bypass with greater saphenous vein, angioscopy and valve lysis. He tolerated the procedure well. He was transferred to the Post Anesthesia Care Unit with a palpable graft pulse in stable condition. Immediately postoperatively, he remained hemodynamically stable. His postoperative hematocrit was 34. Incisions were clean, dry and intact via the palpable dorsalis pedis on the right. Anticoagulation with Coumadin was instituted. The patient was transferred to the Vascular Intensive Care Unit for continued monitoring and care. On postoperative day one, he continued on vancomycin, levofloxacin and Flagyl. He had a low-grade temperature of 100.4. His lungs were clear to auscultation. Heart remained irregular rhythm. Incision examinations were clean, dry and intact. He remained on bed rest. His diet was advanced as tolerated. His fluids were Hep-locked. He was placed on his preoperative medications. Postoperative hematocrit was 31.3. Podiatry was consulted to see the patient regarding his necrotic fourth digit amputation site. The patient underwent a right third ray debridement and right heel nail avulsion on [2132-5-1]. There was purulence at the right hallux medial nail border. There was good bleeding of the ray amputation edges. Initial swab grew staphylococcus coagulopathy negative, sparse with Gram negative rods, sparse and yeast. Fungal culture was obtained, which was negative. Anaerobics were negative. The patient was transferred to the regular nursing floor on postoperative day two. He continued a T-max of 100.4 to 97.2. Blood and urine cultures were obtained, which were no growth, but not finalized at the time of dictation. Physical Therapy was requested to see the patient in anticipation for discharge planning. Physical Therapy felt the patient was well below his baseline functional status and recommended a [Hospital 3058] rehabilitation when the patient was medically ready to be discharged from the hospital. A VAC dressing was placed on the wound site of the foot on [2132-5-3]. This was changed q third day. His white blood cell count on postoperative day three was 9.0. His T-max was 101 to 99.6. The patient's creatinine was found to be elevated from 1.2 to 1.5. His vancomycin trough was monitored and his vancomycin dosing was adjusted accordingly. On [2132-5-5], the patient had a right basilic vein PICC line placed. The remaining hospital course was unremarkable. The patient was discharged to rehabilitation in stable condition. He will continue his antibiotics of vancomycin and levofloxacin for a total of ten more days post discharge. FOLLOW UP: He should follow-up with Dr. [Last Name (STitle) ] in [11-23] weeks. He should follow-up with the Podiatry service, Dr. [Last Name (STitle) ] in one week. DISCHARGE INSTRUCTIONS: VAC dressing should be changed q third day. INR should be monitored. Goal INR is greater than 2.0. Ambulation: Up out of bed essential distances, full weight bear. DISCHARGE MEDICATIONS: 1. Coumadin 2.5 mg q d. 2. Ezetimibe 10 mg q d. 3. Multivitamin capsule, one q d. 4. Colace 100 mg b.i.d. 5. Dulcolax 10 mg suppository, q d p.r.n. 6. Senna tablets, two q d p.r.n. 7. Insulin fixed and sliding scale. 8. Lente 20 units q a.m. prior to breakfast and Lente six units at bedtime with a regular sliding scale before meals and at bedtime as follows: Glucoses less than 200 - no insulin, 201-250 two units, 251-300 four units, 301-350 six units, 351-400 eight units, greater than 400 - notify doctor. 9. Acetaminophen 325-650 mg q 4-6 hours p.r.n. for pain. 10. Oxycodone acetaminophen tablets [11-23] q 4-6 hours p.r.n. for pain. 11. Metoprolol 25 mg b.i.d., hold for systolic pressure of less than 100, heart rate less than 50. 12. Valsartan 80 mg q d, which is on hold. 13. Levofloxacin 50 mg q 48 hours. 14. Vancomycin 1 gm q 48 hours for a total of ten days. 15. Hydrochlorothiazide 25 mg q d., which is held. 16. Benadryl 25 mg q six hours intravenously p.r.n. 17. Right third toe site dressing is normal saline wet- to-dry dressing changes b.i.d. DISCHARGE DIAGNOSIS: Arterial insufficiency with gangrenous right third toe amputation site, status post debridement to right popliteal to dorsalis pedis bypass graft on [2132-4-30]. SECONDARY DIAGNOSIS: Atrial fibrillation, anticoagulated. Type 2 diabetes insulin dependent, controlled. Hypertension, controlled. Hypercholesterolemia, treated. Chronic renal insufficiency, stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3439] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2132-5-5] 13:43:42 T: [2132-5-5] 14:22:55 Job#: [Job Number ] Name: [Known lastname ], [Known firstname ] Unit No: [Numeric Identifier 10543] Admission Date: [2132-4-28] Discharge Date: [2132-5-8] Date of Birth: [2054-11-21] Sex: M Service: VSU The patient's discharge was delayed awaiting referral to appropriate rehab. The patient was discharged in stable condition. A PICC line was placed on [2132-5-5] for continued IV antibiotics. The patient will continue vancomycin for a total of 14 days. As of this dictation on [2132-5-7], he was on day nine out of 14 days of antibiotics. He will continue on levofloxacin. He should follow up as directed previously in the discharge summary. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 10544] Dictated By:[Last Name (NamePattern1) 5143] MEDQUIST36 D: [2132-5-7] 13:18:06 T: [2132-5-7] 13:54:15 Job#: [Job Number ]	[ "427.31", "440.24", "V58.61", "593.9", "250.60", "401.9", "272.0", "997.62", "357.2" ]	icd9cm	[ [ [] ] ]	[ "86.23", "38.93", "96.59", "39.29", "84.3" ]	icd9pcs	[ [ [] ] ]									6488, 7623		7645, 7812		1275, 1641	3320, 6094		6299, 6465								1088, 1249									6106, 6274						1959, 3302										154, 178											207, 833					7834, 9235												856, 1064	1658, 1936
80,419	117,051	23931	Discharge summary	report	Admission Date: [2152-9-13] Discharge Date: [2152-9-25] Date of Birth: [2083-9-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 15397] Chief Complaint: Left knee pain Major Surgical or Invasive Procedure: Revision of left knee replacement History of Present Illness: Mr. [Known lastname 60992] is a 69-year-old gentleman with a past medical history significant for OSA, HTN, sinus bradycardia, chronic renal failure, bipolar disorder, BPH who was admitted for a total left knee replacement, subsequently transferred to the MICU for fever and hypotension, now transferred to the general medicine floor upon resolution of his symptoms. Patient presented on [9-13] for left TKA, and did well post-op with mild hypotension on [9-13] to systolic 80s. However, he spiked a fever to 101.2 on [9-14] with no obvious source. He then triggered for delirium on [9-15] and labs were notable for worsening renal function, Cr 2.3 from 1.8, and WBC 13.2 from 9.7. Med consult was called for fever workup and management of delirium. Patient then spiked another fever to 102.3, and triggered again for hypotension with systolics in the 80s. A voiding trial was attempted on [9-15] but patient could not urinate so a foley was replaced. He was written for 1L bolus and started on Vanc/Cipro to cover for possible knee infection, given recent operation, though no signs of infection of the left knee. Prior to transfer to the MICU, his VS were 102.3 90/48, 74, 98% on 2LNC. On arrival to the MICU patient complained of pain in his right arm and wrist, which he attributed to overuse from writing multiple notes on Facebook. Patient was continued on vanc/cipro and given 2 more liters of IVF. His blood pressure stabilized and he was discharged back to the general medicine floor on [9-16]. Ortho will follow closely. On transfer from MICU, vitals were: 98, 102/60, 76, 16, 96% on RA. ROS: Patient complains of being asked too many questions. He reports pain in his right shoulder and wrist. Discomfort on his left thigh from traction device. No chest pain, shortness of breath, nausea, vomiting, diarrhea. Denies chills or feeling feverish. Has foley in place. Has not moved his bowel since surgery. Past Medical History: - bipolar d/o - sinus bradycardia - 1st degree AV block - HTN - OSA on CPAP - obesity - h/o urinary retension - CKD (Baseline Cr 1.8) - BPH Social History: Lives with wife (or ex-wife). Denies any alcohol use. Stopped smoking in [2133]. Family History: Father and mother died of CAD and DM. Two brothers with DM. Physical Exam: Admission exam: PHYSICAL EXAM [2152-9-16] VS: 98, 102/60, 76, 16, 96% on RA GENERAL: Elderly appearing gentleman, obese, no acute distress HEENT: Mucous membranes dry NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, no MRG ABDOMEN: +BS, obese, soft, non-tender, non-distended EXTREMITIES: Left knee dressing clean, dry, and intact, left leg in traction device, pneumoboots in place, right wrist in soft cast (not removed at this time) SKIN: Ruddy complexion, skin is moist NEURO: Alert and oriented, keeps complaining that people are asking him to name the days of the week and months backward, tangential, usually appropriate but very easily distracted, short attention span Discharge exam: VS: T 99.1 also Tm, BP 152/79, HR 76, R 20, SvO2 95% RA. GENERAL: Elderly appearing gentleman, obese, no acute distress HEENT: MMM NECK: No LAD CARDIAC: RR, nl rate, no MRG Pulm: CTAB, bibasilar crackles, no wheezes, comfortable breathing ABDOMEN: +BS, obese, soft, non-tender, non-distended EXTREMITIES: Left knee dressing clean, dry, and intact, stables in place, right wrist slightly swollen, mildly warm, able to move with limited range of motion secondary to pain, right knee with small effusion, no warmth, able to move freely, pneumoboots in place. NEURO: Alert and oriented, keeps complaining that people are asking him to name the days of the week and months backward, tangential, usually appropriate but very easily distracted, attention stable. Pertinent Results: Admission Labs: [2152-9-14] 07:20AM BLOOD WBC-9.7 RBC-3.83* Hgb-11.5* Hct-34.0* MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 Plt Ct-147* [2152-9-14] 07:20AM BLOOD Plt Ct-147* [2152-9-14] 07:20AM BLOOD Glucose-128* UreaN-28* Creat-1.8* Na-139 K-4.7 Cl-106 HCO3-27 AnGap-11 Imaging: CHEST (PORTABLE AP) Study Date of [2152-9-15]: IMPRESSION: New pleural effusions, left greater than right RIGHT WRIST FILM [2152-9-16]: RIGHT WRIST: Extensive degenerative changes are present within the right wrist. It is maximal at the radial-carpal junction. There is, however, no evidence of a fracture present. IMPRESSION: Degenerative changes within the carpal bones. CXR: FINDINGS: Single frontal image of the chest demonstrates new opacity at the left lateral lung base which could be consistent with fluid and/or atelectasis. It is difficult to assess this opacity fully given the patient's extremely rotated position. Lungs are otherwise clear. There is no pneumothorax. Cardiomediastinal silhouette is unchanged from prior imaging. IMPRESSION: New left lateral lung base opacity consistent with pleural effusion and/or atelectasis. [2152-9-24] 07:50AM BLOOD WBC-20.0* RBC-3.32* Hgb-9.9* Hct-30.6* MCV-92 MCH-29.7 MCHC-32.2 RDW-13.6 Plt Ct-449* [2152-9-23] 07:30AM BLOOD Neuts-84* Bands-3 Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [2152-9-23] 07:30AM BLOOD Glucose-148* UreaN-42* Creat-1.6* Na-141 K-4.6 Cl-104 HCO3-30 AnGap-12 [2152-9-23] 07:30AM BLOOD Calcium-10.0 Phos-2.7 Mg-2.0 [2152-9-16] 05:49AM BLOOD Lactate-1.1 [2152-9-24] 07:55AM BLOOD Vanco-12.6 [2152-9-20] 06:05AM BLOOD ALT-39 AST-41* LD(LDH)-221 AlkPhos-101 TotBili-0.6 [2152-9-25] 05:45AM BLOOD WBC-16.6* RBC-3.17* Hgb-9.4* Hct-29.3* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.7 Plt Ct-443* Brief Hospital Course: 69M with hist [Last Name (un) ] of OSA, HTN, sinus bradycardia, CKD (baseline cr 1.8), bipolar disorder, BPH with history of urinary retention who presents after revision of left knee replacement. The course was complicated by hypotension, fevers, urinary retention, gout and pneumonia. # Pneumonia: The patient had fevers to 102, a rising leukocytosis, productive cough and delirium. He had an CXR which showed an opacity in the left base. It was not clearly infectious in etiology, however, given the clinical symptoms we treated him for health care associated pneumonia with vancomycin and cefepime for a 7 day course to be completed on [2152-8-31]. The fevers resolved, his delirium improved as did his cough. The patient and his family refused any further studies such at CT of the chest. Given his clinical improvement we felt that he was safe to discharge with a course of antibiotics to be completed at rehab. After completion of his antibiotics, he should be monitored for temperature or othesigns of infection. # Acute gout: The patient had significant right wrist swelling and pain worse with active or passive movement. Given his fevers there was some concern for gout vs septic arthritis. He had a joint aspiration which was consistent with crystalopathy. Given his kidney function he was treated with a prednisone taper with significant improvement in his wrist pain and mobility. He has a total of 4 more days of prednisone (as outlined in medication list). # Left knee revision: Per report of our orthodist service went well. No evidence of infection of left knee. The joint is warm but the incision is clear/dry/intact. The recommendations of orthopedists are listed below: - Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) 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 at first follow up appointment two weeks after your surgery. - Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). This is important given your chronic kidney disease. - ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. [Male First Name (un) ] STOCKINGS x 6 WEEKS. - 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 (4) 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 AT FIRST POST OP APPOINTMENT in two (2) weeks. - VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. - ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM 0-60 x 1 week (until [2152-9-20]) then advance as tolerated. No strenuous exercise or heavy lifting until follow up appointment. # Hypotension: He was given IVF and broad spectrum antibiotics. An infectious work up was negative and he initially became afebrile. His blood pressure responded to IV fluids. The antibiotics were discontinued (later restarted for suspected pneumonia -- see above). Atenolol and losartan initially held. Restarted once blood pressure improved. # Hypertension: He did have some hypertension at the time of discharge. Blood pressures ranged from SBP 110s to 150s. He was discharged on losartan and atenolol. Hydrochlorothiazide was held. # Acute on chronic renal failure: Improved with IVF to his baseline chronic kidney disease (baseline around 1.8). He was resumed on his losartan. He was educated on avoiding NSAIDs (which he states that he understands but will refuse to comply with the recommendations as he has been "taking NSAIDs for 70 years and it hasn't hurt him yet" -- he acknowledges and can repeat our concerns but chooses to ignore the recommendations). # Delirium: He had acute change in mental status that was waxing and [Doctor Last Name 688] in nature. He was evaluated by psychiatry who agreed with the diagnosis of acute delirium. The likely etiology was medication effect, hypotension and hospital setting. With usual delirium precuations he returned to his baseline mental status. He did require some haldol for agitation while he was delirius. # Right knee pain: He states that a transporter dropped him. It is unclear as it is not documented and no nurses are aware of this happening. I cannot confirm or deny that he was dropped. His right knee improved at the time of discharge and he has his baseline range of motion. # BPH/URINARY RETENTION: On tamsulosin and finasteride. Failed voiding trial x2 and had a foley placed. He will follow up with Dr. [Last Name (STitle) 3748] for outpatient management of his acute on chronic urinary retention. # OSA: Continue BiPap at night. # Anemia: He had stable anemia. After starting prednisone, his differential was atypical. This should be checked after resolution of prednisone and infectious symptoms to make sure no more atypical cells are present in his blood. # Social issues: The patient was intermittently very upset with the care he received at the hospital. The son was definitely upset. After significant conversations with the patient and his family, the major complaints were: 1) he was held in the hospital against his wishes, 2) he was not medically cleared to go to rehab sooner, 3) we were not able to definitively say he had pneumonia (and refused to undergo CT chest which would have been helpful in the diagnosis), 4) he states we "drilled a hole into his hand" referring to the joint aspiration, he states this was against his wishes despite obtained consent, 5) he refuses to accept that he had fevers or an infection in the hospital (as does the son), 6) he states that we gave him gout, 7) his son was unhappy that he was cared for by a hospitalist, 8) the son accused the hospital of medicare fraud -- given that he didn't have fevers or infections or other issues other than his knee and gout, 9) the son states he will [Doctor Last Name ] the hospital and the physician for multiple reasons including the above and a reported incident with the transporter. After long discussions the patient seems agreeable with the explanations of the issues involved in his case and the care that he received. The wife, [Name (NI) ], is also agreeable and thankful. The son, [Name (NI) ], is very angry and seemed only to get more angry with discussion of any of the above issues. He states that he is in "the medical field" however, seemed to have a limited vocabulary or knowledge of the situation regarding his father. Attempting to explain the situation did not go well and ended in him stating "you better contact your lawyers". I offered the number for patient relations to the family (his son [Name (NI) ] refused - please see [Name (NI) ] note) and I contact[Name (NI) ] our risk management office. # COMMUNICATION: Patient, Wife [Name (NI) ] [Name (NI) 60992] [Telephone/Fax (1) 60993], Son [Name (NI) ] [Telephone/Fax (1) 60994] # CODE: Full Transitional issues: - rehab - ortho follow up - removal of staples, further assessment - urology follow up - consider voiding trial, blood in UA - remove PICC after antibiotics - monitor for signs of infection - PCP follow up regarding gout issues, also, would check CBC with differential to evaluate atypical cells resolve with treated infection and off prednisone Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 2. Atenolol 50 mg PO DAILY hold for SBP < 110, HR < 60 3. Baclofen 10 mg PO BID 4. Tamsulosin 0.8 mg PO DAILY hold for SBP < 110, HR < 60 5. Hydrochlorothiazide 25 mg PO DAILY hold for SBP < 110, HR < 60 6. Lorazepam 1 mg PO HS:PRN insomnia 7. Losartan Potassium 100 mg PO DAILY hold for SBP < 110, HR < 60 8. Mobic NF (meloxicam) 15 mg Oral daily 9. Multivitamins 1 TAB PO DAILY 10. Gabapentin 400 mg PO BID 11. vardenafil NF 20 mg Oral PRN 12. Finasteride 5 mg PO DAILY 13. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: failed left uni-compartmental knee replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2152-9-29] 1:40	[ "274.01", "403.90", "327.23", "293.0", "996.41", "584.9", "585.3", "V43.65", "285.9", "788.20", "486", "600.01", "715.36" ]	icd9cm	[ [ [] ] ]	[ "81.91", "00.80", "38.97" ]	icd9pcs	[ [ [] ] ]	14575, 14646	6037, 8552	319, 354	14737, 14737	4205, 4205	14919, 15122	2626, 2687				14667, 14716		13901, 14552												2702, 3412					3428, 4186														13528, 13875					265, 281								8564, 13507			382, 2345							4221, 6014				14752, 14896						2367, 2508	2524, 2610
9,599	197,399	730	Discharge summary	report	Admission Date: [2118-7-18] Discharge Date: [2118-7-27] Date of Birth: [2042-6-28] Sex: M Service: CSU CHIEF COMPLAINT: Chest pain and back pain. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 76-year-old man with a history of hypertension, hyperlipidemia and prior myocardial infarction with a percutaneous transluminal coronary angioplasty of the right coronary artery in [2107] at the [Hospital1 69]. He states that he has experienced pain and tightness in his back radiating into both shoulders starting on [2118-7-15]. The patient denies shortness of breath, dizziness, diaphoresis, or nausea. The pain lasted for 30 seconds following pushing a wheelbarrow and resolved with rest. The patient denied any prior episodes of pain or any since [2107] following the initial episode of pain. The patient informs his primary care provider who referred him to the emergency room. He then presented to [Hospital3 5363] where he was ruled out for an myocardial infarction by enzymes and electrocardiograms. The patient also underwent a negative evaluation for dissecting aortic aneurysm. On [2118-7-16], the patient began experiencing continuing chest pain of increasing intensity. He was treated with nitroglycerin paste and IV Integrelin as well as Plavix. At that time, he ruled in for an NST EMI with a peak CK of 412 and a troponin of 6.23. Electrocardiograms progressed to inverted T waves in V5 and V6. The patient is now transferred to [Hospital1 69] for cardiac catheterization. PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, IMI in [2107]. PAST SURGICAL HISTORY: Partial thyroidectomy, herniorrhaphy, percutaneous transluminal coronary angioplasty of the RCA in [2107], left knee surgery as well as tonsil and adenoid surgery. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Flomax 0.4 q.d. 2. Aspirin 325 q.d. 3. Lipitor 10 q.d. 4. Naproxen p.r.n. as well as several vitamins and supplements. 5. Zestoretic with an unknown dose. MEDICATIONS ON TRANSFER: 1. Captopril 25 t.i.d. 2. Protonix q.d. 40. 3. Nitroglycerin paste 1 inch q. 6 hours. 4. Lopressor 25 b.i.d. 5. Plavix 75 q.d. 6. Lovenox 90 b.i.d. 7. Aspirin 325 q.d. 8. Lipitor 10 q.d. SOCIAL HISTORY: Married, retired accountant with six children. He denies any tobacco use, 2 to 3 alcohol drinks per week. FAMILY HISTORY: Father died in his 80's of pacemaker failure, also had a myocardial infarction in his 70's. PHYSICAL EXAMINATION: Vital signs: Heart rate is 55, blood pressure is 129/79, Respiratory rate is 22, O2 sat is 96 percent on 2 liters. In general, well-appearing man, lying on a stretcher in no acute distress. Neck: 2 plus carotids with no jugular venous distention and no bruits and no thyromegaly. Lungs: Fine crackles in the bases, otherwise clear. Cardiovascular: Regular rate and rhythm, S1 and S2 with no murmurs, rubs or gallops. Abdomen: Soft and nontender and nondistended, normal active bowel sounds and no bruits. Pulses are 2 plus femoral bilaterally, 2 plus dorsalis pedis as well as posterior tibial bilaterally. No edema. Neurological: Alert and oriented times 3. Chest CT done at the outside hospital showed no gallstones. Left kidney with a small cyst splenic lesion and no triple A. Electrocardiogram has sinus rhythm with Q wave in 2, 3, and F, flattened T waves in the lateral leads, sinus rhythm at a rate of 56. LABORATORY DATA: White blood cell count is 8.3, hematocrit 42.7, platelets 180, INR was 1.1, sodium 135, potassium 4.0, chloride 99, CO2 33, BUN 13, creatinine 1.0, glucose 96. While on transfer, the patient underwent cardiac catheterization. Please see cathed report for full details. In summary, the catheterization showed left main with no obstructive disease, LAD with 70 percent serial lesion, left circumflex with 70 percent proximal, OM1 and OM2 both 70 percent lesions, RCA with nonobstructive disease and ejection fraction of 25 percent. The patient was referred to CT surgery who was seen and accepted for coronary artery bypass grafting. On [7-19], he was brought to the Operating Room, please see the Operating Room report for full details. In summary, he had a coronary artery bypass graft times 4 with a LIMA to the LAD, saphenous vein graft OM1, saphenous vein graft OM2 and saphenous vein graft of the diagonal. His bypass time was 105 minutes with a cross clamp time of 87 minutes. He tolerated the operation well and was transferred from the Operating Room to the cardiothoracic ICU. At the time of transfer, he was AV paced at a rate of 88 beats per minute. He had Propofol at 30 mc per kg per minute and Neo-Synephrine to maintain his blood pressure. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the remainder of his operative day. On postoperative day 1, the patient remained hemodynamically stable on a Neo-Synephrine drip to maintain an adequate blood pressure. He remained in the Intensive Care Unit as he was unable to be weaned off of his Neo-Synephrine drip. On postoperative day 1, his Swan-Ganz catheter was removed as well. On postoperative day 2, another attempt was made to wean the patient off of Neo-Synephrine unsuccessfully. His chest tubes were removed. However, because he could not be weaned from the Neo-Synephrine, he again remained in the Intensive Care Unit. On postoperative day 3, an additional attempt was made to wean the patient from his Neo-Synephrine unsuccessfully. The patient also received a unit of packed red blood cells in an additional attempt to wean from Neo- Synephrine. This also did not help in the attempt to wean from Neo-Synephrine. His Foley catheter was removed and he remained again in the ICU. On postoperative day 4, additional attempts were made to wean the patient off of his Neo-Synephrine, however, he continued to drop his blood pressure whenever an attempt was made. Other than that, the patient remained completely stable. On postoperative day 5, the patient was finally weaned off of his Neo-Synephrine and diuresis was begun. He remained in the Intensive Care Unit for an additional day to monitor his hemodynamics. On postoperative day 6, the patient remained hemodynamically stable and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next two days, the patient had an uneventful hospitalization. His activity level was increased with the assistance of physical therapy department and the nursing staff. On postoperative day 7, it was decided that the patient would be stable and ready to be discharged to home on the following day. At the time of this dictation, the patient's physical examination is as follows: Vital signs were temperature 99, heart rate 84 in sinus rhythm, blood pressure was 114/63, Respiratory rate was 18, O2 sat was 94 percent on room air. Weight preoperatively was 88.5 kilos, at discharge was 90.4 kilos. LABORATORY DATA: White blood cell count 8.8, hematocrit 29.7, platelets 367, sodium 139, potassium 4.7, chloride 102, CO2 27, BUN 17, creatinine 1.1, glucose 95. PHYSICAL EXAMINATION: Neurological: Alert and oriented times 3. Moves all extremities and follows commands. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1 and S2. No murmurs. Sternum is stable, incision with staples, opened to air, clean and dry. Abdomen: Soft and nontender, nondistended with positive bowel sounds. Extremities: Warm and well profuse with 1 to 2 plus edema. Right saphenous vein graft site with Steri-strips, open to air, clean and dry. The patient's condition at discharge is good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass grafting times 4 with LIMA to the LAD, saphenous vein graft to OM1, saphenous vein graft to OM2 and saphenous vein graft to the diagonal. 2. Hypertension. 3. Hypercholesterolemia. 4. Status post partial thyroidectomy. 5. Status post hernia repair. 6. Status post left knee surgery. 7. Status post tonsil and adenoid surgery. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg q.d. 2. Plavix 75 mg q.d. times 3 months. 3. Aspirin 325 mg q.d. 4. Lasix 20 mg q.d. times two weeks. 5. Potassium chloride 20 mEq q.d. times two weeks. 6. Metoprolol 12.5 mg b.i.d. 7. Percocet 1 to 2 tabs q. 4 hours p.r.n. The patient is to be discharged home with visiting nurses. He is to have follow up in the wound clinic in two weeks and follow up with Dr. [Last Name (STitle) 3321] in two to three weeks and follow up with Dr. [Last Name (STitle) ] in 4 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2118-7-27] 12:52:27 T: [2118-7-27] 13:28:05 Job#: [Job Number 5364]	[ "410.71", "412", "272.4", "458.29", "414.01", "V45.82", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.20", "88.72", "36.15", "36.13", "39.61", "37.22", "88.56", "99.04" ]	icd9pcs	[ [ [] ] ]							2415, 2508		8271, 9041		7849, 8248										1896, 2059			1668, 1875															7296, 7828										154, 181											210, 1571																2084, 2273	1594, 1644	2290, 2398
29,755	125,599	2438	Discharge summary	report	Admission Date: [2116-6-24] Discharge Date: [2116-7-6] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3016] Chief Complaint: Fever, RUQ pain Major Surgical or Invasive Procedure: ERCP with CBD stent History of Present Illness: (per daughter, patient and MRs [Last Name (STitle) ] team) This is a 89 year-old female with a history of colon cancer with suspected metastases, biliary obstruction s/p biliary stent x2, last placement 3 months ago who presented to ED with nausea, vomiting, fevers abdominal pain. Patient was on the way to her first appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for oncologic care assessment. She was found to be febrile in the office and had an episode of emesis. She was referred to the ED for further evaluation. . In the ED, initial vitals were 102.4, 97, 110/44, RR18. She received Unasyn and ciprofloxacin and 2 litres normal saline. She was found to have WBC 14.8 with Alkaline phosphatase of 900. ERCP was notified and patient was transferred directly from ERCP to MICU for futher monitoring and concerning for developing sepsis. Had ERCP [2116-6-24]--procedure found metal stent, placed another CBD stent--no stones, no pus. After fever to 102.4 and rigors with WBC 15K, concern for sepsis, BP 90/40. Transferred to ICU. No volume resuscitation required. Had fever until 2pm [6-25] to 102.9 at 2 pm [6-25]. On vanc/unasyn currently. Remained stable while in the ICU. She defervesced and prior to returning to the medicine floor, her vitals signs were 98.1F 64 144/46 19 98% RA. . Patient was admitted to [Hospital6 2752] in [2-8] c/o of CP, SOB and episodes of melena. During this hospital stay she was diagnosed with non-bleeding peptic and duodenal ulcers, developed a DVT (s/p IVC filter), diagnosed with biliary stricture (s/p stent placement), NSTEMI [1-4] demand ischemia and partially obstructing colon adenocarcinoma. Heme/onc evaluation at [Hospital3 ] resulted in no surgical treatment [1-4] age and comorbidities. It was decided to manage the obstructive complications should they arise w/ radiation and stenting (no record of this done). CT also showed a 0.4cm non-Ca LUL nodule. Upper endoscopy from [2116-2-19] showed normall esphageus, gastric erythema, and nodula duodenal bulb only. Pt. represented to [Hospital ] on [5-13] with fevers, n/v and abdominal pain. At that time she underwent another stent placement (ERCP for tumor of the main bile duct (?cholangiocarcinoma per note from Dr. [Last Name (STitle) 12526] from [2116-2-24]) and was d/ced home on ABx (per daughter). Since that time she has been having n/v weekly with fevers and chills intermittently. By [6-24], the patient's symptoms deteriorated and she presented to the ED. . ROS (OMED admission): Denies CP, SOB, DOE, jaw pain, abdominal discomfort, swelling, HAs, dizzyness. Reports + melanotic stools, no diarrhea, n/v, chills, nightsweats, changes in skin, cough, hemoptysis. Reprts poor vision from L eye (chronic), no scotoma, weakness, fatigue, dysuria, incontinence. The remainder of the ROS is negative in detail. . On the floor, was noticed to have dark stools early Sat morning and Hct 19 down from 25. HD stable. Recived 2 U prbc. Past Medical History: Metastatic colon CA - unclear hx regarding diagnosis, but reportedly had colonoscopy a few months ago as part of w/u for anemia; treatment not offered given age and overall condition Breast CA s/p L mastectomy h/o lower extremity DVT, s/p IVC filter in [2-8] HTN Hyperlipidemia CAD, h/o NSTEMI Social History: Denies any tobacco or alcohol use. Lives with daughter. Immigrated from [Location (un) 3156] 10 years ago. Family History: NC Physical Exam: Vitals: T:100.3 BP:109/59 HR:59 RR:16 O2Sat:97% on 2L GEN: Thin elderly female, NAD HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Diffusely TTP, +BS, no rebound or guarding EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2116-6-26] 08:00AM 54* 59* 774* 1.7* [2116-6-25] 03:40AM 59* 86* 129 772* 28 2.1* LFT ADDED [6-25] @ 09:26 [2116-6-24] 04:20PM 57* 75* 181 902 1.9* OTHER ENZYMES & BILIRUBINS Lipase [2116-6-25] 03:40AM 16 LFT ADDED [6-25] @ 09:26 [2116-6-24] 04:20PM 26 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2116-6-26] 08:00AM 8.1 3.10* 7.8* 25.0* 81* 25.1* 31.1 14.5 247 [2116-6-25] 04:30PM 23.4* [2116-6-25] 03:40AM 10.2 2.72* 7.0* 21.5* 79* 25.9* 32.7 14.1 255 [2116-6-24] 04:20PM 14.8# 2.92 7.3# 22.8#1 78# 25.0# 31.9 14.5 309# [2116-6-24] Liver/Gallbladder US: Marked intrahepatic biliary ductal dilatation despite the presence of a CBD stent (metallic). Findings are concerning for obstructed stent. Recommend CT for further evaluation. Echogenic material within the bile ducts is of unclear etiology. The presence of blood, pus, air cannot be excluded. Hepatic metastasis (as in the provided clinical history) not visualized. [2116-6-24] CXR: Allowing for the AP projection, the heart is mildly enlarged. The lungs are clear. There is added density in the right paratracheal stripe with mild shift of the trachea to the left, most likely representing retrosternal extension of the thyroid gland. A cross-sectional examination would perhaps assess this further. There are calcifications present in the aortic arch. There are degenerative changes present at the right acromioclavicular joint with apparent inferior subluxation of the lateral end of the clavicle. This most likely is chronic longstanding. [2116-6-24] ERCP Impression: A metal stent was found in the upper third of the common bile duct A balloon sweep was performed without stone, sludge or debris Given presentation, decision made to place CBD stent Previous intervention in the major papilla Five images are submitted for evaluation. The patient has a metal endoprosthesis. Following opacification, normal-appearing right hepatic duct is identified. No opacification of the left hepatic duct was observed. IMPRESSION: Normal-appearing right hepatic duct. [2116-6-26] CXR: There is a left ventricular configuration. The aorta is calcified and mildlyectatic. There is upper zone re-distribution, but no overt CHF. There ishazy opacity at the right base consistent with atelectasis, possibly slightly improved compared with one day earlier. There is minimal atelectasis at theleft base. No focal consolidation or gross effusion is identified. There isdiffuse osteopenia. Poorly visualized in the upper abdomen are stents and other iatrogenic structures. [2116-6-26] 08:00AM BLOOD WBC-8.1 RBC-3.10* Hgb-7.8* Hct-25.0* MCV-81* MCH-25.1* MCHC-31.1 RDW-14.5 Plt Ct-247 [2116-6-27] 05:55AM BLOOD WBC-6.4 RBC-2.40* Hgb-6.1* Hct-19.4* MCV-81* MCH-25.3* MCHC-31.3 RDW-14.5 Plt Ct-247 [2116-6-28] 08:21AM BLOOD WBC-5.7 RBC-3.59# Hgb-9.7# Hct-28.9# MCV-80 MCH-26.9* MCHC-33.5 RDW-14.7 Plt Ct-275 [2116-6-29] ECHOCARDIOGRAM: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. [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. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Increased LVEDP. [2116-6-30] MRCP IMPRESSION: 1. Stent in place with persistent intrahepatic biliary dilatation involving both lobes of the liver. No definite neoplasm seen. As on CT, thin enhancing tissue at the level of the obstructed ducts and the stent could be reactive inflammation, fibrous tissue, or neoplasm such as cholangiocarcinoma. 2. Multilobulated cystic lesion measuring approximately 9.4mm AP x 23mm transverse x 36mm CC. It contacts the head of the pancreas as well as the caudate lobe, however it does not appear to arise from either of these organs. Differential considerations include necrotic lymph node (though the marked fluid signal intensity argues against this) or primary neoplasm such as a neurogenic or neuroendocrine tumor. Close attention should be paid on follow- up studies. CYTOLOGY & PATH RESULTS FROM TISSUE BIOPSY DONE DURING BRONCHOSCOPY [2116-7-2]: 1. Subcarinal lymph node: NEGATIVE FOR MALIGNANT CELLS. Bronchial cells and lymphocytes, suggestive of lymph node sampling. 2. Paratracheal Mass: NON-DIAGNOSTIC due to insufficient tissue sampling. 3. Bronchial washings neg for malignant cells. 4. FLOW CYTOLOGY: INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by B cell lymphoma are not seen in specimen on a limited panel. 4. PARATRACHEAL PATHOLOGY: GROSS Sample results pending. Brief Hospital Course: 1. Cholangitis: patient with fever, chills, and biliary obstruction (cause of obstruction unclear). Clinically improved on antibiotics. No positive blood cultures. To complete 14 day course of Vancomycin/Unasyn. LFTs trended down after ERCP, though imaging demonstrated that intrahepatic biliary obstruction remained. She will need to have repeat ERCP at the end of [2116-9-2]. 2. Colon cancer: known splenic flexure mass, with bleeding. No repeat flex sig/colonoscopy done on this hospitalizatin. Pathology from [Hospital3 ] to be sent to [Hospital1 18] for evaluation. Both CT and MRCP done of abdomen to elucidate cause of biliary obstruction without definitive result. Outpatient follow up for treatment options. Report is that surgery was not going to be pursued. 3. Mediastinal lymphadenopathy: given her history of breast cancer (asymmetrically prominent internal mammary LN on side of mastectomy) and bilateral thyroid nodules, the patient underwent IP/Bronchoscopy and lymph node biopsy. Preliminary biopsy results available at discharge: Subcarinal lymph node: NEGATIVE FOR MALIGNANT CELLS. Bronchial cells and lymphocytes, suggestive of lymph node sampling. . 4. Anemia: had an acute hematocrit drop to 19 during the hospitalization, requiring blood transfusions. She has a history of PUD as well as known bleeding colonic mass. Anticoagulants, including aspirin were held. She responded well to blood transfusions and no further endoscopy was performed given that she was clinically stable. Her hematocrit continued to drift down during the hospitalization and she was transfused another unit prbc on [2116-7-5]. She has a history of demand ischemia/NSTEMI in the setting of acute blood loss. Hematocrit goal was 28. 5. Coronary artery disease: statin, beta blocker and imdur. Aspirin held (see #4) 6. Hypertension: blood pressure medications initially held in the setting of SIRS, however, restarted prior to discharge. 7. Pancreas lesion: consider EUS/biopsy at the time of next ERCP 8. Disposition: complete 14 day course of IV antibiotics. Outpatient follow up for management of malignancies. Medications on Admission: #. Omeprazole 40mg [Hospital1 ] #. Atenolol 25mg [Hospital1 ] #. Isosorbide 60mg [Hospital1 ] #. Meclizine 12.5mg [Hospital1 ] #. Nifedipine 30mg daily #. Atorvastatin 80mg daily #. ASA 300mg PR daily #. Docuaste 100mg [Hospital1 ] #. Magnesium oxide 400mg daily Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Ascending Cholangitis secondary to Biliary obstruction Secondary diagnosis: # Metastatic colon cancer (moderately differentiated adenocarcinoma) primary biopsy at 65 cm via colonoscopy, diagnosed [2116-2-21] (could not locate documentation of metastases from MRs). # Anemia # GI bleed, upper and lower suspected # History of breast cancer s/p mastectomy. # History of lower extremity DVT, S/P IVC filter in [2-/2116] # Hypertension # Hyperlipidemia # Coronary Artery Diseast, history of NSTEMI # Common bile duct obstruction x3, s/p stent x3 # Cholycystectomy Discharge Condition: GOOD Discharge Instructions: You were admitted to [Hospital1 18] with fever, chills, abdominal pain and nausea/vomiting. You were found to have obstruction of your bile duct stent and underwent a procedure to remove the old stent and place a new one. You were also treated with antibiotics for fevers and chills due to a suspected infection. While in the hospital you were noted to have a low blood cell count. Because a bleed from you abdomen was suspected, you were given red blood cells and your aspirin was stopped to prevent further bleeding. You were also evaluated by gastroenterology and since your bleeding stopped, they did not recommend further work up of your GI bleed. It is possible that the source of this blood loss is your colon cancer. Your colon cancer was also re-evaluated and we did several studies to try to stage your disease. Staging your disease tells us how serious your disease is. To fully stage your disease we are awaiting pathology samples from [Hospital3 2005] to be evaluated by our own pathology department, as well as pathology reports on the tissue sampled during your bronchoscopy. Dr [Last Name (STitle) ] will discuss the results of these tests with you at your next appointment. You were discharged to a skilled nursing facility where you will continue to recieve intravenous antibiotics for another 2 days. Should you experience any fevers, chills, nausea, vomiting, abdominal pain, headaches, lightheadedness, chest pressure or pain, shortness of breath, note any black tarry or bloody stools, or any other symptom concerning to you, please call your primary care provider or go to the nearest emergency room. Followup Instructions: Please follow up with the following providers: You have an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] to further discuss treatment options for your colon cancer scheduled for [2116-7-20] at 9:30am located in SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ]. MD Phone:[Telephone/Fax (1) 22] The Gastroenterology doctors would [Name5 (PTitle) ] to see you to do a repeat ERCP in [10-14] weeks. They will contact you with that appointment information. If you do not hear from them in the next 1-2 weeks, please call Dr.[Name (NI) 2798] office at [Telephone/Fax (1) 2799]. [Name6 (MD) ] [Name8 (MD) 831] MD, [Doctor First Name 3018] Completed by:[2116-7-6]	[ "414.01", "280.0", "577.8", "401.9", "576.1", "272.4", "V10.3", "241.1", "197.7", "578.9", "576.2", "153.7", "412" ]	icd9cm	[ [ [] ] ]	[ "88.73", "06.11", "33.24", "38.93", "51.87", "40.11" ]	icd9pcs	[ [ [] ] ]	12484, 12550	10002, 11054	277, 298	13172, 13179	4463, 9979	14875, 15662	3829, 3833				12571, 12627		12168, 12461			13203, 14852									3848, 4442																	11069, 12142							222, 239											326, 3363					12648, 13151												3385, 3684	3700, 3813
27,155	167,290	3494	Discharge summary	report	Admission Date: [2155-2-11] Discharge Date: [2155-2-16] Date of Birth: [2072-8-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: transfer for carotid stent placement Major Surgical or Invasive Procedure: right CCA/ICA stent placement - [2-12] History of Present Illness: The patient is an 82 year-old woman with a history of a right CEA [7-13], hyperlipidemia, deep brain rods in the thalamus for essential tremor, and L breast cancer s/p mastectomy in [2153] admitted to [Hospital6 33] on [2155-2-6] for brief episode of left facial droop, dysarthria, and paresthesias in the L arm lasting about 10 minutes. Her symptoms occurred shortly after waking and had resolved by the time that EMS arrived. She was admitted to an OSH, where she was ruled out for acute IC bleed by CTA. She was started on heparin at that time. Carotid ultrasounds were done, which showed peak systolic velocities > 450cm/s and elevated end-diastolic velocities > 150cm/ sec on the right per report. CTA showed a critical stenosis of the right distal common carotid artery calculated to be 92%. Per report, during admission to during admission the patient was noted to have frequent ventricular ectopy, and an adenosine stress test was negative for inducible ischemia. Patient had no further neurological symptoms during the remainder of her hospital course in reviewing the notes and per patient report. She was started on Plavix and continued on heparin upon transfer to [Hospital1 18] for anticipated stent placement. . . On arrival to [Hospital1 18], the patient feels well overall. She denies any residual or recurrent facial weakness or dysarthria. No HA, dizziness, CP, palpitations, SOB, numbness/ weakness/ paresthesias. She continues to have chronic right shoulder pain from arthritis and rotator cuff tear. . On review of systems, she endorses prior TIA in [2153] with L sided facial droop and dysarthria similar to this presentation. Workup of this resulted in previous CEA. She denies any prior history of stroke, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. . Cardiac review of systems is notable for DOE (patient reports this is secondary to extensive smoking history). ROS also notable for the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: hypothyroidism hyperlipidemia osteoporosis arthritis COPD right CEA in [2153] deep brain rod placement for an essential tremor in [2153] cholecystectomy in [2153] left rotator cuff repair in [2152] left breast cancer s/p mastectomy in [2151], on arimidex Social History: Social history is significant for the absence of current tobacco use. Previous 90 pack-year smoker - 3ppd x 30 years, quit 40 years ago. There is no history of alcohol abuse. Currently drinks wine occasionally. Family History: She has a positive family history of premature coronary artery disease in her brother, who died of an MI in his 50s. Mother had CHF and died at age [Age over 90 ]. Has several family members with breast cancer. Physical Exam: VS - T 97.8 BP 154/70 P 64 RR 18 O2 96%RA Gen: Elderly woman in NAD. Oriented x3, lying flat in bed in NAD. HEENT: Sclera anicteric. PERRL, EOMI, OP clear, MMM Neck: No JVD, no carotid bruits CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: bilateral crackles in lower/mid lung fields, no wheezes Abd: Soft, NTND. No HSM or tenderness. BacK: no CVAT, no spinal TTP Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: oriented x 3, appropriate. CN II-XII intact, bilateral UE resting tremot. ? of a very slight right facial droop, but able to overcome opposition. limited RUE exam [2-8] pain, but FS throughout otherwise. nl sensation to LT. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2155-2-12] 06:40AM BLOOD WBC-7.1 RBC-4.08* Hgb-13.4 Hct-40.2 MCV-99* MCH-32.8* MCHC-33.3 RDW-13.4 Plt Ct-167 [2155-2-12] 06:40AM BLOOD Glucose-86 UreaN-19 Creat-0.8 Na-140 K-4.4 Cl-106 HCO3-22 AnGap-16 [2155-2-13] 06:07AM BLOOD WBC-6.2 RBC-3.15* Hgb-10.7* Hct-30.2* MCV-96 MCH-34.1* MCHC-35.5* RDW-14.4 Plt Ct-122* [2155-2-13] 12:12PM BLOOD Hct-32.3* [2155-2-15] 06:31AM BLOOD Hct-29.9* . [2-12] catheterization: (preliminary) COMMENTS: 1. Access : retro RFA with catheter to RCCA/ICA 2. Type 3, bovine aortic arch 3. Carotid arteries: The RCCA is post CEA with a proximal 90% lesion prior to site of the "patch". The ICA fills the ipsilateral MCA without noted filling from ACA. 4. Successful PTA/stenting to right CCA/ICA junction with a 8.0x30mm non-tapered Protege stent posted with a 5.0mm balloon. Excellent result with normal flow and 10% residual. * FINAL DIAGNOSIS: 1. Severe restenosis of prior right CEA site. 2. [Name (NI) 9927] PTA/stenting to right CCA/ICA junction. . [2-12] Abd CT without contrast: IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Right groin hematoma in a patient with a known pseudoaneurysm and AV fistula. 3. Colonic diverticulosis, without diverticulitis. . [2-13] R femoral US: IMPRESSION: Successful ultrasound-guided thrombin injection right groin pseudoaneurysm. Brief Hospital Course: The patient is an 82 year-old woman with a history of a right CEA [7-13], hyperlipidemia, deep brain rods in the thalamus for essential tremor transferred from an OSH for right-sided carotid stent placement for reportedly crital carotid stenosis. . # Carotid stenosis: The patient underwent successful PTA/stent placement of the right CCA/ICA junction on [2155-2-12]. After the procedure she was transferred to the CCU for closer monitoring. She briefly required pressors to maintain blood pressures after the procedure, but was quickly and easily weaned off. The catheterizaiton was complicated by a right groin hematoma and ooze at the procedure site requiring epinephrine injection with slowing of bleed. Hct decreased from 40 on admission to 30. An U/S showed small psuedoaneurym and question of an A-V fistula given high proximal pressures. On [2-13] she underwent ultrasound-guided thrombin injection with stabilization of hct. She received 1U pRBCs while in CCU. She remained neurologically stable throughout her course. She was continued on medical managment with aspirin, statin, and plavix. . #. CAD: The patient has no documented CAD, but may have underlying disease given known PVD. Echo performed at OSH showed low-normal EF with no wall motion abnormalities. The patient underwent adenosine stress testing at the OSH, which was negative. She was continued on medical management with an aspirin, statin, and beta-blocker during admission. . #. Rhythm: The patient had a history of frequent ventricular ectopy at the OSH, which prompted stress testing. The patient was in NSR with occasional PVCs during admission here while monitored on telemetry. . # UTI: The patient was diagnosed with a UTI with UCx positive for Klebsiella. She received a course of ciprofloxacin from 2/2-5 with no recurrence of symptoms. . # Osteoporosis: The patient was continued on calcium and vitamin D, actonel q weekly. . # Hypothyroidism: The patient was continued on synthroid 25mcg daily. . #. Code: FULL code (confirmed with patient and discussed with HCP) . #. Contact: daughter [Name (NI) 17] [Name (NI) 7962] (HCP) - [Telephone/Fax (1) 16054] . #. The patient was evaluated by PT inhouse and was thought to benefit from acute rehab. She was discharged in good condition on [2155-2-15], VSS, neurologically stable. Medications on Admission: primidone 25mg po bid arimidex 1mg po daily synthroid 25mcg po daily zyrtec 10mg daily lipitor 20mg po daily Aspirin 325mg po daily calcium and vitamin D 600/400 po bid actonel 35mg po weekly metoprolol SR 25mg po daily Discharge Medications: 1. Primidone 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 3. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO qweek on wednesdays (). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: Health Care Alliance Discharge Diagnosis: - right carotid artery re-stenosis, status-post stent placement - hypertension - hyperlipidemia - osteoporosis - arthritis - chronic obstructive pulmonary disease - hematoma s/p cath - pseudoaneurysm s/p cath Discharge Condition: good, afebrile, VSS, neurologically stable Discharge Instructions: You were admitted for a stent placement in your right carotid artery after symptoms of a TIA, or mini-stroke. You had a stent placed in your artery on [2155-2-12] for this. You should continue to take plavix as prescribed - do not discontinue this medication for any reason until told by your primary care doctor to do so as stopping this medication could result in reblockage of your stent. . Please continue to take all of your medications as prescribed. Please attend all of your follow-up appointments. . If you experience any severe headaches, dizziness/ light-headedness, transient visual change or loss, difficulty speaking, new weakness in any part of the body, or any other concerning symptoms, please conctact your primary care doctor or go to the ER immediately for further evaluation. Followup Instructions: Please follow-up with your pimary care doctor, Dr. [Last Name (STitle) 16055], within 2-3 weeks of discharge. Phone: [Telephone/Fax (1) 8340]. . Please follow-up with your neurologist as advised by your primary care doctor.	[ "414.01", "790.01", "997.2", "733.00", "244.9", "443.9", "996.74", "433.10", "E849.7", "E879.8", "272.4", "442.3", "401.9", "041.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "00.45", "88.77", "00.63", "00.40", "99.29", "00.61" ]	icd9pcs	[ [ [] ] ]	9288, 9335	5703, 8045	352, 396	9588, 9633	4324, 5207	10482, 10717	3200, 3416		8315, 9265		9356, 9567		8071, 8292		5224, 5680	9657, 10459									3431, 4305																								276, 314											424, 2658																	2680, 2956	2972, 3184
