Split (1)

train · 26.9k rows

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16,186	195,071	43168	Discharge summary	report	Unit No: [Numeric Identifier 93031] Admission Date: [2187-4-16] Discharge Date: [2187-4-19] Date of Birth: [2123-3-25] Sex: M Service: Internal Medicine HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male with a past medical history of coronary artery disease, status post renal transplant and recurrent upper gastrointestinal bleed who presents with further gastrointestinal bleed and anemia. The patient had a complicated course following his coronary artery bypass graft in [1-/2187] including multiple deep venous thromboses requiring anticoagulation and an upper gastrointestinal bleed from a duodenal ulcer while on anticoagulation. On [2187-4-14], the patient had one episode of vomiting with ? coffee grounds and on the morning of admission, he began to have further hematemesis, as well as melanotic stool. He went to an outside hospital where his systolic blood pressure was found to be in the 60s to 70s. His hematocrit was reportedly 10. He received three units of packed red blood cells with increase in his blood pressure to the 80s to 90s and increase in his hematocrit to 19. His PTT and INR were reportedly within normal limits at the outside hospital. The patient underwent esophagogastroduodenoscopy and an initially nonbleeding ulcer began bleeding after injection. The ulcer was then clipped times two. The patient had a systolic blood pressure in the 120s post procedure and was transferred to the [Hospital6 256] for further management. On arrival, the patient was without any complaints of nausea, vomiting, chest pain, shortness of breath or lightheadedness. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [1-/2187] complicated by hemothorax. 2. Status post cadaveric renal transplant in [2183]. It is felt that his graft is failing. 3. Hypertension. 4. Upper gastrointestinal bleed secondary to current duodenal ulcer that has been refractory to treatment. 5. Diabetes mellitus. 6. Subclavian deep venous thrombosis in 02/[2187]. 7. Lower extremity deep venous thrombosis in 03/[2187]. 8. Depression. 9. Gout. 10. Status post appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Allopurinol 100 mg q day. 2. Bactrim q Monday, Wednesday and Friday double strength 3. Ativan, one t.i.d. 4. Prednisone 5 mg q day. 5. Lasix 40 mg q day. 6. Norvasc 10 mg q day. 7. Hydrochlorothiazide 25 mg q day. 8. Rosiglitazone 4 mg q day. 9. Hydralazine 75 mg q.i.d. 10. Protonix 40 mg b.i.d. 11. Wellbutrin-SR 150 mg h.s. 12. Hectorol 2.5 mg q day. 13. [Last Name (un) ] p.r.n. 14. Cyclosporin 100 mg q a.m., 75 mg q p.m. 15. Lopressor 125 mg t.i.d. SOCIAL HISTORY: The patient is married and lives with his wife at home. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature 97.3, blood pressure 150-160/50-60, pulse 62, respiratory rate 18 with O2 saturation of 100 percent on two liters. GENERAL: The patient is awake, alert and oriented, pleasant in no acute distress. HEENT: Sclera anicteric, conjunctiva uninjected, pupils equal, round and reactive to light, extraocular movements intact, mucous membranes are moist. NECK: No jugular venous distension. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm, normal S1 and S2. ABDOMEN: Soft, nontender, nondistended. There is a palpable graft. EXTREMITIES: Lower extremities are not edematous and there is no calf tenderness. LABORATORY DATA: On admission, sodium 141, potassium 4.2, chloride 118, bicarbonate 15, BUN 130, creatinine 4.0, glucose 135, white blood cell count 10, hematocrit 19.5, platelets 175, PTT 37.4, INR 1.2. Arterial blood gas reveals a pH of 7.36, CO2 of 28.7 and a PO2 of 355. Electrocardiogram shows normal sinus rhythm with a rate of 65 and LAD, no ST or T-segment changes. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient's hematocrit was followed closely. He had no further episodes of gastrointestinal bleed during this hospitalization. The patient received three units of packed red blood cells and his hematocrit increased from a level of 19 on admission to a level of 27.4 on discharge. The patient was maintained on Protonix intravenously 40 mg b.i.d. A Transplant Surgery consult was obtained for consideration of possible angiographic procedure/Gelfoam versus other surgical intervention to prevent further repeat bleeding. In addition, a gastric level was sent off and came back elevated at 403. Given the multiple large bleeds over the past several months, the Surgical consult recommended proceeding with surgery. The possibilities included antrectomy, vagotomy versus embolization as mentioned above. This was discussed at length with Mr. [Known lastname ] who understood the risks and benefits of the procedure and preferred not to proceed with it at this time. 1. Allograft nephropathy/chronic renal insufficiency: The patient was followed throughout the hospitalization course by the Renal team. The patient has a chronically elevated creatinine for the past several months prior to this admission and is known to have allograft nephropathy. The patient was continued on prednisone, ciclosporin and ciclosporin levels were followed. A renal ultrasound was obtained which demonstrated interval enlargement of the renal transplant with the upper pole caliectasis. There was continued blunted arterial upstrokes. However, the patient did have a urinary tract infection at the time of this study and the findings could represent infection versus interstitial rejection versus a combination of both. The patient was noted to have metabolic acidosis and was increased to 30 cc p.o. of Bicitra b.i.d. from q day. 1. Benign prostatic hypertrophy: The patient's tamsulosin dose was increased from 0.4 mg to 0.8 mg. The patient tolerated this increase well. 1. Diabetes mellitus: The patient was continued on a regular insulin sliding scale, as well as on a diabetic diet. 1. History of deep venous thrombosis: Given the patient's recent bleed, as well as prior complications on anticoagulation, the patient was maintained on pneumatic compression boots. 1. Gout: The patient was restarted on allopurinol at a dose of 100 mg p.o. q day. 1. Coronary artery disease: The patient was restarted on his beta blocker regimen of metoprolol 25 mg b.i.d. His aspirin was held during this hospitalization given his recent bleed. 1. Depression: The patient was felt to have significant clinical depression. He was maintained on his outpatient dosage of Wellbutrin. The patient declined a consultation by Psychiatry while in the hospital though denied any active suicidal or homicidal ideation. 1. Urinary tract infection: The patient was found to have a pansensitive enterococcus on urine culture on [2187-4-13]. He was continued on his regular dose ten day course of ampicillin. On the evening of [2187-4-19], the patient made the decision to leave the hospital against medical advice. The patient had lengthy discussions earlier in the day with several of the consult teams including the Renal team, as well as with the Medical team and the medical attending. Nonetheless, the patient acknowledged the risks of leaving and signed out of the hospital against medical advice. He was given a prescription of ampicillin to complete his ten day course for his urinary tract infection. The patient will follow-up with his primary care physician and with his nephrologist and his hematologist, as well as with his outpatient psychologist. The patient will also follow-up with his gastroenterologist in regard to his current gastrointestinal bleeds. DISCHARGE DIAGNOSES: 1. Acute upper gastrointestinal bleed. 2. Right upper extremity and right lower extremity deep venous thrombosis, status post inferior vena cava filter. 3. Status post renal transplant. 4. Urinary tract infection. 5. Diabetes mellitus. 6. Major depression. 7. Gout. 8. Benign prostatic hypertrophy. DISCHARGE MEDICATIONS: 1. Ampicillin 500 mg b.i.d. to complete his course. 2. Bactrim double strength, three extra a week. 3. Prednisone 5 mg q day. 4. Insulin regular as directed. 5. Ciclosporin 50 mg q p.m. and 75 mg q a.m. 6. Pantoprazole 40 mg q day. 7. Hydralazine 25 mg q.i.d. 8. Amlodipine 5 mg q day. 9. Metoprolol tartrate 25 mg t.i.d. 10. Wellbutrin 150 mg extended release h.s. 11. Colace. 12. Sodium citrate/citric acid 334-500, 60 cc per day. 13. Tamsulosin 0.4 mg b.i.d. 14. Allopurinol 100 mg q day. 15. Bumetanide 1 mg q day. 16. Lorazepam 1 mg t.i.d. p.r.n. anxiety. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 5825] Dictated By:[Last Name (NamePattern1) 8188] MEDQUIST36 D: [2187-6-11] 16:57:40 T: [2187-6-12] 09:57:13 Job#: [Job Number 93032]	[ "E878.0", "599.0", "584.9", "532.40", "296.20", "996.81", "276.2", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]							2855, 2873	7913, 8217	8240, 9105				2270, 2764	3961, 7892																							2896, 3944																	220, 1646														1668, 2244	2781, 2838
4,618	125,578	4203+55560	Discharge summary	report+addendum	Admission Date: [2205-1-16] Discharge Date: [2205-1-24] Date of Birth: [2123-6-15] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 4891] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Central venous line insertion History of Present Illness: 81 y/o male with extensive coronary history who presented with cough and malaise x 1 day. The patient has a chronic cough but felt worse over the past day. Also associated with nb/nb emesis x 1. Came to emergency room and triggered immediately for HTN with presure in 60's on arrivals, repeat SBP 90-100, but then his blood pressures fell again. He was in rapid atria fibrilation on arrival with an initial rate of 133. His temperature was 97 orally temperature and 102.8 rectally. Of note, Last week he had been admitted to the cardiology service for DOE with cath, MIBI demonstrating diastolic failure, CABG consistent with prior cath showing widely patent. He was diuresed during that admission with resolution of symptoms and discharged. Chest x-ray with no findings but empirically treated with broad antibiotics for presumed HAP. New acute renal failure, elevations in Alk Phos/AST/Lipase. A right IJ, and blood cultures were obtained. Levophed was started. Urine cultures were obtained. In the context of putting in the IJ the patient's HR went to the 60's. The patient's laboratory data demonstrated new renal failure, leukocytosis, elevated AST and lipase. Abdominal ultrasound demonstrated RUQ cholelethiasis without cholecystitis. Nutmeg liver reaction, common bile duct within normal limits. The patient was transferred to the ICU for further evaluation. Vitals at the time of transfer were 99.8 81 124/60. SVO2 80, CVP 2. He received a total of 2 liters of fluid in the emergency room. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. H/o remote inferior posterior MI 4. CAD s/p CABG in [2196] (LIMA to LAD, SVG to PDA, SVG to OM1 and OM2) 5. Mild aortic stenosis 6. GERD, chronic gastritis, s/p treatment for H. Pylori, path with 7. high grade dysplasia on [12/2204] EGD bx 7. BPH 8. Vitamin D Deficiency 9. Anxiety 10. S/p resection of benign colon polyps 11. S/p left cataract surgery [06]. H/o latent TB Social History: Widowed once, lives with 2nd wife. [Name (NI) ] six children; oldest son and daughter live upstairs. Denies ETOH or tobacco use. Family History: Father died from an MI at age 62. Mother died from a cerebral aneurysm in her mid 60's, also had asthma. Physical Exam: GEN: Elderly chinese gentleman, alert and fully oriented, mildly weak, no acute distress. No jaundice. HEENT: Sclera anicteric, pupils reactive 3 to 2mm, oropharynx clear, mildly dry. Neck: supple, JVP not elevated, no LAD CV: [3-10] mid-peaking systolic ejection murmur at the left upper sternal border without radiation. Regular rate and rhythm. Lungs: Occasional cough producing clear sputum. Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Liver edge palpable 2cm below costal margin. Mild distention / gas. Soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding. No splenomegaly. No spider angiomas. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ pitting edema in BL LEs Pertinent Results: Admission Labs: [2205-1-16] 10:39PM TYPE-[Last Name (un) ] TEMP-39.4 O2 FLOW-4 PO2-66* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2205-1-16] 10:39PM LACTATE-3.4* [2205-1-16] 09:07PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2205-1-16] 09:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2205-1-16] 08:55PM GLUCOSE-118* UREA N-61* CREAT-3.0# SODIUM-135 POTASSIUM-5.4 CHLORIDE-93* TOTAL CO2-26 ANION GAP-21* [2205-1-16] 08:55PM ALT(SGPT)-37 AST(SGOT)-246* CK(CPK)-175 ALK PHOS-374* TOT BILI-1.2 [2205-1-16] 08:55PM LIPASE-166* [2205-1-16] 08:55PM cTropnT-0.02* [2205-1-16] 08:55PM proBNP-1042* [2205-1-16] 08:55PM CALCIUM-10.6* PHOSPHATE-4.9* MAGNESIUM-2.9* [2205-1-16] 08:55PM WBC-14.8# RBC-4.50 HGB-10.3* HCT-33.7* MCV-75* MCH-22.8* MCHC-30.5* RDW-20.2* [2205-1-16] 08:55PM PT-13.6* PTT-25.9 INR(PT)-1.2* [2205-1-16] 08:48PM LACTATE-4.4* [2205-1-22]: Triple phase MRI: IMPRESSION: 1. Large hepatic mass with rapid arterial enhancement and washout consistent with a hepatocellular carcinoma. 2. The right portal vein is occluded with tumor thrombus and the proximal left portal vein is also likely occluded. Non occlusive tumor thrombus is also noted within the main portal vein and there is cavernous transformation at the porta hepatis. [2205-1-20] CT Chest: IMPRESSION: Essentially unremarkable chest CT without evidence for infection or metastatic disease. Incompletely assessed large liver mass. MRI [1-17]: Large mass almost completely replacing the right lobe of liver with invasion of the right portal vein. The left portal vein may also be occluded. The imaging features are far more suggestive of tumor than abscess. Differential would include a primary HCC, cholangioncarcinoma or a metastasis. EKG [2205-1-16]: Atrial fibrillation with rapid ventricular response. Early R wave transition. Q waves in leads II, III and aVF suggest possible prior inferior myocardial infarction. Compared to the previous tracing of [2205-1-8] atrial fibrillation is new. EKG [2205-1-17]: Normal sinus rhythm. Q waves in leads II, III, aVF and V4-V6 suggest possible prior inferior and myocardial infarction. Compared to tracing #1 atrial fibrillation has been replaced by normal sinus rhythm. CXR [2205-1-16]: FINDINGS: Midline sternotomy wires are unchanged. The cardiomediastinal and hilar contours are unchanged from prior study. The lungs are clear. The lung volumes are low. There is no pleural effusion or pneumothorax. The osseous structures demonstrate degenerative changes of the acromioclavicular joints. IMPRESSION: No acute cardiopulmonary process. [1-17]: RIGHT UPPER QUADRANT ULTRASOUND: There is a large mass in the right lobe of the liver which is echogenic and does not demonstrate any detectable flow on Doppler images. There is normal hepatopetal flow in the portal vein some foci of posterior shadowing are concerning for air in the mass. The common duct measures 2 mm. Small stones are noted in the gallbladder, which is partially collapsed without wall edema or pericholecystic fluid. The pancreas was not visualized due to shadowing bowel gas. There is no free fluid in the abdomen. IMPRESSION: 1. Findings concerning for hepatic abscess. Differential diagnosis includes necrotic tumor such as HCC although this is considered less likely. Please evaluate with multiphasic liver CT. This was called to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2204-1-18] at 8:25 a.m. 2. Cholelithiasis, without acute cholecystitis. Brief Hospital Course: 81 M with a history of CAD s/p CABG [2196], mild aortic stenosis, distolic heart failure, hyperlipidemia, and hypertension who presented on [1-16] with fever, worsening cough, nb/nb vomiting x 1, palpitations, and dyspnea. Initial concern was for sepsis, however no etiology was determined. Patient was temporarily in ICU on pressors and zosyn, but both were discontinued without problem. During workup, found to have large liver mass which was determined to be hepatocellular carcinoma. Patient was set up with Oncology and discharged home. 1) Hepatocellular carcinoma: During workup in ICU, was found to have elevated liver function tests. RUQ ultrasound showed a large mass which was further investigated with MRI. This was concerning for Hepatocellular carcinoma versus cholangiocarcinoma. AFP returned > 50,000. After consultation with Oncology and Hepatology, a triple phase MRI was performed which confirmed the diagnosis of hepatocellular carcinoma. The patient was set up with Oncology follow up. The tumor was noted to be invading the portal veins, however anticoagulation was determined to not be necessary at this time. 2) SIRS physiology - Patient presented in atrial fibrillation with RVR and hypotension. Was started on broad spectrum antibiotics and pressors. Pressors were able to be discontinued quickly after one night. Antibiotics were narrowed to zosyn, then were discontinued on the floor as no source was ever identified. Patient remained afebrile with no localizing signs/symptoms. Also did not have any positive blood/urine cultures. Physiology may have been related to dehydration (from increased diuresis) and IVC compression which led to decreased preload which, in the setting of atrial fibrillation with RVR could have led to hypotension. 3) Atrial Fibrillation - Due to hypotension, the patient's metoprolol was held. This was continued to be held on the floor and the patient was rate controlled on the floor without any medications. After speaking to cardiology, it was decided not to continue anticoagulation, including aspirin. 4) CHF - The patient was noted to have peripheral edema, which was thought to be secondary to fluid resuscitation. The patient's torsemide was restarted but at a lower dose of 10mg every other day. # The patient's chronic medical issues were stable and he was continued on his home regimens Transitional Issues: -The patient's medication list contained an error, listing Vitamin D at 50,000 units daily, rather than monthly. The patient's son was called after discharge and a message was left telling him that he should continue to take it monthly. - Oncology follow-up - ?anticoagulation for afib/Tumor burden - ?aspirin for CAD Medications on Admission: aspirin 81 mg Tablet atorvastatin 40 mg Tablet docusate sodium [Colace] 100 mg Capsule [Hospital1 ] ergocalciferol (vitamin D2) [Vitamin D] 50,000 unit Capsule One (1) Capsule by mouth once a month. ezetimibe 10 mg Tablet finasteride 5 mg Tablet metoprolol tartrate 25 mg Tablet omega-3 fatty acids Capsule omeprazole 40 mg Capsule, Delayed Release(E.C.) torsemide 20 mg Tablet valsartan 160 mg Tablet Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a day. 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 6. omega-3 fatty acids 300 mg Capsule Sig: One (1) Capsule PO once a day. 7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. torsemide 10 mg Tablet Sig: One (1) Tablet PO every other day. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Severe inflammatory response syndrome. - Hepatocellular carcinoma - Acute on chronic systolic heart failure Secondary diagnosis: - Atrial fibrillation 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. You were seen in the hospital for worsening shortness of breath, and were found to be hypotensive and in atrial fibrillation (abnormal heart rhythm) upon arrival to the emergency room. You were treated with intravenous fluids and antibiotics and recovered. No source of infection was found, and a chest x-ray and CT showed no signs of pneumonia. However, you were found to have a large mass in the right lobe of your liver that was determined to be hepatocellular carcinoma, a type of cancer. You were seen by Hepatology (liver specialists) and Oncology (cancer specialists), who recommended outpatient oncology follow-up for treatment of your liver cancer. We also changed your diuretic medication to help your fluid status. We made the following changes to your medications: ADDED: - ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day) DECREASED: torsemide to 10mg by mouth every OTHER day Please DISCONTINUE taking your daily 81mg aspirin as this may increase your risk of bleeding with your new liver mass. You can discuss aspirin use further at your upcoming follow-up with Dr. [First Name (STitle) 437] (your cardiologist). Please weigh yourself daily. If you notice your weight increase by 3 pounds, call your cardiologist Dr. [First Name (STitle) 437]. Followup Instructions: Department: Primary Care Name: [Location (un) ],[Doctor First Name ] J. When: Thursday [2205-1-31] at 12 PM Location: [Hospital3 8233] Address: [State 8234], [Location (un) ],[Numeric Identifier 8235] Phone: [Telephone/Fax (1) 8236] DEPARTMENT: HEMATOLOGY/ONCOLOGY-SC NAME: [Doctor Last Name 3150] [Doctor First Name ],HEM ONC WHEN: [2205-2-1] 03:30p LOCATION: SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Phone: [Telephone/Fax (1) 18284] CARDIOLOGY Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2205-2-6] 11:20 GASTROENTEROLOGY Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] (ST-3) GI ROOMS Date/Time:[2205-2-18] 9:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],MD Phone:[Telephone/Fax (1) 463] Date/Time:[2205-2-18] 9:30 Completed by:[2205-1-31] Name: [Known lastname ],[Known firstname 326] Unit No: [Numeric Identifier 3004] Admission Date: [2205-1-16] Discharge Date: [2205-1-24] Date of Birth: [2123-6-15] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 1085] Addendum: Discharge Labs: 9.4 > 8.9 < 251 28.9 [Age over 90 ]\|102\|32<120 3.9\|32 \|1.1 LDH: 2097 HgbA1C: 7.0% HBsAg HBsAb HBcAb IgM HBc HCV Ab NEGATIVE BORDERLINE1 BORDERLINE2 NEGATIVE NEGATIVE CEA - 106 AFP - [Numeric Identifier 3005] Blood cx - negative x2 Urine cx - negative MRSA - negative C diff - negative Sputum culture - contaminated Central line tip culture - negative The patient was started on iron supplementation for his anemia. Major Surgical or Invasive Procedure: Central venous line insertion Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1086] MD [MD Number(2) 1087] Completed by:[2205-1-31]	[ "414.00", "272.4", "428.33", "459.2", "424.1", "401.1", "276.7", "412", "276.0", "276.3", "427.31", "530.81", "584.9", "280.9", "155.0", "V45.81", "428.0", "268.9", "995.94", "276.2" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	15067, 15230	7138, 9525	15012, 15044	11625, 11625	3371, 3371	13183, 14502	2481, 2587		10323, 11380		11430, 11430		9892, 10300			11776, 12597			14519, 14974					2602, 3352																	9546, 9866	12626, 13160			232, 254									352, 1869			11580, 11604		3387, 7115	11449, 11559			11640, 11752					1891, 2314	2330, 2465
15,466	119,177	14614	Discharge summary	report	Admission Date: [2143-3-22] Discharge Date: [2143-3-26] Date of Birth: [2096-1-28] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 43093] is a 47-year-old gentleman with morbid obesity, current body weight of 349 pounds and a body mass index of 58. He was previously on numerous weight loss programs as well as medications with no long-term success. He also has numerous [Hospital 43094] medical problems including type 2 diabetes, severe sleep apnea, hypertension, gastroesophageal reflux disease, and chronic back pain. He was evaluated for Roux-en-Y gastric bypass procedure. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Diabetes mellitus type 2 for the past 13 years. 3. Hypertension. 4. Recurrent renal stones status post lithotripsy. 5. Chronic low back pain. 6. Depression. 7. Hypercholesterolemia. 8. Severe sleep apnea requiring CPAP. PAST SURGICAL HISTORY: 1. Uvulectomy for treatment of sleep apnea in [2141]. 2. Lithotripsy of right renal stones in [2137], [2138], and [2140]. MEDICATIONS ON ADMISSION: 1. NPH Insulin 60 units q.a.m. and 20 units q.p.m. 2. Regular Insulin sliding scale. 3. Glucophage 1,000 mg p.o. b.i.d. 4. Avandia 4 mg q. day. 5. Verapamil 180 mg p.o. q. day. 6. Zestril 5 mg p.o. q. day. 7. Lipitor 10 mg p.o. q. day. 8. Protonix 40 mg p.o. q. day. 9. Allopurinol 75 mg p.o. q. day. 10. Aspirin 325 mg p.o. q.d. 11. Zoloft 50 mg p.o. q. day. PHYSICAL EXAMINATION: On initial physical examination, Mr. [Known lastname 43093] was a morbidly obese middle-aged man in no acute distress. His heart rate was 88 with a blood pressure of 120/80. His sclerae were anicteric and his pupils were equally reactive light and accommodation. His neck was supple with no lymphadenopathy, thyromegaly or carotid bruits. His lungs were clear to auscultation bilaterally. Heart showed a regular rate and rhythm with no murmurs, gallops, or rubs. Abdomen was obese, soft, nontender, nondistended, with no abdominal wall hernias or other palpable masses. His extremities were warm and well perfused, with trace edema, and early venous stasis changes. He had no focal neurological or motor deficits. HOSPITAL COURSE: Mr. [Known lastname 43093] was admitted to the operating room on [2143-3-22] where he underwent open Roux-en-Y gastric bypass and cholecystectomy. Please refer to the dictated operative note for full details of this procedure. The patient tolerated the procedure well and was transferred postoperatively to the postanesthesia care unit. The patient had some complaints of nausea early on postoperative day number one, so he was maintained n.p.o. at this time. At about noon on postoperative day number one, the patient began to complain of pain across his chest that was constant and worsened by inspiration. He described it as a throbbing pain. The pain did not radiate and the patient did not have any shortness of breath, nausea, or vomiting. It was slightly tachycardic at this time but otherwise hemodynamically stable. An EKG was obtained that demonstrated some flattening of T waves in the lateral leads. At this time a cardiology consultation was obtained as well as a medicine consultation. The was given sublingual nitroglycerin, a beta blocker was started, and the patient was placed on telemetry with rule out procedure for myocardial infarction begun. Of note, it was found that the patient had had a stress test at the [Hospital3 3765] in the spring of [2142] that, by report, was normal. Due to the aforementioned events and the patient's significant risk factors, the decision was made to transfer the patient to the surgical intensive care unit at that time. This would allow for closer monitoring. The patient's chest pain resolved significantly after three rounds of sublingual nitroglycerin tablets. The decision was also made at this time to study the patient by CAT scan of the chest for the possibility of pulmonary embolus. This was found to be a negative study with the CAT scan being completely nonsuggestive of pulmonary embolus. The patient's troponin values and CK MB fractions were also negative. The patient also remained hemodynamically stable at this time. His chest pain resolved without further medication and was present by postoperative day number two with only a cough. His abdomen was soft and his incision was healing nicely. At this time on postoperative day number two the decision was made to discontinue the patient's nasogastric tube and begin a stage I diet. He was continued on the beta blocker at this time, but was deemed ready for transfer to the floor. The patient continued to improve and tolerated stage I diet with no difficulty. On postoperative day three he was advanced to a stage II diet. His Foley catheter was removed and he was changed over to oral medications. On postoperative day number four the patient was advanced to a stage III diet, having tolerated stage II without any difficulty. He again tolerated this well and at this time was deemed stable and ready for discharge home. The medical and cardiology consultation services concurred with this reasoning, and did not feel that the patient had suffered a cardiac event. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Morbid obesity status post Roux-en-Y gastric bypass and cholecystectomy. 2. Diabetes mellitus type 2. 3. Severe sleep apnea requiring CPAP. 4. Hypertension. 5. Dyslipidemia. 6. Gastroesophageal reflux disease. 7. Chronic back pain. 8. Recurrent renal stones. 9. Arthritis. 10. Status post uvulectomy. DISCHARGE MEDICATIONS: 1. Roxicet elixir 5-10 cc every four to six hours as needed for pain. 2. Multivitamin, one tablet p.o. q. day. 3. Zantac elixir 10 cc p.o. b.i.d. 4. Lopressor 37.5 mg p.o. b.i.d. 5. Zoloft 50 mg p.o. q. day. 6. Lipitor 10 mg p.o. q. day. 7. Allopurinol 75 mg p.o. q. day. FOLLOW UP: The patient will follow up with Dr. [Last Name (STitle) ] in [11-5] days post discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2143-8-16] 11:54 T: [2143-8-16] 12:13 JOB#: [Job Number 43095]	[ "272.0", "530.81", "574.10", "786.59", "278.01", "401.9", "571.5" ]	icd9cm	[ [ [] ] ]	[ "51.22", "44.31", "50.12" ]	icd9pcs	[ [ [] ] ]								5363, 5668	5691, 5964				1113, 1482	2248, 5279								946, 1086											5976, 6336				1505, 2230																	169, 649														672, 922		5304, 5342
24,071	195,443	9794+9795	Discharge summary	report+report	Admission Date: [2167-9-11] Discharge Date: Date of Birth: [2126-4-23] Sex: F Service: Medicine-[Hospital1 139] Firm HISTORY OF PRESENT ILLNESS: The patient is a 41 year old white female with end stage liver disease secondary to primary sclerosing cholangitis plus auto immune hepatitis overlap with cirrhosis and hypertension who was complaining of vomiting which had begun the morning of her admission date. The patient stated that she had felt ill over the past night and after eating breakfast today had some projectile vomiting. She had a total of two episodes of emesis. She denied any nausea, blood in her emesis or bile in her emesis. The patient also complained of intermittent belly pain which she could not localize. She also had diarrhea, although she attributed this to being on Lactulose. She noted that her belly had gotten larger over the past few days and that she has found it harder to concentrate recently. She also complained of weight loss since being discharged on [9-8], just three days previously from [Hospital6 649], where she had been a patient for approximately three weeks for treatment of hyponatremia secondary to diuretic use, anemia secondary to gastrointestinal bleeding, coagulopathy secondary to end stage liver disease, and resulting pulmonary and peripheral edema secondary to discontinuing diuretics. With respect to this current admission the patient states that in addition to the symptoms mentioned above, she also has noted some blood-tinged sputum of yellowish color when she coughs. She denies any shortness of breath but states that she has been generally winded and tired recently. She denies any urinary symptoms. PAST MEDICAL HISTORY: 1. Primary sclerosing cholangitis/auto immune hepatitis overlap, causing end stage liver disease diagnosed in [2164], sequelae includes massive hemorrhoids, encephalopathy and ascites; 2. Hypertrophic pulmonary osteoarthropathy; 3. Lower back disc herniation; 4. Duodenal ulcers, status post esophagogastroduodenoscopy. FAMILY HISTORY: Non-contributory, the patient has two children, ages 5 and 3 who are alive and well. SOCIAL HISTORY: The patient denies alcohol, tobacco or drug use. MEDICATIONS PRIOR TO ADMISSION: 1. Multivitamin one a day 2. Vitamin D 400 units q.d. 3. Calcium carbonate 800 mg q.i.d. 4. Estradiol 600 mg b.i.d. 5. Protonix 40 mg b.i.d. 6. Aldactone 100 mg q.d. 7. [Doctor First Name 233]-Ciel 20 mg q.d. 8. Levaquin 500 mg q.d. 9. Lactulose 30 cc q.i.d. 10. Lasix 40 mg p.o. q.d. 11. Carafate 1 gm q.i.d. 12. Mycelex 5 times a day 13. Magnesium oxide 400 mg b.i.d. ALLERGIES: Questionable allergy to Sulfa. PHYSICAL EXAMINATION: Vital signs, temperature 99.2, blood pressure 92/50, heartrate 76, respiratory rate 18. In general, ill-appearing, tired jaundiced thin female in no apparent distress. Head, eyes, ears, nose and throat, yellow ictera, pupils equally round and reactive to light and accommodation. Jaundiced under the tongue, no thrush. Neck was supple with no masses or jugulovenous distension. Cardiac examination, regular rate and rhythm, no rubs or gallops but a III/VI murmur present at the left sternal border. Pulmonary examination, clear to auscultation bilaterally. Abdomen, positive bowel sounds, abdomen is distended but soft. Positive splenomegaly. Extremities, no cyanosis or edema, positive clubbing. LABORATORY DATA: Laboratory data on admission showed white blood cell count 5, hemoglobin 10.9, hematocrit 31.5, platelets 60, MCV 92, sodium 134, potassium 3.9, chloride 100, bicarbonate 28, BUN 21, creatinine 1.0, glucose 78, PT 17.1, INR 2.0, PTT 43.5, calcium 7.7, phosphorus 2.7, magnesium 1.8. ALT 59, AST 90, alkaline phosphatase 169, amylase 118, total bilirubin 25. ASSESSMENT/PLAN: The patient is a 41 year old female with end stage liver disease, admitted directly from clinic after presenting with a complaint of vomiting. The differential diagnosis that was generated to explain the patient's vomiting included gastric outlet obstruction, biliary obstruction, infection, gastrointestinal bleed, portal vein thrombosis and ascites and medication side effects. HOSPITAL COURSE: The patient received an adequate workup in the hospital and the following is a system by system account of what took place: 1. Gastrointestinal/hepatology - The patient's nausea and vomiting was worked up. Esophagogastroduodenoscopy was performed the day of admission and was negative for any new bleed, erosion or mass. An ultrasound of the abdomen was also done to evaluate for portal vein thrombosis and ascites but it too was negative. Because the patient's bilirubin was elevated a cholestatic or hepatic etiology was also feared. However, magnetic resonance cholangiopancreatography of the liver and gallbladder revealed no obstructive strictures, although in general the ductal distribution appeared to be more affected than previously. The patient was also worked up for infectious etiologies of her nausea and vomiting and those we mentioned below in the infectious disease section. With respect to the patient's hepatobiliary disease, it is important to note that the patient's ALT was elevated ranging from 98 to 111 throughout the hospitalization; likewise her AST was also elevated and ranged from 136 to 212. The patient's LDH was high and ranged from 225 to 316; alkaline phosphatase ranged from 189 to 227. Total bilirubin ranged from 35.6 to 42.5, and albumin was 2.1 to 2.8. The bilirubin was fractionated and shown to be mostly direct bilirubin although both direct and indirect bilirubins were increased. With respect to pancreatic enzymes, lipase ranged from 52 to 160 whereas amylase ranged from 85 to 150 during the hospitalization. On hospital day #4 the patient was noted to have asterixes, as well as experiencing changes in her mental status, i.e. lethargy, slurred speech. The patient's regimen of Lactulose was increased so as to have four to six bowel movements per day. Within a few days the patient's encephalopathy improved as there were no asterixes found on examination by hospital day #8. 2. Fluids, electrolytes and nutrition - On hospital day #2 the patient developed hyponatremia, perhaps secondary to diuretic use as the patient had developed before in a prior admission. The sodium on [9-12] was 125. The patient complained of fatigue and still some nausea but did not show any other signs or symptoms of hyponatremia. The hyponatremia had been treated since then with fluid restriction of 1 to 1.5 liters, holding all diuretics, [Name6 (MD) ] [Name8 (MD) ], M.D. Dictated By:[Last Name (NamePattern1) 1595] MEDQUIST36 D: [2167-9-18] 20:40 T: [2167-9-18] 20:49 JOB#: [Job Number 32981] Admission Date: [2167-9-11] Discharge Date: [2167-10-9] Date of Birth: [2126-4-23] Sex: F Service:Liver Transplant Service PRINCIPAL DIAGNOSIS: End stage liver disease secondary to primary sclerosing cholangitis and/or autoimmune hepatitis requiring orthotopic transplant during this admission. dictated summary of [Hospital 228] hospital course covering period [2167-9-11] to [2167-9-21] for history of present illness, past medical history, family history, social history, medications on admission, initial physical examination and early hospital course. HOSPITAL COURSE FROM [2167-9-21] THROUGH [2167-10-9]: The patient [2167-9-21] (hospital day number eleven). The patient was subsequently transferred to the Intensive Care Unit. Notable events while in the Intensive Care Unit from [2167-9-21] through [2167-9-25] include acute renal failure attributed to acute tubular necrosis manifested by gradually worsening creatinine, peaking at 3.6 on [2167-9-24] and then improving to baseline of 1.0 by the day of discharge. In the Intensive Care Unit, the patient was also started on total parenteral nutrition. On discharge from the Intensive Care Unit on postoperative day number five the patient was alert and oriented, tolerating ice chips and sips with medications. She was noted to be anxious and emotionally labile at times. By system, following the notable events during the rest of her hospital stay. 1. Hepatic/transplant: The patient was started on an immunosuppression regimen of CellCept, Cyclosporin and Prednisone in the postoperative period and she was also on Rapamycin briefly. The patient's liver function tests were noted to trend downward steadily. Optimal Cyclosporin dosing was still to be determined on the day of discharge, but it was expected with continue to monitoring Cyclosporin levels following discharge. This should be completed soon. The patient is to be discharged on Cyclosporin dose of 175 mg b.i.d. The patient's incision was monitored for infection in collaboration with the Infectious Disease Service during the immediate postop period. It went from purulent drainage as noted from the unction point of her [Last Name (un) 8314] incision. Culture swabs from the incision were unremarkable and the drainage was minimal by the day of discharge. The patient was not treated with antibiotics specifically targeting this incision and dry gauze dressing was used to cover the draining area prn. The incision will need to be monitored for evidence of developing or worsening infection. The patient's post surgical abdominal pain was managed with Percocet one to two tablets every four to six hours as needed for pain with good relief. The patient had some residual ascites by the date of discharge. 2. Gastrointestinal: The patient was reported to have had an episode of pancreatitis in the immediate postoperative period, but this was resolved by the time of the [Hospital 228] transfer to the floor on postop day number five. The patient was started on a regular diet on postoperative day number five and her total parenteral nutrition was discontinued. The patient's appetite was, however, noted to be poor in the period immediately after initiation of regular diet by mouth. This was confirmed by a calorie count and the decision was made to initiate cycled tube feedings on postoperative day number eight with Mepro. Preference was given to a low potassium formula given the patient's hyperkalemia during that period. The patient's appetite remained marginal on the day of discharge and continued tube feeding as likely to be needed in the short term. A calorie count on the day prior to the patient's discharge revealed the patient was only meeting 6% of her protein needs by mouth and only 22% of her caloric needs. 3. Renal: As mentioned above the patient's acute renal failure resolved steadily with serum creatinine falling from a peak of 3.6 on postoperative day number three to a baseline of about 1 by postoperative day number fifteen. 4. Infectious disease: The patient's stool tested positive for C-difficile on her day of admission and [2167-9-11] and the patient was started on treatment for this infection. By hospital day number two the day prior to surgery the patient's stool was negative for C-difficile. The decision was made to keep the patient on prophylaxis against this infection following surgery to complete a fourteen day course. Out of concern about the ability of her gut to adequately absorb, the patient was double covered with po Vancomycin and intravenous Flagyl. C-difficile toxin performed on postoperative day number ten were negative. The patient's intravenous Flagyl was discontinued and po Vancomycin continued to postoperative day number fourteen. The patient was also on standard post transplant prophylactic antibiotics. Valcyte, Bactrim and Fluconazole. 5. Respiratory: No issues on this admission. 6. Hematology: The patient required platelet transfusion on postop day number three and seven, but by the time of discharge her platelet count was increasing. The patient required transfusions for decreases in hematocrit on postop day number fourteen and seventeen. The patient was evaluated for a source of bleeding, none could be identified. Her stool was guaiac negative. The patient's hematocrit will need to be monitored following discharge. 7. Endocrine: The patient's blood glucose levels were controlled with insulin on a sliding scale. Her insulin requirements were noted to be increasing on postoperative day number thirteen through fourteen. Her sliding scale coverage was increased and the [Hospital ] Clinic consult team was asked to see her.. Their recommendations included placing the patient on six units of NPH at breakfast and dinner and continued the use of sliding scale insulin. The patient's diabetic teaching was deferred for fear of overwhelming the patient. It is believed that the patient's current high blood glucose may be attributable to some of her immunosuppressive medications and may resolve in two to three months. Arrangements were made for the patient to visit the [Hospital ] Clinic for appointments on days to coincide with her visits to the [Hospital1 69] Transplant Center. TSH level was noted to increase from 1.2 on [2167-9-18] to 14 on [2167-10-3] and ultimately to 25 on [2167-10-7]. The cause for the increase in TSH was unclear, but thyroid function tests were drawn on the day prior to admission and follow up is expected from the [Hospital ] Clinic. The patient was started on a minimal dose of Synthroid at 0.125 mg q.d. to be discontinued if this medication is deemed unnecessary. 8. Musculoskeletal: The patient was seen by physical therapy following transfer to the floor from the Intensive Care Unit and with therapy the patient was ultimately able to ambulate safely and independently on the floor with a walker. It is anticipated that she will continue to receive physical therapy following discharge. 9. Fluid and electrolytes: The patient was noted to be hypokalemic with serum potassium in the 5 to 7 range from postoperative day number eight through fifteen, requiring use of Kayexalate twice during that period, and administration of Lasix with the duel purpose of treating hyperkalemia and assisting in diuresis of the patient. The patient was stable on telemetry during the period of highest serum potassium. The etiology for the hyperkalemia was unclear, although it was believed that the patient's ongoing treatment with Fluconazole, Cyclosporin and Vancomycin were contributing factors. The patient's potassium was down to within normal limits by the day of discharge. The patient was also started on 800 mg of magnesium by mouth twice a day when her magnesium levels were noted to be trending downward. Her magnesium levels will need to be monitored following discharge. 10. Neurological: The patient was at times noted to be anxious and emotionally labile by staff (intermittent crying episodes, expressions of frustration and difficulty coping). Neuro/psychiatric evaluation was requested prior to the patient's discharge. Findings from evaluation included the fact that the patient had deficits in memory, visual planning and organization as well as flexibility of attention and naming and as such is prone to confusion. The patient will need to be followed up, preferably by a local psychiatrist in [Doctor Last Name 792]after discharge. In the interim she will continue to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10166] here at the [Hospital1 346]. DISCHARGE MEDICATIONS: CellCept 1 gram b.i.d., prednisone 15 mg po q.d., Neural 175 mg b.i.d., Lasix 40 mg po q.d., Protonix 40 mg b.i.d., Bactrim double strength one tablet q.d., Fluconazole 400 mg q.d., Valcyte 450 mg b.i.d., magnesium oxide 800 mg b.i.d., Seraquel 25 mg q.h.s., Percocet 5 mg one to two tabs po q 4 to 6 hours prn, Colace 100 mg b.i.d., NPH insulin 9 units subQ at breakfast and 6 units subQ at dinner as well as sliding scale insulin. DISCHARGE CONDITION: Stable. FOLLOW UP LABORATORY REQUIREMENTS: The patient will need to have blood drawn for the following tests every Monday and Thursday, a CBC, chem 7, albumin, AST, ALT, alkaline phosphatase, total bilirubin, direct bilirubin, cyclosporin. The results of these tests should be faxed to Dr. [Last Name (STitle) ] at fax number [Telephone/Fax (1) 697]. The patient's blood glucose will need to be checked four times a day with coverage of sliding scale insulin. FOLLOW UP: 1. The patient will need follow up with her primary transplant surgeon Dr. [Last Name (STitle) ] with her first appointment at 10:00 a.m. on [10-14] and a further appointment at 9:30 a.m. on [10-21]. Dr.[Name (NI) 1369] office number is [Telephone/Fax (1) 673]. 2. The patient needs to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10166] of Psychiatry here at the [Hospital1 190] for the next three months. 3. The patient needs to be linked up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], a psychiatrist for complete neuro/psych evaluation following discharge. 4. The patient will need to follow up at the [Hospital ] Clinic for diabetic teaching. Her first appointment is scheduled for [2167-11-4] on Wednesday at 9:00 a.m. with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] nurse educator at the clinic. At 10:00 a.m. on that same day she is to see [Last Name (un) ] physician on the [Location (un) 1773] of the [Last Name (un) ] Center. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 997] MEDQUIST36 D: [2167-10-9] 08:08 T: [2167-10-9] 08:35 JOB#: [Job Number 32982]	[ "577.0", "584.5", "570", "576.1", "998.59", "571.49", "276.7", "276.1", "008.45" ]	icd9cm	[ [ [] ] ]	[ "45.13", "50.59", "88.72", "99.15", "96.6" ]	icd9pcs	[ [ [] ] ]				16033, 16505			2083, 2169		15577, 16011					4221, 15553																			16517, 17854		2268, 2696		2719, 4203																	178, 1714														1737, 2066	2186, 2236
75,023	193,996	48703	Discharge summary	report	Admission Date: [2153-1-17] Discharge Date: [2153-1-18] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2763] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: The patient is a [Age over 90 ] yo man with h/o HTN, HL, DM2, CRI (baseline creatinine of 1.6), who presented from home with hypothermia, bradycardia, and AMS. As the patient is altered, the majority of the history was obtained from the patient's daughter and medical records. In brief, the patient was reportedly in his normal state of health until last week, when he had several days of diarrhea and anuria. Per his daughter, she gave him his night medications last night, and then this morning he was noted to be more lethargic. Given this constellation of symptoms, she called 911 and the patient was brought to the ED. . In the ED, his initial VS were T 95.2, HR 88, NP 100/51, RR 16, Sat 4L NC. He kept repeating to the ED staff that he was having diarrhea, and hadn't urinated. He was in sinus rhythm and normotensive until he was taken to the ED room. Per ED resident there, he was noted to become intermittently hypotensive to the 60s in the setting of bradycardia to the 30s. He was given IV 0.5mg Atropine x 3. With his pressures reponding to increases in his HR. He was also given IVF rescusitation of 5L. His EKG was noted to STE inferiorly V3-V4 with q waves inferiorly, STD depression in AvL, flat twaves in lead I and lateral leads. STEMI team was called at 0831 as well as toxicology, and he was started on a heparin gtt and was given ASA 600 mg PR. He was found to have hyperkalemia and and an initial lactate of 10.1, for which he was given calcium gluconate and albuterol nebs. A CXR was obtained which showed low lung volumes but no pneumonia, vascular congestion, or pleural effusion. A KUB/CT abd was also obtained given the bradycardia, hypotension, elevated lactate with a prelim read showing no acute intrabdominal process. He was started on Vancomycin and Flagyl. Per discussion with his daughter, the patient's code status was reversed from DNR/DNI to full code. Given his AMS, he was intubated in the ED. He was induced with Rocuronium and Etomidate and was noted to go into asystole. Chest compressions were started, and he was given 1 round of epinephrine/atropine. A pulse was noted after 5 minutes of compression. His BPs were noted to be in the 200s following Epi administation. During placement of his femoral line the pt's systolic pressures were noted to drop in the 60s, with HR still in the 60s, he was then started on Dopamine pressor support with an increase in BP to 87/59, last SBP recorded was 130s. He was then admitted to the CCU for further evaluation. . Per report, the ED resident called his previous PCP and was informed that the patient had been lost to follow-up since [Month (only) 116] and was fired for non-compliance. There was also reportedly a question of narcotics abuse in the past between the patient and his daughter. A message was also left with the patient's PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 807]. . In the CCU, renal was consulted and recommended a fluid challenge with 2 L of NS and 1L of sodium bicarbonate rather than immediately starting CVVH. His repeat potassium was elevated to 6.7, so he was given another dose of calcium gluconate, insulin, and dextrose. He was placed on Artic Sun and attempts to place an A-line were unsuccessful. Given the patient's complex medical issues, he was transferred to the MICU for further management. . On the floor, the patient opens his eyes to voice but otherwise is unable to contribute to the history. . ROS: Unable to obtain secondary to patient sedation. Past Medical History: Type 2 Diabetes Hyperlipidemia Hypertension OA of the shoulder Gout Chronic Kidney Disease Peripheral Neuropathy GERD Social History: He occasionally smokes and drinks, but not to a significant degree. He is a retired maintenance worker at [Hospital1 3372]. He emigrated from [Location (un) 4708]. Family History: N/C Physical Exam: GENERAL: Pt currently intubated, not responding to verbal commands or withdrawing from pain. HEENT: 5mm b/l, minimally reactive (pt just received Atropine) CARDIAC: Normal S1, S2, rate in the 80s, no m/r/g. LUNGS: CTA b/l ABDOMEN: Soft, no facial grimacing with palpation, no bowel sounds noted. EXTREMITIES: No edema Pertinent Results: TTE [2153-1-17]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is sparring of the apical RV ([Last Name (un) 13367] sign) suggestive of acute RV strain from pulmonary embolism. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Acute RV strain suggestive of pulmonary embolism. . CT Abdomen [2153-1-17]: 1. No acute intra-abdominal or pelvic pathology. . 2. Left renal cyst and bilateral renal hypodensities that are too small to characterize. [2153-1-17] 08:35AM BLOOD WBC-14.3# RBC-4.08 Hgb-11.8* Hct-36.5* MCV-89 MCH-29.0 MCHC-32.5 RDW-13.9 Plt Ct-170 [2153-1-17] 08:35AM BLOOD Glucose-378* UreaN-69* Creat-7.6# Na-134 K-7.0 Cl-92* HCO3-11* AnGap-38* [2153-1-17] 08:35AM BLOOD ALT-3213* AST-3523* LD(LDH)-3525* CK(CPK)-513* AlkPhos-158* TotBili-0.6 [2153-1-17] 08:35AM BLOOD CK-MB-20* MB Indx-3.9 cTropnT-2.02* [2153-1-17] 09:18AM BLOOD Type-ART pO2-511* pCO2-24* pH-7.27* calTCO2-12* Base XS--13 [2153-1-17] 08:35AM BLOOD Lactate-10.1* K-6.7* Brief Hospital Course: Mr. [Known lastname 102400] was a [Age over 90 ] yo man with h/o DM2, HTN, and HL, who presented from home with lethargy and AMS. He was intubated for worsening mental status in the ED, sustained a PEA arrest, and he was transferred from the CCU to the MICU for further management of multi-organ failure. He became hypotensive during his course in the ICU and the family had decided that they did not want to proceed with resusitation or escalation in care. He was given 2 more liters of fluid however he did not respond. Patient expired at 1:45 PM on [2153-1-18]. . #. s/p PEA arrest: The patient reportedly went into PEA arrest with inducation for intubation with Rocuronium and Etomidate. He received Atropine, Epi x 1 and 5mins of chest compressions before a pulse was detected. Pt's BP was noted to be in 200s following resuscitation. He was started on the Arctic Sun protocol, with core temperatures reaching 34 degrees Celsius at 5:30 PM. DDx for PEA arrest at this time is long and includes hypotension in the setting of anesthesia induction v. hyperkalemia v. PE v. ACS. ECHO showed severe right heart strain concerning for PE. . # Hyperkalemia: The patient's K on presentation was 7.0, which decreased to 5.4 with two doses of insulin, calcium gluconate, and glucose. His hyperkalemia is likely secondary to acute on chronic renal insufficiency and exacerbated by his Lisinopril. Renal is aware and had discussed starting CVVH if needed. . # Complete Heart Block: Per [Name (NI) ] pt would become bradycardic in the ED to the 30s with resulting hypotension to the 30s. Pt received Atropine 0.5mg IV x 3 with improvement in his heart rate and BPs. His EKGs in the CCU appeared to be in heart block with a junctional escape. DDx includes beta blocker toxicity v. metabolic acidosis v. hyperkalemia. Pt's current ventricular rate is in the 50s on Dopamine, pacer pads in place. . # Hypotension: Pt was reportedly normotensive in triage. Following his arrest his BPs were noted to be in the 200s, per ED during placement of the femoral central line he became hypotensive to the 60s and required approximately 5L of IVF, was started on Dopamine which was uptitrated to 20mcg. Will titrate Dopamine for goal MAPs >60. Hypotension may be [1-10] hypovolemia given his diarrhea, at times he was noted to be hypotensive when he became bradycardic however his last episode of hypotension occured in the setting of his heart rate in the 60s-70s. Sepsis needs also to be considered given the leukocytosis, hypothermia, diarrhea. . # Diarrhea: Pt reported diarrhea over several days, unfortunately pt is intubated and daughter is a poor historian making history of the diarrhea difficult to clarify. Will monitor stool output to eval bloody vs watery. Pt had CT abd/pelvis performed, will await final read to look for colitis. Diarrhea could be [1-10] infection, ischaemic colitis. . # Metabolic Acidosis: Pt noted to have a significant Anion gap acidosis with AG 31, HCO3 ranging [7-19]. Suspect this is due to the elevated lactate although elevated BUN could be contributing. He was started on a bicarb gtt, and his HCO3 improved to 22. . #. Transaminits: On arrival to the ED, the patient was noted to have transaminitis with AST/ALT of 3523/3213. It appears that these labs were drawn prior to the time of the cardiac arrest, though this history is uncertain. His elevated transaminases are likely secondary to shock liver in the setting of significant hypotension. . DISPO: Expired 1:45PM [2153-1-18] Medications on Admission: Omeprazole 20mg daily Gabapentin 400mg [Hospital1 ] Lisinopril 10mg daily Colchicine 0.6mg daily Allopurinol 300mg daily Metoprolol XR 50mg [Hospital1 ] Calcium Citrate 250mg [Hospital1 ] Humulin N 10u qHS Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764]	[ "426.0", "276.51", "785.50", "276.52", "585.9", "427.89", "787.91", "274.9", "403.90", "584.9", "250.13", "V15.81", "572.8", "780.97", "518.81", "276.7", "410.41" ]	icd9cm	[ [ [] ] ]	[ "99.60", "96.04", "99.62", "96.71" ]	icd9pcs	[ [ [] ] ]	10262, 10271	6420, 9965	273, 285	10322, 10331	4541, 6397	10383, 10481	4183, 4188		10234, 10239		10292, 10301		9991, 10211			10355, 10360								4203, 4522																					212, 235									313, 3837														3859, 3978	3994, 4167
15,537	139,467	9692	Discharge summary	report	Admission Date: [2196-12-23] Discharge Date: [2196-12-28] Date of Birth: [2134-12-9] Sex: M Service: SURGERY Allergies: Tetanus Toxoid Attending:[First Name3 (LF) 2597] Chief Complaint: Surgical intervention for severe intermittent claudication secondary to right superficial femoral artery occlusion Major Surgical or Invasive Procedure: [2196-12-23]: Right common femoral to below-knee popliteal artery bypass with non-reversed saphenous vein and angioscopy. History of Present Illness: Mr. [Known lastname 13474] is a 62-yom who saw Dr. [Last Name (STitle) ] in [2196-11-6] for evaluation of intermittent claudication of the right lower extremity. He is four and a half years status post orthotopic liver transplantation for hepatitis C viral infection that had been eradicated. He has a history of hepatopulmonary syndrome and has had prostate cancer in the past requiring prostatectomy and radiation therapy. Other problems include hyperlipidemia, hypertension, and a basal cell carcinoma removed in [2196-1-7]. He has a large ventral incisional hernia from his previous liver [Year (4 digits) ] and has had at least one episode of medication-induced acute pancreatitis in the past. In late [Month (only) ]/early [Month (only) ] he noted claudication symptoms in his right leg. They start in the right ankle and calf and progressed upwards into the upper leg, occurring with less than 20 feet of walking, and relieved after a short period of rest. He has no symptoms of rest pain. He thinks he has had milder symptoms in the past but is somewhat nonspecific about that. He underwent a diagnositc Lower Extremity Angiography in early [Month (only) ] and was found to have a right superficial femoral artery occlusion. He presents for surgical intervention on [2196-12-23]. Past Medical History: - OLT - liver [Date Range ] 3 yrs ago for ETOH cirrhosis HBV/HCV cirrhosis. On immunosuppression, HCV was treated and eradicated prior to his [Date Range ] (had cirrhosis and hepatopulmonary syndrome), has had one episode of acute cellular rejection - Prostate CA with radical prostatectomy ([Hospital1 2025] Dr. [Last Name (STitle) 4229] - Appendectomy - H/O multiple traumas: gunshot wound, stabbing and hit by train (while drunk) -HTN -Hyperlipidemia -Osteoarthritis -Rheumatoid Arthritis -Basal Cell CA - tx by derm -Ventral incisional hernia Social History: He is a substance abuse counselor now (has been for 17 years). He lives with his friend. Reports history of multiple incarcerations. Has long EtOH abuse history, but has been [Last Name (STitle) 7758] since [2176]. Smokes 1 pack per day (has 50 pack-year history). Also reports having used illicit drugs in the past (cocaine, heroin, morphine) but denies recent use. Family History: 2 brothers and 1 sister with brain cancer (sister is also breast cancer survivor, has [Year (4 digits) ] mutation), mother had cancer (type unknown), mother and father passed away due to MI. No FHx of liver disease. Physical Exam: well-appearing gentleman who looks older than his stated age. VSS No cervical bruits. Chest is clear. Heart is in regular rhythm. Abdomen is with multiple surgical scars. No aneurysm appreciated. Femoral pulses are palpable bilaterally. His left popliteal and dorsalis pedis pulses are also palpable. He has no palpable distal pulses on the right leg. Pertinent Results: [2196-12-28] 05:34AM BLOOD WBC-5.7 RBC-3.36* Hgb-9.8* Hct-30.1* MCV-89 MCH-29.2 MCHC-32.6 RDW-15.1 Plt Ct-318 [2196-12-28] 05:34AM BLOOD PT-23.7* PTT-74.4* INR(PT)-2.3* [2196-12-28] 05:34AM BLOOD Glucose-92 UreaN-16 Creat-1.0 Na-140 K-4.1 Cl-107 HCO3-25 AnGap-12 [2196-12-28] 05:34AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7 [2196-12-28] 05:34AM BLOOD tacroFK-2.9* Brief Hospital Course: Mr. [Known lastname 13474] was admitted on [2196-12-23] and underwent R femoral-below knee popliteal artery bypass grafting with greater saphenous vein graft. He tolerated the procedure well but in the PACU there was a noted loss of the right posterior tibial artery Doppler signal and the foot became somewhat pallorous and it was decided to re-explore him. He was taken back to the OR where he underwent exploration of right lower extremity and completion arteriogram. The areteriogram showed no defects of the graft however, there was still concern for a problem and we decided to extend the femoral incision proximally given that there was a strong pulse present in the groin and somewhat weaker pulse distally. On opening the incision it further appeared that the vein graft was passing through some slips of the sartorius muscle and near the proximal anastomosis and not completely under the sartorius as is usually seen and appeared as though a small arterial branch of the sartorius muscle could be compressing the small- caliber portion of vein graft. This branch was transected and ligated. The muscle completely freed from around the graft. The vessel and skin were closed. The pt tolerated the procedure well and was transfered to the PACU and then the VICU. Hehad a downward trending hct and was transfused 1u prbcs on [12-23]. He was started on asa, plavix, a heaprin gtt and coumadin. He remained hemodynamically stable throughout his post op course and was voiding, tolerating a regular diet and ambultaing in the [Doctor Last Name ] without difficulty. He was stable for discharge home on [2196-12-28]. I did speak to Dr.[Name (NI) 948] nurse and their office will follow the Pt/Inr. Dr. [Last Name (STitle) 497] usually prescribes the pt percocet #90 each month. We have agreed that I will write the Rx today, and Dr. [Last Name (STitle) 497] will see the pt in 1 month and will refill at that time. Medications on Admission: amlodinpine 10mg qd fenofibrate 145mg qd metorpolol 50mg [Hospital1 ] omerprazole 20mg percocet 5/325 q4hprn (rx by dr. [Last Name (STitle) ]) pravastatin 20mg qhs tacrolimus 0.5mg qam and qhs asa 81mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:90 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: take this medication for 3 months - [Date range (3) 32757]. Disp:30 Tablet(s) Refills:2 9. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day: take this in place of omeprazole while on plavix. Disp:60 Tablet(s) Refills:2 10. STOP MEDICATION omeprazole 20mg daily 11. Outpatient [Name (NI) ] Work PT/INR to be checked 1-2 times per week. Will be reviewed and adjusted by Dr. [Last Name (STitle) 497] Discharge Disposition: Home with Service Discharge Diagnosis: Intermittent claudication of the right lower extremity with Failing right femoral below-knee popliteal artery bypass graft. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [2-9] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Medications: You will be sent home on coumadin for 3 months. This is a blood thinner. You will need to have your blood drawn to check your PT/INR levels 1-2 times per week. The results will be sent to Dr. [Last Name (STitle) 497] and he will adjust your coumadin dose as needed. The goal INR is 2.0-3.0 You will have a VNA come to your home for 1-2 weeks to draw the labs, after that you will go to the liver clinic to have your labs drawn. Followup Instructions: Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Will call you to reschedule appt. You do not have to go on [2197-1-4]. Dr [Last Name (STitle) 497] will follow your PT/INR levels and adjust your coumadin dose as needed Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2197-1-9] 12:40 Provider: [Name10 (NameIs) ] UNIT Phone:[Telephone/Fax (1) 164] Date/Time:[2197-3-8] 10:30 Completed by:[2196-12-28]	[ "V15.3", "440.21", "V10.46", "599.71", "V42.7", "272.4", "444.22", "553.21", "996.74", "401.9", "714.0", "E878.2", "715.90", "V10.83" ]	icd9cm	[ [ [] ] ]	[ "39.29", "38.88", "39.49", "88.48" ]	icd9pcs	[ [ [] ] ]	7244, 7263	3895, 5847	391, 519	7431, 7431	3492, 3872	10740, 11309	2878, 3101		6111, 7221		7284, 7410		5873, 6088			7576, 9861	9887, 10717							3116, 3473																					237, 353									547, 1880									7445, 7552					1902, 2468	2484, 2862
41,448	117,992	26284	Discharge summary	report	Admission Date: [2118-4-17] Discharge Date: [2118-4-25] Date of Birth: [2070-3-9] Sex: M Service: SURGERY Allergies: Penicillins / Codeine / Shellfish Derived Attending:[First Name3 (LF) 695] Chief Complaint: ESRD Major Surgical or Invasive Procedure: deceased donor renal transplant [2118-4-17] History of Present Illness: 48M man w/ ESRD [12-22] HIV associated membranous nephropathy s/p failed renal transplant in [1-/2117] presents for second renal transplant today. Patient reports that he has been in his usual state of health. He denies fevers, chills, nausea, vomiting, dysuria but reports some loose stools. He denies weight loss, and reports that his appetite has been normal. His last BM was this morning and was normal in appearance for him. His last dialysis was friday and his dialyzed on MWF. His Blood group is O and his cPRA is 41% with unacceptable antigens listed as follows: A43, A80, B8, B44, B45, B76, B82. He has not had any class 2 antibodies detected to date. ROS: (+) per HPI (-) Denies pain, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: 1. ESRD [12-22] membranous glomerulonephritis --s/p DCD KT on [2117-2-6], postop course with delayed graft function requiring HD 2. HIV+ - very durable sustained viral suppression with most recent HIV VL < 48 copies/mL and CD4 count in the 800s (per ID note [2117-3-11]) 3. Hyperlipidemia 4. Avascular necrosis of hips 5. Hyperparathyroidism 6. Hypertension 7. Hyperglycemia due to steroids, now on insulin Social History: Lives with partner of in [Name (NI) 3914]. No children, worked as a customer service manager for [Company ] until medically disabled. Does not smoke, drink ETOH or use recreational drugs. Family History: Father is deceased- had CRF, HTN, DM; Mother is deceased- had colon CA. Twin Brother is deceased from HIV related complications and renal failure; sister is alive and healthy and has offered a kidney. Physical Exam: Vitals: 94.1 86 133/80 18 96RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese abdomen, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, right paramedial incision, no hernias DRE: normal tone, no gross or occult blood Ext: LUE arm clotted AVG, LUE forearm clotted AVG Bilateral palpable peripheral pulses (fem, [Doctor Last Name ], DP) No LE edema, LE warm and well perfused Both feet have very dry skin, sensation impaired bilaterally due to diabetes associated peripheral neuropathy Laboratory: Chem10 138 99 53 3.8 19 13.0 ∆ Ca: 8.4 Mg: 2.2 P: 3.2 ALT: 47 AP: Tbili: Alb: 4.4 AST: 44 LDH: Dbili: TProt: [Doctor First Name ]: Lip: CBC 11.9 ∆ > 30.5 < 311 [Name (NI) 2591] PT: 13.6 PTT: 33.8 INR: 1.2 Urinalysis - +leuk, +nitr, +WBC, +epi (contaminated UA) EKG ([2118-4-18]): normal EKG, sinus rhythm, no ST abnormalities Imaging: CXR [2118-4-18]: no consolidation or effusion Pertinent Results: [2118-4-25] 06:45AM BLOOD WBC-7.2 RBC-3.49* Hgb-9.8* Hct-28.3* MCV-81* MCH-28.0 MCHC-34.5 RDW-15.2 Plt Ct-186 [2118-4-20] 02:56AM BLOOD PT-13.5* PTT-27.8 INR(PT)-1.2* [2118-4-21] 05:55AM BLOOD WBC-7.1 Lymph-2.9* Abs [Last Name (un) ]-206 CD3%-21 Abs CD3-42* CD4%-3 Abs CD4-7* CD8%-17 Abs CD8-35* CD4/CD8-0.2* [2118-4-25] 06:45AM BLOOD Glucose-92 UreaN-54* Creat-11.3# Na-140 K-3.4 Cl-100 HCO3-26 AnGap-17 [2118-4-25] 06:45AM BLOOD Calcium-7.8 Phos-4.4 Mg-2.1 [2118-4-25] 06:45AM BLOOD tacroFK-6.8 Brief Hospital Course: On [2118-4-18], he underwent deceased donor renal transplant with 24 hours of cold ischemia. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Initials (NamePattern4) ] [Last Name (NamePattern4) 406] drain was left in place. Please refer to operative note for details. Postop, he experienced hypotension during the case requiring neo for bp support and PRBCs. He made a little urine in the OR then became anuric after the OR. He was transferred to the SICU for management. Pressor support was weaned off and he was extubated. TTE was done to evaluate hypotension. EF was 55%. He was noted to have mild LVH and mild pulmonary artery systolic HTN. He required IV medication treatment for hyperkalemia. Urine output slowly increased to 1 liter per day and creatinine ranged between [10-2]. He experienced delayed graft function and required hemodialysis. Renal duplex demonstrated appropriate vasculature, no hydro and no perinephric fluid collections. [Doctor Last Name 406] drain output was serosanguinous with a lot of leaking around the [Doctor Last Name 406] drain insertion site. Diet was advanced and tolerated. [Last Name (un) ] was consulted to adjust insulin given elevated glucoses from the steroids. Pain medication was adjusted to oral Dilaudid. IR placed a left IJ triple lumen for meds for poor access. Immunosuppression consisted of ATG 150mg for a total of 4 doses given past response to ATG and DGF. CellCept was well tolerated, Solu-Medrol was tapered to prednisone 20mg daily and Prograf was adjusted to 20mg [Hospital1 ] as trough levels were slow to increase to goal (6.8 on [4-25]). Nephrology followed him throughout his stay. ID and pharmacy renally dosed his ARVs. The decision was made to send him home on dialysis to return on Thursday [4-28] at noon for a 1pm renal transplant biopsy. He would then stay overnight for observation and have HD on Friday [4-29]. PT was consulted and recommended PT at home. [Location (un) 43512] Area VNA was arranged. He was ambulating with a walker at time of discharge. Vital signs were stable. [Doctor Last Name 406] drain was removed and site suture the day of discharge. Medications on Admission: abacavir 300', dialyvite 1', cinacalcet 60', emtricitabine 200 every 4 days, ezetimibe 10', tricor 1tab', insulin lispro RISS, metorprolol tartrate 50'', mycophenolate mofetil 2tabs", prednisone 5', raltegravir 400'', sevelamer 800mg x 8'', sirolimus 6', tenofovir 300 Qmon, zolpidem 20 PO Qhs, calcium carbonate 500''', NPH insulin 9U QAM, and 3U QPM, omega-3 fish oil 3000' Discharge Medications: 1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO Q 24H (Every 24 Hours). 6. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn every 8 hours as needed for pain. 8. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. sevelamer carbonate 800 mg Tablet Sig: Eight (8) Tablet PO BID W/ MEALS (). 12. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q72H (every 72 hours). 13. tacrolimus 5 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 14. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous at bedtime. 16. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day. 17. Outpatient Lab Work Every Monday and Thursday: cbc, chem 10, ast, t.bili, UA and trough prograf with results fax'd to [Hospital1 18] Translant Office attn: [Name6 (MD) 5036] [Name8 (MD) 5039] RN coordinator [Telephone/Fax (1) 697] 18. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) 43512] Area VNA Discharge Diagnosis: esrd delayed renal graft function hiv Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have fever, chills, nausea, vomiting, inability to take any of your medications/eat or drink fluid, increased abdominal pain/distension, incision redness/bleeding/drainage, or leaking from old drain site. You should continue with your dialysis schedule on Tues-Thursday-Sat [Location (un) 43512] VNA services have been arranged You will need to have labs drawn every Monday and Thursday. You may shower No driving while taking pain medication No heavy lifting/straining Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2118-4-28] 2:10 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2118-4-28] 3:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2118-5-2] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2118-4-26]	[ "790.01", "585.6", "276.7", "403.91", "357.2", "582.1", "V43.64", "E932.0", "249.60", "E878.0", "588.0", "458.29", "996.81", "V45.11", "V58.67", "042", "416.8" ]	icd9cm	[ [ [] ] ]	[ "39.95", "00.93", "38.95", "55.69" ]	icd9pcs	[ [ [] ] ]	8394, 8459	3981, 6208	304, 354	8541, 8541	3429, 3958	9292, 9863	2124, 2326		6635, 8371		8480, 8520		6234, 6612			8724, 9269								2341, 3410																					260, 266									383, 1452									8556, 8700					1474, 1894	1910, 2108
18,573	190,748	25772	Discharge summary	report	Admission Date: [2118-7-21] Discharge Date: [2118-7-26] Date of Birth: [2081-10-24] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 371] Chief Complaint: L Shoulder Pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 36 yo man complaining of acute onset of [8-27] L shoulder pain and diffuse upper abdominal pain that began while he was sitting working at his computer on the morning of admission. The patient called 911 and was brought by ambulance to the ED, where he was noted to have a large splenic hematoma with a perisplenic free fluid collection. The patient denied any recent abdominal, but has occasionaly heavy lifting duties at work. No nausea/vomitting, change in bowel habits, fevers or chills. The patient admits to drinking 4-6 beers per day. No recent travel history. No sick contacts. Past Medical History: Depression Chronic, intermittent low back pain x 2 yearse No History HTN, hypercholesterolemia, or diabetes. Social History: 10 pack year smoking history, quit 3.5 years ago EtOH - 4-6 beers/day Denies IVDA/recreational drugs works at liquor store Family History: No history hematologic problems. Physical Exam: T=98.9 HR 80->97 BP 135/80->125/60 RR 22 SaO2-97% RA General discomfort RRR CTA bilaterally soft, nondistended, tender LUQ. No percussive/rebound tenderness rectal no masses, heme negative extremities warm, well perfused, no edema or deformity. Pertinent Results: CT CHEST/ABD/PELVIS: Subcapsular splenic hematoma, no appearance of active hemorrhage or extravasation. The splenic vessels appear intact. + Hemoperitoneum. No aortic pathology. CXR - no acute cardiopulmonary abnormality. [2118-7-21] 02:20PM D-DIMER-1736* [2118-7-21] 02:20PM PLT COUNT-220 [2118-7-21] 02:20PM NEUTS-80.1* LYMPHS-14.1* MONOS-4.2 EOS-1.3 BASOS-0.4 [2118-7-21] 02:20PM WBC-13.0* RBC-4.74 HGB-13.9* HCT-38.6* MCV-82 MCH-29.4 MCHC-36.2* RDW-12.0 [2118-7-21] 02:20PM CK-MB-2 cTropnT-<0.01 [2118-7-21] 02:20PM ALT(SGPT)-31 AST(SGOT)-20 CK(CPK)-166 ALK PHOS-63 AMYLASE-46 TOT BILI-0.7 [2118-7-21] 02:20PM GLUCOSE-125* UREA N-18 CREAT-0.9 SODIUM-137 POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-19* ANION GAP-19 [2118-7-21] 08:30PM CK-MB-2 cTropnT-<0.01 [2118-7-21] 08:30PM CK(CPK)-115 [2118-7-21] 10:31PM HGB-12.3* calcHCT-37 Brief Hospital Course: The patient was admitted to the Trauma ICU for bed rest and serial hematocrits. From admission, his hematocrits trended downward from 37-38 to low 30s but remained stable at this level, likely reflecting an improved hydration status with some dilutional effect. His exam remained stable, and he was transferred from the ICU to the floor on #4. By HD#5 he was ambulating, tolerating po intake, and remained hemodynamically stable with stable hematocrits. He was medically stable for discharge on hospital day #6. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Outpatient Lab Work CBC Discharge Disposition: Home Discharge Diagnosis: 1. Splenic hematoma, unkown etiology Discharge Condition: Stable. Discharge Instructions: Avoid and contact sports or any activity that may cause trauma to your abdomen for the next 6 months. Call or return to the emergency department immediately should you experience any increase in abdominal pain, feeling dizzy or lightheaded, chest pain, shortness of breath, or any other symptom which concernes you. Followup Instructions: Follow up in trauma clinic in 1 week. Call 1-[Telephone/Fax (1) 2359] for an appointment. Please get a simple blood test to look at your blood level before your appointment, and bring the results to the appointment. (Prescription included)	[ "724.2", "865.01", "518.0", "E928.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3280, 3286	2463, 2977	301, 308	3367, 3376	1550, 2440	3741, 3988	1228, 1262		3032, 3257		3307, 3346		3003, 3009			3400, 3718								1277, 1531																					246, 263									336, 940														962, 1072	1088, 1212