13,011	147,199	25484	Discharge summary	report	Admission Date: [2160-9-18] Discharge Date: [2160-9-30] Date of Birth: [2108-12-25] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 759] Chief Complaint: COPD flare/tracheomalacia/bronchomalacia Major Surgical or Invasive Procedure: Bronchoscopy on Rigit bronchoscopy and stenting on [9-24] History of Present Illness: 51 F with history significant for COPD with multiple admissions to [Hospital3 2737] who was again admitted there on [2160-9-10] for COPD exacerbation. She underwent a flexible bronchoscopy today which reported evidence of 50% tracheomalacia. It was also notable for R bronhcial tree and the bronchus intermedius showed evidence of bronchomalacia up to 90%. Her pulmonlogist Dr. [First Name (STitle) 32953] [Name (STitle) 63685] refered her to [Hospital1 18] for evaluation by the interventional pulmonology team for possible intervention for dynamic tracheobronchomalacia that may be contributing to her frequent exacerbations. Past Medical History: COPD on home O2 (3L) and BiPAP 14/6. Multiple admissions to [Hospital3 ] for COPD. multiple pulmonary rehabs at [Hospital1 ] without significant improvement in sx. Chronic hypercapnic respiratory failure. PFTS [9-7]: FVC 0.7, FEV1 0.52, FEV1/FVC 54%. ? obstructive sleep apnea type II DM Hyperlipidemia Hypertriglycidemia Depression Anxiety Obesity Anemia osteoporosis [2-6] chronic steroids Social History: habits: tobacco - quit 6 years ago; 90 pack year hx ETOH: none Drugs: none living: lives w/ husband at home. occupational: retired sauderer. h/o dust/ fume exposure. spiritual: jehovah's witness/ refuses blood transfusions. Family History: mother deceased emphysema Physical Exam: VS: Tm 97.8, Tc 96.4, HR 80 (80-100), BP 147/82 (130-147/60-82), RR 24, O2 sats 97% 3L NC, FS 328 and 104 Gen: Obese, middle aged female, lying in bed, on left side. BiPAP on. HEENT: NCAT, sclera anicteric. Pupils asymmetric in shape, but are rxtive to light equally bilaterally. Neck: Supple. Could not assess LAD, JVD or thyroid due to body habitus. CV: Heart sounds are distant, but regular. Could not appreciate any murmurs. Lungs: Decreased breath sounds with poor air movement throughout. ON BiPAP. No crackles, rhonchi, or wheezing appreciated. Abd: Soft, obese abdomen. NTND. + BS. Extr: No c/c. 1+ pitting edema bilaterally, up to mid-shin. Ext warm, 2+ PT pulses, radial pulses bilaterally. R arm with large ecchymosis from blood draw. Neuro: AAOx3. CN II-XII intact. Pertinent Results: Labs on admission [2160-9-19]: WBC 16.7, Hct 37.9, MCV 83, Plt 305 (diff neuts 89.1, lymphs 6.9, monos 3.8, eos 0.1, baso 0.1) PT 13.1, PTT 24.5, INR 1.2 Na 144, K 4.0, Cl 93, HCO3 42, BUN 19, Cr 0.6, Glu 96, Mg 2.2 Fe 109, TIBC 361, ferritin 40, TRF 278 Theophy 4.3 . Rads: [2160-9-19]: Flexible bronchoscopy - Patient with significant tracheobronchial malacia in trachea, right main stem and left main stem bronchus. . [2160-9-19]: CT trachea - 1. Severe tracheobronchomalacia. 2. Severe emphysema. 3. 5-mm diameter right middle lobe lung nodule and tiny bilateral apical micronodules. Recommend a followup chest CT in three months duration to document stability of these small nodules in order to exclude the possibility of early lung neoplasm. . [2160-9-23]: PFTs - SPIROMETRY 1:56P Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.26 2.60 48 FEV1 0.68 1.95 35 MMF 0.32 2.50 13 FEV1/FVC 54 75 72 Brief Hospital Course: 1) Tracheobronchomalacia: Repeat bronchoscopy was repeated here and confirmed severe tracheobronchomalacia, with 80-90% collapse of trachea, right and left mainstem bronchi. It was decided that Mrs. [Known lastname 63686] needed a Y stent, but it was decided to wait until her COPD was optimized. She was continued on oral prednisone of 60mg daily. Pt had persistent hypercarbic respiratory failure following y-stent placement, required intubation. After she was weaned off ventilator and extubated, she was found to have an abg showing 7.07/128/116/39 and was reintubated and ventilated; once she had improved, she was re-extubated but again ineffectively ventilated and was re-intubated. Patient was then once again weaned, extubated and this time did well. Pt's hypercarbic respiratory failure was believed to be due to a combination of severe COPD, tracheobronchomalacia, auto-peeping, and anxiety. After extubation, pt's respiratory status was believed to be at baseline, PFTs were done on the day of discharge to determine the amount of benefit from the stent placement. Pt had a small amount of hemoptysis following the numerous intubations, however this seemed to be improving and was attributed to the trauma from the intubations. . 2) COPD exacerbation: She was continued on oral prednisone 60mg QD, accolate (zafirlukast), theophylline and inhalers/nebs around the clock (fluticasone/salmeterol, alb nebs, ipratroprium nebs). She continued on BiPAP at night. She was also given levaquin for possible bronchitis, and also received a course of vancomycin after sputum cultures showed MSSA. Theophylline levels were checked regularly to insure that they did not become toxic while she was taking levaquin. Pt wil need to weane her prednisone, although her goal dose is not clear as she has chronically required some steroids. . 3) IDDM: She was continued on her outpatient insulin regimen (NPH + regular QAM and QPM) and was covered with a Humalog sliding scale. Despite these measures, her glucose was widely variable and difficult to control, partially due to the oral prednisone but also due to the fact that the patient would not comply with a diabetic diet and ate frequently. Nutrition was consulted. . 4) Hyperlipidemia/Hypertriglycidemia: She was continued on her outpatient dose of pravachol. . 5) HTN: She was continued on her outpatient antihypertensive regimen of verapamil, and lisinopril. . 6) Oral thrush: She had a history of oral thrush, but on admission it seemed to have resolved. She was given nystatin and fluconazole while she was on a steroid taper. . 7) FEN: She was given a diabetic, low sodium diet, but had poor compliance with her diet. Her electrolytes were checked daily and repleted as needed. . 8) PPX: She was given protonix for GI prophylaxis given her chronic steroid usage. For osteoporosis prophylaxis, she was given calcium carbonate, vitamin D, and aledronate. For constipation prophylaxis, she was given colace, senna, and lactulose. For DVT prophylaxis, she was given heparin SQ. . 9) Access: She had peripheral IVs. . 10) Code: FULL Medications on Admission: Fosamax 70 mg po Q Monday Nystatin mouth wash QID Insulin sliding scale Humulin N 47 U Q AM and 17 U Q evening Humulin R 17 U Q AM and QHS Tylenol PRN Robitussin AC 10 cc po QID Tums 500 mg TID Protonix 40 mg QD Advair 500/50 1 puff [Hospital1 ] Colace 100 mg po BID Verapamil SR 120 mg daily Uniphyl (theophylline) 600 mg daily paxil 20 mg daily Pravachol 20 mg QHS Zestril 10 mg daily Accolate (Zarfilukast) 20 mg po BID Prednisone taper started [2160-9-18] 60 mg x 3 d, 40 mg x 3 d, 20 qd Diflucan 100 mg x 5 d to start [2160-9-19] Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). Disp:4 Tablet(s) Refills:0 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 4. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet, Chewable(s) Refills:0 10. Theophylline 400 mg Tablet Sustained Release Sig: 1.5 Tablet Sustained Releases PO DAILY (Daily). Disp:45 Tablet Sustained Release(s) Refills:0 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO bid (). Disp:60 Tablet(s) Refills:0 13. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Care Discharge Diagnosis: Tracheobronchomalacia COPD Diabetes Type II Obstructive Sleep Apnea Discharge Condition: fair Discharge Instructions: Please follow-up with you primary care physician as scheduled. Please schedule an appointment with your pulmonary doctor in the next 2 weeks. Take your medications as prescribed. Please check you blood sugar frequently (preferably four times a day) and take your insulin as prescribed, please call your doctor if your blood sugars are low or very high. Please call if you develop difficulty breathing, increase in cough, fever, chills, or any other questions or concerns. Followup Instructions: Dr. [Last Name (STitle) 16651] - Monday, [10-6] 1:30 PM Tel number [Telephone/Fax (1) 58182] Completed by:[2160-10-26]	[ "250.92", "519.1", "780.57", "491.21", "276.8", "401.9", "518.81", "478.29", "733.09", "276.5", "V58.67", "E932.0", "564.00", "584.9", "V58.65", "278.00", "300.00" ]	icd9cm	[ [ [] ] ]	[ "00.17", "96.71", "96.05", "33.22", "38.93", "93.90" ]	icd9pcs	[ [ [] ] ]	8827, 8928	3538, 6631	314, 377	9040, 9047	2585, 3515	9570, 9707	1745, 1772		7229, 8804		8949, 9019		6657, 7206			9071, 9547									1787, 2566																								233, 276											405, 1055																	1077, 1487	1503, 1729
53,767	188,488	33383	Discharge summary	report	Admission Date: [2176-11-1] Discharge Date: [2176-11-2] Date of Birth: [2104-8-3] Sex: M Service: MEDICINE Allergies: Nexium Attending:[First Name3 (LF) 7055] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Mr [Known lastname 77483] is a 72 year old man with extensive cardiac history including CAD s/p STEMI with 4 vessel CABG IN [2161], NSTEMI in [2-/2175] s/p PTCA to SVG-RCA with BMS, NSTEMI in [3-/2176] s/p cath without intervention, presenting from home for elective cath given progressive dyspnea on exertion. Briefly, patient has been having severe, limiting dyspnea starting [10-28], progressing and recently brought out with minimal exertion, recently with walking 10 steps. Denies any chest pain or chest pressure, syncope, presyncope, no light headedness, blurry vision, orthopnea or PND. During cath, AO 119/61, MAP 84, HR 66, LMCA with mild disease, LAD occluded, LCx 70% disease, RCA occluded, SVT OM1/OM2 with 70% new mid stenosis and SVG-RCA with 90% in stent restenosis in RPL. Attempts were made to dilate the latter however this was technically very challenging. There is reported wire trauma distally to the site of intervention. Stat ECHO was obtained in the lab and patient was transferred to CCU for further management. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of 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: 4 vessel CABG in [2161] see below -PERCUTANEOUS CORONARY INTERVENTIONS: CAD, s/p NSTEMI [2160], CABG x 4 [2161], Cath [2-/2175] with patent Lima-LAD, patent SVG-RI-OM, with a 40% distal stenois, with significant stenosis of SVG-RCA which was stenting (2.5x 12mm Vision) -PACING/ICD: placed [2172] 3. OTHER PAST MEDICAL HISTORY: # Obstructive Sleep Apnea # COPD # Diabetes Type II on Metformin # CKD # CHF EF 30% s/p ICD placement in [2172] Social History: -Tobacco history: [12-26] ppy x 60 (quit 15 yrs ago) -ETOH: Occasional -Illicit drugs: None Family History: [Name (NI) ] brother with MI in 40s. Physical Exam: (96 ??????F) HR: 68 bpm BP: 103/59 RR: 16 SpO2: 95% 2L General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath sounds: Clear : ) Abdominal: Soft, Non-tender Extremities: Right lower extremity edema: 1+, Left lower extremity edema: 1+, Anterior leg venous statis Skin: Warm, Rash: Hyperpigmented lesion throughout, , No(t) Jaundice Neurologic: Attentive, Follows simple commands, Pertinent Results: [2176-11-2] 02:04AM WBC-8.8 RBC-3.69* Hgb-12.0* Hct-33.7* Plt Ct-297 PT-12.7 PTT-28.8 INR(PT)-1.1 Glucose-140* UreaN-14 Creat-1.5* Na-130* K-3.9 Cl-92* HCO3-27 AnGap-15 Calcium-9.3 Phos-4.2 Mg-1.7 EKG: Tracing reveal normal sinus rhythm at 73 beats per minute, normal intervals except QTc 470, inferior Q waves suggestive of prior infarct, overall low voltages, poor R wave progression, compared to prior from [2176-4-10] no diagnostic change is present. . TELEMETRY: . 2D-ECHOCARDIOGRAM: ([2176-11-1] There is moderate regional left ventricular systolic dysfunction with anterior, anteroseptal and apical akinesis. The remaining segments contract normally (LVEF = 30-35%). Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Trivial pericardial effusion on the background of a thick anterior pericardial fat pad. Moderate regional left ventricular systolic dysfunction, c/w LAD disease. Compared with the prior study (images reviewed) of [2176-4-11], the findings (including a tiny pericardial effusion) are similar. Catheterization: [2176-11-1] Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French angled pigtail catheter, advanced to the left ventricle through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French AR1 catheter, with manual contrast injections. Graft Angiography: of 2 saphenous vein bypass grafts were performed using a 5 French multipurpose and AR-1 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. COMMENTS: 1. Selective coronary angiography of this right dominant system showed severe three vessel coronary artery diseas status post bypass surgery. Brief Hospital Course: 72 year old man with extensive coronary artery disease, s/p CABG in [2161], s/p repeat NSTEMI, presenting with progressive angina, s/p failed intervention to SVG-RCA graft complicated by perforation of graft and development of small pericardial effusion. # CORONARY ARTERY DISEASE: Patient with progressive chronic CAD, without unstable symptoms. Intervention was unsuccessful and given the complication will need to reassess the risks vs benefitis for further planning. At this time, since no new stent was deployed, no systemic anticoagulation was indicated. Given wire trauma, pt was monitored and assessed for pericardial tamponade. Aspirin, Plavix, and Statin were continued. Metoprolol and spironolactone were briefly held given concern for hypotension with tamponade. Pt remained stable. There was no evidence of tamponade. # CHRONIC SYSTOLIC HEART FAILURE: EF idepressed at baseline, 30 to 35% at this time. Currently euvolemic and with significant dye load, pt was not diuresed overnight. Once concern for tamponade had abated, he was restarted on BB and spironolactone. He was on a betablocker, but not and ACEI. ACE Inhibitor is recommended in this patient which may be started as an outpatient, pending no contraindication. Medications on Admission: # Albuterol Sulfate MDI # Amiodarone 200 mg Tablet PO BID # Atorvastatin 80 mg Tablet PO daily # Azelastine [Astelin] 137 mcg (0.1 %) Aerosol, Spray nasally PRN # Clopidogrel [Plavix] 75 mg Tablet PO daily # Fluticasone-Salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose Disk inhaled [Hospital1 ] (Prescribed by Other Provider) [2176-10-31] # Furosemide 80 mg Tablet 1.5 tabs by mouth once a day # Hydroxyzine HCl 25 mg Tablet PO daily PRN # Levothyroxine 100 mcg Tablet by mouth once a day # Lorazepam 0.5 mg Tablet by mouth every four (4) hours as needed # Metformin 1,000 mg Tablet PO BID # Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr 0.5 (One half) Tablet(s) by mouth once a day # Potassium Chloride 10 mEq Capsule, Sustained Release PO daily # Spironolactone 25 mg Tablet 2 Tabs by mouth once a day # Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device PO daily # Zolpidem 5 mg Tablet 1 (One) Tablet(s) by mouth at night Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing/SOB. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Astelin 137 mcg Aerosol, Spray Sig: One (1) spray Nasal prn as needed. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO once a day as needed for itching. 9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 14. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Coronary artery disease Secondary diagnosis Atrial fibrillation Diabetes mellitus Chronic systolic heart failure Discharge Condition: Stable blood pressure 114/62 Mental status: alert and oriented x3 Ambulatory status: baseline Discharge Instructions: You were admitted to the hospital for monitoring after your cardiac catheterization. Your blood pressure remained stable while you were hospitalized. No changes were made to your medications. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up with your primary care doctor within the next 1-2 weeks. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 77484] [Telephone/Fax (1) 77350]. Please follow up with your Cardiologist within the next [11-24] weeks as well. Dr. [First Name4 (NamePattern1) 11249] [Last Name (NamePattern1) 11250] [Telephone/Fax (1) 11254].	[ "414.02", "412", "411.1", "414.01", "496", "E870.6", "585.9", "244.9", "998.2", "423.9", "V45.02", "V45.82", "327.23", "428.0", "250.00", "428.22" ]	icd9cm	[ [ [] ] ]	[ "00.40", "88.56", "00.66", "00.46", "36.07", "37.22", "88.72" ]	icd9pcs	[ [ [] ] ]	9344, 9350	5642, 6895	286, 312	9526, 9555	3480, 5619	9953, 10331	2623, 2666		7897, 9321		9371, 9505		6921, 7874			9646, 9930									2681, 3461			2016, 2342																					227, 248											340, 1908											9570, 9622		2373, 2491				1930, 1996	2507, 2607
19,322	169,079	17146	Discharge summary	report	Admission Date: [2196-10-12] Discharge Date: [2196-10-21] Date of Birth: [2131-12-31] Sex: M Service: NEUROSURGERY Allergies: Lisinopril Attending:[First Name3 (LF) 1854] Chief Complaint: Pituitary tumor Major Surgical or Invasive Procedure: Transphenoidal pituitary tumor resection History of Present Illness: The patient is a 64-year-old gentleman with a history of metastatic renal cell carcinoma with hx of recurrence, who was recently found to have new brain metastatic lesions and a pituitary tumor. He is in today for a transphenoid pituitary tumor biopsy. Briefly, pt presented initially to [Hospital 29684] Clinic on [9-19], [2196] with complaints of eye pain, eye lid droop and left eye blurry vision for 1 month. A brain MRI showed [2-13] lesions in the brain consistent with brain metastasis (left inferior cerebellum, left anterior ethmoid). A pituitary tumor with size of 1.8 x 1.3 cm was also found, which seemed to displace the optic chiasm superiorly and may be involving the adjacent right cavernous sinus. He was started on Decadron 4mg PO Qday by oncology on [2196-9-19]. Besides vision change, pt also endorsed fatigue and low energy level, as well as polydipsia and polydipsia. He lost about [5-15] lbs in the past one month. Otherwise, he denied HA, no visual field defect, no nausea, vomiting, no focal weakness. no coordination difficulties, no backaches, no sensory loss, no muscle cramps, no slurred speech, no other pain, no abnormal sensation, no joint aches, no uncontrolled movements. Denied hair/skin change. No heat or cold intolerance. He denied sexual dysfunction. Past Medical History: 1. Metastatic renal cell cancer in [2181]. He is status post left nephrectomy, but then had a recurrence in his contralateral kidney, spine and thoracic cavity, which was detected in [2192]. He was placed on radiation therapy and interleukin, which was unsuccessful. He was then placed on a Pfizer study medication for two years, but was discontinued in [2194] because of a cardiomyopathy and pericardial effusion. Ejection fraction was 15-20%. The trial was discontinued and his cardiomyopathy has since improved. 2. Bladder dysfunction Social History: Non-smoker/non-ETOH drinker Family History: NC Physical Exam: VITAL SIGNS: Blood pressure is 130/60 with a pulse of 96, respirations of 18. SKIN: multiple ecchymosis over lower abd. HEENT; dry oral mucosa CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: mild edema bilaterally. He does have some chronic skin changes consistent with venous stasis. NEUROLOGIC: HEENT: Head was normocephalic, atraumatic. Eyes, there is some mild puffiness around the left eyelid with some slight swelling. No erythema or tenderness. Extraocular movements were intact. Visual fields were full. There was no nystagmus bilaterally. His vision was 20/50 with uncorrected. Mouth, tongue was midline, palate elevates symmetrically. Neck was soft and supple. Cranial nerves II through VII, IX through XII were intact. The patient actually could close his eyes very well and raise them well without any difficulty. There is no evidence of any weakness at all in the facial nerve. Motor was [5-14] bilaterally, normal tone, no drift. Sensation was intact to light touch, temperature, joint position sense and vibration throughout. Reflexes, he was 2+ in the upper extremities, 2+ in the knees, and 1+ in the ankles with reinforcement with downgoing toes. Pertinent Results: MR HEAD W/ CONTRAST [2196-10-12] 8:14 AM Reason: pre-op assessment for surgery planning and localization Contrast: MAGNEVIST FINDINGS: The enlarged pituitary gland, with macroadenoma, two left cerebellar lesions, the largest measuring 1.2 x 1.0 cm and abnormal increased signal in the left anterior ethmoid and frontal sinus are demonstrated. However, accurate assessment is limited due to lack of other sequences and patient motion. IMPRESSION: WAND protocol study, redemonstrating enlarged pituitary macroadenoma, for surgical planning. POSTOP HEAD CT CT HEAD W/O CONTRAST [2196-10-12] Reason: Assess for new bleed IMPRESSION: 1. No intracranial hemorrhage. 2. Interval development of a small locule of air in the hyperdense cerebellar lesion, of uncertain clinical significance. No other interval change from the previous study. MR HEAD W & W/O CONTRAST [2196-10-13] 1:37 PM Reason: check post op tumor residual and r/o stroke, DWI Contrast: MAGNEVIST IMPRESSION: 1. Multiple new diffusion abnormalities with evidence of slow diffusion, including the high right frontoparietal junction, bilateral occipital lobes, bilateral thalami, and a small infarct of the brainstem. These findings are new from prior exams. Differential diagnosis includes embolic infarcts, reversible encephalopathy or seizure related diffusion changes. Clinical correlation and follow up recommended. 2. The pituitary lesion is essentially unchanged from prior studies. 3. Left cerebellar and left ethmoid metastases are unchanged. A second small left cerebellar metastasis is suspected on this exam. 4. Increased FLAIR signal in cerebral sulci and cerebellar folia. This is likely related to retained gadolinium, or less likely from leptomeningeal disease. A repeat examination in several days could further delineate the finding. CT HEAD W/O CONTRAST [2196-10-15] 8:42 PM Reason: evaluate for new bleed following fall IMPRESSION: Unchanged appearance of the brain compared to the previous examination, including redemonstration in the sellar/pituitary soft tissue mass as well as bowing in the medial wall of the left orbit. EEG [2196-10-14] IMPRESSION: This is a mildly abnormal EEG due to the presence of a slow background consistent with a mild encephalopathy of toxic, metabolic, or anoxic etiology, or consistent with diffuse and bilateral subcortical dysfunction. The low amplitude beta activity could represent the intercurrent use of benzodiazepines or barbiturates. No evidence of ongoing epileptogenesis was seen. Brief Hospital Course: Mr [Known lastname ] is a 64yo M who presented with a pituitary tumor. He was admitted to neurosurgery on [2196-10-12] and underwent trans-sphenoidal pituitary tumor resection. He tolerated the procedure well and went to the floor post-operatively. However, on the first night after his surgery, he vomited a large amount of blood and became obtunded. CT showed no ICH. He was reintubated and transferred to ICU. He was also started on Zosyn for possible aspiration. Once there, he had two generalized seizures. He was started on dilantin, although ultimately switched to Keppra as dilantin caused delusions and confusion. EEG showed no seizure activity. MRI showed several masses and concern for leptomeningeal enhancement. He self-extubated 36 hours after intubation and remained stable. He was transferred back to the floor. After that, he vomited blood twice. Plastics re-examined his packing and saw nothing concerning. GI was consulted, who performed an EGD and saw no signs of active bleeding. It was thought most likely to be swallowed blood, but since he had signs of gastritis he was started on a [Hospital1 ] PPI. Endocrinology was consulted immediately postoperatively and his thyroid and steroid replacments were managed according to their recommendations. They felt that his UOP and labs were acceptable on [10-21] and that he was safe for discharge. Radiation Oncology was consulted given the multiple masses seen on his MRI. The patient will be discussed in Tumor Conference on Monday, and he will likely need whole brain radiation. Dr. [First Name (STitle) 13014] saw the patient and has discussed with the patient and his son that he will follow up as an outpt after Tumor Conference when the plan is determined. Plastics removed the nasal stents the morning of discharge without difficulty. Wound care was consulted for left wrist unroofed blister noted - not causing any pain, of unknown cause. They recommended commercial wound cleanser or normal saline to clean, thin layer of Duoderm gel, cover with adaptic and dry gauze. He will have VNA for wound care upon discharge. His hematocrit continued to drift down likely due to his nasal dripping; he was transfused 2 units PRBC on [10-19]. Although PT had recommended rehab, he adamantly wanted to go home with services, so he was discharged with these services arranged. Medications on Admission: 1. Aspirin 325 mg a day. 2. Coreg 6.25 mg Qday. 3. Digoxin 125 mcg a day. 4. MVI 5. Spironolactone 25 mg Qday. 6. Decadron 4mg Qday Discharge Medications: 1. Wheelchair [Month/Year (2) 12106] Sig: One (1) wheelchair Miscellaneous once. Disp:1 chair Refills:0 2. Medical equipment Please provide one bedside commode. 3. [First Name5 (NamePattern1) 4886] [Last Name (NamePattern1) 12106] Sig: One (1) [Last Name (NamePattern1) ] Miscellaneous once. Disp:1 [Last Name (NamePattern1) ] Refills:0 4. Medical Equipment Please provide one shower chair. 5. Medical Equipment Please provide one [Hospital ] hospital bed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:4 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): While taking Percocet. Disp:60 Capsule(s) Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): While taking Percocet. Disp:60 Tablet(s) Refills:2 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day: While taking Percocet. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. 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 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 18. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 19. Self Urinary Catheters Use as needed nightly #1 box with 2 refills 20. Foley Bag Please provide urine foley bag for overnight usuage #2 with 2 refills 21. Leg Bag Please provide leg bag to connect to foley catheter #2 with 2 refills Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Metastatic brain tumors Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit Weigh yourself every morning, call cardiologist if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L/day CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: 1. Neurosurgery: Please call Dr.[Name (NI) 12757] office ([Telephone/Fax (1) 1669]) to schedule a follow-up appointment to be seen in 4 weeks. 2. Endocrinology: Please call Dr.[Name (NI) 48128] office ([Telephone/Fax (1) 1803]) to schedule a follow-up appointment to be seen in [1-12] weeks. 3. Gastroenterology: Please call [Telephone/Fax (1) 463] to schedule an office appointment with Dr. [First Name (STitle) ] [Name (STitle) 2473] to be seen in [8-21] weeks. 4. Plastic Surgery Provider: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern1) 6751], MD Phone:[Telephone/Fax (1) 5343] Date/Time:[2196-10-27] 8:00 5. Oncology Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD [First Name (Titles) ] [Last Name (Titles) 10838] [Name8 (MD) ], NP[MD Number(3) 48129]:[Telephone/Fax (1) 22] Date/Time:[2196-11-7] 5:00 6. Radiation Oncology: [Name8 (MD) ], MD. Please call Dr. [First Name (STitle) 13014] on Monday afternoon [2196-10-24**] to schedule a follow-up appointment to discuss brain radiation treatments. 7. Wound care: Care for wound on L wrist as instructed. VNA will help with dressing changes.	[ "458.9", "427.31", "780.39", "998.11", "198.3", "784.7", "198.89", "585.9", "285.1", "198.5", "E878.6", "425.4", "599.0", "197.3", "198.0", "253.2", "578.0", "786.3", "V10.52" ]	icd9cm	[ [ [] ] ]	[ "99.04", "07.65", "01.6", "38.93", "21.01", "99.60", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	10989, 11050	6187, 8563	294, 336	11118, 11142	3622, 6164	12440, 13593	2318, 2322		8752, 10966		11071, 11097		8589, 8729			11166, 12417									2337, 3603																								239, 256								13605, 13686			364, 1681																	1703, 2257	2273, 2302
19,851	188,384	44320	Discharge summary	report	Admission Date: [2126-6-21] Discharge Date: [2126-6-23] Date of Birth: [2061-2-21] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[First Name3 (LF) 5973] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 65 yo M with a history of HIV (CD 4 331, VL <50 in [12-15]), HCV (VL 4200 in [11-15]), DM II, ESRD on HD, diastolic CHF and anemia transferred from a nursing home with fevers, hypoxia and worsened anemia. . The patient arrived from his nursing home after he was noted to be short of breath, confused, lethargic and hypoxic to 79% on 2L NC. He also had a fever to 100.5. In the ED, 99.7, 97 150/90 28 83% on 6L and 98% on a NRB. He received levofloxacin 750mg IV, cefepime 2g IV and bactrim 400mg IV. The patient was also noted to have Hct lower than baseline anemia with brown, guaiac positive stool. . The patient reports that he feels at his baseline and is unsure of why he was sent to the hospital. He reports that he remembers being told that his temperature was up and his oxygen level was down. He denies new shortness of breath though does note a cough productive of yellow sputum x 2 days. He notes new lower extremity swelling without chest pain, orthopnea or weight gain. He also denies missing HD. Also the patient denies black or bloody stools. Past Medical History: HIV. Follwed by Dr. [Last Name (STitle) 1057]. Diagnosed [2106]. ([12-15] CD4 331), viral load < 50 copies in [11-14], h/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] esophagitis - ESRD, on HD since [2118]. Tues Thurs Sat at [Hospital 1263] Hospital ([Telephone/Fax (1) 95037]) (Nephrologist Dr. [Last Name (STitle) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 95038]) - Hep C- Ib [11-15] VL 4,290 IU/mL - DM II c/b neuropathy, charcot foot, neuropathy and ?mild retinopathy - CHF, echo [10-15] EF 50% (diastolic dysfunction, 1+ MR) - History of multi-drug resistant organisms including VISA (Vanc-intermediate sensitivity staph aureus) and MRSA. - Necrotizing Fasciitis: [2112-10-17]- [2113]: multiple surgeries and circumcision during hospitalization. - Hypertension - Hypercholesterolemia - LE Diabetic ulcers - Herpes zoster of the left mandibular distribution of the trigeminal nerve. [2115] - R suprapatellar abscess: [2115]. - IVDU (heroin and cocaine) [2079]-[2102], none since [2102] - Obesity - GI Bleed: [2117]. OB positive stool. No frank blood. Colonic AVM on [3-9] colonoscopy s/p thermal therapy. - Anemia: [2117]. Started Epogen. - Colonic Polyps - Gastritis with large hiatal hernia. - Lipodystrophy - Charcot foot: dx in [9-13]. - Positive AFB in sputum: [2119-11-17]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [2121]. Social History: previously lived alone. now basically long care care facility resident. Hx of tobacco abuse (quit 20 yrs ago), hx of alcohol abuse (quit >20 yrs ago), hx of heroin and cocaine abuse (quit >20 yrs ago) Family History: non-contributory Physical Exam: per unit team: VS 37.2 87 103/42 94% NRB GEN: Well-appearing, NAD. HEENT: PERRL. No palpable cervical or clavicular lymphadenopathy. Neck supple. CARD: RRR. Normal S1 and S2. No M/R/G. PULM: CTA bilaterally. ABD: Soft, nontender, no organomegaly. EXT: Bilateral lower leg skin breakdown consistent with chronic edematous and venous stasis changes. 1+ bilateral lower extremity edema. Bilateral charcot feet. NEURO: A&Ox3. Appropriate mood and affect. Pertinent Results: [2126-6-21] 10:03AM WBC-6.5 RBC-2.52* HGB-7.3* HCT-22.7* MCV-90 MCH-28.9 MCHC-32.2 RDW-21.0* [2126-6-21] 10:03AM NEUTS-78.5* LYMPHS-15.3* MONOS-5.2 EOS-0.6 BASOS-0.3 [2126-6-21] 10:03AM PLT COUNT-228 [2126-6-21] 10:03AM ALT(SGPT)-5 AST(SGOT)-13 ALK PHOS-61 TOT BILI-2.0* [2126-6-21] 10:03AM LD(LDH)-162 CK(CPK)-32* [2126-6-21] 10:03AM CK-MB-NotDone proBNP-GREATER TH [2126-6-21] 10:03AM CALCIUM-8.7 PHOSPHATE-4.6* MAGNESIUM-2.0 IRON-11* [2126-6-21] 10:03AM GLUCOSE-110* UREA N-26* CREAT-5.3* SODIUM-140 POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-34* ANION GAP-13 [2126-6-21] 10:52AM LACTATE-1.9 . [2126-6-21] 6:07 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [2126-6-22]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Preliminary): . INR on discharge 6.5 CXR: Limited study demonstrating stable mild cardiomegaly with mild pulmonary vascular congestion. Brief Hospital Course: 65 yo M with a history of HIV (CD 4 331, VL <50 in [12-15]), HCV (VL 4200 in [11-15]), DM II, ESRD on HD, diastolic CHF and anemia transferred from a nursing home with fevers, hypoxia and worsened anemia. HOSP COURSE BY PROBLEM: . # Hypoxia. Thought [2-9] overload although PNA also considered given the ? fever. He was initially treated with cefepime and levaquin. He received HD urgently and had 6kg removed with significant improvement in symptoms. He was tranferred out of the ICU and remained stable on the floor with 2L O2 by nasal canula. We recommend: - adhere to low na diet - HD as scheduled - extra HD session tomorrow (Monday) per d/w renal team - complete 5d course of levaquin for ? pneumonia. Since he is on every other day dosing, only needs one more dose on Tuesday - consider outpatient sleep study. . # Anemia: at baseline. Will need IV iron at HD. . # INR supratherapeutic: thus making PE very unlikely. Held coumadin and recommend continue holding it especially since he is on levaquin. Consider recheck in [2-10] days. If remains >6.0, consider vitamin K. There was no evidence of active bleeding. Can restart coumadin when INR < 3.0. . # Altered mental status. Mentating well currently. Continue to monitor. . # Cardiac enzyme elevation. Likely secondary to renal failure. Not elevated compared to prior measurements. No signs of acute ischemia based upon history and EKG. . # ESRD on HD. Patient reports compliance with HD schedule. . # History of graft clots. - Continue systemic anticoagulation. IVC clot as well. we held coumadin as above. . # HIV. Stable. Continue antiretroviral regimen. . # Hep C. Stable. No current therapy. . # DM II. Insuling sliding scale. . # Diastolic CHF. Fluid removal at HD. Continue cardiac regimen of beta-blocker, calcium channel blocker and [Last Name (un) ]. . # History of multi-drug resistant organisms including VISA (Vanc-intermediate sensitivity staph aureus) and MRSA. - Strict contact precautions. . # Hypertension. Continue home antihypertensives . # Access: Left femoral HD line. . # FEN: Cardiac, diabetic, renal diet. . # Prophylaxis. Systemic anticoagulation as at home, bowel regimen. . # Code: Full per referral form. . # Dispo: back to NH . Medications on Admission: Metoprolol 25mg Twice daily Indinavir I-C Crixivan 800 twice daily (12AM and 12PM) Ritonavir I-C Norvir 100mg Twice daily with Indinavir (12AM and 12PM) Zerit I-C Stavudine 20mg Daily at noon after dialysis Amlodipine 2.5mg Daily at noon Epivir I-C Lamivudine 150mg at noon 2x/week after dialysis Valsartan 160mg Daily at 12PM Warfarin 0.5mg Daily at 5PM Methadone 15mg Twice daily Albuterol 90mcg 2 puffs every 6 hours Acetaminophen 650mg every 4 hours as needed Compazine 10mg Three times a day as needed Milk of magnesia 30ml at 8PM if no BM in 3 days Gabapentin 200mg at bedtime Renagel 800mg three times a day Citalopram 40mg Daily Docusate 100mg Twice daily B Complex 1 cap Daily at 12 noon Calcitriol 0.25 mcg every other day Senna 8.6mg Twice daily as needed Bisacodyl 10mg suppository as needed Eucerin cream Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO TWICE DAILY (). 3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Zerit 20 mg Capsule Sig: One (1) Capsule PO at noon after HD. 6. Epivir 150 mg Tablet Sig: One (1) Tablet PO at noon 2x/wk after hd. 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Methadone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Vitamin B Complex-C Tablet Sig: One (1) Tablet PO once a day. 17. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 doses: give after HD on Tuesday. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] Rehabilitation & Nursing Center - [Location (un) 538] Discharge Diagnosis: Primary: - Pneumonia - fluid overload [2-9] ESRD - anemia Secondary: - diastolic CHF - HIV - Hep C - DMII - HTN Discharge Condition: on 2L NC oxygen. aaox3 Discharge Instructions: You came in with shortness of breath and confusion. We treated you with dialysis and you improved. We also treated you with antibiotics for possible pneumonia. Please continue levaquin for one more dose. Please hold coumadin since your level was too high. This can be rechecked in [3-13] days. You should get an extra hemodialysis session tomorrow (Monday). Followup Instructions: Please have hemodialysis tomorrow in addition to normal schedule.	[ "585.6", "285.21", "042", "272.0", "357.2", "250.60", "V45.1", "070.54", "428.0", "486", "428.33", "403.91" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	9608, 9762	4867, 7118	301, 308	9922, 9948	3712, 4685	10365, 10434	3198, 3216		8008, 9585		9783, 9901		7144, 7985			9972, 10342									3231, 3693									4720, 4844															254, 263											336, 1408																	1430, 2962	2978, 3182
13,076	178,157	4221	Discharge summary	report	Admission Date: [2152-8-4] Discharge Date: [2152-8-9] Date of Birth: [2074-2-1] Sex: M Service: MEDICINE Allergies: Streptokinase Attending:[First Name3 (LF) 783] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo M with PMH significant for NIDDM, HTN,and atrial fibrillation (not on coumadin since [2095]), who was transferred from OSH in Nantuckett to [Hospital1 18] MICU for management of PE in the bilateral pulmonary arteries. The pt is now transferred to medicine service for further management as the pt has been stabilitzed. Pt presented to OSH w/2 wk h/o progressive SOB, severe 2-3 days prior to that admission. The pt was SOB both at rest and on exertion with "labored breathing". The pt denies CP at that time. The pt was found to have bilat PEs on CT at the OSH. At the OSH, O2 sat 89% on RA. ABG: 7.47/34/66 on 3 lt O2. Received heparin gtt, albuterol and Lasix. Trop 0.20. INR 1.15. Transferred to [Hospital1 18] MICU. Venous duplex of the LLE revealed occlusive thrombus within a branch of the L popliteal vein. The pt has been continued on heparin gtt and started on coumadin in the MICU. . Recent trip from [Hospital1 6687] to NY, but was already SOB at the time. ROS: Denies CP/N/V Past Medical History: Afib (was on coumadin, but stopped it) NIDDM HTN Spinal stenosis/DJD Ventral hernia bilat TKRs COPD Social History: Ex-smoker (quit tob in his twenties, but continued smoking occ cigars until a few years ago). Occ EtOH. No IVDA. Married. Family History: NC Physical Exam: PE: T 97.4, HR 116, BP 153/104, RR 35, O2 sat 100% NRB NAD PERRL, MMM CTAB Tachy, [Last Name (un) 3526] [Last Name (un) 3526], no MRG S/NT/obese. Ventral hernia. OB (-). [Location (un) ] L>[Initials (NamePattern4) ] [Last Name (NamePattern4) 5813] -. . On Tranfer to floor: PE: Tm/c 97 P80-113 BP 137-164/78-92 R 18-28 Sat 95%RA I:428 O: 925 General: obese [Male First Name (un) ], lying in bed, NAD, appearing tachypneic with slightly short-winded sentences HEENT: PERRL, MMM Neck: JVP 7-8 cm, obese, supple CV: distant heart sounds, [Last Name (un) 3526] [Last Name (un) 3526], no m/r/g Lungs: CTAB, diminished breath sounds throughout Ab: soft, nontender, obese, umbilical hernia. Extrem: no c/c/e, 2+ DP/PT pulses, LE cool, negative [Last Name (un) 5813] Neuro: CN II-XII grossly intact, sensation intact to LT, strength 5/5 throughout Pertinent Results: ECG in MICU on arrival: Afib, tachy, RAD, S1Q3T3. CXR (OSH): No acute CO process. CTA chest (OSH): Extensive pulm emboli involving R and L pulm arteries, bilateral lobar and segmental arteries. Bilateral calcified pleural plaques (? asbestos exposure). LENIs: obstructing clot in branch of L popliteal vein likely within L posterior tibial vein . [2152-8-4] 08:50PM GLUCOSE-233* UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 [2152-8-4] 08:50PM CK(CPK)-62 [2152-8-4] 08:50PM CK-MB-NotDone cTropnT-0.07* [2152-8-4] 08:50PM WBC-14.0# RBC-4.96 HGB-16.6 HCT-47.7 MCV-96 MCH-33.5 MCHC-34.8 RDW-13.3 [2152-8-4] 08:50PM NEUTS-74.5* LYMPHS-20.7 MONOS-4.2 EOS-0.4 BASOS-0.2 [2152-8-4] 08:50PM MACROCYT-1+ [2152-8-4] 08:50PM MACROCYT-1+ [2152-8-4] 08:50PM PT-18.2* PTT-150* INR(PT)-2.2 Brief Hospital Course: Briefly, this is a 78 yo M with PMH significant for afib, HTN, and DM who presented for further management of PEs in bilateral pulmonary arteries diagnosed at OSH. Pt still subtherapeutic on coumadin at the time of discharge. . 1) PE: Per OSH record, the pt had extensive bilateral pulmonary artery embolisms extending into the segmental arteries. Lower extremity duplex at our hospital revealed a L posterior tibial vein thrombus, which is the likely etiology for the pulmonary embolisms. TTE was negative for thrombus and revealed EF >55%. Pt was continued on a heparin gtt with goal PTT 80-100, and started on coumadin 5 mg po qhs. Ultimately the coumadin was increased to 7.5 mg po qhs given his subtherapeutic INR (goal [1-20]). The pt was discharged home with a prescription for lovenox injections to cover him for 5 days while his INR becomes therapeutic. The pts wife was instructed on proper lovenox injection technique. The pt is to follow up with his PCP in [Name9 (PRE) 18344] for coag checks and coumadin adjustment over the next week. Consideration may be given to a hypercoaguable workup as an outpt (ie. r/o malignancy with PSA and colonoscopy screening). . 2) HTN: The pts home dose metoprolol was increased to 75 mg po BID for SBP in the 150s. . 3) Afib: Apparently pt has not been on coumadin since [2095]. As stated above, the pt was started on coumadin and bridged with heparin. He was discharged home with Lovenox bridge. . 3) NIDDM: The pt was on a RISS while inpatient. He was discharged home on his home glyburide regimen. Given h/o DM, pt was started on daily ASA. Medications on Admission: Home Meds: Glyburide 5 mg [Hospital1 ] Verapamil 120 mg qd Lopressor 50 mg qam, 25 mg qpm Advair On transfer from MICU: alb nebs bisacodyl colace heparin gtt SSI Protonix Coumadin 5 Ambien prn Metoprolol 25 qpm, 50 q am Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous twice a day for 5 days. Disp:10 syringes Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:2 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:10 Tablet(s) Refills:0 5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:10 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 8. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation every six (6) hours as needed for wheezing. 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:180 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Submassive bilateral pulmonary emboli Discharge Condition: Stable hemodynamically and from a respiratory standpoint, with 95% oxygen saturation on room air at rest and with ambulation Discharge Instructions: Please continue all medications as prescribed and follow up with Dr. [Last Name (STitle) ]. Your wife will need to administer the Lovenox for at least the next five days, once in the morning and once in the evening. If she has difficulty doing this, she should contact Dr. [Last Name (STitle) 18345] office or the [Hospital6 18346] Emergency Room immediately. If you develop shortness of breath, chest pain or bleeding, please go to the Emergency Room immediately for evaluation. You will remain on the coumadin for at least 6 months and will need to have your blood checked frequently to make sure it is thin enough. Your goal INR is 2.0-3.0. Dr. [Last Name (STitle) ] will want you to have this checked Thursday AM, Friday AM and Sunday AM, with your coumadin dose adjusted based on the results (Dr. [Last Name (STitle) ] will adjust the dose). Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] on Thursday at your scheduled appointment. Call his office at [Telephone/Fax (1) 18347] with any questions. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "415.19", "496", "401.9", "250.00", "453.42" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6463, 6469	3414, 5028	274, 281	6551, 6678	2525, 3391	7594, 7891	1606, 1610		5304, 6440		6490, 6530		5054, 5281			6702, 7571									1625, 2506																								231, 236											309, 1326																	1348, 1450	1466, 1590
23,243	188,104	46987	Discharge summary	report	Admission Date: [2122-7-21] Discharge Date: [2122-7-30] Date of Birth: [2062-4-10] Sex: M Service: ADMISSION DIAGNOSES: 1. Metastatic stage four lung cancer. 2. Jejunal metastasis. 3. Paroxysmal atrial fibrillation. 4. Depression. DISCHARGE DIAGNOSES: 1. Jejunal metastasis times two - status post laparoscopic resection. 2. Metastatic lung cancer. 3. Paroxysmal atrial fibrillation. 4. Upper gastrointestinal bleeding. 5. Blood loss anemia. 6. Stage four lung cancer. ADMISSION HISTORY AND PHYSICAL: This patient is a 60 year-old male who was diagnosed with stage four nonsmall cell lung cancer in [2122-6-2]. He was started on chemotherapy for this and recently complained of abdominal pain to his physician. [Name10 (NameIs) ] underwent an esophagogastroduodenoscopy in [2122-7-3] and was found to have a jejunal masses for which biopsies were taken. These came back being metastatic lesions. Given the small nature of these lesions and the symptomatology that was causing the patient it was felt these could be resected laparoscopically. INITIAL PHYSICAL EXAMINATION: The patient's preoperative height 5'[28]", weight 190 pounds. His temperature 100.0. Pulse 82. Respiratory rate 18. Sating 95% on room air. Blood pressure 124/59. He was in no acute distress. There was no scleral icterus. There were no oral lesions. He had full extraocular movements. He had no adenopathy in the neck. His lungs were clear to auscultation and percussion. He was not wheezing. Heart was regular rate and rhythm. Abdomen was benign. There was no organomegaly or mass or tenderness. He had no peripheral edema, phlebitis or clubbing. Neurologically he was nonfocal. LABORATORY: In terms of preoperative laboratory evaluation the patient's preoperative hematocrit was 32.9 on [2122-7-17]. His preoperative platelet count was 371. His preoperative creatinine was 23 and 0.8 respectively. HOSPITAL COURSE: The patient was admitted on [2122-7-21] and on that same day underwent laparoscopic resection of two small bowel presumably metastatic tumors. There was no note of intraoperative complications or excessive blood loss. This was noted to be about 150 cc. The patient was taken to the Post Anesthesia Care Unit where he was stable postoperatively and was making good urine. The patient's postoperative pain was initially controlled with Dilaudid PCA. On postoperative day one the patient was complaining of inadequate pain control and had his PCA increased with the addition of Toradol. The patient again had complaints of severe pain with inadequate relief on postoperative day two, although his PCA had been increased in dosage, therefore an acute pain service consultation was obtained and their recommendations were taken into account and they recommended an epidural for pain relief given the patient having a history of metastatic cancer and in order to avoid a postoperative ileus. This was agreed to with anesthesia. Notably during the day of postoperative day two the patient is complaining of some abdominal pain. During discussion with the patient about one of these episodes of pain he had an episode of 600 cc of coffee ground emesis. This occurred in front of myself and the patient was assessed immediately clinically. His vital signs were stable. The patient was not tachycardic with a pulse of 84 and his blood pressure was in the 120s/60s. Immediately the patient had another large bore intravenous placed. No boluses of fluid were given to the patient. The patient was clinically stable. He had 2 units typed and crossed. His coag times were drawn and he was ordered for serial hematocrits and an nasogastric tube was to be placed. This was discussed with the attending physician and it was determined that an nasogastric tube could be held on until the patient absolutely needed one if the patient refused. The patient did refuse an nasogastric tube. Subsequently the patient did have the house staff member paged and requested an nasogastric tube to be placed. During attempts of placement of this tube the patient again had another episode of about 400 cc of coffee ground emesis and continued to retch at each attempt. It was determined after discussion with anesthesia that these attempts might be easier after placement of the epidural catheter. The patient was taken for placement of an epidural catheter to the patient preoperative holding area. He underwent placement of this catheter without notable complications. After the catheter was placed and the anesthesiologist attempted to place the nasogastric tube with the use of Lidocaine jelly for intranasal anesthetic. The patient had some difficulty with this and again began to have symptoms of Lidocaine toxicity with brief episodes of desaturation, which were later controlled with oxygen and bag mask breathing. At this point an nasogastric tube was able to be placed and the patient was lavaged with 3 liters until a clear return was obtained. He was transfused with 2 units of blood given his hematocrit had dropped to 27 at this time. The patient was stabilized and taken to the Intensive Care Unit subsequently. The patient was taken to the Intensive Care Unit for a problem of upper gastrointestinal bleeding. He had only been given a few doses of Toradol prior to this. In the Surgical Intensive Care Unit the patient was aggressively hydrated and had serial hematocrits monitored. He remained NPO with an nasogastric tube suction. Notably he did obtain excellent pain control with his epidural. Notably in the Intensive Care Unit the patient did have multiple episodes of paroxysmal atrial fibrillation. These were controlled with Metoprolol. It was noted that the patient may have aspirated during the course of his episodes of Lidocaine toxicity in the preop holding area during placement of his nasogastric tube, therefore he was empirically started on Levofloxacin for possible aspiration pneumonia. There was a question of this on chest x-ray. The patient's course in the Intensive Care Unit was fairly uneventful. He remained in the Intensive Care Unit for intensive monitoring of his vital signs and to assure adequate pain control and for management of his paroxysmal atrial fibrillation. By postoperative day seven the patient was ready for transfer back to the floor as he had been afebrile and was having some improved pain control and was not having episodes of atrial fibrillation. Notably throughout this time the patient had no relief of pain, although he had been tried on a morphine PCA, Dilaudid PCA, Demerol PCA, po Percocet, po Vicodin and intravenous Toradol. By postoperative day eight the patient was then transferred to the floor. He was doing well. He had his diet advanced to a full diet. His hematocrit stabilized. His previous O2 requirement was discontinued. The patient was maintaining sats in the mid 90%, 95 to 96 without any oxygen requirement. He was having no problems with shortness of breath, but he continued to have pain. His primary care physician [Name9 (PRE) ] that he receive Vicodin, Percocet and a Fentanyl patch. This was discussed with acute pain management and they did not agree with these recommendations. This was conveyed to the primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 2450] who took acute pains recommendations into account and said he would manage the patient's pain as an outpatient. The patient's epidural was pulled on postoperative day eight after receiving 2 units of fresh frozen platelets, because the patient's INR remained at 1.6. By postoperative day nine although the patient continued to have pain he no longer had any surgical issues and it was determined that he could be discharged to home. By the time of discharge the patient's hematocrit was 35.2. His white blood cell count remained elevated 25.9. Notably it had been 26.6 preoperatively. The patient's INR before discharge was 1.6. His BUN and creatinine at the time of discharge were 10 and 0.7 with a K of 4.2 and no cardiac enzymes had come back as ruling patient in for an myocardial infarction. This patient's sputum cultures taken showed contamination with oropharyngeal flora. He had no positive blood cultures. Essentially the summary course for this patient is that the patient is the patient did well after laparoscopic resection of two small bowel metastases from his primary stage four lung cancer. Postoperatively likely suffered a gastrointestinal bleed, which probably started sometime even before surgery possibly secondary from stress from surgery in addition to the use of non-steroidal anti-inflammatory drugs. This gastrointestinal bleed was complicated by an episode of desaturation during attempted placement of an nasogastric tube after placement of an epidural catheter for poorly controlled pain, which likely had a chronic and acute component. The patient was subsequently transferred to the Intensive Care Unit for management of his upper gastrointestinal bleed, which stabilized after the patient received 2 units of packed red blood cells. The patient also had a question of aspiration pneumonia after placement of the nasogastric tube for which he was given antibiotics empirically, but for which no final sputum culture was definitive. The patient's main issue was essentially pain control, which was not resolved by the time of discharge, but his primary care physician felt that he would best be able to deal with this as an outpatient. The patient was discharged on the following pain medications as per his primary care physician. DISCHARGE MEDICATIONS: 1. Vicodin 5/500 mg take one to two tablets po every four to six hours, dispensed 100. 2. Percocet 5/325 mg take one to two tablets po q 4 to 6 hours dispensed 100. 3. Fentanyl 25 mcg per patch t.d. 72 hours take one patch every three days, dispensed 20. No refills on the Vicodin, Percocet or Fentanyl. 4. He was also given a Pectin cream. 5. Colace 100 mg po b.i.d. 6. Bisacodyl 10 mg suppositories. 7. Protonix 40 mg po b.i.d. 8. Levaquin 500 mg po q.d. for ten days. 9. Metoprolol 50 mg take one half tablet (25 mg t.i.d.). He was given 45 of these. The patient was advised to follow up with Dr. [Last Name (STitle) ] in ten days and also advised to follow up with his primary care physician as soon as possible. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Last Name (NamePattern1) 13262] MEDQUIST36 D: [2122-7-30] 01:06 T: [2122-7-31] 10:33 JOB#: [Job Number 99644]	[ "196.2", "724.5", "197.4", "507.0", "162.9", "427.31", "578.0", "789.07", "285.1" ]	icd9cm	[ [ [] ] ]	[ "03.90", "96.34", "45.61" ]	icd9pcs	[ [ [] ] ]								285, 1108	9686, 10696					1975, 9663																							148, 264		1131, 1957