55,781	186,666	55009	Discharge summary	report	Admission Date: [2193-8-30] Discharge Date: [2193-9-9] Date of Birth: [2116-8-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1515] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation Catheter-directed thrombolysis ECMO Tandem heart History of Present Illness: 77 y/o gentleman with SOB and black stools. He presented to OSH on [2193-8-30] with sudden onset SOB that began while reurning from the bathroom. His wife reported he had worsening DOE for previous 3 days. He also reported having dark stools. He denied, CP, cough, fevers, or chills. At OSH he was found to have right heart strain and CT PE demonstrated bilateral PEs. Pt was not given heparin at OSH [1-31] h/o GI bleeding, however his H/H was wnl. He was given protonix gtt, octreotide, and levaquin. At OSH his HR was 137 and BP was 115/65 he was given 1 unit of blood and 4L crystalloid. He was flown to [Hospital1 18], On arrival he was started on heparin drip. Bedside echocardiography demonstrated right heart strain, and ultrasound of the lower right limb demonstrated a proximal femoral clot. He was urgently taken to the cath lab where he received an IVC filter. His PA pressure was noted to be in the 70s. Catheter directed lysis of embolus with TPA infusion resulted in a drop of the PA pressure to 50s. Patient was transferred to the CCU where he remained tachypnic, tachycardic and hypotensive and distressed. It was noted that his lower extremities appeared mottled and cool. Central venous access was obtained and he was started on dobutamine and nipride, and BiPAP. . In the ED, initial vitals were: Temp: 97.6 HR: 125 BP: 116/88 Resp: 18 O(2)Sat: 98 Normal Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, -DM, -HTN 2. CARDIAC HISTORY:none -CABG:none -PERCUTANEOUS CORONARY INTERVENTIONS:none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -Rt knee surgical repair -h/o TB of the spine in college, s/p spinal surgery in the past -h/o DVT 4-5 years ago was on coumadin. Not in the past year. -h/o prior GIBs (at least one in the setting of ASA) Social History: -Tobacco history: Quit smoking 50 years ago -ETOH: per wife 1-2 drinks of gin qnight (2 gin martinis with 4oz EtOH in each) -Illicit drugs: denies Family History: Mother with CHF, died in 60s, father died in 60s of Alzheimers. Maternal GPs both died of heart failure. Physical Exam: ADMISSION EXAM: VS: T=97.9 BP=121/93 HR=96 RR=37 O2 sat= 95% on NRB GENERAL: WDWN. distressed Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP visible. CARDIAC: Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resperations are rapid. Decreased breath sounds at bases, otherwise clear. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. +BS EXTREMITIES: Mottled, cool skin in LE bilaterally. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 0 PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Right DP biphasic on doppler DISCHARGE EXAM: expired Pertinent Results: [2193-8-30] 11:47PM GLUCOSE-178* UREA N-31* CREAT-1.5* SODIUM-142 POTASSIUM-3.9 CHLORIDE-113* TOTAL CO2-18* ANION GAP-15 [2193-8-30] 11:47PM HCT-42.0 [2193-8-30] 08:51PM O2 SAT-61 [2193-8-30] 08:50PM TYPE-ART TEMP-36.5 PO2-89 PCO2-24* PH-7.45 TOTAL CO2-17* BASE XS--4 [2193-8-30] 08:30PM PT-13.3* PTT-47.9* INR(PT)-1.2* [2193-8-30] 08:29PM WBC-13.6* RBC-4.14* HGB-15.2 HCT-43.8 MCV-106* MCH-36.6* MCHC-34.6 RDW-14.0 [2193-8-30] 08:29PM PLT COUNT-150 [2193-8-30] 06:06PM LACTATE-4.1* [2193-8-30] 05:33PM ALT(SGPT)-47* AST(SGOT)-150* ALK PHOS-68 TOT BILI-2.2* [2193-8-30] 12:23PM CALCIUM-7.5* PHOSPHATE-5.0* MAGNESIUM-2.0 [2193-8-30] 12:23PM CK-MB-6 cTropnT-0.03* [2193-8-30] 08:30AM proBNP-5987* . ECHO (TTE) [2193-8-30] The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function appears normal (LVEF>50%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with depressed free wall contractility (the RV apical function is preserved/[Last Name (un) 13367] sign suggestive of acute pulmonary embolism/RV strain). Tricuspid regurgitation is present but cannot be quantified. There is severe pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: RV strain pattern suggestive of acute pulmonary embolism. Brief Hospital Course: Mr. [Known lastname ] is a 77 y/o gentleman with h/o DVT, GIB and hyperlipidemia who presented to an OSH on [2193-8-30] with SOB and bilateral pulmonary emboli on CTPE. He was transfered to the [Hospital1 18] ED and was found to have signs of right heart strain on bedside ECHO. He urgently underwent catheter directed thrombolysis with TPA and IVC filter placement. . # Pulmonary Emboli: Patient tachypneic with signs of severe RV strain s/p catheter thrombolysis and IVC filter placement. We continued heparin drip for despite initial concerns for GIB. He had an IVC filter placed, but the filter was removed on [8-30] at the time the ECMO was instituted. He went to the cath lab on [9-5] for possible thrombectomy; there was improvement in the size of the emboli bilaterally and no thrombectomy was performed. . # GIB: Pt presented with dark stools, reported guiac + in OSH and [Hospital1 18] ED. Hx of prior GIB, given octreotide at OSH. Given cardiogenic shock, currently benefits of heparin gtt outweigh risks. His HCT was monitored carefully and he was transfused when HCT <24. In addition, PLTs were maintained >100 while patient was on ECMO. His hospital course was c/b nasopharyngeal bleeding requiring packing by ENT. He was treated with cefazolin while packing was in place. . # Cardiogenic/Obstructive Shock: On arrival to the CCU, laboratory data demonstrated a Lactate of 2.8, which trended up to 4, Elevated Transanimases which improved to WNL by [9-7]. High SVR and low Cardiac Index on arrival to the CCU. Dobutamine was started with mild improvement in CI. Nitroprusside started for vasodilation to reduce RV afterload with improvement in peripheral perfusion. Maintaining high-flow O2 (tolerating BiPAP), also to assist with pulmonary vasodilation. Over the following 12 hours, he became increasingly hemodynamically unstable. A TTE showed a RV strain pattern suggestive of acute pulmonary embolism (LVEF 50%). He converted to AF with RVR during which time he became hypotensive requiring cardioversion. He was taken urgently to the cath lab, but on the way he suffered a PEA arrest, chest compressions were performed and ROSC. He was placed on ECMO with cannulations of the IJ with catheters both in the RA and RV and another cannula in his right Femoral artery (to allow for both VV and VA ECMO support). He was maintained on ECMO from [8-30] to [9-5] during which time there was interval improvement in his RV function on echo. This course was c/b AF requiring cardioversion and Amiodarone gtt, and hypotension requiring pressors. At this point he was switched over from ECMO to a tandem heart ([9-5]). Attempts to diurese resulted in hypotension. At this point, it was felt that although he was grossly volume overloaded, he was actually intravascularly depleted and diuresis was discontinued. We attempted to re-initiate diuresis on subsequent days when CXRs continued to show pulomonary edema, but we were not able to maintain adequate MAPs, even on two pressors. After a discussion with his family, his code status was changed to DNR. On [9-9], his family asked us to begin withdrawing care. He was slowly weaned off pressors. Within 45 minutes, he became asystolic and passed away with family and clergy at his bedside. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Atorvastatin 80 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "287.5", "570", "416.8", "599.71", "453.41", "518.0", "518.51", "584.9", "V49.86", "V66.7", "427.5", "784.7", "578.9", "276.69", "785.51", "272.4", "V12.51", "276.1", "427.31", "V12.01", "415.19" ]	icd9cm	[ [ [] ] ]	[ "99.60", "99.62", "37.21", "21.01", "37.23", "39.99", "37.68", "96.72", "38.7", "33.22", "39.65", "00.12", "88.43", "99.10" ]	icd9pcs	[ [ [] ] ]	8556, 8565	4996, 8313	323, 384	8616, 8625	3448, 4967	8681, 8691	2400, 2507		8524, 8533		8586, 8595		8339, 8501			8649, 8658								2522, 3404		1902, 1979					3420, 3429														264, 285									412, 1811											2010, 2217			1833, 1883	2233, 2384
2,589	130,440	313	Discharge summary	report	Admission Date: [2185-7-6] Discharge Date: [2185-7-8] Date of Birth: [2120-1-2] Sex: M Service: MEDICINE Allergies: Pneumovax 23 Attending:[First Name3 (LF) 2297] Chief Complaint: weakness, achyness Major Surgical or Invasive Procedure: none History of Present Illness: . Boiseau is a pleasant 65 yo man with paroxysmal atrial fibrillation, bipolar disorder and h/o EtOH abuse who presented to the ED today with complaints of R arm pain, achiness and "feeling off." His wife reports that he did not complain of any of the above on the morning of admission, either. Per his wife, the pt awoke early this morning, which is unusual, and was c/o some R shoulder pain (the site of the vaccination. He was just a little "off," and he fell in the living room. Both he and his wife deny loss of consciousness. Past Medical History: 1. Bipolar disorder. 2. History of rheumatic heart disease. 3. Status post clipping of cerebral aneurysm in [2167] at the [Hospital1 756]. 4. Gastroesophageal reflux disease. 5. History of hepatitis. 6. Status post cholecystectomy. 7. Status post appendectomy. 8. History of alcohol abuse. 9. FE deficient anemia followed by hematology and on IV iron therapy 10. Atrial fibrillation not on warfarin for ? fall Social History: Lives with wife, 3 cigs per day for 50 years, last EtOH was 3 months ago when he had 1 drink. Family History: NC Brief Hospital Course: In the ED, he was initially hypotensive (70s/40s) and bradycardic (50s). He was treated as a beta-blocker overdose and given IVF (~2L NS) and glucagon, with improvement in his hemodynamics. He had a CXR, CTA and CT torso, all of which were unrevealing. . He recieved empiric broad spectrum antibiotics (metronidazole 500 mg IV, levofloxacin 750 mg IV and vancomycin 1 g IV) and was transferred to the medical floor. On the floor, he developed rigors, fevers to 104.1 with tachycardia to the 110s and hypoxemia to 88% on RA. There was no witnessed aspiration event, although the pt does have a h/o aspiration for which he was treated at an OSH. He received a dose of diazepam for possible EtOH withdrawal that had no immediate effect. Of note, the pt did receive a pneumococcal vaccination on the day prior to admission. . On transfer to the ICU, the pt reported feeling well. He denied shortness of breath, and reported that the arm pain that he presented with had gotten better. He denies lightheadedness, neck stiffness, cough, sputum production, diarrhea, abdominal pain, dysuria. . ICU COURSE; Fever hypotension/Shock: Given the pt's history of aspiration, considered aspiration pneumonitis. Although he did not have a witnessed aspiration event, his wife reports a nearly identical admission ~2 years ago. Also in the differential were pulmonary embolism, an intrabdominal source of infection with associated sepsis, a reaction to the pneumococcal vaccine-which chronologically fits well with the story/cytokine like effect, neuroleptic malignant syndrome, serotonin syndrome. PE is unlikely given his normal CTA. An intrabdominal infection is unlikely given his normal CT scan and abdominal exam. A reaction to the pneumococcal vaccine is the most likely factor at this point as there is no signs of infection/endocrine phenomenon. His CK is not elevated, and he is not rigid on exam, making NMS unlikely. He is, if anything, hyporeflexive, making serotonin syndrome unlikely. As his hypotension was accompanied by bradycardia it is felt likely that an etiology could be beta blocker overdose (not felt to be intentional). [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim was negative, no growth from his cultres at 48 hours. TSH was normal. An EKG showed 1st degree AVB. He was given IV fluids, stress dose steroids, vanco/levo/flagyl for broad empiric coverage and pan cultured. A CXR on [7-8] showed ?LLL infitlrate vs atelectasis. Diuresis with 10mg IV lasix was performed and a PA and LAT were done after diuresis that showed a retrocardiac density, no overload but clinical suspicion of pneumonia was low. An echo did not show any vegetations. Pneumovax was added to his allergy list. . #hypoxemia-Pt had 02 req of 2-3L prior to transfer. He did not have symptoms such as cough/SOB/wheeze. Pt was given aggressive hydration on admission for hypotension. Resultant CXR showed this as well as crackles on exam. He autodiuresed once his BP had improved and his CXR showed improvement in hilar edema. However there was question of LLL infiltrate on CXR [7-8] and persistent 3L NC O2 requirement. Vanco was discontinued and levo/flagyl was continued until diuresis and repeat PA and LAT to assess LLL, CXR showed a left retrocardiac density (pna vs atelectasis)-however he no longer had an oxygen requirement even with ambulation. He will follow up with his PCP. . #Incontinence-Pt had two episodes of fecal incontinence on the day of discharge, pt reports this is a chronic occurence which happens when he is not at home. He denies back pain, rectal exam was with normal tone, no saddle anesthesia, no paraspinal tenderness. Pt given prescription for bedside commode. He was instructed to seek medical attention if any symptoms of leg weakness, saddle anesthesia, back pain developed or if the incontinence continued at home. . # Paroxysmal atrial fibrillation: He had runs of irregular SVT on telemetry. He was continued on flecainide. His metoprolol was held due to bradycardia. An echo showed LVEF 70%, mild AS . # Bipolar disorder: antipsychotics/SSRI restarted. . # FEN/Lytes: Regular diet, replete lytes prn . # Prophylaxis: For DVT prophylaxis he was given Heparin SC 5000 tid, pneumoboots, bowel reg. . # Communication: Wife [Telephone/Fax (1) 2938] Medications on Admission: Metoprolol 25 tid Divalproex 500 qam, 1000 qpm Olanzapine 5 qhs Topirimate 25 [Hospital1 ] Citalopram 20 qhs Flecainide 100 mg [Hospital1 ] Aspirin 325 daily MVI Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 7. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Home Discharge Diagnosis: hypotension secondary to pneumovax, beta blocker Paroxysmal atrial fibrillation Bipolar disorder History of rheumatic heart disease Status post clipping of cerebral aneurysm in [2167] at the [Hospital1 756] Gastroesophageal reflux disease. History of alcohol abuse Discharge Condition: stable, afebrile, BP 120/77, 94%ra, HR 61, ambulatory Discharge Instructions: You were admitted with symptoms of weakness, you had low blood pressure and a slow heart rate. You had imaging of your head, chest, and abdomen without evidence of infection or blood clot in your lungs. You received antibiotics as infection was suspected. You had no evidence of a problem with your adrenal glands, or thyroid. It is believed that your low blood pressure was due to a reaction from your pneumovax that was given the day before. Also, since your heart rate was low it is possible that this was due to a high dose of beta blocker. In addition you had two episodes of fecal incontinence which you have had in the past when you are not home. Your rectal exam was normal. If this does not improve when you go home you need to seek medical attention. You have been given a prescription for a bedside commode. You should continue taking your medications as prescribed. You should not take your metoprolol until you follow up with with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Please seek medical attention for chest pain, shortness of breath, palpitations, weakness, dizzyness, or any other concerning symptoms. It is very important that you follow up as outlined below. Followup Instructions: please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2939] to make an appointment within one week of being discharged from the hospital. Completed by:[2185-7-17]	[ "305.03", "785.50", "427.31", "530.81", "280.9", "V13.8", "V12.09", "296.80", "427.89", "799.02", "E949.6", "787.6", "E849.9", "458.29" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6956, 6962	1476, 5795	289, 295	7280, 7336		8599, 8782	1449, 1453		6016, 6933		6983, 7259		5821, 5993			7360, 8576																													231, 251									323, 856														878, 1321	1337, 1433
751	141,048	18368	Discharge summary	report	Admission Date: [2153-1-27] Discharge Date: [2153-2-9] Date of Birth: [2097-8-15] Sex: M Service: SURGERY Allergies: Nalfon Attending:[First Name3 (LF) 3376] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Central Line Placement IVC Filter placement History of Present Illness: 55yoM with h/o hypertension, type II diabetes mellitus, CAD, and morbid obesity, presenting with massive PE. . The patient initially presented today to his PCP with [Name Initial (PRE) ]/o dyspnea. He was recently treated for pneumonia but dyspnea persisted. He was referred to [Hospital1 ] [Location (un) 620] ED where he became acutely unresponsive and hypotensive. He was intubated for airway protection and given CTX, Azithro. A heparin gtt was started given concern for PE, aspirin given, and he was started on dopamine gtt for BP support. . On arrival to [Hospital1 18] ED VS T 98 HR 87 BP 208/175 RR 29 97%intubated . Bedside echo revealed right heart strain and right heart failure raising further concern for PE. CTA confirmed diagnosis of bilateral PA PEs. He was heparinized and then received tPA 100mg. He also received 8L NS. ECG showed new TWI in V1-V3 with elevated CK's. Labs showed acute renal failure, lactic acidosis, and +AG metabolic acidosis. Past Medical History: Hypertension morbid obesity Type II diabetes mellitus c/b nephropathy, baseline creat not known CAD s/p cath [10/2149] showing 1v dz, s/p bare metal stent to RCA CHF - EF not known Gout Social History: divorced. lives with his son. disabled. remote tob use, quit at age 23. no etoh, illicits Family History: mother and father d. complications of diabetes Physical Exam: T 101.5 HR 97 BP 174/74 RR 30 100% AC Tv 600 RR 26 FiO2 100% PEEP 10 GEN: responding to commands, comfortable HEENT: PERRL, anicteric, ETT/OGT Neck: JVP not appreciated, no LAD CV: distant heart sounds, regular Resp: coarse anteriorly with occasional crackle, clear posteriorly Abd: obese, soft, NT, ND, +BS Ext: venous stasis changes, decreased but palp DP L, radial, nonpalp DP R, no edema Neuro: responds to command to squeeze hands, moves all extremities Pertinent Results: Radiology: BLENI: Non-occlusive filling defect in right common femoral vein. No left lower extremity DVT. . CTA: Large bilateral pe's including withing the right and left main pulmonary arteries; perhaps slight right ventricular enlargement, but no pulmonary artery enlargement . CXR: Linear areas of atelectasis and area of subsegemental atelectasis in the left lower lobe. A small, focal area of infiltrate cannot be excluded. Endotracheal tube 8 cm superior to the carina. . ECG: 85bpm, NSR, RBBB, left axis deviation, TWI V1-V3 . Echo: The right atrium is dilated. The estimated right atrial pressure is >20 mmHg. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no pericardial effusion. Brief Hospital Course: 55yoM with h/o HTN, CAD, TIIDM p/w massive bilateral PE resulting in obstructive shock, NSTEMI, and right heart failure who underwent surgery for colonic mass found upon colonoscope for GI bleed. . # PE/shock: Massive PE with resultant obstructive shock and right heart failure s/p lysis with TPA. Patient was intubated at OSH and was continued on mechanical ventilation for airway protection. He was transiently on dopamine for pressure support which was weaned with stable blood pressures. Echo showed RV strain and RV dilation. BNP was >70,000 with troponin leak (TnT 1.0) c/w massive PE. He was doing well on PS and had an RSBI of 44 and extubated on [1-29] without problems. [Name (NI) ] was continued on an IV heparin gtt. A right sided permanent IVF filter was placed due to clot burden in the right right common femoral vein. Patient was also started on stress dose steroids due to h/o of chronic prednisone use due to either gout vs. nephrotic syndrome. He was intially on Hydrocortisone 100 mg q 8 hrs then tapered to 50 mg q 8 hrs. Upon leaving the ICU to the floor his hemodynamics were stable. Patient will need a reapeat Echo in aproximately 3 months to assess his RV. Heparin was held starting [2-2] due to findings on colonoscopy and ongoing melena despite stable hematocrit. Patient likely needs to be anticoagulated in the long term given PE and permanent IVC filter. . # Respiratory Failure: Patient was intubated for airway protection. Initial gas showed inadequate compensation for metabolic acidosis which improved with increase in resp rate. He was weaned off the vent and extubated on [1-29] without complications. . # GIB. Patient developed melena while on IV Heparin. EGD by GI showed mild gastritis. Patient had ongoing melena with stable Hct. C-scope showed at 6 cm polyp in the sigmoid colon. ?if this is causing melena given lesion is distal, ?small bowel lesion as well. Plans for sigmoidoscopy by GI on Monday [2-5] for bx vs. excision. IV heparin on hold since [2-2] given ongoing bleeding. # Colonic mass: The patient underwent a colonoscopy which revealed a large mass in the distal sigmoid or upper rectum. Plans were made for colonoscopic resection. The patient was taken to the endoscopy suite on [2-5] and despite multiple attempts the polyp was seen to be quite large, friable and the base could not be visualized. The polyp was large and seemed to be prolapsing down into the rectum from the sigmoid colon. The base of the polyp was tattooed and surgery was recommended. The patient underwent Laparoscopically assisted sigmoid colectomy, primary end to end stapled anastomosis on [2153-2-5]. . # Leukocytosis with left shift and bandemia. Thought to be a stress response in setting of acute PE. His WBC normalized rapidly. He was initially treated with Vancomycin due to GPC in [1-11] bottles at OSH which eventually grew beta strep. Vancomycin was discontinued. During perioperative period, the patient was started on Levofloxacin and Flagyl empirically. Patient remained afebrile throughout the hospitalization. . # ARF: h/o chronic kidney disease d/t diabetic/hypertensive nephropathy vs. h/o nephrotic syndrome. Baseline creatinine not known. Patient continued to make good urine. ARF likely prerenal azotemia vs. ATN. U/A showed granular casts, rare eos. Cr continues to trend down. Restarted [Last Name (un) ] on [2-3] at lower dose to titrate up as tolerated. . # DM2. Patient on NPH and sliding scale. FS wnl here while NPO then increased to 200's with fluids. [Last Name (un) ] consult placed and following. Scale increased on [1-31]. FS 124 at time of discharge. #Adrenal status: Patient was placed on stress dose steroids given home Prednisone use. His Hydrocortisone was tapered and the patient was discharged on his home regimen of 5mg Prednisone. . # Hypertension. Patient hypotensive and in shock initially, started to become hypertensive off all meds on [2-2]. Given lasix and IV hydral with response. BP in 180s during the evening, restarted [Last Name (un) ] at lower dose, Cr stable, on [2-3]. Also given prn IV hydral for elevated systolic pressures. Patient was on beta blocker at home however has baseline HR in 40-50s therefore not restarted. The patient was restarted on his home anti-hypertensive therapy with return to bowel function. . # Bradycardia. Sinus brady to 40's while sleeping and during the day while awake. Patient reports HR in the 40s at home and has never been symptomatic. Held BB while here. Normal rate at time of discharge. . restarted diet, tolerating well, likely needs to be NPO for signoidoscopy planned for [2-5], repleting lytes prn. The patient's diet was advanced when bowel function returned following surgery and was tolerating regular diet at time of discharge. . # Access: R subclavian placed by IR. . # PPx: Pneumoboots, IV filter in place, Protonix #Physical: Physical Therapy consulted and recommended rolling walker at time of discharge. The patient used abdominal binders to support his girth following surgery while ambulating. # Post operative course: The patient's course was uncomplicated. His diet was advanced upon return of bowel function/flatus. Incision remained clean/dry and intact. . # Communication: daughter [Name (NI) 803] [Telephone/Fax (1) 50587](c) [Telephone/Fax (1) 50588] (h) son [Name (NI) ] [Telephone/Fax (1) 50589] (h) [Telephone/Fax (1) 50590] (c) . # Full Code Medications on Admission: KCl, MVI, folic acid, mag oxide Lasix 120 mg daily Metoprolol 100 [Hospital1 ] Prednisone 5 mg daily Colchicine 0.6 mg daily Maalox NPH insulin Gemfibrozil Diovan 160 mg daily Allopurinol 400 mg daily Oxycodone 5/325 ASA Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Massive Pulmonary Embolism complicated by obstructive shock, hypotension, NSTEMI, right heart failure/strain 2) s/p tPA and IVC filter placement (permanent) 3) course complicated by GI bleed, gastritis on EGD, colonic polyp, acute blood loss anemia 4) sinus bradycardia Secondary: 1) hypertension 2) Diabetes Type II - controlled with complications 3) CAD s/p NSTEMI 4) Morbid Obesity 5) CHF with history of diastolic dysfunction 6) Obstructive Sleep Apnea 7) history of gout Discharge Condition: Stable, oxygenating well room air, pain controlled, moving bowels Discharge Instructions: Please call Dr. [Last Name (STitle) 1120] if: Notify MD or return to the emergency department if you experience: Increased or persistent pain Fever > 101.5, chills Nausea, vomiting, diarrhea, or abdominal distention Inability to pass gas, stool, or urine If incision develops redness or drainage Shortness of breath or chest pain Any other symptoms concerning to you You may shower and wash incision with soap and water No swimming or tub baths for 2 weeks Please use your abdominal binders when out of bed and ambulating until your follow up with Dr. [Last Name (STitle) 1120]. Please use your walker as prescribed by Physical Therapy when ambulating. You will have your staples removed at your appointment at Dr. [Name (NI) 14120] office. Continue all your home medications as prescribed. This is very important. Lasix Potassium Metoprolol Diavan NPH insulin Magnesium Aspirin Gemfibrozil Allopurinol Prenisone 5 mg daily Colchicine For pain: may take Percocet for extreme pain. [Month (only) 116] take Tylenol for pain. Do not take Percocet and Tylenol together. Please use stool softener (Colace) twice daily to keep bowel movements soft. Followup Instructions: Follow up with Dr. [Last Name (STitle) 1120] in [1-9] weeks for staple removal and postoperative check. Follow up with your Primary Care Provider on [Name9 (PRE) 766*] for Potassium level, edema in legs (fluid balance) and your finger stick glucose. Please use rolling walker as prescribed by Physical Therapy until cleared by your primary care provider. You may eat regular diet; recommend low fat, low cholesterol diet healthy for your diabetes.	[ "785.51", "274.9", "327.23", "250.40", "276.2", "278.01", "410.71", "211.4", "578.1", "562.10", "584.9", "211.3", "V45.82", "453.8", "285.1", "V64.41", "415.19", "428.31", "401.9", "518.81", "583.81" ]	icd9cm	[ [ [] ] ]	[ "38.7", "45.13", "45.23", "99.10", "00.17", "96.71", "99.04", "38.93", "45.76", "45.25" ]	icd9pcs	[ [ [] ] ]	9401, 9407	3369, 8863	273, 318	9940, 10008	2210, 3346	11231, 11696	1667, 1715		9139, 9378		9428, 9919		8889, 9116			10032, 11208								1730, 2191																					226, 235									346, 1329														1351, 1544	1560, 1651
59,941	185,204	459	Discharge summary	report	Admission Date: [2176-3-19] Discharge Date: [2176-3-25] Date of Birth: [2098-7-3] Sex: M Service: CARDIOTHORACIC Allergies: Demerol Attending:[First Name3 (LF) 922] Chief Complaint: Exertional dyspnea Major Surgical or Invasive Procedure: [2176-3-19] 1. Aortic valve replacement with a 27-mm [Company 1543] Ultra Aortic Valve Bioprosthesis. 2. Epiaortic duplex scanning. History of Present Illness: Mr. [Known lastname ] is a 77yo male with known aortic stenosis and coronary artery disease. He has been followed with serial echocardiograms which have shown progression of his aortic valve disease. Over the last year to six months, he has developed slight exertional dyspnea most notable on his one mile walk, which he does routinely as well as taking out the trash barrels subtle but a change. Dr [Last Name (STitle) 914] was consulted for surgical evaluation Past Medical History: Past Medical History - Aortic Stenosis - Coronary Artery Disease - Dyslipidemia - Hypertension - Prior CVA, affecting left eye ( 10 yrs ago) - Carotid Disease, Right ICA - L subclavian steal - Left Renal Artery Stent - Chronic Renal Insufficiency, baseline Cr around 2.0 - Rheumatoid Arthritis - Macular Degeneration ( legally blind) - Cognitive Impairment, progressive memory loss - History of Mesenteric artery insufficiency - Cataracts - Anemia Past Surgical History: -tonsillectomy -R cataract [Doctor First Name ] Social History: -Tobacco history: quit 45 yrs ago, used to smoke 1PPD x 25 yrs -ETOH: drinks 4-6 beers on wknd -Illicit drugs: denies Family History: Pt reports that his father had heart problems, but unsure what kind as died when pt was 9 at age 60. [Name (NI) 1094] sister had a valve replaced at age 81, but died at age 82 from colon cancer. [Name (NI) 1094] brother also had rhematic fever when he was a child, but died of alcoholism related causes. Physical Exam: Admission Pulse: 60 Resp:16 O2 sat: 98% B/P Right:124/54 Left: 96/55 Height: 67" Weight:150# General: NAD, takes time to formulate his sentences Skin: Dry [x] intact [x]dry rash B hands and L forearm HEENT: PERRLA [x] EOMI [x]injected sclera B; OP unremarkable Neck: Supple [x] Full ROM []no JVd appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [x] grade [6-16] harsh systolic that radiates to B carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM; mild dry rash B groins Extremities: Warm [x] well-perfused [x] Edema []none Varicosities: None [x]; mild rubor B hands with deformity of digits Neuro: Grossly intact , nonfocal exam, MAE [6-15] strengths; mild memory loss Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:1+ Radial Right: 2+ Left:1+ Carotid Bruit: murmur radiates loudly to B carotids Discharge 99.1 75SR 137/66 20 97%-RA Gen NAD CV RRR, no murmur. Sternum stable, incision CDI Pulm CTA-bilat Abdm soft, NT/ND/NABS Ext warm, well perfused, trace edema Pertinent Results: Admission labs [2176-3-19] 08:10AM HGB-11.5* calcHCT-35 [2176-3-19] 08:10AM GLUCOSE-97 LACTATE-1.7 NA+-140 K+-4.1 CL--106 [2176-3-19] 01:30PM UREA N-28* CREAT-1.6* SODIUM-142 POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-23 ANION GAP-11 [2176-3-19] 01:30PM WBC-13.7# RBC-3.33 HGB-11.1* HCT-32.4* MCV-98 MCH-33.5* MCHC-34.3 RDW-15.3 [2176-3-19] 01:30PM PLT COUNT-101* [2176-3-19] 01:30PM PT-11.9 PTT-29.7 INR(PT)-1.1 Discharge labs [2176-3-25] 04:30AM BLOOD WBC-7.9 RBC-3.11* Hgb-10.1* Hct-31.1* MCV-100* MCH-32.4* MCHC-32.3 RDW-15.5 Plt Ct-176# [2176-3-25] 04:30AM BLOOD Plt Ct-176# [2176-3-25] 04:30AM BLOOD PT-28.5* INR(PT)-2.7* [2176-3-24] 05:40AM BLOOD PT-35.3* INR(PT)-3.4* [2176-3-23] 06:20AM BLOOD PT-16.8* INR(PT)-1.6* [2176-3-25] 04:30AM BLOOD UreaN-30* Creat-1.7* Na-137 K-4.1 Cl-96 [2176-3-25] 04:30AM BLOOD Mg-2.0 Radiology Report CHEST (PA & LAT) Study Date of [2176-3-24] 5:34 PM Preliminary Report Small bilateral pleural effusions are smaller. Lungs are clear. Heart size normal. Thoracic aorta generally large but not focally dilated. Slight misalignment of the lower four sternal wires with respect to the upper three has been a constant feature since surgery. The wires are intact and there has been no interval displacement. No pneumothorax. DR. [Last Name (STitle) 3889] [Name (STitle) 3890] DR. [Known firstname ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: 3.7 cm <= 3.4 cm Aortic Valve - Peak Velocity: 3.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 59 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 35 mm Hg Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: 0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results before surgical incision.. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. The aortic valve bioprosthesis is stable, functioning well with a residual mean gradient of 3 mm of Hg. Mild MR. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD, Interpreting physician [Last Name (NamePattern4) ] [2176-3-19] 12:35 Brief Hospital Course: Mr [Known lastname ] was a same day admission to the operating room for aortic valve replacement with Dr [Last Name (STitle) 914]. Please see the operative report for details, in summary he had: 1. Aortic valve replacement with a 27-mm [Company 1543] Ultra Aortic Valve Bioprosthesis. 2. Epiaortic duplex scanning. His CARDIOPULMONARY BYPASS TIME was 108 minutes, with a CROSS-CLAMP TIME of 90 minutes. He tolerated the operation well and was transferred post-operatively to the cardiac surgery ICU in stable condition. He remained hemodynamically stable in the immediate post-op period, woke neeurologically intact and was extubated. He remained hemodynamically stable throughout the operative day and on POD1 was transferred to the stepdown floor for continued post-operative care. He was noted to have several bursts of atrial fibrillation for which he was started on BBlockers, amiodarone and anticoagulation. All tubes lines and drains were removed per cardiac surgery protocol. Once on the floor he had an umeventful post-op course. He worked with nursin and physical therapy to increase his strength and endurance and by POD6 was ready for discharge home with a visiting nurse. He is to follow up with Dr [Last Name (STitle) 914] in 1 month . Dr [First Name (STitle) 1022] will follow INR and dose Coumadin. Medications on Admission: ATENOLOL 25mg daily, CALCITRIOL 0.25 mwf, Hctz 25mg, MELOXICAM 7.5mg daily, METHOTREXATE 5mg WEEKLY, NIFEDIPINE 60mg daily, SIMVASTATIN 40mg daily, VALSARTAN 80mg daily, ASA 325mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 3. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 10 days. Disp:20 Tablet Extended Release(s) Refills:0 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:45 Tablet(s) Refills:0 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day: 200mg [Hospital1 ] x7days then 200mg QD. Disp:40 Tablet(s) Refills:1 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:10 Tablet(s) Refills:0 10. warfarin 2 mg Tablet Sig: as directed by Dr [First Name (STitle) 1022] Tablet PO once a day: titrate to keep INR 2-2.5. Patient to take 1mg on [3-25]. Disp:45 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 3894] Health VNA Discharge Diagnosis: s/p AVR-tissue Past Medical History - Aortic Stenosis - Coronary Artery Disease - Dyslipidemia - Hypertension - Prior CVA, affecting left eye ( 10 yrs ago) - Carotid Disease, Right ICA - L subclavian steal - Left Renal Artery Stent - Chronic Renal Insufficiency, baseline Cr around 2.0 - Rheumatoid Arthritis - Macular Degeneration ( legally blind) - Cognitive Impairment, progressive memory loss - History of Mesenteric artery insufficiency - Cataracts - Anemia Past Surgical History: -tonsillectomy -R cataract [Doctor First Name ] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Edema: trace bilat LE 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call 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:[First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] :[2176-4-22] @1:15PM Cardiologist:[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2176-4-25] 11:40A Please call to schedule appointments with your Primary Care Dr.[First Name (STitle) ],[Last Name (un) 3895] [Doctor First Name 3896] [Telephone/Fax (1) 719] in [5-16] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation Goal INR 2-2.5 First draw [3-26] Results to phone [Doctor Last Name ],[Last Name (un) 3895] [Doctor First Name 3896] [Telephone/Fax (1) 719] fax [Telephone/Fax (1) 3897] Completed by:[2176-3-25]	[ "427.31", "585.9", "714.0", "369.4", "403.90", "424.1", "V45.82", "287.5", "272.4", "427.89" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	10789, 10851	7869, 9206	291, 437	11433, 11613	3131, 7846	12416, 13401	1640, 1955		9442, 10766		10872, 11335		9232, 9419			11637, 12393						11358, 11412		1970, 3112																					233, 253									465, 937														959, 1407	1500, 1624
20,382	170,404	26747	Discharge summary	report	Admission Date: [2159-4-16] Discharge Date: [2159-4-17] Date of Birth: [2077-4-8] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 2704] Chief Complaint: elective admission for right coronary artery stent Major Surgical or Invasive Procedure: right coronary artery stent History of Present Illness: 81 year old female with carotid artery stenosis, CAD, severe PVD, h/o bilateral CEA who presents with recurrent right carotid artery stenosis, s/p ICA stent in [2157], now here for repeat stent. Pt is s/p bilateral CEA in [2139] (done at [Hospital6 1130]) following episode of right eye amaurosis fugax and left hand numbness/paresthesias. Following CEAs, pt was followed with routine ultrasounds. Patient underwent a right ICA stent for re-stenosis in [4-1] without complication. A routine CT done this past [Month (only) 547] revealed an 80-90% stenosis of the proximal right ICA at or just distal to the stent tip. The stent was otherwise patent. Her left proximal ICA had a 50% stenosis which was virtually unchanged from [2158-6-2]. She is referred for a repeat right carotid angiogram with possible intervention. She was admitted today for angiography. She underwent repeat stent to R ICA today. Pt currently has no complaints. Specifically she denies any neurologic deficits, including no weakness or numbness, no lightheadedness/dizziness, pain, shortness of breath, chest pain, or other complaints. REVIEW OF SYSTEMS: 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. Denies recent fevers, chills or rigors. 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. Carotid artery stenosis status post bilateral endarterectomy in [2139] now with recurrent stenosis. 2. Chronic Obstructive Pulmonary Disease on home oxygen at 2.5L at night. 3. Severe peripheral vascular disease. 4. Hypertension 5. Hyperlipidemia 6. Right renal artery stenosis 7. Abdominal aortic aneurysm 8. Status post left eye cataract surgery. 9. Right eye cataract (untreated) 10. History of panic attacks Social History: She is widowed with five adult children. She lives alone with family nearby. She used to smoke 2 packs per day for 40 years and quit 18 years ago. She also has a history of heavy alcohol use and belongs to AA. Family History: Her father died of a myocardial infarction at the age of 59. Physical Exam: PHYSICAL EXAMINATION: VS: T 97.5, HR 90, BP 142/72, RR 20, O2 98% 2L Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no elevated JVP on exam. Positive for bilateral 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Dopplerable DP and PT pulses bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP dop PT dop Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP dop PT dop Pertinent Results: Pre Procedure labs dated [2158-3-27]: WBC 6.6, HGB 13.9, HCT 42.0, PLT 186, INR 0.97, NA 140, K 4.0, CL 99, CO2 33, BUN 9, CR 1.0 Brief Hospital Course: Patient is an 81 year-old female with carotid artery stenosis, CAD, severe PVD, h/o bilateral CEA who presents with recurrent right carotid artery stenosis, now s/p right ICA stent without complications. . 1. Carotid Stenosis s/p ICA stent: Currently clinically stable without any neurological deficits, with stable BP. All hypertensive medications were initially held. They were restarted on discharge. A cholesterol panel was sent and was pending at time of discharge. Pt. was given fluids for renal protection post-cath and for borderline low blood pressure. She did not require pressors. . 2. Htn - on quinapril, lopressor, cardizem at home. These were held for low BP after cath. Her BP stabalized and she was restarted on her home meds on discharge. . 3. CAD - continue outpt ASA, zocor, betablocker. . 4. Depression - continue outpatient celexa, nortryptiline. . 5. COPD - Continue outpt albuterol, spiriva, O2 PRN. . 6. FEN - cardiac diet. Replete lytes. . 7. Contact - [Name (NI) ], [Name (NI) ], phone # [Telephone/Fax (1) 65888]. Medications on Admission: Celexa 30 mg daily Nortriptyline 50 mg daily Lopressor 25 mg [Hospital1 ] Cardizem 120 mg daily Quinapril 40 mg daily Zocor 20 mg daily Spiriva 18 mcg 1 puff daily Albuterol 90 mcg 2 puffs q 6 hours ASA 325 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months: you must take this medication every day. Disp:30 Tablet(s) Refills:0 3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Cardizem 120 mg Tablet Sig: One (1) Tablet PO once a day. 10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Discharge Disposition: Home Discharge Diagnosis: primary: carotid artery stenosis status post right carotid stent Severe peripheral vascular disease. Hypertension Hyperlipidemia carotid artery stenosis status post bilateral endarterectomy in [2139] Chronic Obstructive Pulmonary Disease on home oxygen at 2.5L at night. Right renal artery stenosis . secondary: Abdominal aortic aneurysm Status post left eye cataract surgery. Right eye cataract (untreated) History of panic attacks Discharge Condition: good. Discharge Instructions: You were admitted for an elective stent placement in your carotid artery. . Please follow up with your appointments as below. . please take your medications as prescribed. It is very important that you continue to take your plavix everyday for 1 month . If you experience any lightheadness, fevers or chills or other worrisome symptoms please seek medical attention. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2159-9-11] 1:00 . Please follow up with your primary care physician [Last Name (NamePattern4) ] 2 weeks. [Last Name (LF) ],[First Name3 (LF) 1575] J. [Telephone/Fax (1) 14655] . You have an appointment with [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 3100] (Dr.[Name (NI) 3101] nurse) on [2159-4-26] at 1pm. [Last Name (LF) ],[First Name3 (LF) ] A. [Telephone/Fax (1) 4022] . Completed by:[2159-4-17]	[ "414.01", "496", "443.9", "V17.3", "366.9", "433.10", "V15.82", "401.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "00.45", "00.63", "00.61", "00.40" ]	icd9pcs	[ [ [] ] ]	6236, 6242	3960, 5015	322, 351	6723, 6731	3802, 3937	7146, 7748	2722, 2784		5288, 6213		6263, 6702		5041, 5263			6755, 7123								2799, 2799													2821, 3783						1536, 2032		232, 284									379, 1517														2054, 2475	2491, 2706
59,275	148,530	45249	Discharge summary	report	Admission Date: [2136-5-10] Discharge Date: [2136-5-11] Date of Birth: [2064-12-29] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[Last Name (NamePattern4) 290] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 71 yo man with h/o MS, OSA, s/p gastric bypass surgery [2136-1-10] with multiple complications including bowel obstruction s/p ex-lap, c. diff colitis, and subseqent trach and peg. He presents from [Hospital 100] Rehab with cough, mild abdominal pain and fever to 102. In the ED, initial vs were: 98.0 88 129/76 18 95% on SIMV (FiO2 40%, 500 x 14, 15/5). Exam notable for rhonchus breath sounds. Labs notable for wbc of 22.7 with a left shift. Patient was given vancomycin and zosyn for VAP. Due to abdominal pain, a CT abd/pelvis showed mild right sided colitis. No further antibiotics given. Trop elevated so given ASA. Tender red scrotum also noted c/f torsion: Scrotal u/s performed and negative. Access: 20G. PICC line appears infected and was not used. Received 2 liters NS. VS prior to transfer: 82 28 SIMV 5 peep 100% Fio2 135/59 100%. Upon arrival to the MICU, patient is responding to voice, however is quite sleepy at present. Review of systems: Unable to obtain Past Medical History: Morbid Obesity Post polio syndrome unable to walk without a cane hypertension MS [Name13 (STitle) 96698] OSA Depression Melanomoa [2131] Shoulder surgeries HAP [2136-3-24] Roux-En-Y [2136-1-18] c/b bowel obstruction, antrostomy, afib, renal failure, critical care neuropathy, PNA, UTI and c. diff. Ex/Lap enteroteomy repair reduction [2136-2-10] trach percutaneous cholecystostomy [2136-3-2] Known right pleural effusion H/o upper GI bleed Social History: Married. Ex-smoker since [2109]. Gave up alcohol one year ago after having a gout attack. H/o marijuana use in [2084]. Family History: Brother: MI and lung cancer Mother: CHF Physical Exam: On admission: Vitals: 99.6 115/36 82 95% on AC General: Alert, but sleepy, oriented, no acute distress HEENT: Sclera anicteric, midly dry MM. Neck: supple, JVP not elevated, trach in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Stage 4 sacral decub with erythema GU: Tender red scrotum without induration or crepitus Pertinent Results: ON ADMISSION: [2136-5-9] 08:00PM BLOOD WBC-22.7* RBC-3.32* Hgb-9.9* Hct-30.1* MCV-91 MCH-29.7 MCHC-32.8 RDW-17.1* Plt Ct-643* [2136-5-9] 08:00PM BLOOD Neuts-86* Bands-0 Lymphs-7* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [2136-5-9] 08:00PM BLOOD PT-14.8* PTT-27.5 INR(PT)-1.3* [2136-5-9] 08:00PM BLOOD Glucose-109* UreaN-34* Creat-1.0 Na-140 K-4.3 Cl-104 HCO3-22 AnGap-18 [2136-5-10] 04:37AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.6 [2136-5-10] 04:37AM BLOOD Albumin-3.2* ALT-20 AST-36 AlkPhos-66 TotBili-0.4 [2136-5-9] 08:00PM BLOOD cTropnT-0.08* [2136-5-10] 04:37AM BLOOD CK(CPK)-36 CK-MB-2 cTropnT-0.08* ON DISCHARGE: [2136-5-11] 02:03AM BLOOD WBC-20.6* RBC-2.85* Hgb-8.8* Hct-26.9* MCV-94 MCH-30.8 MCHC-32.6 RDW-16.7* Plt Ct-528* [2136-5-11] 02:03AM BLOOD Neuts-82.6* Lymphs-9.4* Monos-2.7 Eos-5.1* Baso-0.3 [2136-5-11] 02:03AM BLOOD PT-16.4* PTT-30.2 INR(PT)-1.4* [2136-5-11] 02:03AM BLOOD Glucose-118* UreaN-31* Creat-1.2 Na-138 K-3.8 Cl-108 HCO3-19* AnGap-15 MICRO: [5-9] Blood cultures x 2 PENDING [5-10] Blood culture PENDING [5-10] Urine culture PENDING [5-10] Sputum gram culture PENDING (gram stain with 4+ gram neg rods) [2136-5-10] Stool culture: Fecal PENDING, Campylobacter PENDING, C. difficile Toxin A & B test NEGATIVE IMAGING: [5-9] CT abd/pelvis with contrast: 1. Bibasilar opacities including partial right middle lobe collapse and small-to-moderate bilateral effusions concerning for pneumonia. 2. Foley balloon inflated in the prostate. 3. Several indeterminate renal cysts, for which ultrasound should be performed to better evaluate. * 4. Inflammatory stranding in the right colon with possible wall thickening may reflect mild, resolving colitis. Sigmoid diverticulosis without diverticulitis. 5. Status post gastric bypass without obstruction. 6. No subcutaneous air. [5-10*] Scrotal ultrasound: Heterogeneous appearance to bilateral testicles, which are of normal size. Arterial waveforms could be identified; however, venous waveforms could not be identified. Torsion in a patient of this age would be very unusual and the presence of arterial flow essential excludes torsion. Brief Hospital Course: 71 yo M s/p trach/peg who presents from LTAC with fever, cough, and abdominal pain. 1. Respiratory Failure: Fever, leukocytosis, and CXR findings supportive of a multifocal, vent-associated pneumonia; also with right middle lobe collapse, bilateral effusions, and worsening pulmonary edema. He was maintained on CPAP and started on vancomycin and cefepime. Patient still with fevers to 102 prior to discharge so started on standing Tylenol tid, but WBC slowly improving on discharge. His lasix was initially held but restarted at home dose of 20 mg IV bid on discharge. Plan for 8-day course of vancomycin and cefepime; last dose on [5-17]. * Check vancomycin trough at 7pm on [5-11] and as needed thereafter * Follow up pending sputum (gram neg rods on stain), blood, and urine cultures * Adjust lasix dose as indicated 2. Colitis: Pt with a history of C. diff. He was empirically started on flagyl and po vancomycin on [5-9] at [Hospital 100] Rehab. Here, he was initially continued on po vancomycin. However, CT abdomen showed mild resolving colitis, and C. diff toxins returned negative, so po vancomycin was stopped on day of discharge. 3. Scrotal swelling/tenderness: Scrotal ultrasound unremarkable with absent venous waveform but normal arterial inflow. Urology consult felt this was not consistent with testicular torsion and highly unlikely given age and bilateral presentation. [Month (only) 116] represent a mild orchitis; scrotal elevation and anti-inflammatories recommended. Potential infection would be treated with his current antibiotic regimen for pneumonia. 4. Positive troponin: Mildly elevated on presentation but patient without chest pain. Repeat troponin was flat, ruling out MI. This likely represented mild demand in the setting of infection. He was continued on his ASA and beta blocker. 5. Hypertension: Continued on outpatient amlodipine, metoprolol, and lisinopril. Lasix restarted prior to discharge. Hydralazine was discontinued. 6. Anemia: Hct remained stable in 27 to 30 range. 7. Depression: Continued citalopram. 8. Gout: Continued allopurinol. 9. Hypothyroid: Continued levothyroxine. 10. H/o GI Bleed: Continued sucralfate and omeprazole. 11. Incidental finding: CT Abd/pelvis showed "several indeterminate renal cysts." * Ultrasound recommended for better evaluation. 12. Code status: Pt confirmed full code with alternate HCP (son) present. Medications on Admission: acetaminophen 650 q 6 prn albuterol MDI 12 puffs q 6 hours allopuronol 100 mg daily amlodipine 10 mg daily aspirin 81 mg daily chlorhexidine gluconate cholestyramine 4 g [Hospital1 ] citalopram 20 mg daily furosemide 20 mg IV BID heparin SQ hydralazine 20 mg TID lactobacillus 2 tabs [Hospital1 ] levothyroxine 37.5 mcg daily lisinopril 20 mg daily metoprolol 50 mg QID metronidazole 500 mg TID omeprazole 40 mg daily potassium 40 meq daily simethicone 80 mg q 6 hours sodium bicarbonate 650 TID vancomycin 125 po q8 hours morphine 4 mg q 4 hours prn zofran 4 mg q8 hours prn Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 7. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection twice a day. 10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. lactobacillus acidophilus Tablet, Chewable Sig: Two (2) Tablet, Chewable PO twice a day. 12. levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. simethicone 80 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 17. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 19. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours): D1 = [5-10], course complete [5-17]. 20. cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q12H (every 12 hours): D1 = [5-10], 8 day course to be complete [5-17]. 21. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Four (4) mg PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: PRIMARY: Hospital acquired pneumonia, fever, colitis SECONDARY: Hypertension, anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: It was a pleasure to participate in your care Mr. [Known lastname 93337]. You were admitted to the ICU at [Hospital1 ] Hospital for fever, cough, and abdominal pain. We found that you have a pneumonia and started treatment for pneumonia. You had a CT scan of your abdomen showing some inflammation of your colon. We tested you for c. diff which was negative. Please make the following changes to your medications: 1. Start cefepime 2 g IV every 12 hours for 8 day course, to be complete on [2136-5-17] 2. Start vancomycin 1000 mg IV every 12 hours for 8 day course, to be complete on [2136-5-17] 3. Stop hydralazine 4. Stop flagyl 5. Stop PO vancomycin Followup Instructions: You will follow-up with the doctors [First Name (Titles) ] [Last Name (Titles) 100] Rehab. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "138", "272.4", "V10.82", "V44.0", "707.22", "558.9", "340", "285.9", "244.9", "518.81", "327.23", "274.9", "401.9", "707.24", "707.05", "707.07", "486" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.71" ]	icd9pcs	[ [ [] ] ]	9968, 10034	4894, 7311	300, 307	10163, 10163	2657, 2657	10998, 11236	1969, 2010		7945, 9945		10055, 10142		7337, 7922			10300, 10697								2025, 2025																3310, 4871		10726, 10975	1303, 1321		255, 262									335, 1284							2672, 3295		10178, 10276					1343, 1808	1824, 1953
8,207	151,811	18045+18046	Discharge summary	report+report	Admission Date: [2184-2-16] Discharge Date: [2184-3-16] Date of Birth: [2127-3-15] Sex: F Service: MICU/KURLA CHIEF COMPLAINT: Transfer from outside hospital for management of bilateral pneumonia and pancytopenia. HISTORY OF PRESENT ILLNESS: The patient is a 56 year old woman with past medical history of ulcerative colitis who was transferred from [Hospital3 417] Hospital for further management of bilateral pneumonia and pancytopenia. Patient's present illness began in [2183-6-26] when colonoscopy revealed mild inflammatory changes consistent with ulcerative colitis. In [2183-10-26] she had a UC flare with increasing frequency of bloody diarrhea and was treated with prednisone for weeks without result. Eventually in [2183-11-26] she was admitted to [Hospital3 417] Hospital where she was treated with IV steroids, metronidazole, IV fluids and PPN with good effect. However, every time that it was attempted to wean her from IV to p.o. steroids, her symptoms flared again. Ultimately she received one dose of Remicade 300 mg in early [Month (only) 956] with good response after four to five days and was then treated with p.o. steroids, Asacol and 6-mercaptopurine. She was discontinued from visiting nurses on [2184-1-9] from that hospitalization. Prior to discharge then her LFTs were normal. Patient was seen in followup on [1-22] at which time her LFTs were noted to rise and 6-mercaptopurine was discontinued. Her UC remained well controlled. It was also noted at that visit from routine labs that her white blood cell count was 1.7 and it was felt that she was pancytopenic due to bone marrow toxicity from 6-mercaptopurine. She was treated with two doses of Neupogen on [2-13] and [2-14]. She then presented to the outside hospital with complaints of weakness, fever, chills and a chest x-ray showing bilateral pneumonia. For difficulty with oxygenation, patient was begun on BiPAP. She was given nebulizers and IV steroids. She was treated with Neupogen and started on epo. Patient was then transferred to [Hospital1 1444] for further management. At the time of transfer patient reported improvement in her cough, but still complained of fever and chills. She denied shortness of breath except with activity. She denies abdominal pain, diarrhea, chest pain or leg pain. PAST MEDICAL HISTORY: Ulcerative colitis. Diabetes secondary to chronic steroids. Pancytopenia secondary to 6-mercaptopurine. ALLERGIES: 6-mercaptopurine. MEDICATIONS ON TRANSFER: Vancomycin 1 gm q.18 hours, levofloxacin 500 mg p.o. q.day, ceftazidime 2 gm q.12 hours, Neupogen 480 mcg subcu q.day, albuterol nebs, Atrovent nebs, atenolol 25 mg p.o. q.day, Decadron 1 mg q.six hours, Pepcid 20 mg IV q.day, glyburide 10 mg p.o. q.day, insulin sliding scale, mesalamine 1200 mg t.i.d., Paxil 20 mg q.day, Tylenol, morphine p.r.n. SOCIAL HISTORY: The patient lives with her husband. Denies use of tobacco. Had no sick contacts. [Name (NI) ] recent travel. No pets. PHYSICAL EXAMINATION: On admission patient had a low grade temperature of 100.6, heart rate 96, blood pressure 104/56, respiratory rate 26, O2 sat 100% on nonrebreather. In general, she was very pleasant. She was in no acute distress. She was oriented times three. HEENT exam revealed scleral icterus. Pupils were reactive bilaterally. She had no JVD. Heart exam was regular without murmur. Lungs revealed decreased breath sounds at the bases bilaterally, but were otherwise clear to auscultation bilaterally. She was not in respiratory distress at the time and was not using any accessory muscles for breathing. Abdominal exam was benign with no hepatosplenomegaly. Extremities revealed 2+ pitting edema to the knees bilaterally with 2+ DP pulses. LABORATORY DATA: Labs at the time of admission were significant for sodium 131, potassium 3.5, elevated BUN and creatinine of 16 and 1.2 respectively, hyperglycemia with glucose of 191. CBC revealed white blood cell count of 1.2, hematocrit 23.6, platelets 71. LFTs revealed ALT of 202, AST 97, alka phos 363, amylase 89, total protein 4.5, direct bili 5.0, LDH 662. TSH was checked and was 0.96. Coags were within normal limits. ABG on arrival was 7.47, 31, 66 and that was on 100% nonrebreather. HOSPITAL COURSE: 1. Pulmonary. At the time of transfer the patient was on antibiotics for coverage of community acquired pneumonia. In this immunosuppressed patient with pancytopenia as well as the fact that she was in the process of weaning from steroids, it was very concerning that she was infected with Pneumocystis pneumonia. For this she was started empirically on primaquine and clindamycin. Treatment with Bactrim was precluded by the fact that it is myelosuppressive and patient was pancytopenic. BiPAP was initiated on the day of admission because of poor oxygenation. On the night of admission patient awoke acutely agitated, screaming with acute hypoxemic event. Patient was sedated and intubated. The following morning bronchoscopy was performed with BAL which returned positive for Pneumocystis. Primaquine and clinda were continued given her pancytopenia as were other antibiotics for community acquired pneumonia pending respiratory culture from BAL. When the culture returned negative, those antibiotics were discontinued and she was continued only on treatment for PCP. [Name10 (NameIs) ] addition to primaquine and clindamycin she was begun on prednisone, initially 40 mg p.o. b.i.d. as extrapolated from treatment of PCP in HIV patients. She was treated with a taper of 40 mg b.i.d. for five days, followed by 40 mg q.day for five days, followed by 20 mg q.day for 11 days. After treatment with Neupogen for three days, all patient's cell lines responded appropriately and her antibiotics were changed from clindamycin and primaquine to Bactrim. With worsening of her infiltrate on chest x-ray, patient's oxygenation worsened as well. FIO2 and PEEP were both titrated upward to maintain good oxygenation, at its worst requiring FIO2 of 0.7 and PEEP of 22. PEEP and FIO2 were attempted to be weaned daily unsuccessfully. Throughout her admission in the ICU she exhibited frequent bronchospasm with a very strong gag reflex which would lead to desaturation. For this her sedation was often increased, however, despite high levels of fentanyl and Versed, patient was awake throughout the bulk of her hospitalization. On [2184-2-27] patient tolerated weaning of PEEP to as low as 8, however, ultimately desated, requiring increasing levels again as high as 18. On [2184-2-28] sputum gram stain was sent which was positive for gram positive cocci, ultimately returned as MRSA. Patient was started on vancomycin empirically for MRSA ventilator associated pneumonia for which she was treated for 14 days. This treatment was begun on [2184-3-2]. Because of the prolonged course of her infection and the inability to wean, tracheostomy was entertained, however, not performed. On [3-7] an attempt at extubation was performed. Patient became immediately stridulous and hypoxemic and was immediately reintubated. She remained stable throughout that night and extubation was performed again the following day with heliox. She tolerated extubation successfully and continued to both oxygenate and ventilate well with supplemental oxygen that was able to be weaned over the subsequent three days. At the time of transfer from the intensive care unit to the floor, patient was in room air and oxygenating well. 2. GI. As above, patient was continued on steroids, both for PCP as well as for treatment of ulcerative colitis. Once intubated p.o. mesalamine was not possible, therefore, she was treated with mesalamine enemas. LFTs were followed daily and rapidly improved as 6-mercaptopurine toxicity wore off. Right upper quadrant ultrasound was performed to rule out cholestatic pathology as a cause of the elevated LFTs. Right upper quadrant ultrasound was normal. From the time of admission patient did not have any bloody stool. On [2184-2-21] patient's abdomen was noted to be slightly distended and an abdominal flat plate was performed which showed two air fluid levels. As patient was found to have decreased stool output, CAT scan of the abdomen was performed to rule out obstruction which was negative. Patient was given a more aggressive bowel regimen including lactulose with limited result. She was continued on mesalamine enemas. Ultimately the bowel regimen was successful with five bowel movements on [2184-2-24] and at this time patient was found to have heme positive stool. GI, who was following, recommended continuing treatment with mesalamine and steroids and no other change in therapy for UC at that time. With continuing loose stool output, patient was checked multiple times for C.diff which was negative times three. Nutrition was consulted regarding different tube feeds to help maximize absorption. She was changed to Criticare at that point and shortly thereafter noted a decrease in loose stools. Her stool also ceased to be guaiac positive. At the time of transfer to the floor, patient was having scant amount of loose, heme negative, brown stool with GI continuing to follow. She was continued on mesalamine and steroids as above. 3. Cardiovascular. Throughout her hospital course, the patient was found to be tachycardiac rarely with a heart rate below 100. It was felt that patient had multiple reasons for tachycardia including hypovolemia, anemia, hypoxemia, fever, agitation, discomfort, etc. Patient's blood pressure initially was stable and she presented from the outside hospital on atenolol. This was initially continued, but changed to Lopressor for easier titration. However, due to ensuing hypotension, her beta blocker was held. Upon admission because of patient's pancytopenia, she was initially transfused two units of packed red blood cells to correct her anemia. With this her heart rate did slow to the high 90s to low 100s, but again she continued to be tachycardiac. With correction of all obvious causes of sinus tachycardia as listed above, patient continued to be tachycardiac, leaving the most likely cause of her tachycardia to be that of agitation/anxiety. On [2184-3-2] patient complained of some chest discomfort which sounded atypical. However, despite her persistent tachycardia there was concern for ischemia. Electrocardiogram was checked with no change from her baseline. CKs were cycled which were negative times three. Lopressor again was used transiently during this episode for fear of ischemia, however, was discontinued after patient ruled out for MI as again she was having sinus tachycardia and not requiring specific therapy. 4. Infectious disease. The patient was treated for PCP pneumonia as above. Likewise she was treated for MRSA pneumonia as above. Approximately three days into patient's hospitalization she became hypotensive requiring pressors. She was started on Neo-Synephrine to control her blood pressure and was given multiple fluid boluses as well. Over the course of her ICU stay she was able to be weaned from Neo-Synephrine. Frequently it was often restarted for short periods of time as needed. 5. Heme. As above, the patient was pancytopenic secondary to 6-mercaptopurine treatment. Patient was continued on Neupogen from the time of admission and hematology was consulted. They recommended that Neupogen be continued until the white count was sustained above 5000. Neupogen was discontinued after a total of four days. No further dosing was needed. Patient's white count remained stable and bumped appropriately in the setting of infection. Likewise, her platelets remained stable, not requiring any transfusions. Patient was intermittently transfused packed red blood cells at a threshold of hemoglobin of 7 or hematocrit of 21. Anemia was likely due to both chronic disease and frequent phlebotomy. 6. FEN. Because of her hypotension and sepsis, the patient received multiple fluid boluses and became very volume overloaded. Her lytes were checked daily and repleted on a p.r.n. basis. Ultimately patient was approximately 15 liters positive and with resolution of her sepsis, auto-diuresed frequently to the point of becoming hypotensive, requiring replacement of that fluid. At the time of transfer from the intensive care unit, her volume status was euvolemic and she had diuresed off all of her excess volume and was no longer edematous. 7. Neuro. Upon extubation it was noted that the patient was very depressed and unable to speak. Initially there was concern for airway obstruction including laryngeal edema. However, it became more obvious that it was more due to depression than an anatomic problem. Psychiatry was consulted regarding the possibility of post traumatic stress disorder, given patient's level of wakefulness during her intubation. It was felt that she was most likely delirious both from her prolonged stay in the ICU as well as lingering effects of sedation that she had received. Studies were performed including B-12, folate, TSH and RPR, all of which were normal. Patient's Paxil was doubled from 20 to 40 mg. An EEG was performed which showed findings consistent with diffuse encephalopathy. Subsequently a head CT was performed which was normal. At the time of transfer from the unit patient continued to be extremely withdrawn and tearful, avoiding eye contact and not speaking above a rare faint whisper. 8. Access. Upon admission to the ICU, the patient had a left subclavian triple lumen catheter placed. When becoming febrile, this line was changed to a right internal jugular triple lumen catheter. Again after becoming bacteremic, this line was changed to a left internal jugular triple lumen. In addition, patient also had a right radial A-line placed. This line was removed accidentally by patient and was replaced in the left arm. At the time of transfer out of the unit, all of these lines were discontinued. This dictation covers the [Hospital 228] hospital course from admission on [2184-2-16] through transfer to the medical floor on [2184-3-12]. The remainder of [Hospital 228] hospital stay will be done by the accepting intern on the [Doctor Last Name ] service. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Name8 (MD) 6166] MEDQUIST36 D: [2184-3-16] 15:26 T: [2184-3-16] 15:36 JOB#: [Job Number 49933] Admission Date: [2184-2-16] Discharge Date: [2184-3-19] Date of Birth: [2127-3-15] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 56-year-old female with a history of ulcerative colitis, steroid-induced diabetes with recent prolonged ulcerative colitis flare from [2183-10-26] to [2183-12-27] treated with steroids, Remicade, Asacol and 6-MP. Patient was discharged home stable and at follow up was seen to have liver function test abnormalities and pancytopenia. At that point the 6-MP was discontinued. She presented to an outside hospital at the end of [Month (only) 958] with fevers and cough and was found to have bilateral pneumonia by chest x-ray. She was transferred to [Hospital1 69] for further management of primary care physician. HOSPITAL COURSE IN MICU: 1. Infectious disease/pulmonary: The patient was found to have Pneumocystis carinii pneumonia by bronchoscopy with bronchoalveolar lavage. She was initially treated with clindamycin and primaquine in the setting of neutropenia and then changed to Bactrim after treatment with Neupogen. Now the patient is status post 21-day treatment with Bactrim and steroids. She continued on steroids for ulcerative colitis. She was also found to have MRSA pneumonia considered to be a ventilator acquired pneumonia and started on vancomycin on [3-3] for a 14-day course. She also had methicillin-resistant Staphylococcus epidermidis, positive blood culture likely secondary to new line infection, and her lines were changed on [3-4]. The patient had a prolonged medical intensive care unit course secondary to her pulmonary status, initially intubated one day after treatment for PCP. [Name10 (NameIs) ] had difficulty weaning secondary to continued hypoxia and increased suspicion for acute respiratory distress syndrome. Initial extubation on [3-7] failed secondary to increased stridor. Subsequent extubation on [3-9] was without complications and currently without an oxygen requirement. 2. GI: The patient had a history of ulcerative colitis. She was relatively stable except for one episode of melanotic stool in the setting of steroid taper, now stable on prednisone, mesalamine and hydrocortisone enemas. Steroid again being tapered slowly 3. Cardiovascular: The patient had been transiently pressor dependent, weaned successfully and noted to have persistent sinus tachycardia with all obvious causes ruled out. Heart rate has been 110s to 130s. Her blood pressure, hematocrit and TSH were all within normal limits. 4. Hematology: The patient required several transfusions secondary to increased phlebotomy and episode of melena. Her hematocrit remained stable at the end of her medical intensive care unit course. She had initially received Neupogen for her pancytopenia which responded well without further decreases. 5. Psychiatry: The patient had persistent delirium and depression with increased tearfulness. Psychiatry had been following her. She had an EEG which showed diffuse encephalopathy. No further work-up was done as the MICU team felt the patient was improving. On the floor she was found to have no delirium and to be oriented [Last Name (un) 22121] intact mental status but profoundly depressed. PAST MEDICAL HISTORY: 1. Ulcerative colitis for many years. 2. Diabetes mellitus secondary to steroids. ALLERGIES/MEDICATION TOXICITIES: 6-MP with pancytopenia. SOCIAL HISTORY: No tobacco or alcohol. She lives with her husband. MEDICATIONS ON TRANSFER: 1. Mesalamine enemas. 2. Nystatin. 3. Miconazole. 4. Regular Insulin sliding scale. 5. Vancomycin 1 gram q. 12, start date [3-3]. 6. Hydrocortisone enemas. 7. Prednisone p.o. 20 mg q. day. 8. Lansoprazole 30 mg p.o. q.d. 9. Paroxetine 40 mg p.o. q.d. 10. Tube feeds. PHYSICAL EXAMINATION: On transfer her temperature was 98, heart rate 125, blood pressure 116/55, respiratory rate 36, she was 98% on room air. Her I's and O's were 2050/1150. In general she was a middle-aged female not verbal, minimally responsive to questions but awake. HEENT: Positive thrush, no neck stiffness. Heart: Tachycardic. Lungs: Clear bilaterally with coarse breath sounds. Abdomen: Soft, nontender, nondistended. Bowel sounds were present. Extremities: Warm with 2+ dorsalis pedis pulses, no edema. Neurologic: Minimal cooperation. LABORATORY STUDIES ON TRANSFER: White count of 8.7, hematocrit 27.2, platelet count 170, sodium 139, potassium 3.3, chloride 103, bicarbonate 26, BUN 18, creatinine 0.4, glucose 162, calcium 9.0, phosphorous 2.5, magnesium 1.7, free calcium 1.25, vitamin B12 1,321, folate 8.0, ammonia 49, TSH 0.94. Arterial blood gases were pH 7.44, CO2 42, oxygen 159. Her RPR was nonreactive. She had an EEG on [3-11] which was an abnormal portal EEG due to moderately slow background rhythm along with occasional bursts of generalized slowing and some minimal left temporal slowing consistent with widespread encephalopathy affecting both the cortical and subcortical structures. Medications, metabolic disturbances and infection are the most common causes. Additional focal slowing consistent with focal abnormality in the left hemisphere, but this is less reliable. Tachycardia was noted. No epileptiform features. Cardiac echocardiogram on [2-17] showed normal left ventricular cavity size, echocardiogram that was normal. CT of the abdomen on [2-22] showed extensive consolidation with ground glass opacity in the lung bases consistent with PCP. [Name10 (NameIs) 3754] was no evidence of an intra-abdominal abscess, small amount of free fluid in the pelvis, extensive subcutaneous edema. ASSESSMENT: The patient is a 56-year-old female with a history of ulcerative colitis complicated by steroid dependence and liver function tests abnormalities and pancytopenia on 6-MP. She was admitted with PCP complicated by [Name Initial (PRE) ] prolonged MICU course secondary to respiratory failure with vent dependence, adult respiratory distress syndrome, MRSA pneumonia, ulcerative colitis flare, severe delirium and depression. HOSPITAL COURSE: 1. Infectious disease: The patient was continued on her full 14-day course of vancomycin for her MRSA pneumonia as well as her methicillin-resistant Staphylococcus epidermidis bacteremia thought secondary to a line infection. The patient was also status post a 21-day treatment with Bactrim and steroids for her PCP [Name Initial (PRE) 1064]. Given that she would be continued on steroids for her history of ulcerative colitis with difficulty weaning, we felt that she should be placed on prophylactic Bactrim doses to help prevent further episodes of PCP. [Name10 (NameIs) ] day prior to her discharge she had developed some lower abdominal tenderness. A urinalysis was checked and it was found to be positive for urinary tract infection. Her urine culture was still pending but at this time given that she had had a chronic Foley catheter and has been hospitalized for over a month, we discontinued her Foley catheter and continued a 14-day course of levofloxacin. 2. Cardiovascular: The patient had a history of an elevated heart rate and persistent tachycardia with no clear etiology, not hypovolemic, no significant anemia. Her TSH was normal. She was afebrile. Her echocardiogram did not show any evidence of right heart strain, less likely a PE. Her oxygen saturations were stable suggesting no evidence of hypoxia. Given that she was in sinus tachycardia we did not treat her with a beta blocker. Her tachycardia may have been secondary to anxiety. 3. Pulmonary: The patient had been originally hyperventilating when she first got to the floor but her arterial blood gas did not show evidence of a respiratory alkalosis. This resolved as she continued to be monitored on the floor with no further sequelae. 4. GI: The patient has a history of ulcerative colitis. She had had one episode of melenic stool with tapering of her steroids in the ICU suggesting a steroid dependence. She was actually tapered slightly from 20 to 15 mg p.o. q. day and she was kept on this p.o. dose of prednisone. She was continued on the mesalamine and hydrocortisone enemas which she should continue on indefinitely as they have less systemic toxicity. Her p.o. prednisone dose should be tapered very slowly and will need to be adjusted according to her ulcerative colitis symptoms. This should be followed carefully by her gastroenterologist who should be very vigilant about her steroid doses. She did not have any further episodes of ulcerative colitis flares when she was on the regular medical floor. 5. Hematology: The patient's neutropenia and anemia were not active issues when she was transferred to the medical floor. 6. Endocrine: The patient had a history of diabetes mellitus secondary to steroids. We monitored her fingersticks four times a day and her fingersticks were actually very reasonable and ranged between 100 and 140s. 7. Neuropsychiatry: The patient had a persistent delirium and depression since extubation. She was followed by psychiatry and she was placed on Paxil 40 mg p.o. q.d. She had had a few episodes where she had fallen out of bed. Her neurological examination was unchanged but she had a head CT which showed no focal abnormalities or no etiologies or reasons for her delirium or depression. A lumbar puncture was not performed as the patient was not showing any evidence of having meningitis as the cause of her delirium/depression, and so we monitored her and she actually did show signs of improvement. She was very cooperative with the medical staff and would follow with physical therapy and with all medical interventions. She showd no evidence of deliriium late in her hospital stay. She should be followed when she is at rehabilitation and at home by a social worker or a psychiatrist every few days for continual assessment of her mental status. 8. Fluids, electrolytes and nutrition: The patient was noted to have some difficulty swallowing and had a speech/swallow evaluation, which was showing that she had difficulty with thin liquids. She did tolerate thickened consistency diet very well. Given her difficulties with this, ENT was consulted and they did a laryngoscopy which showed that she had a left vocal cord paralysis. A follow-up CT scan of the neck was done to see if she had any evidence of damage to the recurrent laryngeal nerve and the CT scan was essentially negative. The ENT team felt that there was no clear reason why the patient was exhibiting this left vocal cord paralysis and it was not clear that it was secondary to any problems with her prolonged intubation in the medical intensive care unit. They felt that she should follow up with ENT as an outpatient in four weeks to see if there have been any changes, and she should continue on the diet as prescribed by the speech/swallow team. She should call [Telephone/Fax (1) 41] to make an appointment. DISPOSITION: The patient will be discharged to an extended care facility. She should seek medical attention if she develops worsening shortness of breath, cough, fevers, bloody stools, weakness, fatigue or any other symptoms of concern. DISCHARGE DIAGNOSES: 1. Pneumocystis carinii pneumonia. 2. Ulcerative colitis flare. 3. Methicillin-resistant Staphylococcus aureus pneumonia. 4. Adult respiratory distress syndrome. 5. Blood loss anemia. 6. Left vocal cord paralysis. 7. Catheter related bacteremia - coagulase negative staphylococci 8. Depression FOLLOW UP: She should follow up with her primary care physician in one week regarding her recent hospitalization, to have her complete blood count checked. The patient is to follow up with her gastroenterologist regarding her oral steroid taper. This will need to be done very slowly. She is on Bactrim for prophylaxis for Pneumocystis carinii pneumonia while she is on this dose of steroids. She should continue on her mesalamine and hydrocortisone enemas every day. The patient should follow up with psychiatry as needed. She will need to follow up with ENT for further evaluation of her left vocal cord paralysis. She is to call [Telephone/Fax (1) 41] to make an appointment in three to four weeks. The patient should have her oral intake monitored as she was slow to take p.o. initially, thought maybe secondary to her underlying depression. She should have her weight checked every day and if it is noted that she is having continued weight loss, it might be helpful to have a nutritional consultation to assure that she has the appropriate amount of daily caloric intake. MAJOR SURGICAL INVASIVE PROCEDURES: Bronchoscopy and intubation in the intensive care unit. CONDITION ON DISCHARGE: Stable, cooperative with physical therapy, tolerating thickened consistency p.o., urinating, having bowel movements. Again, she should have her oral intake monitored. DISCHARGE MEDICATIONS: 1. Mesalamine 4 grams in 60 mL enema, 60 mL rectal q.h.s. 2. Hydrocortisone 100 mg in 60 mL enema, 60 mL rectal q.a.m. 3. Paxil 40 mg p.o. q.d. 4. Prednisone 15 mg p.o. q.d. 5. Pantoprazole 40 mg p.o. q. 24 hours. 6. Bactrim 800-160 mg p.o. q.d. 7. Megestrol 40 mg p.o. q.i.d. to help with her appetite. 8. Levofloxacin 500 mg p.o. q. day. This was started on [2184-3-18] and should continue for a complete 14-day course for her recent urinary tract infection. [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. [MD Number(1) 28963] Dictated By:[Name8 (MD) 12269] MEDQUIST36 D: [2184-3-19] 10:30 T: [2184-3-19] 10:57 JOB#: [Job Number 49934]	[ "038.9", "518.81", "482.41", "284.8", "292.81", "263.9", "996.62", "599.0", "136.3" ]	icd9cm	[ [ [] ] ]	[ "33.24", "38.93", "96.04", "38.91", "96.72" ]	icd9pcs	[ [ [] ] ]								25977, 26275	27678, 28418					20842, 25956																			26287, 27461				18536, 20824								161, 249									14833, 17973													18234, 18513	17996, 18138	18155, 18208	27486, 27655