16,014	175,525	7646	Discharge summary	report	Admission Date: [2198-3-12] Discharge Date: [2198-3-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10223] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: 83 w/MMP presents w/respiratory distress/sepsis. (history of asbestosis, pleural plaques, esrd), recently admitted for 48 day course notable for CP/PNA/seizures/renal failure/MS change. Patient at rehab with notation of recent rise in wbc, bandemia. Over few days prior to admission increasing malaise, pale, diarrhea for which flagyl started on [3-12]. At HD desaturate to 70% in respiratory distress, tachy in 140s. transferred to ER. Code sepsis initiated with vanc/ceftriaxones, intubated. In ED in ?SVT SBP 30s, with wire placement. Resolved with wire removal. Zosyn/Flayl initiated by MICU team, ceftriaxone discontinued. On transfer to MICU on 5th liter of fluid and Levofed of 10. T103, R 140, Bp 130/64. CPAP 60%. abg 7.38/36/232, lactate 4.1. free ca 1.07. Has sacral decub, G-J tube. Past Medical History: Past Medical History: 1.)asbestosis: pleural plaques; CT [9-23] with LUL spiculated nodule not seen on follow up PET scan; followed with serial CT 1.5) COPD (PFT's [9-23] FEV1 69%, FVC 69%, DLCO 61%; obstructive pattern) 2.)chronic renal insufficiency (creatinine 3.7 [8-23]) 3.)hypertension 4.)cardiac w/u - Stress Echo [2192]- patient exercised for 4 minutes of the [Doctor Last Name 4001] protocol and stopped for fatigue. This represents a limitedphysical working capacity for his age. No arm, neck, back or chest discomforts were reported by the patient throughout the study. There were no significant ST segment changes at peak exercise or in recovery. The rhythm was sinus with several isolated apbs. Appropriate hemodynamic response to exercise. No objective or subjective evidence of myocardial ischemia at the achieved high rate pressure product. Echo report w/o signs of ischemia. 5.)status post colonic perforation during colonoscopy status post colectomy 6.)rotator cuff disease 7.)left hip replacement; b/l TKR x 2 8.) atrial fibrillation in setting of colectomy surgery 9.) spinal stenosis 10) anemia, CRI 11) epididymitis, hydrocele Social History: Lives alone, functions independently; wife died 2 years ago2 grown sons (contact [Telephone/Fax (1) 27845]90 pack year tobacco hx (quit 30 yr ago); Steam Ship engineer with significan asbestos exposure; denies EtOH Family History: The family history includes his father who died in his 90's of chronic renal failure and leukemia. Brother age 80 alive with enlarged heart and Alzheimer's disease, and sister age 75 S/P CVA Pertinent Results: [2198-3-12] 12:45PM WBC-11.1* RBC-3.94# HGB-12.4 HCT-38.8# MCV-98 MCH-31.5 MCHC-32.0 RDW-16.8 [2198-3-12] 12:45PM PLT COUNT-572# [2198-3-12] 12:45PM NEUTS-93.1 BANDS-0 LYMPHS-5.0* MONOS-1.7* EOS-0.1 BASOS-0.1 [2198-3-12] 12:45PM PT-13.3 PTT-54.8* INR(PT)-1.1 [2198-3-12] 12:45PM GLUCOSE-125* UREA N-70* CREAT-5.4# SODIUM-139 POTASSIUM-5.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-22 [2198-3-12] 12:45PM ALBUMIN-3.0* [2198-3-12] 12:45PM ALT(SGPT)-19 AST(SGOT)-20 CK(CPK)-14* ALK PHOS-185* AMYLASE-169* TOT BILI-0.3 [2198-3-12] 12:45PM LIPASE-49 [2198-3-12] 12:43PM LACTATE-4.3* [2198-3-12] 12:45PM cTropnT-0.22* [2198-3-12] 12:45PM CK-MB-NotDone [2198-3-12] 05:12PM CORTISOL-23.1* [2198-3-12] 06:10PM CORTISOL-27.4* [2198-3-12] 06:16PM CORTISOL-26.3* Brief Hospital Course: 1. Sepsis: Pt was admitted to MICU with septic shock with associated elevated WBC, fevers likely [2-21] MRSA pneumonia. No other source of infection identified. Pt was give IVF resussitation and started on pressors (levophed) and gradually weaned off. He was pan cultured and started on broad spectrum antibiotics of vanco (dosed for lvel <15), flagyl, zosyn (day 7). Sputum cultures grew MRSA. Urine and blood cultures remained negative. Pt had inappropriate response to [Last Name (un) 104] stim test. Was started on hydrocort (day [6-26]). Sepsis resolved. Continued on Vancomycin and Zosyn. Also emperically started on oral Flagyl [2-21] loose stools, low grade fever. On D/C pt. stable on Vanco only, dosed at HD, to be continued for one week for MRSA pneumonia. Flagyl also to be continued for one week at the time of discharge. Zosyn D/C'd at time of discharge. . 2. Respiratory failure: In the setting of sepsis and pneumonia. Pt was weaned off the ventilator and successfully extubated on [3-18]. . 3. Acute on chronic renal failure: Pt has ESRD on HD. Pt continued to be followed by renal with qod dialysis. All meds were renally dosed and was given vanco by dose levels <15. Pt was given phoslo for elevated phosphate and continued on epogen. . 4. Cardiac: Cardiac enzymes cycled on admission with flat enzymes. Pt has elevated Tn with negative CKMB in setting of renal failure; no acute cardiac event. Unremarkable echo with EF of 50-55% and mild focal hypokinesis. Pt was continued on ASA. Antihypertensives were held in setting of intial hypotension. Pt was restarted on lopressor after resolution of sepsis. 5. GI:s/p colectomy, g-j tube. G-J tube hub was noted to be broken and was changed by IR on [3-14]. -cont TF via G-J tube given aspiration risk. . 6. HEME - follow hematocrit -cont epo . 7. Neuro - baseline altered ms/aspiration on last discharge. Much improved with decreased sedation and tx of sepsis -cont to monitor mental status - waxing and [Doctor Last Name 688] with sundowning. Responded well to 1 mg Haldol q hs. . 8.Endocrine -cont RISS - bp well controlled. . 9.f/e/n: Maintained on TF with free water boluses. . 10.line : L SC (placed [3-12];changed over wire on [3-13]); L A line ([3-12]), R dialysis catheter. L SC discontinued after being in 7 days, prior to d/c . 11.prophylaxis -Given SC heparin, ppi. . 12.Code: full After coming out of the MICU, the patient did well on the floor. He remained afebrile and blood cultures remained negative. He was continued on empiric therapy for vancomysin and clostridium difficile and d/c'd back to [Hospital ] [Hospital ] Hospital on [2198-3-21]. Medications on Admission: ASA, Heparin, Lansoprazole, Epogen, Insulin (reg.). Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Month/Day/Year ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Injection TID (3 times a day). [Month/Day/Year ]:90 Injection Refills:2 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [Month/Day/Year ]:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL Injection QMOWEFR (Monday -Wednesday-Friday). [Month/Day/Year ]:24 mL Refills:2 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). [Hospital1 ]:1 bottle Refills:2 6. Acetaminophen 160 mg/5 mL Elixir Sig: Ten (10) mL PO Q4-6H (every 4 to 6 hours) as needed. [Hospital1 ]:QS mL Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). [Hospital1 ]:270 Tablet(s) Refills:2 8. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Units, regular insulin Injection ASDIR (AS DIRECTED): For BG: 151-200 give 2 units 201-250 give 4 units 251-300 give 6 units 301-350 give 8 units 351-400 give 10 U If >401 give 12 U and [Name8 (MD) 138] MD. [Last Name (Titles) ]:QS Units, regular insulin Refills:2 9. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg Injection HS (at bedtime) as needed for Agitation/Hallucination. [Last Name (Titles) ]:30 mg Refills:0 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. [Last Name (Titles) ]:21 Tablet(s) Refills:0 11. Vancomycin HCl 1,000 mg Recon Soln Sig: mg, dosed at Dialysis as appropriate per level mg Intravenous q HD for 7 days. [Last Name (Titles) ]:QS mg Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Pneumonia, MRSA Discharge Condition: Fair Discharge Instructions: Followup with [Hospital6 310]. Followup Instructions: With primary care doctor as needed.	[ "482.41", "403.91", "285.21", "496", "V09.0", "038.9", "584.9", "518.81", "501", "785.52", "507.0", "427.31", "275.2", "995.92" ]	icd9cm	[ [ [] ] ]	[ "39.95", "97.02", "33.23", "96.71", "38.93", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	8339, 8418	3637, 6328	284, 290	8478, 8484	2777, 3614	8567, 8606	2565, 2758		6430, 8316		8439, 8457		6354, 6407			8508, 8544																																	224, 246											318, 1119																	1163, 2313	2329, 2549
77,734	140,521	26215	Discharge summary	report	Admission Date: [2202-9-26] Discharge Date: [2202-10-6] Date of Birth: [2142-2-14] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 6075] Chief Complaint: Sudden onset left sided weakness Major Surgical or Invasive Procedure: 1. Intraarterial tPA injection and MERCI device clot retrival 2. Percutaneous closure of PVO 3. Percutaneous placement of IVC filter History of Present Illness: Ms. [Known lastname 59366] is a 60-year-old woman with h/o lung cancer, s/p R lower lobectomy, hyperlipidemia, hypertension, hypothyroidism, recent frontal emboli ([7-/2201]) with patent PFO, now presenting with a left hemiplegia. * Patient's partner, [Name (NI) ], called PCP stating new [Name9 (PRE) ] weakness. PCP recommended nearest hospital then [Hospital1 18] transfer. At OSH, there was concern for infarction and small bleed, so declined TPA and arranged [Hospital 64964] transfer to [Hospital1 18]. At [Hospital1 18], Dr. [Last Name (STitle) 39380] noted left hemipleiga arranged for urgent studies and tranfer to IR lab for interventional intra-arterial TPA. Clot in M1/M2 initially lysed (TPA) and merci with some distal embolization and reduced flow in anterior temporal artery. Patient was improved and admitted to ICU. Good strength noted in left. Ms. [Known lastname 59366] was examined in the late afternoon and dense left hemiparesis had again appeared. Patient was also quite wakeful and able to follow commands on right. CTA was performed given deterioration with evident re-occlusion of proximal MCA on right (see below). Past Medical History: Previous right frontal embolic stroke ([2201]) Right lung lower lobe nodule s/p RLL resection; s/p recurrence Hypothyroidism Hemorrhoids Lower GI bleed with a colonscopy Unilateral oophorectomy and partial contraleral oophorectomy [2162] Vaginal polypectomy [2198] Social History: She lives with her partner. [Name (NI) 1139]: 30-pack-year smoker, stopped [2176]. ETOH: drinks wine on weekends. Occupation: works in human resources. Exposure: worked at ground zero for 4 days. Family History: Mother had [Name2 (NI) 64962] cancer Father coronary artery disease Brother has diabetes and sister endometriosis Physical Exam: Vital Signs and exam on arrival to TSICU: T 96.7 F ; HR 77 BPM ; BP 134/82 mmHg ; RR 14 BPM ; O2Sat 100 % General Observations and Appearance General Physical Exam Head - Size appears within normal limits, symmetric, no exostoses nor tenderness. Eyes - Non-pulsatile, no bruits, no exophthalmos, normal [Doctor First Name 2281], round pupils, normal sclera. ENT/OP - TMs intact, ear canals with normal appearances, no lesions, no discharge. MMM and tongue surface normally papillated. Tongue of normal size/muscle bulk. Neck - No bruits, pulses normal, no LAD, supple, normal appearance, thyroid normal. Chest/Thorax/Breasts - CTA, RR, good air entry, no dysmorphic features. Cardiovascular - RRR, normal PMI, normal s1 s2, no M/R/G. Peripheral pulses normal. Abdomen - No scars, stigmata of liver disease, soft, non-tender, no masses nor organomegaly. Genitalia and Rectum - No cutaneous lesions, normal size. Good tone and able to bare down. Spine - Normal curvatures, non-tender, no dimpling or unusual hair growth. Extremities - No deformities, nor contractures. No clubbing, cyanosis nor edema. No arthropathy. Normal digits. No palmar erythema. Skin - Neither greasy nor dry, no spider angiomas, no tattoos, scars other markings. Hair and Nails - Normal appearances. Full scalp of hair with normal hairline. Nodes - No LAD in axilla, cervical chains. Mental Status No psychomotor agitation nor retardation nor adventitious movement/abnormal motor phenomena. Attitude was cooperative and conversational. Affect was appropriate with full range, stable and of quality. Mood was euthymic. Speech rate, volume, prosody and quality were normal. Thought process logical and thought content appropriate. Clear sensorium and no abnormal perceptions. Registration of three objects at one trial and recall of _ objects at two minutes. Language Cranial Nerves Patient reports baseline olfaction. Visual fields were grossly intact with normal acuity with contact lenses/spectacles. Direct ophthalmoscopy revealed normal retina and optic cup. Pupillary reaction to light and accommodation intact ( mm to mm), including consensual reactions. Eye movements were full without observed deviation of either eye nor report of diplopia. No neutral position nystagmus and end-gaze nystagmus within normal limits ( beats). Pursuit movements were smooth. Jaw opening was symmetric and facial sensation intact to light touch. Facial expressions were strong and symmetric. Hearing was grossly intact. Soft palate symmetric at rest and with elevation. Apparently normal salivation and swallowing. No dysphonia. Patient reports normal yawn and hiccup. Shoulder shrug and head turning strong, full range and with symmetry within normal limits. Tongue bulk and movements normal and symmetric. No dysarthria. Tone Normal in upper and lower limbs. Normal axial/postural tone without negative myoclonus (asterixis). No spasticity. Power and Muscle Bulk ( left ; right ) Normal bulk throughout the upper and lower extremities Deltoid ( 5 ; 5 ) Triceps ( 5 ; 5 ) Biceps ( 5 ; 5 ) Wrist and finger extensors ( 5 ; 5 ) Finger flexion ( 5 ; 5 ) Finger (fifth) abduction ( 5 ; 5 ) Hip flexors ( 5 ; 5 ) Quadriceps femoris ( 5 ; 5 ) Biceps femoris ( 5 ; 5 ) Plantar flexors ( 5 ; 5 ) Tibialis anterior ( 5 ; 5 ) Toe extensors ( 5 ; 5 ) Reflexes ( left ; right ) Biceps ( ++ ; ++ ) Triceps ( ++ ; ++ ) Brachioradialis ( ++ ; ++ ) Quadriceps ( ++ ; ++ ) Plantar flexors ( ++ ; ++ ) Plantar responses ( down ; down ) Routing reflex, grasp, snout and palmar-mental reflexes not tested. Clonus not present in plantar flexors. Coordination, Fine Motor Control and Patterned Movements Hand roll and rapid sequential finger apposition normal. Finger to nose normal with eyes closed. Sensation Light touch intact and symmetric on medial and lateral surface of upper and lower limbs. Anterior surface of trunk intact. Vibration sense intact on the first metatarsophalangeal joint bilaterally. Joint position sense intact at distal interphalangeal joints of halluces. Temperature sensation (cool) intact .Pain (30g needle) sensation intact Gait and Station Stride, arm swing, base and turning normal. Tandem gait normal and Romberg's test revealed no instability. Other Signs No pronator drift. Stereognosis intact. No extinction on double simultaneous stimulation of the hands or legs. Exam on discharge Normal mental status exam, left facial droop and a dense left hemiparesis. Pertinent Results: Latest routine laboratory studies: [10-5] CBC: 7.2 >-- 10.7 / 30.2 --< 199 BMP: 143 / 3.7 110 / 24 8 / 0.6 < 98 Ca/Mg/PO4: 9.0 / 2.1 / 2.7 Albumin ALT/AST = 27/26 Tbili = 0.4 peak troponin-I 0.05 [9-26] TC 184 Tg 180 LDL 104 HDL 44 HgbA1c 5.6% TSH 0.70 / fT4 1.8 stox negative for ASA, EtOH, APAP, BDZ, Barbit, TCA Urine Hematology GENERAL URINE INFORMATION Type Color Appear Sp [Last Name (un) ] [2202-10-3] 22:22 Yellow Clear 1.009 Source: CVS DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [2202-10-3] 22:22 NEG NEG NEG NEG NEG NEG NEG 5.0 NEG Source: CVS MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [2202-10-2] 00:17 >50 >50 OCC NONE 0 ** NCHCT [2202-10-1]: FINDINGS: Again noted is cytotoxic edema involving the right middle cerebral artery territory including the temporal lobe, portions of the right parietal and frontal cortices, caudate nucleus, and putamen. These regions appear slightly more hypodense than on prior examination, reflecting infarct evolution. There is continued effacement of sulci and slight compression of the right lateral ventricle, with unchanged 2 mm leftward shift of the normally midline structures. There is no new hemorrhage, edema, mass effect, or infarct. The basal cisterns remain patent. No fractures are identified. Mild mucosal thickening is present in the anterior ethmoid air cells. The mastoid air cells are clear. -IMPRESSION: 1. Evolving right MCA infarct. 2. No new hemorrhage or fractures. MRI/MRA of the head and neck [2202-9-27]: IMPRESSION: 1. Proximal M1 segment occlusion of the right MCA with large area of right-sided acute infarction involving the right temporal greater than parietal lobes, right globus pallidus, and putamen. New concurrent left-sided punctate areas of acute infarction involving the left apical anterior parietal cortex, left occipital lobe, and left cerebellum. As there is no obvious plaque at the right carotid bifurcation as of [2202-9-26*], proximal cardiac embolic source is felt more likely. Echocardiogram may be considered for further evaluation. 2. Redemonstration of mild-to-moderate microvascular ischemic disease. 3. Please note that current exam is not optimized for evaluation of intracranial metastasis without contrast administration. TTE 8/x/10 (prior to PFO closure) -Conclusions: 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. A patent foramen ovale is present. The width of the PFO is 3 mm with a tunnel length of 10 mm. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. -IMPRESSION: Patent foramen ovale present. Normal left ventricular systolic function. * TTE [2202-10-1] (after percutaneous closure of PFO) -Conclusions: A septal occluder device is seen across the interatrial septum. 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. Trace aortic regurgitation is seen. There is a trivial/physiologic pericardial effusion. -IMPRESSION: Well-seated atrial septal occluder in place. Trivial aortic regurgitation. No significant pericardial effusion. Compared with the prior study (images reviewed) of [2202-9-27], there is now a septal occluder in place. The other findings are similar. ECG [2202-10-1]: Sinus rhythm 72bmp, normal axis/intervals. Brief Hospital Course: ICU Course: patient was admitted with R MCA infarct. She was taken to interventional suite and IA tPA was performed with MERCI clot retrieval. Follow-up CTA showed probable expansion of the infarct into the territory of proximal M1. She was kept on pressure support for 48 hours for systolic 140-160. TTE revealed a PFO, and a right peroneal DVT was noted on LE Dopplers. The patient was scheduled for TEE on [9-28], but SICU team felt there was a change in mental status and ordered repeat CT which showed no interval change. TEE rescheduled for [9-29], and planned closure of PFO. Patient started on heparin drip on [9-28] with goal PTT 50-70. Pressors taken off and patient SBP in the 120s-140s. Transferred to floor. On the neuro-medicine floor the patient went for her TEE on [2202-9-30], which again revealed a PFO, and which did not show any evidence for clot or aneurysm. On [2202-10-1], percutaneous PFO closure was performed by interventional caridology. There was no complications of closure and a retrievable IVC filter was also placed because of the right leg DVT and our stroke Neurology team's preference not to place the patient on warfarin or heprin gtt post procedure. The patient was started on aspirin 325mg and plavix 75mg with discontinuation of the heprin gtt on [2202-10-1]. Retrieval of the IVC filter is scheduled for Cardiology clinic follow-up at 6 weeks post procedure, at which time the patient may be started on warfarin, and Cardiology will probably discontinue the Plavix at this point. She was kept on the Neuromedicine floor for several additional days with no indication for inpatient hospital stay except that it took a while for her insurance to approve the LTAC/Rehabilitation facility she preferred ([Hospital1 ]). She was discharged without further incident in the late morning of [2202-10-6]. Exam that morning was unchanged and VS remained stable/normal. Medications on Admission: 1. Boniva 150 mg Q month 2. Levothyroxine 100 mcg QD 3. Lisinopril 20 mg QD 4. Lorazepam 0.5 mg PRN anxiety QD 5. Simvastatin 20 mg QD 6. ASA 325 mg QD Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<95mmHg. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Whether or not to continue this medication will be determined by Cardiology in six weeks after discharge. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [2-13] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. orthotic devices Left wrist splint Left AFO 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: 1. Left-MCA stroke 2. PFO 3. DVT Discharge Condition: Normal mental status exam (left hemineglect has largely resolved). Left facial droop and a left hemiparesis. Hemodynamically stable, saturating well and breathing comfortably on room air. Discharge Instructions: You were treated at [Hospital1 ] hospital for a stroke. The stroke occurred due to the blockade of a major blood vessel that supplies a large part of the right side of your brain. A catheter was placed in this blood vessel and the blockage was removed, but some brain tissue was already damaged from the stroke, which is the reason for your right-sided weakness. Your stroke was likely the result of a blood clot passing through a leak in your heart called a patent foramen ovale (PFO). This was closed during your hospital stay using a catheter-device in your heart. You also had a blood clot in one of your veins (the right peroneal vein), and a filter was flaced in your inferior vena cava (IVC) to catch any particles from this clot that breaking off and prevent them from flowing into your lungs. This IVC filter will need to be removed in six weeks in Cardiology clinic. The Cardiologists will also make a decision at that time as to whether or not to continue your Plavix and whether or not to start you on warfarin. Followup Instructions: 1. Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] (stroke [Hospital 878] clinic at [Hospital1 18]; [Location (un) ] of [Hospital 23] Clinic building) Phone [Telephone/Fax (1) 2574] Date: [2202-11-5] Time: 12:00pm (noon) 2. Cardiology clinic in six weeks Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 62] Date: [2202-11-19] Time: 12:00pm (noon) -Also, already scheduled -- Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 62] Date: [2203-3-23] Time: 12:00pm (noon) Completed by:[2202-10-6]	[ "V15.82", "272.4", "V10.11", "745.5", "342.92", "733.00", "244.9", "434.01", "453.41", "784.51", "401.9", "V12.54" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.74", "99.10", "35.52", "88.72", "38.7", "00.40" ]	icd9pcs	[ [ [] ] ]	14007, 14081	10906, 12839	306, 441	14158, 14348	6858, 10883	15426, 16151	2199, 2318		13041, 13984		14102, 14137		12865, 13018			14372, 15403									2333, 6839																								234, 268											469, 1659																	1681, 1959	1975, 2183
17,245	196,101	14397+14422	Discharge summary	report+report	Admission Date: [2101-6-7] Discharge Date: [2101-6-13] Date of Birth: [2035-1-29] Sex: F Service: CARDIAC SURGERY CHIEF COMPLAINT: Congestive heart failure HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 976] is a 66-year-old retired OB nurse [First Name (Titles) 767] [Last Name (Titles) 1727] who was diagnosed with a new heart murmur in [2099-7-21]. She was found to have severe mitral regurgitation, and had a mitral valve repair in [2099-7-21]. She describes the surgery as being very difficult, requiring a repeat operation the same admission. Postoperatively, she developed atrial fibrillation and was managed with amiodarone for about a year. She has since been off of that as of [Month (only) ], and is in normal sinus rhythm. She has been plagued by episodes of congestive heart failure since her surgery, the first of which was in [2099-7-21], which required admission to her local hospital. She was diuresed and kept on lasix for some time, but eventually tapered off. Again in [2100-2-18], she felt like she was getting more short of breath. Her lasix was restarted, with some improvement of her symptoms. She currently finds that she gets dyspnea with walking up an incline or with any type of exertion. At times she will notice it when she is talking. Echocardiograms performed recently had revealed mitral stenosis, and she is now referred for a mitral valve replacement. She denies having any anginal symptoms, but does report occasional heaviness in her chest when she is short of breath. She denies any claudication, orthopnea, edema, paroxysmal nocturnal dyspnea or lightheadedness. PAST MEDICAL HISTORY: 1. Mitral valve disease (no history of scarlet or rheumatic fever) 2. Hiatal hernia/gastroesophageal reflux disease 3. Prior atrial fibrillation 4. Congestive heart failure 5. Hypertension 6. Hyperlipidemia PAST SURGICAL HISTORY: 1. Status post mitral valve repair in [2099-9-20] 2. Status post hysterectomy 3. Status post cholecystectomy 4. Status post eye surgery as a child ALLERGIES: She is not allergic to any medicines. MEDICATIONS: 1. Aspirin 325 mg once daily 2. Premarin 0.3 mg once daily 3. Lopressor 50 mg twice a day 4. Lasix 20 mg once daily 5. Potassium chloride 20 mEq once daily 6. Diovan 80 mg once daily 7. Zocor 20 mg once daily 8. Multivitamin once daily 9. Calcium PHYSICAL EXAMINATION: Her heart rate is 68, her blood pressure is 100/60, her preoperative weight is 53.5 kg. Head, eyes, ears, nose and throat are normal. Her neck is without bruit. The chest is clear to auscultation bilaterally. The heart has a respiratory rate, with a diastolic murmur. The abdomen is soft, nontender, nondistended. The extremities have normal pulses with no varicosities. CARDIAC CATHETERIZATION: Ejection fraction 68%, left ventricular end diastolic pressure 14, pulmonary capillary wedge pressure 33, pulmonary artery pressure 63/26, mitral valve area 0.65, mitral valve gradient 19 mm. There are normal coronaries. HOSPITAL COURSE: The patient was admitted as an outpatient on [2101-6-7], for her cardiac catheterization. She was kept overnight, and the following day she was taken to the operating room, where she had a minimally-invasive mitral valve replacement. Her valve is a #25 Mosaic. Postoperatively, the patient was taken intubated to the Intensive Care Unit. She did require some support with milrinone overnight, and also received two units of Hespan. She spent her first postoperative day in the Intensive Care Unit and was extubated in the middle of postoperative day number one. The following day, she remained in the Intensive Care Unit, and required a bit of a nitroglycerin drip. Her chest tubes were discontinued in a normal fashion, and later that day she was transferred to the floor. On the evening of her second postoperative day, she had an episode of rapid atrial fibrillation with a pulse rate of 180 beats per minute. During this time, she did maintain an adequate blood pressure between 90 and 110 systolic. She required a total of 10 mg of intravenous Lopressor in order to convert back to a sinus rhythm. A couple of hours later, she had another episode of rapid heart rate and required another 20 mg of intravenous Lopressor. The decision was made to load her with intravenous amiodarone and replete her electrolytes. She was then converted to oral amiodarone, which she will likely need to be on for some time. The patient was kept in sinus rhythm by increasing her oral Lopressor. By the fourth postoperative day, the patient was ambulating in the hallway. She continued to be diuresed, and her pacing wires were discontinued. By the fifth postoperative day, we believed that the patient was ready for rehabilitation, and appropriate arrangements were made for her transfer. On the day prior to her discharge, her weight was 59.2 kg, which is still 6 kg up from her preoperative weight. This discharge summary was dictated on [2101-6-12], in anticipation of a potential transfer to rehabilitation tomorrow. The patient is discharged on the following medications: 1. Premarin 0.3 mg by mouth once daily 2. Zocor 20 mg once daily 3. Captopril 12.5 mg three times a day 4. Enteric-coated aspirin 325 mg once daily 5. Colace 100 mg twice a day 6. Lasix 20 mg twice a day for seven days, then 20 mg once daily 7. Potassium chloride 20 mEq twice a day for seven days, then 20 mEq once daily 8. Amiodarone 400 mg once daily 9. Lopressor 50 mg twice a day 10. Multivitamin once daily 11. Percocet 5/325 one to two by mouth every four to six hours as needed 12. Tylenol 650 mg every four to six hours as needed 13. Ibuprofen 400 mg by mouth every four to six hours as needed 14. Zantac 150 mg twice a day The patient is to follow up with her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42662], in two weeks. In addition, she is to follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in approximately four weeks. DISCHARGE DIAGNOSIS: 1. Mitral valve stenosis, now status post minimally-invasive mitral valve replacement 2. Rapid atrial fibrillation, controlled 3. Hypertension, controlled 4. Hypercholesterolemia 5. Congestive heart failure [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 9638] MEDQUIST36 D: [2101-6-12] 21:59 T: [2101-6-13] 01:26 JOB#: [Job Number 42663] Admission Date: [2101-6-7] Discharge Date: [2101-6-14] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 66 year-old female with a history of mitral regurgitation who had a mitral valve repair and ring anuloplasty in [2099-9-20]. Since then she recently presented with congestive heart failure and anemia. The echocardiogram showed mitral stenosis. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Congestive heart failure. 3. Hypertension. 4. Hyperlipidemia. 5. Status post mitral valve repair with anuloplasty ring. PAST SURGICAL HISTORY: Hysterectomy, cholecystectomy and eye surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Premarin, aspirin, Lopressor, Lasix, Diovan and multivitamins. PREOPERATIVE LABORATORIES: Sodium 138, K 4.2, chloride 101, CO2 29, BUN 21, creatinine 0.8, blood sugar 90. Preoperatively, white blood cell count was 10.4, hematocrit 39.8 and a platelet count of 333,000. INR was 1.1, PT was normal. PHYSICAL EXAMINATION: The patient was regular rate and rhythm with audible diastolic murmur. The lungs were clear. The abdominal examination was benign. She had normal distal pulses in her feet and no varicose disease. Cardiac catheterization showed an ejection fraction of 68% with PA pressures of 63/26. Mitral valve area was decreased and the patient had normal coronaries. HO[Last Name (STitle) ] COURSE: On [6-8] the patient underwent mitral valve replacement with a mosaic tissue #25 mm valve through a minimally invasive approach by Dr. [Last Name (Prefixes) ]. The patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day one the patient was awake and following commands. She received some repletion with Hespan and was on Milrinone and was continued on her perioperative Vancomycin. Postoperatively, hematocrit was 24.8 with a K of 4.0, BUN 12 and a creatinine of 0.5. Her lungs were clear bilaterally. She had some trace edema. She had palpable dorsalis pedis pulses. Her incisions were intact. She was starting to wake up and sedation was held with plans to extubate her during the day. She was seen by case management. On postoperative day two his creatinine was stable at 0.5. Her hematocrit remained in the low 20s. She had some rhonchi. She had normal heart sounds. She had 1+ edema. She remained on a nitroglycerin drip at 0.75 mics per kilo per minute and was completing his perioperative Vancomycin. Her chest tubes were discontinued. She started her Lasix diuresis. She remained on sliding scale insulin as needed. Her diet was advanced. She was seen by physical therapy and had been extubated and was transferred out to the floor. On postoperative day three she had several episodes of atrial fibrillation. She received an Amiodarone bolus and intravenous Lopresor and then switched to po Amiodarone. Those were her two primary cardiac medications. She had a blood pressure of 120/85 with a heart rate of 62, sating 90% on room air. Hematocrit was stable at 25. She had some coarse breath sounds. Her heart was regular rate and rhythm. Her lytes were repleted and her Lopressor was increased to 50 mg po b.i.d. She continued to work with physical therapy. On postoperative day four she completed her antibiotics and had no acute events over the 24 hour period. She was hemodynamically stable. She was still sating on 89% on room air and 95% with 1 liter. She had bibasilar crackles. Heart was regular rate and rhythm. Incision was clean, dry and intact. Extremities had trace edema. Her pacing wires were discontinued. She continued to ambulate. She continued her diuresis and was screened for rehab. On[Last Name (STitle) 14810]perative day five she again remained stable with a good blood pressure and was now sating 91% on room air still with some crackles. Her incisions were clean, dry and intact. She had 2+ edema bilateral lower extremities. She received Zofran times one dose for nausea with the plans to try and discharge her the following day. On postoperative day six she did spike a temperature to 101.3 and remained afebrile at 98.6. Her urinalysis was negative. She was now sating 92% on room air with a blood pressure of 112/40 and was in sinus rhythm at 70. Her lungs were clear. Heart regular rate and rhythm. Incisions were clean, dry and intact with trace edema. She remained afebrile and was discharged to home on the 25th with instructions to follow up with Dr. [First Name (STitle) ] [Name (STitle) 42699] in two weeks her primary care physician and instructions to follow up with Dr. [Last Name (Prefixes) ] in one month in the office postoperatively. Laboratories on discharge white blood cell count 9.5, hematocrit 25.5, platelet count 257,000, K 5.1, BUN 23, creatinine 0.7. She was below her preoperative weight by 3 kilograms. Her examination was benign. Her extremities were warm and well perfuse. She still had a faint murmur. Her right thoracotomy site looked clean and intact. She was alert and oriented. DISCHARGE MEDICATIONS: Premarin 0.3 mg po q day, Zocor 20 mg po q.d., Captopril 12.5 mg t.i.d., enteric coated aspirin 325 mg po q.d., Colace 100 mg po b.i.d., Amiodarone 400 mg po q day, Lopresor 50 mg po b.i.d., Lasix 20 mg po b.i.d. times seven days and then q.d., K-Ciel 20 milliequivalents po b.i.d. times seven days and then q.d. Single multivitamin q.d., Zantac 150 mg po b.i.d., Percocet one to two tabs po prn q 4 to 6 hours for pain, Ibuprofen 400 mg po prn q 4 to 6 hours, Tylenol 650 mg po prn q 4 to 6 hours. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Status post minimally invasive mitral valve replacement with pericardial valve. 2. Status post mitral valve anuloplasty in [2098]. 3. History of congestive heart failure. 4. History of atrial fibrillation. 5. Hypertension. 6. Hypercholesterolemia. Again, the patient was discharged to home on [2101-6-14] in stable condition. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2101-9-14] 15:11 T: [2101-9-20] 07:45 JOB#: [Job Number 42700]	[ "996.71", "E878.8", "530.81", "424.0", "401.9", "272.0", "427.31", "553.3", "428.0" ]	icd9cm	[ [ [] ] ]	[ "35.23", "88.72", "88.56", "37.23", "88.53" ]	icd9pcs	[ [ [] ] ]								12327, 12935	11776, 12306		6151, 6750		7354, 7655	3088, 6130										7241, 7327															7678, 11752										165, 191											6779, 7039																	7062, 7217
50,721	186,681	20087	Discharge summary	report	Admission Date: [2105-2-23] Discharge Date: [2105-2-26] Date of Birth: [2019-1-28] Sex: F Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 425] Chief Complaint: Bilateral arm heaviness Major Surgical or Invasive Procedure: [2105-2-23] Cardiac catheterization- drug-eluting stent to left anterior descending coronary artery History of Present Illness: Mrs. [Known lastname 54011] is an 86 year old female with a PMH significant for CAD s/p PCI with DES to LAD, PDA, and RCA in [2097] and DES x2 to mid-LAD in [2-/2104] for in-stent restenosis, now presenting with anterior/septal STEMI s/p another DES to proximal-LAD. . Patient states she has been feeling bilateral arm heaviness for past 2-3 weeks. Heaviness was intermittent, spontaneous in onset and self-alleviating. She denies increased heaviness with exertion and has had no dyspnea or orthopnea. Arm heaviness has been increasing in frequency until it was especially heavy this morning. This is the same arm heaviness she presented with the last two times she had STEMIs requiring coronary stents. This arm pain has been noted to be her anginal equivalent. She denies any associated chest pain, shortness of breath, palpitations, nausea, vomiting, or pain radiating to the arm, back, or jaw. . She presented to an OSH, where ECG was notable for STE in aVR, V1, V2 with STD in inferior leads and V4-V6. She was given aspirin, and started on a nitroglycerin and heparin gtt, and transferred to [Hospital1 18] ED. She was taken emergently to cardiac cath. She was given 5mg IV lopressor for tachycardia. She was bolused with Integrilin and then on a drip. She was found to have diffuse in-stent restenosis in the proximal LAD to >90%, now s/p DES. Patient received total 400 cc ivf, 215 contrast. Right groin was angiosealed, and pt transferred to CCU in stable condition. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CAD s/p drug-eluting stents to LAD, PDA, RCA ([2097]), as well as acute very late in-stent thrombosis of proximal LAD stent on [2104-2-6]. 2. Hypertension 3. Hyperlipidemia 4. Chronic low back pain Social History: Lives with son, husband recently died. Tobacco - none. EtOH - none. Denies IV, illicit, or herbal drug use. Family History: No early CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 98, HR 91, BP 123/100, RR 23, O2 sat 100(2L), weight 66.4kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, unable to assess JVP as patient needed to lie flat CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Normoactive bowel sounds, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: warm, 1+ DP, PT pulses b/l NEURO: AAOx3, CNII-XII intact, upper and lower extremity strength grossly intact b/l . DISCHARGE PHYSICAL EXAM: Vitals: Tc/Tm 97.9/99.1, BP: 140/77 (123-144/58-84), HR 68-86, RR 18-20, SaO2 95-100% RA, weight 64.9kg of note pt had a 20 point BP between arms GENERAL: Pleasant elderly female seated in chair, talking comfortably, NAD. AAOx3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL, EOMI. Lips moist and pink with small blue/purple lesion to center lower lip. NECK: Supple, JVD 2cm above the clavicle with pt. seated at 90 degrees. CARDIAC: RRR, heart sounds pronounced with normal S1, S2. No m/r/g. LUNGS: Unlabored work of breathing, no accessory muscle use or retractions. CTAB, good aeration, no cough, crackles, wheezes, or rhonchi. ABDOMEN: Normoactive bowel sounds, Soft, NTND. No HSM. EXTREMITIES: Warm, radial pulses 2+ bilaterally, 1+ DP, PT pulses bilaterally. Pedal edema 1+ to below the ankles. NEURO: AAOx3, upper and lower extremity strength grossly intact b/l SKIN: Right groin healing, minor bruising below cath site, no hematoma, dressing c/d/i. PIV to right hand and left forearm. No rashes or sores. Pertinent Results: ADMISSION LABS: WBC-9.7 RBC-3.81* Hgb-12.1 Hct-33.6* MCV-88 MCH-31.7 MCHC-36.0* RDW-13.3 Plt Ct-223 Neuts-77.1* Lymphs-18.0 Monos-3.2 Eos-1.1 Baso-0.7 PT-12.3 PTT-150* INR(PT)-1.1 Glucose-189* UreaN-23* Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-25 AnGap-14 Calcium-9.5 Phos-3.7 Mg-1.7 cTropnT-0.02* . CARDIAC ENZYMES: [2105-2-23] 1:30 AM - cTropnT-0.02* [2105-2-23] 4:04 AM - CK-MB-47* MB Indx-14.7* cTropnT-0.42* CK(CPK)-320* [2105-2-23] 3:09 PM - CK-MB-89* MB Indx-12.4* cTropnT-1.96* CK(CPK)-720* [2105-2-23] 10:15 PM - CK-MB-44* MB Indx-9.3* cTropnT-1.95* CK(CPK)-472* [2105-2-24]: 5:20 AM - CK-MB-23* MB Indx-7.1* cTropnT-1.83* CK(CPK)-324* . CARDIAC CATH REPORT ([2105-2-23]) 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA had a 50% distal plaque that extends into both the LAD and LCx ostium, and appears to be essentially unchanged from prior angiography done in 2/[2104]. The LAD had diffuse ISRS - was noted to be mild proximally but tapers to a focal lesion of ~90%. TIMI 2 flow was noted in the distal LAD. A sizeable singular diagonal branch was patent and unchanged from prior. The LCx was noted to be retroflexed and tortuous proximally, with an ostial lesion of 40%. The proximal segment was diffusely diseased but appears unchanged (50-60% stenosis). The RCA had mild diffuse plaquing with patent stents and a normal flow pattern. 2. Successful PCI of proximal LAD in-stent restonsis (new lesion and culprit for STEMI presentation) with 3.0x12mm Promus [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated to 3.25mm (see PTCA comments). 3. Residual disease (distal bifurcation LMCA, ostial LAD/LCx, proximal LCx) to be treated medically and revascularization if clinically indicated. 4. Limited resting hemodynamics revealed normal systemic arterial pressures, with a central aortic pressure of 122/65, mean 74 mmHg. 5. Successful closure of the R CFA access site with 6F AngioSeal device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. 90% ISRS in proximal LAD successfully treated with primary angioplasty and 3.0 x 12mm Promus DES, post-dilated to 3.25mm. 3. Residual disease (distal bifurcation LMCA, ostial LAD/LCx, proximal LCx) to be treated medically, with revascularization if clinically indicated. 4. Systemic arterial normotension. 5. Integrilin IV gtt for 6 hours. 6. Reload with plavix 300 mg today (previously on 75 mg daily) and then continue plavix 75 mg daily. Assess for discontinuation of plavix after a minimum of [12-28] months (patient had very late stent thrombosis in [2104] and is not a prasugrel candidate due to age). 7. Continue aspirin 162 mg minimum daily indefinitely. 8. Global CV risk reduction strategies. . TRANSTHORACIC ECHO ([2105-2-23]): Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %) secondary to moderate global hypokinesis sparing only the inferior free wall. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2104-2-7], contractile function of the anterior septum, anterior free wall, and apex (LAD territory) (previously akinetic) is significantly improved, but contractile function of the posterior and lateral walls (circumflex territory) is worse, with a net effect of an increased overall left ventricular ejection fraction. Mitral regurgitation is increased, consistent with a functional ischemic etiology related to posterolateral wall and papillary muscle dysfunction. DISCHARGE LABS: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2105-2-25] 06:40 5.9 3.47* 11.0* 30.6* 88 31.7 35.9* 13.5 178 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2105-2-25] 06:40 961 15 0.8 139 3.5 104 28 11 Brief Hospital Course: 86 year old female with a PMH significant for CAD s/p PCI with DES to LAD, PDA, and RCA in [2097] and DES x2 to mid-LAD on [2104-2-7] for in-stent restenosis, now presenting with anterior/septal STEMI s/p another DES to proximal-LAD. . # STEMI: Patient with prior history of CAD s/p multiple stents in [2097] and late in-stent restenosis in [2104], now presents again with another in-stent rethrombosis in proximal-LAD. She was loaded with 300mg PO plavix and started on heparin gtt, and sent to cath lab. Pt??????s UE pain disappeared once pLAD ballooned, and thus this is likely culprit lesion. However, pt w/ disease in LCx as well that will need to be aggressively managed medically. Post-cath TTE on [2105-2-23] showed improved wall motion in the LAD territory, but worsened wall motion in the LCx territory, with a net overall effect of increased LVEF since prior MI in 3/[2104]. Persistent LCx disease was medically managed by continuing patient's home meds: ASA 325mg PO daily, clopidogrel 75mg PO daily, atorvastatin 80mg PO daily, Toprol XL 100mg PO daily, and Losartan 100mg PO daily. . # ACUTE SYSTOLIC CONGESTIVE HEART FAILURE: TTE [2105-2-23] showed EF 25-30%. Pt. with similar pattern following [Name Prefix (Prefixes) ] [Last Name (Prefixes) 54064] repair [2-/2104], one-month f/u TEE with EF improved to 50% in 3/[2104]. Patient appeared clinically euvolemic throughout hospitalization and thus did not require any diuresis. Home metoprolol and losartan were continued. She will require follow-up echo in 6 weeks to assess for improvement. Patient was educated on s/s of HF; she will watch for SOB, DOE, increasing weight or swelling . # HLD: continued home atorvastatin 80mg PO daily. . # HTN: Normotensive to slighly hypertensive, controlled with Metoprolol succinate 100mg daily and Losartan 100mg PO daily as above. . #ANEMIA: stable throughout hospitalization. =================== TRANSITION OF CARE: 1. Pt will need a follow up echo in 6 weeks to re-evaluate her EF and determine if she needs an ICD. Following her prior STEMI in [2104], her EF improved quite nicely ( [2-/2104] EF 25% to [3-/2104] EF 50%). If EF remains <35%, should start spironolactone and be considered for ICD placement. 2. Pt will need a lipid panel as an outpt to evaluate effectiveness of lipitor. and A1C as BS in hospital have been high Medications on Admission: Aspirin 325mg daily Toprol 100 mg daily Losartan 100 mg daily Lipitor 80 mg daily Plavix 75 mg nitro p.r.n. Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual AS DIRECTED as needed for chest pain. Disp:25 tablets Refills:0 Discharge Disposition: Home With Service Facility: All Care [Year (4 digits) 269] of Greater [Location (un) ] Discharge Diagnosis: Anterior-septal ST Elevation myocardial infarction Stent restenosis, s/p drug-eluting stent to left anterior descending coronary artery Acute systolic congestive heart failure coronary artery disease hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You had 2-3 weeks of intermittent, spontaneous heaviness felt in both of your arms. On [2105-2-23], the heaviness felt much worse and you recognized this as the feeling you had before your other cardiac hospital admissions. You went to the Emergency Department at [Hospital3 1443] Hospital, where you were diagnosed with a heart attack. You were then transferred to [Hospital1 18], where you were sent right away to have a cardiac catheterization lab. This procedure indicated that the stent placed last [2104-2-5] was no longer functioning and a new stent was placed. An echocardiogram was also completed to assess your heart function and it showed that you have had some improvements, but coronary artery disease remains, which will be best treated with aggressive medications. Additionally, the echo indicated that your heart function is weaker compared to your last echo in [2104-3-4]. However, you also had weakened heart function following your heart attack in [2104], which did resolve, and we are hopeful this will be the case again, as your heart recovers and grows stronger. You spent the night in the Cardiac ICU and did very well. You were transferred to the cardiac step down unit, [Hospital Ward Name 121] 3, on Tuesday [2105-2-24], and have continued to progress. Now you are ready to be discharged home with your son and we will have [Name (NI) 269] (visiting nursing) arranged. Weigh yourself every morning before breakfast, call Dr. [Last Name (STitle) 5686] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Also watch for increasing swelling in your legs, trouble breathing and sleeping. We have made no changes to your home medications other than adding a daily aspirin (325mg). Followup Instructions: Follow-up appointment with Primary Care Provider: Follow-up appointment with Cardiology Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2105-3-30] 4:20	[ "410.11", "272.4", "428.21", "V45.82", "428.0", "401.9", "414.01" ]	icd9cm	[ [ [] ] ]	[ "37.22", "00.45", "88.56", "36.07", "00.40", "00.66", "99.20" ]	icd9pcs	[ [ [] ] ]	12444, 12541	9264, 11658	294, 400	12813, 12813	4594, 4594	14805, 15047	2821, 2837		11817, 12421		12562, 12792		11684, 11794		6634, 8981	12964, 14782		8997, 9241							2877, 3496																						4905, 6617		231, 256											428, 2446							4610, 4888				12828, 12940						2468, 2679	2695, 2805			3521, 4575
17,899	175,635	45283	Discharge summary	report	Admission Date: [2173-8-30] Discharge Date: [2173-9-2] Date of Birth: [2094-4-11] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 4232] Chief Complaint: Falls, Hypoxia in ER Major Surgical or Invasive Procedure: NONE History of Present Illness: This is a 79 y.o. male with history of smoking, CAD, HTN, DM2, obesity, who was initially sent from home by VNA due to multiple falls (s/p rib fxs/humeral fx) and lethargy. He was recently discharged from the emergency department after a right humeral fracture (an oblique fracture through the proximal/mid shaft of the humerus, + lateral displacement of the distal bony fragment). In the emergency department, patient was noted to have decreased oxygen saturations to low 80s, although he denied any symptoms with this. The hypoxia would intermittently correct with supplemental O2 up to 6 liters, but then subsequently recur. Patient denies any symptoms such as exertional dyspnea (walks with walker), orthopnea, PND, or worsening of lower extremity edema. He does endorse decreased sleep latency, falling asleep in less than 5 minutes, and also questionable daytime hypersomnolence, but denies morning headaches. Of note, patient received prescription for Vicodin upon discharge from ED on [2173-8-28]. . In the ED on this vist, patient received 80mg furosemide, 2 tablets percocet, nebulizers and 60mg prednisone in addition to supplemental O2. His O2 Saturation was 92% after this. ABG showed compensated hypercarbia, 7.39/57/87. . Review of Systems: . POS: low grade T 100, [Name6 (MD) 96748] to md 80's when talking, increased lasix requirement over past week w/ increase in periph edema NEG: CP/SOB/other pain Past Medical History: 1. CAD w/ h/o STEMI [2171-11-16] s/p RCA stent (cypher stent x 2 to RCA w/ TIMI III flow) 2. CHF (diastolic dysfunction) - ECHO '[69]: EF > 60%, LA mod dilated, mild symm LVH w/ normal cavity size, 1+ MR, aortic valve leaflets mildly thickened 3. NIDDM (>15 years) 4. HTN 5. Osteopenia 6. Hyperlipidemia 7. ? TIA like sx [2168] (numb around the mouth, relieved w/ [Year (4 digits) ]) 8. h/o pyonidal cyst 9. gout (last flare 1 1/2 years ago) 10. carpal tunnel syndrome 11. CRI (Cr 1.3 since STEMI [2171-11-16], previously 0.9) 12. s/p thyroidectomy 13. s/p appy 14. s/p TKR 15. Anemia 16. L-sided stroke several years ago 17. BPH 18. Erectile dysfunction 19. Right humeral fracture ([2173-8-28]) Social History: He was most recently D/C'd to [Hospital1 5595] MACU on [11-2] for further care. Prior to that, he was at home with his wife. Further history limited. Quit smoking 39 years ago but 100 pack-year history. Family History: Mother: heart problems; father: arthritis, brother died at 19 of Hodgkins disease Physical Exam: PE: VS: T 99.3, HR: 109; BP 152/53; RR 20; O2 sat: 98% on 4L NC [Month/Year (2) 4459]:NCAT; Neg lesions nares, oral pharnyx, auditory intackt, Supple range of neck motion. Negative lymphadenopathy, supraclavicular nodes LUNGS: CTA bilaterally CARDIAC: RRR witout murmurs, rubs, gallops ABDOMEN: Soft, Non tender to palpation, non-distended, positive Bowel Sounds EXT: 2+ Lower extremity edema NEURO: Alert and Oriented X 3, nonfocal, sleepy SKIN: ecchymoses on Left shoulder Pertinent Results: [2173-8-30] 06:15PM PT-13.2* PTT-36.7* INR(PT)-1.1 [2173-8-30] 06:15PM PLT SMR-NORMAL PLT COUNT-170 [2173-8-30] 06:15PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ STIPPLED-OCCASIONAL [2173-8-30] 06:15PM NEUTS-65.7 BANDS-0 LYMPHS-20.9 MONOS-3.7 EOS-9.0* BASOS-0.7 [2173-8-30] 06:15PM WBC-9.3 RBC-2.91* HGB-7.8* HCT-23.9* MCV-82 MCH-26.9* MCHC-32.8 RDW-18.7* [2173-8-30] 06:15PM CK-MB-NotDone cTropnT-0.04* proBNP-680 [2173-8-30] 06:15PM CK(CPK)-88 [2173-8-30] 06:15PM estGFR-Using this [2173-8-30] 06:15PM GLUCOSE-195* UREA N-38* CREAT-1.7* SODIUM-133 POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-31 ANION GAP-15 [2173-8-30] 07:24PM TYPE-ART PO2-87 PCO2-57* PH-7.39 TOTAL CO2-36* BASE XS-7 . [2173-8-30] CHEST, PA AND LATERAL: The cardiac and mediastinal contours are stable. There is slight unfolding of the aorta. No focal pulmonary opacities are identified to indicate pneumonia. Flowing syndesmophytes are again seen involving the thoracic spine. IMPRESSION: No acute cardiopulmonary disease. . . [2173-8-30] CT HEAD WITHOUT IV CONTRAST: Focal areas of hypoattenuation involving the left posterior temporal lobe and left central sulcus consistent with encephalomalacia from prior infarctions appears stable. No new areas of hypoattenuation are identified and the [Doctor Last Name 352]-white matter differentiation appears intact. There is no evidence of intracranial hemorrhage. There is no evidence of hydrocephalus or shift of normally midline structures. Partially aerosolized secretions within both maxillary antra appear similar when compared to the previous exam with mild mucosal thickening within the ethmoid air cells. IMPRESSION: 1. Stable encephalomalacia of the left posterior temporal lobe and left central sulcus, indicating areas of previous infarction. No definite evidenceof new infarction identified. 2. No intracranial hemorrhage or edema. . Brief Hospital Course: . 79 yo man with history of coronary artery disease, hypertension, diabetes mellitus, obesity, presumpted obstructive sleep apnea and poor compliance with medical follow-up, with recent mechanical falls here with dizziness, hypoxia, and lethargy. . 1. Hypoxia: Though patient appears to have long standing pulmonary disease, oxygen requirement on transfer appeared to be new. Patient has improved significantly and appears to be at baseline. Chest x-ray from [8-30] had increased diffuse opacities along bases consistent with physical exam findings of crackles upon arrival to floor. Would suspect patient had component of atelectasis in addition to central hypoventilation. Would also suspect patient has baseline hypercarbia and oxygen supplementation with agressive goals resulted in further decreased respiratory drive. We titrated oxygen supplementation and started ipratropium inhaler. He was transfused 1 unit of PRBC and improved very well, likely due to improved oxygen delivery and improvement of pre-existing pulmonary vasoconstriction. Patient has continued to refuse non-invasive positive pressure devices and is aware of importance of being evaluated for obstructive sleep apnea but declines any workup. . 2. Multiple falls: Patient initially provided hisotry of dizziness and weakness which were difficult to confirm during admission. It appears he has been having disequilibrium and would benefit from physical therapy. With recent falls and prior stroke however, these were concerning for new cerebrovascular events. Physical exam however remained non-focal and patient was receiving [Hospital ] medical therapy for secondary prevention. Head CT was negative, and MRI head could not be performed secondary to anxiety and positional arm pain. We continued aspirin, statin and [Hospital 4532]. Patient will require continuing physical therapy after discharge, will defer decision to pursue MRI to primary care physician. . 3. Coronary artery disease/Congestive Heart Failure: Stable during admission, with low suspicition for pulmonary edema. We continued home meds of lasix, [Hospital ], [Hospital 4532], metop, lipitor. We held imdur however due to concerns of orthostatic hypotension and will defer decision to restart it to primary care physician. . 4. Diabetes Mellitus type 2: Patient was kept on insulin sliding scale and was discharged back on oupatient hypoglycemic regimen. . 5. Chronic Renal Insufficiency: Patient presented with baseline creatinine and continued to be at baseline during admission. . 6. Anemia - {atient was found to be anemic at admission. Because of hypoxia and concern for obstructive sleep apnea causing pulmonary vasoconstriction, patient was trasfused 1 unit of PRBC with good post trasfusion response. Workup revealed normal TSH, folate and B12 with inappropriately normal reticulocyte count in setting of normal colonoscopy and EGD last year. Will defer further workup to primary care team. . 7. Leukocytosis: Most likely secondary to prednisone, was resolving and patient had no signs of infection. . 8. Gout: We continued outpatient regimen of allopurinol, colchicine. . 9. BPH: We continued Terazosin per outpatient regimen . 10. FEN: Patient tolerated a diabetic, low sodium diet without difficulty. . 11. Prophylaxis: heparin sq, PPI, bowel regimen. . 12. Code status: Patient remained FULL CODE, confirmed directly with patient. . Medications on Admission: Lasix 60 daily Metoprolol 12.5 mg [Hospital1 ] Clopidogrel 75mg daily Isosorbide 60 mg daily Terazosin 10mg daily Lipitor 80mg daily [Hospital1 ] 325 mg daily Prilosec 20mg daily Potassium 20 mEq [Hospital1 ] Glipzide 5 mg [Hospital1 ] Metformin 500mg daily Allopurinol 150mg daily Colchicine 0.6mg daily Vicodin 1 tab TID for pain PRN Senakot 1 qd Colace 100mg [Hospital1 ]. Iron Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 19. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: PRIMARY: 1. HYPOXIA 2. ANEMIA 3. RIGHT HUMERAL FRACTURE 4. HYPERTENSION 5. DIABETES MELLITUS SECONDARY 1. HISTORY OF STROKE Discharge Condition: Stable, saturating greater than 94% on room air. Discharge Instructions: You were admitted to the hospital because you began feeling sleepy and tired, and were found to have low levels of oxygen in your blood. You were taken to the intensive care unit where you were closely monitored and multiple tests were performed. We believe this was caused by your underlying lung disease and the effects of the pain medicines you were given for the arm pain. We have changed your medicine to another type, gave you blood to correct your anemia and you recovered very well. You will still need to work with the physical therapist for some time. Please take all medications as directed and keep all doctors [Name5 (PTitle) 4314]. If you develop severe pain, constant somnolence, confusion, difficulty breathing, chest pain, shortness of breath or feel ill, please call your primary care physician or come into the emergency room for evaluation. Followup Instructions: Please schedule an appointment with your primary care physician, [Name10 (NameIs) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 8417] within 2 weeks of returning home. Your doctor will also visit you at the rehab facility. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236]	[ "403.90", "412", "V43.64", "V45.82", "414.01", "272.4", "250.00", "799.02", "274.9", "496", "428.0", "585.9", "V54.11", "428.32", "600.00", "327.23", "E935.2" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	10894, 10967	5374, 8785	315, 321	11135, 11185	3371, 5351	12100, 12471	2771, 2855		9237, 10871		10988, 11114		8811, 9214			11209, 12077									2870, 3352																					1616, 1784			255, 277											349, 1597																	1806, 2527	2543, 2755