31,033	120,713	48641	Discharge summary	report	Admission Date: [2200-12-28] Discharge Date: [2201-1-1] Date of Birth: [2136-2-28] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 12174] Chief Complaint: Black stool Major Surgical or Invasive Procedure: EGD History of Present Illness: 64M s/p LRKT in [2196] and h/o colon CA s/p R hemicolectomy presents with three weeks of melena. He has had dark stools for ~3 weeks, nearly black for the last 3 days; but, stools are formed, up to 2x/day. Of note, he has had intermittant black stools since his colon cancer was found in [2195]. Denies recent NSAID use. In the ED, NG lavage returned dark red blood, guiaic positive dark stool. Started on ppi. GI contact[Name (NI) ] and plan to scope in am. 97.8, 150/64, 64, 14, 98% 2L. Prior to transport to the ICU, he received both zofran and ativan for nausea. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache. Past Medical History: ESRD s/p living unrelated kidney transplant in [2196] HTN Obstructive sleep apnea--does not have CPAP machine at home. Type 2 Diabetes H/o colon cancer s/p right colectomy in [2195] Hyperlipidemia Tertiary Hyperparathyroidism Abnormal LFTs [1-12] alcohol +/- fatty liver disease Social History: He is single and has 3 children. He is retired photographer. He doesn't smoke and has never used drugs. He gave up drinking alcohol in [2200-6-10]. Family History: Noncontributory Physical Exam: On Presentation: Vitals: T:98.3 BP:114/59 HR:73 RR:14 O2Sat:99% 2L NC GEN: Well-appearing, somnolent African American male HEENT: EOMI, PERRL, sclera anicteric, + conjunctival pallor, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords; L forearm AVF with palpable thrill NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Labs on admission and discharge: [2200-12-27] 10:40PM BLOOD WBC-4.3# RBC-3.20* Hgb-10.7# Hct-29.5# MCV-92 MCH-33.5* MCHC-36.2* RDW-16.0* Plt Ct-84* [2201-1-1] 06:20AM BLOOD WBC-7.3 RBC-3.16* Hgb-10.4* Hct-29.2* MCV-92 MCH-33.0* MCHC-35.7* RDW-16.6* Plt Ct-113* [2200-12-27] 10:40PM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1 [2201-1-1] 06:20AM BLOOD Plt Ct-113* [2200-12-27] 10:40PM BLOOD Glucose-248* UreaN-56* Creat-1.8* Na-139 K-3.5 Cl-99 HCO3-30 AnGap-14 [2201-1-1] 06:20AM BLOOD Glucose-49* UreaN-14 Creat-1.6* Na-142 K-3.8 Cl-108 HCO3-27 AnGap-11 [2200-12-27] 10:40PM BLOOD ALT-40 AST-50* AlkPhos-77 TotBili-0.4 [2201-1-1] 06:20AM BLOOD ALT-22 AST-33 LD(LDH)-194 AlkPhos-49 TotBili-0.8 [2200-12-27] 10:40PM BLOOD Lipase-68* [2200-12-27] 10:40PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.6* Mg-2.0 [2201-1-1] 06:20AM BLOOD Albumin-3.4 Calcium-8.5 Phos-2.5* Mg-1.8 [2200-12-28] 08:20AM BLOOD tacroFK-1.8* [2200-12-31] 06:30AM BLOOD tacroFK-9.1 [2201-1-1] 06:20AM BLOOD tacroFK-4.9* . Imaging: . IMAGING; EGD [2200-12-28]: -The esophagus was normal. Specifically, there were no esophagela varices. -No blood was seen in the duodenum. -Retained fluids in stomach -Erythema, congestion and erosion in the antrum, stomach body and fundus compatible with erosive gastritis -Varices at the fundus -Otherwise normal EGD to third part of the duodenum . US [12-29]: FINDINGS: Secondary to midline bowel gas, the pancreas and splenic artery cannot be assessed. Heterogeneous echotexture of the liver is unchanged. The main portal vein is patent with appropriate direction of flow. Normal main hepatic arterial and right and left hepatic artery waveforms are obtained. IMPRESSION: Very limited assessment of the splenic artery and pancreas secondary to overlying bowel gas. Patent portal vein and hepatic artery. . MRV abdomen: . FINDINGS: There is minor bibasilar atelectasis. The liver parenchyma appears normal. There is no intra- or extra-hepatic biliary ductal dilatation. There is an eccentric thrombus which begins in the uppermost part of the superior mesenteric vein and extends through the length of the main portal vein. Although it is nonocclusive at these sites, it fully occludes the left main portal vein, while the clot terminates in the proximal right main portal vein and does not involve its distal branches. The caliber of the left portal vein is attenuated compared to the earlier CT. The splenic vein is completely patent. There are large gastric varices along the posterior wall of the fundus and cardia that connect with both the left renal and splenic veins. The spleen is normal in size. There is edema in the gallbladder wall, which is a nonspecific appearance. Stones and distension are absent. Pancreas divisum is noted. The native kidneys are atrophic with multiple bilateral cysts. A renal graft in the right lower quadrant is partly visualized but not fully assessed here. There is no ascites or lymphadenopathy. No osseous abnormality is demonstrated. Multiplanar 2D and 3D reformatted and subtracted images of the dynamic series were helpful in evaluating the study. IMPRESSION: 1. Chronic-appearing nonocclusive thrombosis beginning in the upper superior mesenteric vein, extending through the entire main portal vein, occluding the left portal vein, and partly involving the proximal right portal vein. 3. Atrophic kidneys with cysts. . Brief Hospital Course: 64M with ESRD s/p LRKT in [2196] and colon CA s/p hemicolectomy now with upper GI bleeding given HCT drop from [Month (only) 359] of 39 to 30 on admission. . # GI bleeding: Patient presented with several days of black sticky stool. Hct on admission was ~30 suggesting a subacute bleed since [Month (only) ]. Patient was treated with IV Protonix, octreotide and ceftriaxone for possible SBP prophylaxis. He received 1 unit of PRBC with appropriate increase in his Hct. GI was consulted and EGD was performed showing a large gastric varix. Abdominal ultrasound was performed showing that the portal vein appeared patent with normal directional flow. Patient's ASA was held and he was started on nadolol 20mg QD and transferred from MICU to the floor. Pt was hemodynamically stable through the remainder of hospitalization. Pt. received only 1 unit total. He also had erosive gastritis on EGD and a nl [4-17] colonoscopy. . The source of varix remained unclear, possibly due to portal thrombus vs. cholangitis, but patient had no hx consistent w/ cholangitis. MRV was performed and confirmed extensive thrombus in the portal vein but a patent splenic vein. Pt had attempted TIPS, but gradient was only 7mmHg. Given high risk of re-bleeding varices were injected [12-31]. . # Gastric varix and portal vein thrombosis. Varix injected as above without complications. Patient did not have history of cirrhosis and cause of liver cirrhosis if present was unclear. Pt. had hx of EtOH abuse, Stage 1 fibrosis on Bx of poor quality in [2195]. EtOH abuse was felt to be the most likely possibility. HCV and HBV negative as of [9-17], as well as [Doctor First Name ], and HIV were negative. Fe studies were not suggestive of hemochromatosis. . Portable u/s showed patient PV and hepatic veins, but MRV revealed a chronic-appearing nonocclusive thrombosis beginning in the upper superior mesenteric vein, extending through the entire main portal vein, occluding the left portal vein, and partly involving the proximal right portal vein. This may have lead to increased PV and splenic vein pressures. There were no ascites on U/S. . There was no clear source for the portal vein thrombus. Given chronicity and GIB, patient was not anticoagulated. Patient was not encephalopathic during the admission. He was started on carafate, pantoprazole and ciprofloxacin for GIB. A liver biopsy was performed and results were pending at time of discharge. Patient was to undergo general hypercoagulability work up as outpatient and was arranged follow up with Liver clinic. . # ESRD s/p Renal Transplant: graft function has been stable with Cr 1.7-2.2 for past several months. Current Cr. 1.6. Tacrolimus levels were low on admission and dosing was increased to 2mg [Hospital1 ], azathioprine was continued. Patient was continued on Bactrim for prophylaxis. . # DM: s/p renal transplant. lantus 42 units qam (home dose) + SSI. Last A1C was 8.0 on [9-17]. Patient was continued on lantus and ISS. . # HTN: Goal 130/80 or less. Pt. was normotensive. He was started on nadolol. Carvedilol, Hydrochlorothiazide and norvasc were held given normal blood pressures on nadolol and concern for hypotension in setting of GIB. These medications are to be restarted in outpatient setting as deemed appropriate by outpatient providers. . # Hyperlipidemia: Continued zetia, pravastatin 20mg daily. . # OSA: Sleep study in [11/2199] recommended initiation of CPAP 11 cm H2O, which pt apparently never followed through with. He continued to refuse CPAP while inpatient. . Patient was discharged in a hemodynamically stable condition, with appropriate follow up. Medications on Admission: Carvedilol 25 mg twice a day Hydrochlorothiazide 25 mg once a day Amlodipine 10 mg once a day Flomax 0.4 mg hs Bactrim 80 mg-400 mg once a day Aspirin 81 mg once a day Azathioprine 100 mg once a day Prograf 1 mg twice a day Pravastatin 20mg daily Ezetimibe 10mg daily Humalog Pen Sliding Scale Lantus 42 Units in the morning Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 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. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Two (42) units Subcutaneous once a day: 42 units glargine and insulin sliding scale as per your sliding scale. 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: including today. Disp:6 Tablet(s) Refills:0 12. Carafate 1 gram Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:2 13. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: gastric variceal bleed portal vein thrombosis Secondary: s/p renal transplant Discharge Condition: stable hematocrit, stable vital signs Discharge Instructions: You were admitted with black stools and found to have a gastric varix. This was injected with Cyanoacrylate and your blood levels have remained stable. You were given one blood transfusion. A thrombus was found in your portal vein. It is unclear what the cause of this thrombus is at this time. To help determine that, you also received a liver biopsy to assess for liver damage and cirrhosis. -Please continue all medications as you previously had including immunosuppressant medication -Please do not take Aspirin, Carvedilol, Hydrochlorothiazide or Norvasc until you follow up with Dr. [Last Name (STitle) 696] and Dr. [First Name (STitle) 805]. -Please take nadolol daily -Please take protonix 40 mg twice daily -Please do not take NSAIDS -Please take carafate 1 gram QID -Please take ciprofloxacin for three more days to prevent infection after bleed -Please follow up with Dr. [Last Name (STitle) 696] [Name (STitle) ] will have re injection of the gastric varix and assessment of further intervention. Should you feel like you're becoming confused, fatigued, notice new black stools, blood in your stool, chest pain, shortness of breath, leg swelling, fevers, chills or any other symptom concerning to you, please call you primary care doctor or call Dr. [First Name (STitle) 805] or go to the emergency room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 3688] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2201-1-7] 2:10 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 3688] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2201-1-16] 10:30 Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2201-1-16] 10:30 Please call Dr. [First Name (STitle) 805] from renal for follow up appt within the month, please call [Telephone/Fax (1) 102309]. Completed by:[2201-1-17]	[ "456.8", "452", "V10.05", "578.9", "250.00", "V42.0", "327.23", "572.3", "252.08", "535.40", "V58.67", "537.89", "272.4" ]	icd9cm	[ [ [] ] ]	[ "44.43", "45.13", "50.11" ]	icd9pcs	[ [ [] ] ]	11415, 11421	6030, 9718	288, 293	11562, 11602	2578, 6007	12991, 13611	1731, 1749		10094, 11392		11442, 11541		9744, 10071			11626, 12968								1764, 2559																					237, 250									321, 1230														1252, 1545	1561, 1715
16,928	110,117	51766	Discharge summary	report	Admission Date: [2187-10-1] Discharge Date: [2187-10-6] Date of Birth: [2119-4-19] Sex: M Service: CSURG Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain on exertion Major Surgical or Invasive Procedure: CABG X 3 History of Present Illness: 68 y/o male w/angina for 5 years prior to admission, recent increase in symptoms, with decreased exercise tolerance. Had + ETT, followed by cardiac catheterization which revealed 40% LM, 60-70% LAD, 70 % Cx, and diffuse, mild RCA disease, LVEF 59%. He was admitted on [2187-10-1] for CABG. Past Medical History: Type 2 DM sleep apnea prostate cancer (s/p prostatectomy) hypercholesterolemia s/p penile implant s/p appy s/p bilat hernia repairs Social History: retired engineer married, lives with wife [Name (NI) ]. ETOH (few per week) remote smoker (quit 40 years ago) Family History: non-contributory Physical Exam: pulse 63, bp 176/104 (pre-op), physical exam entirely WNL on admission pre-op labs unremarkable. Pertinent Results: [2187-10-6] 09:15AM BLOOD WBC-8.4 RBC-3.48* Hgb-10.8* Hct-31.4* MCV-90 MCH-31.0 MCHC-34.3 RDW-12.5 Plt Ct-321 [2187-10-6] 09:15AM BLOOD PT-13.0 PTT-24.0 INR(PT)-1.1 [2187-10-3] 06:58AM BLOOD PT-12.7 INR(PT)-1.0 [2187-10-6] 09:15AM BLOOD Glucose-157* UreaN-13 Creat-0.8 Na-140 K-4.2 Cl-101 HCO3-28 AnGap-15 Brief Hospital Course: To OR on day of admission ([10-1]), underwent CABG X 3 (LIMA > LAD, SVG > OM, SVG > Diag) by Dr. [Last Name (STitle) ]. Extubated day of surgery. Transferred from ICU on POD # 1, went into rapid AFib on POD #1 (v. rate 120's), treated with IV amiodarone, transitioned to PO amiodarone, lopressor increased, converted back to NSR the following day, but went back into AF (110-120's) again on POD #3. Coumadin started. Pt. has since converted back to NSR (70's). Pt. has progressed well from a PT standpoint, ambulating independently. BP has been a bit more elevated with increased activity. He received captopril 50mg once this morning, lisinopril 20 mg this afternoon, and should start lisinopril 40 mg po QD in the am. PE: neuro: intact pulm: lungs CTA bilat cor: RRR abd: benign sternal incision clean, steris intact trace peripheral edema Medications on Admission: ASA 325 mg QD Metformin 1000 mg [Hospital1 ] lisinopril 60 mg PO QD Norvasc 10 mg po QD Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for 1 week, then 400 mg (2 tabs) QD for 1 week, then 200 mg (1 tab) poQD until D/c'd by Dr. [Last Name (STitle) ]. Disp:120 Tablet(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 5mg today ([10-6]) and tomorrow ([10-7]), then INR draw, and check with Dr. [Last Name (STitle) ] for continued dosing. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD post-op AFib DM HTN Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or ointments to incisions no lifting > 10 # or driving for 1 month Followup Instructions: with Dr. [Last Name (STitle) ] in [1-30] weeks with Dr. [Last Name (STitle) ] next week (pt. has appt) with Dr. [Last Name (STitle) ] in 4 weeks Completed by:[2187-10-6]	[ "250.00", "997.1", "E878.2", "427.31", "401.9", "413.9", "414.01", "780.57", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "36.12", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	3800, 3858	1425, 2281	292, 303	3926, 3932	1079, 1402	4113, 4305	929, 947		2423, 3777		3879, 3905		2307, 2400			3956, 4090								962, 1060																					230, 254									331, 627														649, 782	798, 913
42,995	160,439	44570	Discharge summary	report	Admission Date: [2178-8-13] Discharge Date: [2178-8-23] Date of Birth: [2101-8-29] Sex: M Service: MEDICINE Allergies: Nsaids / Dyazide / Aspirin Attending:[Last Name (NamePattern1) 1167] Chief Complaint: chronic systolic congestive heart failure, ventricular tachycardia Major Surgical or Invasive Procedure: dialysis line placement History of Present Illness: Mr. [Known lastname ] is a 76 year-old man with coronary artery disease s/p 4 vessel CABG [2158] (LIMA to the LAD, SVG to PDA, SVG to D1, SVG to OM1 with jump to OM2 & Om3) c/b aortic dissection and bioprosthetic [Last Name (LF) 1291], [First Name3 (LF) ] 35% ([8-2]) s/p BiV pacemaker, AF on amiodarone, failed endovascular repair of AAA, R->L fem-fem bypass graft ([2169]) following resulting in R iliac dissection, AAA repair [2172], with recent admissions for diuresis that now presents to the CCU with AMS. . The pt was at [Hospital6 33] (discharged [2178-8-5]) following admission for worsening dyspnea and bilateral lower extremity edema. At that time the pts symptoms had been progressive over the prior 2 months. The pt had experienced worsening of his edema, preventing him from ambulating even with his walker, mild DOE, and nausea and vomitting for days prior to her admission to [Hospital3 ]. . The pt was then admitted to [Hospital1 18]([Date range (3) 95453]) during which he was on lasix drip with aggressive diuresis. SBP somewhat low that admission and was ~85-95 when discharged. . The patient then re-presented on [2178-8-13] with generalized malaise, ankle pain, and intermittent lethargy. Over the past 8 days the pt has been lethargic and intermittently delirius. He was found to have a coag negative staph UTI which is being treated with vancomycine (day 1=[8-18]). Because of his altered mental status and transient abdominal pain he had a CT head and abdomen, both of which were negative for any acute process. He has appeared total body overloaded, but mostly with normal O2 Sat on RA. Lasix has been held in the setting of borderline BP. He has triggered 5 times for his altered mental status and hypotension, which has been attributed to a combination of delirium from UTI and oxycodone, which he has been getting because of ankle pain of unclear etiology. Creatinine has also been rising from baseline 2.0 up to 3.5 today. . Because he remained with tenuous blood pressures and apparent volume overload, Mr. [Known lastname ] was planning on being electively transferred to the CCU for ionotropic support and further diuresis. . Immediately prior to transfer, he noted on telemetry to have slow VT at a rate of ~110. Patient was found lethargic but arousable, then briefly rolled his eyes back and became briefly unresponsive for seconds. Monitor showed VT that returned to NSR, and patient returned to responsiveness before any drugs or shocks could be delivered. ABG showed 7.42/46/39. . On arrival to the CCU, patient difficult to arouse but following commands and A&O x 1. Shortly after arrival to the CCU, Mr. [Known lastname ] had several further episodes of self-terminating VT with ? decreased responsiveness and BP falling to 60s. Episodes resolved within 30 seconds without intervention, with BP returning to the 80s systolic. . On arrival to the CCU, review of systems was positive for shortness of breath. The patient denies chest pain. Other review of systems was negative. Past Medical History: --Hypertension --Hyperlipidemia --Gout --Atrial fibrillation on amiodarone. --Coronary artery disease status post 4vCABG in [2158] (LIMA to the LAD, SVG to PDA, SVG to D1, SVG to OM1 with jump to OM2 & Om3) complicated by aortic dissection and bioprosthetic aortic valve replacement --Severely depressed left ventricular systolic function, EF 20% --with BiV pacemaker implant. --History of R->L fem-fem bypass graft in [2169] after failed endovascular repair of AAA, resulting in R iliac dissection --Peripheral vascular disease, status post AAA repair at the [State 15946] Heart Institute in [2173-9-24] under the care of Dr. [Last Name (STitle) 95452] and Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ]. Social History: Retired fire fighter, lives w/ wife in a ranch house (no stairs) in [Location (un) 38640], MA. Family very involved. Previous 60 pack-year smoking history, occasional to rare alcohol use. (Used to be heavy drinker) Denies drug use. Family History: Some distant family hx of CA, aneurysms in twin brother, no hx CAD, DM, HTN Physical Exam: GENERAL: A/Ox3, irritated w/ questioning 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 at level of ear LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Bilateral 2+ pitting edema to mid-thigh, unable to palpate DP/PT pulses but feet warm/wp. Ankles tender bilaterally w/ no erythema or wamth. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. Pertinent Results: Source: CVS Other Urine Chemistry: UreaN:294 Creat:57 Na:55 TotProt:19 Uric-Ac:13.7 Comments: URINE Uric-Ac: Desirable Ph Greater Than 6.5; Interpret Results Accordingly Prot/Cr:0.3 Osmolal:312 Source: CVS Color Yellow Appear Clear SpecGr 1.008 pH 5.0 Urobil 1 Bili Neg Leuk Sm Bld Tr Nitr Neg Prot Neg Glu Neg Ket Neg RBC 0-2 WBC [11-13] Bact Few Yeast None Epi 0 [2178-8-14] 06:25a 136 93 50 114 AGap=16 3.8 31 2.6 estGFR: 24/29 (click for details) CK: 191 MB: 5 Trop-T: 0.07 Comments: CK(CPK): Verified By Replicate Analysis cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 8.4 Mg: 2.2 P: 4.3 ALT: AP: Tbili: Alb: AST: LDH: Dbili: TProt: [Doctor First Name ]: Lip: UricA:6.5 97 9.7 9.0 131 27.4 PT: 16.5 PTT: 34.6 INR: 1.5 [2178-8-13] 4:50p Trop-T: 0.06 Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi 135 92 46 121 AGap=14 4.0 33 2.6 CK: 96 MB: Notdone ALT: AP: Tbili: Alb: 3.0 AST: LDH: Dbili: TProt: [Doctor First Name ]: Lip: 95 9.7 9.4 151 28.5 N:78.0 L:14.9 M:5.8 E:1.1 Bas:0.4 PT: 15.9 PTT: 34.3 INR: 1.4 [8-15]- CT Abd/Pelvis w/o contrast- 1. B/L small-to-moderate pleural effusion with associated atelectasis. 2. Increased attenuation of the liver, compatible with history of amiodarone therapy. There are no focal liver lesions and no biliary dilatation. However, the liver does appear somewhat nodular, and correlation with liver function tests is recommended. 3. Small perihepatic and perisplenic ascites, with diffuse anasarca of the mesentery and superficial soft tissues, likely reflecting third spacing. 4. Marked atherosclerotic disease involving the aorta, renal arteries, celiac axis, and SMA. 5. Status post endovascular aneurysm repair of infrarenal abdominal aortic aneurysm, with decreased size of the aneurysm sac compared to [2173-2-22]. 6. Diverticulosis without convincing evidence of diverticulitis. 7. Marked degenerative change of the lumbar spine. [8-14]- CT head w/o contrast- 1. No hemorrhage or edema. 2. Parenchymal involutional change. 3. Severe white matter ischemic change. [2178-8-22] 01:20PM BLOOD WBC-10.6 RBC-2.83* Hgb-8.8* Hct-27.4* MCV-97 MCH-31.2 MCHC-32.2 RDW-19.2* Plt Ct-161 [2178-8-22] 08:27PM BLOOD WBC-10.9 RBC-2.79* Hgb-8.7* Hct-26.9* MCV-97 MCH-31.2 MCHC-32.3 RDW-19.4* Plt Ct-152 [2178-8-23] 03:47AM BLOOD WBC-14.1* RBC-2.72* Hgb-8.4* Hct-26.4* MCV-97 MCH-30.8 MCHC-31.8 RDW-20.5* Plt Ct-100* [2178-8-21] 06:00AM BLOOD Neuts-74.3* Lymphs-18.6 Monos-4.2 Eos-2.4 Baso-0.5 [2178-8-22] 01:20PM BLOOD Neuts-75.9* Lymphs-18.5 Monos-3.8 Eos-1.6 Baso-0.3 [2178-8-22] 08:27PM BLOOD PT-16.3* PTT-45.2* INR(PT)-1.4* [2178-8-23] 03:48AM BLOOD PT-19.6* PTT-57.2* INR(PT)-1.8* [2178-8-20] 10:35AM BLOOD Glucose-127* UreaN-68* Creat-3.4* Na-139 K-4.3 Cl-98 HCO3-28 AnGap-17 [2178-8-21] 06:00AM BLOOD Glucose-103 UreaN-72* Creat-3.5* Na-137 K-4.1 Cl-99 HCO3-28 AnGap-14 [2178-8-21] 07:14PM BLOOD Glucose-92 UreaN-74* Creat-3.4* Na-136 K-4.0 Cl-100 HCO3-24 AnGap-16 [2178-8-22] 03:33AM BLOOD Glucose-96 UreaN-74* Creat-3.6* Na-135 K-4.5 Cl-100 HCO3-25 AnGap-15 [2178-8-22] 01:20PM BLOOD Glucose-131* UreaN-76* Creat-3.7* Na-135 K-4.5 Cl-100 HCO3-24 AnGap-16 [2178-8-22] 08:29PM BLOOD Glucose-108* UreaN-78* Creat-3.7* Na-133 K-4.4 Cl-97 HCO3-23 AnGap-17 [2178-8-23] 03:47AM BLOOD Glucose-113* UreaN-63* Creat-3.2* Na-134 K-4.3 Cl-99 HCO3-20* AnGap-19 [2178-8-14] 06:25AM BLOOD CK-MB-5 cTropnT-0.07* [2178-8-15] 12:45PM BLOOD CK-MB-5 cTropnT-0.05* [2178-8-21] 07:14PM BLOOD CK-MB-NotDone cTropnT-0.04* [2178-8-22] 03:33AM BLOOD CK-MB-NotDone cTropnT-0.05* [2178-8-21] 03:54PM BLOOD Type-ART pO2-39* pCO2-46* pH-7.42 calTCO2-31* Base XS-4 [2178-8-21] 07:19PM BLOOD Type-ART pO2-202* pCO2-41 pH-7.43 calTCO2-28 Base XS-3 [2178-8-21] 10:26PM BLOOD Type-ART pO2-124* pCO2-40 pH-7.43 calTCO2-27 Base XS-2 [2178-8-22] 04:38AM BLOOD Type-ART pO2-77* pCO2-39 pH-7.44 calTCO2-27 Base XS-1 [2178-8-22] 01:28PM BLOOD Type-ART Temp-37.1 pO2-82* pCO2-38 pH-7.43 calTCO2-26 Base XS-0 Intubat-NOT INTUBA [2178-8-22] 08:54PM BLOOD Type-ART pO2-87 pCO2-36 pH-7.44 calTCO2-25 Base XS-0 [2178-8-23] 03:58AM BLOOD Type-ART pO2-71* pCO2-38 pH-7.35 calTCO2-22 Base XS--3 [2178-8-21] 07:19PM BLOOD Lactate-1.3 [2178-8-21] 10:26PM BLOOD K-3.9 [2178-8-22] 04:38AM BLOOD Lactate-2.0 [2178-8-22] 01:28PM BLOOD Lactate-2.3* [2178-8-22] 08:54PM BLOOD Lactate-2.9* [2178-8-23] 03:58AM BLOOD Lactate-4.2* [2178-8-21] 10:26PM BLOOD freeCa-1.06* [2178-8-22] 08:54PM BLOOD freeCa-1.05* [2178-8-23] 03:58AM BLOOD freeCa-0.85* Brief Hospital Course: Mr. [Known lastname ] is a 76-year old gentleman with known coronary artery disease, congestive heart failure, peripheral vascular disease and hypertension who was recently ([8-12]) discharged after aggressive diuresis for CHF exacerbation, who re-presents to hospital due to marked family concern that patient is not doing well at home as he has become more lethargic. 1. Lethargy- Mr [Known lastname ] felt more tired than usual and has not changed any medications except for torsemide since his last admission. Urinalysis and culture were sent, and U/A showed bacteria and leukocytes. Urinary tract infection could contribute to his change in mental status so he was started on a 7 day course of Double Strength Bactrim 1 tab [Hospital1 ]. A CT head was done to rule out any acute intracranial process and this returned negative. [8-18], Urine culture grew out coagulase negative staphylococcus, so IV Vancomycin was initiated. Blood cultures were drawn prior to antibiotic administration to assess for possible bacteremia, as this could contribute to his hypotension and mental status change. Mr. [Known lastname ] was screened for rehab and had a bed at [Location (un) 38] for [8-15], but he triggered on [8-15] for changes in mental status. Head CT done at the time showed no acute intracranial process. He triggered again on [8-16] for hypotension (70/40) which resolved with minimal intervention, and again on [8-18] for Respiratory Rate above 30 (as per nursing, RR was 32). However, when re-checked RR was 19. EKG was obtained which was unchanged from patient's baseline. Stat Chest X-ray was done to assess for any potential source of infection; however, this too was unchanged from baseline. His mental status resolved on its own spontaneously on [8-18] and his altered states of consciousness was most likely delerium attributed to narcotic use for his bilateral ankle pain as it was discovered he received 2.5mg oxycodone at 12 midnight and at 0800 on [8-18]. This was discontinued and strictly enforced that he could only have lidoderm patches and tylenol for pain. He was agitated and disoriented when he came out of his hypoactive delerious state and was given IV fluids and 0.5mg IV haldol x4 for a total of 2mg IV haldol. He rested comfortably with his family overnight and was more responsive in the morning of [8-19], becoming very anxious and concerned for his mortality and for the care of his family. 2. Ankle pain- Increasing bilateral ankle pain with no history of trauma. Nightfloat thought this may due to gout flare, so Allopurinol was continued and Colchicine added although no podagra, no hot swollen joints or appreciable effusion. Pain was controlled with lidoderm patches, around the clock tylenol and liquid oxycodone for breakthrough pain, with symptomatic relief. Lidoderm patches were discontinued on [8-17], as increasing pain could be due to allodynia, as patient was getting continuous patches without a patch-free period. Morphine was given by night team despite patient's increasing lethargy so strong pain medications were strictly prohibited by primary team. Ankle pain seemed to resolve with conservative medical management. 3. Congestive Heart Failure- Mr. [Known lastname ] presented with 2+ pitting edema on his bilateral lower extremities from feet to mid-thighs bilaterally, which is how he appeared on previous discharge (much improved from beginning of last admission). We continued his outpatient medication regime including torsemide [Hospital1 ]. He has follow-up with Dr. [First Name (STitle) 437] in heart failure clinic. Mr. [Known lastname ] also complained of abdominal pain which is likely related to intestinal congestion from his right-sided heart failure. A CT abdomen was conducted; it ruled out an acute intra-abdominal process and showed mesenteric edema. 4. Acute vs. Chronic Renal Failure- Mr [Known lastname 60602] creatinine had risen quite bit since his last discharge (2.6-->2.8-->3.2) which could be due to active diuresis and decreased PO intake as he notes he has not been drinking fluids or eating much. He has been given multivitamins, encourage to take PO and given carnation plus supplements. On [8-17] since Cr was 3.2, Mr. [Known lastname ] was given a 250cc bolus of NS and transfused 1 unit of PRBCs over 3 hours. Some small rise in creatinine could be attributed to bactrim use. NSAIDs were avoided and lisinopril was held for renal function. He was given D5NS on [8-18]. 5. Patient transferred to CCU on [8-22] for ionotropic report and diuresis. On arrival to the CCU, patient was difficult to arouse but followed commands and A&O x 1. Shortly after arrival to the CCU, Mr. [Known lastname ] had several further episodes of self-terminating VT with signs of decreased responsiveness and BP falling to 60s. Episodes resolved within 30 seconds without intervention, with BP returning to the 80s systolic. He was started on lasix drip at 25mg/hr and milrinone gtt .5mcg/kg/hr. In addition, patient required phenylephrine for pressure support. Patient had minimal output to lasix gtt (5-7cc/hr). Continued to experience shortness of breath and hypoxia (was placed on NC plus facemask). Mental status remained stable- patient oriented to person and place. Family was with patient throughout the day. Renal consulted for low UOP and decided to initiate CVVH that evening. Temporary dialysis line placed aroun 7pm and dialysis initiated shortly thereafter. Lasix drip was stopped. Milrinone was continued at .25mcg/kg/hr. MAP trended down to 50's in the evening. Patient was anxious/agigtated. At midnight, MAP was 51 and patient was mentating. House officer paged at 3pm for low BP. MAP down to 47- patient maxed out on phenylephrine. Milrinone was discontinued. Dopamine gtt started with minimal response. BP continued to trend down and then patient went into VT. He was coded and passed away at 0500. Medications on Admission: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO DINNER (Dinner). 9. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO ONCE MR1 (Once and may repeat 1 time) for 1 doses. 13. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Expired Discharge Diagnosis: Congestive heart failure Coronary artery disease Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2178-8-23]	[ "274.9", "427.1", "V42.2", "427.31", "403.90", "414.00", "440.1", "V45.01", "585.9", "428.0", "599.0", "562.10", "440.0", "584.9", "428.33", "V45.81", "272.4" ]	icd9cm	[ [ [] ] ]	[ "38.93", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	17117, 17126	9982, 15995	362, 387	17219, 17228	5270, 9959	17280, 17314	4558, 4635				17147, 17198		16021, 17094			17252, 17257								4650, 5251																					256, 324									415, 3511														3533, 4288	4304, 4542
80,696	153,743	39410	Discharge summary	report	Admission Date: [2107-7-29] Discharge Date: [2107-8-16] Date of Birth: [2029-5-17] Sex: M Service: SURGERY Allergies: Food Extracts Attending:[First Name3 (LF) 473] Chief Complaint: Distal cholangiocarcinoma versus pancreatic adenocarcinoma Obstructive jaundice. Major Surgical or Invasive Procedure: [2107-7-29] ERCP with pancreatic stent [2107-7-29] Interventional Radiology Biliary drain placement. [2107-8-2] Interventional Radiology for internal external drain placement History of Present Illness: 78 y.o. M presenting with 3 wks of painless jaundice, loss of appetite and weight loss. MRCP shows dilation of biliary tree down to ampulla, normal PD. ERCP on [2107-7-29] showed stricture of distal CBD, unable to cannulate CBD. A pancreatic duct stent was placed as well as a PTBD. Past Medical History: HCV, Dislipidemia, COPD, Arthritis/Gout, Type 2 DM, Gastritis, pernicious anemia Social History: Married Family History: Noncontributory Physical Exam: On Admission: Vitals-98.3 70 130/70 15 1004Lnc Gen-Axox3, NAD, jaundiced RRR, no MRG CTABL Abdomen-soft, mildly tender to epigastric palpation, PTBD in place draining dark green fluid. Ext-no C/C/E Pertinent Results: [2107-7-29] 09:31AM BLOOD WBC-7.4 RBC-3.45* Hgb-11.4* Hct-32.9* MCV-95 MCH-33.0* MCHC-34.6 RDW-14.9 Plt Ct-283 [2107-7-29] 09:08PM BLOOD Glucose-85 UreaN-17 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-26 AnGap-15 [2107-7-29] 09:08PM BLOOD Lipase-672* [2107-7-29] 09:08PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2 [2107-8-3] 11:45AM BLOOD calTIBC-202* Ferritn-603* TRF-155* [2107-8-13] 12:56PM BLOOD WBC-14.3* RBC-2.55* Hgb-7.9* Hct-21.5* MCV-84 MCH-31.1 MCHC-37.0* RDW-15.8* Plt Ct-159 [2107-8-13] 05:51PM BLOOD PT-15.2* PTT-42.5* INR(PT)-1.3* [2107-8-13] 12:56PM BLOOD Glucose-129* UreaN-39* Creat-1.3* Na-139 K-4.7 Cl-109* HCO3-22 AnGap-13 [2107-8-13] 12:56PM BLOOD ALT-158* AST-108* LD(LDH)-178 AlkPhos-222* TotBili-6.1* [2107-8-12] 07:38PM BLOOD Lipase-41 [2107-8-13] 12:55PM BLOOD CK-MB-2 cTropnT-<0.01 [2107-8-13] 12:56PM BLOOD Calcium-7.9* Phos-4.2 Mg-1.8 [2107-7-29] ERCP: A bulging of the major papilla was noted. The pancreatic duct was filled partially with contrast and appeared normal The distal most part of the CBD was filled with contrast and there was a tight 1cm malignant appearing stricture Cannulation of the CBD was not successful using a sphincterotome A small pre-cut sphincterotomy was performed in the 12 o'clock position using a needle-knife to aid in accessing the CBD Cannulation of the pancreatic duct was performed with a sphincterotome using a free-hand technique A 6cm by 5FR plastic single pigtail pancreatic stent was placed successfully to aid in CBD cannulation and decrease risk of acute pancreatitis. Despite extensive maneuvering and use of different catheters and guidewires, the CBD was not able to be cannulated. [2107-7-29] PTBD PLACEMENT: IMPRESSION: 1. Percutaneous transhepatic cholangiogram demonstrating dilated right and left intrahepatic biliary ducts and dilated common bile duct. A complete obstruction of the distal CBD was noted and attempts to cross into the bowel were unsuccessful at this stage. 2. A modified 6 French external biliary catheter was placed with the pigtail formed and locked in the distal CBD and connected to an external drainage bag. [2107-7-30] ABD CT: IMPRESSION: 1. 24 mm mass in the pancreatic head/ampullary region which appears to be confined to the pancreas except possible extension in to the duodenal wall and slightly into the pancreaticoduodenal groove. This most likely represents a pancreatic adenocarcinoma, but amopullary carcinoma and cholangiocarcinoma are possible. 2. Replaced right hepatic artery otherwise conventional hepatic arterial and venous anatomy with widely patent SMA, SMV, and portal veins, without evidence of vascular involvement. No definite lymphadenopathy. Pancreatic stent in expected position without pancreatic duct dilation snd percutaneous transhepatic biliary catheter with tip in the CHD with no bile duct dilation. 3. 4.8-cm slightly complex cyst in the left kidney. Attention on follow up recommended. [2107-7-31] ECG: Sinus rhythm. Tracing is within normal limits. No previous tracing available for comparison. [2107-8-1] EGD: No evidence of active bleeding and no evidence of hemobilia. Small pigmented area over ulcer at ampulla, which is a possible site of intermittent bleeding. Successful bipolar cautery treatment. [2107-8-2] PTBD REPLACEMENT: IMPRESSION: 1. Removal of the external 6.3 French biliary drain over the wire. 2. Check cholangiogram demonstrating decompression of the biliary ductal system as compared to the prior study dated [2107-7-29]. However, there is high grade stenosis noted in the terminal CBD with trickle of contrast flowing into the distal bowel. 3. Successful negotiation of the stricture and placement of internal-external drain, 8 French in size with pigtail formed in the jejunal loop. [2107-8-12] ECG: Sinus tachycardia, rate 114. Low voltage in the limb leads. Otherwise, tracing is within normal limits. Compared to the previous tracing of [2107-7-31] the low voltage is new. T waves are also more prominent throughout the tracing. These changes are non-specific but myocardial ischemia is not excluded as an etiology. Consider electrolyte changes. [2107-8-12] 11:29 pm BILE GRAM STAIN (Final [2107-8-13]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN SHORT CHAINS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. FLUID CULTURE (Final [2107-8-16]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [2107-8-12] 9:40 pm BLOOD CULTURE Source: Line-arterial . Blood Culture, Routine (Preliminary): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [2107-8-13]): GRAM NEGATIVE ROD(S). Brief Hospital Course: The patient with history of painless jaundice x 3 weeks was admitted to the General Surgical Service for evaluation and treatment. On [2107-7-29], the patient underwent ERCP, which was unsuccessful for CBD stent placement and only pancreatic stent was placed ( please refer to the Operative Note for details). On same day, patient underwent placement of PTBD. After procedure, the patient arrived on the floor and was started on regular diet, on IV fluids and antibiotics, with a foley catheter (placed by Urology), and IV Dilaudid for pain control. On [2107-7-30] patient underwent CTA, which demonstrated 24 mm mass in the pancreatic head/ampullary region with possible extent ion into duodenal wall. Patient was evaluated for possible Whipple/bypass resection. Neuro/Delirium: Patient was completely independent with ADL prior admission. Pain was controlled with IV Dilaudid with good result. Patient was on baseline mental status until [2107-8-1], where overnight patient became extremely agitated, required Haldol and four point restraints. Patient's mental status improved during day time, but overnight patient's mental status changed again. Patient received IV Haldol and 4 points restraints were applied again. Next day geriatric consult was called and recommendations were followed. Patient was ordered to have 1:1 sitter and started on olanzapine. Pain medication was reduced, patient was encouraged to take more PO nutrition. Mental status was slightly improving day by day. On [2107-8-10], sitter was discontinued, patient did fairly well with 15 min safety checks. Patient was AO x 2, more interactive, he followed all commands. Patient was screened to be discharge in long term facility and was accepted for transfer on [2107-8-12]. On [2107-8-11] patient was triggered for tachycardia, became unresponsive and was transferred in ICU. On [8-13], patient was made DNR/DNI and started on [Month/Year (2) 3225] protocol. Patient expired on [2107-8-16]. CV: During admission patient had several episodes of sinus tachycardia. His cardiac status was monitored via telemetry unit. The patient remained stable from a cardiovascular standpoint until his death. Pulmonary: The patient remained stable from a pulmonary standpoint until his death. GI/GU/FEN: Patient was on regular diet after ERCP and PTBD placement. When mental status declined, nutritional consult was obtained and patient was started on TPN. Patient continue to have good PO, and he was only on starter TPN. TPN was discontinued on [2107-8-11]. PICC line was removed. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: Patient was started on empiric ABX treatment on admission. On [2107-8-3], PTBD was capped and patient was tolerated well. Patient's cultures were sent and came back positive for Pseudomonas Aeruginosa in bile and blood. Patient was continued on ABX until [Date Range 3225] protocol initiated. WBC and fever curve were closely monitored during hospitalization, patient had WBC of 29 on transfer in the ICU. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: Patient was found to have bloody diarrhea on [7-31] x 2 and small hematemesis. HCT dropped to 20.2 from 31.5. Patient was given 5 units of RBC total, HCT improved to 29.6. EGD was performed and found no active bleeding. GI was consulted for colonoscopy, no colonoscopy was performed due to patient's status improved and HCT was stable. Patient's HCT was monitored throughout hospitalization and was stable until [8-12]. Patient was in ICU for acute mental status change, his HCT dropped from 31.4 to 18. 3 units of RBC was transferred, HCT up to 29. EGD was performed and found brisk bleed in ampullary region, suspecting hemobilia. Angio was recommended, HCP decided to make patient [Name (NI) 3225]. No further interventions were made, patient was started on [Name (NI) 3225] protocol and expired on [2107-8-16]. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay. Medications on Admission: Glipizide XL 5', Avodart 0.5', B12, Zantac 300' Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Cholangiocarcinoma versus pancreatic adenocarcinoma 2. Delirium 3. Melena 4. Tachycardia Discharge Condition: Expired Discharge Instructions: No instructions Followup Instructions: None Completed by:[2107-8-16]	[ "038.9", "070.54", "285.1", "716.90", "564.00", "578.9", "281.0", "535.50", "576.2", "576.8", "518.81", "600.00", "041.7", "V66.7", "788.99", "995.91", "157.0", "496", "274.9", "155.1", "293.0", "427.89", "250.00" ]	icd9cm	[ [ [] ] ]	[ "51.98", "99.15", "38.93", "44.43", "96.71", "57.32", "87.51", "96.04", "52.93", "51.85", "57.94", "97.05", "45.13", "38.91" ]	icd9pcs	[ [ [] ] ]	11705, 11714	7350, 11578	353, 542	11850, 11860	1260, 6586	11924, 11960	1005, 1022		11676, 11682		11735, 11829		11604, 11653			11884, 11901								1037, 1037						6761, 7327															233, 315									570, 859							1051, 1241	6622, 6717						881, 964	980, 989
11,235	147,720	904	Discharge summary	report	Admission Date: [2194-2-1] Discharge Date: [2194-2-7] Date of Birth: [2154-3-3] Sex: M Service: MEDICINE Allergies: Sulfamethoxazole/Trimethoprim / Lisinopril Attending:[First Name3 (LF) 30] Chief Complaint: 39y/o M with HIV/AIDS, last CD4 count 4, blind [1-29] CMV retinitis, hep B presents with fatigue and fever to 103 at home. Major Surgical or Invasive Procedure: 1. removal of Portacath 2. placement of triple lumen central catheter History of Present Illness: Pt felt tired in the day prior to admission, with decreased appetite. Developed fever to 103F. Denies nausea, vomiting, chills, abdominal pain, or diarrhea. Denies dysuria, nasal congestion, chest congestion. Denies headache; had similar symptoms to sinus headache, but since resolved. Pt reports thrush. Also denies SOB, CP. In ED, was noted to be hypoxic at 92% RA, placed on 3L NC and sats rose to 97%. Tachy to 130s, hypotensive to SBP 80s, T at 102.2, tachypneic to 30s. Rec'd Tylenol 1g, demerol 25mg x2, levo 1g x1, vanco 1g x1. On transfer, pt notes that he feels much better than prior, and started to feel significantly better yesterday. Is able to eat and drink without difficulty, denies pain with swallowing. Has not noticed rash, does not feel pruritus. No SOB or CP. Mild epigastric abdominal pain, which is intermittent and feels sharp in some areas and more like pressure in other areas. Pt has noted diarrhea since being in the hospital, no perianal tenderness, but discomfort due to rectal tube and Foley. Past Medical History: 1. HIV since '[77], now with AIDS, CD4 of 4, complicated by Klebsiella oxytoca PNA/bacteremia [9-30], [Month/Year (2) 6108] bacteremia in [6-28], blindness secondary to cytomegalovirus retinitis, oroesophageal candidiasis, oral hairy leukoplasia, toxo in [2184], anal warts, lipodystrophy. 2. Dermatitis. 3. Hypertension. 4. Hemorrhoids. 5. Anemia. 6. Leukopenia. 7. Angioedema. 8. Ulcerations. 9. Herpes simplex. 10. Shingles. 11. Hepatitis B. 12. Bacterial meningitis. 13. EF of 45% 14. peripheral neuropathy Social History: Lives in JP with his male partner. Denies current alcohol use. Smoked 1 ppd for 15 years, quit in [2179]. Used to use marjuana, now on marinol. No IVDA. Family History: father had MI at age 41 mother had salivary cancer in her 60's Physical Exam: on admission: T 102.2 [Telephone/Fax (2) 6120] 97% 3L Gen: A&O x3, NAD, pleasant emaciated male, lipodystrophy changes HEENT: temporal wasting, EOMI, PER, not reactive to light, + oral thrush, leukoplakia on both sides of tonguee, multiple papules with central umbilication on chin/face Neck: sm palpable LN ant/post cervical, supple CV: tachy, reg rhythm, no murmurs R Portacath in place, no erythema/tenderness, or crepitus Pulm: CTA bilaterally Abd: soft, ND, minor tenderness at RUQ, +BS Ext: no clubbing/cyanosis/edema; 2+ distal pulses on transfer to floor: Tm 98.9 Tc 98.0 108/66 91 21 97% RA Gen: thin, chronically ill appearing, no acute distress HEENT: temporal wasting, + oral thrush and leukoplakia Neck: supple, mild lymphadenopathy CV: RRR, nl S1/S2, no murmurs appreciated Pulm: CTAB, no wheezes Abd: soft, mildly tender in epigastrium, +BS, nondistended, no masses Ext: no edema, 2+ distal pulses Skin: R Portacath in place, no significant erythema in surrounding skin; no tenderness to palpation papules with some vesiculation on face Pertinent Results: Labs on admission: LACTATE-1.6 CBC: WBC-2.3* RBC-2.69* HGB-7.3* HCT-23.6* MCV-88 MCH-27.1 MCHC-30.9* RDW-19.0* diff: NEUTS-71* BANDS-22* LYMPHS-5* MONOS-0 EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 electrolytes: GLUCOSE-108* UREA N-27* CREAT-2.1* SODIUM-133 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-17* ANION GAP-17 LFTs: ALBUMIN-3.6 LIPASE-28 ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-180 ALK PHOS-173* AMYLASE-77 TOT BILI-0.6 UA: COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-1 WBC-1 BACTERIA-FEW YEAST-RARE EPI-0 On transfer to floor: CBC: WBC-5.0# RBC-2.71* Hgb-7.5* Hct-23.6* MCV-87 MCH-27.8 MCHC-32.0 RDW-18.5* Plt Ct-104* electrolytes: Glucose-110* UreaN-31* Creat-2.3* Na-136 K-4.4 Cl-113* HCO3-15* AnGap-12 Calcium-7.5* Phos-4.3# Mg-1.8 On discharge: CBC: WBC-3.6# RBC-3.33 Hgb-9.5* Hct-29.1* MCV-87 MCH-28.6 MCHC-32.7 RDW-17.9* Plt Ct-143* Neuts-73* Bands-10* Lymphs-9* Monos-6 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 electrolytes: Glucose-89 UreaN-27* Creat-1.8* Na-139 K-3.8 Cl-113* HCO3-20* AnGap-10 Calcium-8.0* Phos-3.1 Mg-1.4* Micro data: [2194-2-1]: UCx yeast 10,000-100,000 organisms/ml [2194-2-1]: BlCx x3: Klebsiella oxytoca ([2-27]) R to piperacillin and ceftazidime, otherwise sensitive [2194-2-3]: BlCx x2 negative [2194-2-5]: BLCx x2 negative [2-3], [2-4], [2-6]: stool negative for C diff, Campylobacter, Shigella, Salmonella, O&P [2-7]: cath tip negative CXR [2194-2-1]: No focal pulmonary parenchymal consolidation identified. Diffuse coarsening of the interstitial markings appears unchanged from multiple previous examinations, consistent with chronic interstitial changes. RUQ ultrasound [2194-2-2]: Stable ultrasonographic appearance of the right upper quadrant from [2193-12-20]. No gallstones or evidence of cholecystitis. A small amount of ascites. Echogenic kidney consistent with medical renal disease or HIV nephropathy. CXR [2194-2-3]: IMPRESSION: Unchanged appearance of the chest with no acute cardiopulmonary process. However, normal chest x-ray does not exclude PCP [Name Initial (PRE) 1064]. echo: [2194-2-5]: The left atrium is elongated. LV systolic function appears moderately depressed. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic root is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Compared with the prior study (tape reviewed) of [2193-3-28], left ventricular systolic function is now slightly worse. Brief Hospital Course: 1. bacteremia - Pt's blood cultures showed Klebsiella oxytoca, which was not surprising given his recent Klebsiella oxytoca bacteremia. It was thought that the presence of pt's Portacath was likely a colonizing factor and the urgency of its removal was increased. Pt was initially admitted to MICU as had septic physiology. MUST protocol initiated, pt fluid resuscitated with 6L of NS and transfused with 1U PRBC, broad spectrum antibiotics given - initially levofloxacin, vancomycin, and cefepime in the ED, then levofloxacin, meropenem, and clindamycin. He did not require any pressors. A cortisol stim test was performed, with empiric steroids begun, but there was no evidence of adrenal insufficiency, so this was discontinued. Pt did not have signs of a perirectal abscess or UTI, and CXR did not show pneumonia. Subsequent blood cultures were negative, and on transfer to the floor, pt remained afebrile and was hemodynamically stable. Eventually, the portacath was removed by surgery, and the tip was sent for culture. It ultimately did not grow any organisms. After the Portacath was removed, the plan after discharge was for him to return for surveillance cultures, and then to get a tunneled catheter placed the following week. He was given a 2-week course of levofloxacin for the Klebsiella oxytoca, starting from the date of Portacath removal. 2. acute renal failure - baseline creatinine from [2193-3-28] was 1.4 - 1.6; of note, during his last hospitalization, Cr rose into 2's, as it was during the initial stages of this hospitalization. At baseline, pt has echogenic kidney consistent with HIV nephropathy vs medical renal disease; however, clearly had an acute on chronic process, and his urine lytes revealed a FENa of 1.3%, consistent with neither ATN nor prerenal etiology. Pt was treated with IVF while awaiting these results, with little change in his creatinine. However, he continued to have good urine output and began to experience a diuresis concomitant with a decreasing creatinine shortly prior to his discharge, supporting ATN as the etiology of his ARF. This was thought most likely to be due to hypoperfusion during the period of sepsis on presentation. Of note, urine eos were negative, as well. 3. diarrhea - Pt had diarrhea after admission to the hospital, after having received broad spectrum antibiotics. This raised the concern for C diff. Stool studies were sent, which were all negative. His diarrhea resolved within a few days, without a specific enteric pathogen identified. 4. anemia - Pt had Hct around 24 on transfer, with a normal MCV and high RDW, pointing to a combination of microcytic and macrocytic anemias. He was transfused 2 U PRBCs with good response. He was guaiac negative. This was thought to be due to multifactorial processes, including bone marrow suppression with medications given his retic count of 1.2%. In addition, acute renal failure was thought to be a contributor. His hematocrit thereafter remained stable at about 30. 5. CHF - pt's last echo showed an EF of 45%. There were no acute issues while in the hospital, and pt tolerated aggressive IVF given in the setting of his initial sepsis without significant pulmonary edema. A repeat echo showed some interval worsening of his systolic function. 6. HIV/AIDS - Pt was not on HAART during his hospitalization. He was continued on dapsone for PCP [Name Initial (PRE) 1102] (has an allergy to Bactrim), pyrimethamine for toxo prophylaxis, and clarithromycin for [Doctor First Name ] prophylaxis. He was continued on aldara and ketoconazole. 7. FEN/GI - Pt was maintained on a house diet. His electrolytes were repleted as needed, particularly potassium, which was likely low in the setting of diarrhea. 8. Code - full Medications on Admission: aldara 5% atarax 25mg po bid ativan 0.5mg prn calcium carbonate 500mg po tid clarithromycin 500mg po bid clindamycin 300mg po tid clotrimazole 10mg po four times/day dapsone 100mg po daily dronabinol 2.5mg po bid epogen 40,000 units weekly immodium 2mg po qid prn foscarnet 4186mg po bid kaletra 3mg po bid ketoconazole [Hospital1 ] lamivudine 150mg po bid leucovorin 10mg po daily loratadine 10mg po daily neupogen 300mg po daily neurontin 100mg po tid pyrimethamine 75mg po daily ritonavir 100mg po bid tenofovir 300mg po daily trazodone 50mg po daily zyrtec 10mg po daily 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. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:14 Tablet(s) Refills:0 3. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TIDAC (3 times a day (before meals)). 7. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 9. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Megestrol Acetate 40 mg/mL Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). 12. Leucovorin Calcium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cetirizine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 15. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Epoetin Alfa 20,000 unit/2 mL Solution Sig: 40,000 units Injection once a week. 17. Filgrastim 300 mcg/mL Solution Sig: Thirty (30) mcg Injection Q24H (every 24 hours). 18. please continue your other medications as you have at home Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Primary: 1. Klebsiella oxytoca sepsis, likely source Portacath 2. Acute Renal Failure. 3. Recurrent Neutropenia. Secondary: 1. HIV/AIDS 2. congestive heart failure, EF ~45% 3. oral thrush 4. Blindness secondary to CMV Retinitis. 5. Oral Hairy Leukoplakia. 6. history of toxoplasmosis. 7. Peripheral Neuropathy. 8. HSV/VZV w/ shingles. 9. Angioedema. 10. Hepatitis B. 11. Molluscum contagiosum Discharge Condition: stable, tolerating po, Portacath removed Discharge Instructions: Please take all of your medications and keep all of your appointments. If you notice increased fevers, difficulty tolerating food, or overall feeling worse rather than better, please call your primary care doctor or go to the emergency room. Followup Instructions: The following appointment is to get surveillance blood cultures drawn: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Name8 (MD) 6121], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2194-2-10] 2:00 The following appointment is to get another line placed: Provider: [Name10 (NameIs) 454],ONE DAY CARE [Hospital Ward Name ] 8 Where: DAY CARE [Hospital Ward Name ] 8 Date/Time:[2194-2-14] 7:00 Provider: [Name10 (NameIs) 6122] WEST OUTPATIENT RADIOLOGY Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2194-2-14] 8:30	[ "288.0", "995.92", "042", "070.30", "276.5", "428.0", "363.20", "078.5", "038.49", "996.62", "584.9", "112.0" ]	icd9cm	[ [ [] ] ]	[ "86.05", "99.04" ]	icd9pcs	[ [ [] ] ]	12414, 12468	6343, 10135	425, 499	12909, 12951	3483, 3488	13242, 13906	2313, 2377		10764, 12391		12489, 12888		10161, 10741			12975, 13219								2392, 2392																4355, 6320					259, 387									527, 1568							3503, 4340							1590, 2123	2139, 2297
25,189	170,401	51820	Discharge summary	report	Admission Date: [2198-9-26] Discharge Date: [2198-10-15] Date of Birth: [2158-6-23] Sex: F Service: SURGERY Allergies: Penicillins / Cephalosporins / Bactrim / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1481] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Open splenectomy ([9-28]) History of Present Illness: Ms [Known lastname ] presented w/ BRBPR over few days. Recently she was seen for increased gingival bleeding, vaginal bleeding, and petechiae. She has a very large spleen which gave her a lot of symptoms. She also has a low platelet count which has been refractory to therapy. She originally responded to gammaglobulin, but this is becoming more difficult to control and her platelet count is in the single digits. She presents now for splenectomy. A liver biopsy was entertained if thought to be safe because of her Insulin PI issues, she has liver function abnormalities and hepatomegaly. Her past medical history includes a diagnosis of common variable immunodeficiency in [2189] treated with IVIG every 3 weeks, a diagnosis she shared with her twin sister who died from metastatic anal carcinoma. Ms. [Known lastname ] developed acute on chronic thrombocytopenia with platelets less than 10 without significant bleeding sequelea, refractory to steroids but mildly responsive to increased doses of IVIG. Bone marrow [6-27] consistent with ITP. She was also noted to have [Doctor First Name ] in her stool, now being treated with the hope of decreasing splenomegaly and platelet sequestration. Past Medical History: Common variable immunodeficiency Idiopathic thrombocytopenic purpura Family History: Sister with CVID. Sister died of metastic anal Carcinoma Physical Exam: HEENT: No current epistaxis, dried blood in the nares. She does have some ecchymosis on her tongue and no current gingival bleeding. CHEST: RRR, CTAB ABD: Soft, nontender, palpable spleen, increasing in firmness, although not feeling increasing in size about eight centimeters below the costal margin. EXT: She has petechiae on her lower extremity and on her upper arm where she has been scratching. She does have some small ecchymosis but no purpura. Pertinent Results: [2198-9-25] 08:24AM WBC-3.0* RBC-3.94* HGB-11.3* HCT-34.1* MCV-87 MCH-28.6 MCHC-33.1 RDW-17.9* [2198-9-25] 08:24AM NEUTS-54.0 LYMPHS-26.8 MONOS-17.0* EOS-1.3 BASOS-0.8 [2198-9-25] 08:24AM NEUTS-54.0 LYMPHS-26.8 MONOS-17.0* EOS-1.3 BASOS-0.8 [2198-9-25] 08:24AM WBC-3.0* RBC-3.94* HGB-11.3* HCT-34.1* MCV-87 MCH-28.6 MCHC-33.1 RDW-17.9* [2198-9-27] 12:00AM HCT-31.8* Brief Hospital Course: Patient was admitted to undergo open splenectomy. Her Hct were followed serially every 8'. Pain was well controlled thoughout course of hospitalization.On POD2, she was transferred to SICU with dropping O2 sats. Patient was also noted to have increased LFTs. Her Hct were noted to be stable, and her platelets were increased. She received daily Warfarin post-op. On POD4, ID was consulted and recommendations were followed. Respiratory status was noted worsen. She was intubated electively. On ID recommendation, Vanco/Levo were continued and Clinda and Primaquine were added to cover PCP. [Last Name (NamePattern4) ] POD5, she underwent bronchoscopy with BAL. Patient developed a nosocomial pneumonia by POD7. Right CVL was placed on POD9. Patient ascites was tapped (paracentesis) secondary to increased abdominal distention. On POD10, patient was successfully extubated. Physical therapy was consulted to evaluate patient. Patient was placed on Gancyclovir [12-25] CMV viremia. She is to undergo CMV PVL checks every Monday per ID. Patient was subsequently transferred to the floor. CVC was removed on POD14. On POD15, TPN and foley were discontinued. On POD 17, patient was deemed stable and suitable for discharge. Medications on Admission: ACYCLOVIR 400MG--One by mouth twice a day ALDARA 5%--Apply to area twice a day AZITHROMYCIN 600MG--One by mouth every day CIPROFLOXACIN HCL 500MG--One by mouth twice a day CYTOGAM 2.5G--Uad EMLA 2.5-2.5%--Apply two hours prior to proceedure ETHAMBUTOL HCL 400MG--One by mouth twice a day PREDNISONE 10MG--Take 5 tablets daily by mouth RANITIDINE 150 MG--Take one tablet twice daily by mouth Discharge Medications: 1. Ganciclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 15 days. Disp:30 Recon Soln(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 3. Fluoxetine HCl 20 mg Capsule Sig: Four (4) Capsule PO QAM (once a day (in the morning)). 4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Therapies Discharge Diagnosis: Common variable immunodeficiency Idiopathic Thrombocytopenic purpura Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. You may remove your dressings 2 days after your surgery if they were not removed in the hospital. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise contraindicated and follow up with PCP. Followup Instructions: Follow up with [Doctor Last Name ] in 1 week. Call for appointment. Follow up with [Doctor Last Name ] (Infectious Disease) in 1 week. Call for appointment. Completed by:[2198-10-16]	[ "280.0", "486", "279.06", "202.87", "789.5", "287.3", "997.1", "998.11", "518.5" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "41.5", "54.91", "96.04", "99.15", "99.04", "33.24" ]	icd9pcs	[ [ [] ] ]	4880, 4949	2706, 3935	350, 382	5062, 5068	2286, 2683	6274, 6471	1740, 1798		4377, 4857		4970, 5041		3961, 4354			5092, 6251								1813, 2267																					283, 312									410, 1632														1654, 1724
3,226	149,986	23201	Discharge summary	report	Admission Date: [2114-12-30] Discharge Date: [2115-1-9] Service: MEDICINE Allergies: Indocin / Allopurinol Attending:[First Name3 (LF) 106] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p cardiac cath without intervention [12-30] History of Present Illness: HPI: [Age over 90 ] yo female with PMH HTN, hypercholesterolemia presents with chest pain. Pt has 1 week hx of difficulty breathing, cough, wheezing. Pt saw PCP on [Name9 (PRE) 2974], who started her on Zithromax for treatment of presumed pneumonia; completed antibiotic course today. . Pt states that chest pain began around 2pm after walking to get a glass of juice. Describes pain as [11-25], pressure-like, located under left breast, non-radiating, associated with SOB and racing heart rate. Denies associated nausea, diaphoresis. Pt called PCP who instructed her to go to [Hospital3 4107]. . Pt arrived at [Hospital1 ] at 1735. Pt was hypertensive on admission with SBP up to 170s. Labs included: Hct 31.2, Plt 220, creatinine 2.8, CK 145, Tn 0.92. CXR read as slight increased vascular congestion. At OSH given ASA, lipitor, IV nitro. Transfered to [Hospital1 18] at for cardiac cath where cath did show 2 vessel dz but no culprit vessel. Found w/ elevated filling pressures w/ wegde of 27, so given lasix, nipride gtt for systolic blood pressures in 200's, and transferred to CCU for further evaluation. . ROS: Pt denies ever having similar chest pain in the past. Denies presyncope/syncope. States she had chronic non-productive cough, which has worsened over the past 2 weeks. +DOB x [8-25] days. Denies medication or diet noncompliance. Denies changes in medications. Denies fever, chills, nausea, vomiting. Past Medical History: COPD hypercholesterolemia HTN Diverticulosis GI bleed [3-19] tic s/p hysterectomy for fibroids s/p mastectomy for breast ca ([2089]) glaucoma cataracts Social History: widowed. lives alone in elderly living facility. independent. home aide helps out. drives a car -quit smoking 20 years ago. 55 pack year history -denies ETOH, drugs Family History: Mother had MI at age 61 Physical Exam: VS: temp 98, p99, 146/72, 97% on 3Lnc Gen: very pleasant, mild effort in breathing, lying on back s/p cath HEENT: 1mm right pupil minimally responsive to light, 5mm left pupil not responsive to light, EOMI, clear OP, MMM Neck: unable to appreciated JVP, no cervical lymphadenopathy CVS: tachy, nl s1 s2, ?s3, no m/g/r appreciated Lungs: expiratory wheezes throughout Abd: soft, NT, ND, +BS right groin: no hematoma, no bruit Ext: no edema bilaterally, dopplerable pulses bilaterally Pertinent Results: [2114-12-30] 09:54PM WBC-5.6 RBC-2.86* HGB-9.2* HCT-26.2* MCV-91 MCH-32.2* MCHC-35.3* RDW-13.5 [2114-12-30] 09:54PM PLT COUNT-221 [2114-12-30] 09:54PM PT-12.9 PTT-74.5* INR(PT)-1.1 . [2114-12-30] 09:54PM GLUCOSE-148* UREA N-32* CREAT-2.4* SODIUM-138 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13 [2114-12-30] 09:54PM CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.9 . [2114-12-30] 07:58PM TYPE-ART PO2-97 PCO2-38 PH-7.35 TOTAL CO2-22 BASE XS--3 [2114-12-30] 07:58PM HGB-9.2* calcHCT-28 O2 SAT-97 . [2114-12-30] 09:54PM BLOOD CK(CPK)-114 [2114-12-30] 09:54PM BLOOD CK-MB-8 cTropnT-0.32* [2114-12-31] 03:03AM BLOOD CK(CPK)-112 [2114-12-31] 03:03AM BLOOD CK-MB-10 MB Indx-8.9* cTropnT-0.32* [2115-1-2] 05:07AM BLOOD CK(CPK)-112 [2115-1-2] 05:07AM BLOOD CK-MB-6 cTropnT-0.33* . [2115-1-2] 05:07AM BLOOD WBC-9.2 RBC-3.62* Hgb-11.1* Hct-32.4* MCV-89 MCH-30.6 MCHC-34.2 RDW-15.1 Plt Ct-208 [2115-1-2] 05:07AM BLOOD Plt Ct-208 . [2115-1-2] 05:07AM BLOOD Glucose-145* UreaN-31* Creat-2.6* Na-138 K-3.6 Cl-101 HCO3-23 AnGap-18 [2115-1-2] 05:07AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.9 . EKG: initial: sinus rhythm @102. left axis deviation. 2-3mm ST elevation in V2-V6 . after cath: sinus @93, 2-3mm ST elevations in V3-6. . [2114-12-30]: TTE Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (EF 35%). The distal third to one half of the left ventricle is akinetic. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. . [2114-12-31]: CXR Cardiomegaly with no evidence of failure. No evidence of pneumonia. . [2114-12-31]: TTE Conclusions: 1. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (EF 35%) 2. The aortic valve leaflets (3) are mildly thickened. 3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 4. There is mild pulmonary artery systolic hypertension. 5. There is a small to moderate sized, loculated (over RV) pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. . [2115-1-2]: CXR Again note is made of mild cardiomegaly. The mediastinal and hilar contours are unchanged compared to the previous study. Again note is made of increased pulmonary vasculature, as well as increased interstitial markings, suggesting mild congestive heart failure. No parenchymal consolidation is noted. Again note is made of multiple staples in the right axilla. . [2115-1-2]: TTE LV apical kinesis, no aneurysm seen stable pericardial effusion Brief Hospital Course: 1. CAD: Transferred from OSH in the setting of chest pain, hypertension and impressive ST elevations in leads V4-V6. Cath however, failed to show culprit vessel. Left main showed small ulcer on superior roof without evidence of thrombus or luminal compromise. LAD: mild luminal irregularities. LCX: 80% OM1 stenosis. RCA: diffuse disease proximally and 60% stenosis in mid vessel. No evidence of flow reduction. No intervention performed. Right heart cath was performed which did show elevated filling pressures with RA 6, RV 49/10, PA 49/24 and wedge of 27 w/ CI - 2.46. Pt was ultimately transferred to CCU post cath chest pain free and started on nipride gtt for bp control. Since there was no clear culprit vessel, it was decided to medically manage pt and maintain good blood pressure control. Enzymes trended down during hospital course. Repeat echo showed moderate LV systolic dysfunction with EF 35-40% and inferolateral hypokinesis/akinesis and apical akinesis/dyskinesis without evidence of apical aneurysm or thrombus. Pt had several episodes of chest pain during admission associated with shortness of breath which were relieved with nitroglycerine and morphine. EKGs during these episodes showed no changes. Pt continued to be medically managed on ASA, Plavix, Lipitor 80. Pt was unable to tolerate a beta-blocker secondary to wheezing and an ACE inhibitor was unable to be started in the setting of her renal failure. Her hypertension was managed by titrating up verapamil and isosorbide dinitrate. . 2. CHF: Found w/ elevated filling pressures on right heart cath w/ wedge of 27. Echo on [12-31] showed EF 35% but w/ E/A ratio of 0.6 and tr gradient of 30-36. Had moderate mr and trace TR. Thought to have component of diastolic dysfunction. Diuresed w/ iv lasix 40 w/ moderate diuresis and started on beta blockade. Given elevated creatinine, decided to hold [Month/Year (2) ] and switched to hydralizine and nitrates. However, pt continued to remain mildly hypoxic and quite wheezy w/ CXR not showing florid failure. Later, during hospital course, felt that shortness of breath, more likely secondary to COPD/RAD flare and pt started on po prednisone 60 qd. . 2a: Pericardial effusion: echo w/ small to moderate pericardial effusion, loculated and echo dense thought secondary to inflammation. Recheck on [12-31] showed stable effusion and w/o pulsus paradoxus on A-line. Will likely need f/u echo in future. . 3. Rhythm: Stable throughout hospitalization . 4. HTN: Found w/ elevated systolic BP's into the 200's in the cath lab. Initially started on nipride gtt which was weaned off by hospital day 1. Pt had been on [Month/Year (2) ] from OSH but given elevated creatinine (and unclear of baseline), opted to hold [Name (NI) ] and switch to hydralyzine and nitrates. She was also started on BB in the setting of recent ischemia. However, discussions w/ PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] suggested that pt did not tolerate BB secondary to wheezing, also consistent w/ [Hospital ] hospital course at the [Hospital1 ]. As such, BB d/c'd and restarted on verapamil 240 per day. Hydralazine was discontinued and verapamil and isorsorbide dinitrate was titrated up good blood pressure control. These medications were converted to daily dosing prior to discharge: Verapamil 480mg qd and Imdur 60mg qd. . 5. Wheezing: As mentioned above, initially treated for CHF exacerbatioin w/ moderate diuresis but w/o significant improvement. Recently treated w/ zithromax for ?COPD flare. Given significant wheezing and mild hypoxia (95 on 2 liters), decided to d/c BB. Pt's wheezing and SOB was thought to be secondary to COPD flare superimposed upon mild CHF. Initially, we tried steroid inhalers but given persistent wheezing, elected to begin po steroids w/ prednisone 60 qd. After an episode of moderate respiratory distress with desats to 90s, pt was started on IV methylprednisolone which she received for a couple of days. Pt was subsequently switched back to po prednisone and continued on a taper. Initially given that she has not had fevers or wbc or change in sputum, we decided to hold on additional abx. On [2115-1-3], pt was started on Levofloxacin for question of pneumonia on chest x-ray; she received a 7 day course. Etiology of pt's SOB is likely multifactorial with elements of COPD exacerbation, pneumonia, and mild CHF. These issues were treated and pt's respiratory status improved significantly during the rest of the hospitalization. Pt is being discharged on Prednisone taper. She needs one more day of Prednisone 20mg followed by 3 days of Prednisone 10mg. . 6. COPD exacerbation: Most likely triggered by attempting to start beta-blockade. Pt was treated for COPD exacerbation as stated above. . 7. ID: CXR showed suggestion of consolidation. In the setting of pt's respiratory complaints, she was treated for presumed pneumonia with levofloxacin, of which she got a 7 day course. Pt needs 3 more days of antibiotic treatment to complete a 10 day course. Pt continued to have occasional elevated WBC while on antibiotic treatment with no other signs of infection; possibility etiology of WBC is steroid treatment. Urine cultures were found to be negative. . 8. Renal failure: Pt has a baseline creatinine of 1.9. She was transferred from OSH w/ creatinine of 2.4 w/ initial increase to 2.7. Received gentle post cath IVF w/ bicarb and also received mucomyst. As mentioned above, ACE was held. After the cardiac catherization, pt's creatinine progressive increased to peak of 4.7. The etiology of acute renal failure was felt to be contrast-induced ATN. Urine sediment was looked at with the renal fellow which showed granular casts. No intervention was done for ATN and creatinine trended down; it is 4.3 on discharge. . 9. Hematuria: Pt has had a foley in for most of this hospitalization. On the day before discharge, pt was reported to pull at foley. Pt developed hematuria without clots, which resolved overnight. A UA was sent during the episode of hematuria and showed 1000 RBC, 230 WBC, moderate leuks. However, urine culture was negative and pt was afebrile with normalized WBC. Pt is unlikely to have a UTI after 6 days of antibiotic treatment. We recommend rechecking the UA in a few days as well as completing 10 day course of Levofloxacin. . 10. Anemia: Had decrease in hematocrit from reported baseline of 34 to 27 on hospital day 1. Ultimately, required 2 unit PRBC over course w/ appropriate bumps. Hemodymically stable. Guiac was negative. She has been continued empirically on Protonix. She has also had lower dose of aspirin at 81 qd. Pt's hct stabilized at 28-31. Would consider transfusing for hct less than 28. . 11. Code: Based upon discussions w/ patient on several occasions, she wishes to be DNR/DNI. Medications on Admission: verapamil 240mg qd Moxepril Cimetidine glaucoma eye drops Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for BP<100. Tablet(s) 11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 0.75 Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 12. Hydralazine HCl 10 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours): Hold for BP<100. 13. Verapamil HCl 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Morphine Sulfate 10 mg/mL Syringe Sig: One (1) Injection Q2H (every 2 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 10353] TCU Discharge Diagnosis: ST elevation MI - no culprit vessel, medical management Hypertension Congestive Heart failure Presumed COPD/reactive airway flare acute on chronic renal insuffiency Discharge Condition: stable Discharge Instructions: If you develop chest pain or difficulty breathing, call your doctor or go to the emergency room. Followup Instructions: follow up with your primary care doctor, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD. ([Telephone/Fax (1) 38979]). Completed by:[2115-1-9]	[ "867.0", "562.10", "599.7", "410.01", "530.81", "780.52", "584.5", "491.21", "272.0", "401.9", "423.9", "E947.8", "414.01", "486", "V10.3", "285.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56" ]	icd9pcs	[ [ [] ] ]	13966, 14018	5568, 12387	239, 290	14226, 14234	2690, 5545	14379, 14553	2147, 2172		12495, 13943		14039, 14205		12413, 12472			14258, 14356								2187, 2671																					189, 201									318, 1766														1788, 1949	1965, 2131
28,750	161,213	45448	Discharge summary	report	Admission Date: [2194-7-12] Discharge Date: [2194-7-18] Service: MEDICINE Allergies: Tetanus Toxoid / Vasotec / Neomycin / Adhesive Tape / Levaquin Attending:[First Name3 (LF) 2297] Chief Complaint: Cough / shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Dr [Known lastname 3314] is an 83 year old [Hospital1 18] surgeon, on disability since [Month (only) 116] with a diagnosis of multiple myeloma. He presents today with worsening O2 sats both at rest and exertion (he keeps an O2 sat monitor at home), worsening cough, and increasing shortness of breath. . Although he has not felt altogether well for the past six months, he had been feeling better since his original admission in [2194-4-1], for community-acquired pneumonia, in which he was diagnosed with MM. Prior to that [Month (only) 116] admission he had also been having worsening cough, SOB and DOE. . Three or four weeks ago by his account, he began having cough again, although a CXR was negative for pulmonary process. But over the last 24-48 hours, the cough "blossomed" and he also became much more short of breath. He notes that before he would have O2 sats at 90-92 after getting up and walking now they were 86-88, and he was much more uncomfortable. He was having low-grade fevers. He came to the [Hospital1 18] and is now admitted for diagnosis and management. . Per heme/onc fellow: "HEMATOLOGIC HISTORY: Dr. [Known lastname 3314] was diagnosed in [4-7] when he presented with a multilobar PNA and worsening renal function and was found to have serum monoclonal IgA of 2.8 gm. His renal fxn has generally been stable since admission (creat 2.6->2.1-> 2.4). A UPEP showed intact IgA kappa and no bence [Doctor Last Name 49] proteins. Anemia is mild and no hypercalceia. His skeletal survey did not show lytic lesion but no fx or impending fx. Beta-2 Microglobulin was elevated but hard to interpret in face of renal insufficiency. IgG level 200 and IgM slightly suppressed. . "He was initially treated with Decadron alone and then with Decadron and Thalidomide, however, this was stopped in the setting of disequilibrium and peripheral edema. The peripheral edema was ultimately thought to be related to some right-sided heart failure and he was thought to be hypervolemic. He was then started on Revlimid and pulse Decadron in [6-7]." . Past Medical History: PMH (per chart and hx): IgA multiple myeloma kappa type - diagnosed [4-7] Per outpt cards note: long-standing RBBB and left axis deviation (bifascicular heart block) Cards note suggests "NQMI" - [4-7] ? demand ischemia --enzymes rose in context of larger admission for shortness of breath (in which MM was diagnosed) --not mentioned as issue in d/c summary Hypertension Chronic Renal Insufficiency - (cr 2.0)- followed by Dr. [Last Name (STitle) 1366] Chronic Obstructive Pulmonary Disease - controlled on bronchodilators, followed by Dr. [Last Name (STitle) ]. Per chart: on 0.5L O2 at night, 1L in the day for activities. Per patient: uses O2 mainly when he takes showers, which requires additional exertion; for this he uses 1.5L. Atrial fibrillation - on coumadin Chronic laryngopharyngeal reflux Gastroesophageal Reflux Disease Benign thyroid enlargement Gout R Elbow - on allopurinol Bladder Ca - superficial, s/p BCG . PSH: Multiple right inguinal hernia repairs s/p reoccurence Right nephrectomy for renal cell carcinoma [2164] . ALLERGIES: Levaquin, adhesive tape, neomycin, Vasotec and tetanus toxoid. Social History: Colorectal surgeon. He is married and lives with his wife; lives downtown near the Prudential Center. Former pipe smoker for many years, quit 25 years ago. He drinks 1-2 drinks a week. He enjoys sailing as a hobby; none of his hobbies expose him to toxic chemicals. Family History: Mother died in 80s, father in his 90s. Sister alive and well. Physical Exam: T 98.6 HR 80 RR 20 BP 126/66 O2 97% 2L Ht 67.5 in Wt 175.3 lbs . GEN: Elderly man in NAD breathing with nasal cannula; sitting forward with arms on knees; ruddy face. HEENT: Eyes: anicteric. Mouth: OP clear. MMM. No lesions. PULM: Diffusely and significantly diminished air movement at bases. No wheezing. Minimal crackles. COR: RRR. No murmurs, rubs, gallops. ABD: Pos BS. Liver ~2 cm below costal margin. No spleen tip felt. Non tender, non-distended. SKIN: No rashes. Discoloration at the shins c/w chronic edema. No petichiae. EXT: 2+ pitting edema at the ankles. NEURO: Strength 4+ and symmetrical at all extremities. Shoulder shrug intact. Mild tremor of hands when extended, less at rest. Language fluent and coherent. Pertinent Results: [2194-7-12] 01:20PM GLUCOSE-109* UREA N-75* CREAT-3.0* SODIUM-140 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-19* ANION GAP-20 [2194-7-12] 01:20PM WBC-7.0 RBC-3.67* HGB-12.0* HCT-34.5* MCV-94 MCH-32.7* MCHC-34.7 RDW-16.8* [2194-7-12] 01:20PM NEUTS-80.4* BANDS-0 LYMPHS-13.9* MONOS-3.7 EOS-1.5 BASOS-0.5 [2194-7-12] 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2194-7-12] 01:20PM PLT SMR-LOW PLT COUNT-113* . [2194-7-12] CXR: Development of patchy opacity in the right middle lobe, compatible with atelectasis and/or pneumonia. . [2194-7-15] CT head: IMPRESSION: No acute intracranial abnormalities. Small vessel ischemic changes and calcifications of the left temporal and occipital lobes. At least two lytic lesions of the skull which likely represent known multiple myeloma. . [2194-7-15] TTE: IMPRESSION: Mild symmetric left ventricular hypertrophy with mild global hypokinesis. Right ventricular dilation and dysfunction. At least moderate pulmonary hypertension. Moderate tricuspid regurgitation. Dilated thoracic aorta. . [2194-7-16] EEG: IMPRESSION: This is an abnormal portable EEG due to the presence of sharply contoured waveforms seen bifrontally and more often with a rightsided predominance in the setting of a slow and disorganized background rhythm. The significance of the first finding is not entirely clear as there were no frank epileptiform discharges seen. The second finding is consistent with a moderate encephalopathy suggesting the presence of deeper midline dysfunction. Medication, metabolic disturbances, infections, or anoxia are among the most common causes but there are others. There were no clearly epileptiform discharges noted. No electrographic seizure activity was seen. Brief Hospital Course: Dr. [Known lastname 3314] is an 83 yo [Hospital1 18] surgeon with h/o Multiple Myeloma s/p decadron/revlimid therapy, COPD, CHF, afib on coumadin, who initially presented on [7-12] with fatigue, low grade fever, and increased productive cough from his baseline. He noted decreased 02 saturations at home on his pulse ox with increased DOE (92% -> 88%). He had previously been treated for CAP indergoing a hospital stay. He denied any chest pain, pleurisy, orthopnea, n/v/d, or increased LE swelling during that time. Moreover, he had recently finished a decadron taper for his MM. In the ED, he was found to have a RML infiltrate on CXR. Cultures were obtained and the patient was started on Ceftriaxone. He was subsequently transferred to the BMT service for further care. . On the BMT service, his Ceftriaxone was continued, and was started on Vancomycin on [7-14] for [1-5] + blood cultures for coag neg Staph. Additionally, he was given IVIG on [7-14] for his MM, which he tolerated well. . On the morning of transfer, the patient was found unresponsive in his room at 7AM with blood coming from mouth. Code team was activated. Patient was found to be in asystolic arrest. CPR was initiated and the patient was intubated. He received epi 1mg x3, atropine 1mg x1 where he regained pulse. ABG was 7.04/49/252. . He then presented to the [Hospital Unit Name 153] after suffering cardiac arrest in the setting of RML PNA and Staph bacteremia. [Hospital Unit Name 153] course by problem is as follows: . # Cardiac Arrest: Patient was found to be unresponsive for an unclear duration (most likely < 10 minutes as the nurse had seen him prior to code and he was mentating normally) and was intubated, as above. Most likely the cause of arrest was felt to be secondary to a poor conduction system given periods of prolonged asystole without capture rhythms and spontaneous return to NSR on telemetry in the MICU. ICH and large stroke was unlikely causes given a neg. head CT. MI was unlikely given TTE findings of mild global hypokinesis without focal deficits. PE was unlikely given that the patient was therapeutic on coumadin. Infection was also in the differential as the patient had a RML PNA and coag neg. staph bacteremia. On admission to the [Hospital Unit Name 153] the patient did not complete artic cooling protocol s/p arrest given periods of prolonged asystole (up to ~10seconds). On [7-16] an EEG was performed, which showed evidence of moderate encephalopathy consistent with deeper midline dysfunction. The patient did not meet criteria for brain death. Neurology was consulted to further assess encephalopathy and long-term prognosis, and they corroborated a poor prognosis with low likelihood of a meaningful neurologic recovery. . # Renal failure: rising cre from baseline of 2.0 to 3.3 to 3.9 to 4.6, most likely due to hypoperfusion - either from the initial asystolic arrest or subsequent periods of asystole. There was concern for arrhythmias given increasing potassium and acidemia. . # PNA: Has R base consolidation, with 2+ GPC in [7-15] sputum. also found to have coag neg. staph bacteremia = MRSE. The patient was continued on vanco and zosyn, renally dosed, and azithromycin. . # Bacteremia: The patient was found to have coag neg. staph (=MRSE) on admission blood cultures, which was concerning for endocarditis given the patient's immunocompromised state. The patient was continued on vancomycin and zosyn. Surveillance cultures were negative to date. A TEE was held until long-term prognosis could be determined and per family wishes . # HTN: The patient's BP was borderline following intubation, and required levophed upon admission to the MICU. This was weaned as tolerated, with anti-hypertensives held. . # Afib: HR was well rate-controlled during MICU course. Rate controlling agents were held given the patient's tenuous status. The patient was maintained on heparin gtt for prophylaxis. . # Code: As the patient valued quality of life and given that a meaningful neurological recovery was not likely per the assessment of the MICU team and Neurology, the patient was made DNR with no further escalation of care during a discussion with the family. He was extubated on [2194-7-17] and passed away due to cardiopulmonary arrest. . # Communication: Wife [Name (NI) 2048] [Name (NI) 3314] [Telephone/Fax (1) 96988] Medications on Admission: Advair Allopurinol 100 mg tab every other day (odd-numbered days) Combivent (as rescue, rarely used) Albuterol (as rescue, not often used) Coumadin 5 mg daily, 7.5 mg Monday Flomax 0.4 mg daily Hydralazine 100 mg [Hospital1 ] Pindolol 2.5 mg [Hospital1 ] Spironolactone/HCTZ 25/25 daily Discharge Disposition: Expired Discharge Diagnosis: Primary: Cardiopulmonary arrest Secondary: Multiple Myeloma, A fib, Chronic Renal Insufficiency, COPD Discharge Condition: Expired	[ "203.00", "038.19", "585.9", "403.90", "496", "486", "V58.61", "530.81", "274.9", "427.31", "584.9", "995.92" ]	icd9cm	[ [ [] ] ]	[ "99.14", "96.71", "99.60", "96.04" ]	icd9pcs	[ [ [] ] ]	11298, 11307	6543, 10953	298, 304	11452, 11462	4708, 5343		3884, 3947				11328, 11431		10979, 11275											3962, 4689																					231, 260									332, 2429		5352, 6520												2451, 3585	3601, 3868