80,267	156,408	22958	Discharge summary	report	Admission Date: [2120-11-21] Discharge Date: [2120-11-28] Date of Birth: [2057-3-20] Sex: F Service: SURGERY Allergies: Latex / Penicillins / Adhesive Tape Attending:[First Name3 (LF) 1481] Chief Complaint: Reflux diseae and paraesophageal hernia Major Surgical or Invasive Procedure: Laparoscopic paraesophageal hernia repair with fundoplication. History of Present Illness: 63-year-old woman who has some histories of reflux and regurgitation as well as some chest pain and coughing. She has had some epigastric pain. She is improved with proton pump inhibitors, but is not totally satisfied. Coughing may occur after meals, but does not seem to be associated with regurgitation. Past Medical History: HTN recently diagnosed (<6 months ago) Hypercholesterolemia recently diagnosed (<6 months ago) Obesity GERD long-standing S/p cholecystectomy Social History: Tobacco history: denies tobacco abuse ETOH: Denies EtOH abuse Illicit drugs: Denies IVDA Family History: No family history of early MI; mother had MI at age 82, father with MI at age 74. Pertinent Results: [2120-11-21] 08:16PM GLUCOSE-137* UREA N-28* CREAT-1.0 SODIUM-139 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13 [2120-11-21] 08:16PM estGFR-Using this [2120-11-21] 08:16PM CK(CPK)-106 [2120-11-21] 08:16PM CK-MB-3 cTropnT-<0.01 [2120-11-21] 08:16PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.8 [2120-11-21] 05:56PM TYPE-ART RATES-15/ TIDAL VOL-600 O2-70 PO2-127* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2120-11-21] 05:56PM GLUCOSE-173* LACTATE-1.3 NA+-136 K+-3.6 CL--98* [2120-11-21] 05:56PM HGB-13.8 calcHCT-41 [2120-11-21] 05:56PM freeCa-1.21 Brief Hospital Course: This woman had a symptomatic paraesophageal hernia with symptoms of reflux, as well as other problems associated with her hernia. She presented for laparoscopic paraesophageal hernia repair with fundoplication. Post-operatively Patient developed an pneumonia with low oxygen saturations which required a stay to the ICU. Patient was started on vanc and cefepime and continued to improve clinically. Patient was transitioned to the floor and all antibiotics were stopped. Rehab screening was started and patient was initially cleared for rehab. Patient continued to be stable on room air at rest with sat's of 90-95% on ambulation. Given patient's desire to return home versus rehab home oxygen was set up and patient was discharged home [2120-11-28]. Medications on Admission: BENZONATATE - (Prescribed by Other Provider) - Dosage uncertain HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Capsule - 1 Capsule(s) by mouth DAILY (Daily) METOPROLOL SUCCINATE [TOPROL XL] - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every twenty-four(24) hours PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 2 Tablet(s) by mouth HS (at bedtime) Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Home Oxygen 2L continuous pulse dose Oxygen for portability 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:80 Tablet(s) Refills:2 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 10 days. Disp:35 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Paraesophageal hernia and Reflux disease Postoperative hypoxemia and possible pneumonia Atrial fibrillation Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were additted for a Laparoscopic paraesophageal hernia repair with fundoplication. While you were in the hospital you developed a pneumonia that has resolved. You are going home with oxygen in the event that you become short of breath. While in the hospital you also developed an atrial fibrillation. Your heart rythmn returned back to normal on a beta-blocker and amniodarone. Please follow-up with your primary care doctor after leaving the hospital to discuss and review any new medications you are on. If there are any questions please call your surgeon to discuss. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [3-31] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) *] within 1-2 weeks of leaving the hospital. Please follow-up with you primary care doctor to review all home medications	[ "272.0", "486", "401.9", "530.81", "518.0", "553.3", "427.31", "997.39" ]	icd9cm	[ [ [] ] ]	[ "53.71", "44.67" ]	icd9pcs	[ [ [] ] ]	3985, 3991	1794, 2552	337, 402	4142, 4142	1131, 1771	6346, 6521	1029, 1112		3210, 3962		4012, 4121		2578, 3187			4287, 6323																																	258, 299											430, 741											4156, 4263						763, 906	922, 1013
49,420	106,044	38922	Discharge summary	report	Admission Date: [2111-2-4] Discharge Date: [2111-2-9] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 85 y/o female with PMH of CAD, Afib, hemorrhagic stroke ([April 2110]), HTN, COPD, Hyperlipidemia, CHF, pleural effusion and a history of falls. She reports generalized weakness since her stroke. She states she was in her usual state of health today but does not have any recollection of falling just remembers waking up on the floor and pressing her Lifeline button. She was taken to [Hospital 86350]Hospital and was found to have a small SAH on CT imaging. She was then transferred to [Hospital1 18] for further care. Past Medical History: CAD, Afib, L CVA [4-12], HTN, COPD, HLP, CHF, pl eff, h/o falls Family History: Noncontributory Physical Exam: Upon admission: T: 97.4 BP:196/90 HR:70 R16 O2Sats 96% Gen: WD/WN, comfortable, in collar. HEENT: Pupils: [3-6] EOMs full Neck: in collar no neck pain, no stepoff or point tenderness. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 2 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. B T IP Q H AT [Last Name (un) 938] G R 4- 5 5 5 5 5- 2 5 L 4+ 5 5 5 5 5 5 5 No pronator drift Sensation: Decreased in feet Reflexes: Pa Right 5 Left 5 Toes downgoing bilaterally Pertinent Results: [2111-2-4] 08:58PM GLUCOSE-132* UREA N-19 CREAT-0.6 SODIUM-144 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-30 ANION GAP-13 [2111-2-4] 08:58PM CK(CPK)-265* [2111-2-4] 08:58PM CK-MB-10 MB INDX-3.8 cTropnT-0.03* [2111-2-4] 08:58PM WBC-7.1 RBC-4.23 HGB-12.9 HCT-38.8 MCV-92 MCH-30.5 MCHC-33.3 RDW-13.1 [2111-2-4] 08:58PM PLT COUNT-198 [2111-2-4] 08:58PM PT-12.1 PTT-23.9 INR(PT)-1.0 [2111-2-4] 02:10PM cTropnT-0.03* [2-4] CT head: Right sided subarachnoid blood in temporal area possibly small contusion no mass effect or shift. [2-4] CT cervical spine: 1. No evidence of acute fracture. 2. Degenerative changes including listhesis and mild loss of height as described above. These findings are age indeterminate given lack of comparison. [2-4] CXR 1. Moderate cardiomegaly. 2. No focal consolidation. [2-4] Hip xray PELVIS, ONE VIEW; LEFT HIP, TWO VIEWS: There is diffuse osseous demineralization. There are no fractures or dislocations. Moderate degenerative disease is noted in the lower lumbar spine. Retained stool is noted in the rectum. The bowel gas pattern is nonspecific. The soft tissues are unremarkable. IMPRESSION: No fractures. [2-5] Rpt head CT: IMPRESSION: 1. No interval change in size or configuration of right temporal and right frontal vertex subarachnoid hemorrhage. 2. Punctate hyperdensity within the left cerebellum is too small to fully characterize, but may represent a calcification. Ill-defined hyperdensity along the tentorium on the left appears unchanged, possibly chronic thickening or subtle focal subdural hematoma. 3. No new focus of hemorrhage. No mass effect or midline shift. 4. Chronic small vessel ischemic disease. Brief Hospital Course: She was admitted to the Trauma service. Neurosurgery was consulted for her SAH; frequent neurologic checks and serial head CT scans were done and remained stable. She was loaded and started on Dilantin and remained on this for 7 days for seizure prophylaxis; no seizure activity has been noted during her hospital stay. She will need to follow up with neurosurgery in 1 month for repeat head CT scan. Her home medications were restarted with the exception of her aspirin. Her Dig level was normal at 0.9. Her diet was advanced for which she is tolerating. She was evaluated by Physical therapy and is being recommended rehab after her acute hospital stay. Medications on Admission: Dig 0.125', ASA 81', lop 25'', lasix 40'' Discharge Medications: 1. Phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) MG PO Q8H (every 8 hours) for 1 days. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Digoxin 125 mcg 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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110 . 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for contipation. 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Port Rehab & Skilled Nursing - [Location (un) 5028] Discharge Diagnosis: s/p Fall Right temporal subarachnoid hemorrhage Left temporal laceration Right elbow laceration 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 hospitalized following a fall where you sustained a bleeding injury to your brain. The bleeding was monitored closely by neurologic examination and by head CT scans. Your CT scans remained stable with no evidence of further bleeding. Your mental status has also improved during your hospital stay. You were given a medication called Dilantin to prevent seizures; there were no seizure activity noted during your hospital stay. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 548] in 4 weeks with head CT - please call [Telephone/Fax (1) 2992] to arrange this appt. You will need to follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ]e from rehab. Completed by:[2111-2-10]	[ "881.01", "272.4", "438.89", "851.81", "401.9", "496", "E888.9", "728.89", "427.31", "428.0", "873.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5757, 5839	3925, 4583	268, 274	5978, 5978	2179, 2637	6610, 6908	943, 960		4675, 5734		5860, 5957		4609, 4652			6150, 6587									975, 977																								220, 230											302, 836	1434, 2160		2646, 3389			3399, 3902				991, 1182	5993, 6126						858, 927
82,068	181,021	4933	Discharge summary	report	Admission Date: [2119-8-4] Discharge Date: [2119-8-11] Date of Birth: [2064-12-11] Sex: F Service: NEUROLOGY Allergies: Keflex Attending:[First Name3 (LF) 20506] Chief Complaint: Seizure Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 55 y/o F with h/o of migraines and depression who was presented to [Hospital3 ] with seizure. Stablized, intubated for airway protection and transferred to [Hospital1 18]. The patient was found at 12:30pm by her husband having seizures in bed. He called EMS who noted the patient to be having a tonic-clonic seizure with eyes deviated to the left and left arm/leg convulsing and administered 2mg ativan and narcan without improvement. Brought to [Hospital3 ] where seziure was broken with 8mg of ativan and 1500mg of dilantin. CT head (-). UTox (+) for amphetamine, barbituates, [Hospital3 18496] and opiates. Lactate elevated. Intubated for airway protection and trsnferred to [Hospital1 18]. In discussion over the phone with the patient's husband she has been very depressed recently. Unclear if taking all of her meds. At [Hospital1 18], VS 102 157/84 TV 500 RR 14 60% fio2 5 peep. An OGT was placed and drained 300ml of dark fluid that was hemmocult (+). Started on IV pantoprazole and ocreotide and admitted to the MICU. On arrival to the MCIU, VS 99.3 77 160/69 99%. Intubated and sedated. Past Medical History: - Sleep apnea - Tobacco abuse - Migraines - Bronchitis - Hypothyroidism - Depression - Back surgeries - HL - HTN Social History: Long h/o smoking. Lives with her husband and two daughters. Does administrative work. Has had a live-in "friend" named [Name (NI) ] who has been supplying the Pt. with opiates such as heroin and presciption pills. Family and Pt. have voiced their wishes that he does not visit in the hospital. Family History: Long h/o migraine Physical Exam: Admission Exam: Vitals: 99.3 77 160/69 99% Intubated General: Intubated and sedated. Opens eyes to voice. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA but sluggish Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Somewhat coarse BS b/l Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: (+) foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Pupils reactive but sluggish. Sedated. Discharge Exam: VS: T 98.3 BP 128/80 HR 88 RR 16 O2sat 96% RA Gen: NAD, comfortable Neuro: Mental status: alert, oriented, conversing appropriately with normal f l u e n c y /comprehension/naming/repetition/[Location (un) 1131]/writing/prosody/thought process/affect; digit span 6 forward, 3 back; misspells "world" backwards but otherwise no evidence of attentional deficits. Excellent recall of recent events. CN: EOM intact, VF full, face symmetric. Pertinent Results: IMAGING STUDIES: CXR [2119-8-6] IMPRESSION: 1. There has been interval appearance of mild to moderate pulmonary and perihilar edema. No pleural effusions or pneumothorax. Overall, cardiac and mediastinal contours are stable. MRI Head [2119-8-5] FINDINGS: Study is limited due to motion-related artifacts on multiple sequences. Within this limitation, on the diffusion sequences, there is no focus of slow diffusion to suggest an acute infarct. There is asymmetry in the size of the lateral ventricles, with the left being slightly larger than right. On the FLAIR sequence, there are several areas of hyperintense signal, involving predominantly the cortex, in the frontal, parietal, and the occipital lobes as well as in the left medial temporal lobe. Small areas of involvement in the adjacent white matter are also seen. There is no abnormal enhancement noted in these areas. There is no focus of negative susceptibility to suggest hemorrhage allowing for the areas of mineralization. Patient is intubated. There is mildly increased signal intensity in the mastoid air cells on both sides from fluid/mucosal thickening. The major intracranial arterial flow voids are noted. MR ANGIOGRAM OF THE HEAD: The left vertebral artery is dominant. The major arteries of the intracranial circulation are patent, without focal flow-limiting stenosis. The A1 segment on the left side is diminutive. There is contour irregularity related to atherosclerotic disease at multiple levels. A tiny outpouching is seen from the lateral aspect of the left cavernous carotid segment and also the right, question artifactual related to pulsation artifacts/small outpouchings. The P1 segment on the left side is diminutive, with prominent posterior communicating artery. IMPRESSION: 1. Several areas of FLAIR hyperintense signal in the cerebral parenchyma, - The etiology of these findings is uncertain, a broad differential diagnosis including encephalitis, seizure-induced changes either reactive or inflammatory changes or related to medication/toxic etiology. Clinical and lab correlation and close followup can be considered to assess stability. 2. Patent major intracranial arteries as described above, with evidence of mild contour irregularity related to atherosclerotic disease. Echocardiogram [2119-8-7] Results Measurements Normal Range Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm Left Ventricle - Ejection Fraction: >= 75% >= 55% Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 9 < 15 Aortic Valve - Peak Velocity: 2.2 m/sec <= 2.0 m/sec Aortic Valve - Pressure Half Time: 519 ms Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A ratio: 0.90 Mitral Valve - E Wave deceleration time: 128 ms 140-250 ms Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. The patient is mechanically ventilated. Cannot assess RA pressure. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: RV not well seen. AORTIC VALVE: No valvular AS. The increased transaortic velocity is related to high cardiac output. Significant AR, but cannot be quantified. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve appears structurally normal with trivial mitral regurgitation. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Aortic regurgitation - ? Mild. CLINICAL IMPLICATIONS: Based on [2114] 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. EEG [2119-8-7] IMPRESSION: This telemetry captured no pushbutton activations. It showed a mildly slow background throughout with frequent epileptiform spike discharges in the left temporal region. The discharges, however, did not occur repetitively in short segments nor were they rhythmic or prolonged. The slow encephalopathic background was unchanged from the previous day's recording. There were no periodic discharges or electrographic seizures. ECHO [2119-8-8] LEFT VENTRICLE: Hyperdynamic LVEF >75%. AORTIC VALVE: Mild (1+) AR. Conclusions Left ventricular systolic function is hyperdynamic (EF>75%). Mild (1+) aortic regurgitation is seen. Compared with the findings of the prior study (images reviewed) of [2119-8-7], the findings are similar. CXR [2119-8-9] The left perihilar component of pulmonary abnormality has improved substantially over approximately 48 hours suggesting the diagnosis of asymmetric edema or acute aspiration. There is new opacification at the base of the right lung, at least some of which is due to atelectasis given progressive elevation of the hemidiaphragm and ipsilateral mediastinal shift. Nevertheless findings could also be explained by aspiration to that side. Clinical correlation advised. Previous pulmonary vascular engorgement has improved indicating improved cardiac or hemodynamic status. Pleural effusion is minimal on the right, if any. MICRO/PATH LABS: ADMISSION LABS: [2119-8-4] 06:26PM BLOOD WBC-22.1* RBC-5.26 Hgb-13.5 Hct-43.3 MCV-82 MCH-25.7* MCHC-31.2 RDW-14.6 Plt Ct-302 [2119-8-4] 06:26PM BLOOD Neuts-91.6* Lymphs-4.5* Monos-2.9 Eos-0.9 Baso-0.1 [2119-8-4] 06:26PM BLOOD PT-12.8* PTT-28.1 INR(PT)-1.2* [2119-8-4] 06:26PM BLOOD Glucose-147* UreaN-8 Creat-1.1 Na-141 K-3.4 Cl-101 HCO3-25 AnGap-18 [2119-8-4] 06:26PM BLOOD ALT-9 AST-18 AlkPhos-100 TotBili-0.6 [2119-8-4] 06:26PM BLOOD Albumin-4.2 [2119-8-4] 06:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2119-8-4] 06:55PM BLOOD Type-ART Temp-36.1 Rates-14/5 Tidal V-500 FiO2-60 pO2-67* pCO2-44 pH-7.41 calTCO2-29 Base XS-2 -ASSIST/CON Intubat-INTUBATED [2119-8-4] 06:25PM BLOOD Lactate-1.2 MRI brain w/ & w/o contrast [8-11]: FINDINGS: Extensive T2/FLAIR hyperintensities in bilateral white matter, thalami, left medial temporal lobe have significantly improved since [2119-8-5] exam. Increased FLAIR signal persists in bilateral parietal, occipital regions and right frontal lobe (4:20), predominantly in white matter distribution. No diffusion abnormality is seen to suggest acute infarct. No abnormal parenchymal, leptomeningeal or dural enhancement is seen. There is no intracranial hemorrhage, sulci and ventricles are normal in size and configuration. There is no mass effect or shift of normally midline structures. Basal cisterns are patent. Orbital and nasopharyngeal soft tissues are grossly unremarkable. Paranasal sinuses are clear. Principal intracranial flow voids are preserved. IMPRESSION: In comparison to [2119-8-5] exam, there is near complete resolution of diffuse bilateral FLAIR hyperintensities. T2/FLAIR hyperintensities remain predominantly in bilateral occipital and parietal white matter, the above findings likely represent resolving PRES. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Ms. [Known lastname 20507] is a 55 y/o F with admitted to the MICU following tonic-clonic seizure and intubation. Hospital Course --------------- Brought to [Hospital3 ] where seizure was broken with 8mg of ativan and 1500mg of dilantin. CT head (-). UTox (+) for amphetamine, barbituates, [Hospital3 18496] and opiates. Lactate elevated. Intubated for airway protection and trsnferred to [Hospital1 18]. At [Hospital1 18], an OGT was placed and drained 300ml of dark fluid that was hemmocult (+). Started on IV pantoprazole and octreotide and admitted to the MICU. In MICU had heavy secretions and leukocytosis 22.1 WBC on [8-4], CXR [8-5] with new left retrocardiac opacity, possibly due to aspiration (possible pneumonia, atelectasis), started on levofloxacin. CXR [8-6] showed mild/moderate pulmonary edema, gave IV lasix. No seizure activity on continuous EEG. Weaned off O2 and extubated [8-6]. Transferred to the floor [2119-8-9]. Required oxygen on the floor. Normal mentation and no seizure activity on the floor. Restarted home meds and gave gentle diuresis with IV lasix. #Hypoxia: Likely fluid overload vs. Aspiration vs. PNA. Has remained afebrile, although spikes to 99.0, decreasing leukocytosis. Lung exam is remarkable to rhonchi and wheezes with copious secretions. With diuresis has not had robust UOP and then drops to 20-30/hour. Given this most likely chemical pneumonitis secondary to aspiration. Received levofloxacin IV x 3 days, PO x 2 days, empirically for aspiration pneumonia vs. CAP. - Gave scheduled albuterol / ipatroprium; albuterol nebs; prn albuterol inhaler - Will discharge home on long-acting bronchodilator (spiriva) - Gave IV lasix for pulmonary edema #: Seizure - No seizures during hospitalization. Got dilantin in the ICU and floor. The patient has no obvious findings on CT head to suggest structural abnormality or CVA. However, with multiple FLAIR hyperintensities, with an initial differential of PRES vs seizure-related changes vs encephalitis. Her Utox was (+) for [Last Name (LF) 18496], [First Name3 (LF) ], opiates and amphetamines at OSH but here only for opiates/[First Name3 (LF) ] and the patient is known to be prescribed these medications. Could be a withdrawal seizure as, by report, the patient may have abruptly stopped taking her [First Name3 (LF) 18496] two days ago, also may have recently stopped buprenorphine. Also with unclear [Name2 (NI) 7344] abuse history (pt denies this). Lytes normal. Transferred to inpatient Neurology [8-10] for continued management. On neurology service, pt initially displayed some very mild residual cognitive deficits that subsequently resolved. On the day of discharge, her mental status was normal. Because of this rapid improvement, no LP was performed, and no empiric treatment for encephalitis was initiated. Repeat MRI on [8-11] demonstrated near-resolution of the previously seen FLAIR hyperintensities, thus suggesting that these may have been related to PRES. Phenytoin was discontinued, and pt was discharged with levetiracetam 750 mg [Hospital1 ] instead. As pt's polypharmacy likely contributed to her episode of unconsciousness, her burden of sedating medications was decreased by discontinuing meclizine, and changing lorazepam 1 mg TID to clonazepam 0.5 mg [Hospital1 ]. Pt's other psychiatric medications (quetiapine 50 mg qhs, zolpidem for sleep) were continued. #: Depression - Contracts for safety, no SI, but pt and husband report significant depression, no longer has a psychiatrist. Continue citalopram. #Upper GI bleed: Patient with 300cc dark fluid from OGT in the ED and started on octreotide and pantoprazole. In the MICU, hematocrit remained stable. The patient was continued on intra-venous pantoprazole. Her hematocrit remained stable throughout her MICU stay however she was found to have guiac positive stools. On transfer to the floor, IV pantoprazole was transitioned to PO metoprolol. Hgb on discharge was 11.3. # Dermatophytosis - hand & foot rash - likely fungal. Gave miconazole ointment. #Hypertension: This is a chronic [Last Name ] problem. We continued her home dose of metoprolol, verapamil. Outpt adjustments of these meds should be considered as they both risk side effects of bradycardia and hence hypoperfusion-related events. #Hyperlipidemia Statin was continued. #Hypothyroid: This is a chronic stable issue. We continued her home levothyroxine. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from OSH notes. 1. Zolpidem Tartrate 10 mg PO HS 2. Lorazepam 1 mg PO Q8H 3. Citalopram 40 mg PO DAILY 4. Quetiapine Fumarate 50 mg PO HS 5. Metoprolol Succinate XL 200 mg PO DAILY 6. Atorvastatin 40 mg PO DAILY 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing 8. Acetaminophen-Caff-Butalbital [1-9] TAB PO Q6H:PRN Migraine 9. Migranal NF (dihydroergotamine) 0.5 mg/pump act. (4 mg/mL) NU Daily Migraine 10. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 11. Hydrochlorothiazide 25 mg PO DAILY 12. Levothyroxine Sodium 150 mcg PO DAILY 13. Meclizine 12.5 mg PO Q6H:PRN HA 14. Omeprazole 20 mg PO DAILY 15. Ondansetron 4 mg PO Q8H:PRN Nausea 16. TraMADOL (Ultram) 50 mg PO Q6H:PRN HA 17. Verapamil SR 240 mg PO Q24H Discharge Medications: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN Wheezing RX ProAir HFA 90 mcg 1-2 puffs inhaled every 6 hours Disp #2 Inhaler Refills:0 2. Atorvastatin 40 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Metoprolol Succinate XL 200 mg PO DAILY 6. Quetiapine Fumarate 50 mg PO HS RX quetiapine 50 mg 1 tablet(s) by mouth at night Disp #5 Tablet Refills:0 7. Zolpidem Tartrate 10 mg PO HS RX zolpidem 10 mg 1 tablet(s) by mouth at night Disp #5 Tablet Refills:0 8. Verapamil SR 240 mg PO Q24H RX verapamil 240 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 9. Clonazepam 0.5 mg PO BID RX clonazepam 0.5 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 RX clonazepam 0.5 mg 1 tablet(s) by mouth twice daily Disp #20 Tablet Refills:0 10. LeVETiracetam 750 mg PO BID RX levetiracetam 750 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:3 11. Acetaminophen-Caff-Butalbital [1-9] TAB PO Q6H:PRN Migraine 12. Hydrochlorothiazide 25 mg PO DAILY 13. Migranal NF* (dihydroergotamine) 0.5 mg/pump act. (4 mg/mL) NU Daily Migraine 14. Omeprazole 20 mg PO DAILY 15. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 16. Miconazole 2% Cream 1 Appl TP [Hospital1 ] to both hands RX DermaFungal 2 % 1 application twice daily Disp #1 Tube Refills:0 Discharge Disposition: Home Discharge Diagnosis: Seizure Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after being found down at home with rhytmic jerking concerning for seizure activity. You were initially admitted to the medicien service in the intensive care unit where you were started on seizure medications. You had an MRI which showed non-specific diffuse changes. These resolved on follow-up imaging studies. You were transitioned to a different seizure medication on discharge. We discussed performing a lumbar puncture, but you noted that you were improving in terms of your thinking and that this was not necessary. You were seen by social work during this admission and told them you felt as if you had a safe home environment and would be able to go there on discharge. You cannot drive a car for 6 months. 1. You will need to continue on Keppra at 750 mg twice daily until you see your neurologist Dr. [Last Name (STitle) 1206]. 2. We stopped meclizine as this medication was not needed. 3. We switched your ativan to clonazepam which should help with your anxiety. Please discuss these changes with your primary care doctor. 4. You were given refills for many of your medications. You should see Dr. [Last Name (STitle) 20508] early next week in order to get refills. You told us you would be able to get an appointment. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2119-12-12] 10:30 Completed by:[2119-8-11*]	[ "311", "507.0", "272.4", "327.23", "305.1", "578.9", "293.0", "401.9", "345.3", "244.9", "305.91", "288.60", "346.90", "518.81", "496" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	17899, 17905	11192, 15690	277, 303	17967, 17967	2972, 2972	19421, 19598	1929, 1950		16561, 17876		17926, 17946		15716, 16538			18118, 19398									1965, 2494					2510, 2586	7572, 9238																		230, 239											331, 1459							9254, 11169				17982, 18094						1481, 1596	1612, 1913				2990, 7549
75,181	161,609	40084	Discharge summary	report	Admission Date: [2114-10-31] Discharge Date: [2114-11-7] Date of Birth: [2035-10-12] Sex: M Service: MEDICINE Allergies: Baclofen Attending:[Last Name (NamePattern4) 290] Chief Complaint: Fever, hypoxia, tachypnea Major Surgical or Invasive Procedure: Endotracheal intubation [2114-10-31] Central venous catheter placement [2114-11-1] History of Present Illness: 79 yo M w/ CHF, PVD, s/p AKA, s/p ureteral stents and s/p partial penisectomy (distal shaft of penis excised) with indwelling catheter transferred from [Hospital 1263] hospital with fevers, bilateral rhonchi, and hypoxia. . Patient intubated so history is limited. Daughter [Name (NI) 653] but has not seen patient in weeks and was unable to provide history. Per [Hospital 1263] hospital records patient had temp 101.8, hr 124, bp 142/80, and 78% on NRB. He was transferred to [Hospital1 18] ED for further management. . In [Hospital1 18] ED, VS HR 125, BP 145/68, RR 30, 99% NRB. Patient was found to be minimally responsive, only moaning. He was very tachypneic to 30s and rhonchorous on exam. He was intubated and noted to not have a gag reflex. Urology was consulted concern for penile/scrotal infection at area of excision. Urology did not feel that there was superficial wound infection and recommended keeping foley to gravity. In the ED his HR ranged 120s-140s, SBP 100s-130s. An ECG was notable for sinus tachy, 123 bpm, w/ twi v3-v6. On labs he had leukocytosis of 14.5 w/ left shift, no bands, lactate 3.2, Na 171, Cl 131, Cr 3.7. UA w/ blood, prot, wbc, bact, and leuks. ABG on FIO2 100 was 7.45, 34, 212. CXR read to have low lung volumes, no infiltrates. He was written for vanc/cefepime, but due to nursing error received vanc/gent becaus error. He also received 2L NS and started on propafol gtt. Has REJ and piv. His vitals on transfer are: 94/57, 120s, 99% on vent. Past Medical History: Seizure disorder Depression HTN PVD s/p bilateral AKA cholelithiasis Social History: Resident of [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] skilled nursing facility. Family History: NC Physical Exam: PHYSICAL EXAM ON ADMISSION General: Intubated, responds to sternal rub, otherwise minimally follows commands HEENT: Sclera anicteric, MMM, oropharynx clear Neck: intubated, JVP 8cm, no LAD Lungs: rhonchorous anterior breath sounds CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops, PMI not displaced Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: scrotal edema, foley in place, wound dressed w/ guaze, no pustulous drainage/fluctuance Ext: AKA, onychomycosis of the hands, right hand contracted Pertinent Results: [2114-10-31] 09:00PM BLOOD Glucose-234* UreaN-82* Creat-3.7* Na-171* K-4.5 Cl-131* HCO3-22 AnGap-23* [2114-11-7] 04:22AM BLOOD Glucose-88 UreaN-27* Creat-1.1 Na-147* K-3.4 Cl-113* HCO3-25 AnGap-12 [2114-10-31] 09:40PM BLOOD Type-ART Tidal V-500 FiO2-100 pO2-212* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 AADO2-493 REQ O2-80 -ASSIST/CON Intubat-INTUBATED [2114-11-6] 12:24PM BLOOD Type-ART pO2-76* pCO2-38 pH-7.40 calTCO2-24 Base XS- [2114-11-1] 8:40 am SPUTUM Source: Endotracheal. FINAL REPORT [2114-11-4] GRAM STAIN (Final [2114-11-1]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2114-11-4]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 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. YEAST. RARE GROWTH. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . [2114-11-3] 12:13 pm URINE Source: Catheter. FINAL REPORT [2114-11-7] URINE CULTURE (Final [2114-11-7]): YEAST. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S CT ABD/PELVIS [2114-11-1] 1. Multifocal pneumonia with right greater than left parenchymal consolidation. 2. Bilateral double-J nephroureteral stents in standard positions. Right renal calculi measuring 1.0 cm in the right interpolar region. 3. Heterogeneous nodular thyroid. 4. Extensive heterotopic calcification and degenerative changes in the shoulders and hips. TTE [2114-11-2] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global biventricular systolic function. Mild mitral and aortic regurgitation. Limited study. Brief Hospital Course: #Acute hypoxemic respiratory failure - Due to multifocal healthcare-associated pneumonia and altered mental status in the setting of hypernatremia. Supported with mechanical ventilation from [10-31] to [11-6], antibiotics, and IV fluids. Sputum Cx [11-1] grew MRSA and H. influenzae. Antibiotics discontinued [11-7] when the patient was made CMO. . #Acute complicated urinary tract infection - Urine culture [2114-11-3] grew >100K Enterococcus. Treated with vancomycin until made comfort measures only. . #Acute kidney injury - Resolved with fluid resuscitation. Did not require renal replacement therapy. . #Hypernatremia - Presumably due to poor free water intake. Resolved with gradual correction of free water deficit. . #Nutrition - Given tube feeds while intubated. After extubation, NG tube placed but the patient removed it. Not replaced given overall goals of care. [Month (only) 116] eat and drink as desired for comfort. . #Goals of care - Given the patient's poor functional status and quality of life, the decision was made to pursue comfort measures only (and do not rehospitalize order) after a discussion between the medical team and the patient's daughter/healthcare proxy. Hospice services arranged for after discharge. Medications on Admission: erythromycin eye drops diltiazem 50mg remeron prilosec mvi aspirin iron milk of mag tums nebs Discharge Medications: 1. morphine 20 mg/5 mL Solution Sig: 0.5-1 mL PO q2h as needed for pain/shortness of breath. 2. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: [12-30] Tablet, Rapid Dissolves PO every 4-6 hours as needed for anxiety/insomnia. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] Rehabilitation & Nursing Center - [Location (un) 538] Discharge Diagnosis: Hypoxemic respiratory failure Healthcare associated pneumonia Acute complicated urinary tract infection Acute kidney injury Hypernatremia Discharge Condition: Follows simple commands. Interacts meaningfully but nonverbal. Bedbound. Discharge Instructions: You were admitted to the hospital with multisystem organ failure and altered mental status due to pneumonia, urinary tract infection, and an elevated sodium level in the blood. After discussions between the medical team and your daughter and healthcare proxy, it was determined that your care would have a comfort-based approach. Followup Instructions: You should continue to receive comfort care and hospice services after transfer. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2114-11-7]	[ "584.5", "276.4", "443.9", "518.81", "482.2", "428.0", "787.91", "110.1", "401.9", "995.92", "428.32", "482.42", "038.9", "311", "780.39", "V49.76", "V45.89", "285.9", "599.0", "348.30", "276.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.97", "96.72", "96.6" ]	icd9pcs	[ [ [] ] ]	8183, 8337	6519, 7783	304, 397	8519, 8594	2780, 6496	8973, 9221	2164, 2168		7928, 8160		8358, 8498		7809, 7905			8618, 8950									2183, 2761																								239, 266											425, 1931																	1953, 2023	2039, 2148
18,902	140,250	16989	Discharge summary	report	Admission Date: [2188-5-12] Discharge Date: [2188-5-15] Date of Birth: [2115-3-22] Sex: M Service: Cardiac Care Unit CHIEF COMPLAINT: Coronary artery disease and slurred speech. HISTORY OF PRESENT ILLNESS: A 73-year-old male with known coronary artery disease, inferior myocardial infarction in [2175], two vessel disease seen in cardiac catheterization in [2184] with a positive stress test in [2187-11-9], now transferred from [Hospital3 1280] for interventional catheterization after a two week history of unstable angina. On routine stress test in [2187-11-9], Mr. [Known lastname 47790] experienced chest pain. He was managed medically at that time, but has had daily chest pain at rest and with exertion relieved by nitroglycerin sublingually starting two weeks prior to admission. The patient saw his primary care physician who increased his atenolol dose to 50 mg [Hospital1 ] from 50 and 25 with improvement in his symptoms, but given his recent change, he was sent for a cardiac catheterization at [Hospital3 1280] on [2188-5-12]. At [Hospital3 1280], the cardiac catheterization showed greater than 95% stenosis of the proximal left circumflex, less than 50% stenosis of the distal left main, and 100% occlusion of the right coronary artery with 3-4+ collaterals in the left circumflex and left anterior descending. He had retained left ventricular systolic function with abnormal diastolic dysfunction. The patient was transferred to [Hospital1 346] for intervention of the left circumflex on Heparin drip and Plavix. While in the catheterization laboratory at [Hospital1 346], his 90% mid left circumflex stenosis was seen and a tortuous segment of the artery lesion was predilated with great difficulty during angioplasty. His systolic blood pressure dropped to 70 from 160. His heart rate dropped to the 50s. He had low filling pressures on Swan-Ganz catheter. His blood pressure slowly improved with atropine 1 mg, dopamine 10 mcg/kg/minute and normal saline bolus. Catheterization course is also significant for nausea with coffee-ground emesis. A STAT hematocrit was 31.9. The lesion was then stented with good results, however, patient developed slurred speech, but remained oriented x3 poststent. Neurology was consulted, who recommended a head CT scan and q2h neurologic checks given that the patient was deemed unstable to go down for a CT scan and his neurologic examination was nonfocal. He was transferred for the Cardiac Care Unit for close monitoring and observation. Of note, the patient reports a 14 year history of slurred speech when he is fatigued or somnolent. REVIEW OF SYSTEMS: No chest pain, no shortness of breath, no lightheadedness, no diaphoresis, no abdominal pain. The nausea had resolved by the time the patient reached the Cardiac Care Unit, no bright red blood per rectum, no melena. Denies any fevers, chills, or dysuria. He denies any history of any gastrointestinal bleed. PAST MEDICAL HISTORY: 1. Inferior myocardial infarction in [2174] complicated by ventricular fibrillation arrest, anoxic encephalopathy resulting in residual short-term memory loss and minor speech impediment, and unsteady gait. 2. He had a catheterization in [2184] that showed total occlusion of the right coronary artery with collaterals 70-80% stenosis of the proximal left circumflex and 40% occlusion of the distal left main. He has been medically managed since then. 3. Hypertension. 4. Hypercholesterolemia. 5. Prostate cancer treated seven years ago. ALLERGIES: He has no known drug allergies. MEDICATIONS AT HOME: 1. Accupril 20 mg po q day. 2. Atenolol 50 mg po bid. 3. Verapamil SR 240 mg po q day. 4. Folgard 2.2 q pm. 5. Folic acid 1 mg po tid. 6. Vitamin E 400 units po q day. 7. Fish oil 500 units tid. 8. Lopid 600 mg po bid. 9. Niaspan ER 750 mg po q day. 10. Probenecid 500 mg po bid. 11. Lipitor 80 mg po q day. 12. Nitroglycerin sublingually prn. 13. Aspirin 81 mg po q day. 14. Zoloft 100 mg po q day. SOCIAL HISTORY: He smoked 10-15 years for a pack a day and quit 25 years ago. No alcohol history. He lives with his wife. [Name (NI) ] has two grown children. He is an electronic engineer, retired 11 years ago. His father had a myocardial infarction in his 30s. PHYSICAL EXAMINATION: He was afebrile, blood pressure 112/57, heart rate 74, respiratory rate 14, O2 saturation was 95% on 2 liters nasal cannula. He is in no acute distress. He is pleasant, sleepy, but easily arousable. Mucous membranes moist. Unable to appreciate his jugular venous pressures. Pupils are equal, round, and reactive to light. Chest had bibasilar crackles laterally. Heart was regular, rate, and rhythm with distant heart sounds. Abdomen was softly distended, no hepatomegaly. He had minimal epigastric tenderness. He had 1+ dorsalis pedis pulses bilaterally. He is alert and oriented times three with slurred speech. He was attentive to examination and able to say world forward and backward with one mistake. Speech is appropriate, fluent without paraphasic errors. Repetition was intact. Naming was intact. Comprehension was intact. He was able to read, he is moderately dysarthric, moderately preservative. Cranial nerves II through XII were intact. Extraocular movements were full with full visual fields, no nystagmus. Muscular strength was [5-12]. He had bilateral palate elevation. Tongue was midline. Hearing is grossly intact. Face was symmetric. He had normal bulk and tone in the upper extremities. The lower extremities were unable to assess because of groin access. No pronator drift. Strength appears full throughout except unable to assess right leg. Sensation was intact to light touch and pin prick with intact proprioception. Reflexes were 1+ globally with downgoing toes. Finger-to-nose was intact, but slow with intention tremors. LABORATORY DATA: His white count was 9.3, hematocrit 31.9, platelets 197, INR 1.3, PTT 33.8. Sodium 137, potassium 3.8, chloride 103, bicarbonate 23, BUN and creatinine of 21 and 1.2, glucose of 122, calcium 8.6, phosphate 3.5, magnesium 1.6. The patient remained stable and went down for head CT scan which showed no hemorrhage, no mass effect, and no shift, and however, it showed atrophic changes, marked calcification of both vertebral arteries as well as cavernous carotid arteries. There is minimal ethmoid mucosal thickening and minimal right maxillary sinus wall thickening likely reflecting chronic changes. Chest x-ray showed bibasilar atelectasis. Liver function tests were normal. The patient's CKs reached a peak of 353 with a CK MB peak of 16, and thereafter trended down. The patient was without chest pain the entire hospital course. He was continued on his medical regimen in addition to Plavix. There were no other episodes of coffee-ground emesis after the episode and the catheterization laboratory, the patient was evaluated by Physical Therapy, who felt that he was safe to go home with home safety evaluation and home Physical Therapy. Patient had an acute renal failure with creatinine rise to 1.6 attributed to the dye load. By the end of the hospital course, the creatinine was back down to 1.1. The patient was discharged in good condition to home with services. He was to continue all home medications with the addition of Plavix 75 mg po q day. DIAGNOSES: 1. Cerebral vascular insufficiency. 2. Acute native coronary artery disease status post percutaneous intervention and stent placement. 3. Postcatheterization complications. 4. Unstable angina. FOLLOW-UP INSTRUCTIONS: He was to followup with his primary care physician and his cardiologist. MAJOR PROCEDURES: Cardiac catheterization and stent placement. DISCHARGE MEDICATIONS: 1. Accupril 20 mg po q day. 2. Atenolol 50 mg po bid. 3. Verapamil SR 240 mg po q day. 4. Folgard 2.2 q pm. 5. Folic acid 1 mg po tid. 6. Vitamin E 400 units po q day. 7. Fish oil 500 units tid. 8. Lopid 600 mg po bid. 9. Niaspan ER 750 mg po q day. 10. Probenecid 500 mg po bid. 11. Lipitor 80 mg po q day. 12. Nitroglycerin sublingually prn. 13. Aspirin 81 mg po q day. 14. Zoloft 100 mg po q day. 15. Plavix 75 mg po q day. [First Name8 (NamePattern2) 870] [Last Name (NamePattern1) ], M.D. [MD Number(1) 5219] Dictated By:[Name8 (MD) 6371] MEDQUIST36 D: [2188-5-16] 11:43 T: [2188-5-20] 08:12 JOB#: [Job Number 47791]	[ "272.0", "997.5", "458.2", "401.9", "584.9", "414.01", "E947.8", "411.1" ]	icd9cm	[ [ [] ] ]	[ "36.01", "37.23", "88.56", "36.06", "99.20" ]	icd9pcs	[ [ [] ] ]									7812, 8500												3658, 4059																		4355, 7625							2711, 3022			164, 209											238, 2691															7650, 7789		3044, 3637	4076, 4332
63,305	131,327	52089	Discharge summary	report	Admission Date: [2125-3-12] Discharge Date: [2125-3-13] Date of Birth: [2059-8-25] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6736] Chief Complaint: Hematuria, Anemia Major Surgical or Invasive Procedure: None History of Present Illness: 65 y/o with prostate CA s/p radial prostatectomy 10y ago, radiation cystitis, and b/l nephrostomy tubes who presented today w/ worsening hematuria, weakness and Hct 15. Pt was started on taxotere + carboplatin chemo 1yr ago, devleoped hematuria for the first time in [11-27], had a cystoscopy and found to have radiation cystitis. At [Hospital1 112] flushing was tried (?CBI), which was unsuccessful, then formalin in the bladder. Pt was admitted to [Hospital1 112] for persistent hematuria 6 wks ago and had b/l nephrostomy tubes placed, and was inpt for 3wks. During this time pt was on ?mitotane(?mitazantrone) + high dose prednisone, which stopped the pt's hematuria. It was thought that the source was still the bladder and was having reflux up the ureter's to the nephrostomy tubes. Pt does make small amounts of urine from his urethra. Pt was d/c 3wks ago, spent 1 wk in rehab, then was home for 2wks PTA. Pt also received last round of chemo was 1 wk ago. Over the last wk pt has required 2units PRBC q3 days. Last friday pt presented to [Hospital1 ] [Location (un) 620] w/ a hct 21 and received 2 units PRBC. Pt has felt more SOB this last week. This morning (3d later) pt felt very LH and weak. BP was checked by his wife, and dropped to 73/46. As EMS came, while he was being placed flat onto the stretcher pt syncopized w/ LOC for a few seconds, no trauma. Pt went to [Hospital1 ] [Location (un) 620], found to have a hct 15, and received 2u PRBC and 6u plts. EKG showed R heart strain. Pt transferred here. In the emergency department T 99.3, BP 120/76, HR 98, 18, 100%4L/NC. received 1 more units PRBC, was checked at 18. Pt does have suprapubic pain and occaisonal dysuria but his urine cx has never returned positive. otherwise denies fevers/chills/night sweats/vomiting/diarrhea/melana/hematochezia. Past Medical History: 1. radical prostectomy 2. sleep apnea 3. GERD 4. anxiety Social History: no etoh, no smoking, worked as a banker Family History: brother w/ prostate ca, fther mi - age 57, mother [Name (NI) ] Physical Exam: GENERAL: Pleasant, well appearing male in 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 not elevated LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [12-22]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2125-3-12] 06:45PM BLOOD WBC-3.4* RBC-2.21* Hgb-6.9* Hct-18.6* MCV-84 MCH-31.3 MCHC-37.2* RDW-19.5* Plt Ct-72* [2125-3-13] 04:20AM BLOOD WBC-3.2* RBC-2.91# Hgb-8.9# Hct-24.4# MCV-84 MCH-30.5 MCHC-36.5 RDW-17.9* Plt Ct-43* [2125-3-12] 06:45PM BLOOD Neuts-69.6 Lymphs-26.4 Monos-3.4 Eos-0.4 Baso-0.3 [2125-3-12] 06:45PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL [2125-3-13] 04:20AM BLOOD PT-17.1* PTT-32.9 INR(PT)-1.5* [2125-3-13] 04:20AM BLOOD Glucose-124* UreaN-25* Creat-0.7 Na-137 K-4.5 Cl-104 HCO3-25 AnGap-13 [2125-3-13] 04:20AM BLOOD Calcium-7.1* Phos-3.5 Mg-2.0 [2125-3-12] 06:59PM BLOOD Hgb-6.9* calcHCT-21 Urine culture pending [2125-3-12] KUB: 1. The nephrostomy tubes are projected over the expected locations of the kidneys bilaterally. 2. Non-obstructive bowel gas pattern. Brief Hospital Course: 65yo M w/ h/o radical prostatectomy and chemo 1wk ago, b/l nephrosomty tubes who presents w/ worsening hematuria and Hct 15. . #. [Name (NI) 3674] The pt's anemia was likely due to blood loss from radiation cystitis and neprostomy tubes in combination recent chemo treatment. The pt had 5 RBC transfusions during this admission (2 at [Hospital3 628] and 3 at [Hospital1 18]) and subsequently vital signs were stable. On transfer to [Hospital1 112] the pt's hematocrit had been stable at 24 for the past 12 hours. The pt was afebrile, with pulse in the 100's, blood pressure 130's/60's and 100% on room air. . #. Prostate [Last Name (un) 3711]- The pt is s/p radical prostectomy, getting mitotane + high dose prednisone. . # Coronary artery disease- At [Hospital1 ] [Location (un) 620] the pt had a troponin T of 0.011, which is 0.001 above the normal assay. At [Hospital1 18] the pt's EKG appeared normal, but with low voltage. . # Disposition: Transfer to [Hospital6 1708]. Medications on Admission: - prilosec 20 QD - prednisone 20 QD - iron 325 QD - folate 1mg QD - ambien 10mg qhs - ativan 0.5mg q8 prn - compazine 10mg q6 rn - vitamin k 10mg qday - mvi Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Discharge Diagnosis: Prostate cancer, radiation cystitis Discharge Condition: Fair. Discharge Instructions: Mr [Known lastname 7049], you are being transfered to the [Hospital6 13185] for further care of your blood loss in your urine. Followup Instructions: Please follow up with your outpatient oncologist and urologist.	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18,942	193,213	19537	Discharge summary	report	Admission Date: [2130-12-21] Discharge Date: [2130-12-25] Date of Birth: Sex: Service: HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: This is a 56-year-old male referred by Dr. [Last Name (Prefixes) ] for outpatient cardioangiogram and PTCA prior to having a CABG. Mr. [Known lastname 52999] has recently been diagnosed with severe generalized vasculopathy. He has high-grade asymptomatic stenosis of the right internal carotid artery and a 3 cm infrarenal AAA. In addition, he also has severe stenosis of the left internal iliac artery that causes disabling claudication. The stress test done showing apical, inferior, and posterolateral fixed perfusion defects. The cardiac catheterization was done on [2130-11-28] at [Hospital3 1280] revealing severely diseased left main and proximal bifurcation to these including 70 percent left main stenosis, 50 to 60 proximal LAD stenosis, and 100 percent ostia of left circumflex occlusion. A PTCA of his carotids followed by CABG at the [Hospital1 18] having consideration of percutaneous and surgical revascularization of his iliac disease. Echocardiogram done on [2130-11-17] revealed concentric LVH with inferoposterior hypokineses with preserved systolic function and EF of 50-55 percent. In addition, there is trace MR, trace TR, and left atrial enlargement. Mr. [Known lastname 52999] reports burning in his left toes and legs for years. He denies chest pain or shortness of breath. He denies any orthopnea, PND, lightheadedness, or edema. Denies any visual changes or headache. CARDIAC RISKS FACTORS: Hypertension, cholesterol, family history of aneurysm on maternal side, and smoking approximately half pack per day. PAST MEDICAL HISTORY: The patient was admitted for bacteremia approximately 18 years ago. History of IV drug use 11 years ago. Chronic low back pain. Spinal stenosis. AAA. Sleep apnea. PVD. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with wife. [Name (NI) ] smokes half a pack per day, occasional alcohol. MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Toprol 25 mg q.d. 3. Lipitor 20 mg q.d. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.0, blood pressure 116/56, heart rate 57, breathing 11, 94 percent on room air. The patient is calm, no acute distress. Pupils are equal, round, and reactive to light. Moist mucous membranes. No lymphadenopathy. CARDIOVASCULAR: Regular rate, S1 and S2, no appreciable murmurs. LUNGS: Clear to auscultation. ABDOMEN: Bowel sounds. Soft, nontender, and nondistended. EXTREMITIES: No lower extremity edema. Pulses are palpable bilaterally. NEURO: Alert and oriented x3. Cranial nerves II through XII intact. Strength 5/5. Sensation intact bilaterally. DTRs are 1 plus bilaterally. LABORATORY DATA ON ADMISSION: White count 8.4, hematocrit 44.4, and platelets 184. Chemistry, sodium 138, potassium 4.3, chloride 104, bicarbonates 26, BUN 10, creatinine 0.9, and INR 1.0. HOSPITAL COURSE: This is a 56-year-old male with history of multivessel CAD, awaiting CABG, also with hypertension, hyperlipidemia, spinal stenosis, and known cerebellar vascular disease status post recent TIA admitted for stenting of the right ICA prior to CABG. Cerebrovascular disease: On day of admission, the patient was taken to the catheterization lab. Carotid and vertebral angiogram revealed normal left common carotid artery with internal carotid artery having a tubular 50 percent lesion. Right common carotid is normal with the right internal carotid having a focal of 90 percent lesion. The patient's right internal carotid artery was stented. The patient was transiently started on atropine for bradycardia and Neo- Synephrine for low systolic blood pressures. The patient's heart rate and blood pressure subsequently recovered. The patient was started on Plavix 75 mg (x 9 months). The patient was followed in the CCU to monitor blood pressure. The goal is to maintain systolic blood pressure in the range of 120 to 140. The patient's antihypertensive medications were held. The patient remained off of pressors and was able to maintain blood pressures within goal. The patient remained asymptomatic. Neurologic exam remained stable. The patient denied any visual changes or lightheadedness. Coronary artery disease. The patient was continued on aspirin, Plavix, and statin. Daily EKGs were followed. The patient was awaiting CABG as stenting of internal carotid artery was abridged through CABG/CEA. During this hospital course, the patient denied any chest pain. No active ischemic issues. Bradycardia. The patient had several periods of sinus bradycardia in the 50s. The patient remained asymptomatic. The patient did not require further atropine to maintain heart rate. Most of his heart rates were noted when the patient was sleeping. FEN. The patient was given a cardiac diet. Prophylaxis was with the PPI and bowel regimen. The patient remained full code during this hospitalization. DISPOSITION: To home with surgery rescheduled. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient was asked to continue aspirin and Plavix everyday and to follow up with Surgery if they want to discontinue it prior to surgery. DISCHARGE DIAGNOSES: Right carotid stenosis status post stent. Coronary artery disease. Peripheral vascular disease. Hypertension. Hyperlipidemia. Tobacco abuse. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg q.d. 2. Plavix 75 mg q.d. 3. Lipitor 20 mg q.d. 4. Nicotine patch 1 patch transdermal q.24h. 5. Tylenol 325 mg 1 to 2 tablets p.o. q.4-6h. as needed for back pain. 6. Oxycodone 5 mg 1 tablet p.o. q.4-6h. as needed for breakthrough pain. FO[Last Name (STitle) ]: The patient is to follow up with Dr. [First Name (STitle) ] in 2 days. The patient is to follow up with Dr. [Last Name (Prefixes) ] for cardiac bypass. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 53000] Dictated By:[Name8 (MD) 5978] MEDQUIST36 D: [2131-5-10] 08:33:32 T: [2131-5-11] 07:45:45 Job#: [Job Number 53001]	[ "441.4", "724.00", "414.01", "427.81", "433.30", "443.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "39.90", "39.50", "88.41" ]	icd9pcs	[ [ [] ] ]								5347, 5489				5515, 6237		3059, 5124		5183, 5325								1974, 2019															2224, 2865																															2880, 3041							1775, 1950	2036, 2201	5149, 5158
48,038	141,060	8836	Discharge summary	report	Admission Date: [2145-10-29] Discharge Date: [2145-11-3] Date of Birth: [2112-9-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3991] Chief Complaint: Saddle PE Major Surgical or Invasive Procedure: IVC placement History of Present Illness: [Known firstname ] [Known lastname 174] is a 33F with childhood NHL s/p XRT and chemo in remission, meningioma status post resection 4 months [Hospital ] transferred from [Hospital3 ] with saddle PE. Per the patient and her mother, the patient had been having intermittent SOB and congestion for a couple of weeks, though no complaints of chest pain. Two days ago she was very somnolent and her parents noted she was speaking less clearly. This morning the patient became persistently short of breath and complained of a substernal chest pain. She was taken to [Hospital3 3583] where she was found to be 97.5 130 24 112/55 92% on ?L. The pt had a CTA showing massive pulmonary emboli and RV strain. She was given 1L ns, Lovenox 70mg and transferred to [Hospital1 18]. . In the [Hospital1 18] ED the pt was found to have VS 97.5 120 90/62 20 90% RA. She had an EKG showing sinus tach, partial RBBB, TWI inf ant/lat. Neurosurgery was consulted and felt it was safe to anticoagulate but requested a baseline CT head which did not show any bleed. Heparin gtt was started without bolus as Lovenox dosing at OSH was subtherapeutic. Bilateral lenis were done with DVT on R (non-occlusive). . On the floor, the pt was VS afebrile HR 120s, SBP in the 90s, satting 99% on 3L. She denied CP, endorsed mild SOB but said she felt improved from the am. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # Non-Hodgkin's lymphoma: Her oncological problem began when she was born. She was noted to have bruising in her skin. Initial skin biopsy was inconclusive but later, at the age of 3 years (in the [2114]'s), she developed an abdominal mass that was later diagnosed as non-Hodgkin's lymphoma. She was treated with chemotherapy and prophylactic whole brain cranial irradiation. Her lymphoma was in remission since then. She was followed by Dr. [First Name4 (NamePattern1) 4468] [Last Name (NamePattern1) 13534] at the [Hospital3 1810] of [Location (un) 86]. When he retired, she was lost to medical follow up. Of note, patient received max dosing of Adriamycin as part of her chemotherapy. # Basal cell carcinoma to scalp at radiation site status post excision [2144] and [2145]. # Meningioma status post resection complicated by severe stroke in the left pons. She left opthalmoplegia and right hemiparesis. # Question neurogenic bladder versus urge incontinence now treated with medication. # Hypokalemia secondary to recent steroid use Social History: No tobacco use, previously drank alcohol socially. She is now living at home with her parents, [Doctor First Name 717] and [Doctor First Name ] in [Location (un) ]. Family History: Diabetes Physical Exam: Admission Exam: General: L facial droop, wig in place, cushingoid appearance, HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, with wheeze ?cardiac vs pulmonary CV: tachycardic, sinus, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: L facial droop, 5/5 strength on L, 4/5 strength on R, verbal aphasia Pertinent Results: Admission Labs: [2145-10-29] 10:26PM PTT-147.4* [2145-10-29] 04:53PM GLUCOSE-191* UREA N-10 CREAT-0.6 SODIUM-141 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-18* ANION GAP-21* [2145-10-29] 04:53PM estGFR-Using this [2145-10-29] 04:53PM CALCIUM-9.1 PHOSPHATE-2.6# MAGNESIUM-1.7 [2145-10-29] 04:53PM HCG-<5 [2145-10-29] 04:53PM WBC-7.9 RBC-4.69 HGB-11.9 HCT-36.2 MCV-77* MCH-25.3* MCHC-32.8 RDW-16.2* [2145-10-29] 04:53PM PLT COUNT-322 [2145-10-29] 04:53PM PT-13.9* PTT-85.0* INR(PT)-1.2* [2145-10-29] 11:03AM GLUCOSE-245* NA+-143 K+-3.9 CL--109* TCO2-18* [2145-10-29] 10:45AM UREA N-10 [2145-10-29] 10:45AM CK-MB-7 cTropnT-0.39* proBNP-516* [2145-10-29] 10:45AM WBC-8.1 RBC-4.82 HGB-11.7* HCT-36.9 MCV-77* MCH-24.4* MCHC-31.8 RDW-15.5 [2145-10-29] 10:45AM NEUTS-81.4* LYMPHS-16.8* MONOS-0.9* EOS-0.6 BASOS-0.2 [2145-10-29] 10:45AM PLT COUNT-338 [2145-10-29] 10:45AM PT-13.6* PTT-32.4 INR(PT)-1.2* . Micro: u/a osh: blood 1+, LE 3+, nitrites +, wbc [11-25], epithelial H, bacterial 3+ . EKG: sinus tach 121 NA partial RBBB TWI inf ant/lat no STEMI c/w R heart strain . Imaging: [10-29] OSH CTA chest: massive pulmonary emboli. This includes large saddle embolus, a portion which is folded in the left pulm artery and a portion of which extends into and occlude the descending R pulmonary artery. Multiple segmental pulmonary emboli are seen in the R upper lobe and subsegmental pulmonary emboli are seen through the left lung, especially at the base. Evidence of R ventricular straing with dilatation of the ventricle and bowing of the septum. Fatty infiltration of the liver. . [10-29] CT head: no intracranial bleed . [10-29] LENIs: 1. + non-occlusive DVT of right superficial femoral vein with reconstitution at the level of the popliteal vein 2. no DVT in left lower extremity . TTE [2145-10-29]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. There is "sparing" of the RV apex from systolic dysfunction because of tethering to the LV, consistent with acute pulmonary hypertension ("[Last Name (un) 13367] sign"). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated right ventricle with severe systolic dysfunction, most c/w acute pulmonary hypertension. Preserved left ventricular systolic function. Compared with the prior study (images reviewed) of [2145-7-6], RV dilation and systolic dysfunction are new. Findings relayed to the ordering team by phone at [Pager number ] hours on the day of the study. . Discharge Labs: . [Hospital1 18] Microbiology: [2145-10-30] Urine culture: > 100,000 E. coli Brief Hospital Course: 33F with hx of NHL (at 3yo) s/p XRT in remission, radiation induced Meningioma s/p resection [6-16] c/b L pontine stroke who presents from OSH with complaints of CP and SOB, found to have saddle PE and RLE DVT. . # Saddle PE: The pt presented with SOB and CP at outside hospital and found to have saddle embolus. She was transfered to the [Hospital1 18] ICU for further management. She had a new 2-3L O2 requirement, sinus tachycardia to the 110s-120s, and dilated right ventricle with severe systolic dysfunction. However her SBPs are stable in the 90s-100s and the pt is relatively comfortable. Given her hemodynamic stability and her recent brain surgery, she did not meet criteria for lytic therapy. However, given her severe RV strain and RLE DVT, an IVC filter was placed on [2145-10-29]. She was transferred to the general medicine floor on [2145-10-30] after resolution of her oxygen requirement, though had mild persisting tachycardia related to her RV failure. She began lovenox bridge to warfarin at 5mg daily on [2145-10-29]. Her INR was 1.5 on discharge, and she was scheduled to have biweekly INR checks to be drawn by a visiting nurse and was referred to the [Hospital3 ] at [Hospital1 18] [Company 191]. Heme/Onc felt that this Pt's blood clots count as a provoked event given her immobilization due to her stroke. Recommended at least 6-12 months of anticoagulation, consideration of ongoing anti-coagulation. Decision to be made in outpatient setting when to remove filter. # RLE DVT: Pt with RLE DVT likely [3-10] hemiparesis and immobility. IVC filter placed as above. DVT treated w/ anticoagulation (see above). Heme/Onc consult felt that IVC filter should ideally be removed after several months of anticoagulation if Pt does not have any further symptoms to minimize long-term consequences of retained IVC filter (further clot formation behind the filter). # URINARY TRACT INFECTION: She had plentiful leuks and bacteria on UA. Given her previous somnolence, she began a 3 day course of cipro 250mg [Hospital1 ] on [10-30] and had good response. # Meningioma s/p resection c/b stroke: Patient has significant deficit subsequent to surgery, however improvement of strength and independence with rehab. Her neurological exam was stable when compared with previous documentation in OMR. The patient's home aspirin was continued through the admission. Physical therapy as well as speech therapy also came to work with the patient. She was discharged with home physical therapy and speech therapy. Pt will continue to be followed in [Hospital ] clinic. . # s/p Non-Hodgkin's Lymphoma (at 3yo): Deemed to be in remission by inpatient Oncology consult. No further imaging necessary. . # Bladder dysfunction: Patient was admitted on oxybutynin. She complained of urinary retention on presentation to the medicine floor. Her oxybutynin was discontinued in light of recent urinary tract infection out of concern that the patient's urinary retention may have contributed. Pt's oxybutynin was restarted after she completed her course of ciprofloxacin for UTI due to incontinence. She was referred to [Hospital 30818] clinic. . # chronic hypokalemia: thought to be due to several month course of steroids for her meningioma and post-op causing adrenal suppression. Pt was discharged on her home dose of potassium 40mEq po bid. . # TRANSITION OF CARE: - Patient will need regular follow-up of INR in the setting of starting warfarin therapy to insure that the patient's INR is therapeutic between 2 and 3. She has been provided w/ visiting nurse to check biweekly INRs and was referred to [Hospital 191] [Hospital 2786] clinic. - Pt will follow-up in [Hospital ] clinic for her meningioma - Pt will follow-up in [Hospital 30818] clinic for her incontinence Medications on Admission: levetiracetam 500 mg Tablet [Hospital1 ] oxybutynin chloride 5 mg Tablet daily potassium chloride 40 mEq [Hospital1 ] aspirin 81 mg Tablet, 1 Tablet daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. 4. Outpatient Lab Work Please check INR on Tuesdays and Fridays starting [2145-11-5]. Please send results to [Hospital 18] [Hospital6 733] [Hospital3 271] (their phone number is [Telephone/Fax (1) 2173]). Please fax results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 30819]. Please check a blood potassium on [11-9] and fax to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 30819]. 5. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day. Disp:10 Refills:2 6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO BID (2 times a day). 8. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [2-7] puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 Refills:2 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 10. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. Disp:30 Capsule, Extended Release(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary diagnosis: Pulmonary embolism Secondary diagnosis: Urge incontinence of bladder Meningioma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 174], It was a pleasure taking care of you during your hospitalization at [Hospital1 69]. You were hospitalized with a large blood clot in the vessels leading to your lungs (known as a pulmonary embolism). Initially, you were in the intensive care unit. You were transferred to the medicine floor once you were stable. You were started on anticoagulation therapy for treatment of your pulmonary embolism. You are currently on Lovenox (an anti-coagulation medication that is injection) while we wait for the warfarin (an oral anti-coagulation medication) to reach therapetuic levels. You INR will need to be monitored by your doctor while you are on warfarin therapy. You warfarin doses may need to be adjusted based on your INR. You will be on warfarin therapy for at least 6 months and likely longer. Please take all medications as prescribed. Please note the following medication changes: NEW: -lovenox 80mg subcutaneous injection twice a day - warfarin 5mg tablets, 1 tab by mouth every afternoon - xopenex inhaler, use [2-7] puff every 4-6 hours for wheeziness -ferrous sulphate extended release tablet 325mg daily There are no other changes to their medications. Please keep all follow-up appointments. Please make a follow-up appointment with your primary care doctor for within 2 weeks from discharge from the hospital. Followup Instructions: Department: [Hospital 30820] Clinic number: [Telephone/Fax (1) 30821] Department: NEUROLOGY When: THURSDAY [2145-11-11] at 10:00 AM With: [Doctor Last Name 640] [Doctor First Name 747] [Name8 (MD) ], M.D. [Telephone/Fax (1) 1844] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: TUESDAY [2145-11-30] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990], [First Name3 (LF) ] [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990] DO 12-BJM Completed by:[2145-11-4*]	[ "786.59", "276.8", "V10.79", "V12.41", "415.19", "599.0", "453.41", "438.20", "788.31", "438.11" ]	icd9cm	[ [ [] ] ]	[ "38.7" ]	icd9pcs	[ [ [] ] ]	12871, 12942	7357, 11201	314, 329	13086, 13086	4100, 4100	14664, 15617	3494, 3504		11415, 12848		12963, 12963		11227, 11392			13269, 14176		7247, 7334							3519, 4081																					1745, 2193		14196, 14641	265, 276											357, 1726			5790, 7231		13023, 13065		4116, 5781	12982, 13002			13101, 13245						2215, 3283	3299, 3478
19,059	114,583	48187	Discharge summary	report	Admission Date: [2126-12-17] Discharge Date: [2126-12-27] Date of Birth: [2065-11-22] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / apple / bees Attending:[First Name3 (LF) 594] Chief Complaint: shortness of breath, altered mental status Major Surgical or Invasive Procedure: Tracheostomy Central Venous line Endotracheal intubation Arterial Line History of Present Illness: 60yo woman w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF, CKD who presents from rehab facility with several days of fatigue and altered mental status. Over the past several months she has undergone prolonged course with several hospitalizations including a recent admission from [Date range (1) 49798] for shortness of breath thought intially to be pneumonia but eventually atrributed to COPD exacerbation as opposed to infection. Family states she has never returned to baseline at rehab complaining of increasing fatigue, continued shortness of breath, and now altered mental status which was noted to be primarily increasing somnolence. She otherwise has denied any fever, chills, headache, cough, chest pain, abdominal pain, nausea or vomiting. Of note she is supposed to be using bipap for severe OSA but has poor compliance due to intolerance of the bipap. . In the ED, initial VS were: 97.7 92 97/72 28 95% neb. Physical exam notable for tachypnea. She was given IV methylprednisone 125 mg, vancomycin, cefepime, azithromycin and nebs for COPD exacerbation. 500 cc NS was given for tachycardia and low blood pressure. . On arrival to the MICU, she was noted to be somewhat somnolent but opened eyes to voice and followed basic commands. Her respiratory effort was shallow with low tidal volumes and generally low minute ventilation (range 4 to 6L/min) given her severe hypercarbia. She subsequently was intubated. . Review of systems: Unable to complete review due to patient being sedated and intubated. Past Medical History: 1. Morbid obesity (s/p gastric bypass) 2. Obstructive sleep apnea (noctural BiPAP 18/15, home oxygen requirement of 3-4L via nasal cannula) 3. Obesity hypoventilation syndrome 4. Severe pulmonary artery hypertension (attributed to OSA) 5. Cor pulmonale (right heart failure attributed to severe pulmonary hypertension) 6. Asthma 7. Osteoarthritis (bilateral knee involvement) 8. Diastolic heart failure (2D-Echo [1-/2124] showing LVEF 70-80%, PAP 64 mmHg) 9. Chronic kidney disease (stage III-IV, baseline creatinine 1.8-2.2) 10. Rosacea 11. Hypertension 12. Iron deficiency anemia 11. s/p ventral hernia repair with mesh and component separation ([5-/2119]) 12. s/p gastric bypass surgery ([2113]) 13. s/p debridement of anterior abdominal wall and complex repair ([6-/2119]) Social History: Patient lives at home with disability services. She has 2 adult children. She notes no toabcco use, rare alcohol use currently but notes a former heavy alcohol history in the distant past. She denies recreational substance use. Family History: Notable for diabetes mellitus in her mother and sister, hypertension in siblings, mother and throughout the maternal family as well as kidney disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: P 100 BP 111/59 R 24 89% Bipap FiO2 60% General: Alert but somnolent, follows commands HEENT: MMM, oropharynx clear, EOMI, PERRL CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops although heart sounds were muffled Lungs: Dimished bilaterally w/ wheezing throughout all fields Abdomen: Obese, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses throughout extremities, trace edema Neuro: Grossly intact Pertinent Results: ADMISSION LABS: [2126-12-17] 10:10PM BLOOD WBC-9.8 RBC-3.33* Hgb-9.3* Hct-32.4* MCV-97 MCH-27.8 MCHC-28.6* RDW-16.7* Plt Ct-202 [2126-12-17] 10:10PM BLOOD Neuts-88.8* Lymphs-7.3* Monos-1.9* Eos-1.6 Baso-0.4 [2126-12-18] 04:55AM BLOOD PT-11.1 PTT-39.0* INR(PT)-1.0 [2126-12-17] 10:10PM BLOOD Glucose-102* UreaN-69* Creat-2.6* Na-141 K-4.5 Cl-86* HCO3-46* AnGap-14 [2126-12-18] 04:55AM BLOOD ALT-20 AST-27 LD(LDH)-389* CK(CPK)-36 AlkPhos-66 TotBili-0.4 [2126-12-17] 10:10PM BLOOD proBNP-4737* [2126-12-17] 10:10PM BLOOD cTropnT-0.03* [2126-12-18] 04:55AM BLOOD CK-MB-3 cTropnT-0.02* [2126-12-18] 04:55AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.6* Mg-2.0 [2126-12-17] 11:07PM BLOOD pO2-119* pCO2-131* pH-7.20* calTCO2-54* Base XS-17 [2126-12-18] 01:03AM BLOOD Type-ART Temp-37.6 PEEP-8 FiO2-40 pO2-54* pCO2-140* pH-7.17* calTCO2-54* Base XS-15 [2126-12-18] 01:03AM BLOOD freeCa-1.15 [2126-12-17] 10:10PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.010 [2126-12-17] 10:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2126-12-18] 03:49PM URINE Hours-RANDOM UreaN-346 Creat-81 Na-35 K-53 Cl-37 [2126-12-19] 11:24AM URINE Hours-RANDOM UreaN-232 Creat-230 Na-LESS THAN K-50 Cl-LESS THAN . MICRO: [12-17] BLOOD CULTURE NO GROWTH TO DATE [12-17] URINE CULTURE NEGATIVE [12-19] BAL CULTURE PENDING [12-19] RESPIRATORY VIRAL CULTURE PENDING [12-19] URINE CULTURE PENDING Brief Hospital Course: Ms. [Known lastname ] is a 60 year old woman with history of chronic obstructive pulmonary disorder (COPD), pulmonary artery hypertension (PAH) with cor pulmonale, (chronic kidney disease (CKD) who presented from rehab facility with several days of fatigue and shortness of breath. # Hypercarbic respiratory failure: Required intubation in the ED prior to transfer to the MICU. Likely a COPD exacerbation (with pCO2 140 on admission) and recent non-compliance of her BiPAP at rehab (although previously very compliant even during the day). Also, she has obstructive sleep apnea which contributes to her PAH and cor pulmonale. Lastly, a superimposed pneumonia was considered [1-30] a small amount of opacity on initial CXR and one fever. She was started on vancomycin/cefepime/levofloxacin initially for empiric coverage of PNA, but suspicion was low (she never had a WBC count or recurrence of fever) and vanc/cefepime were stopped after a few days and she was continued only on levofloxacin for 7 days for abx coverage in the setting of a COPD exacerbation. She did have a bronch after a few days on the ventilator which demonstrated severe airway edema and almost complete airway collapse on exhalation. While the most likely etiology of her airway edema and collapse was from pulmonary edema and pulmonary parenchymal volume overload, given she had signs of decreased left-sided cardiac output, aggressive diuresis was not pursued. She was treated with systemic and inhaled corticosteroids to address a possible component of inflammation contributing to her airway edema, as well a scheduled nebulizers for bronchodilation. Due to persistent hypercarbic respiratory failure the patient underwent a tracheostomy for long term assisted ventilation and CPAP. Patient tolerated the procedure well. Her cultures remained negative. Prior to discharge her vent settings were weaned to pressure support 10, PEEP 5, FiO2 40% which she was tolerating well. # Abdominal pain. Patient started complaining of diffuse, crampy abdominal pain several days prior to discharge. In reviewing recent OMR notes, she has been extensively evaluated by her PCP and GI over the month prior to admission for the same pain. KUB showed diffuse gas distension throughout her bowels but no clear obstructive process. Her tube feeds continued to be well tolerated despite her pain, with minimal nausea and no vomiting, and she continued to have multiple daily stools; all of which decrease the liklihood of bowel obstruction. We restarted her on Donnatal, a home medication that we were holding that GI had suggested prior to admission to treat her symptoms. She was being discharged on the day of restarting this medication so efficacy of intervention will need to be assessed by ECF. She was also started on simethicone and given zofran prn for mild nausea that she experienced several times during her hospital course. # Acute kidney injury ([Last Name (un) ]): Baseline creatinine 1.8, elevated to 2.6 on admission. Fe Urea 15%, Fena 0.9%, both suggest prerenal in etiology. She was also oliguric. Renal was consulted and agreed with suspicion for pre-renal etiology. Her urine output improved significantly after fluids and her BUN and Cr had normalized at the time of discharge without further intervention. # Cor pulmonale/right sided heart failure: TTE in [2123] showed estimated right atrial pressure of [10-17] mmHg; LV systolic function was hyperdynamic (EF 70-80%), and the RV free wall was hypertrophied with marked dilation and with depressed free wall contractility consistent with severe right-sided dysfunction with cor pulmonale resulting from severe pulmonary HTN and OSA. She was intitially diuresed in the MICU, but then was given back volume for oliguria and [Last Name (un) ] as discussed above. # Pumonary artery hypertension: Likely type 3 due to combination of chronic hypoxemia from obstructive sleep apnea and COPD. Discontinued sildenafil without any significant changes. # Obstructive sleep apnea: Now with tracheostomy. #Gout: initially lowered dose of allopurinol to 100mg po every other day due to [Last Name (un) ], but once renal function normalized she was placed back on her home dose of allopurinol 300mg daily with incident. # Iron deficiency anemia: Continued iron supplementation when taking PO. Pt is being discharged to vent rehab. Transitional issues: 1. Abdominal pain. Evaluated by PCP and GI for similar pain prior to admission during [2126-11-28]. We will email her gastroenterologist with whom she should followup if her pain persists. 2. Physical therapy. She refused to work with PT on several occasions during her ICU stay. We expressed the importance of PT with both the patient and her family. 3. Acute kidney injury. Her creatinine trended upward on admission, but then stablized and decreased to baseline levels on discharge. Renal was consulted while inpatient and was in agreement with the MICU team that etiology was likely pre-renal. 4. Family and patient education. Ms. [Known lastname ] multiple, severe cardiopulmonary comorbidities do not imply a seemless transition from the ICU to rehab to home. She will likely suffer multiple complications and set-backs along the way given her baseline poor cardiopulmonary function. We endeavored to educate the family about these realities as well as educate them about her relatively limited anticipated life expectancy now that she is (apparently) chronically vent-dependent and now (likely) chronically critically ill. Her sister [Name (NI) 4944] seemed to understand this, while other family members (particularly the patient's mother and daughter) did not seem to comprehend the severity of Ms. [Known lastname ] circumstances and the high likelihood of future adverse outcomes, morbidity, and - potentially - mortality. Further frank discussions with the family and the patient will be necessary to ensure that all parties are aware of the possibilities associated with Ms. [Known lastname ] clinical circumstances. Medications on Admission: - sildenafil 20mg TID - aspirin 81mg daily - prednisone 10mg daily (until - fluticasone 110mcg inhaled [Hospital1 ] - home oxygen 3-4 L/min N/C - albuterol 90mcg HFA Q6hrs prn wheezing/SOB - albuterol 2.5mg nebulized Q4hrs prn SOB - allopurinol 300mg daily - metolazone 5mg [Hospital1 ] - ISS QID - acetaminophen 500mg Q6hrs prn pain - ferrous sulfate 300mg daily - metronidazole 1% gel topically daily - docusate 100mg [Hospital1 ] - bisacodyl 10mg daily - PEG 17g powder daily - heparin SQ TID Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). Disp:1 Refills:2 2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every six (6) hours. Disp:1 Refills:2 3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 Refills:2 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 5. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 6. metolazone 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 7. omeprazole 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:0 8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 9. Insulin Please administer insulin as according to attached slinding scale worksheet. 10. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:15 Tablet(s) Refills:0 11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 12. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five (5) ml PO DAILY (Daily). 14. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Hypercarbic respiratory failure Acute Kidney Injury Cor pulmonale 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: Ms. [Known lastname ], We appreciated the opportunity to partipate in your care at [Hospital1 18]. As you transition to your extended care facility we wanted to highlight several ongoing issues with your care: 1. Physical therapy: please work each day with the physical therapy team. This will increase your strength and improve your lung function. 2. Abdominal pain: your pain is similar to the chronic pain you experienced prior to admission. We will contact your GI doctor to discuss your hospitalization, but you should also schedule a followup appointment with your GI doctor within the next several weeks to further evaluate and manage your chronic abdominal pain. 3. Obstructive sleep apnea: while you are on the vent you will receive respiratory support while you are both awake and asleep. When you are weaned from the vent you will need to continue using your bipap machine while you are asleep. This is very important as sleep apnea contributes to worsening of your pulmonary function and heart failure. 4. Rehab course: we believe you are now ready to continue rehabilitation from your illness at an extended care facility. Please keep in mind that you were very sick while in the hospital, and recovery may be prolonged despite not needing to remain in the hospital at this time. To help guide what types of things should prompt calling your primary care physician or returning to the hospital, please refer to the information listed below. You should call your primary care physician or return to the ED if you experience: persistent high fever, increasing oxygen requirements, severe nausea/vomiting, bloody diarrhea, decreased urine output, bloody urine, confusion, loss of consciousness, slurred speech, chest pain, or any other concerns. Followup Instructions: 1. Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 3029] at the following appointment that has been scheduled for you: Provider: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Date/Time: [2127-1-14] 10:20 2. Please follow up with the acute care surgery clinic in 2 weeks. Your appointment is [2127-1-9] at 2pm in the [Hospital Ward Name ] Office building at [Hospital1 18]. You can call [Telephone/Fax (1) 600] for any questions. Completed by:[2126-12-27**]	[ "403.90", "715.36", "560.1", "695.3", "585.4", "493.22", "V45.86", "V58.65", "584.9", "V15.81", "327.23", "276.0", "518.81", "278.03", "280.9", "428.32", "416.8", "428.0", "V85.43" ]	icd9cm	[ [ [] ] ]	[ "96.72", "33.24", "38.97", "31.1", "96.04", "38.91", "96.6" ]	icd9pcs	[ [ [] ] ]	13584, 13650	5285, 9674	356, 429	13760, 13760	3743, 3743	15733, 16335	3065, 3217		11909, 13561		13671, 13739		11376, 11886			13936, 14159									3257, 3724	14177, 15710																		9695, 11350		1913, 1985			273, 318											457, 1894							3759, 5262				13775, 13912						2007, 2803	2819, 3049
9,710	162,169	47752	Discharge summary	report	Admission Date: [2168-9-21] Discharge Date: [2168-9-29] Date of Birth: [2105-10-26] Sex: F Service: MEDICINE Allergies: Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin / Clindamycin / Dilaudid / Iodine Attending:[First Name3 (LF) 1881] Chief Complaint: ? seizure Major Surgical or Invasive Procedure: NG lavage History of Present Illness: History of Present Illness: Ms. [Known firstname ] [Known lastname 100774] is a 62 year old woman with multiple medical problems including MS, DM2, CAD s/p RCA stent [2165], PVD s/p R BKA, CVA, and seizure disorder who presents from clinic with episode of tremor and decreased alertness which she reports is consistent with prior seizure activity. . In the ED, initial vs were: T 97.8 P 120 BP 131/47 R 18 O2 sat 100% RA. She was found to have a hematocrit of 21 (down from baseline of 30). She admits to feeling dizzy and shaky over the last two to three days. She denies recent use of alcohol, NSAIDs, steroids, antibiotics. She denies recent nausea, vomiting, diarrhea. She uses the bathroom with the help of home aides and is uncertain if she has been having black tarry stools at home. She denies history of GI bleeding but later states she has chronic colitis that is managed with acidophilis supplements. Patient was given 1 u pRBC and 2 u FFP prior to transfer to ICU. Neurology was consulted on presentation to the ED and recommended use of valium IV in lieu of tegretol while npo. . While in the ICU, pt was given another 2 units of PRBCs, 2mg of vit K for INR of 3 (on coumadin), and was started on protonix drip. Her Hct increased to 26. She had no active bleeding, and is hemodynamically stable. GI has evaluated the pt and the plan is for her to have both upper and lower GI studies under anesthesia given her body habitus and comorbidities. For now holding plavix and coumadin given possible bleed. Neuro is following pt for seizures, she had no other seizure activity since admission. She is currently on valium since she was [Month (only) 116] be able to restart tegretol once PO. . On arrival to the floor, pt appears comfortable and denies any specific complaints. . Review of sytems: (+) Per HPI, + decreased visual acuity, + dizziness x 3 days (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: CAD [12-18] s/p 2 stents placed RCA, mild ICM. Echo [6-20] with EF >55% History of recurrent DVTs --first DVT in [2148], given coumadin for 6 months --second DVT in [2162], given coumadin then plavix --third DVT in [2164-4-11], now on coumadin and plavix MS diagnosed in [2150], wheelchair bound since [2151] s/p CVA in [2152], h/o TIAs on plavix [Hospital1 ] PAD on recent angiogram [7-20]-significant left SFA, [Doctor Last Name ] and anterior tibial disease, not amendable to stenting-->complicated by LLE ulcer, nonhealing Left BKA [2167-9-28] for non-healing ulcer h/o spinal cord compression s/p C3-7 and T2-11 laminectomies and fusion, with residual paraparesis and absent sensation in bilateral LE. No sensation below T10 Seizure disorder, with staring spells due to MS, had status recently [7-20] T2DM on insulin, most recent HgA1c: 8.1% in [2165] Hypertension Hypercholesterolemia Sarcoidosis Anemia Uterine/cervix cancer s/p radical hysterectomy Asthma/COPD Cardiac arrest after delivery (C-sect) of her 1st child OSA no BiPAP/CPAP use Social History: She lives with her 26 year old daughter [Name (NI) 3235] who is very involved in her care. She is wheelchair bound and has three different home aides help her with her ADLs. She is a former alcoholic, sober since [94] y/o when pregnant, 70 pack-year tobacco quit at 36yo; no hx of drug use; retired RN at [Hospital1 756]. She is single. Family History: Multiple relatives with DM, CAD, HTN, asthma, and cancers (at least two with brain cancers). Mother died age 50 brain cancer had DMII and "mild MIs", father died age 48 MI and had DMII. No FH of MS, or DVT/PE. Brother deceased 53yo had 3 bypass surgery. Physical Exam: Physical Exam on discharge: Vitals: T:99.3 BP: 150/80, HR: 88, RR: 20, 96% on RA General: Alert, oriented, no acute distress HEENT: Legally blind, Sclera anicteric, MMM, oropharynx clear, hirsutism, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley catheter-> clear light yellow urine Ext: L BKA, RLE warm with no tenderness to palpation, 1+ PD Pertinent Results: Imaging: 1. Right LE ultrasound: No evidence of DVT in the right lower extremity. 2. CXR: No acute cardiopulmonary process; borderline enlarged heart and left costophrenic atelectasis. Lab results: 1. On admission: - WBC-8.4 RBC-2.68# Hgb-6.1# Hct-21.2# MCV-79 MCH-22.8# MCHC-28.7# RDW-16.8* Plt Ct-554# - PT-30.8 PTT-30.3 INR(PT)-3.1* - Glucose-176* UreaN-30* Creat-1.1 Na-138 K-4.7 Cl-99 HCO3-28 AnGap-16 2. On discharge: - WBC-7.4 RBC-3.22* Hgb-8.3* Hct-26.5* MCV-83 MCH-25.6* MCHC-31.1 RDW-17.8* Plt Ct-322 - PT-19.8* PTT-138.0* INR(PT)-1.8* - Glucose-204* UreaN-18 Creat-1.0 Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 Brief Hospital Course: 62 yo F with MS, DM2, CAD s/p RCA stent, PVD s/p R BKA, history of CVA and DVTs, presents with ? seizure activity found to have 9 point Hct drop with guaiac positive stools, refused EGD/colonoscopy, received 3 units pRBC with appropriate response, who was hemodynamically stable for the remained of the hospitalization. . # GI bleed: On admission, patient was found to have Hct of 21, down from baseline of 30, and guaiac positive stool. Admitted to ICU where she received 3 units of pRBC, bringing Hct to 26. INR was found to be supratherapeutic at 3 and was reversed with Vit K, bringing it down to 1.3. GI consulted but patient refused EGD and colonoscopy. Transferred to the floor and remained HD stable. . # Epistaxis: Patient developed an unprovoked nosebleed, which stopped after 1.5 hours of pressure. INR was 1.4 at the time and on heparin drip, which was temporarily held. ENT was consulted but didn't get cauderization. Treated with nasal spray and Oxymetazoline. There was no resulting drop in her Hct. . # History of DVT/CVA: Patient complained of right leg pain on admission and LENI ruled out DVT. Given her history of CVA/DVT, decision was made to restart her home anticoagulation regimen including coumadin and plavix. Her INR slowly rose and at the time of discharge it was therapeutic at 2.0. . # Seizures: On admission, patient complained of dizziness and visual changes, consistent with prior seizures, normally evoked by stress. Neurology consulted but did not find signs of active seizure. Kept on home dose of tegretol. . # Hypertension: Anti-hypertensive medications were initially held in the context of her GI bleed with resulting blood pressure 160-180/80-100. Antihypertensives were restarted once she became HD stable. . # CAD: No active signs of ACS despite the low Hct on admission. EKG without ischemic changes. Once HD stable she was restart on home plavix dose and also imdur for angina. . # DM2: Patient was kept on home regimen of NPH and regular insulin, with resulting blood sugar ranging from 160 - 250. Medications on Admission: 1. ALBUTEROL SULFATE - (Prescribed by Other Provider) - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 (One) inhaled every four (4) hours as needed 2. ATORVASTATIN [LIPITOR] - 80 mg QD 3. BACLOFEN - 10 mg Tablet [Hospital1 ] 4. CARBAMAZEPINE - 200 mg Tablet QID 5. CLOPIDOGREL [PLAVIX] - 75 mg Tablet [Hospital1 ] 6. DIAZEPAM - 5 mg Tablet QD PRN 7. FLUTICASONE - 110 mcg/Actuation Aerosol - 2 puffs(s) orally [Hospital1 ] 8. FUROSEMIDE - 40 mg Tablet QD 9. HYDROCODONE-HOMATROPINE - 5 mg-1.5 mg/5 mL Syrup - 1 tsp up to QID PRN cough 10. ISOSORBIDE MONONITRATE [IMDUR] SR - 90 mg qd 11. LISINOPRIL - 5 mg Tablet - 1 Tablet(s) QD 12. METOPROLOL TARTRATE - 75 mg [Hospital1 ] 13. MIRTAZAPINE - 7.5 mg Tablet - 1 QHS 14. NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually Q5 minutes x 3 as needed for chest pain 15. TRAMADOL - 50 mg Tablet QID 16. WARFARIN [COUMADIN] - 5 mg Tablet QD 17. ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth every eight (8) hours 18. ASCORBIC ACID SR - 1,500 mg Tablet QD 19. CHOLECALCIFEROL (VITAMIN D3) 400 unit Capsule - 2 Capsule(s) QD 20. DOCUSATE SODIUM - 100 mg [Hospital1 ] 21. FAMOTIDINE - 10 mg Tablet - [Hospital1 ] 22. INSULIN REGULAR HUMAN [HUMULIN R] - (Not Taking as Prescribed: not listed on nsg home med records) - 100 unit/mL Solution - 15 units qam and 10 units qpm 23. INSULIN REGULAR HUMAN [NOVOLIN R] - (Prescribed by Other Provider) - 100 unit/mL Solution - 10-12 units as needed 10 u BS 351-400; 12 u BS 401-450 24. LACTOBACILLUS ACIDOPHILUS Dosage uncertain 25. NPH INSULIN HUMAN RECOMB [NOVOLIN N] - (Prescribed by Other Provider) (Not Taking as Prescribed: per nsg home records, also takes 85 units each morning) - 100 unit/mL Suspension - 25 units q pm 26. ZINC SULFATE 220 mg Tablet QD Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 10. Warfarin 2.5 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhelation Inhalation every four (4) hours as needed for wheezing. 12. Diazepam 5 mg Tablet Sig: One (1) Tablet PO once a day as needed. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. Hydrocodone-Homatropine 5-1.5 mg/5 mL Syrup Sig: One (1) tsp PO four times a day as needed for cough. 15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual q5 minutes x 3 as needed for chest pain. 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a day. 17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 18. Ascorbic Acid 1,500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 19. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 21. Famotidine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 22. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule PO once a day. 23. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day. 24. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: Eighty Five (85) units Subcutaneous qAM. 25. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: Twenty (20) units Subcutaneous qPM. 26. Insulin Regular Human 100 unit/mL Solution Sig: see below Injection once a day: 10 units for blood sugar 351-400. 12 units for blood sugar 401-450. . Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Gastrointestinal bleed . Secondary: Seizure disorder Multiple sclerosis Peripheral vascular disease Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname 100774], you were admitted to the [Hospital3 ] Medical Center because you had some symptoms suggestive of seizures while you were at the ophthalmologist's office. When you arrived at the hospital, we did some blood tests and found that your red blood cell count was very low and there was evidence of blood in your stool. We were very concerned that you might be actively bleeding so you were briefly admitted to the intensive care unit where you received a total of 3 units of red blood cells. We also gave you vitamin K because your INR was elevated which made you more likely to bleed. You were then transferred to the regular medical floor. You did not want an endoscopy or colonoscopy to look for the source of bleeding. After extensive discussion, we restarted you on your home anticoagulation medications. We asked the neurologists to see you to make sure you were not having seizures. They did not think you were. You were kept on your home medications for seizure prophylaxis. You had a nosebleed and we asked the ear, nose, and throat doctors to [Name5 (PTitle) 788] [Name5 (PTitle) ]. They did not feel that you needed cauterization. We also put you back on your hypertension medications. You also had an eye exam by one of the ophthalmologists here prior to discharge. . We did not make any changes to your medications. Followup Instructions: Department: [Hospital3 249] (Primary care doctor) When: TUESDAY [2168-10-4] at 12:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ], [First Name7 (NamePattern1) 10827] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (Ear Nose and Throat) Location: [Doctor Last Name ] & [Doctor Last Name 3880] LLC Address: [Location (un) 3881], [Apartment Address(1) 3882], [Location (un) ],[Numeric Identifier 3883] Phone: [Telephone/Fax (1) 2349] Appointment: Monday [2168-10-10] 8:45am Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2168-10-11] at 1:30 PM With: [Name6 (MD) 21154] [Last Name (NamePattern4) 21155], 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 Name: [Last Name (LF) ], [First Name3 (LF) ] S. MD (Cardiology) Location: [Hospital1 18] - CARDIAC SERVICES Address: [Location (un) ], [Hospital Ward Name ] 7, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 62] Appt: We are working on appt for you within the next two weeks with this doctor. The office will call you at home wiht an appt. If you dont hear from them by tomorrow, please call office at the above number. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883] Completed by:[2168-9-29]	[ "340", "707.22", "578.1", "366.8", "493.20", "285.1", "V45.4", "250.50", "V13.02", "V15.82", "790.92", "784.7", "V10.42", "414.01", "362.01", "V12.53", "V45.82", "272.0", "V88.01", "280.9", "401.9", "V11.3", "369.00", "V46.3", "327.23", "707.05", "V58.61", "345.90", "250.60", "278.01", "782.0", "357.2", "135", "V12.04", "V12.51", "V58.67", "V49.75" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11867, 11924	5668, 7714	362, 374	12101, 12101	5016, 5218	13677, 15413	4158, 4414		9566, 11844		11945, 12080		7740, 9543			12284, 13654									4429, 4429																4457, 4997		5450, 5645						313, 324						2222, 2650					430, 2204										5232, 5436	12116, 12260						2672, 3776	3792, 4142
77,772	172,268	40423	Discharge summary	report	Admission Date: [2161-5-18] Discharge Date: [2161-5-23] Date of Birth: [2094-12-22] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4327] Chief Complaint: RCA [First Name3 (LF) ], bradycardia, AMS Major Surgical or Invasive Procedure: None History of Present Illness: 66 y.o woman with past medical history significant only for hypertension who was transferred from [Hospital3 ] hospital for management of her RV [Hospital3 ]. In brief, the patient initially began feeling unwell on [5-11] with symptoms, of nausea, vomiting and subsequently increasing lethargy. She first presented to [Hospital3 ] hospital on [5-13], when she was found to have ST segment elevations on her EKG and was found to have an inferior MI. . The patient was taken to the cath lab where a complete occlusion of her RCA was found, and 4 bare metal stents were placed with restoration of TIMI 3 flow. Her initial echocardiogram demonstrated RV free wall hypokinesis but preserved LV ejection fraction. Right heart cath at that time demonstrated slightly elevated right atrial pressures. . While initially stable, she subsequently declined hemodynamically and was managed with fluid resuscitation and lasix in an intermittent fashion. She was found to have a [Month/Year (2) ], and a GI workup including RUQ ultrasound, HIDA and CT abdomen was negative. Repeat echocardiogram demonstrated severe hypokinesis of the RV with enlargement with severe tricuspid insufficinecy; her [Month/Year (2) ] was subsequently thought be secondary to congestive hepatopathy. . On the day of transfer on [2161-5-18], the patient suffered an R-on-T phenomenon that caused ventricular fibrillation. K was 3.1 and Mg was 1.7 at the time, which were repleted. She was defibrillated to SVT with 1 to 1 conduction, and later 2 to 1 conduction with a right atrial focus. She then developed episodes of v-tach that responded to lidocaine, in addition to amiodarone that had previously been started. Her rhythm later changed to sinus bradycardia or junctional rhythm, and she was transferred to [Hospital1 18] for further care. Of note, just prior to transfer she was noted by family to be quite incomprehensible with an altered mental status. This was probably a result of lidocaine toxicity. . On arrival, the patient denied any complaints. She denied chest pain, palpitations or shortness of breath. The family observed her to be much more interactive from the time she left [Hospital3 ] hospital, and while bradycardic she was hemodynamically stable. Past Medical History: Hypertension S/p melanoma resection on left arm. Left femur fracture Social History: Helps her husband with his work as an accountant and manages properties from home. Has 4 sons. -[Name2 (NI) 1139] history: 25 years, quit [2129] -ETOH: Occasional glass of wine. -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION: Tmax: 36.5 ??????C (97.7 ??????F), HR: 41, BP: 135/59(76) , RR: 11, SpO2: 95% General: No acute distress, alert and oriented x 2 HEENT: Pupils dilated 6mm, reactive. EOMI. Neck: JVP elevated to mandible, prominent V-waves CV: Bradycardic, no murmurs noted. Pulm: Bibasilar crackles Abdomen: Soft, non-tender, non-distended with bowel sounds present. Extremities: No edema. . DISCHARGE: Tmax 99.5/98.9 BP:141/60 (SBP:141-151) P: 49 RR20 95 RA I/O 24 hours 120/300 General: Elderly female laying flat appering comfortable in NAD Neck: JVP 1cm above clavicle with patient laying at 10 degrees CV: Regular rate, brady, normal S1 and S2, no murmurs, no s3. Pulm: CTA BL, no wheezes, no rales Abdomen: Soft, non-tender, non-distended bowel sounds normoactive Extremities: warm, no peripheral edema Pertinent Results: ADMISSION LABS: . [2161-5-18] WBC-13.4* RBC-3.99* Hgb-11.9* Hct-36.0 MCV-90 MCH-29.8 MCHC-33.0 RDW-15.5 Plt Ct-323 Glucose-127* UreaN-19 Creat-1.0 Na-135 K-4.8 Cl-97 HCO3-26 AnGap-17 ALT-755* AST-694* AlkPhos-351* Calcium-8.8 Phos-3.6 Mg-2.3 . DISCHARGE LABS: . [2161-5-23] WBC-8.1 RBC-3.78* Hgb-11.9* Hct-35.4* MCV-94 MCH-31.4 MCHC-33.5 RDW-16.0* Plt Ct-353 CK-MB-3 cTropnT-4.10* Glucose-117* UreaN-16 Creat-0.8 Na-138 K-4.0 Cl-101 HCO3-26 AnGap-15 ALT-321* AST-114* LD(LDH)-408* AlkPhos-260* TotBili-0.5 Calcium-9.1 Phos-2.6* Mg-2.1 . EKG: Sinus bradycardia at ~50, mild residual ST elevations in III, aVF . CXR: IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Cardiac silhouette is moderately enlarged. Hazy opacification over the both lower lungs, probably due to dependent pleural effusion and bibasilar atelectasis. Upper lungs are clear. No pneumothorax. . STRESS: INTERPRETATION: This 66 year old woman s/p IMI and s/p PCI to the RCA on [2161-5-13] and VT/VF arrest on [2161-5-18] was referred to the lab for evaluation. The patient exercised for 11 minutes of a modfied [Doctor Last Name 4001] protocol and stopped for fatigue. The estimated peak MET capacity was 4.3 which represents a fair functional capacity for her age. No arm, neck, back or chest discomfort was reported by the patient throuughout the study. There were no significant ST segment changes during exercise or in recovery. The rhythm was sinus with occasional isolated apbs and rare isolated vpbs. Blunted HR and BP response to exercise and recovery on beta blocker therapy that was held today. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Echo report sent separately. . STRESS ECHO: The right ventricular cavity is dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. There is partial flail of a tricuspid valve septal leaflet. Moderate to severe [3+] tricuspid regurgitation is seen. . The patient exercised for 11 minutes 0 seconds according to an modified [Doctor Last Name 4001] treadmill protocol (4.3 METS) reaching a peak heart rate of 85 bpm and a peak blood pressure of 168/78 mmHg. The test was stopped at the patient's request. This level of exercise represents a fair exercise tolerance for age. In response to stress, the ECG showed equivocal/borderline ischemic ST wave changes (see exercise report for details). There was a blunted heart rate response to stress. The blood pressure response to stress was blunted. . Resting images were acquired at a heart rate of 64 bpm and a blood pressure of 168/80 mmHg. These demonstrated regional left ventricular systolic dysfunction with basal inferior aneurysm/dyskinesis and severe hypokinesis of the rest of the inferior free wall. The remaining segments contracted well. There is no pericardial effusion. Doppler demonstrated mild-to-moderate (posteriorly directed) mitral regurgitation with no aortic stenosis, aortic regurgitation or significant resting LVOT gradient. Echo images were acquired within 49 seconds after peak stress at heart rates of 84 - 78 bpm. These demonstrated persistence o0f baseline abnormalities but no definite new wall motion abnormalities. . IMPRESSION: fair functional exercise capacity. borderline ECG changes with 2D echocardiographic evidence of prior inferior myocardial infarct but no definite evidence of residual ischemia. Brief Hospital Course: ASSESSMENT AND PLAN: 66 y.o woman who is transferred from [Location (un) 21541] hospital with a RV [Location (un) ] s/p 4 BMS, bradycardia and RV failure with evidence of congestive hepatopathy. The patient is also s/p v-fib arrest and successful resuscitation. . ACTIVE ISSUES: #RV [Name (NI) ] - Pt had symptoms beginning [5-11], however delayed presentation to the hospital until [5-13], at which point she underwent cardiac catheterization with successful revascularization and placement of BMSx4 in the RCA. Post-cath EKG revealed residual mild ST-segment elevations in the inferior leads. ECHO at outside hospital revealed that her MI had caused significant RV dysfunction and failure, causing dilation and tricuspid regurgitation. Repeat ECHO at [Hospital1 18] confirmed right ventricular cavity dilation with depressed free wall contractility and severe [4+] tricuspid regurgitation. Pt also underwent stress EKG and ECHO to evaluate for residual ischemia. Stress EKG revealed no significant ST segment changes during exercise or in recovery. Stress ECHO showed persistent baseline abnormalities but no new wall motion abnormalities, and was consistent with evidence of prior inferior myocardial infarct but no definite evidence of residual ischemia. She was started on aspirin, plavix, atorvastatin, lisinopril, and metoprolol while inpatient. . #BRADYCARDIA- The patient developed ventricular fibrillation after R on T phenomenon at [Hospital3 ], for which she received defibrillation and was started on lidocaine and amiodarone drips. Her episode of v-fib may have been due to her significant bradycardia which put her at risk for R on T. Upon transfer to [Hospital1 18], she was taken off the lidocaine drip as it was thought to be contributing to her altered mental status. She became more alert and oriented and returned to baseline status within 24 hours. She was continued on the amiodarone drip for 24 hours before discontinuing. Stress test showed blunted HR and BP response to exercise and recovery despite holding beta blocker prior to test (peak heart rate of 85 bpm and a peak blood pressure of 168/78 mmHg, resting at a heart rate of 64 bpm and a blood pressure of 168/80 mmHg). Because of episode of VT/VF at OSH, pt was deemed a candidate for life vest and was discharged home with vest for 1 month. Multiple EKGs in the CCU demonstrated sinus bradycardia which was likely due to elevated parasympathetic tone in the setting of her RV infarction. She remained asymptomatic with her bradycardia and remained hemodynamically stable. She was started on low dose metoprolol for her hypertension and new onset CHF, which her heart rate tolerated well. She was discharged home with a resting heart rate of 55-65. . #RIGHT SIDED [Name (NI) 4964] Pt developed new onset RV dysfunction as a result of her [Name (NI) ]. Her volume status was monitored carefully, as too much volume will cause further dilation and RV failure, while too little will cause hypotension as the RV is preload dependent. She developed trace peripheral edema that resolved with activity. Her JVP was not used as a measure of volume status as it was likely elevated secondary to her severe tricuspid regurg. She was started on lisinopril and metoprolol for long term management of her CHF with close monitoring of her heart rate. She was euvolemic on discharge. . #[Name (NI) 5779] - Pt had GI workup at OSH, including RUQ ultrasound, HIDA and CT abdomen, that were all unrevealing. No further work-up was done at [Hospital1 18] as her [Hospital1 ] was attributed to congestive hepatopathy from RV failure. Her LFTs were monitored while in the CCU and were noted to trend down, consistent with the thought that it was secondary to congestion. She will need follow up as an outpatient to ensure complete resolution. . CHRONIC ISSUES: . HYPERTENSION: Pt was initially normotensive on transfer to [Hospital1 18]. During her hospital course, her blood pressure became elevated to systolic 150-160s despite remaining bradycardia in the 50-60s. She was slowly titrated on lisinopril and metoprolol for blood pressure control in the setting of her new onset CHF. Her heart rate was monitored closely and remained stable in the 50-60s with the addition of beta blocker. Pt was asymptomatic at this heart rate. . ANXIETY: Pt reports being an anxious person at baseline, which has recently been exacerbated by the course of her hospitalization. She was encouraged to seek counseling upon discharge and was agreeable to this suggestion. . TRANSITIONAL ISSUES: Pt was full code. She will need to wear a life vest for 1 month and have close follow-up with cardiology. She has decided to follow up at [Hospital1 18], at least in the short term, before eventually transferring care to a cardiologist in [State 2748] where she resides. It was suggested to her to persue counseling to help manage her anxiety, especially given the events surrounding her recent hospitalization. She has good family support. Medications on Admission: MEDICATIONS ON TRANSFER: lovenox 60mg q12h lidocaine 1mg/minute amiodarone 0.5mg/minute toprol 25mg daily on hold iron 325 [Hospital1 ] protonix 40mg [Hospital1 ] plavix 75mg daily aspirin 325 daily lasix 40mg IV q8h potassium 20meq q8h Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction (heart attack) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You had a heart attack at [Hospital3 ] Hospital where you underwent an operation to open up your blocked artery. You then developed a very dangerous heart rhythm that required an electric shock. You were transferred to the cardiac intensive care unit here at [Hospital1 18] for closer monitoring. While here you underwent a stress test, which showed that you have no new areas of impaired blood flow in your heart. . Please weigh yourself every day and let your doctor know if you gain 3lbs in one day. Since you had this dangerous heart rhythm, we are discharging you with a Life Vest. Please wear it every day for the next 30 days at all times except when taking a shower. . The following medications were added during your admission: 1. Start taking Aspirin 325mg daily for your heart disease. 2. Start taking Plavix 75mg daily for your heart disease. 3. Start taking Lisinopril 20mg daily for your blood pressure. 4. Start taking Metoprolol 12.5 twice daily for your blood pressure. Followup Instructions: Please ask your doctor to check your kidney function and potassium at this appointment since you started taking lisinopril. Name: [Last Name (LF) 88591],[First Name3 (LF) ] H. Location: NEW [Last Name (un) ] INTERNAL MEDICINE Address: [Street Address(2) 88592], NEW [Last Name (un) ],[Numeric Identifier 88593] Phone: [Telephone/Fax (1) 88594] Appointment: Monday [6-1] at 12:45PM . Department: CARDIAC SERVICES When: THURSDAY [2161-7-2] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11899], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2161-5-26]	[ "V45.82", "401.9", "428.0", "300.00", "427.1", "424.2", "427.41", "414.01", "428.21", "V10.82", "573.0", "427.89", "V12.53", "410.41" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13366, 13372	7579, 7852	351, 358	13465, 13465	3972, 3972	14695, 15462	3016, 3132		12943, 13343		13393, 13444		12673, 12673			13615, 14672		4236, 7556							3147, 3953																			12196, 12647					266, 313		7867, 11456									386, 2676							3988, 4220				13480, 13591			11472, 12175		12698, 12920	2698, 2769	2785, 3000