22,684	143,653	18408	Discharge summary	report	Admission Date: [2185-2-9] Discharge Date: [2185-2-14] Service: MEDICINE Allergies: Lasix Attending:[First Name3 (LF) 4052] Chief Complaint: cough and malaise Major Surgical or Invasive Procedure: 1. None History of Present Illness: 87M with recent admission for PNA here with increasing productive cough. Pt was admitted [Date range (1) 50681] with a RML pneumonia. Pt was treated with 7-day course of levofloxacin. Pt reported that he felt better when he went home, but 2-3 days later, felt increasing fatigue and increasing cough productive of yellow and then green-yellow sputum. Pt states he is sore from coughing but denies CP. Denies frank SOB. Denies n/v/abd pain, no fevers/chills at home. Does not use O2 at baseline. Pt denies any blood in sputum. Denies any difficulty eating or swallowing at home. . In the [Name (NI) ], pt was noted to be tachypneic but satting well on 3-4L NC. As pt was subtherapuetic on coumadin, he was sent for CT angio to r/o PE. When he returned from CT scanner, was tachypneic to 40s, hypoxic to 90s on NRB, BP in 240s. Was transiently placed on a NTG gtt, and BP dropped into 170s. Chest CT showed multifocal PNA. Initial ABG 7.29/57/173 on NRB, lactate 1.5. In the [Name (NI) ], pt rec'd NS x2L, ceftazidime 2g IVx1, vancomycin 1g IVx1, albuterol nebs x2, robitussin with codeine, tylenol 1g, NTG gtt. . In the MICU, he was treated with vancomycin, azithromycin, and zosyn for pneumonia refractory to levofloxacin. His O2 requirement was weaned down. However, on hospital day 2, he developed hypertension with acute shortness of breath; this was treated with a NTG gtt. Isosorbide DN was added to his BP regimen replace the NTG. . Because of his dyspnea and tight, wheezy lung exam, he was started on steroids for COPD exacerbation, although he does not carry a history of COPD. A short course followed by short taper was planned to treat the COPD. He was then able to wean down from a face mask to nasal cannula. Past Medical History: Bladder cancer- originally diagnosed [2160] and treated with conservative mgmt, recurred in [2181] in NY, s/p chemo/XRT, s/p intravesical BCG/IFN x6 completed [4-29], recurrent tumors on cystoscopy, s/p transurethral resection [12-29] Peptic ulcer disease DVT- [2183] DVT occured spontaneously, DVT 35y ago in postop setting (varicose vein stripping),on coumadin since [2183] CRI- etiology unclear, baseline creatinine 1.3-1.5 spinal stenosis (low back pain and B LE pain) left hernia repair. venous stripping surgery. left cataract repair. Social History: Patient denies any history of smoking or alcohol consumption. He is currently a retired post-office worker. He lives in [Location ] with his wife and has a son in the [Name (NI) 86] area. Family History: non-contributory Physical Exam: VS: 99.7 145/67 107 46 97% 5L NC Gen: well appearing, hard-of-hearing, NAD HEENT: PERRL, EOMI, MM dry, OP clear CV: tachy, regular, nl S1/S2, no m/r/g Pulm: diffusely rhonchorous with scattered wheezes, DTP at L lung field superiorly; no E->A change Abd: soft, NT/ND, +BS, no masses Ext: no c/c/e Pertinent Results: EKG: 101bpm, NSR, no ST/T wave changes, nl axis, nl R wave progression . CXR [2185-2-10]: Multifocal pulmonary opacities in the right mid and both lower lung regions show interval improvement with residual confluent opacity most prominent in the right middle lobe. Vascular engorgement and perihilar haziness have also improved. IMPRESSION: Improving multifocal pneumonia and likely resolving superimposed interstitial edema. . TTE [2185-2-10]: Normal EF, No valvular disease . CXR [2185-2-9]: 1.Improving right middle lobe airspace opacity likely representing resolving pneumonia. 2. 7-mm right lower lobe nodular opacity seen on a single view. Further characterization of this finding with repeat PA and lateral chest radiographs is recommended following resolution of the right middle lobe consolidation. . CT angio [2185-2-9]: Multifocal PNA, cannot see PE but limited exam (patient movement) . Micro: BlCx x2: 1/4 bottles w/Coag Negative Staph Negative for Influenza A and B Brief Hospital Course: 87M with recent PNA on levofloxacin, now with worsening multifocal pneumonia. had episode of respiratory difficulty overnight requiring numerous interventions including lasix (although CXR afterwards showed no signs of CHF), albuterol nebs, nitro for afterload reduction, and finally BiPAP . # Respiratory distress/Multifocal pneumonia - Patient readmitted for multifocal PNA that did not respond to levofloxacin as an outpatient. It was thought that the patient either did not receive long enough treatment with Levofloxacin or possibly that the patient's pneumonia was resistant to Levofloxacin. Alternatively, it was considered that the patient could have a secondary infection superimposed on his prior pneumonia. The patient was started on Zosyn/Vanco to cover broadly given progression of symptoms and radiographic appearance of PNA as well as Azithromycin to cover atypicals. He was admitted to the MICU given his oxygen requirement and respiratory distress. In the MICU, the patient had two episodes of tachypnea to the 40s. The first episode of sudden tachypnea and increased O2 requirement was thought to be [2-25] mucous plugging. The patient had a second episode of respiratory distress with RR 40s and was given bipap with improvement of rr 20-30. The patient did not require intubation in the MICU. The patient was started on IV solumedrol for wheezing thought to be consistent with COPD/reactive airways disease. A TTE perfomed showed no evidence of valvular disease with EF > 55%. His CTA showed multifocal pneumonia but no evidence of PE (although it was somewhat limited study due to patient motion). He did not require endotracheal intubation. His pneumonia and respiratory status began to improve on the Vanc/Zosyn. Additionally, the patient was found to have significant wheezing on exam thought to be consistent with a component of COPD/reactive airways disease. Although the patient does not have known COPD, he was started on IV steroids for presumed reactive airways disease contributing to his severe respiratory distress. He was started on Solumedrol IV and then subsequently switched to Prednisone. He also received nebulizer treatments and his wheezing has improved during his hospital course. He will complete IV antibiotics and a Prednisone taper after discharge at the [Hospital 100] rehab MACU. Upon discharge, he was requiring 2-3L Nasal cannula to maintain saturation of 96%. On room air, the patient's oxygen saturation was 90%. . # Hypertension - Patient's hypertension to SBPs 240s in the ED were thought to be likely from catecholamine surge in the setting of possible early sepsis. He was transiently put on a nitro gtt which improved his SBPs to 160s-170s and was transitioned to isosorbide DN and metoprolol after it was clear that he was no longer septic. His antihypertensive regimen can be further uptitrated as necessary in the outpatient setting. . # Anemia: Patient found to have new anemia with Hct 30-32. Stool guiacs x 2 were negative. Hemolysis labs were sent with no evidence of hemolysis. . # Bladder Ca - Patient was found to have recurrent bladder cancer on a recent cystoscopy. He is s/p transurethral resection [12-29]. There are no acute issues at this time. His UA was noted to have many RBCs which is not seen in prior UAs but pt has known bladder Ca. The patient will need further followup as an outpatient with his urologic oncologist. Currently no acute issues at this time. UA was noted to have many RBCs which is not seen in prior UAs but . # CKD - No acute issues. Renally dose meds. The patient's baseline Cr ranges between 1.3-1.6. . # h/o DVT - The patient's coumadin was stopped in the ICU in the event a procedure was necessary and he was bridged with a heparin gtt. Upon discharge, his INR was 2.2 and heparin gtt was no longer needed. Goal INR 2.0-3.0 . # FEN/GI - heart healthy diet . # PPx - tolerating po Medications on Admission: Ultram 50mg q4-6h prn Toprol XL 25mg daily celexa 20mg daily levofloxacin 250mg daily (last day [2185-2-9]) guaifenesin Edecrin 25mg daily coumadin 2.5mg daily Discharge Medications: 1. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 4 days. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. 11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: Start after 60mg x 3 days is completed. 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: Start after 40mg x 3 days is completed. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 14. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 16. Insulin sliding scale Please continue insulin sliding scale while patient is on Prednisone taper. See attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: 1. Multifocal Pneumonia . Secondary: 1. Bladder cancer 2. PUD 3. DVT [2183], on coumadin 4. CKD - basline Cr 1.3-1.5 5. spinal stenosis 6. L henia repair 7. Venous stripping 8. Hard of Hearing Discharge Condition: 1. Stable, patient clinically improved. Patient is stable but still with O2 requirement and wheezing on exam. Patient will benefit from close follow up with MACU. Discharge Instructions: 1. Please take all medications as prescribed. You were started on antibiotics for your pneumonia (Vancomycin, Zosyn and Azithromycin) . 2. Please keep all outpatient appointments . 3. Please return to the hospital for symptoms of worsening dyspnea, chest pain, nausea/vomiting, chest pain, or any other concerning symptoms Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1266] after discharge from your rehab admission. Please call his office at [Telephone/Fax (1) 608] to make an appointment within one to two weeks after discharge from rehab. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 4055] Completed by:[2185-2-15]	[ "787.91", "285.9", "403.90", "533.90", "585.9", "486", "493.92", "188.8", "724.02", "518.81", "428.0", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10002, 10068	4201, 8124	230, 240	10318, 10483	3180, 4178	10855, 11315	2829, 2847		8339, 9979		10089, 10297		8150, 8316			10507, 10832								2862, 3161																					173, 192									268, 2003														2025, 2599	2615, 2813
53,007	116,408	47859	Discharge summary	report	Admission Date: [2199-4-8] Discharge Date: [2199-4-16] Date of Birth: [2138-9-20] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: overdose, suicide attempt Major Surgical or Invasive Procedure: None History of Present Illness: 60 M with PMH of Depression, Parkinson's, suicidal ideation/ attemps was found down face down by friends down since Saturday by report. He began taking colchicine 5-6 days ago and developed diarrhea as a side effect. On Saturday, he attempted suicide by overdose with Xanax and "parkinson's med". He took ~6 xanax, [2-27] pills of 5 mg percocet, 4 vicodin unknown strength, 2 colchicine 0.6 mg tabs, [3-1] acetaminophen tabs. He was found by his friends 2 days later who brought him to the ED. . In the ED, initial vs were: T 99.8 P:103 BP:137/75 RR:16 O2 sat 100% 2L. He smelled of EtOH, was soaked in urine and had the following pill bottles: Tramadol (empty), Colchicine (empty), Allopurinol (empty), Tylenol (empty), Sinemet (empty), Naproxen, Statin, Indomethacin, Flomax, Carbidopa, Keflex, Cyclobenzaprine, Urelle, Paroxetine, and some unlabeled pill bottles in possession. The following pills were unlabeled but were found by pill finder: Vicodin, Ambien. Physical exam was notable for pill rolling tremor, pressure sores on face, chest, knees. He was somnolent but following commands, answering questions, protecting airway but some with some gurgling of secretions. On rectal exam, he had decreased rectal tone, flecks of blood, empty vault. There was no clonus, asterixis, or hyperreflexia. Labs were notable for WBC 15.7 with 90% neutrophils, CK 5963, ALT 60, AST 117, Alk Phos 66, LDH 359, negative acetominophen level. His CXR, CT head and neck were negative. His EKG revealed EKG: ST@107 QRS 84 QTc 426. He was given NAC 150 mg IV over 1 hour. On transfer to the [Hospital Unit Name 153], his most recent VS were P: 105, BP: 153/85, RR: 18, O2 sat 100% on 5L NC. . . Review of sytems: (+) Per HPI, also occasional 'Parkinson's pain'. denies pain currently, + diarrhea after taking colchicine (-) Denies fever, chills, night sweats. Denies rhinorrhea or congestion. Denied cough, shortness of breath. Denied bloody or black stools. No dysuria. Denied arthralgias or myalgias. Past Medical History: Depression with hx of past suicidal ideation Parkinson's Hyperlipidemia Chronic Back Pain- managed on oxycodone Social History: Patient lives by himself. He is disabled and not currently working. He previously worked in contruction. He is divorced. Patient denies tobacco use. He states he drinks very rarely, drinking [11-25]- 1 glass of wine on those occasions. He smokes marijuana ~2x/month. He has used cocaine and heroine in the remote past. Patient states this is his first suicide attempt although he has had suicical ideations in the past. Family History: unable to obtain on admission Physical Exam: Admission: Vitals: T: 99.2, BP: 158/82 P: 109 R: 14 O2: 100% on 2L NC General: lethargic but arouable, oriented to person, place, month, year but not to day of the week or date, no acute distress, affected blunted, somewhat tearful during interview HEENT: Sclera anicteric, dry MM, dried blood on the lips, pressure ulcer on his chin Neck: supple, in cervical collar, no cervical pain Lungs: loud upper respiratory noises over anterior chest, otherwise CTAB, no wheezes, rales, rhonchi CV: tachy, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, erythema over bilateral ribs Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: exam somewhat limited by lethargy, CNII- surgical defect of right pupil, left pupil reactive, CN III/ IV- somewhat limited movements, CNV-XII intact; 4+ strength in bilateral upper/ lower extremities, sensation intact throughout to light touch; 2+ biceps, patellar, no dystonia, no rigidity, no tremor, patient unable to complete finger to nose exercise [12-26] inattention Pertinent Results: CXR [4-8] Bibasilar atelectasis, left greater than right. CT head [4-8] No acute intracranial process. CT C-spine [4-8]: No acute process Elbow x-ray [4-8]: No evidence of acute fracture [2199-4-8] 11:58AM BLOOD WBC-15.6# RBC-4.70 Hgb-14.7 Hct-41.7 MCV-89 MCH-31.2 MCHC-35.1 RDW-13.7 Plt Ct-276# [2199-4-13] 07:15AM BLOOD WBC-8.4 RBC-3.98* Hgb-12.2* Hct-35.6* MCV-89 MCH-30.7 MCHC-34.3 RDW-13.4 Plt Ct-220 [2199-4-8] 11:58AM BLOOD PT-13.1 PTT-22.0 INR(PT)-1.1 [2199-4-8] 11:58AM BLOOD Glucose-131* UreaN-22* Creat-1.1 Na-142 K-4.4 Cl-106 HCO3-24 AnGap-16 [2199-4-10] 05:55AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-140 K-3.8 Cl-108 HCO3-26 AnGap-10 [2199-4-8] 11:58AM BLOOD ALT-60* AST-117* LD(LDH)-359* CK(CPK)-5963* AlkPhos-66 TotBili-0.7 [2199-4-9] 04:38AM BLOOD ALT-43* AST-71* LD(LDH)-208 CK(CPK)-2559* AlkPhos-54 TotBili-0.6 [2199-4-10] 05:55AM BLOOD CK(CPK)-1121* [2199-4-11] 06:00AM BLOOD CK(CPK)-861* [2199-4-13] 07:15AM BLOOD CK(CPK)-451* [2199-4-10] 05:55AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8 [2199-4-8] 05:30PM BLOOD Acetmnp-NEG [2199-4-8] 11:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2199-4-8] 12:20PM BLOOD Glucose-131* Lactate-2.1* Na-142 K-4.3 Cl-103 calHCO3-25 [2199-4-9] JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL INPATIENT [2199-4-8] URINE URINE CULTURE-FINAL INPATIENT [2199-4-8] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2199-4-8] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] [2199-4-8] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [Hospital1 ] Brief Hospital Course: 60 yo male with PMH of Parkinson's disease, depression, hx of suicical ideation who presents after being being found down for ~2 days after an intentional overdose Patient took excessive doses of several medications including benzodiazepines, opiates, tylenol, colchicine, carbidopa. Pt was found down after 2 days with pressure ulcers on chin, ribs and knees. Patient admitted that this was an attempt to "end it all." His CK was elevated and peaked at 6000 and he was volume depleted; he received 3L of IV normal saline in the ED and 1.2 L in the ICU for rhabdomyolysis. Given his significant elbow pain, elbow x-ray was done which showed no fracture and a moderate effusion. Joint was tapped with grossly bloody fluid, sent for culture and cell count. Psychiatry and social work were consulted for suicide attempt, he was monitored with a 1:1 sitter. He was noted to have a leukocytosis with WBC 15, and pulmonary infiltrate that may have been due to aspiration, but no fevers or other localizing symptoms, and his WBC decreased to 8.4. His sinemet for parkinson's disease was restarted (had missed 2 days), and the dose was adjusted by his outpatient Neurologist. He was started on Remeron on evening [2199-4-15] per psychiatry recs given complaints of insomnia. He has chronic back pain at SI joints for which he was taking opiates as an outpatient. Pt admitted to misuing the opiates prior to his suicide attempt. His back pain was managed with alternative agents to avoid narcotics. He was started on scheduled tylenol, naproxen, lidoderm patch, and warm packs. He was encouraged to ambulate and maintain activity, as bed rest will only make pain worse. He was noted to "inflate" his ratings of his pain, which he admitted when challenged about his reports of [2198-7-2] pain, then saying, "I exaggerate, may be more like a [5-3]." Pt was noted to have some mild hypertension, with SBP generally in mid-140's. He was started on low-dose HCTZ. He should have lytes, BUN, Cr check on [2199-4-23] to ensure he tolerates, and he should be monitored to ensure that he has sufficient po intake considering his depression so that he does not become dehydrated. He also complained of constipation, for which he has been started on a bowel regimen, and he will receive an enema. He is being discharged to an inpatient psychiatric facility for further treatment of his depression. Medications on Admission: Allopurinol 300 mg PO daily Tramadol 50 mg PO QID PRN Oxycodone 5 mg PO QID PRN Ambien 10 mg QHS PRN Colchicine 0.6 mg PO BID PRN Alprazolam 2 mg PO TID PRN Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. carbidopa-levodopa 25-250 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): 8am, 12pm, 4pm. 9. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): 8pm . 10. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 12. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Please check lytes, BUN/Cr on [2199-4-23] to ensure tolerates. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stools. 14. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Depression Suicide Attempt by Ingestion Parkinson's Disease Chronic back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the intensive care unit following ingestion of multiple medications. You were found to have significant muscle breakdown (rhabdomyolysis) and a collection of fluid around your elbow. You were treated with IV fluids and your symptoms slowly improved. Your dose of Sinemet was also adjusted during this hospitalization. You are being discharged to a psyhiatric facility for further treatment of your depression. Followup Instructions: Please follow up with your PCP and your Neurologist upon discharge from your psychiatric facility.	[ "728.88", "296.33", "965.09", "E950.3", "E950.4", "707.20", "724.2", "275.3", "969.4", "780.01", "272.4", "327.23", "965.4", "332.0", "719.02", "E950.0", "401.1", "974.7", "790.01", "274.9", "V62.84", "707.09", "966.4" ]	icd9cm	[ [ [] ] ]	[ "81.91" ]	icd9pcs	[ [ [] ] ]	9707, 9713	5850, 8265	330, 337	9835, 9835	4180, 5827	10473, 10575	2962, 2994		8473, 9684		9734, 9814		8291, 8450			10018, 10450								3009, 4161																					264, 292					2077, 2369				365, 2059									9850, 9994					2391, 2504	2520, 2946
32,234	187,336	6393	Discharge summary	report	Admission Date: [2145-12-3] Discharge Date: [2145-12-7] Date of Birth: [2085-4-10] Sex: F Service: MEDICINE Allergies: Wellbutrin / Darvon Attending:[Doctor Last Name 10493] Chief Complaint: DKA, NSTEMI Major Surgical or Invasive Procedure: PICC line placment and removal History of Present Illness: A 60 yo F with DM I and severe PVD admitted with chest pain overnight is transferred to MICU for persistent BS in 400s despite boluses of insulin through pt's insulin pump. She was admitted with 2 episodes of exertional chest pressure on the day of admission in the setting of BS in 300-400s. EKG was unremarkable and two sets of cardiac enzymes were negative for ACS. On the floor, pt refused sc/iv insulin although there was a suspicion that her pump was kinked/not working properly. In the ED, 78-100 100-170/20-70 17 96% RA. The patient received aspirin 325mg, metoprolol 50mg PO, SL NG 0.3mg x1. Cardiology consultation in the ED verbally recommended that the patient not be heparinized if she could be kept chest pain free. The patient was made chest pain free in the ED. ROS: Negative in detail, including no DOE, edema, fevers, chills, cough. Past Medical History: - DM I. Uses an insulin pump, followed by Dr. [Last Name (STitle) 10088] at [Last Name (un) ]. Complications of peripheral neuropathy and retinopathy - PVD, involving lower extremities and carotid arteries followed by Dr. [Last Name (STitle) 1391] s/p R fem-[Doctor Last Name ] vein graft [2127] s/p urokinase treatment in [2136-11-25], Vein patch angioplasty of R fem-[Doctor Last Name ] bypass in 09/[2140]. - Hypothyroidism - Genital herpes - Fatigue with question of autonomic disorder - S/p vitrectomy and cataract Social History: Retired strategic planner. She lives alone and has no family. 2-3ppd tobacco use x decades, quit 2.5 years ago. Denies EtOH or drugs. Family History: Non-contributory. Physical Exam: PE: 98.4 81 96/33 21 99% RA FS 411 Gen: NAD. Comfortable. HEENT: PERRL. CV: RRR. Systolic murmur loudest at the 2nd intercostal space, right sternal border. Pulm: CTA bilaterally. Abd: Soft, nontender. Ext: No edema. 1+ bilateral dorsalis pedis pulses. Neuro: AOx3 Pertinent Results: On admission: [2145-12-3] Glucose-413* UreaN-24* Creat-1.2* Na-136 K-6.2* Cl-100 HCO3-21* AnGap-21* . On discharge: [2145-12-6] Glucose-124* UreaN-18 Creat-0.9 Na-138 K-4.0 Cl-113* HCO3-20* AnGap-9 . Cardiac enzymes peaked at Tropnin 1.0 and CK 515. [2145-12-3] 09:00PM BLOOD CK(CPK)-296* CK-MB-8 cTropnT-0.02* [2145-12-4] 03:22AM BLOOD CK(CPK)-254* CK-MB-7 cTropnT-0.04* [2145-12-4] 04:50PM BLOOD CK(CPK)-435* CK-MB-26* MB Indx-6.0 cTropnT-0.55* [2145-12-5] 03:01AM BLOOD CK(CPK)-515* CK-MB-29* MB Indx-5.6 cTropnT-1.00* [2145-12-6] 03:17AM BLOOD CK(CPK)-295* CK-MB-12* MB Indx-4.1 cTropnT-0.66* [2145-12-5] 04:00PM BLOOD cTropnT-0.62* . . ECHO: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe inferior wall hypokinesis and mid to apical inferolateral wall hypokinesis. . Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction consistent with coronary artery disease. Brief Hospital Course: 60 yo F with DM I and severe PVD admitted with DKA in setting of chest pain and subsequently ruled in for MI. . # DKA: Etiology of her DKA was felt to be secondary to her NSTEMI. There was also some intial concern for insulin pumpfailure causing not proper insulin delivery. She was cmonitored in MICU with standard DKA treatment with insulin gtt, aggressive IVF, and monitoring of electolytes. Her AG closed within 24 hours, [Last Name (un) ] was consulted, and recommmended that she restart the insulin pump upon discharge. Dr. [Last Name (STitle) 10088], her [Last Name (un) ] endocrinologist, was aware. Of note, Pt very resistant to invasive procedures in past, during this admission has intermittently refused blood draws, PIV placements, heparin, IV insulin, procedures, etc. Ultimately, she agreed to treatment for DKA and her acidosis resoved quickly. On discharge, she was switched back to her insulin pump as [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations. She had follow-up with [Last Name (un) ]. . # NSTEMI. Pt is a high risk patient with known extensive PVD and signs of extensive atherosclerosis of the coronary arteries on CTA. She was found to have NSTEMI with troponin peak at 1.0, CK peak at 500's. She received aspirin, plavix, ezetimibe increased to 80mg, and started on heparin gtt. Given initial SBP's in 90's, BB and ACEI were not started. Cardiology consulted and recommended Cardiac cath. However, patient was very adamant that she would not wish to have any stents placed and she has not decided whether she would like to have CABG, should there be any vessel disease. In light of this, she decided not to undergo cath. Echo revealed regional WMA in RCA vs circ territories. She remained chest pain free and on heparin gtt for 48 hours. Integrillin was not started as per cardiology. She had one episode of 5 beats of asymptomatic NSVT. Upon discharge, plan to start low dose lopressor 12.5 [Hospital1 ] and she will f/u with PCP in [Name Initial (PRE) ] few days to check BP. If she tolerates this well, she could then start low dose ACEI as well by PCP. . # PVD. Followed closely by Dr. [Last Name (STitle) 1391]. Recent U/S with unchanged carotid stenosis and patent R fem-[Doctor Last Name ] graft. Continue aspirin, plavix. . #HTN-Pt found to have elevated BP while in the MICU. She was started on Lopressor and Lisinopril with improvement in her pressure. She will continue these medications as an outpatient and follow up with her PCP to adjust as needed. . # Peripheral neuropathy. Continued duloxetine. . # Hypothyroidism. Continued thyroid hormone replacement. . # Fatigue with question of autonomic dysfunction. Contine home fludrocortisone. . # Genital herpes. Continued home valacyclovir. . # FEN: Cardiac, diabetic diet. . # Prophylaxis: heparin gtt, protonix given starting anticoagulation and DKA. . # Access: PICC line placed (for ease of lab draws and IV meds) and removed at discharge . # Code: DNR/DNI. confirmed Medications on Admission: Aspirin 81mg Daily Atorvastatin 40mg Daily Clopidogrel 75mg Daily Duloxetine (Cymbalta) 20mg Daily Ezetimibe 10mg Daily Fludracortisone 0.1mg Daily Insulin, Novolog insulin pump, basal rate MN 0.5, 2AM 0.6, 3AM 0.8, 8AM 0.6, 10AM 0.5 Levothyroxine 125mcg Daily Valacyclovir 500mg Daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO daily (). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: NSTEMI diabetic ketoacidosis Secondary: Hypothyroidism peripheral vascular disease Discharge Condition: stable, normoglycemic, chest pain free Discharge Instructions: You had a heart attack which likely caused elevation in your blood sugars and diabetic ketoacidosis. The diabetic ketoacidosis has resolved. Please call your primary doctor or go to the emergency room if you have any hyperglycemia, chest pain, palpitations, shortness of breath, swelling in your legs or any other concerning symptoms. You should follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] regarding your blood pressure medications. You should follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 120] regarding your recent heart attack. Followup Instructions: Please call your primary doctor, Dr. [Last Name (STitle) 1007], to make an appointment to have your blood pressure checked on Wednesday morning. His number is : [Telephone/Fax (1) 10492]. Please follow-up with cardiology regarding your recent heart attack. Your appointment is with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] at 1 PM on [2145-12-15] in [Hospital1 18] [Hospital Ward Name 516] [Hospital Ward Name 23] Building 7th. Please call [Telephone/Fax (1) 62] if you need to change the appointment. Please attend your [Last Name (un) ] appointment with Dr. [Last Name (STitle) 24668]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495]	[ "276.51", "250.13", "250.63", "250.53", "054.10", "583.81", "433.10", "244.9", "427.1", "250.43", "410.71", "357.2", "443.9", "362.01" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	7912, 7918	3808, 6832	294, 327	8055, 8096	2276, 2276	8761, 9553	1956, 1975		7169, 7889		7939, 8034		6858, 7146			8120, 8738								1990, 2257																2396, 3785					242, 256									355, 1213							2290, 2382							1235, 1789	1805, 1940
43,561	153,392	42730	Discharge summary	report	Admission Date: [2160-7-19] Discharge Date: [2160-7-22] Date of Birth: [2079-4-20] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 39752] is an 80 year old female well known to the cardiac surgery service s/p coronary artery bypass grafting times one with reverse saphenous vein to the right coronary artery, aortic valve replacement, [Street Address(2) 17167]. [Hospital 923] Medical BioCore tissue valve on [2160-7-10] with Dr.[Last Name (STitle) ]. Please see her discharge summary for further details of her hospital course postop. On [2160-7-15] she was discharged to a rehabilitation facility. She presented to the emergency department of [Hospital1 827] complaining of chest pain and her family reported altered mental status. Her chest pain was determined to be sternal incisional discomfort, as it was reliably reproducible. Her ECG was normal. She was started on antibiotics for a urinary tract infection. While in the emergency department she became hypotensive. She was fluid resucitated and required pressor support and was therefore admitted to the cardiac surgery intensive care unit. Past Medical History: - CVA [60] yrs ago - Myocardial infarction - Aortic stenosis - Mitral regurgitation - Anxiety/Depression - Hyperlipidemia - Hypertension - Gout - History of blood clot in left leg / ? iliac - chronic neck/back pain; osteoarthritis - chronic diastolic heart failure - coronary artery disease - sacral ulcer - colitis - tobacco abuse recently stopped - anemia -Recent fall left thigh hematoma -decubitus of coccyx - B CEA - TAH - L flank ? sympathectomy - ? L femoral vein [Doctor First Name ] Social History: Currently lives at rehab but was living with son in his home. There is an in-law-apartment in son's home, [Location (un) ] VNA nurse visits 3 x per wk for dressing changes to coccyx. Contact:[Name (NI) ] (son) Phone #[Telephone/Fax (1) 92341] Occupation:retired Cigarettes: Smoked no [] yes [x] quit few weeks ago Hx:30-50 PY Hx Other Tobacco use:denies ETOH: < 1 drink/week [x] [2-26] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- father with myocardial infarction at age 62 Physical Exam: Pulse:84 Resp:19 O2 sat:95/O2 nasal cannula B/P Right:96/53 Height:5'3" Weight: General: NAD, A&Ox2 Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] Wound: sternal wound C/D/I. sternum stable. No [Doctor Last Name ]/click (R)EVH site C/D/I Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 92343]Portable TTE (Focused views) Done [2160-7-19] at 6:04:00 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18] - Department of Cardiac S [Last Name (NamePattern1) 439], 2A [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2079-4-20] Age (years): 81 F Hgt (in): 66 BP (mm Hg): 111/90 Wgt (lb): 160 HR (bpm): 84 BSA (m2): 1.82 m2 Indication: S/p bioprosthetic AVR. Congestive heart failure. Left ventricular function. ICD-9 Codes: 425.4, 424.0, 424.2, 428.0, 410.91, 424.1 Test Information Date/Time: [2160-7-19] at 18:04 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: Portable TTE (Focused views) Son[Name (NI) 930]: Cardiology Fellow Doppler: Limited Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2012W000-0:00 Machine: Q-2 Vivid Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 5.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.2 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 55% >= 55% TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A prominent Chiari network is present (normal variant). LEFT VENTRICLE: Mild regional LV systolic dysfunction. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Small to moderate pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. No RA or RV diastolic collapse. GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality - patient unable to cooperate. Emergency study performed by the cardiology fellow on call. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is elongated. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior wall and mid inferolateral walls. There is normal contraction of the remaining segments (overall LVEF 55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is well-seated and the aortic valve prosthesis leaflets appear to move normally. The gradients across the aortic valve are not well assessed. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. Overlying the right ventricle, the effusion is echo dense, consistent with blood, inflammation or other cellular elements. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Overall normal left ventricular systolic function with inferior wall/inferolateral hypokinesis, as described. Well-seated bioprothetic aortic valve without aortic regurgitation. Moderate tricuspid regurgitation. Small to moderate sized circumferential pericardial effusion without echocardiographic signs of tamponade. [2160-7-22] 05:33AM BLOOD WBC-9.7 RBC-3.39* Hgb-10.0* Hct-31.0* MCV-91 MCH-29.4 MCHC-32.2 RDW-17.7* Plt Ct-270 [2160-7-19] 12:53PM BLOOD WBC-10.6 RBC-2.74* Hgb-8.1* Hct-25.8* MCV-94 MCH-29.6 MCHC-31.5 RDW-16.0* Plt Ct-247 [2160-7-21] 02:18AM BLOOD PT-13.7* PTT-28.9 INR(PT)-1.3* [2160-7-22] 05:33AM BLOOD Glucose-100 UreaN-63* Creat-1.9* Na-142 K-4.1 Cl-97 HCO3-38* AnGap-11 [2160-7-19] 12:53PM BLOOD Glucose-122* UreaN-78* Creat-2.5* Na-136 K-5.6* Cl-94* HCO3-29 AnGap-19 [2160-7-21] 02:18AM BLOOD ALT-12 AST-20 LD(LDH)-314* AlkPhos-70 TotBili-1.8* [2160-7-19] 12:58 pm URINE URINE CULTURE (Preliminary): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. [Known lastname 39752] presented to the emergency department of [Hospital1 1535] complaining of chest pain and her family reported altered mental status. Her chest pain was determined to be sternal incisional discomfort, as it was reliably reproducible. Her ECG was normal. She was started on antibiotics for a urinary tract infection. While in the emergency department she became hypotensive. She was fluid resucitated and required transient pressor support and was therefore admitted to the cardiac surgery intensive care unit. She was transfused packed red blood cells for anemia. Due to her mental status changes she was placed on ultram and tylenol only for pain management. An echocardiogram was performed which confirmed that no tamponade was present. Wound care was consulted for her nonhealing coccyx ulcer. Recommendations appreciated. Her mental status improved on HD #1 and she was weaned off pressor support. She remained in the CVICU for close monitoring. Hospital day 3 she was transferred to the step down unit for further monitoring and progression. Repeat urine culture sent. She continued to remain stable, ambulating with Physical Therapy and was cleared for discharge to [Hospital1 ] transitional Care and rehabilitation. All follow up appointments were advised. Medications on Admission: CITALOPRAM 10 mg Daily COLCHICINE 0.6 mg Daily DIAZEPAM 10 mg HS ADVAIR DISKUS 500 mcg-50 mcg/Dose Disk with Device - one puff inhaled [Hospital1 ] FUROSEMIDE 20 mg daily. HYDROCORTISONE ACETATE 25 mg Suppository - PRN METOPROLOL TARTRATE 12.5 mg [Hospital1 ] OXYCODONE 15 mg - 1-2 Tablets every six hours POLYETHYLENE GLYCOL 3350 17 gram/dose Powder - one capful Daily SIMVASTATIN 10 mg Daily ASPIRIN 81 mg Daily DULCOLAX as directed PRN DOCUSATE SODIUM 100 mg Daily MULTIVITAMIN Dosage 1 tablet daily SENOKOT 8.6 mg Daily Nicotine patch Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN fever, pain 2. Aspirin EC 81 mg PO DAILY 3. Ciprofloxacin HCl 250 mg PO Q24H Duration: 3 Doses 4. Citalopram 10 mg PO DAILY 5. Colchicine 0.6 mg PO EVERY OTHER DAY 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 7. Heparin 5000 UNIT SC TID 8. Multivitamins 1 TAB PO DAILY 9. Nicotine Patch 7 mg TD DAILY 10. Ranitidine 150 mg PO DAILY 11. Simvastatin 10 mg PO DAILY 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 Tablet(s) by mouth q 6 h prn Disp #45 Tablet Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 ] Transitional Discharge Diagnosis: hypotension/ change in mental status Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] WOUND NURSE Phone:[Telephone/Fax (1) 23664] Date/Time:[2160-8-6] 2:00 Surgeon Dr. [First Name (STitle) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2160-8-6] 2:00 Cardiologist Dr. [Last Name (STitle) ] [2160-8-8] at 11:30a Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ] in [4-24] weeks [Telephone/Fax (1) 39662] 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:[2160-7-22]	[ "401.9", "V15.82", "599.0", "458.9", "707.03", "412", "428.32", "414.00", "V12.54", "272.4", "V43.3", "274.9", "780.97", "707.24", "786.59", "V45.81", "285.9", "V45.89", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10396, 10452	7922, 9227	332, 339	10533, 10689	3028, 5605	11561, 12279	2402, 2483		9827, 10373		10473, 10512		9253, 9804			10713, 11538							5654, 7808	2498, 3009																					271, 294				7843, 7899					367, 1386														1408, 1909	1925, 2386