186	164,405	13989	Discharge summary	report	Admission Date: [2176-9-25] Discharge Date: [2176-10-1] Date of Birth: [2100-12-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Banding x 4 of esophageal varices History of Present Illness: Pt is a 74yo woman with PMH of MS, Autoimmune Hepatitis, and NIDDM presenting with acute episode of hematemasis brought in by EMS to ED and was vomiting large amounts of blood, history was not available from pt but pts family was able to relate some facts. Husband relates several days of malaise, then in the evening of the night of admission the pt had nausea and subsequently vomited a large amount of blood, EMS was called and pt brought to the ED. Family denies former bouts of GI bleeds in the patient. Pt does not take ASA and is also on Prednisone. Family denies anticoagulation use. Past Medical History: MS, wheelchair bound, requiring self catherization Hx of UTIs HTN NIDDM Hypercholesterolemia Autoimmune Hepatitis Social History: Greek Speaking only, family members speak english, Married No EtOH Hx as per family Family History: non-contributory Physical Exam: T 98.9 BP 106/55 HR 82 RR 20 O2 99% Gen: morbidly obese woman sitting on her chair, in NAD Lungs: coarse BS, bilaterally Cardiac: RRR 3/6 systolic murmur Abd: soft, NT, non-distended, +BS Ext: No edema Pertinent Results: [2176-9-25] 11:50PM PT-14.3* PTT-23.7 INR(PT)-1.4 [2176-9-25] 10:43PM GLUCOSE-384* UREA N-43* CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18 [2176-9-25] 10:43PM ALT(SGPT)-23 AST(SGOT)-17 LD(LDH)-210 CK(CPK)-42 ALK PHOS-80 TOT BILI-0.4 [2176-9-25] 10:43PM LIPASE-25 [2176-9-25] 10:43PM CK-MB-NotDone cTropnT-<0.01 [2176-9-25] 10:43PM WBC-19.2# RBC-3.10# HGB-9.7# HCT-28.8# MCV-93 MCH-31.3 MCHC-33.7 RDW-14.0 [2176-9-25] 10:43PM NEUTS-63.0 LYMPHS-31.8 MONOS-3.6 EOS-1.1 BASOS-0.6 [2176-9-25] 10:43PM PLT COUNT-262 ELECTROCARDIOGRAM PERFORMED ON: [2176-9-28] Normal sinus rhythm with atrial premature beats. Left ventricular hypertrophy with repolarization changes. Compared to the previous tracing of [2176-9-17] atrial premature beats are present and the axis is less leftward. AP CHEST 4:20 A.M. ON [9-27] HISTORY: GI bleed following intubation and right subclavian line repositioning. IMPRESSION: AP chest compared to [9-26] at 5:15 a.m.: Lung volumes are low and mild pulmonary edema has worsened. Perihilar opacification on the right could be asymmetric edema or developing pneumonia. ET tube and right subclavian line are in standard placements. No pneumothorax or pleural effusion. Heart size normal. PORTABLE AP CHEST RADIOGRAPH CLINICAL DETAILS: Post repositioning of right subclavian line. FINDINGS: Endotracheal tube at the precarinal level. The inferior tip of the right subclavian line lies at the inferior level of the SVC. Minor kink noted at its cutaneous entry. Increased opacity at the left costophrenic angle likely due to a small pleural effusion. The lungs are otherwise clear. Brief Hospital Course: In the ED on presentation pt was tachcardic at 118, had an O2 sat of 93% on RA up to 98%on 6L, and vomited 500cc of blood with clots, the decision was made to intubate the patient for airway protection, 2 liters of NS and 3 Units PRBCs were given while waiting for an Abd CT scan in the ED her pressure dropped to low 80s/40s, nursing decided to transport pt to MICU, bypassing CT scan, MICU team and GI met pt in MICU pts BP measure at 140s/80s, Right subclavian was placed, GI performed gastric lavage and scoped pt in MICU. Discovered bleeding esophageal varices in the lower [1-1] of the esophagus and banded x 4 as well as non-bleeding gastric varices in the cardia. . In the MICU, pt was extubated on [2176-9-28]. She began to develop a non-productive cough. She denies any recent bleeding. She denies any nausea/vomiting/diarrhea. No chest pain/tightness. No lightheadedness. No fever/chills. She states she feels comfortable ROS: + non-productive cough 1) Upper GI Bleed/Esophageal Varicies: Unknown cause, ? secondary due history of Autoimmune hepatitis, GI evaluated and banded times 4. She received 5 days of octreotide and Hct was stable since banding. US shows normal flow in hepatic and portal veins and no ascites. - Continue protonix 40 mg PO BID - Levoflox 500 mg PO QD x 8d for SBP prophylaxis on discharge - Nadolol 20 mg PO QD - will see GI in 1-2wks/endoscope 4-5wks . 2)BP Pt initially hypotensive most likely due to hypovolemia but normalized after fluid resuccitation. On transfer from the MICU to the floor, she was slightly hypertensive with SBP in the 140s. According to her family, she has no history of hypertension and was on no hypertensive meds at home. We will leave her on nadolol and have her follow up with her PCP. [Name Initial (NameIs) ] Nadolol 20 mg PO QD . 3)Respiratory distress: On admission, she was intubated for airway protection, also ? lung infiltrate: ? bloody aspirate vs. PNA. She was started on levofloxacin/flagyl for aspiration pneumonia. On the floor, she was afebrile and her WBC count was normalized on discharge to 5.5. - continue levo/flagyl day for 8 more days on discharge for total of 11 days . 4) NIDDM: slightly high during this admission to low 200s - 70/30 Insulin 25 qd, glypizide 10mg [Hospital1 ] - will follow up with her PCP . 5) Multiple Sclerosis - no issues this admission - continue home dose of prednisone 5 mg po qd - evaluation for home services Medications on Admission: Prednisone 5 mg PO QD Paxil 20 mg PO QD Trazodone Glipizide 10 mg PO BID Cimetidine Nystatin and miconazole powder Medication for urinary yeast infection Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 3. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 10 days. Disp:40 Tablet(s) Refills:0 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days: for pneumonia. Disp:24 Tablet(s) Refills:0 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: for pneumonia and prophylaxis against abdominal infection. Disp:8 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:2 9. Insulin 70/30 70-30 unit/mL Suspension Sig: Twenty Five (25) Units Subcutaneous once a day. 10. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day: take your home dose of paxil. 11. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: 1. Bleeding esophageal varices 2. Nonbleeding gastric (stomach) varices 3. Aspiration pneumonia Secondary: 1. Autoimmune hepatitis 2. Diabetes Mellitus type 2 3. Hypertension 4. Hypercholesterolemia 5. Multiple Sclerosis Discharge Condition: Stable Discharge Instructions: 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments. Call Dr. [Last Name (STitle) ] tomorrow at [Telephone/Fax (1) 2422] to schedule to have another endoscopy next week! tell the person making the appointment you were banded in the hospital for esophageal varices and need a follow up Endoscopy in one week. 3. Please seek medical attention or call 911 if you start to cough or vomit blood, for prolonged lightheadedness or weakness or for chest pain or shortness of breath. Followup Instructions: Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2422] tomorrow to schedule an endoscopy for next week to follow up on your banded varices. You have a follow up Thursday [2176-10-3] at 1 PM with Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 11139] ([Telephone/Fax (1) 11144]). You also should follow up with gastroenterology, Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 2422]) on [2176-10-14] at 8:20 AM in [Hospital1 ] [Initials (NamePattern4) 36418] [Last Name (NamePattern4) ] Medical Building [Location (un) ] for a general appointment and ask if you should restart aspirin at that time. Completed by:[2176-10-2]	[ "456.0", "571.49", "458.9", "340", "250.00", "401.9", "507.0", "272.0", "456.8", "518.81", "276.52" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.33", "42.33", "96.04", "99.04", "96.71" ]	icd9pcs	[ [ [] ] ]	7137, 7186	3220, 5675	326, 362	7460, 7469	1493, 3197	8040, 8748	1237, 1255		5879, 7114		7207, 7439		5701, 5856			7493, 8017									1270, 1474																								275, 288											390, 983																	1005, 1120	1136, 1221
19,142	116,155	4777	Discharge summary	report	Admission Date: [2120-7-24] Discharge Date: [2120-8-2] Date of Birth: [2058-8-3] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: recurrant adenoCA of the lung Major Surgical or Invasive Procedure: thoracotomy for right lower lobectomy History of Present Illness: Mr. [Known lastname 7011] is a very pleasant 61-year-old gentleman with a prior history of stage IIIB carcinoma of the left upper lobe diagnosed by Dr. [Last Name (STitle) 20042] in the remote past and treated with chemoradiotherapy. He was recently also diagnosed with CLL and then was found to have a second lung primary in [2117], treated with video-assisted local resection. This was found to be an adenocarcinoma. A followup shows increasing infiltrative appearance of the right lower lobe, prompting a bronchoscopy done earlier this month, which unfortunately confirms recurrent adenocarcinoma. The patient notes somewhat worsening dyspnea on exertion. Past Medical History: coronary artery disease, status post CABG in [2115-11-15]; inguinal hernia repair; some degree of obstructive lung disease; non-small cell cancer as above; and emphysema. Social History: previous smoker Family History: noncontributory Physical Exam: His weight is 156.6 pounds, pulse 52 and regular, blood pressure 103/69, and his room air saturation is 94%. HEENT: He has no scleral icterus. LYMPHATICS: There is no palpable cervical or supraclavicular adenopathy. CHEST: Breath sounds are diminished at the right base, and air entry is otherwise equivalent here. He has a well-healed sternotomy as well as VATS incisions on the right chest. HEART: Regular rhythm and rate without a murmur or gallop. EXTREMITIES: He has no peripheral cyanosis, clubbing, or edema. Pertinent Results: [2120-8-1] 10:30AM BLOOD WBC-27.2* RBC-3.76* Hgb-11.6* Hct-34.7* MCV-92 MCH-30.9 MCHC-33.5 RDW-15.1 Plt Ct-353 [2120-7-30] 07:55AM BLOOD Glucose-117* UreaN-20 Creat-0.8 Na-138 K-4.2 Cl-101 HCO3-27 AnGap-14 Brief Hospital Course: Patient was taken to the OR on [2120-7-24] for bronchoscopy, mediastinoscopy, and thoracotomy for RLL lobectomy. Frozen section of mediastinal LN were negative for lung CA but CLL involvement could not be ruled out. In the PACU, Neo was required to maintain blood pressure and the patient was admitted to the SICU post-op. Urine output was good, but blood pressure did not improve despite several fluid boluses. Epidural d/c'd in PACU as it was not working. Pain controlled with Dilaudid PCA. POD 2 Levofloxacin added for ?PNA on CXR. Neo still necessary to maintain BP on POD 2. Cortisol stim test was negative. Transfused 1U PRBC on POD 3 for a HCT which was steadily trending down, and again 1U PRBC on POD4. Mitodine started POD5 and Neo gtt could be stopped. Patient was transfered to floor on POD 5. Episode of rapid AFib late POD 4, controlled with metoprolol. CT #2 also d/c'd on POD5. CT #1 d/c'd POD6, post-pull CXR showed substantial PTX. New CT placed POD 6 with poor placement (along diaphragm). CT replaced on POD 7. Late POD 7, patient again in rapid AFib, did not convert with lopressor, Amiodorone started. CT water sealed POD 8 able to d/c O2. CT d/c'd on POD 9, post-pull CXR showed very small R apical PTX and R pleural effusion. Pt discharged home on POD 9 with a total of 14 days Levoquin and PO amiodorone. Medications on Admission: Altace 10mg po daily Lipitor 10mg po daily Atenolol 25 mg po daily ASA 81 mg po daily. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:120 Tablet(s) Refills:0 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Take 2 tablets 3 times a day until [8-5]. Then take 2 tablets 2 times a day until [8-12]. Then take 2 tables once a day until seen in clinic. Disp:60 Tablet(s) Refills:1 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Bronchioalveolar carcinoma, s/p Right lower lobectomy Discharge Condition: good Discharge Instructions: Amiodorone 400mg TID until [8-5], 400mg [Hospital1 ] [Date range (1) 20043], 400mg qday until seen in clinic. Call Dr.[Doctor Last Name 4738] office for: fever, shortness of breath, chest pain, drainage from incision site. You may remove the dressing Sunday morning then you may shower. No tub baths or swimming for 3-4 weeks. You may keep the chest tube sites covered with small dressings as needed. Do not remove small strips on incision site, let them fall off. No lifting more than 5 pound for 2 weeks, them as per lung surgery booklet. Restart regular medicine as previous except hold Atenolol & Altace until seen by Dr. [Last Name (STitle) ]. Take new medication as directed for pain. No driving if taking narcotic medication. Can transition to tylenol when able Followup Instructions: Call Dr.[Name (NI) ] office [Telephone/Fax (1) 170] for a follow up appointment in [9-27] days. You will need to arrive 45 minutes prior to your appointment and report to [Location (un) ] [Hospital Ward Name 23] Clinical center radiology for a chest XRAY.	[ "486", "427.31", "204.10", "V10.11", "V45.81", "162.5", "E878.6", "998.11", "512.1" ]	icd9cm	[ [ [] ] ]	[ "40.29", "32.4", "99.04", "34.04", "33.24", "34.22" ]	icd9pcs	[ [ [] ] ]	4377, 4435	2145, 3487	350, 390	4532, 4539	1907, 2122	5379, 5657	1338, 1355		3624, 4354		4456, 4511		3513, 3601			4563, 5356									1370, 1888																								280, 312											418, 1091																	1113, 1289	1305, 1322
17,526	193,493	14905	Discharge summary	report	Admission Date: [2157-11-24] Discharge Date: [2157-12-12] Date of Birth: [2120-5-20] Sex: M Service: This is 32-year-old male with a history of end-stage renal disease on hemodialysis since [2152]. The patient had hemodialysis at 7 o'clock through 11 o'clock on [2157-11-23] and he noted an acute onset of crampy left upper quadrant pain. The patient denied nausea, vomiting, no change in bowel movement, no fever or chills, no history of trauma. Recent evaluation at [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 18896]: he was recommended to have patient transferred to the [Hospital1 188] Hospital. PAST MEDICAL HISTORY: End-stage renal disease as above, hypertension secondary to renal disease, moderate diastolic dysfunction on catheterization in [2157-7-10], malaria one year ago. PAST SURGICAL HISTORY: Left arm arteriovenous fistula. MEDICATION: 1. Minoxidil 5 mg twice a day. 2. Valsartan 80 mg twice a day. 3. Carvedilol 25 mg twice a day. 4. Nifedipine 20 mg twice a day. 5. Nephrocaps. 6. Multivitamins. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No smoking, no alcohol. MBA student. PHYSICAL EXAMINATION: Temperature 95.6, heart rate 74 through 96. Blood pressure 174 to 216 systolic, diastolic 74 to 106. Respirations 16. Saturation 100% on room air. Alert and oriented times three in pain and heart with heart rate tachycardiac without murmurs, rubs or gallops. Abdomen is soft, nondistended, nontender in the left upper quadrant to percussion. Extremities: Warm, no edema. LABORATORY: White blood cell count 8.2, hematocrit first sample 38, pulse 81.4, 148, sodium 142, potassium 4.1, chloride 93, bicarbonate 37, BUN 12, creatinine 6.2, glucose 129. Prothrombin time 13.7, PTT 29.1, INR 1.2. ALT 16, AST 21, CK 172, alk phos 105, amylase 153, total bili 101, MB 2. Troponin 0.04. Abdominal CT on [11-23] showed acute hemorrhage in the left renal fossi and large retroperitoneal hematoma with moderate amount of intraperitoneal fluid likely. Extension of the retroperitoneal bleed. Multiple kidney cysts bilaterally. The patient was admitted the same day, went to the O.R. on the 16th where he underwent emergent left nephrectomy. Postop the patient developed increased AP drainage output of bright red blood, became tachycardiac in the 100's. The patient was taken back to the O.R. for re-exploration to evaluate bleeding. During the operation he was found to have 1500 cc's of blood intra-abdominally. No source of bleeding was discovered. The patient was hemodynamically depleted and idiopathic in Post Anesthesia Care Unit preop hematocrit had dropped to 20 before exploration interop the patient received 6 units of packed red blood cells, 250 cc's of cells and 4 units of FFP with two units of platelets. After surgery the patient was taken to the Intensive Care Unit where he was stabilized and eventually was transferred to the floor. Eventually the patient had an uneventful course on the floor, started tolerating clears on the 21st. The patient's blood pressure was controlled with Minoxidil, Valsartan, Nifedipine and Carvedilol. His pain medication was well controlled with Dilaudid 2 mg p.o. and was initially treated with Unasyn antibiotics as a prophylaxis. The patient is currently afebrile, has been receiving hemodialysis every Monday, Wednesday and Friday and his labs remained within normal limits with the above aforementioned values. The patient is being discharge today to [Hospital 745] Health Care Center and was instructed to resume outpatient dialysis at [Hospital1 392]. MEDICATIONS: 1. Carvedilol 12.5 mg twice a day. 2. Nifedipine 20 mg q day. 3. Valsartan 80 mg q day. 4. Folic Acid. 5. Vitamin B complex. 6. Vitamin C. 7. Calcium oscitate 60 mg three times a day. 8. Dulcusate sodium 9. Bisacodyl. 10. Lactulose p.r.n. constipation. 11. Percocet for pain. 12. Albuterol aerosol p.r.n. The patient was instructed to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [2157-12-26]. Outpatient treatment includes physical therapy, and hemodialysis. DIET: Renal diet as tolerated. PHYSICAL THERAPY: Weight bearing as tolerated. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Dictator Info ] MEDQUIST36 D: [2157-12-12] 15:56 T: [2157-12-12] 16:00 JOB#: [Job Number 43692]	[ "403.91", "428.0", "998.12", "593.89", "568.81", "593.2", "285.1", "583.9" ]	icd9cm	[ [ [] ] ]	[ "54.12", "55.51", "54.0", "39.95" ]	icd9pcs	[ [ [] ] ]																								885, 1137		4233, 4525													1216, 4214																																						693, 861	1154, 1193
8,020	128,204	855	Discharge summary	report	Admission Date: [2166-10-14] Discharge Date: [2166-10-20] Date of Birth: [2137-3-5] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5911] Chief Complaint: Menometrorrhagia, pelvic pain. Major Surgical or Invasive Procedure: 1. Abdominal Supracervical hysterectomy 2. Exploratory laparotomy and hematoma evacuation 3. Cystoscopy & retrograde ureterogram History of Present Illness: The patient is a 29-year-old G5 P1-1-3-2 thin African-American female with a large symptomatic fibroid uterus, complaining of prolonged menometrorrhagia as well as severe pelvic pain, who presented with severe anemia with a hematocrit of 25. The patient was being evaluated by her PCP for suspected underlying thalassemia. Iron studies revealed severe iron-deficiency anemia, however the patient was not compliant with p.o. iron. Given the source of anemia was likely due to her fibroid uterus, the patient was transfused 2 units of packed red blood cells 1 day preoperatively, as well as 125 mg of Ferrlecit IV to try to improve her iron stores and blood supply. The patient was offered to delay the surgery to improve her iron stores with p.o. iron, however the patient had been noncompliant and declined this option. The risks of infection with blood transfusion, as well as the side effects of blood transfusion, were discussed with the patient at length. The patient was counseled extensively and she opted for the preop transfusion and IV iron, and to proceed with the surgery. Even after the patient was transfused the 2units of packed red blood cells, her post-transfusion heamtocrit was only 27 since she continued to bleed heavily from her uterine fibroids since the last HCT of 25. Past Medical History: PMH: She states that she is otherwise healthy with the exception of this left lower extremity swelling episode, which was not painful, unclear etiology. She is currently not being evaluated as she was not compliant with followup with her PCP after the emergency room visit. PAST SURGICAL HISTORY: 1. D&C x2 for elective termination of pregnancies. 2. Her IUFD at 6 months was successfully delivered vaginally with an induction of labor. Social History: Admits to smoking 3 cigarettes per day for the last 2 years. Also, admits to drinking occasionally 3 drinks per week on Fridays. Denies any recreational drug use or IV drug use. She is currently employed as an administrative assistant at [Hospital1 ] at the Radiation Oncology Department. She is single, not currently dating, lives with her mother. Denies a history of sexual abuse and domestic violence. Family History: Mother, maternal aunt, and maternal niece with history of breast cancer. She has a sister who is alive and well without breast cancer. Denies a family history of ovarian, uterine, cervical, or vaginal cancer, or colon cancer or any other cancers in the family. Also, denies family history of diabetes, heart disease, or hypercholesterolemia. Paternal grandmother and sister both suffer from hypertension. Denies any other significant family medical history. Physical Exam: Vitals T:98.6F HR:60 RR:16 GEN: NAD CVS: RRR Resp: CTAB ABD: (post-op) soft, non-tender, +BS, well healing incision with resolved induration/erythema/crepitus, incision is packed with wet gauze with intermittent staples placed a few cnetimeters apart. The tissue appears healthy & there is no drainage. Ext: NTNE GU: No VB Pertinent Results: [2166-10-14] 12:42PM TYPE-[Last Name (un) ] PH-7.54* INTUBATED-INTUBATED [2166-10-14] 12:42PM GLUCOSE-89 LACTATE-1.0 NA+-140 K+-3.3* CL--111 TCO2-24 [2166-10-14] 12:42PM HGB-8.9* calcHCT-27 [2166-10-14] 12:42PM freeCa-1.15 Brief Hospital Course: Pt was admitted for routine post operative care after a supracervical hyst. On post-operative day 1, the patient was noted to have a 3cm non-tender subcutaneous hematoma of the right superior margin of the surgical wound. There was tenderness on the right inferior margin of the wound without errythema or induration. On post operative day 2, the pt complained of new onset LLQ pain. On exam, the subcutaneous hematoma was stable, but the inferior wound margin had developed dark red ecchymoses. There was tenderness at the left pole of the wound tracking superolaterally to include the left lower quadrant and left flank. There was underlying emphysema to auscultation and crepitus with palpation. CT was ordered confirming subcutaneous emphysema at the left pole of the wound tracking superolaterally as described above. Additionally, there was emphysema involving the fascia on the right, beneath the hematoma. The pt was started on antibiotics and taken to the OR for wound exploration. The hematocrit remained stable throughout. Approximately 400 cc of clot was found. There was no odor or purulence. The fascia itself appeared to be viable. The rectus muscles were viable and responded to electrocautery. There was no evidence of ongoing bleeding. Inspection of the abdomen revealed no evidence of intra-abdominal injury or bowel injury. The small bowel was run throughout its entirety. The colon appeared intact. The sigmoid appeared intact. The resection base from the uterus had no bleeding. No signs of necrotizing fasciitis was identified. The abdomen was irrigated. Post-operatively, patient was admitted to SICU for close monitoring, and was transferred to floor without incidence on POD [4-1]. Her abdominal exam was followed serially over the course of her hospital stay and dressings were continued to be changed daily wet to dry. On post-operative day [4-1], patient's creatinine reached height of 1.6 [0.6 (11.17)-> 1.0 (11.18)-> 1.6 (11.19)] with Fena 0.34%. ATN secondary to a combination of contrast + NSAIDs + dehydration was suspected per renal consult. However, there was no significant blood loss in the initial Abd SCH nor the re-operation to suggest a pre-renal causes of the ATN. The pt's urine output remained good throughout her hospitalization. CT urogram [2166-10-19] showed no hydronephrosis bilaterally; normal R ureter, no extravasation; but in L ureter, dye did not pass past superior portion of ureter, no extravasation; no ureteral pulsation seen in 9 min during study. On post-op day [5-3], per urology consult, retrograde cystoscopy was performed and showed no evidence of obstruction or extravasation bilaterally. Moreover, her Cr trended down to 1.3. She was discharged same day in good condition; afebrile, vital signs stable, tolerating po, and ambulant. Pt will have VNA to follow and do wound dressing changes daily. Pt was advised to return to clinic on [2166-10-22] to have her creatinine redrawn and evaluated, as well as a wound check. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:20 Tablet(s) Refills:0 4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Supracervical hysterectomy for uterine fibroids 2. Exploratory laparotomy for hematoma 3. Cystoscopy, retrograde ureterogram Discharge Condition: Good; afebrile, vital signs stable, tolerating po. Discharge Instructions: Please call your doctor if you have nausea/vomiting, unable to keep food down, have redness, swelling, foul smelling drainage or pus from your wound site, fever/chills, vaginal bleeding that saturates greater than one pad per hour, or any other concerns that worry you. Please take all your antibiotics as directed. Please follow up with the appointments you have as directed below. Followup Instructions: Please return to [Hospital Ward Name 23] [Location (un) ] for creatinine blood draw on [2166-10-22]. Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5912], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2166-11-5] 2:00 Provider [Name6 (MD) ] [Name9 (PRE) ], MD Phone:[Telephone/Fax (1) 2664] Date/Time:[2166-11-13] 9:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 5913] Completed by:[2166-10-22]	[ "E878.6", "218.1", "682.2", "998.12", "305.1", "276.51", "E935.9", "E947.8", "E849.7", "280.0", "E878.8", "584.5", "788.30", "998.81", "998.59", "V16.3", "280.9", "238.71", "626.2" ]	icd9cm	[ [ [] ] ]	[ "57.32", "68.39", "99.04", "54.12", "87.74" ]	icd9pcs	[ [ [] ] ]	7401, 7459	3828, 6858	361, 492	7631, 7684	3553, 3805	8117, 8622	2726, 3190		6881, 7378		7480, 7610					7708, 8094								2137, 2281	3205, 3534																								291, 323											520, 1816																	1838, 2114	2297, 2710
11,318	114,458	50710	Discharge summary	report	Admission Date: [2123-6-4] Discharge Date: [2123-6-7] Date of Birth: [2052-2-14] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 1620] Chief Complaint: hypoxia, fever/cough Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 71 y/o female with PMH significant for for severe diastolic dysfunction, atrial fib, severe PVD with chronic LE ulcers, and CAD admitted through the ED with hypoxia. Pt had a recent admission to the MICU [Date range (1) 32718]/5 for septic shock (presumed [3-10] LE ulcers). She was in her normal state of health until this morning when she appeared very lethargic when trying to get out of bed. Her oxygen saturation was found to be 60% on room air at [Hospital1 100] Senior Life. Pt was sent to the [Hospital1 18] ED where her sat was 85 to 100% on a NRB with a ABG of 7.30/63/161. She was started on CPAP of 10 which she tolerated well for approximately 20 minutes. However, she then became hypotensive to 78/40 so CPAP was discontinued and she was put back on a nonrebreather. After a 500 cc bolus, pt's SBP increased to around 90. Her Sats came up to 94-100% on 4L NC. Pt states she has had productive cough x 5 days. Otherwise ROS neg for f/c, HA, stiff neck, abd pain, d/c/n/v. . In ED, received vanco, levofloxacin, flagyl, solumedrol 50mg, tylenol . Past Medical History: 1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal) DRY WEIGHT 194 lbs 2. DM 2 on insulin 3. Atrial Fibrillation 4. Anemia 5. CAD s/p PTCA x 3 (RCA '[09], LCx '[10], RCA '[13]) 6. Pulmonary HTN 7. Hypercholesterolemia 8. COPD/[Year (2 digits) 105496] on home O2 (sometimes on home O2) 9. Thyroid CA s/p resection/now hypothryoid 10. Myoclonic tremors 11. H/O PE 12. OSA on CPAP (started last admission) 13. Depression/Anxiety 14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve endocarditis and pseudomonal sepsis (secondary to wound infection), status post intubation x 2. 15. S/p laproscopic cholecystectomy [34]. s/p right throcoscopy and decortication. Right lung bx. 17. s/p right hip ORIF 18. s/p right ankle ORIF Social History: SH: Pt lives at [Hospital1 100] Senior Life. She is divorced and has three children. She quit smoking in [2104] but has a history of 1 PPD for 15 years. No ETOH or drugs. Family History: FH: [Name (NI) 1094] father died at age 47 from a MI. Her mother died of colon CA. Pt has a brother with DM. Physical Exam: PE: 103.8 --->101.7 w/o meds 88 107/52 18 98% 2L NC Genl- well appearing, conversant, NAD HEENT- anicteric, sclera/op clear, dry mm Neck- jvd difficult to appreciate, supple Cardiac- irregular no m Lungs: crackles halfway up on R and [2-8] way up on L Abdomen- +bs, soft, nt Extremities- chronic LE ulcers b/l, chronic venous stasis changes Neuro- alert and oriented, moving all extremities Pertinent Results: [2123-6-4] 11:45AM LACTATE-1.6 [2123-6-4] 11:18AM K+-4.8 [2123-6-4] 11:15AM URINE HOURS-RANDOM [2123-6-4] 11:15AM URINE GR HOLD-HOLD [2123-6-4] 11:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2123-6-4] 11:15AM URINE RBC-0-2 WBC-[4-10] BACTERIA-FEW YEAST-NONE EPI-0-2 [2123-6-4] 09:16AM TYPE-ART RATES-/30 O2-100 PO2-161* PCO2-53* PH-7.30* TOTAL CO2-27 BASE XS-0 AADO2-506 REQ O2-84 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [2123-6-4] 09:16AM HGB-11.4* calcHCT-34 [2123-6-4] 09:05AM CK(CPK)-122 [2123-6-4] 09:05AM CALCIUM-8.7 PHOSPHATE-4.8* MAGNESIUM-1.9 [2123-6-4] 09:05AM CK-MB-2 [2123-6-4] 09:05AM WBC-22.0# RBC-4.44 HGB-12.0 HCT-38.3 MCV-86 MCH-27.1 MCHC-31.4 RDW-30.5 [2123-6-4] 09:05AM NEUTS-86* BANDS-6* LYMPHS-3* MONOS-2 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2123-6-4] 09:05AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2123-6-4] 09:05AM PLT COUNT-331# [2123-6-4] 09:05AM PT-13.4 PTT-31.9 INR(PT)-1.1 ECG- Narrow complex tachycardia at 134 beats per minute. No clear ST-T wave changes. . CXR (WET READ)- Cardiomegaly. Question of mild edema. Brief Hospital Course: 71f w/ extensive PMHx, including recent admit [Date range (1) 32718]/5 for septic shock (presumed [3-10] LE ulcers) who presents from Rehab with hypoxia, fever, leukocytosis and transient hypotension. 1. Hypoxia: This was most likley secondary to bronchitis/mucous plugging. Her hypoxia resolved with bringing up a mucous plug, and her oxygen saturation remained appropriate with minimal supplemental oxygen. She was weaned from 2L nc to room air. Her chest film on admission revealed stable chronic interstitial lung disease, with no evidence of acute PNA or CHF. h/o [Month/Day (2) 105496], ILD. transient hypoxia over hours. Pt's sat already up to 99% on 2L NC. . 2. Fever/leukocytosis: possible sources include LE ulcers, and pulmonary. UA neg. She recently completed 2week course of vanco/ceftaz/flagyl for her ulcers. Over course of hospital stay, trimmed abx down to just levo/vancomycin for presumed bronchitis since she has a hx of MRSA. She got a PICC line placed on [6-7] and will complete a 10 day course of Vanc/Levo for prsumed bronchitis vs bacterial pneumonia. She was seen by [Month/Day (2) ] while in house, and continued her routine dressing changes and wound care. There was no evidence of wound infection at this time. . 3. Hypotension - Overall, this was transient, and likely secondary to decreased preload in the context of positive pressure ventilation. Thereafter, she remained normotensive, and required no further hemodynamic support. There was no evidence of sepsis, and her [Last Name (un) 104] stim test showed no evidence of adrenal insufficiency. . 5. DM - She was continued on glargine and RISS . 6. Pain - She was continued on fentanyl patch, prn oxcodone, and gabapentin. . 7. Asymmetric leg swelling: She has a hx of severe PVD and chronic venous stasis. LENI was negative for DVT. Asymmetric leg edema is likely from her chronic venous change. . 8. Access - She got a PICC line placed in the right arm on [6-7]. . 9. PPx - PPI, hep SC . 10. Code status - FULL CODE Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 8. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO NOONTIME (). 12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 17. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 18. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 19. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Vancomycin HCl 1000 mg IV Q12H 22. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): day#1 was [6-5] for first full day of abx; continue for 10d course. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: 1. Hypoxia - resolved 2. fever, bronchitis/pneumonia 3. hypotension - resolved 4. atrial fibrillation 5. h/o CAD 6. DM 2 7. hypothyroidism 8. COPD/[Location (un) 105496], pulmonary htn 9. anxiety/depression 10. h/o MRSA and VRE 11. chronic lower extremity [Location (un) 1106] disease/ulcerations Discharge Condition: good Discharge Instructions: Weights at NH to monitor fluid status 2 gm sodium diet Continue antibiotics and regular medications. Follow up with [Hospital1 100] SeniorLife primary physician Completed by:[2123-6-7]	[ "414.00", "707.19", "440.23", "285.9", "263.9", "427.31", "491.22", "428.0", "482.9", "428.30", "V45.82", "516.8", "416.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	8246, 8331	4288, 6330	344, 351	8680, 8686	2989, 4265		2445, 2559		6353, 8223		8352, 8659					8710, 8904									2574, 2970																								284, 306											379, 1461																	1483, 2233	2249, 2429
8,317	185,100	14884	Discharge summary	report	Admission Date: [2120-8-6] Discharge Date: [2120-8-9] Date of Birth: [2053-8-4] Sex: F Service: Medicine, [Hospital1 ] Firm HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with a past medical history of coronary artery disease, hypertension, diabetes mellitus, and congestive heart failure who transferred from the Medical Intensive Care Unit where the patient was since [8-6] following an incident of hypotension (probably due to sepsis) and collapsed in the Emergency Department where the patient needed to be intubated. The patient originally came to the Emergency Department overnight on [8-5] with 24 hours of abdominal pain and shortness of breath. In the Emergency Department, the patient collapsed in the bathroom, was intubated, and was noted to have fevers as well as shortness of breath, and was noted to have a systolic blood pressure in the 60s. The patient was initially given intravenous fluids, resuscitated, and then started on dopamine which was eventually switched to Levophed to regulate her blood pressure. The patient was then transferred to the Medical Intensive Care Unit on [8-6]. The patient had originally been started on ceftriaxone, and vancomycin, as well as levofloxacin and Flagyl. First CT scan done without contrast showed concern for bowel ischemia of the semicolon as well as mild hydronephrosis of the left kidney, and a right kidney stone. The patient was status post cholecystectomy; therefore, a right upper quadrant ultrasound was not done. A second CT scan with contrast of the abdomen and pelvis was done and was shown to be within normal limits; this was done the day after the first CT was done. Upon transfer to the Medical Intensive Care Unit, vancomycin and ceftriaxone were discontinued. The patient was kept on levofloxacin and Flagyl. Abdominal pain and right upper quadrant pain persisted, but the patient was extubated on [8-6] and then weaned off oxygen over the next 24 hours. The patient had an electrocardiogram that was done earlier in the Emergency Department which showed ST-T wave depressions in the lateral leads, but the patient was ruled out for a myocardial infarction per cardiac enzymes. Also, there was concern for aortic dissection since the patient complained of right upper quadrant radiating to the back, but the CT scan results were negative for aortic dissection. Again, the patient was extubated on [8-6]; and during her time in the Medical Intensive Care Unit was stabilized with no complications and was transferred to the Medicine Service on [8-7]. Before transfer, it was noted that there was a first set of stool cultures drawn that were negative for Clostridium difficile. Upon transfer, the patient did not complain of any nausea, vomiting, abdominal pain, diarrhea, dysuria, or any leg swelling. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Diabetes mellitus. 4. Congestive heart failure; cardiac catheterization done three weeks ago was within normal limits. 5. Gastroesophageal reflux disease. 6. Status post cholecystectomy. 7. Status post tubal ligation. 8. Status post appendectomy. 9. Status post cesarean section. ALLERGIES: SULFA (tongue swelling). MEDICATIONS ON ADMISSION: Univasc, insulin NPH 75/regular 25; 50 units q.a.m. and 50 units q.h.s., Lasix 20 mg p.o. q.d., aspirin 325 mg p.o. q.d., Nexium. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 98.6, blood pressure was 120/50, heart rate was 108, respiratory rate was 22, 91% on room air. In general, the patient was obese, lying in bed, in no acute distress, cooperative. Head, eyes, ears, nose, and throat revealed right eye pupil was fixed at 4 mm; left eye pupil fixed at 2 mm. The oropharynx was pink. Mucous membranes were moist. Neck was supple. No jugular venous distention. No hepatojugular reflux. Jugular venous pressure at approximately 7 cm. Chest examination revealed decreased breath sounds diffusely, but more decreased at the bases. Right basilar crackles. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. A crescendo-decrescendo 3/6 systolic ejection murmur at the right upper sternal border radiating to the clavicle. Abdomen was soft and nontender, slightly distended, bowel sounds were present but hypoactive, tympanitic. No guarding or rebound. No peritoneal signs were noted. Extremities revealed trace edema bilaterally up to the ankles. No cyanosis, and no edema. Distal pulses were palpable and 2+. Neurologic examination revealed cranial nerves II through XII were normal. Muscle strength was [4-28] in the upper and lower extremities; grossly intact. PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell count was 13.7, hemoglobin was 11.2, hematocrit was 34.3, platelets were 180. Potassium was 4, chloride was 111, bicarbonate was 21, blood urea nitrogen was 17, creatinine was 1, glucose was 151. Differential with neutrophils of 81.1, lymphocytes of 12.8, monocytes of 5.6, eosinophils of 0.2, basophils of 0.3. PT was 12.9, PTT was 27.9, INR was 1.2. First set of cardiac enzymes: Creatine kinase was 79, troponin was 0.3, MB was not done. Second set of cardiac enzymes: Creatine kinase was 109, troponin was not done, MB fraction was 6. The third set of cardiac enzymes: creatine kinase was 85, troponin was 0.3, MB was not done. Blood acetone level was negative. Calcium was 7.6, magnesium was 1.6, phosphorous was 4.1. HOSPITAL COURSE: Hospital course upon transfer to the floor as follows; 1. PULMONARY: The patient has no history of chronic obstructive pulmonary disease of sleep apnea. Therefore, pulmonary problems (her shortness of breath) was most likely related to congestive heart failure complications. In the meantime, incentive spirometry was provided at the bedside, daily weights were checked, ins-and-outs were started, and oxygen saturations were monitored, as well as clinical symptoms of shortness of breath. Lasix was started on the day prior to hospitalization discharge which the patient tolerated well. The patient tolerated incentive spirometry well. 2. FLUIDS/ELECTROLYTES/NUTRITION: Intravenous fluids were run at 75 units per hour for 1 liter per day for the first two days. Electrolytes were serially repleted as needed. The day prior to discharge, intravenous fluids were discontinued. The patient was started on a regular diet which she tolerated well. Rectal tube and Foley catheter were discontinued the night prior to discharge. The patient was able to ambulate to the commode. 3. INFECTIOUS DISEASE: The patient's first set of Clostridium difficile toxin per stool culture was negative. The patient's stool cultures were also negative for evidence of Salmonella, Shigella, and Campylobacter. Blood cultures done showed no growth to date times three days. Urine cultures showed a result of 7000 organisms per milliliter which was noted to most likely be due to asymptomatic bacteruria. The patient's white blood cell count steadily decreased (trended lower) to the day of discharge when it was 5.3. The patient was afebrile for the rest of the hospital stay. 4. RENAL: The patient's creatinine as well as blood urea nitrogen was normal throughout the hospital stay, and therefore was monitored. No other intervention was done. 5. GASTROINTESTINAL: The patient was continued on gentle hydration per intravenous fluids for her recent diarrhea which was discontinued on the night prior to discharge. The patient's first set of Clostridium difficile was negative (as noted above). The patient's symptoms were most likely due to an acute infectious etiology. Therefore, the patient was continued on levofloxacin and Flagyl. An increase in oral intake was encouraged without any complications. 6. ANEMIA: The patient had a hematocrit drop from 38.8 to 34.3 upon transfer, though it was stabilized on the day of discharge from a value of 34.1; therefore, the acute drop in hematocrit was most likely secondary to hemodilution due to aggressive intravenous fluid hydration in the Medical Intensive Care Unit. No further workup was done regarding anemia. 7. ENDOCRINE: The patient was put on an insulin sliding-scale regular regimen with fingersticks q.i.d. The patient was also put on a standing dose of NPH 30 units in the morning and 30 units at night. Fingerstick blood sugars were stable in the low 100s to high 90s throughout the hospital stay. Therefore, no further intervention was done to that respect. 8. CARDIOVASCULAR: The patient had a lipid study done which were all within the normal range. Triglycerides were 106, high-density lipoprotein was 31, cholesterol to high-density lipoprotein ratio was 35, low-density lipoprotein was 57. DISCHARGE DIAGNOSIS: The patient's discharge diagnosis was infectious gastroenteritis. MEDICATIONS ON DISCHARGE: 1. Moexipril 7.5 mg p.o. q.d. 2. Acetaminophen 650 mg p.o. q.4-6h. as needed for pain. 3. Protonix 40 mg p.o. q.d. 4. NPH 75/regular 25; 50 units q.a.m. and 50 units q.p.m. 5. Metronidazole 500 mg p.o. t.i.d. (times five days). 6. Levofloxacin 500 mg p.o. q.d. (times five days). 7. Enteric-coated aspirin 325 mg p.o. q.d. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the Infectious Disease Clinic (telephone number [Telephone/Fax (1) ]) in approximately two weeks from the day of discharge. DISCHARGE INSTRUCTIONS: The patient was to continue levofloxacin and Flagyl until the full 10-day course is completed. In the meantime, the patient was to have all medications restarted as previously. The patient was not to drink any milk, as the patient may have a question of lactose intolerance which may have caused abdominal problems. The patient was also instructed not to drink alcohol, as per drug reactions with Flagyl (disulfiram-like effect). The patient was also to follow up with the Infectious Disease Clinic regarding results of the rest of the stool cultures; for vibrio, for Aeromonas as well, and Campylobacter. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 568], M.D. [MD Number(1) 3808] Dictated By:[Last Name (NamePattern1) 17322] MEDQUIST36 D: [2120-8-9] 17:50 T: [2120-8-16] 08:59 JOB#: [Job Number 43648]	[ "276.5", "599.0", "401.9", "250.00", "V45.82", "276.4", "785.59", "591", "038.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]											8893, 8960	8986, 9317	3295, 5205	5588, 8871		9599, 10518																															5417, 5569						9338, 9574							186, 2870																	2892, 3268
83,394	162,940	39706	Discharge summary	report	Admission Date: [2106-9-27] Discharge Date: [2106-10-1] Date of Birth: [2043-12-15] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Occassional palpitations Major Surgical or Invasive Procedure: Minimally invasive mitral valve repair using a right mini thoracotomy and posterior leaflet (P2) triangular resection with a ring annuloplasty using an [Doctor Last Name ] Physio 2 34-mm annuloplasty ring, serial #[Serial Number 87505], model #5200. [2106-9-27] History of Present Illness: This is a 62 year old female with longstanding history of mitral valve prolapse. Most recent echocardiogram in [2106-7-28] showed severe mitral regurgitation. At baseline, she is very active and remains asymptomatic. She denies chest pain, shortness of breath, palpitations, orthopnea, PND and pedal edema. Cardiac surgery consulted for Mitral Valve repair/Replacement. Past Medical History: Hyperlipidemia Hypertension Mitral valve prolapse Osteoporosis Diabetes mellitus - Borderline s/p Left knee surgery s/p Appendectomy Social History: Race: Caucasian Last Dental Exam: 5 months ago Lives with: Husband Occupation: Lives on a farm, rides horses on a daily basis Tobacco: Denies ETOH: Social, 1 drink daily Family History: No premature coronary artery disease Physical Exam: Admission Physical Exam Pulse: 57 SB Resp: 16 O2 sat:100% B/P Right: 156/84 Left: 155/75 Height: 62" Weight: 115 General: WDWN In NAD Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] PERRLA [X] EOMI [X] Sclera anicteric. OP Unremarkable. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] III/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: None [X] Neuro: Grossly intact, MAE [3-31] strengths,nonfocal exam Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Murmur radiates bilaterally Pertinent Results: [2106-9-28] 01:50AM BLOOD WBC-15.7* RBC-3.42* Hgb-10.0* Hct-28.7* MCV-84 MCH-29.4 MCHC-35.0 RDW-13.9 Plt Ct-178 [2106-9-27] 02:02PM BLOOD WBC-14.8# RBC-3.61 Hgb-10.3* Hct-30.6* MCV-85 MCH-28.5 MCHC-33.6 RDW-13.5 Plt Ct-166 [2106-9-27] 02:02PM BLOOD PT-13.3 PTT-27.8 INR(PT)-1.1 [2106-9-28] 01:50AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-137 K-3.9 Cl-107 HCO3-23 AnGap-11 [2106-9-27] 02:02PM BLOOD UreaN-15 Creat-0.7 Na-141 K-4.0 Cl-114* HCO3-24 AnGap-7* [2106-9-27] 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 is moderately dilated. 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. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is moderate/severe posterior leaflet mitral valve prolapse with an anteriorly directed jet. Both mitral leaflets are severely myxomatous. Severe (4+) mitral regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results. Post CPB: There is a mitral ring in place. There is trace MR. The peak gradient across the mitral valve is 9 and the mean gradient is 5mmHg. There is trace aortic regurgitation. The visible contours of the thoracic aorta are intact. Brief Hospital Course: On [2106-9-27] Ms.[Known lastname ] was taken to the Operating Room and underwent a minimally invasive mitral valve repair using a right mini thoracotomy and posterior leaflet (P2) triangular resection with a ring annuloplasty using an [Doctor Last Name ] Physio 2 34-mm annuloplasty ring with Dr.[Last Name (STitle) 914]. Please refer to operative report for further details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She awoke neurologically intact and was extubated without difficulty. Beta-[Last Name (LF) ], [First Name3 (LF) ], a statin and diuresis were initiated. Anti-inflammatory medications were started per protocol. All lines and drains were discontinued in a timely fashion. On POD# 1 she was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. She continued to make steady progress and was discharged home on postoperative day three. She will follow-up with Dr. [Last Name (STitle) 914], her cardiologist and her primary care physician as an outpatient. As per Dr. [Last Name (STitle) 914], she will take motrin 600mg every eight hours for three months. Medications on Admission: Lipitor 10 mg daily, Calcium with Vitamin D, Actonel 35mg Every Friday, Multivitamin Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for miniMAZE for 3 months. Disp:270 Tablet(s) Refills:0 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 6. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:30 Tablet(s) Refills:0 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: home health and hospice of [Location (un) ] Discharge Diagnosis: Severe mitral regurgitation. s/p Minimally invasive mitral valve repair/annuloplasty Hyperlipidemia Hypertension Mitral valve prolapse Osteoporosis Diabetes mellitus - Borderline Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: 1)Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2)Please NO lotions, cream, powder, or ointments to incisions 3)Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4)No driving for approximately 2 weeks and while taking narcotics. This will be discussed at follow up appointment with surgeon when you will be able to drive. 5)You may resume your actonel as per presurgery 6)Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] ([Telephone/Fax (1) 170]) on [2106-10-26] at 1:15pm Cardiologist:Dr. [Last Name (STitle) ] on [2106-10-28] at 10:20am Please call to schedule appointments with: Primary Care: Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 13013] ([Telephone/Fax (1) 10862]in [11-28] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2106-10-1]	[ "272.4", "429.5", "250.00", "424.0", "458.29", "733.00", "401.9" ]	icd9cm	[ [ [] ] ]	[ "35.33", "39.61" ]	icd9pcs	[ [ [] ] ]	6407, 6485	3795, 5056	347, 623	6708, 6919	2213, 3538	7777, 8414	1389, 1428		5192, 6384		6506, 6687		5082, 5169			6943, 7754									1443, 2194																								282, 309											651, 1028																	1050, 1185	1201, 1373					3548, 3772
45,349	122,952	50419	Discharge summary	report	Admission Date: [2189-11-28] Discharge Date: [2189-12-11] Date of Birth: [2136-1-25] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Total gastrectomy 2. Billroth II esophago-jejunal reconstruction 3. [Doctor Last Name 105069] enteroenteroanastomosis 4. Placement of long intestinal feeding tube 5. Tru-Cut needle liver biopsies x2 History of Present Illness: PHYSICAL EXAMINATION upon admission: [2189-11-27] Temp:97.5 HR:76 BP:109/58 Resp:15 O(2)Sat:100 normal Constitutional: Uncomfortable secondary to pain HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation poor in the left upper chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended, moderate diffuse tenderness, voluntary guarding, no rebound GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry, No rash Neuro: Speech fluent Psych: Normal mood, Normal mentation Past Medical History: Breast CA s/p R mastectomy '[75]; Chemo '[80], R reconstrxn '[80]; L lymphadenectomy '[83], anxiety Social History: Social History: The patient lives alone in [Location (un) 6691], but has some friends at her new place of employment as well as a cousin who lives locally. She works with people with disabilities as a social worker. She has never smoked tobacco and drinks alcohol on a social basis. Family History: She denies any family history of colon cancer, although both of her parents did have previous colonic polyps. Family history is remarkable for breast cancer in her mother in her 70s. There is no family history of colon or rectal cancer Physical Exam: PHYSICAL EXAMINATION upon admission: [2189-11-28] Temp:97.5 HR:76 BP:109/58 Resp:15 O(2)Sat:100 normal Constitutional: Uncomfortable secondary to pain HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation poor in the left upper chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended, moderate diffuse tenderness, voluntary guarding, no rebound GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry, No rash Neuro: Speech fluent Psych: Normal mood, Normal mentation Pertinent Results: [2189-11-28] 01:20AM BLOOD WBC-5.7 RBC-2.61* Hgb-7.6* Hct-22.2* MCV-85 MCH-29.0 MCHC-34.1 RDW-13.8 Plt Ct-437 [2189-11-28] 03:30PM BLOOD WBC-6.3 RBC-4.07# Hgb-12.0# Hct-35.7# MCV-88 MCH-29.6 MCHC-33.7 RDW-14.4 Plt Ct-321 [2189-11-29] 02:12AM BLOOD WBC-9.5# RBC-3.54* Hgb-10.8* Hct-30.6* MCV-87 MCH-30.5 MCHC-35.3* RDW-14.5 Plt Ct-324 [2189-12-5] 08:20AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.1* Hct-26.4* MCV-87 MCH-29.9 MCHC-34.3 RDW-14.1 Plt Ct-465* [2189-12-6] 04:30AM BLOOD WBC-5.9 RBC-2.97* Hgb-8.7* Hct-25.8* MCV-87 MCH-29.4 MCHC-33.9 RDW-14.1 Plt Ct-530* [2189-12-7] 05:30AM BLOOD WBC-6.1 RBC-3.02* Hgb-9.2* Hct-26.4* MCV-87 MCH-30.5 MCHC-34.9 RDW-14.2 Plt Ct-607* [2189-11-28] 03:30PM BLOOD PT-14.8* PTT-27.3 INR(PT)-1.3* [2189-12-2] 05:28AM BLOOD Plt Ct-369 [2189-12-6] 04:30AM BLOOD Plt Ct-530* [2189-12-7] 05:30AM BLOOD Plt Ct-607* [2189-11-28] 03:30PM BLOOD Glucose-192* UreaN-6 Creat-0.4 Na-136 K-3.3 Cl-107 HCO3-20* AnGap-12 [2189-11-29] 02:12AM BLOOD Glucose-145* UreaN-6 Creat-0.5 Na-136 K-3.9 Cl-108 HCO3-22 AnGap-10 [2189-11-30] 05:10AM BLOOD Glucose-122* UreaN-8 Creat-0.5 Na-138 K-3.6 Cl-107 HCO3-26 AnGap-9 [2189-12-8] 05:15AM BLOOD Glucose-121* UreaN-4* Creat-0.4 Na-140 K-3.5 Cl-108 HCO3-28 AnGap-8 [2189-12-9] 05:45AM BLOOD Glucose-108* UreaN-9 Creat-0.4 Na-145 K-3.9 Cl-111* HCO3-24 AnGap-14 [2189-11-28] 01:20AM BLOOD ALT-19 AST-24 AlkPhos-51 TotBili-0.6 [2189-12-8] 05:15AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.2 [2189-12-9] 05:45AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1 [2189-11-28] 01:23AM BLOOD Lactate-0.9 [2189-11-28]: Abdominal x-ray: IMPRESSION: Pneumoperitoneum, concerning for perforated viscus. No bowel wall thickening or pneumatosis is apparent [2189-11-28]: Cat scan of abdomen and pelvis: Large pneumoperitoneum, as seen on radiograph. There is also fluid seen insinuating about the porta, right anterior pararenal space, and tracking into the right paracolic gutter and pelvis. Additional extraluminal air is seen about the porta and lesser sac. Although definite site of perforation cannot be identified given the lack of oral or intravenous contrast, the distribution of air and fluid suggests a possible site such as gastric antrum or duodenum. 2. Sigmoid anastomosis seen in the pelvis, appears unremarkable. 3. Stable hepatic cyst. Otherwise, limited evaluation of the intra-abdominal organs without intravenous contrast [2189-12-2]: x-ray of the abdomen: IMPRESSION: 1. Dilated air- and stool-filled colon, consistent with ileus. 2. Left pleural effusion. Further evaluation is recommended with chest radiograph [2189-12-4]: Upper GI: SINGLE CONTRAST UPPER GI: Water-soluble contrast and thin barium passes freely through the esophagus into the proximal jejunum without evidence of leak. A Dobhoff feeding tube is seen with tip in the proximal jejunum and likely distal to the enteroenterostomy, the location of which may be indicated by surgical staple line in the upper abdomen. There is slight dilation and holdup of contrast near just distal to the tip of the feeding tube. Fifteen minutes after administration of oral contrast, additional view demonstrates passage of contrast distal to the site of hold-up. The afferent limb does not opacify. IMPRESSION: No evidence of leak [2189-12-7]: Abdominal x-ray: MPRESSION: Interval decrease in amount of air and fecal material seen in colon. Residual contrast in large bowel. No evidence of small-bowel obstruction. [2189-11-28]: Nasal swab: [2189-11-28] 3:30 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2189-12-1] MRSA SCREEN (Final [2189-12-1]): No MRSA isolated [2189-11-28]: Tissue/total gastrectomy/liver: SPECIMEN SUBMITTED: Total gastrectomy, Liver biopsy. Procedure date Tissue received Report Date Diagnosed by [2189-11-28] [2189-11-30] [2189-12-10] DR. [Last Name (STitle) ]. [Doctor Last Name 15706]/ttl Previous biopsies: [-8/2074] SIGMOID COLON, DISTAL TRANSVERSE AND LEFT COLON, PROXIMAL [Numeric Identifier 105070] COLON BIOPSIES (2 JARS). [-6/4207] RIGHT BREAST IMPLANT & CAPSULE. [Numeric Identifier 105071] LEFT BREAST TISSUE/jg/ds (and more) DIAGNOSIS: I. Total gastrectomy (A-N): Gastric adenocarcinoma with 2.0 cm perforation; see synoptic report. II. Liver, biopsy (X): 1. No malignancy identified. 2. Mild portal and lobular acute inflammation; likely operative effect. 3. Minimal microvesicular steatosis (<5%). Stomach: Resection Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [2188] MACROSCOPIC Specimen Type: Total gastrectomy. Tumor Site: Body: Lesser curvature. Tumor configuration: Diffusely infiltrative (linitis plastica), ulcerating. Tumor Size: Greatest Dimension: 7.5 cm. Additional dimensions: 4.5 cm. MICROSCOPIC Histologic Type: Signet-ring cell carcinoma (greater than 50% signet-ring cells). Histologic Grade: G3: Poorly differentiated. Primary Tumor: pT4a: Tumor invades serosa (visceral peritoneum). Regional Lymph Nodes: pN2: Metastasis in 3 to 6 perigastric lymph nodes. Lymph Nodes Number examined: 11. Number involved: 5 (confirmed by a keratin AE1/3 immunohistochemistry on blocks M and R). Distant metastasis: pM1: Distant metastasis. Site(s): Numerous peritoneal deposits seen. MARGINS Proximal margin: Involved by invasive carcinoma. Distal margin: Uninvolved by invasive carcinoma. Omental (radical) margin: Cannot be assessed. Lymphatic (Small Vessel) Invasion: Absent. Venous (Large vessel) invasion: Absent. Perineural invasion: Present. TNM Descriptors: None. Additional Pathologic Findings: Chronic inactive gastritis. Comments: Immunohistochemical stain for Helicobacter is negative with adequate controls on block F. Immunohistochemistry for CDX2 shows focal and weak nuclear expression. GCDFP and mammoglobin are negative. Controls are adequate. These findings are consistent with primary gastric carcinoma. Brief Hospital Course: 53 year old female who presented to the Acute Care Service on [11-27] with abdominal pain. Upon admission, she was made NPO, given intravenous fluids and had blood work done. She had an x-ray and cat scan of the abdomen which showed a pneumoperitoneum. She was given ciprofloxacin and flagyl and prepared for surgery. She was taken to the operating room on [11-28] where she was found to have a perforated bleeding gastric carcinoma. She underwent a total gastrectomy, bilroth 2 reconstruction with [Doctor Last Name 105069] enteroenteroanastomosis, placement of intestinal feeding tube, and a liver biopsy. Her operative course was complicated with a 1500 cc blood loss for which she received packed red blood cells and fresh frozen plama. She was extubated in the operating room. She was admitted to the Intensive Care Unit post-operatively where her hemodynamic status was monitored. Her pain was controlled with dilaudid PCA. She was maintained on ciprofloxacin, flagyl, and fluconazole. Her antibiotics were discontinued on [12-7]. Jejunal tube feedings were started for nutritional support. On [11-30] she was transferred to the floor. She developed nausea and vomitting with tube feedings which required suspension of her feedings. She was noted to have an ileus on an x-ray of the abdomen as well as constipation. She was given laxatives for the constipation with good results. Her ileus resolved and the feeding tube was clamped. She began clear liquids with advancement to regular diet. Her feeding tube was discontinued on [12-8] and she has been tolerating a regular diet without complaints of nausea and vomitting. She began having diarrheal stool over the last 48-72 hours which is decreasing in frequency and has resolved. She was evaluated by physical therapy and hospice care. She is preparing for discharge with VNA services. Her vital signs are stable and she is afebrile. She has been ambulating in the [Doctor Last Name ]. She is requiring minimal pain medication. Her foley catheter has been discontinued and she is voiding without difficulty. Her staples have been removed from her abdomen and have been replaced with steri-strips. She will follow-up with Dr. [Last Name (STitle) ] of the Acute Care Service as well as her primary care provider. Medications on Admission: [Last Name (un) 1724]: alendronate, leuprolide, prilosec, calcium vit D3, MVI Discharge Medications: 1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily): as needed for constipation. 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). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [5-12] hours: as needed for pain. 7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours: as needed for anxiety. Disp:12 Tablet(s) Refills:0 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day for 1 months: take 30 mins prior to meals.. Disp:90 Tablet(s) Refills:0 10. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) cc Injection once a month. Discharge Disposition: Home With Service Facility: HospiceCare in the Berkshires Discharge Diagnosis: Viscus perforation Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You are being discharged from the hospital after you were admitted for abdominal pain. You had a surgical procedure called a gstrectomy. Please follow these instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [11-20] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [Doctor Last Name 24141], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2190-1-25] 10:30 Provider: [Name10 (NameIs) ] DENSITY TESTING Phone:[Telephone/Fax (1) 4586] Date/Time:[2190-3-15] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10545], M.D. Phone:[Telephone/Fax (1) 4586] Date/Time:[2190-3-15] 10:00 Please follow up with the Dr. [Last Name (STitle) ] after [Holiday 1451]. You can schedule this appointment by calling #[Telephone/Fax (1) 600]. You should also follow-up with your Primary care provider [Name Initial (PRE) 176] 2 weeks. Completed by:[2189-12-17]	[ "560.1", "425.4", "V10.3", "997.4", "733.90", "196.2", "V10.05", "E933.1", "E878.8", "V49.86", "568.89", "564.09", "151.4", "V87.41", "578.9", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.91", "43.99", "96.6", "96.08", "50.12" ]	icd9pcs	[ [ [] ] ]	12246, 12306	8805, 11133	331, 539	12369, 12369	2643, 8781	13994, 14660	1701, 1939		11265, 12223		12327, 12348		11159, 11242			12517, 13624									1954, 1977																								277, 293								13636, 13971			567, 590										1992, 2624	12384, 12493						1259, 1377	1410, 1685
18,225	147,217	29682	Discharge summary	report	Admission Date: [2167-8-7] Discharge Date: [2167-8-12] Date of Birth: [2085-11-30] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Ativan / Ciprofloxacin Attending:[First Name3 (LF) 613] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Ms. [Known lastname 2520] is an 81 year-old female with past medical history significant for respiratory failure s/p tracheostomy and decannulation who presents from home with decreased level of consciousness. Per daughter, the patient had been doing well all week. She saw her PCP on [Name9 (PRE) 766] and was given a clean [Doctor First Name ] of health. On Thursday evening the patient continued to have problems for sleep so her PCP recommended that her dose of Ambien being increased from 5mg to 10mg. The patient took her 2nd dose of Ambien at 11pm and within 1 hour she became quite sleepy and more difficult to arouse and also tachypneic. Her daughter called 911 and the patient was brought to [Hospital1 18] ED. Per daughter, her mother did not have any difficulty breathing. No recent fevers, chills, chest pain, SOB, dizziness, or dysuria. Patient has been compliant with all her medications. . In the ED her initial vitals were T 97.3 BP 145/47 AR 103 RR 26 O2 sat 98% on 4L NC. She was reactive to tactive stimuli and sternal rub. Patient appeared to become more agitated and her O2 sats continued to drop. She was placed on face mask at this time with improvement in O2 sats to 98-100%. Patient was taken to CT scan but was found to be in increased distress and was found to be "blue". Given prior tracheostomy, underwent fiberoptic tracheostomy. Given chest xray findings she received Lasix 120mg IV and Cipro 400mg IV. She then went to CT scan and then transferred to MICU for closer monitoring. . Past Medical History: . - Respiratory failure: Admitted to BIMDC in [1-14] after cardiac arrest, presumed to be secondary respiratory failure. She had a tracheostomy at that time. She was decannulated on [2167-6-19] and tolerated the procedure well. - Hypertension - Type 2 Diabetes - Lymphoma, s/p chemotherapy several years ago and s/p XRT [11-12] (unclear where radiation was targeted to) - followed at [Hospital1 2025] - Glaucoma - Cataracts, baseline anisocoria (R pupil) . Social History: Lives at home with her daughter, at baseline very active. No tobacoo/EtOH/illicits. Receives medical care primarily from B&W and [Hospital1 2025]. Family History: non-contributory Physical Exam: Vitals T 98.4 BP 105/66 AR 83 RR 16 Vent settings: AC TV 450 FIO2 1.0 RR 16 Peep 5 Gen: Patient sedated, responsive to tactile stimuli HEENT: ETT in place; anisicoria L Heart: nl s1/s2, no s3/s4, +systolic murmur Lungs: CTAB anteriorly Abdomen: soft, NT/ND, +BS Extremities: 3+ bilateral pitting edema, pulses difficult to palpate . Pertinent Results: PERTINENT LABS: [2167-8-7] WBC-12.3 Hgb-12.7 Hct-39.2 Plt Ct-267 [2167-8-7] Neuts-66.8 Lymphs-27.2 Monos-3.5 Eos-2.2 Baso-0.3 [2167-8-7] Glucose-55 BUN-18 Creat-0.9 Na-143 K-3.6 Cl-98 HCO3-37 [2167-8-7] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [2167-8-7] ABG (admission) pH-7.26 pCO2-95 pO2-106 [2167-8-11] ABG (discharge) pH-7.47 pCO2-51 pO2-73 . [2167-8-12] ALT-16 AST-15 LD(LDH)-180 AlkPhos-95 TotBili-0.3 [2167-8-11] TSH-2.2 . STUDIES: [8-7] CXR: No acute cardiopulmonary process. [8-7] CTA chest: 1. No evidence of pulmonary embolism. 2. Limited evaluation of the lung parenchyma with bibasilar atelectasis. Subtle ground-glass change may represent acute infection or subtle edema, though this is more likely to be due to patient respiratory motion. 3. Narrowing of trachea near carina may represent a component of tracheobronchomalacia, though this is unclear. . [8-7] EKG: normal sinus rhythm at 81bpm. . Brief Hospital Course: Ms [Known lastname 2520] is an 81 year-old female with PMH significant for DM, HTN, 2 prior admissions this year for respiratory failure, s/p tracheostomy in [6-13], who presented with hypercarbic respiratory failure in the setting of sedative overdose. She was initially intubated in the MICU but was extubated in less than a day. . # Hypercarbic Respiratory failure: The patient was admitted with hypercarbic respiratory failure in the setting of overdose of Ambien requiring brief intubation. The etiology of her hypercarbia was unclear but felt likely due to underlying obesity hypoventilation syndrone and obstructive sleep apnea. This was supported by the fact that she had elevated bicarbonate suggesting she is a chronic CO2 retainer. ABG on RA [2167-8-11] was also consistent with chronic CO2 retention. Her hypercarbia resolved when on bipap overnight, however she was not always able to use the mask secondary to her anxiety. She was evaluated by pulmonary who felt that the etiology of her hypercarbia was likely multifactorial as above. She had a CTA of the chest which was negative for PE but did reveal some atelectasis and interstitial edema. It was recommended that she have PFTs and a sleep study, however the patient refused both of these studies. She also refused TTE to evaluate her cardiac function given her fluid overload on exam. Overnight pulse oximetry study was attempted but had to be discontinued secondary to anxiety, though it did note that she desaturated to the mid-80s on rooma air. She was discharged with home O2 and bipap. . # Anxiety: Throughout her hospitalization, the patient demonstrated significant anxiety regarding her medical condition and being in the hospital. She responded well to frequent reassurance. She was given trazodone for sleeping. Ambien and other sedatives were avoided. She was evaluated by psychiatry in house. They did not have any further specific recommendations at this time. Outpatient follow-up was recommended but the patient was not interested at the time. . # Hypertension: She takes Diltiazem and Metoprolol at home. Both were held while in MICU. Lopressor was re-started on the floor. She was re-started on her home dose of diltiazem on discharge, as she had been normotensive on the floor with only the beta blocker. . # Insulin-dependent Type II DM: She takes Humulin at home (40 qAM, 28 pre-dinner). She was treated with NPH here as well as a humalog sliding scale. On discharge she was to re-start her home insulin regimen. It was recommended that she discuss with her PCP starting [Initials (NamePattern4) ] [Last Name (NamePattern4) 71114] ACEI, baby aspirin, and a statin as an outpatient, as these have all been shown to decrease cardiovascular risk in patients with diabetes. . # Positive UA: Urinalysis on admission showed moderate leukocytes & bacteria. She also had a peripheral leukocytosis with WBC of 12.3. She denied urinary symptoms. She was started on Cipro in the ED, however given history of cipro allergy, was changed to Macrobid. Urine culture was unremarkable (~[2159]/mL gram positive bacteria and ~1000/mL probable enterococcus) so macrobid was discontinued. . Medications on Admission: Diltiazem 360mg PO daily Omeprazole 40mg PO daily Metoprolol 12.5mg [Hospital1 ] Furosemide 40mg PO BID Humulin-N 40 units qAM, 28 units qPM . Discharge Medications: 1. Home Oxygen Continuous home oxygen at a rate of 2L per minute to maintain O2 sat >92% 2. Furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 3. Timolol Maleate 0.25 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Dorzolamide 2 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Dorzolamide-Timolol 2-0.5 % Drops [Hospital1 ]: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 6. Brimonidine 0.15 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 8. Trazodone 50 mg Tablet [Hospital1 ]: 0.5 Tablet PO HS (at bedtime). 9. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge [Hospital1 ]: Forty (40) units Subcutaneous before breakfast. 10. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge [Hospital1 ]: Twenty Eight (28) units Subcutaneous at night. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Hypercarbic respiratory failure Secondary: 1) Anxiety 2) Type II Diabetes, insulin-dependent 3) Hypertension Discharge Condition: Stable, sat'ing well on 2L of oxygen. Discharge Instructions: You were admitted to the hospital for respiratory failure after taking an extra dose of your sleeping medication Ambien. Given that you have had 2 recent prior admissions for respiratory failure, including one that led to intubation and tracheostomy, it is likely that you have an underlying breathing disorder that caused you to be extra sensitive to the Ambien. You were briefly intubated in the medical intensive care unit but quickly stabilized and they were able to take the breathing tube out without any difficulty. On the medicine floor you were treated with a breathing machine called BiPAP for one night. Upon discharge the underlying breathing disorder causing your respiratory is still unknown. You were evaluated by the pulmonary doctors here who think that you may have a disorder called obesity hypoventilation syndrome and possibly sleep apnea. You would need pulmonary function tests and a sleep study to confirm the diagnosis. . At home you should use oxygen at night while sleeping. The best treatment would be to use the BiPAP mask at night, however you have refused the sleep study and pulmonary function tests necessary to qualify for this treatment. . You should NOT take Ambien at nighttime. You may take the trazodone at the dose prescribed for you (25mg at bedtime). Do not take higher doses of the trazodone, or combine it with any other sedative (sleeping) medicines. . If you should develop fever, chest pain, shortness of breath, or lethargy please go to the nearest emergency room. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] of Pulmonary on [8-31]. Your appointment is at 2:30pm but please arrive at 2pm for breathing tests prior to your appointment. The office is in the [Hospital Ward Name 23] Building at [Hospital1 18], [Location (un) 436], medical subspecialties. Phone number is [Telephone/Fax (1) 612]. . It was recommended that you have an outpatient sleep study, and one was in the process of being arranged for you during your admission, however you have declined having the study performed. If you change your mind, please call the Sleep Health Center. The phone number is ([Telephone/Fax (1) 71115]. . Please follow up with Dr. [First Name (STitle) ] in the Sleep clinic on [2167-8-26] at 1:40pm. The office is located in the [Hospital Ward Name 23] building, [Location (un) ]. . Please also follow-up with your primary care provider in the next two weeks. Talk to your primary care provider about starting [Name9 (PRE) 71114] aspirin, which is recommended for people like yourself who have diabetes. . [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "V15.3", "250.02", "967.8", "V46.2", "492.8", "365.9", "E852.8", "E849.0", "276.4", "518.81", "327.23", "401.9", "V10.79", "278.00", "599.0", "309.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	8412, 8469	3986, 7172	324, 349	8631, 8671	2975, 2975	10235, 11479	2589, 2607		7369, 8389		8490, 8610		7198, 7346			8695, 10212									2622, 2956																								276, 286											377, 1908												2992, 3963					1930, 2404	2420, 2573
19,763	188,613	19559	Discharge summary	report	Admission Date: [2185-4-30] Discharge Date: [2185-5-6] Date of Birth: [2126-1-10] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Norvasc Attending:[First Name3 (LF) 6114] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Bronchoscopy with embolization of branches of left bronchial artery [2185-4-30], [2185-5-1] and bronchospcopy with endobronchial Argon tumor destruction on [2185-5-5]. History of Present Illness: 59 year-old male w/hx of renal cell CA with lung mets diagnosed in [1-7] s/p nephrectomy and experimental chemotherapy who initialy presented to OSH with 3 episodes of hemopytsis and was subsequently transferred to [Hospital1 18]. Last infusion w/chemo was 5 days prior to admission. He had 2 episodes of frank hemoptysis in [Hospital1 ] ED (up to 300cc). Vital signs were stable on arrival to the ED. CTA was done and showed consolidation of middle lobe and suspicious lymph node in area of pulmonary artery bifurcation and bronchial tree. He was taken to the OR by Dr. [First Name (STitle) ] [Name (STitle) ] and underwent selective right mainstem intubation. Rigid bronch showed massive bleeding from left lower lobe. There was no endobronchial lesions seen initially. IR was called for emergent embolization. [4-30] the patient underwent embolization of the left bronchial artery. Past Medical History: 1. Stage IV Renal Cell Carcinoma: Metastatic to lung. Diagnosed [12-7] when presented with cough and noted on CT to have Left hilar mass and right renal mass as well as RP lymophadenopathy. Bone scan and brain MRI were negative. S/p debulking nephrectomy at OSH on [2184-3-1], complicated by pulmonary embolism and near fatality. Started on PROTOCOL:04-099 Avastin + Tarceva/placebo [7-7]. 2. HTN 3. Hiatal Hernia repair [2159] 4. Pulmonary Embolism after nephrectomy [2-4], treated with lovenox x 6 months, s/p IVC filter placement. 5. Colonscopy approx [2179] s/p polypectomy 7. Oral Mucositis improved with decreased Tarceva dose and addition of prednisone and kelfex Social History: Tobacco: quit smoking approximately 25 years ago. He smoked one pack per week prior to this for approximately 10-15 years. He currently drinks [12-5] glasses of wine per night with dinner. He lives in [State 2748] and is currently employed as a contract negotiator. Family History: The patient notes he has 4 maternal uncles who died of colon cancer. Physical Exam: VS: Tm 101.3 ([5-1] @1400) Tc 98.9 HR 55 (49-88) BP 145/76 ABP: (118-171/61-94) RR 20([11-28]) Sat 98% RA Gen: WN/WD man in bed laying on right side. Wife @ bedside. HEENT: PERRL, MMM, sclerae anicteric. CV: regular, normal S1/S2, no m/r/g Pul: CTA b/l, no wheezes Abd: + BS, nontender, ND, no rebound or guarding. Ext: no edema, + excoriations on RLE. Neuro: A&Ox3, no gross focal neurological deficits Pertinent Results: Labs on admission: [2185-4-30] 01:35PM BLOOD WBC-10.6 RBC-5.46 Hgb-16.7 Hct-46.5 MCV-85 MCH-30.6 MCHC-35.9* RDW-13.8 Plt Ct-286 [2185-4-30] 01:35PM BLOOD Neuts-76.5* Lymphs-16.4* Monos-4.7 Eos-2.1 Baso-0.3 [2185-4-30] 01:35PM BLOOD Glucose-102 UreaN-14 Creat-1.2 Na-142 K-4.6 Cl-112* HCO3-18* AnGap-17 [2185-5-1] 03:07AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1 [2185-5-1] 12:58PM BLOOD Lactate-1.2 [2185-5-1] 12:42AM BLOOD Type-ART pO2-384* pCO2-52* pH-7.26* calHCO3-24 Base XS--4 Labs on discharge: [2185-5-6] 08:30AM BLOOD WBC-8.9 RBC-4.64 Hgb-13.9* Hct-39.6* MCV-85 MCH-30.0 MCHC-35.2* RDW-13.4 Plt Ct-262 [2185-5-6] 08:30AM BLOOD Glucose-101 UreaN-16 Creat-1.3* Na-140 K-4.2 Cl-108 HCO3-21* AnGap-15 [2185-5-6] 08:30AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0 MICRO DATA: [5-1] Blood, urine, sputum cultures no growth [5-6] Urine cx <10,000 organisms CTA [2185-4-30]: 1) Interval development of ground-glass opacity within the left lower lung lobe and left lingula, which in this patient with history of hemoptysis, may represent alveolar hemorrhage. Differential diagnosis also includes infection or pulmonary edema. In the bronchus supplying this region of the lung is seen small amount of soft tissue density, which could represent metastatic disease, blood clot or alternatively respiratory secretions. 2) Small nonocclusive pulmonary embolus in a branch of the pulmonary artery to the left upper lung lobe. This embolus is located peripherally within the vessel, is nonocclusive, and is therefore likely subacute. Dilated bronchial arteries seen within the aortopulmonary window, which could be secondary to chronic pulmonary emboli. 3) No evidence for aortic dissection within the thoracic, abdominal aorta, extending to the bifurcation. 4) Unchanged disease status from the CT torso 5 days prior. CXR [2185-4-30]: No evidence of pneumonia, pleural effusions, or hemothorax. CXR [2185-5-6]: Persistent left lower lobe patchy opacity with small effusion, which may represent pneumonia in this patient with fever. Brief Hospital Course: 1. Hemoptysis. The patient underwent emergent bronchoscopy and embolization of left bronchial artery on [2185-4-30]. Post-procedure, the patient was admitted to the MICU. On [5-1], he underwent another bronchoscopy which revealed old blood clot and endobronchial mass in the superior segment of LLL. There was no active bleed. He was called out to the floor on [5-2] but shortly after the transfer, Mr. [Known lastname 20889] had another episode of hemoptysis (~400cc). He was then brought back to the MICU. Thoracic Surgery was called to evaluate the patient for pneumonectomy. They thought that he is not a candidate for pneumonectomy. After consultation with Surgery and Interventional Pulmonology, the decision was made to proceed with a more aggressive embolization at this time. On [5-3], the patient underwent another IR-guided embolization of the branch of the left bronchial artery that was thought to be the culprit lesion. Interventional radiology concluded that the endobronchial lesion seen on CT is unlikely the source of the bleed and therefore another rigid/flexible bronchoscopy was performed [5-5] for Argon coagulation of endobronchial lesion in left superior lingular segment. The patient tolerated the procedure well and is now transferred to the medical floor on [2185-5-5]. He was monitored overnight and had no further episodes of cough or hemoptysis. The patient was started on codeine for cough suppression. 2. Fever. Shortly after initial presentation, the patient spiked fever and was transiently treated with Levo/Vanc empirically for fever but this was discontinued. His blood culture, urine culture, and sputum collected at that time were unreveling. Fever was attributed to post-procedural fever/atelectasis. However, the patient continued to have intermittent fevers. He spiked to 100.6 on [2185-5-5]. CXR was read as patchy LLL opacity with small pleural effusion for which pneumonia was in the differential. UA was negative. Because the patient was on codeine for cough suppression which could have masked his symptoms and because of his likely immunocompromised status due to malignancy/chemo, the decision was made to treat him empirically with a 7-day course of Levaquin. 3. Renal cell carcinoma, stage IV. His chemotherapy was discontinued on [2185-5-2] per his primary oncologist Dr. [Last Name (STitle) ]. The patient will follow up with Dr. [Last Name (STitle) ] in clinic in approximately one week at which time the need to continue chemo will be discussed. 4. H/o HTN. The patient was continued on outpatient dose of Atenolol. He was on low sodium diet. 5. H/o peri-operative PE s/p IVC filter placement in remote past. CTA revealed subsegmental subacute PE. He was not anticoagulated during this admission given hemoptysis. He also has a h/o GI bleed while on Lovenox. Had a polypectomy in [2179]. However, the risks/benefits of anticoagulation will need to be reassessed if the patient remains stable from bleeding perspective as IVC filters do not offer long-term protection against PE. 6. Code: full Medications on Admission: Avastin and Tarcevia/placebo (chemo) Atenolol Protonix Benzoyl Peroxide Wash Clindamycin topical Cream Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for cough. Disp:60 Tablet(s) Refills:0 4. Levaquin 250 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Please take 2 pills today then take one pill once a day. Disp:8 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Hemoptysis Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep follow up with Dr. [Last Name (STitle) ] in Hematology/Oncology in one week. Please call your doctor or return to emergency room for evaluation immediately if you start coughing blood, have fever, shotness of breath, or other concerning symtoms. Followup Instructions: Please keep follow up with Dr. [Last Name (STitle) ] in Hematology/Oncology in one week. Completed by:[2185-5-8]	[ "V10.52", "V12.51", "401.9", "528.0", "197.0", "518.82", "786.3", "564.00" ]	icd9cm	[ [ [] ] ]	[ "96.04", "32.01", "39.79", "88.44", "33.23", "96.71", "88.43" ]	icd9pcs	[ [ [] ] ]	8825, 8831	5065, 8168	300, 483	8889, 8898	2971, 2976	9253, 9376	2450, 2521		8322, 8802		8852, 8868		8194, 8299			8922, 9230									2536, 2952																								250, 262					3490, 5042						511, 1423										2990, 3471							1445, 2142	2158, 2434
56,589	154,175	24331	Discharge summary	report	Admission Date: [2129-5-7] Discharge Date: [2129-5-30] Date of Birth: [2084-8-24] Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media / Penicillins Attending:[First Name3 (LF) 1515] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Chest tube Endotracheal intubation Central line CVVH, hemodialysis Laparoscopic Right Adrenelectomy, Urology History of Present Illness: The patient is a 44 yo woman with h/o anxiety who presented to an OSH ED with abdominal pain. Mrs. [Known lastname 8738] was reportedly in her normal state of health until approximately 9 am this morning, when she developed abdominal pain. She vomited twice and then developed worsening abdominal pain radiating to her back. She also had associated palpitations and diaphoresis. She thus presented to [Hospital1 18] [Location (un) 620] for further evaluation. . At the OSH ED, her initial VS were BP 204/100, P 138, R 36, O2 99% on RA. She was initially given Zofran, 1L of NS, and she was ordered for a CTA to evaluate for PE and aortic dissection. While in the CT scanner, she became increasingly hypoxic and confused and was emergently intubated. She was also given Diltiazem 10 mg IV for tachycardia and received one dose of Lasix 60 mg IV. EKG at the time demonstrated STE in V2 with ST depressions in V3-V6, so she was sent to [Hospital1 18] for urgent cardiac catheterization. . In the cath lab, she was found to have clean coronary arteries. She was found to have a PCWP of 25, and bedside TTE demonstrated an EF of 25-30%. She developed tachycardia to the 160s, for which she received Adenosine x3 and carotid massage, which did not improve the tachycardia. She was then given another dose of Diltiazem, which briefly decreased her pulse to the 130s. She became hypotensive to SBP of 70, was started on Levophed, and was transferred to the CCU. . In the CCU, the patient is intubated and sedated and cannot provide further history. Per her family, she has been complaining of frequent sweating, an increase in her resting tremor, and recent diarrhea. Otherwise, she has had no recent complaints. . Review of systems was unable to be obtained. Past Medical History: Anxiety Tremor Social History: The patient lives with her husband and son in [Name (NI) ], MA. She has three children who all live in the area. She currently works in medical records. She does not smoke cigarettes and she drinks ~1 glass wine/night. She does not use illicit drugs Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam VS: T= 102.8 (rectal) BP= 107/93 HR= 156 RR= 25 GENERAL: Intubated, sedated. Not withdrawing to painful stimuli. HEENT: PERRL. CARDIAC: PMI located in 5th intercostal space, midclavicular line. tachycardic. No m/r/g. No S3 or S4. LUNGS: Course breath sounds diffusely. Crackles at bases. ABDOMEN: Soft, NTND. EXTREMITIES: Cool, mottled extremities. SKIN: No rashes appreciated. PULSES: Right: Femoral 1+ DP dopplerable Left: Femoral 1+ DP dopplerable . Discharge Exam VS: T= Afebrile BP= 110/80's HR= 90-100 RR= 15 GENERAL: NAD, Pleasant HEENT: PERRL. EOMI CARDIAC: Regular, No m/r/g. No S3 or S4. LUNGS: CTA B ABDOMEN: Soft, NTND. EXTREMITIES: Lower extremity swelling bilaterally SKIN: No rashes appreciated. Pertinent Results: Admission labs: [2129-5-7] 03:00PM GLUCOSE-252* UREA N-21* CREAT-2.0* SODIUM-143 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-13* ANION GAP-26* [2129-5-7] 06:01PM WBC-21.3* RBC-4.95 HGB-14.8 HCT-45.7 MCV-92 MCH-29.9 MCHC-32.4 RDW-13.4 [2129-5-7] 06:01PM NEUTS-87* BANDS-4 LYMPHS-3* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2129-5-7] 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2129-5-7] 03:09PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . Discharge labs: [2129-5-30] 08:50AM BLOOD WBC-5.8 RBC-3.17* Hgb-9.6* Hct-28.4* MCV-90 MCH-30.2 MCHC-33.7 RDW-14.2 Plt Ct-373 [2129-5-30] 08:50AM BLOOD Glucose-107* UreaN-56* Creat-7.9* Na-133 K-4.2 Cl-97 HCO3-22 AnGap-18 . Plasma Metanephrines and MEN2 AND FMTC MUTATIONS: Test Result Reference Range/Units EXONS 10,11,13-16 SEE NOTE RESULT: NO MUTATION DETECTED Interpretation: Nucleotide sequence analysis of the RET [Last Name (un) ]-oncogene (exons 10, 11, 13, 14, 15, and 16) was negative for mutations associated with MEN2 or FMTC. This negative result must be evaluated in conjunction with this patient's clinical findings and family history. This assay will not detect all mutations causing MEN2 or FMTC. Laboratory results and submitted clinical information reviewed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 61649]-Burckle, Ph.D., ABMG, CGMB, HCLD. Multiple endocrine neoplasia type 2 (MEN2) is an autosomal dominant genetic disorder with a high lifetime risk of medullary thyroid cancer. It is classified into three subtypes, MEN2A, familial medullary thyroid carcinoma (FMTC), and MEN2B, based on the presence of other clinical presentations. MEN2 is caused by mutations in the RET [Last Name (un) ]-oncogene. This assay detects disease-causing mutations in over 95% of MEN2A and MEN2B cases, and over 85% of FMTC cases. Mutation identification can be used to confirm a diagnosis, screen individuals at risk for familial disease, or distinguish familial from sporadic disease. In this assay, sequences including exons 10, 11, 13, 14, 15 and 16 of the RET [Last Name (un) ]-oncogene are amplified from genomic DNA by polymerase chain reaction (PCR) followed by nucleotide sequence analysis on an automated capillary DNA sequencer. Particular attention is paid to the sequence changes at the codons known to be hot spots for mutations causing MEN2. Since genetic variation and other problems can affect the accuracy of direct mutation testing, the results should always be interpreted in light of clinical and familial data. This test is performed pursuant to a license agreement with [Doctor Last Name ] Molecular Systems, Inc. This test was developed and its performance characteristics have been determined by [Company 5620] [Doctor Last Name ] Institute, [Location (un) 42066] Capistrano. Performance characteristics refer to the analytical performance of the test. . Metanephrines (Plasma) Test Name Flag Results Units Reference Value --------- ---- ------- ----- --------------- Metanephrines, Fract., Free Normetanephrine, Free H 405 < 0.90 nmol/L Metanephrine, Free H 325 < 0.50 nmol/L . STUDIES: [5-7] TTE: Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to akinesis of all basal segments, hypokinesis of the midventricular segments, and relative preservation of apical function, although the true apex was poorly visualized. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [5-7] post-line CXR: In comparison with the earlier study of this date, there has been placement of a left IJ catheter that extends to the mid portion of the SVC. However, there has also been the development of a large left pneumothorax. Transabdominal U/S: IMPRESSION: 8.9 cm right adnexal mass appears to engulf the right ovary but does not appear to arise from it and appears immediately adjacent to the right uterine fundus, though it does not show typical signs that it arises from it. This suggests that it may be adnexal in origin and a differential possibility includes extra-adrenal paraganglioma, given the known right adrenal mass. For further characterization of this lesion, MRI would be very helpful. MRI Abdomen 3.1 cm right adrenal mass, nonspecific by imaging, but apparantly hemorrhagic in nature. Differential includes pheochromocytoma, adrenocortical carcinoma, or metastasis. [5-27] TTE Overall left ventricular systolic function is low normal (LVEF 50%). Compared with the findings of the prior study (images reviewed) of [2129-5-12], the left ventricular ejection fraction is increased Pathology: Right Adrenal Gland Tissue: Pending Brief Hospital Course: # Adrenal mass: On admission to [Hospital1 ]-[Location (un) 620], CT-A was performed to evaluate for PE (was negative for PE). Incidentally, a 5 cm adrenal mass was seen as well as a 9 x 6 cm mass on the right ovary. The 5-cm adrenal mass was 50-70 Hounsfield units and was concering for pheochromocytoma. Plasma metanephrines were > 500x normal. MRI was obtained and could not characterize the adrenal mass further. Endocrine felt strongly that the mass was consistent with pheochromocytoma. Empiric therapy was begun with doxazosin at 1 mg [Hospital1 ] and labetalol at 200 mg [Hospital1 ]. She was taken to the OR on [2129-5-25] where urology performed a laparoscopic right adrenalectomy. Pt recovered from the procedure well though remained tachycardic to the 100s several days post-procedure and was started on metoprolol. Final pathology results of adrenal tissue pending at time of discharge. # HYPOTENSION: Initially thought to be secondary to cardiogenic versus septic shock, also in differential was anaphylaxis from IV contrast. On exam patient with peripheral vasocontriction, ECHO demonstrating depressed EF 20-25% with apical sparing, PCWP of 25, CXR with pulmonary edema -> all suggestive of cardiogenic shock. Patient with leukocytosis to 21.3, bands 4% and febrile without a clear source of infection though patient did report abdominal pain to her family earlier in the day. Given her troponin elevation to 6.22 (in the abscence of shock liver lab values), myocarditis was high on differential. Other considerations included pheochromocytoma causing catecholamine-induced cardiomyopathy in reverse Takasubo distribution. She was started on multiple pressors overnight - 12L of fluids were also administered. Empiric anitbiotics were begun and continued for 7 days. The morning after admission, pressors were weaned after needle decompression of L pneumothorax and chest tube placement. Of note, the patient was on 2 pressors prior to line placement and subsequent pneumothorax. Her pressures remained in the 100s-120s/40s-50s for the next several days. Her echo with apical sparing were consistent with a catecholamine-induced cardiomyopathy, and her hypertension on presentation as well as reports of episodic diaphoresis and nausea from her husband, were all consistent with pheochromocytoma. Thus endocrinology was consulted (see below). Her lactate, which had been elevated to 8 with her most profound hypotension, improved to 2 shortly after pressors were weaned. . # Hypertension: After resolution of the above hypotension, the patient had episodic hypertension. She was started on doxazosin 1 mg [Hospital1 ] and labetalol 200 mg [Hospital1 ]. Despite this, the patient had intermittent episodes where BP acutely raised to 200s/100s. She was intermittently treated with IV labetalol and nitro gtt. She was transitioned to doxazosin 1 mg po BID and labetalol 200 mg po BID with stability in her blood pressure. . # SYSTOLIC HEART FAILURE: Cardiac cath demonstrated no coronary disease but elevated PCWP to 25. ECHO showed depressed EF 20-25% with apical sparing, and troponin was elevated to 7. These findings were thought to be most likely related to catecholamine-induced cardiomyopathy and myocarditis. Repeat TTE after resolution of hypotension showed slightly improved EF, but with persistent systolic dysfunction. ECHO prior to discharge showed improving myocardial function with EF of 50%. . # HYPOXIC RESPIRATORY FAILURE: Likely caused by pulmonary edema due to systolic CHF and possibly anaphylaxis. Patient was intubated at OSH. Blood gas on arrival demonstrated acidemia (7.08) and hypoxemia. She was ventilated, and acidemia corrected with bicarbonate. Once her blood pressure stabilized, fluid was removed with CVVHD and her mental status improved, she was extubated on [2129-5-15] without any complications. . # Altered Mental Status: After intubation, the patient was initially sedated with midazolam and fentanyl drips. Unfortunately, altered mental status remained the main barrier to extubation 1 week after admission. Fent/midazolam drips were stopped 4-5 days into admission, but were thought to have accumulated in the setting of renal and liver failure. Neurology was consulted. Head CT on [5-13] was negative. She gradually became more responsive and mental status dramatically improved on [5-15] and she was extubated. # ACUTE RENAL FAILURE: Likely secondary to hypotension and consequent dense ATN, her creatinine continued to rise and she made <10cc/h of urine in the first few hours at [Hospital1 18]. Potassium also rose to 7. Thus, L IJ hemodyalisis line was placed and CVVHD initiated. After several days, intermittent HD was attempted, but the patient because hypotensive. CVVH was restarted. Tunneled line was placed on [5-17]. She required CVVH and then intermittend HD. Her ATN continued to resolve. She made over two liters of fluid the day prior to discharge with stability in her creatinine and other electrolytes. Patient will follow up with labs two days after discharge and see renal on [6-8] for further evaluation. . # PHEUMOTHORAX: After placement of hemodialysis line, patient was noted to become progressively more hypotensive and difficult to oxygenate the night of admission on [2129-5-7]. She was found to have a large left pneumothorax with diaphragmatic eversion and mediastinal shift. Needle decompression followed by chest tube placement were undertaken, and her hypotension and hypoxia improved considerably after this on [2129-5-8]. . # METABOLIC ACIDOSIS: Gap acidosis likely secondary to elevated lactate/hypoperfusion. In the setting of concominant pressor-requiring hypotension, she was given bicarb gtt and She later developed a concominant alkalosis (normal bicarb and anion gap 25) due to the CVVHD bath. . # TACHYCARDIA: Sinus, initially in the 150s, secondary to hypotension initially. HR improved to the 120s after hypotension resolved, and was likely secondary to underlying hyper-adrenergic state. At discharge patient had heart rates ranging 80-100s on Metoprolol. . # Fever: The patient was febrile to 102 on admission and began to spike fevers again on [5-11]. Blood cultures were negative. CXR did not show infiltrate concerning for infection. She completed 7 days of vancomycin/flagyl/cefepime. The fevers persisted throughout the first 10 days of admission. . # Anemia: Hct fell from 45 to 26.3 on [5-14]. 1U of PRBCs was transfused. Hemolysis labs were negative. The drop was thought to be secondary to decreased production in the setting of critical illness - retic count was suppressed at ~ 1% and also RP bleed, likely from cardiac cath on [5-7]. Hct stabilized after transfusion. CT scan on [5-17] showed RP bleed contained within the pelvis. Transfused 1 unit of PrBC on [5-21] . # Shock Liver: After admission and hypotension the first night of admission, the patient's liver enzymes rose - ALT/AST were in the 20,000s. These gradually trended down over the 1st week of admission. . ACCESS: Initially, a swan ganz catheter was placed in the R femoral vein. This was eventually removed in order to obtain MRI. A left HD catheter was placed. On [5-17] in IR, the HD catheter was tunneled and a PICC line was placed. . CODE: Full (confirmed with family) . COMM: [Name (NI) 4906] and sisters. [Known lastname ],[First Name3 (LF) ]. Phone: [Telephone/Fax (1) 61650], Other Phone: [Telephone/Fax (1) 61651]. . FOLLOW-UP: Patient has been scheduled to see renal, endocrine, primary care, and renal in the coming weeks. Patient to have basic metabolic profile checked two days after discharge. Outstanding tests: final pathology report from right adrenal tissue and urine culture. Medications on Admission: Clonazepam prn for anxiety MVI daily Fish Oil daily Excedrin prn for headache Discharge Medications: 1. Outpatient Lab Work check Chem-7, Ca, Mag and Phos, CBC on Wednesday [6-1] with results to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1366], MD [Telephone/Fax (1) 721] and [Last Name (un) ],PERMINDER [Telephone/Fax (1) 29110] 2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 4. Fish Oil Oral 5. heparin (porcine) 5,000 unit/mL Solution Sig: 4,000-11,000 units Injection PRN (as needed) as needed for line flush: needs to be done at least once a week. 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Capsule(s) Refills:2 11. Dialysis catheter flush Heparin flush 1000 units per ml. Withdraw old heparin flush. Inject volume that equals dwell volume recorded on the catheter (about 4 ml). Please flush 2 times per week. Please also change dressing two times per week at the same time. Call Dialysis here at [Hospital1 18] with any questions. [Hospital Ward Name 121] 7 Hemodialysis Operating Unit:[Hospital1 18] Office Location:W/[Hospital Ward Name ] Office Phone:([Telephone/Fax (1) 61652] Office Fax:([Telephone/Fax (1) 61653] Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Right adrenal mass/pheochromocytoma s/p adrenalectomy Acute Systolic Dysfunction, now resolving Acute Tubular necrosis Delerium Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain and we found a mass on your adrenal gland that we think is a pheochromocytoma. This diagnosis will be confirmed with the biopsy results. This mass caused changes in your blood pressure and acute kidney failure. Your kidneys are slowly improving and you will need to be followed closely by Dr [Last Name (STitle) 1366] to see if you need to have more dialysis. You will need to have your labs checked this week to follow your kidney function. You needed to be on a breathing machine to help you through the acute illness as well. Your heart became weak because of your illness but is improving and almost normal now. A cardiac catheterization did not show any blockages in your coronary arteries. You still have some fluid overload because of your kidney dysfunction. Weigh yourself every morning, call Dr. [Last Name (STitle) 11302] if weight goes up more than 3 lbs. in 1 day or 5 pounds in 3 days. You were confused in the CCU because of your sickness and the medicines you received. This is very common and has resolved. You may have some memory issues and occasional confusion over the next week or so but please call Dr. [Last Name (STitle) 11302] if you notice this is worsening. We made the following changes to your medicines: 1.Take tylenol instead of excedrin for any pain 2. START taking ferrous sulfate (iron) to treat your anemia 3. START taking docusate (colace) to prevent constipation with the iron 4. START taking nephrocaps while your kidneys are not working well 5. START taking Calcium acetate to lower your phosphorus level 6. START taking Metoprolol to slow your heart rate. 7. You will have the dialysis catheter flushed and the the dressing changed twice weekly by VNA. Followup Instructions: Department: DIV OF GI AND ENDOCRINE When: FRIDAY [2129-7-1] at 1 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1803] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: WEST [Hospital 2002] CLINIC When: Thursday [2129-6-9] at PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1366], MD [Telephone/Fax (1) 721] Campus: WEST Best Parking: [Street Address(1) 592] Garage Name: [Last Name (un) ],PERMINDER Address: [Apartment Address(1) 45001], [Location (un) ],[Numeric Identifier 3862] Phone: [Telephone/Fax (1) 29110] Appt: Wednesday, [6-1] at 1:30pm Department: SURGICAL SPECIALTIES When: THURSDAY [2129-6-23] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 11307], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "428.0", "428.21", "785.50", "276.7", "584.5", "427.89", "285.9", "780.09", "287.5", "518.81", "E879.8", "780.60", "429.83", "276.2", "401.9", "E879.0", "998.11", "E879.1", "300.00", "512.1", "276.1", "570", "227.0" ]	icd9cm	[ [ [] ] ]	[ "39.95", "96.72", "54.21", "88.56", "37.23", "38.95", "38.97", "07.22", "96.6", "34.04" ]	icd9pcs	[ [ [] ] ]	18355, 18404	8613, 12508	326, 437	18583, 18583	3440, 3440	20503, 21613	2562, 2677		16537, 18332		18425, 18562		16435, 16514			18734, 20480		4001, 8590							2692, 3421																								275, 288											465, 2235							3456, 3985				18598, 18710						2257, 2274	2291, 2546
50,507	163,741	37021+58118	Discharge summary	report+addendum	Admission Date: [2142-8-1] Discharge Date: [2142-8-6] Date of Birth: [2077-9-24] Sex: F Service: NEUROSURGERY Allergies: Aleve / Erythromycin Base / Simvastatin / Boniva / Augmentin / diltiazem Attending:[First Name3 (LF) 1271] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: [2142-8-3]: Right craniotomy for tumor resection History of Present Illness: This is a 64 year old woman with a h/o stage III NSCLC s/p completion of chemoradiation approximately 8 weeks ago, transferred from [Location (un) 620] with L-sided weakness and head CT demonstrating a new right brain lesion. Reportedly, the patient experienced left arm pain approximately 4 weeks ago although thought the symptoms were related to her pre-existing diagnosis of polymyalgia rheumatica. However, over the past 1 week, the patient has experienced generalized left-sided weakness in association with tingling of her left hand/fingers. In the evening on [2142-7-31], she was noted to "slump" to the floor, having lost strength on her left side, and was subsequently taken to [Location (un) 620] ED for further evaluation. She underwent a head CT which demonstrated an approximate 4x4cm right brain lesion with mass effect (1cm right-to-left) and surrounding vasogenic edema. She was then transferred to [Hospital1 18] for neurosurgical evaluation. Of note, she reports mild headache, although denies vertigo, dizziness, lightheadness, blurry/double vision, nausea/vomiting, head/neck/abdominal pain. No history of similar symptoms. Past Medical History: ONCOLOGIC HISTORY: -Presented in Spring [2141] to cardiologist with dyspnea and lightheadedness. CXR prior to catherization showed a possible pneumonia. CT then showed evidence of mediastinal lymphadenopathy, as well as a splenic abnormality. Underwent a CT guided core biopsy of the spleen on [2141-5-25] consistent with diffuse large B-cell lymphoma. Bone marrow biopsy on [2141-6-12] without disease. [Date range (2) 83474] 6 cycles of R-[Hospital1 ]. . -Stage III NSCLC (dx on [11-5] apical posterior segment of the left upper lobe mass). Treated chemoradiation with [Doctor Last Name ]/taxol on [12-4] . - Coronary artery disease with history of myocardial infarction in [2126], s/p 3 stents w/ last one in [2138] - Osteoarthritis. - Polymyalgia rheumatica - Hypertension. - Steroid-induced hyperglycemia. - Status post bilateral oophorectomy for ovarian cyst ([2125]). - Status post bilateral cataract surgeries - Status post cholecystectomy. - Status post R hip replacement in [2140-6-27]. Post-op, the patient developed bilateral pulmonary emboli, IVC placed - She underwent a left hip replacement in [2140-10-27]. - GERD. - Obesity. - Depression. - "Clot" involving left kidney. - Hypercholesterolemia - PE in [2141-7-27], lovenox-->coumadin bridge - COPD Social History: - Married - Lives in [Location 1411] with her husband, 2 of her daughters and a son who has special needs - 6 children in total and 3 grandchildren - Does not work outside the home - Former smoker for 40 years, quit 3 years ago - Rare alcohol - Denies use of illicit drugs. Family History: - Father died of unknown malignancy - Mother died from complications secondary to hip surgery Physical Exam: On Admission: O: T: 97.6 BP: 109/83 HR:73 RR:18 O2Sat:96%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: equal, reactive; EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake, cooperative with exam, able to respond to directed questions. Orientation: Oriented to person, place, and date. Language: Speech with good comprehension and repetition. Naming intact. Some word finding difficulty and initial hesitance starting sentences at times. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally. 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 on RUE and RLE. L-sided weakness throughout; able to maintain antigravity with LUE and LLE, with strength 3/5. Pronator drift on left. Sensation: Intact to light touch, pinprick bilaterally. Coordination: normal on finger-nose-finger on right; unable to perform on left PHYSICAL EXAM UPON DISCHARGE: Alert/oriented x3. [Last Name (LF) 2994], [First Name3 (LF) 2995] with -5/5 strength on the left side. Incision C/D/I with staples Pertinent Results: MRI Brain w/and w/o contrast [2142-8-3]: 2.9 x 3.9 x 4.8 cm heterogenous ring enhancing mass in the medial aspect of the right temporal lobe with associated extensive vasogenic edema and mass effect over the right lateral ventricle. A 1.1 cm midline shift to the left is noted. This finding likely represent a metastatic lesion. CT Head [2142-8-3]: IMPRESSION: Postoperative changes with right temporal craniotomy, pneumocephalus, a small amount of hemorrhage surrounding the tumor resection site, and small amount of hemorrhage in the right lateral ventricle. Leftward shift of normally midline structures by 8 mm. MRI Brain [2142-8-4]: IMPRESSION: Status post resection of right temporal mass. Postoperative changes are seen with some residual enhancement, particularly at the posterior, as well as at the anterior margin of the surgical cavity. No evidence of hydrocephalus or significant change in the mass effect. CT Head [2142-8-4]: IMPRESSION: 1. Postoperative changes, with residual vasogenic edema and blood products. 2. Resolving pneumocephalus, resulting in decreased 8-mm leftward shift. 3. Increased right subgaleal seroma. Brief Hospital Course: Ms. [Known lastname 83476] was admitted from the emergency room to the floor on the Neurosurgery Service for neurological observation. She was started on decadron and dilantin, and continued her home medications except for aspirin. She was on SQH for DVT/PE prophylaxis. PT was consulted for mobilization. An MRI of her brain was obtained.... Neuro and Radiation Oncology were consulted for assistance with plan of care. On [8-2], patient had an MRI of brain with and without contrast which showed large right frontal temporal mass. Medicine was consulted for medical clearance. They recommended proceeding with the craniotomy for tumor resection. Patient went to the Operating room on [8-3] for a right frontal temporal craniotomy for tumor resection. Post operatively patient was extubated in the OR and transferred to the ICU for close monitoring. Post operative CT showed a good decompression. On [8-4] floor orders were written as she was neurologically stale. SQH was started. Post-op MRI was done. This showed expected post-op changes and some residual tumor as expected. PT thought she would benefit from acute rehab. Overnight she had an episode where she was going to the bathroom, slumped over and was unresponsive. She had a CT that was stable. Dilantin was increased as this epsidoe could have been a seizure but she started to develop a rash and she was swicthed to Keppra. On [8-5] she remained stable. On [8-6], she was awake and alert. Ambulating with assist. PT saw her and felt she was clear for home with services. She was discharged home with her Daughter and services. Medications on Admission: methyprednisolone 4mg daily, albuterol sulfate 90mcg 2puffs q4-6hprn dyspnea, digoxin 125mcg daily, advair 250/50 mcg 1 puff [Hospital1 ], lasix 20mg daily, glipizide ER 2.5mg daily, levothyroxine 175mcg daily, metoprolol ER 100mg daily, paroxetine 30mg daily, pravastatin 20mg daily, aspirin 81mg daily, tylenol prn, calcium/Vit D daily, magnesium 400mg [Hospital1 ], folic acid 0.4mg daily, multivitamin daily Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. Disp:1 bottle Refills:0 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever/headache. 15. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath. 19. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: Begin on [8-10], Please stay on this until follow-up. Disp:90 Tablet(s) Refills:1 20. dexamethasone 1 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours: For 2 days starting [8-6], then on [8-8] begin 3 tabs every 8hrs for 2 days. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Right Brain Mass Left sided weakness Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after obtaining clearance from your Neurosurgeon. ?????? You are on Keppra (Levetiracetam), please continue to take this until your follow-up when it will be decided whether it needs to be continued. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Dexamethasone taper: -On [8-6], please begin 4mg (4 tablets) every 8hrs for 2 days then taper to 3mg (3 tablets) every 8hrs for 2 days, then 2mg every 8hrs. -You will continue the 2mg every 8hrs until seen in clinic. -Continue your PPI during this time -This medication may increase your blood glucose, so limit any unnecessary sugar. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days(from your date of surgery) for removal of your staples. This appointment can be made by calling [Telephone/Fax (1) 1272]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call Dr[Name (NI) 4674] office ([Telephone/Fax (1) 4676] with any questions or concerns. ?????? You will follow-up with Neurosurgery and Neuro-Oncology at the Brain [Hospital 341] Clinic, located on the [Hospital Ward Name 516], Shapario [Location (un) ], the Neurology Suite, [Telephone/Fax (1) 1844]. Please call to make this appointment. You also have the following appointments listed: - Dr [Last Name (STitle) ]/ Dr [Last Name (STitle) ] (Heme/Onc) [Hospital Ward Name 23] Clinical Ctr [Location (un) 8939] on [2142-8-13] at 12:00pm - Dr [Last Name (STitle) 3060] (Heme/Onc) [Hospital Ward Name 23] Clinical Ctr [Location (un) ] on [2142-9-21] at 9:30 am [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2142-8-6] Name: [Known lastname 13279],[Known firstname ] Unit No: [Numeric Identifier 13280] Admission Date: [2142-8-1] Discharge Date: [2142-8-6] Date of Birth: [2077-9-24] Sex: F Service: NEUROSURGERY Allergies: Aleve / Erythromycin Base / Simvastatin / Boniva / Augmentin / diltiazem Attending:[First Name3 (LF) 1698] Addendum: Added Oxycodone to d/c meds Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. Disp:1 bottle Refills:0 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever/headache. 15. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 18. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath. 19. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: Begin on [8-10], Please stay on this until follow-up. Disp:90 Tablet(s) Refills:1 20. dexamethasone 1 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours: For 2 days starting [8-6], then on [8-8] begin 3 tabs every 8hrs for 2 days. Disp:42 Tablet(s) Refills:0 21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 136] Homecare [Name6 (MD) ] [Name8 (MD) 1041] MD [MD Number(2) 1709] Completed by:[2142-8-6]	[ "401.9", "693.0", "427.31", "198.3", "348.5", "162.2", "311", "V45.82", "E849.7", "412", "428.32", "780.39", "E932.0", "202.80", "348.4", "428.0", "496", "E936.1", "272.0", "414.01", "725", "249.00", "530.81" ]	icd9cm	[ [ [] ] ]	[ "01.53" ]	icd9pcs	[ [ [] ] ]	16547, 16729	6058, 7681	355, 410	10601, 10601	4877, 6035	12488, 14100	3259, 3354		14123, 16524		10533, 10580		7707, 8129			10784, 12465									3369, 3369																								296, 317							4717, 4858				438, 1601	3932, 4687									3383, 3629	10616, 10760						1623, 2947	2963, 3243
8,727	127,427	47643	Discharge summary	report	Admission Date: [2150-5-20] Discharge Date: [2150-6-1] Date of Birth: [2081-12-27] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 68 year old white male patient, who is a dentist, who has previously known history of coronary artery disease, who presented with chest pain with mild exertion as well as occasional chest pain at rest. He underwent cardiac catheterization which revealed significant three vessel coronary artery disease with a left ventricular ejection fraction of 60 percent and he was referred for coronary artery bypass graft. PAST MEDICAL HISTORY: Coronary artery disease, status post angioplasty in [2137]. Hypertension. Noninsulin dependent diabetes mellitus. Hypercholesterolemia. Obesity. Asthma. Benign prostatic hypertrophy. Gout. Status post total knee replacement on the left in [2145]. Nephrolithiasis. History of transient ischemic attack in [2148], as well as one in [2150-5-5], with some slurring of speech at the time. MEDICATIONS ON ADMISSION: 1. Metoprolol 50 mg p.o. once daily. 2. Cozaar 25 mg p.o. once daily. 3. Glyburide 10 mg p.o. twice a day. 4. Flomax 0.4 mg p.o. once daily. 5. Norvasc 5 mg p.o. once daily. 6. Celebrex 200 mg p.o. twice a day. 7. Lipitor 10 mg p.o. once daily. 8. Allopurinol 300 mg p.o. once daily. 9. Metformin 1000 mg p.o. twice a day. 10. Nitroglycerin p.r.n. 11. Zetia 10 mg p.o. once daily. 12. Aspirin 325 mg p.o. once daily. HOSPITAL COURSE: The patient was actually transferred to the [Hospital1 69] from [Hospital3 ] Hospital where he did present with chest pain. The patient underwent carotid artery studies at [Hospital3 ] Hospital which revealed no significant occlusion warranting treatment at that time. The patient underwent neurologic evaluation due to his prior history of transient ischemic attacks and it was the recommendation of the neurology stroke service to maintain the patient's blood pressure 120 to 160s systolic. There was no clear abnormality found in the magnetic resonance imaging which was obtained at that time. The patient was taken to the operating room on [2150-5-22], with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70], where the patient underwent coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to the diagonal and saphenous vein graft to the ramus. Postoperatively, the patient was transported from the operating room to the Cardiac Surgery Recover Unit on insulin, Levophed and Propofol intravenous drips. The night of surgery the patient was weaned from mechanical ventilation and successfully extubated. On postoperative day number one, the patient remained somewhat hypotensive on intravenous Levophed drip. By postoperative day number two, his Levophed was transitioned to Neo-Synephrine due to continued hypotension. He did remain hemodynamically stable in sinus rhythm with the rate in the 80s and blood pressure 126/69, however, on Neo-Synephrine at 1.2 mcg/kg/minute, aggressive pulmonary toilet was initiated and the patient was begun on Lopressor. On postoperative day number three, the patient had remained somewhat hypotensive, remaining on Neo- Synephrine drip, but this was ultimately weaned off by the end of the day on postoperative day number three with a systolic pressure in the one teens to 120s. The patient's chest tubes had been discontinued. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 1661]- [Location (un) 1662] drain in his leg was also discontinued. He was ultimately transferred to the telemetry floor on postoperative day number three. The patient had atrial fibrillation initially noted on the morning of [2150-5-26], which was postoperative day number four with a ventricular response of 120 to 140s. Later that day, the patient was noted to be in atrial flutter with variable ventricular response. He was treated with Metoprolol intravenously and ultimately placed on Amiodarone. The patient remained in atrial flutter over the next few days with some difficulty controlling his ventricular rate. On [2150-5-28], the patient went to the Electrophysiology Laboratory where he was treated with intravenous Ibutilide which ultimately converted him to a normal sinus rhythm with a ventricular rate in the 60s. The patient's blood pressure was stable and he was brought back to the telemetry floor after the cardioversion with Ibutilide. The patient remained on Amiodarone and has not had subsequent atrial fibrillation. Anticoagulation was initiated at that time. He was placed on intravenous Heparin drip and oral Coumadin dosing was initiated on [2150-5-28], and has been increased over the past few days. The patient remained in the hospital until today, [2150-6-1], postoperative day number ten due to the need for anticoagulation and intravenous Heparin drip as his Coumadin levels were increasing, waiting for his INR to become therapeutic. His INR was up to 1.6 today, [2150-6-1], and he was discharged to home in good condition. CONDITION ON DISCHARGE: Temperature 98.9, pulse 75, in normal sinus rhythm, blood pressure 104/60, oxygen saturation in room air 94 percent. Most recent chest x-ray was obtained today, [2150-6-1], which showed a left lower lobe atelectasis with a very small left effusion in that area. On physical examination, the patient is intact neurologically. His lungs are clear to auscultation bilaterally. His coronary examination is regular rate and rhythm. His abdomen is obese and soft. Incisions are clean and healing well. No erythema or drainage. MEDICATIONS ON DISCHARGE: 1. Zantac 150 mg p.o. twice a day. 2. Enteric Coated Aspirin 81 mg p.o. once daily. 3. Percocet 5/325 one p.o. q6hours p.r.n. pain. 4. Plavix 75 mg p.o. once daily times three months. 5. Metformin 1000 mg p.o. twice a day. 6. Glyburide 10 mg p.o. twice a day. 7. Ambien 5 mg p.o. q.h.s. p.r.n. sleep. 8. Combivent meter dose inhaler, two puffs two to four times a day as needed. 9. Flovent 110 mcg two puffs twice a day. 10. Lopressor 25 mg p.o. twice a day. 11. Flomax 0.4 mg q.h.s. 12. Celebrex 200 mg p.o. once daily. 13. Allopurinol 300 mg p.o. once daily. 14. Lipitor 10 mg p.o. once daily. 15. Amiodarone 200 mg p.o. three times a day times one week and then he is to decrease the dose to 200 mg p.o. twice a day times one week and then decrease to 200 mg once daily times two weeks and then discontinue the Amiodarone. This is per the recommendations of the Electrophysiology service here and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284]. 16. Coumadin 5 mg p.o. today [2150-6-1], and tomorrow, [2150-6-2]. The patient is scheduled to have a blood draw to check his INR and this result is to be called to Dr. [Last Name (STitle) 83606] office. Telephone number is [Telephone/Fax (1) 100656]. Dr. [Last Name (STitle) 83602] will be continuing to dose the patient's Coumadin for a target INR of 2.0 to 2.5 for postoperative atrial fibrillation. Also with the INR, the patient is going to have a blood urea nitrogen and creatinine drawn as his creatinine today was 1.4. It had been 1.5 three days ago and come down to 1.3 and then back up to 1.4 so this should be followed up as well as an outpatient. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: Coronary artery disease. Postoperative atrial fibrillation. Type 2 diabetes mellitus. FOLLOW UP: The patient is to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] in six weeks. The patient is to follow-up with Dr. [Last Name (STitle) 83602] on [2150-6-9], at 10:30 a.m. The patient is to follow-up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 100657], and the patient is also to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284] in two to three weeks. She is the electrophysiologist who saw him here at [Hospital1 69] and treated him with Ibutilide in the Electrophysiology Laboratory. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2150-6-1] 15:45:53 T: [2150-6-1] 19:22:06 Job#: [Job Number 100658]	[ "V58.61", "427.31", "414.01", "427.32", "600.00", "997.1", "E878.2", "274.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.12", "99.69", "99.29", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]								7539, 7628				5755, 7485	1049, 1483	1501, 5172																			7640, 8535																											165, 589																	612, 1023		7510, 7517
16,076	165,149	5207	Discharge summary	report	Admission Date: [2180-10-31] Discharge Date: [2180-11-7] Date of Birth: [2119-6-30] Sex: M Service: MEDICINE Allergies: Lasix / Betalactams Attending:[First Name3 (LF) 10370] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: HPI: The pt. is a 61 yo w/h/o DM1, s/p cadaveric kidney transplant([2175]), h/o CVA and chronic aspiration with recent admission to MICU in [8-15] for aspiration PNA. At this time he was treated with Zosyn/Vancomycin/Ciprofloxacin for presumed HAP. He also showed some evidence of pulmonary edema and was initially treated w/ Lasix, however he developed a rash on his chest and UE and required ethycrinic acid. Tracheostomy and PEG were placed prior to discharge. A blood cx from [8-13] drawn from a PICC line placed [8-1] grew CNS and pt was discahrged on a 2 week course of Vancomycin. . Pt presented to ED from home with respiratory distress. He was started on ceftriaxone and levofloxacin for concern for multifocal PNA. Femoral line was placed after multiple attempts at central access. He was intubated in the ER, subsequently dropped his pressure with propofol and briefly required a dopamine gtt. He was also given glucagon 5mg IVP. Initial vitals in ED showed RR 44 and O2 87% RA. Vitals in the ED, BP 130/63, HR 58. 100% AC. Started on fentanyl and versed for sedation. . On arrival to MICU, the pt's wife is present at the bedside. She reports that the patient has been home from rehab for the past 3-4 weeks and doing well. Over the past 3 days the pt has had episodes of dyspnea while laying flat, which resolved with sitting, occurring in the evenings. Denies fever or cough. . Past Medical History: Past Medical History: Cadaveric renal transplant in [2175] CVA-residual right hemiparesis DM Type I HTN Hx non-QMI and Vfib arrest [2169] with anoxic brain injury CAD/CABG [2170] Swallow study-showed silent aspiration Social History: Social History: Lives with wife at [Year (4 digits) 5348]. Most recently at [Location (un) 582] of [Location (un) 583] s/p clavicular fracture. Former endocrinologist in [Country 532]. Has homemaker who comes in 5 times a week. Has 3 daughters who visit him. Family History: Family History: Non-contributory Physical Exam: PE: Vitals: BP 122/36, HR 54 Gen: pt sedated and intubated HEENT: pupils pinpoint Neck: scar from prior trach site CV: RRR, II/VI SM loudest at apex, unable to assess JVP Resp: diffuse crackles in ant and post fields Abd: soft, NT/ND NABS, non-tender of RLQ - transplanted kidney, scar from prior PEG placement Ext: L femoral line, trace LE edema, no sacral edema Pertinent Results: [2180-10-31] 06:05AM BLOOD WBC-7.2 RBC-3.29* Hgb-9.4* Hct-29.9* MCV-91 MCH-28.6 MCHC-31.5 RDW-15.3 Plt Ct-190 [2180-10-31] 12:24PM BLOOD WBC-6.5 RBC-4.26# Hgb-11.2 Hct-36.3* MCV-85 MCH-26.4* MCHC-30.9* RDW-15.4 Plt Ct-186 [2180-11-1] 02:50AM BLOOD WBC-12.4# RBC-4.14 Hgb-11.2* Hct-35.9* MCV-87 MCH-27.0 MCHC-31.2 RDW-14.5 Plt Ct-192 [2180-11-2] 07:30AM BLOOD WBC-10.7 RBC-4.76 Hgb-12.8* Hct-41.0 MCV-86 MCH-26.9* MCHC-31.2 RDW-14.8 Plt Ct-194 [2180-10-31] 06:05AM BLOOD PT-11.3 PTT-22.1 INR(PT)-0.9 [2180-10-31] 06:05AM BLOOD Fibrino-341 [2180-10-31] 12:24PM BLOOD Glucose-361* UreaN-29* Creat-1.0 Na-137 K-4.0 Cl-104 HCO3-26 AnGap-11 [2180-11-1] 02:50AM BLOOD Glucose-203* UreaN-30* Creat-1.1 Na-138 K-4.0 Cl-105 HCO3-26 AnGap-11 [2180-11-2] 07:30AM BLOOD Glucose-167* UreaN-32* Creat-1.1 Na-145 K-3.7 Cl-106 HCO3-29 AnGap-14 [2180-10-31] 12:24PM BLOOD CK(CPK)-28* [2180-11-1] 02:50AM BLOOD CK(CPK)-23* [2180-10-31] 12:24PM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-[2166]* [2180-11-1] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2180-10-31] 12:24PM BLOOD Calcium-7.6* Phos-2.5* Mg-1.7 [2180-11-2] 07:30AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3 [2180-11-1] 02:50AM BLOOD tacroFK-2.8* [2180-10-31] 06:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2180-10-31] 06:36AM BLOOD pO2-140* pCO2-29* pH-7.25* calTCO2-13* Base XS--12 Comment-GREEN TOP [2180-11-1] 03:09AM BLOOD Type-ART Temp-36.6 Rates-/14 PEEP-5 FiO2-40 pO2-105 pCO2-45 pH-7.40 calTCO2-29 Base XS-1 Intubat-INTUBATED Vent-SPONTANEOU . ECG: [10-31] NSR, LAD, significant [Month/Year (2) 5348] artifact, no clear ST changes. . CXR: ET in place, no effusion, multifocal areas of opacity - asymetric edema vs PNA Brief Hospital Course: 1. Hypoxic Respiratory Failure The patient recently recovered from multifocal PNA requiring long intubation and trach placement. He had been doing well at home s/p trach removal. Now presenting with acute onset of respiratory distress. No witnessed aspiration event. CXR with multifocal opacities concerning for edema vs infiltrate. While on invasive ventilation had versed and fentanyl for sedation. A diagnostic bronchoscopy was preformed to evaluate and to obtain sputum culture. Pt chronically immunosuppressed given kidney transplant, has been on PCP [Name Initial (PRE) 6187]. Pt with evidence of volume overload on exam, diuresis was attempted with ethacrynic acid as the pt has history of lasix allergy. A TTE was performed to evaluate for worsening AR/MR or new focal wall motion abnormality as cause for CHF. The TTE was a limited study, and MR could be exacerbating [Last Name 3545] problem, however, no evidence of worsening by Echo. There was no evidence of infection by sputum, fever, or WBC and bronch appearance was consistent with pulmonary edema. The patient was extubated without complication and was breathing comfortably on room air. The pt was periodically agitated despite seroquel 75mg. His wife stated patient has had paradoxical response to haldol in the past, given zyprexa SL with good result. Upon arrival to the floor, the patient had one episode where he felt subjectively short of breath with no desaturation that was resolved with positioning in a seated position, and another episode which was related to aspiration of his breakfast which resolved with suctioning, sitting, and O2 cannula therapy. The patient has been saturating in the high 90's on room air since. In addition, the patient has been given ethacrynic acid IV to maintain fluid negative status. On discharge, pt's oxygen saturation was 95-98% on room air. He was breathing comfortably without the sensation of shortness of breath. He was no longer requiring diuretics and Is/Os were kept even. 2. CKD s/p cadaveric renal transplant: Pt was continued on his current regimen of tacrolimus, prednisone and cellcept. His Cr remained stable at 1.0 and 1.1 during his course. Renal was following and tacrolimus dose was increased to 4mg [Hospital1 ]. Tacrolimus levels were followed and pt was discharged on Tacrolimus 2mg PO BID. Creatinine remained stable throughout admission and but increased to 1.4 on day of discharge. Patient was instructed to have labs draws as outpatient with results faxed to primary care physician and nephrologist. 3. Hypertension: BP meds were held initially given recent hypotension with intubation. HCTZ was started for [Doctor Last Name 1567] diuresis. Patient was started on half of home dose of metoprolol. Lisinopril was not restarted due to concerns for worsening creatinine on day of discharge. 4. DM1: Patient's home regimen of NPH and insulin sliding scale. Blood sugars initially ranged into the high 200's low 300's after transfer to the floor; however, the patient was placed on bedtime lantus with HISS, and morning NPH. FS's down into mid to high 100's. Patient will be discharged on home regimen of NPH [Hospital1 ] with lispro Sliding Scale. 5. CAD s/p CABG: The patient has extensive cardiac disease, as he is s/p NSTEMI and V-fib arrest in [2169] and CABG [2170]. No evidence of ischemia on EKG. CE enzymes were cycled and negative. Medications on Admission: Medications: (Confirmed with wife) Pravastatin 20 mg Tablet PO DAILY Trimethoprim-Sulfamethoxazole DS 2X weekly Prednisone 5 mg PO Daily Tacrolimus 2mg PO Q12H Cellcept 1000mg [Hospital1 ] Metoprolol Tartrate 25 mg PO BID Insulin NPH 16U in am, [2-9] U PM Insulin Lispro 100 unit/mL Solution [Month/Day (2) ]: One (1) unit Subcutaneous q6hrs: per sliding scale. Prilosec 20mg po daily Amlodipine 5mg po daily ASA 81mg daily Seroquel 75mg [Hospital1 ] Discharge Medications: 1. Pravastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Hospital1 ]: One (1) Tablet PO 3x/week (MWF). 3. Tacrolimus 1 mg Capsule [Hospital1 ]: Two (2) Capsule PO Q12H (every 12 hours). 4. Prednisone 1 mg Tablet [Hospital1 ]: Four (4) Tablet PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 7. Insulin Sliding Scale Please see attached sliding scale 8. Insulin NPH Human Recomb 100 unit/mL Suspension [Hospital1 ]: Seventeen (17) units Subcutaneous QAM. 9. Insulin NPH Human Recomb 100 unit/mL Suspension [Hospital1 ]: Two (2) units Subcutaneous QPM. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: [2-9] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 Inhaler Refills:2 12. Ipratropium Bromide 17 mcg/Actuation Aerosol [Month/Day (2) ]: [2-9] Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 Inhaler Refills:2 13. Quetiapine 25 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO BID (2 times a day). 14. Aspirin 81 mg Tablet, Chewable [Month/Day (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). 15. Hydrochlorothiazide 12.5 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO DAILY (Daily): First dose on [2180-11-9]. Disp:60 Capsule(s) Refills:2 16. Fluvoxamine 50 mg Tablet [Date Range ]: Two (2) Tablet PO BID (2 times a day). 17. Humalog 100 unit/mL Solution [Date Range ]: 0-12 units Subcutaneous four times a day: per sliding scale. Disp:10 mL Refills:2 18. Outpatient Lab Work Please draw the following lab tests on [2180-11-9]: Na, K, Cl, CO2, BUN, Cr. Forward results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5717] (ph [Telephone/Fax (1) 250]) and Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] (ph [Telephone/Fax (1) 7403]). 19. Outpatient Lab Work Please draw the following lab tests on [2180-11-16] before 8am (prior to prograf dose): Na, K, Cl, CO2, BUN, Cr, tacrolimus. Please forward the results to Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] (ph [Telephone/Fax (1) 21301]) and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5717] (ph [Telephone/Fax (1) 250]). Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary: -Hypoxic Respiratory Failure -Hypotension, now resolved Secondary: -Chronic Renal Failure with cadaveric renal transplant in [2175] -Cerbrovascular Accident with residual right hemiparesis -Diabetes Mellitus Type I -Hypertension -Coronary Artery Disease with Coronary Artery Bypass Graft -Aspiration Pneumonia Discharge Condition: Stable, aspiration risk on solid foods, somewhat confused, responsive, legally blind, russian speaking. Discharge Instructions: You were admitted to the hospital due to shortness of breath and hypoxic respiratory failure. Because your hypoxia was so severe, you were intubated (a tube was placed down into your lungs to help you breath) and moved to the intensive care unit. During this time you also developed some transient lowering of blood pressure which resolved. After looking at your chest X-ray, it was decided that the reason that you had become short of breath and had the respiratory failure was because of increased fluid in your lungs. You were given a drug called ethacrynic acid, which caused your body to remove the fluid from your lungs, and you began to breath better. Given that many times, it is the heart that is the cause of this sort of respiratory failure, you had a study done of your heart called an echocardiogram which showed that your heart was working fairly well. It may have been a temporary increase in your heart rate that may have caused it to be unable to pump blood outwards causing fluid to back up in your lungs. In addition, given that you have a history of aspirating on your food, it is important that you eat only ground up solids and pureed forms of food with crushed tablets. If you feel extremely short of breath, have severe chest pain, nausea, vomiting, diarrhea, experience loss of consciousness, please call your primary care physician [Name Initial (PRE) 2227]. Followup Instructions: Please call your primary care physician [Name Initial (PRE) 176] 1 to 2 weeks to set up an appointment. Your family members were advised to set this appointment up as well when discussing your status with the doctors.	[ "428.31", "276.0", "414.00", "427.31", "518.81", "250.01", "401.9", "428.0", "V45.81", "V42.0", "707.03", "458.9" ]	icd9cm	[ [ [] ] ]	[ "33.24", "38.93", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	11127, 11213	4576, 7999	303, 327	11580, 11686	2764, 4553	13130, 13356	2344, 2363		8517, 11104		11234, 11559		8025, 8494			11710, 13107									2379, 2745																								243, 265											355, 1765																	1809, 2019	2051, 2312
15,369	187,738	17726+56884	Discharge summary	report+addendum	Admission Date: [2151-6-28] Discharge Date: [2151-7-21] Date of Birth: [2107-3-14] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 40-year-old gentleman who was an unrestrained driver involved in a roll-over motor vehicle crash who was ejected from the car. The [Known firstname ] was found unresponsive at the scene with a GCS of 8 and was taken to an outside hospital where he was intubated for airway control. The [Known firstname ] was then transferred to the [Hospital1 346] for further evaluation and management. While in the trauma bay the [Known firstname ] was intubated and was not moving extremities. PAST MEDICAL HISTORY: Significant only for hypertension and alcohol abuse. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: In the trauma bay, the [Known firstname 228] temperature was 96 degrees with a blood pressure of 176/103, heart rate 124. As previously mentioned, the [Known firstname ] was intubated. His head examination was notable for reactive pupils. He did have blood in his nares. There was no obvious mid face instability. His chest was clear to auscultation bilaterally with equal breath sounds. His trachea was midline. Cardiovascular was regular but tachycardic. His abdomen was soft and non-distended. Extremities: Notable for a right forearm open large laceration with brisk what appeared to be arterial bleeding, a palpable radial pulse, however. His lower extremities were notable for a left leg deformity, however, he had palpable dorsalis pedis and posterior tibialis pulses bilaterally. His back had no step-offs and no obvious contusions. Rectal examination was significant for lax tone and it was guaiac negative. The [Known firstname ] had a FAST examination in the trauma bay which was negative for free fluid. LABORATORY: On arrival, white count 14.3, hematocrit 32, platelet count 209,000. His coagulation studies were PT 13.9, PTT 27.3 with INR 1.3. His chemistries were essentially normal. He had a lactate of 2.9 and an EToH level of 306. RADIOLOGY: The [Known firstname 228] chest x-ray taken in the trauma bay was notable for a small pneumothorax in the left base as well as likely pulmonary contusions involving the left mid to lower lung zones. Plain film of the pelvis was negative for obvious fracture or dislocation. The [Known firstname ] had multiple imaging studies in his workup including CT of the head, chest and abdomen. CT of his chest showed a moderate-sized left hemothorax with a small anterior pneumothorax. There fractures of the first and third through tenth as well as 12th ribs on the left side with associated atelectasis and contusion in the left mid lung zones. There were no obvious right-sided fractures or right-sided pleural effusions. CT of the abdomen was negative for solid organ injury. There was no free fluid. CT of the head showed moderate amount of acute intracranial hemorrhage extending on the right frontal lobe inferiorly into the middle cranial fossa. There was also a moderate sized hematoma within the anterior aspect of the right temporal lobe. Additionally, there was noted a small focus of acute hemorrhage within the right cerebral hemisphere with associated edema within the right frontal and right temporal lobes. There was slight mass effect in the frontal [Doctor Last Name 534] of the right lateral ventricle without shift of the midline structures. There was no hydrocephalus. Bone windows demonstrated a skull base fracture centered over the left occipital bone to the level of the foramen magnum. A second fracture line extended laterally to the left external ear canal extending superior into the squamosa portion. There was some fluid noted in the left middle ear. There was trace pneumocephalus in the posterior fossa and adjacent to the left temporal bone fracture. There was noted to be acute hemorrhage lying over the sphenoid sinuses bilaterally. The [Known firstname ] also underwent CT scan of his entire spine including cervical, thoracic and lumbar. This revealed nondisplaced fracture of the posterior elements of C6 as well as a chip fracture of the left transverse process of T1 and a left first rib fracture. CT scan of the lumbar spine was negative for any acute fractures. The [Known firstname ] had a left-sided chest tube for his left hemothorax and pneumothorax secondary to his multiple rib fractures. The [Known firstname ] was resuscitated with crystalloid and taken to the Trauma Surgical Intensive Care Unit for further monitoring and resuscitation. A Neurosurgery consult was obtained to evaluate his head injury. The [Known firstname ] had an intraventricular drain placed by the Neurosurgery team to monitor his intracranial pressures. He was placed on mannitol to control his intracranial pressures which were initially high. Much more central IV access was obtained for resuscitation as well as monitoring purposes. The large laceration on the [Known firstname 228] right arm was sutured once the bleeding had been controlled. There was no major arterial or vascular injury associated with that laceration. The [Known firstname ] did receive tetanus toxoid booster. There was noted to be blood draining from the ear canals. Because of that an ENT consult was obtained. They evaluated the [Known firstname ] and thought no intervention was needed as related to his skull fractures. [Known firstname ] was treated with ciprofloxacin otic drops for prophylaxis against infection. The [Known firstname ] continued to be monitored in the Intensive Care Unit and was noted to have worsening intracranial pressures. The [Known firstname ] also started to develop intense seizure activity for which he was loaded with Dilantin and ultimately was required to be put in a pentobarbital coma to control his severe seizures. Because of his worsening seizure activity as well as his increasing intracranial pressures, the Neurosurgical team decided to take him to the Operating Room where he underwent craniotomy on the right side. A right temporal craniotomy with evacuation of hematoma and a right temporal lobectomy was performed on [2151-7-7]. The [Known firstname ] prior to this had undergone an angiogram of the cerebral vessels which did not show any acute dissection of the carotid arteries or vertebral arteries. The [Known firstname 228] mental status remained extremely poor. The [Known firstname ] was weaned off of the pentobarbital coma and was maintained on seizure prophylaxis with Dilantin and Depakote and his seizure activity ceased to be a problem. The [Known firstname ] remained in a hard C-collar throughout his hospital stay because of his posterior C6 fracture. He did not have cord compromise from this fracture and the plan per Neurosurgery was to just treat him with a hard collar at this time. The [Known firstname ] remained on ventilatory support throughout this stage of his hospital course. Over the next several weeks he was weaned off of his ventilatory support. His left-sided chest tube was removed and he eventually was maintained on a trach collar with satisfactory blood gases. His neurologic status slowly improved. He became more awake and alert, was moving all of his extremities although his left extremities were weaker and he did not move those as much as the right but there was noted improvement throughout the end of his hospital stay. His ventriculostomy drain was ultimately clamped and his ICP's remained acceptable for 48 hours and, because of this, the ventriculostomy drain was removed. The [Known firstname ] continued to make slow improvement neurologically. Because of his poor mental status and likely need for long term neuro rehab, he underwent tracheostomy placement as well as PEG placement during his hospital stay. These procedures were performed without difficulty. Not previously mentioned is the fact that the [Known firstname 228] left foot was imaged with plain films to evaluate what appeared to be a deformity. He was found to have fractures to the second and third metatarsals of the proximal fourth phalanx. This was treats nonoperatively with a splint which was decided upon by Orthopedic Surgery who were consulted. The [Known firstname ] had several follow-up CT scans after his temporal lobectomy and craniotomy which did not show worsening of his intracranial hemorrhage. The edema, etc., was slowly noted to be improving on follow-up CT scan evaluations. The [Known firstname ] remained on vancomycin for prophylaxis while the ventriculostomy drain was in place. The [Known firstname ], it should be noted, had continuous fever spikes throughout his postoperative course. Multiple cultures were sent including blood, urine and sputum. There were several sputum cultures which had rare growth of yeast which were not felt to be pathogenic. Towards the end of his hospital stay, however, he had a sputum culture which grew methicillin-resistant Staphylococcus aureus. Again, it was not entirely clear whether this was pathogenic causing a pneumonia but it was felt that he should be treated so the vancomycin was continued. Once the [Known firstname ] had had his ventriculostomy drain removed, he had tracheostomy placed as well as a PEG, it was felt that he was ready to be transferred to long term rehab facility for ongoing rehabilitation. On [2151-7-21], the [Known firstname ] was discharged to rehabilitation in stable condition with a diagnosis of motor vehicle collision resulting in left-sided rib fractures with resultant hemopneumothorax requiring chest tube placement, severe closed head injury with a basilar skull fracture and large left-sided intraparenchymal hemorrhage involving the left cerebral hemisphere of the left frontal and left temporal lobes which resulted in elevated intracranial pressures and severe seizure activity requiring pentobarbital coma and ultimately craniotomy with evacuation of right-sided hematoma and right temporal lobectomy. The [Known firstname ] had respiratory failure postoperatively requiring tracheostomy tube placement. The [Known firstname ], as previously mentioned, underwent percutaneous endoscopic gastrostomy tube placement for long term nutrition. The [Known firstname ] also sustained a posterior C6 fracture with nondisplacement and no cord compression as well as a T1 transverse process chip fracture and a left forefoot fracture through the metatarsals and phalanx. This was treated with splint. The cervical fracture was treated with long term C-collar. DISCHARGE MEDICATIONS: Included: 1. Lopressor 75 mg per PEG b.i.d. 2. The [Known firstname ] was prophylaxed against DVTs with subcu heparin 5000 units q. 12h. 3. Levetiracetam for seizure prophylaxis 500 mg p.o. b.i.d. 4. Depakote 300 mg per PEG q. 6h. 5. Hydralazine 20 mg p.o. q. 6h. for hypertension. 6. Pepcid 20 mg per PEG b.i.d. 7. Ciprofloxacin otic drops 10 drops in left ear twice a day. 8. Bacitracin ointment as needed to the right forearm wound. 9. Vancomycin 1250 mg IV q. 12h. 10. Haldol 2 mg IV q. 4h. p.r.n. for agitation. 11. Miconazole powder 2% applied to affected areas q.i.d. 12. Tylenol p.r.n. 13. Dulcolax. 14. Albuterol and Atrovent metered dose inhalers p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 33441] MEDQUIST36 D: [2151-7-20] 15:22 T: [2151-7-20] 15:59 JOB#: [Job Number 49292] Name: [Last Name (LF) ], [First Name3 (LF) ] K Unit No: [Numeric Identifier 9138] Admission Date: [2151-6-28] Discharge Date: [2151-7-24] Date of Birth: [2107-3-14] Sex: M Service: ADDENDUM: Mr. [Name13 (STitle) 6772] was slated for discharge on [7-21], however, over night he spiked a temperature high-grade to 103 which eventually over the course of the next four days maxed out at 104. A fever workup was conducted which showed a left lower lobe pneumonia and sputum cultures eventually grew out Methicillin-sensitive resistant Staphylococcus aureus. He was already on Vancomycin and Zosyn and during this time a PICC line was placed for longterm antibiotic use. Further cultures were sent and workup on those were negative save for sputum. His white count during these four days did not go above 10. LENIs were conducted which demonstrated that the [Known firstname ] had no evidence of deep vein thrombosis. In consultation with all ancillary services, and culture showing only Methicillin-sensitive resistant Staphylococcus aureus his Zosyn was discontinued and the decision was made to continue Vancomycin to treat his Methicillin-sensitive resistant Staphylococcus aureus. Following his thorough workup he was discharged to rehabilitation on [2151-7-24]. During the additional four days we also had Orthopedics give us the final recommendations with regards to his metatarsal fracture. The final recommendations included leaving the left lower extremity in a posterior splint with partial weightbearing and follow up with Dr. [Last Name (STitle) 998], all of which was done. Upon discharge, the [Known firstname ] was in good condition, was stable and tolerating his tube feeds and had defervesced from 104 which was his temperature maximum during those four days. DISCHARGE MEDICATIONS: 1. Lopressor 75 b.i.d. 2. Heparin subcutaneously 5000 b.i.d. until ambulating 3. Depakote 300 p.o. q. 6 4. Pepcid 20 b.i.d. 5. Vancomycin 1750 intravenously q. 12 for an additional seven days 6. Hydralazine 20 mg every 6 hours p.o. via gastrostomy tube 7. Haldol 2 mg intravenously q. 4 prn for agitation 8. Benadryl as needed and q. 6 h. 9. Miconazole powder for any affected areas 10. Dulcolax suppository as needed 11. Albuterol metered dose inhaler 12. Nephro tube feeds, 50 cc/hr, goal which were continuous DISCHARGE STATUS: Upon discharge his wound was clean and dry with no evidence of infection. His physical examination revealed the [Known firstname ] was awake and was tracking, following limited commands with regular rhythm, mildly tachycardiac 100 to 115, with coarse breathsounds bilateral consistent with the [Known firstname 1325] prolonged Intensive Care Unit ventilatory and injury course. His belly was soft with percutaneous endoscopic gastrostomy tube in place and no signs of erythema. Incision was clean, dry and healing. His extremities were warm bilaterally. His last complete blood count on [2151-7-24] was 9, 29.8 and 280. His BUN and creatinine were normal at 16 and 0.6. There were no further incidents. [First Name11 (Name Pattern1) 389] [Last Name (NamePattern1) 3595], M.D. [MD Number(1) 3596] Dictated By:[Name8 (MD) 2965] MEDQUIST36 D: [2151-10-8] 18:51 T: [2151-10-8] 20:36 JOB#: [Job Number 9139]	[ "860.4", "805.06", "286.6", "518.5", "801.36", "807.08", "482.41", "305.00", "780.39" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.6", "96.04", "43.11", "02.2", "01.18", "31.1", "88.41", "34.04", "01.39", "86.59", "38.93", "01.53" ]	icd9pcs	[ [ [] ] ]									13620, 15151															772, 817															840, 10741																					160, 671																	694, 748
12,938	165,691	2322	Discharge summary	report	Admission Date: [2102-2-16] Discharge Date: [2102-2-20] Date of Birth: [2057-6-6] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base / Floxin / Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[First Name3 (LF) 1283] Chief Complaint: 44 [Last Name (un) ] with PMH invasive leiomyotosis, IVC tumor, saddle PE s/p embolectomy, presented to ER with chest pain associated with nausea and lightheadedness. Denies SOB Major Surgical or Invasive Procedure: None History of Present Illness: Partial hysterectomy in [2094] for noninvasive leiomyotosis with completion hysterectomy in [2095]. Saddle PE/embolectomy in [2096]. followed since then for IVC tumor Past Medical History: Invasive Leiomyotosis IVC tumor Saddle PE- s/p embolectomy asthma PUD hiatal hernia s/p repair '[96] colitis partial hysterectomy [2094](benign leiomyotosis) completion hysterectomy [2095] C-section '[76]&'[78] CCY '[78] Tubal ligation Appy '[96] sternal wire removal '[01] Social History: lives with mother and sister. [Name (NI) 1403] for [Location (un) 5700] ambulance Denies ETOH and tobacco Family History: noncontributory Physical Exam: Admission VS HR 65 BP 126/70 RR19 Ht 5'0" Wt 198 Gen NAD Skin unremarkable- well healed sternal wound incision Chest CTA-bilat CV RRR Abdomen soft, NT/ND/NABS Ext warm-well perfused 1+ pedal edema bilat Neuro grossly intact Discharge VS T 97.8 HR 71 BP 98/50 RR 18 O2sat 95%RA Gen NAD Neuro A&Ox3 Pulm CTA bilat CV RRR no MRG Abdm obese NT/ND +BS Ext no edema Pertinent Results: [2102-2-16] 09:37PM PT-19.5* PTT-150* INR(PT)-1.9* [2102-2-16] 12:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2102-2-16] 11:30AM GLUCOSE-97 UREA N-10 CREAT-0.9 SODIUM-144 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14 [2102-2-16] 07:26PM CK(CPK)-40 [2102-2-16] 11:30AM cTropnT-<0.01 [2102-2-16] 11:30AM PT-16.5* PTT-29.7 INR(PT)-1.5* [2102-2-20] 07:20AM BLOOD WBC-4.0 RBC-4.63# Hgb-13.3 Hct-39.7# MCV-86 MCH-28.8 MCHC-33.6 RDW-14.1 Plt Ct-142* [2102-2-20] 07:20AM BLOOD PT-22.1* PTT-84.4* INR(PT)-2.2* [2102-2-20] 07:20AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-140 K-4.1 Cl-108 HCO3-25 AnGap-11 [2102-2-19] 01:35PM BLOOD ALT-39 AST-38 LD(LDH)-129 AlkPhos-46 Amylase-30 TotBili-2.3* [2102-2-17] 03:19AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE RADIOLOGY Final Report CHEST (PORTABLE AP) [2102-2-19] 7:26 PM CHEST (PORTABLE AP) Reason: r/o PNA [Hospital 93] MEDICAL CONDITION: 44 year old woman with CP REASON FOR THIS EXAMINATION: r/o PNA STUDY: AP chest [2102-2-19]. HISTORY: 44-year-old woman with chest pain. Evaluate for pneumonia. FINDINGS: The lung volumes are low due to poor inspiratory effort. Cardiac silhouette and mediastinum are within normal limits. There is no focal consolidation, pulmonary edema, or large pleural effusions. IMPRESSION: Low lung volumes without signs for acute cardiopulmonary process. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Cardiology Report ECHO Study Date of [2102-2-17] PATIENT/TEST INFORMATION: Indication: History of IVC leiomyoma. Assess [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] vs thrombus Height: (in) 60 Weight (lb): 200 BSA (m2): 1.87 m2 BP (mm Hg): 112/64 HR (bpm): 74 Status: Inpatient Date/Time: [2102-2-17] at 10:57 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West Other Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Tumor or myxoma in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Normal mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. 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 monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. Conclusions: No spontaneous echo contrast is seen in the body of the left atrium. A large homogenous mass (suspicious for tumor; thrombus less likely given the size and appearance) is seen in the right atrium extending from the IVC and filling the IVC (3cm in diameter) with severely narrowed residual flow. There is no extension into the SVC. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is a small pericardial effusion. Electronically signed by [Known firstname 553] [Last Name (NamePattern4) 4133], MD on [2102-2-17] 17:35. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[Known firstname ] [Name Initial (NameIs) ]. ([Numeric Identifier 12119]) RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [2102-2-16] 12:03 PM CTA CHEST W&W/O C&RECONS, NON- Reason: eval: PE (known reaction of hives to IV [Last Name (LF) ], [First Name3 (LF) ] [Hospital 12120] [Hospital 93] MEDICAL CONDITION: 44 year old woman with h/o saddle PE in [2096] p/w CP, lightheadedness REASON FOR THIS EXAMINATION: eval: PE (known reaction of hives to IV [Last Name (LF) ], [First Name3 (LF) ] PREMEDICATE; please scan at noon) CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of pulmonary embolus and IVC thrombus/tumor. Please evaluate for pulmonary embolus. TECHNIQUE: Multidetector CT images were first obtained through the chest without contrast with a low-dose technique, followed by contrast-enhanced CT angiogram of the chest. Coronal, sagittal, and oblique sagittal reformatted images were obtained. CT ANGIOGRAM OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Again seen is a massively dilated inferior vena cava containing a large non-enhancing filling defect, which extends into the right atrium. This has not significantly changed since the CT torso of [2101-12-19]. However, comparison is difficult secondary to different technique. There is no evidence of mass or thrombus in the right ventricle or pulmonary arteries. There is no pulmonary embolus. Probable contrast mixing defect in SVC. The aorta is normal in caliber throughout. The coronary arteries are normal. There is no pericardial effusion. The airways are patent to the segmental level bilaterally. There is unchanged probable scarring in the anterior segment of the right upper lobe. Dependent changes are seen in the lung fields bilaterally. There are no nodules or areas of airspace consolidation. There is no pleural effusion. There is no pathologically enlarged axillary, hilar, or mediastinal lymphadenopathy. Although this examination is not tailored evaluation of the abdominal organs, limited images through the upper abdomen show unremarkable portions of the spleen and kidneys. The liver shows a small amount of biliary air and metallic clips within the gallbladder fossa. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. CT REFORMATS: Coronal and sagittal reformatted images confirm the axial findings. IMPRESSION: 1. Large, nonenhancing filling defect within the IVC extending into the right atrium measuring up to 4 x 7 cm, which has not significantly changed in size since the prior noncontrast examination of [2101-12-19]. 2. No evidence of pulmonary embolus. The lungs are grossly clear. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 5998] DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Approved: [Doctor First Name ] [2102-2-16] 4:08 PM Brief Hospital Course: Pt admitted to r/o MI and PE and assess IVC tumor. She was admitted to Cardiac surgery ICU started on heparin infusion, her cardiac enzymes as well as CTA were negative. On hospital day 2 she had a TEE was transferred to the general floors and was restarted on her coumadin. On hospital day 4 here INR was therapeudic and she was discharged home Medications on Admission: Warfarin 5' Protonix 40' Vicodin 750/5-prn Albuterol Ativan 2" Advair Lomotil-prn Compazine-prn Lasix 40-80-prn Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Leiomyotosis Asthma IVC tumor saddle PE PUD Hiatal hernia s/p repair Hysterectomy c-section x2 CCY Appy sternal wire removal Discharge Condition: Stable Discharge Instructions: 1. Continue to take coumadin as scheduled 2. Call Dr[Name (NI) ] office on Tuesday to schedule appointment on thursday 3. Follow up INR on Wednesday with primary care Followup Instructions: 1. Call Dr[Name (NI) ] office on Tuesday to schedule appointment on thursday 2. Follow up INR on Wednesday with primary care Completed by:[2102-2-21]	[ "493.90", "780.4", "453.2", "238.1", "V12.51", "786.59", "873.63", "V58.61", "E927" ]	icd9cm	[ [ [] ] ]	[ "88.72" ]	icd9pcs	[ [ [] ] ]	10034, 10040	9156, 9503	547, 554	10209, 10218	1659, 2637	10440, 10602	1238, 1255		9665, 10011	6495, 6570	10061, 10188		9529, 9642			10242, 10417						3304, 6078			1270, 1640																								326, 509	6599, 9133										582, 762				6110, 6458													784, 1091	1107, 1222
30,564	132,947	16304	Discharge summary	report	Admission Date: [2158-2-24] Discharge Date: [2158-3-1] Date of Birth: [2076-10-24] Sex: M Service: MEDICINE Allergies: Aspirin / Motrin / Penicillins Attending:[First Name3 (LF) 689] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: colonoscopy, angiography with right femoral artery puncture History of Present Illness: 81M h/o PPM, tia on plavix, p/w bloody stool. He states that he was in his USOH until he noted a bowel movement yesterday at noon. The BM was mostly bright blood with clots. He called his PCP who advised him to come to the ED where he was noted to be hemodynamically stable with pulse 55, BP 127/67. He denies CP, SOB, though did mention slight lightheadedness when walking around. He received 3L NS and 2U pRBCs. Initial hct was 31.1 from 38.6 on the prior day when he was seen in the ED for dizziness. He underwent tagged red cell scan which revealed a colonic bleeding source at the hepatic flexure. He was taken to radiology though the bleed was unable to be localized. Hct remained in the 30 range overnight depsite the 2U pRBCs. He continues to have bloody stools, though he states this has decreased from yesterday. Past Medical History: Sick sinus syndrome s/p Biotronik Philos dual chamber pacemaker placed at [Hospital1 2025] [2152]; s/p cath Hyperlipidemia Mild asthma Allergic rhinitis GERD LBP related to DJD Hx Rectal bleeding thought diverticular Carrier of Wilson's disease Social History: Lives alone in [Location (un) 3146] Beach [Last Name (un) ], widowed; has 2 kids and few grandchildren. Formerly worked in commercial real estate, bartending. No tob, no drugs. Rare EtOH - few drinks wine per week. Of Italian ancestry. Family History: 6 siblings, 4 with pacemakers. Brother died of stroke at 81. Father had non-fatal stroke at 62. Brother with cad, colon ca; mother had CA; Father had Wilson's disease. Physical Exam: VITALS: T 97.5 119/55 p60 RR 20 Sat 95% RA GEN: awake, alert, pleasant, conversant HEENT: MM slightly dry, EOMI, PERRLA, LUNGS: CTAB b/l HEART: bradycardic, no m/r/g ABD: soft, NT/ND +BS EXT: wwp, no edema, 2+ DP Pertinent Results: Tagged red cell study [2158-2-24]: IMPRESSION: Brisk extravasation of the tagged cells is noted in the hepatic flexure of the colon, compatible with active bleeding in this region. . Angiogram: IMPRESSION: Arteriogram was performed without signs of extravasation of contrast material/active bleeding in the SMA and [Female First Name (un) 899] tributaries. . ecg: Sinus bradycardia. Normal ECG. Compared to the previous tracing of [2158-2-22] Q waves are not seen in lead V2 and the inferior leads are of slightly decreased amplitude. . Select labs: [2158-2-24] 02:47PM BLOOD WBC-5.8 RBC-4.12* Hgb-13.6* Hct-38.6* MCV-94 MCH-33.1* MCHC-35.3* RDW-12.7 Plt Ct-280 [2158-2-25] 12:20AM BLOOD WBC-7.3 RBC-3.36* Hgb-11.0* Hct-31.1* MCV-93 MCH-32.7* MCHC-35.3* RDW-13.3 Plt Ct-228 [2158-2-28] 05:25AM BLOOD WBC-6.2 RBC-3.36* Hgb-10.8* Hct-30.5* MCV-91 MCH-32.2* MCHC-35.4* RDW-14.2 Plt Ct-205 [2158-3-1] 05:30AM BLOOD WBC-7.3 RBC-3.30* Hgb-10.7* Hct-29.9* MCV-91 MCH-32.5* MCHC-35.8* RDW-14.1 Plt Ct-233 [2158-2-25] 04:44AM BLOOD PT-14.2* PTT-31.0 INR(PT)-1.2* [2158-2-24] 02:47PM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-137 K-4.8 Cl-102 HCO3-26 AnGap-14 [2158-2-28] 05:25AM BLOOD Glucose-97 UreaN-5* Creat-0.7 Na-141 K-3.7 Cl-106 HCO3-28 AnGap-11 [2158-2-25] 04:44AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9 Brief Hospital Course: Briefly, 81M h/o PPM, recent tia on plavix, presented with bloody stool. It was felt likely that he had diverticular bleeding, though on arteriography and colonscopy there was no active bleeding seen. . 1. GI bleed, likely lower etiology: Mr. [Known lastname 46489] presented with a history of bloody stool with clots. In the ED he was noted to be hemodynamically stable with pulse 55, BP 127/67. He received 3L NS and 2U pRBCs. Initial hct was 31.1 from 38.6 on the prior day when he was seen in the ED for dizziness. He underwent tagged red cell scan which revealed a colonic bleeding source at the hepatic flexure. He was taken to radiology though the bleed was unable to be localized. He did continue to have bloody stools. He was taken for colonoscopy which showed severe diverticulosis but no active bleeding. There was also note of several polyps. He was scheduled to have a repaeat conlonscopy on [3-10] for a polypectomy. He had one more episode of a small volume of BRB after his colonoscopy, but not large enough to pursue repeat angiography. On the day of discharge he had a normal, brown, formed bowel movement. His plavix was held this admission because of the bleed, but there is significant concern about recurrent TIA if he remains off of plavix. He will need to restart this after his colonoscopy. . # Sick sinus syndrome: s/p PPM. Anticipate chronotropic incompetence in setting of bleed, and he was fine on telemetry during the admission. . # TIA: Pt has been evaluated by neurology for symptoms of dizziness and gait instability. Given his risk factors for TIA and stroke, he likely should be restarted on his plavix if his HCT remains stable after one week post repeat colonoscopy. . # Hyperlipidemia: continuee atorvastatin . # Code Status: He was a Full Code during this admission. . He was discharged to home with VNA services for HR, BP, and HCT check, to be followed up by his PCP. . Medications on Admission: Clopidogrel 75 mg daily Omeprazole 20 mg daily Glucosamine Chondroitin MaxStr 500-400 mg daily Atorvastatin 20 mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Glucosamine Sulf-Chondroitin 500-400 mg Capsule Sig: One (1) Capsule PO once a day. 4. Outpatient Lab Work Hematocrit on [2158-3-2] drawn by VNA; results sent ot PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. [Telephone/Fax (1) 1579] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Diagnosis: blood loss anemia gastrointestinal hemorrhage Secondary Diagnosis: sick sinus syndrome with pacemaker Colonic polyps Discharge Condition: Good, ambulating, stable hematocrit, normotensive. Discharge Instructions: You were seen in the hospital for bloody stools. You were taken for colonoscopy which revealed diverticulosis but no active bleeding sites. Your blood levels are stable after receiving a total of 4 units of blood products in the hospital. You should hold your plavix until you have your blood levels checked by your PCP. You should have another colonoscopy within the next two weeks, to remove the polyps, while you are OFF of the plavix. If the blood level is stable, you should likely restart your plavix for stroke prevention. Please call your doctor or go to the emergency room if you have further blood in the stool or dark stools, dizziness, light-headedness, chest pain, difficulty breathing, or any other concerning symptoms Followup Instructions: Provider [Name9 (PRE) 1576],[First Name8 (NamePattern2) 2352] [Doctor Last Name 4694] APG (SB) Phone:[Telephone/Fax (1) 1579] Date/Time:[2158-3-1] 10:10 Provider [Name9 (PRE) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2158-4-11] 2:30 Provider [Name9 (PRE) 1576],[First Name8 (NamePattern2) 2352] [Doctor Last Name 4694] APG (SB) Phone:[Telephone/Fax (1) 1579] Date/Time:[2158-5-12] 8:30 COLONOSCOPY with Dr. [First Name (STitle) 452] on [2158-3-10] at 12:30pm. The number is [Telephone/Fax (1) 11048]. Please have the VNA check your heart rate, blood pressure, and hematocrit later this week. The results should be called to Dr. [Last Name (STitle) ], who is aware of this plan, and she will follow up on them. Her number is [Telephone/Fax (1) 1579].	[ "V45.01", "285.1", "455.0", "V12.54", "211.3", "493.90", "530.81", "272.4", "562.12", "427.81" ]	icd9cm	[ [ [] ] ]	[ "45.23", "99.04", "88.47" ]	icd9pcs	[ [ [] ] ]	6201, 6258	3570, 5497	318, 380	6439, 6492	2205, 3547	7277, 8176	1786, 1955		5667, 6178		6279, 6279		5523, 5644			6516, 7254									1970, 2186																								251, 280											408, 1232					6366, 6418			6298, 6345									1254, 1509	1525, 1770

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