21,115	144,579	30366	Discharge summary	report	Admission Date: [2166-3-11] Discharge Date: [2166-3-20] Date of Birth: [2093-3-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: increased edema, orthopnea, decreased urine output Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo M w/ a PMH of dilated cardiomyopathy (EF <20%) s/p ICD placement [2162], afib on coumadin, HTN, CRI (baseline Cr 2.3), hyperlipidemia and asthma presents to the ED in decompensated CHF. Patient most recently saw Dr. [First Name (STitle) 437] on [2-25] was noticed to have gained weight, weighing 183lbs, up from his dry weight of 176 lbs. His Lasix dosing was changed from 80 [Hospital1 ] to 160 qam / 80 qpm, and HCTZ 25mg was added two days later for increased diureses. Patient was seen but outpatient cardiologist on [2166-3-10] at which time he reported an increase in lower extremity edema, increased orthopnea, increased weight from baseline and decreased urine output over the past week. . Pt seen in [Hospital ] clinic yesterday with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437]. Labs drawn at that visit BUN 131 creatinine 6.4 Na 133 K 4.0 Cl 93 Bicarb 28 Phos 5.1 Mg 2.8. . Of note, patient was recently admitted in [2166-1-30] for evaluation of chronic dyssynchronization therapy and also required aggressive diuresis with lasix gtt and afterload reduction. Past Medical History: # Dilated cardiomyopathy - EF <20% # Atrial fibrillation - controlled on amiodarone # CRI - baseline Cr 2.4 # HTN # Asthma # GERD # Hyperlipidemia Social History: Lives on [Hospital3 4298] with his second wife. [Name (NI) ] 5 children from a previous marriage. Is retired x 14 yrs, but used to work in sales for [Company 25186]/[Company 25187]. No tobacco currently, but smoked 15 pack years. Quit in [2128]. Was a heavy drinker in the past - used to drink 6 drinks/day x 29 years. No EtOH in last 7-8 years. Used to exercise and participated in cardiac rehab but has not been able to do so since before [Holiday 1451]. Family History: + for HTN and diabetes; no heart disease/strokes Physical Exam: Blood pressure was 87/55 mm Hg while seated. Pulse was 58 beats/min and regular, respiratory rate was 15 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 12 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S4. There was an S3. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was pulsitile hepatomegaly. There was no splenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, or clubbing. There was pitting edema bilaterally extending to the midshin. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Imaging: CHEST (PA & LAT) [2166-3-11] 7:08 PM IMPRESSION: Compared to prior radiograph from [2166-2-14], there is decreased size of the right pleural effusion. No overt pulmonary edema. . CHEST (PORTABLE AP) [2166-3-17] 10:11 AM IMPRESSION: Interval decrease in right pleural fluid. . RENAL U.S. [2166-3-12] 10:22 AM IMPRESSION: No evidence of hydronephrosis. . Micro: None . Labs: Brief Hospital Course: Patient is a 73M with complex cardiac history admitted with decompensated CHF. . #. CAD: Patient with negative biomarkers and EKG changes not suggestive of ischemia. Patient was continued on his outpatient doses of ASA and Statin. Warfarin was reinstited as the INR drifted from admission level of 3.8 to 2.0 He is to have this checked as an outpatient to ensure therpeutic levels, which may be difficult to maintain if patient has congestive hepatomegaly. . #. Pump: Patient with known dilated cardiomyopathy & biventricular dysfunction, EF 20%. Lack of forward flow likely contributing to renal failure. Patient was maintained initially on a Lasix gtt & Dobutamine gtt titrated to a UO of 30 cc/hr, and Dopamine gtt was added to aid in splanchnic vasodilation and renal perfusion. The patient's outpatient doses of BB were held, and ACE was held in the setting of ARF. Aldactone was held in the setting of hyperkalemia on presentation. The ACE was slowly added back on as the patient was diuresed and renal function improved. The patient was started on Bumetanide for further diuresis. The CHF team was following the patient and outpatient medications were discussed. The patient was discharged on an appropriate medical regimen consisting of and is to follow-up in [Hospital 1902] clinic. . #. Rhythm: Patient known pAfib on rate control with amiodarone and toprol. As mentioned above the BB was held, although the patient remained on amiodarone. His dose was changed from 100 twice daily to 200 once a day. He was also restarted on Warfarin for his pAF and his INR was therapeutic upon discharge. The patient was maintained on telemetry throughout the entire hospital stay, and there were nor events on telemetry. The patient's BB was restarted prior to discharge. . #. CRI: Baseline Cr is 2.3, thought to be due to hypertensive/poor cardiac output nephropathy. Patient was admitted with Cr of 6.5, thought to be due to pre-renal renal failure in the setting of forward flow. The Nephrology consult team saw the patient and as per their recommendations the Lasix gtt was discontinued. Once his CHF was optimized and his forward flow was enhanced his was given Lasix boluses with good result, although did not diurese well to PO lasix. His renal function progressively improved with increased renal perfusion and he did not require dialysis upon this admission. The patient was also restarted on his diuretics prior to discharge. The patient was also scheduled for follow-up with nephrology. . Hyperkalemia: Likely a result of renal failure. The patient didn't have any EKG changes and serial checks of his potassium revealed an appropriate decrease to normal levela in concordance with an increase of his renal function. . #. Asthma - Patient was continued on his home dosing of spiriva, flovent, and albuterol . #. GERD: Patient was continued on his H2blocker and PPI . #. FEN: low salt diet . . After discussion with the patient and the medical staff, all were in agreement that [Known firstname 72233] [Known lastname ] was a suitable candidate for discharge. Medications on Admission: 1. Amiodarone 100 mg [Hospital1 ] 2. Pravastatin 20 mg qd 3. Metoprolol Succinate SR 12.5 4. Ranitidine HCl 150 mg qd 5. Tiotropium Bromide 18 mcg Capsule qd 6. Fluticasone 110 mcg/Actuation 2 puffs [Hospital1 ] 7. Albuterol 90 mcg/Actuation Aerosol Sig: [12-3] q6h prn 8. Aciphex 20 mg qd 9. Spironolactone 25 mg [Hospital1 ] 10. Zolpidem 5 mg qhs prn 11. Warfarin 5 mg qhs 12. Asmanex Twisthaler 220 mcg qd 13. Lasix 160/80 mg qam/qpm 15. Lisinopril 2.5 mg qd Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 30 Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:60 Tablet(s) Refills:2 11. Outpatient Lab Work Chem 10 - to be drawn at outpatient appointment with Dr. [First Name (STitle) 437] ([2166-3-24]). 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] [Last Name (un) 19700] Community Services Discharge Diagnosis: Primary Diagnosis: Decompensated Congestive Heart Failure . Secondary Diagnoses: # Severe diastolic [Hospital1 ]-ventricular dysfunction: EF <20% # Atrial fibrillation # Hyperlipidemia Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted with heart failure. It is essential that you eat a low salt diet (less than 2 grams) and that you continue to take all your medications, as prescribed. Please also weigh yourself every morning and call your doctor if your weight increases by 3 or more lbs. Please call your doctor if you have worsening swelling, shortness of breath, chest pains or have any other questions or concerns. Please note the following medication changes: CHANGES: 1. Amiodarone: Your total daily dose has not changed (200mg total). You can now take this once a day (200mg daily) as opposed to 100mg twice a day. STOPPED: 1. Metoprolol: This medication has been stopped. Your blood pressure and heart rate should be monitored as an outpatient and at all appointments. 2. Lasix: This diuretic has been stopped. STARTED: 1. Bumex (bumetanide): This is a new diuretic. You should take 2mg three times daily. Followup Instructions: You have the following appointments scheduled: . 1. Cardiology - DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3512] Date/Time:[2166-3-24] 1:00 PM . 2. Kidneys - DR. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 60] Date/Time:[2166-4-2] 2:00 PM . 3. ICD - [Name6 (MD) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2166-9-5] 2:40 . 4. You have an appointment with Dr. [Last Name (STitle) ] in Device Clinic on [2166-9-5] 2:00 pm . Please also make an appointment to see your PCP ([Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 24287]) Completed by:[2166-3-20]	[ "425.4", "V45.02", "493.90", "530.81", "428.30", "274.9", "427.31", "584.9", "272.4", "428.0", "585.6", "403.91" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9356, 9453	4334, 7435	364, 371	9686, 9765	3909, 4311	10729, 11466	2221, 2272		7964, 9333		9474, 9474		7461, 7941			9789, 10224								2287, 3890	9555, 9665																			10245, 10706	274, 326									399, 1537						9493, 9534								1559, 1707	1723, 2205
25,679	114,589	267	Discharge summary	report	Admission Date: [2171-4-4] Discharge Date: [2171-4-9] Date of Birth: [2086-10-29] Sex: F Service: MEDICINE Allergies: Calcium Channel Blockers Attending:[First Name3 (LF) 2108] Chief Complaint: hypoxia, lip and tongue swelling Major Surgical or Invasive Procedure: None History of Present Illness: 84yo w/PMHx significant for HTN, CKD, CVA (hemiplegia in [2155]), diastolic heart failure, HLD, PVD refered from [Hospital 100] rehab after bolus fluids for [Last Name (un) ] given poor PO intake and elevated Cr on labs (felt to be pre-renal) and lasix held yesterday. However after fluids bolus of 1L, pt became hypoxic to 85% w/crackles. K elevated to 5.5 at [Hospital ] rehab, got kayexalete. She was then given 60mg lasix w/out much improvement despite diuresis at which point transferred to [Hospital1 18]. Pt has had gradual decline in MS (somnolent, but no confusion). Also developed large tongue and protruding lower lip concerning for angioedema in setting of chronic ACEI use. However, per report swelling developed slowly since her recent ED admission on [2171-4-1] during which she was started on augmentin. Other than this she has had no medications but has been on enalapril for extended period (duration unknown). Of note, pt was hospitalized ~1 mo ago for PVD, failed LLL angioplasty and stent intervention for ischemia which failed and amputation under consideration for chronic non healing ulcer. Pt has been on oxycodone for pain which has resulted in sedation and consequently poor PO intake. Pt now has Cr of 3.3 (baseline 2.0) on labs. Also had bought of cellulitis for which she presented to ED on [4-1] which was treated w/augmentin and cellulitis improved. In ED, arousable, follows comands, VS 98.4 74 139/59 20 97% 4L, now on 2L 96%. Diffuse crackles throught; no lower extremity edema,benign ab exam. Replaced foley with stable inguinal hematoma (firm indurated, no erythematous or warm there for [1-18] days). Elected not to image given ok VS and no abnormalities on exam, hemotoma has been stable. On CXR pt had retro-cardiac opacity, given recent outbreak of RSV at nursing home, pt was given Vanc/Cipro (HCAP). On the floor, appears in NAD however does have swelling of the lower lip, [Last Name (un) 2599] and eyes. Has difficulty pronouncing words given lip and tongue swelling. Denies pain but does say that her foot bothers her. States that her breathing is fine, no chest pain, no abdominal pain Review of sytems: (+) Per HPI. has leg pain from chronic PVD (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: - CORONARY ARTERY DISEASE - HEART FAILURE, DIASTOLIC - HYPERTENSION - HYPERCHOLESTEROLEMIA - DM-2 - RENAL INSUFFICIENCY [6-/2153] - ?ATHEROEMBOLIC DISEASE - BELL'S PALSY - STROKE [8-/2156] CVA w/L hemiplegia, wheelchair bound; has decreased speech at baseline but generally good comprehension - GASTROINTESTINAL BLEEDING [11/2155] - MULTINODULAR GOITER - LOWER EXTREMITY EDEMA 99 - HEADACHES - ANEMIA (IRON/B12) - CHRONIC NONHEALING UCLER ON TOE--> Left lower extremity ischemia with ulceration of left 3rd toe - glaucoma - cataracts -dementia -constipation -diabetic retinopathy - macular degeneration - a fib - peripheral edema Social History: coming from [Hospital ] rehab. Russian speaking but some English. Married, daughter and son. Family History: Non-contributory Physical Exam: Admission: Vitals: 98.3,130/72, 69, 16, 93% 2L General: Sleepy but rousable, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, lower lip, eyes and tongue swollen Neck: supple, JVP not elevated, no LAD Lungs: fine crackles at bases but no [Hospital ] wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: cool, no edema, chronic PVD non-healing ulcer on 3 toe Pertinent Results: [2171-4-4] 06:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [2171-4-4] 06:30PM URINE RBC-7* WBC->182* BACTERIA-FEW YEAST-NONE EPI-55 TRANS EPI-2 CXR [2171-4-5]: There is severe cardiomegaly associated also with bilateral hilar enlargement, findings that might be consistent with complex valvular problems as well as cardiomyopathy. There are most likely present bilateral pleural effusions. There is no evidence of pulmonary edema. Calcified right pleural plaques are redemonstrated. There is no evidence of pneumothorax TTE [2171-4-5]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). 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 are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. There is mild functional mitral stenosis (mean gradient 6 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild left ventricular hypertrophy with preserved global biventricular systolic function. Mild aortic stenosis and mitral regurgitation. Mild functional mitral stenosis from annular calcification. [2171-4-4] 03:59PM BLOOD WBC-5.2 RBC-3.20* Hgb-9.3* Hct-28.7* MCV-90 MCH-29.1 MCHC-32.4 RDW-16.6* Plt Ct-185 [2171-4-7] 09:15AM BLOOD WBC-5.5 RBC-3.56* Hgb-10.1* Hct-31.0* MCV-87 MCH-28.4 MCHC-32.6 RDW-16.1* Plt Ct-255 [2171-4-4] 03:59PM BLOOD Neuts-74.1* Lymphs-17.6* Monos-6.1 Eos-1.0 Baso-1.1 [2171-4-5] 04:22AM BLOOD PT-14.2* PTT-36.2* INR(PT)-1.2* [2171-4-4] 03:59PM BLOOD Glucose-145* UreaN-99* Creat-3.2* Na-144 K-4.6 Cl-111* HCO3-20* AnGap-18 [2171-4-9] 09:14AM BLOOD Glucose-163* UreaN-71* Creat-2.3* Na-145 K-4.9 Cl-112* HCO3-24 AnGap-14 [2171-4-4] 03:59PM BLOOD CK-MB-4 cTropnT-0.09* proBNP-[Numeric Identifier 2600]* [2171-4-5] 04:22AM BLOOD Calcium-8.1* Phos-8.0# Mg-2.7 [2171-4-9] 09:14AM BLOOD Mg-3.2* [2171-4-6] 06:45AM BLOOD C4-51* [2171-4-6] 11:00AM BLOOD Vanco-19.1 [2171-4-4] 7:00 pm BLOOD CULTURE 2ND. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2171-4-6]): Reported to and read back by DR. [Last Name (STitle) ]. [Doctor Last Name 2601] ON [2171-4-6] AT 0610. GRAM POSITIVE COCCI IN CLUSTERS. Other blood culture from [2171-4-4] no growth by the time of discharge Blood cultures x 2 on [4-6] no growth by the time of discharge Brief Hospital Course: 84yo w/PMHx significant for HTN, CKD, CVA (hemiplegia in [2155]), diastolic heart failure, HLD, PVD refered from [Hospital 100] rehab for hypoxia after receiving IVF, along with tongue and lip swelling for the last few days concerning for angioedema. ANGIOEDEMA: the patient was seen by the allergy consult team ([First Name8 (NamePattern2) 2602] [Doctor Last Name 2603]) who thought this was consistent with angioedema, she was started on dexamethasone 4mg q8hrs and H2 blockers. her symptoms improved and she was sent to the regular medical wards from the ICU. Her steroids were tapered to 2mg po q8hrs on [4-8] and stopped completely on [4-9]. PULMONARY EDEMA: She improved with blood pressure control. Her home lasix of 40mg po daily was restarted on [4-9] as she had some rales at the R base of her lung and mild shortness of breath. Her O2 sat was 95% on room air. Her creatinine had improved. In addition for BENIGN HYPERTENSION her ACEi had been stopped as noted above and she was started on hydralazine 25mg po q6hrs, her nifedipine was increased to 60mg po bid (from 40mg po bid) and her imdur was increased from 30mg po daily to 60mg po daily. ACUTE ON CHRONIC RENAL FAILURE: urine electrolytes consistent with a pre-renal cause but given recent angiogram this also could be related to contrast nephropathy. Her renal failure improved with time and blood pressure control. Her creatinine at discharge was 2.3 (baseline 2-2.2). Chem 7 should be checked in the next 5-7 days to ensure stability. TOE ULCERATION, PERIPHERAL VASCULAR DISEASE: non infected toe ulceration. She had a recent angiogram and will f/u with podiatry and vascular surgery (appointments have been made) URINARY TRACT INFECTION: Started on PO cipro on [2171-4-5]. She has completed a 5 day total course. POSITIVE BLOOD CULTURE: on [4-4], this was treated with vancomycin until it returned as 1/2 bottles from one set of coag negative staph. At this point she did not have a PICC or mid line or any other foreign body. She was afebrile and had no white blood cell elevation, her vancomycin was last dosed on [2171-4-6] (1 gram IV), this was likely a contaminant so antibiotics were discontinued. DIABETES TYPE II: the patient was on pioglitazone as an outpatient, given pulmonary edema this was stopped. While inpt on steroids she was treated with an insulin sliding scale, on discharge she was switched to glipizide xl 2.5mg po daily, this can be further adjusted as an outpatient. For her history of CVA with chronic left sided hemiparesis and depression as well as iron and B12 deficiency anemia, the patient continued on her home med regimen. Medications on Admission: -augmentin 250mgBID [4-1] to [4-11] -oxycodone ER 10mg [Hospital1 ] -oxycodone IR7.5mg Q4h/prn -calcitriol 0.25mcg daily -artificial tears -nitroglycerin 2% ointment 0.5inch daily -bisacodyl 10mg qpm -bisacodyl 10mg suppository -omeprazole 20mg -oxcarbazepine 150 mg -polyethlen glycol 17 [Hospital1 ] -isosorbide mononitrate 30mg -trazadone25mg qhs -??trazadone 12.5mg --> total 37.5mg -nifedipine 40mg [Hospital1 ] -iron 325 daily -aspirin enteric 81mg -pioglitazone 30mg daily -acetaminophen 325 mg TID -citalopram 20mg -heparin sq -milk of mag 30mg daily -vasotec 10mg daily, stopped prior to admission on [2171-4-2] -furosemide given PRN at [Hospital 100] Rehab, was on 40mg daily started [2171-3-16] Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [11-18] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO BID (2 times a day). 8. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as needed for insomnia. 9. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO twice a day. 10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily). 16. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Hypoxia and shortness of breath due to acute diastolic CHF exacerbation Acute on chronic kidney failure, CKD4 Angioedema UTI Peripheral vascular disease Chronic non-healing left toe ulcer Hypertension Hyperlipidemia CAD Chronic diastolic CHF CVA, late effects Depression Iron deficiency and B12 deficiency anemia DM2 uncontrolled with PVD complications Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted with shortness of breath due to volume overload. Continue to take lasix. You had acute on chronic kidney failure likely due to an effect of medications and due to volume depletion within the blood vessel (despite having too much fluid elsewhere). You had swelling of your lip due to angioedema - probably an allergic reaction to either ACE inhibitors (of which your chronic medicaion vasotec is one example) or augmentin (which you were recently started on for cellulitis). From now on please avoid all ACE inhibitor medications and penicillin containing antibiotics. You had a urinary tract infection. You were treated with 5 days of ciprofloxacin. MEDICATION CHANGES: Your OXYCONTIN was stopped and your pain was treated with short acting OXYCODONE in the hospital Your BLOOD PRESSURE MEDICATIONS were adjusted: NITROPASTE was STOPPED NIFEDIPINE was INCREASED from 40mg twice daily to 60mg twice daily IMDUR was INCREASED from 30mg daily to 60mg daily HYDRALAZINE 25mg four times daily was added YOUR DIABETES MEDICATIONS WERE ADJUSTED: PIOGLITAZONE was STOPPED GLIPIZIDE was STARTED Followup Instructions: Department: PODIATRY When: TUESDAY [2171-4-16] at 2:35 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: VASCULAR SURGERY When: MONDAY [2171-4-22] at 4:15 PM With: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "266.2", "241.9", "414.01", "403.10", "440.23", "250.52", "362.01", "438.20", "428.33", "427.31", "428.0", "280.9", "707.15", "599.0", "584.9", "E942.9", "272.4", "799.01", "585.4", "995.1", "351.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12577, 12642	7429, 10117	317, 324	13039, 13039	4277, 6857	14308, 14958	3668, 3686		10905, 12554		12663, 13018		10143, 10882			13174, 13846								3701, 4258						6901, 7406														13866, 14285	245, 279					2543, 2872				352, 2525									13054, 13150					2894, 3537	3553, 3652
12,661	154,035	20603+57180	Discharge summary	report+addendum	Admission Date: [2144-3-11] Discharge Date: [2144-3-24] Date of Birth: [2110-8-30] Sex: F Service: [Hospital Ward Name 332] Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old female who was admitted to the [Hospital Ward Name 332] Intensive Care Unit after a Klonopin overdose and was intubated for airway support. She has a long history of bipolar disorder and was found slumped over in a car. By report, she was initially unresponsive and cyanotic with a respiratory rate of 10. She was found by a family member who is an emergency medical technician. She was given oxygen via nasal cannula and reportedly told the medical staff that she had taken Klonopin, and an empty Klonopin bottle was found. The patient's friend noted that other drugs were missing as well; which included diabetic and hypertensive medications. A suicide note was found as well, and the patient was taken to the Emergency Department. In the Emergency Department, her temperature was 99.2 degrees Fahrenheit, her blood pressure was 116/56, and she was saturating 96% on room air, with a heart rate of 107. On examination, she appeared somnolent. She received Narcan times one in the Emergency Department without improvement. There was consideration to give her flumazenil. She was not given flumazenil for fear it would precipitate seizures with the chronic benzodiazepines use. Because of the need for nasogastric tube placement and activated charcoal, she was nasally intubated for airway protection. After she was intubated, she was given Ativan with an initial drop in her blood pressure into the 70s to 80s; requiring 15 minutes of Levophed and intravenous fluid hydration with improvement. She was subsequently taken off Levophed. Her chest x-ray showed no obvious pulmonary abnormalities. She received a FAST ultrasound in the Emergency Department which was unremarkable. She was then admitted to the [Hospital Ward Name 332] Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Bipolar disorder (times eight years). 2. Type 2 diabetes mellitus. 3. Osteoarthritis. 4. A questionable history of asthma. 5. Gastroesophageal reflux disease. 6. History of gastric bypass surgery (complicated by a ventral hernia, and reversal of her bypass, as well as abdominal wall abscesses, and chronic abdominal pain). 7. Status post cholecystectomy in [2133]. 8. History of iron deficiency anemia. 9. History of amenorrhea and possible polycystic ovary syndrome. ALLERGIES: Unknown at the time of admission, but was reported as no known drug allergies on previous medical records. MEDICATIONS ON ADMISSION: (By report, her medications on admission included) 1. Paxil 30 mg by mouth once per day. 2. Klonopin 2 mg by mouth. 3. Seroquel 200 mg by mouth. 4. Topamax. 5. Trazodone. 6. Ambien. 7. Albuterol as needed. By report, medications the patient may have ingested (which were prescribed to a friend of hers) included Glucophage, glyburide, Lipitor, Wellbutrin, and atenolol. SOCIAL HISTORY: Positive tobacco use. No intravenous drug use. By report, the patient is homeless but has been living with friends. She recently moved from [State 108]. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission included a temperature of 99.6 degrees Fahrenheit, her blood pressure was 101/48, her heart rate was 88, initially on assist control 500 X 20 with an FIO2 of 40% and a positive end-expiratory pressure of 5 with PIPS of 32 and plateau pressures of 20. On examination, she was nasally intubated. She was comfortable, intubated, and sedated. Head and neck examination revealed the sclerae were anicteric. The mucosa were moist. Jugular venous distention was difficult to assess secondary to obesity. The lungs were clear anteriorly and laterally. Cardiovascular examination revealed a regular rate and rhythm. The abdomen was notable for positive bowel sounds. There was a ventral hernia. The abdomen was nondistended. The extremities had trace edema bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Initial laboratories were notable for a white blood cell count of 5.8, her hematocrit was 43.3, and her platelets were 207. Coagulations were normal. Initial Chemistry-7 revealed her sodium was 143, potassium was 4.1, chloride was 109, bicarbonate was 20, blood urea nitrogen was 10, creatinine was 0.7, and her blood glucose was 95. Her calcium, magnesium, and phosphate were within normal limits. Normal anion gap. Initial urinalysis with positive nitrites, 3 to 5 white blood cells, and many bacteria. There were no epithelial cells. Her lithium level was 0.2. Initial urine toxicology screen was negative. Her liver function tests were within normal limits. Urine pregnancy test was negative. PERTINENT RADIOLOGY/IMAGING: Initial head computed tomography revealed no intracranial hemorrhage. No fractures. Suboccluded ethmoid sinuses likely secondary to nasogastric intubation. An electrocardiogram with nonspecific ST changes, but no Q-T prolongation. A chest x-ray was without acute cardiopulmonary abnormalities. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: The patient was initially intubated for airway protection prior to nasogastric tube placement and activated charcoal for a likely overdose. After the charcoal was given, and the effects of the benzodiazepines had worn off, she was slowly weaned off the ventilator and extubated on [3-13]. After her extubation, she continued to have respiratory distress with an increased respiratory rate and increased A-A gradient. She continued to have respiratory distress with an increased respiratory rate and increased A-A gradient on arterial blood gas. Because of this, she was reintubated. During her reintubation she had episodes of vomiting and was thought to have possible aspiration pneumonia. A right internal jugular central line was placed, and an arterial line was placed for close monitoring of her central venous pressure and blood pressure. During her hospital course, she had some difficulty weaning because of elevated transpleural pressures given her obesity. Her positive end-expiratory pressures were increased accordingly because of these elevated transportal pressures. A Big Boy bed was obtained which would allow the patient to sit more upright so she would have decreased pressure from the abdomen affecting her respiratory ability. Her sedation was weaned down, and she had good respiratory rates and had done well on a breathing trial. On [3-18], she was extubated and slowly weaned off oxygen to nasal cannula. It was felt that she likely had baseline oxygen saturations in the low 90s and was weaned down accordingly. She was continued on nighttime [Hospital1 ]-level positive airway pressure as done previously. 2. INFECTIOUS DISEASE ISSUES: The patient likely had an aspiration pneumonia during her reintubation. Bronchial washings obtained were notable for methicillin-resistant Staphylococcus aureus, and she was treated empirically for methicillin-resistant Staphylococcus aureus and/or aspiration pneumonia with vancomycin and Flagyl; to complete a 10-day course. She had [12-30] positive blood cultures which grew coagulase-negative Staphylococcus and were thought to likely be contaminant. She had a transthoracic echocardiogram performed prior to the speciation of her blood cultures which was negative for vegetations and showed a normal ejection fraction. Subsequently, her internal jugular line and arterial line were pulled. She remained afebrile. 3. GASTROINTESTINAL ISSUES: The patient has a history of gastric bypass surgery with numerous complications including a ventral hernia and chronic abdominal pain. Records were obtained for [Hospital6 1129] where she had her previous surgeries. On the day of her reintubation, she was noted to have significantly increased abdominal distention and there was concern for a small-bowel obstruction given her history of surgeries and likely adhesions. The Surgery Service was consulted. The orogastric tube was placed to suction, and the patient had an abdominal computed tomography which was concerning for an ileus versus a small-bowel obstruction. She was kept on bowel rest and slowly had a decrease in her abdominal distention and had good bowel sounds. After extubation her orogastric tube was pulled. The patient was able to tolerate a by mouth diet with minimal abdominal pain. She was felt to be at her baseline. 4. CARDIOVASCULAR ISSUES: While intubated the patient required several intravenous fluid boluses to maintain appropriate central venous pressures and to maintain good urine output. Over her Intensive Care Unit course, she was over 12 liters positive with no evidence of congestive heart failure or lower extremity edema. After her extubation, she auto-diuresed a significant amount of fluid and was hemodynamically stable upon transfer. 5. PSYCHIATRIC ISSUES: The patient was restarted on her outpatient medications once these records were obtained. After she was extubated, she was placed on a one-to-one sitter. The Psychiatry Service was consulted. Their recommendations were to continue her on Seroquel as well as Klonopin and Ativan as needed. Other medications would be added during subsequent psychiatric followup. It was felt that she would likely need eventual transfer to an inpatient psychiatric facility after medically stabilized. 6. DISPOSITION ISSUES: The patient continued to do well after extubation and was felt to be stable from a respiratory standpoint. Her mental status was felt to be at baseline, and she was tolerating by mouth without complaints. She was then transferred to the medical team for further care with eventual transfer to an inpatient psychiatric facility given her history of bipolar disorder and recent suicide attempt. NOTE: A follow-up dictation will dictate the [Hospital 228] hospital course after [3-20]. DR [First Name4 (NamePattern1) 2416] [Last Name (NamePattern1) 2415] 12.929 Dictated By:[Last Name (NamePattern1) 6289] MEDQUIST36 D: [2144-3-20] 18:12 T: [2144-3-21] 09:13 JOB#: [Job Number 55081] Name: [Known lastname 10312], [Known firstname 10313] Unit No: [Numeric Identifier 10314] Admission Date: [2144-3-11] Discharge Date: [2144-3-23] Date of Birth: [2110-8-30] Sex: F Service: HOSPITAL COURSE: (Addendum): Since the previously dictated discharge summary, the patient was called out from the Intensive Care Unit to the regular medicine floor. At the time of call out, the patient was extubated and on five liters nasal cannula. She was on day eight of antibiotics for treatment of aspiration pneumonia, and she was constipated. PROBLEM #1: Respiratory status: Within two days, the patient's oxygen was weaned to room air, and she was saturating 96 percent in room air. She was continued on metered dose inhalers, Atrovent and albuterol. In addition, the patient's family brought in her continuous positive airway pressure machine, and she was started on continuous positive airway pressure at night. She finished a ten-day course of intravenous antibiotics, metronidazole and Vancomycin, for treatment of aspiration pneumonia. She was maintained on Methicillin resistant Staphylococcus aureus precautions as she had a positive sputum culture while she was in the Intensive Care Unit. The patient was ambulating well without dyspnea. She had a chair bed to prevent hypoventilation during the night from lying flat. PROBLEM #2: Constipation: The patient had not had a bowel movement from the day of admission, approximately ten days. She was given an aggressive bowel regimen and had a large, black bowel movement. Her hematocrit remained stable, and her stool was not guaiac positive. In addition, the patient is on iron which is most likely the cause of the black coloration of her stool. She continued to have stools daily prior to discharge. PROBLEM #3: Diabetes/glucose intolerance: The patient has glucose intolerance at baseline. She was placed on an insulin sliding scale; however, she did not require any insulin during her hospitalization. This should be followed as an outpatient. PROBLEM #4: Psychiatry: The patient is status post a suicide attempt by overdose of Klonopin. The patient was maintained on Seroquel, Klonopin, and her paroxetine was increased from 20 mg to 40 mg prior to discharge. The patient will be transferred to a psychiatric inpatient unit. The patient is being discharged to .................... Care Facility. DISCHARGE CONDITION: Ambulating. Oxygen saturation is approximately 96 percent in room air, using continuous positive airway pressure at night. The patient is having bowel movements. She is pleasant, on a one-to-one sitter, and off of antibiotics. Medical issues are resolved. FINAL DIAGNOSIS: 1. Suicide attempt. 2. Bipolar disorder. 3. Klonopin overdose. 4. Aspiration pneumonia with Methicillin resistant Staphylococcus aureus isolated from sputum. 5. Hypotension. 6. Anion gap metabolic acidosis. 7. Partial small bowel obstruction. 8. Hypoxia. 9. Constipation. 10. Urinary tract infection. 11. Obesity. 12. Sleep apnea on continuous positive airway pressure. 13. Gastroesophageal reflux disease. 14. Iron deficiency anemia. 15. Glucose intolerance. 16. History of gastric bypass. FOLLOW-UP: She is to have recommended follow-up with primary care physician as needed. She is to follow-up with a psychiatrist as directed. DISCHARGE MEDICATIONS: Her discharge medications include ferrous sulfate 325 mg p.o. b.i.d., bisacodyl 10 mg p.o. q.day p.r.n. constipation, clonazepam 1 mg p.o. t.i.d., quatiapine 200 mg p.o. b.i.d., quatiapine 50 mg p.o. q.4 hours p.r.n., Lactulose 30 cc q.8 hours p.r.n. constipation, ipratropium metered dose inhaler two puffs q.i.d., albuterol inhaler one to two puffs q.6 hours p.r.n., Paroxetine 40 mg p.o. q.day, Colace 100 mg p.o. b.i.d. p.r.n. constipation, and Senna 8.6 mg p.o. b.i.d. p.r.n. constipation. DR.[First Name (STitle) ],[First Name3 (LF) ] 12-929 Dictated By:[Last Name (NamePattern1) 2823] MEDQUIST36 D: [2144-3-23] 14:27 T: [2144-3-23] 14:10 JOB#: [Job Number 10315]	[ "507.0", "482.41", "560.9", "599.0", "518.81", "E950.3", "296.7", "969.4", "276.2" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "99.15", "38.91", "38.93" ]	icd9pcs	[ [ [] ] ]				12781, 13042					13727, 14454				2690, 3069	10581, 12759	13059, 13703																					5217, 10563																		206, 2034														2056, 2662	3086, 5183
10,188	152,457	9030+55996	Discharge summary	report+addendum	Admission Date: [2110-5-16] Discharge Date: [2110-5-29] Date of Birth: [2047-12-12] Sex: M Service: MEDICINE Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[First Name3 (LF) 2297] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 951] is a 62 year-old male with a history of aortic coarctation status post homograft repair at age 13, recently status post ascending to descending aorta bypass graft with 18 mm Gelweave [2110-1-29] complicated by sternal wound dehiscence and graft infection (CNS, non-hemolytic streptococcus), RV laceration requiring repair, VRE bacteremia, candidemia ([3-26] [Female First Name (un) 564] parapsilosis), VAP (MRSA in sputum [3-6], then ESBL Klebsiella and yeast), HIT, with two recent admissions for fever, most recently discharged on [2110-5-9] following admission for fever attributed to UTI (Pseudomonas at [Hospital1 ]). * He now presents from [Hospital3 105] with a 2-day history of recurrent fever while on Bactrim (for ESBL in sputum [5-13]), Ciprofloxacin and Doxycycline suppressive therapy. Per nurse [First Name (Titles) ] [Hospital1 31242], he was pancultured. This AM, he was tachycardic, hypotensive (BP 70/44), and was given Vancomycin 1 gm IV and Amikacin 450m mg IV X1. He was given about 2 L of IVF, and started on Levophed for persistent hypotension. His Hct was also 23, but no transfusion was administered. Per nursing notes, ? black stools. He was transferred to the [Hospital1 18] ICU for further care. * On ROS, patient reports abdominal pain. Review of records reveals a KUB performed at [Hospital1 ] on [2110-5-14] that revealed an ileus, but no definite obstruction or free air was noted. Past Medical History: -Status-post ascending aorta to descending aorta bypass graft with 18mm gelweave [2110-1-29] -Repair of right ventricular laceration and sternal wound debridement [2-10] -Coarctation of the distal Arch s/p Surgical Repair of Arch/Desc. -Aorta w/ Homograft via Left Thoracotomy at age 13 -Bicuspid Aortic Valve -Congestive Heart Failure: most recent echo was TEE [2-21] done after RV laceration repair, but at that time EF was >55% -Hypercholesterolemia -Psoriatic Arthritis -Osteoarthritis -Asthma -Sciatica -Hemorrhoids -Meckel's Diverticulum s/p surgery -Right Lung Nodule -s/p L2-L3, L4-L5 sacral fusion -s/p L Subacromial decompression via arthroscopy -s/p Appendectomy -s/p Open Cholecystectomy -s/p R Inguinal Hernia Repair -s/p Nasal surgery for deviated septum -s/p Lens Implants -h/o HIT -recent MRSA pneumonia -h/o atrial fibrillation during hospitalization -h/o VRE bacteremia (linezolid through [2110-4-2]) -recent MRSE aortic graft infection -s/p open jejunostomy tube placement [2110-2-24] -s/p percutaneous tracheostomy [2110-3-21] Social History: No tobacco, no EtOH. Married, has 2 children. Family History: Maternal Uncles died in 50's from MI Physical Exam: VITALS:T 98.0 BP 103/66 HR 100 RR26 VENT: AC 500X16, PEEP 5, FiO2 0.60, Saturation 100% GEN: Middle-aged male with tachypnea, in mild discomfort. HEENT: Anicteric, MMM NECK: Trach in place, difficult to assess JVP secondary to collar. CV: Tachycardic, regular. Normal S1,S2. No murmurs. CHEST: Area of protrusion over central chest, wound healed. RESP: Coarse BS anteriorly, bialteral crackles. ABD: Soft, mild abdominal distension. Mild TTP over LLQ, no rebound or guarding. Negative [Doctor Last Name 515]. PEG tube in place. EXT: 2+ pedal bilaterally. Strong left DP, right DP. Right PICC line in place. NEURO: Awake, alert, unable to speak due to trach. INTEGUMENT: Sacral ulcers, with erythema, no purulence. Pertinent Results: MICRO DATA: [5-8] Sputum ESBL Klebsiella, yeast [4-20] Sputum ESBL Klebsiella, yeast [4-17] Pleural fluid negative [4-16] Sputum ESBL Klebsiella, yeast [4-8] Sputum ESBL Klebsiella [3-26] Blood culture 1 bottle [Female First Name (un) 564] parapsilosis (PICC) [3-8] Sputum MRSA [3-6] Wound VRE [3-3] Fem a-line CNS [3-2] Blood culture VRE [2-24] Wound CNS, non-hemolytic streptococcus * EKG on arrival: NSR, rate 78 bpm, normal axis, QRS 112 msec, IVCD. Diffuse non-specific ST-T changes, no change versus prior. * RELEVANT IMAGING DATA: [2110-5-16] AXR: Non-specific gas pattern. * [2110-5-16] CXR (comparison [2110-5-8]): Heart size stable, marked worsening of bilateral pulmonary edema and pleural effusions, no change in retrocardiac opacity/atelectasis. * [2110-5-14] AXR: Dilated loops of bowel without evidence of obstruction, suggestive of ileus. * [2110-5-8] ECHO: [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated. RA moderately dilated. Mild symmetric LVH. LV cavity size normal. LV systolic function appears depressed. Overall LVEF. Moderately thickened AV valve leaflets. AV not well seen. Mild AV stenosis. MV valve leaflets mildly thickened. 1+ MR. [First Name (Titles) ] [Last Name (Titles) ] systolic hypertension. E/A ratio 1.07. Brief Hospital Course: #Sepsis: Patient was admitted to the [Hospital Unit Name 153] and underwent agressive fluid resuscitation. He required pressor support with levophed. Patient has a very complicated history of multiple infections by multiple organisms including MRSA, VRE, and ESBL klebsiella. He has a chronically infected intra-thoracic graft for which he is on chronic suppressive therapy with doxycycline. He had a PICC line which was discontinued as a possible source of infection. Multiple cultures were sent, including blood, urine, sputum, and the PICC tip. Patient was started on Linezolid and meropenem, and on HD#3, his blood cultures from [5-15] drawn at [Hospital3 105] came back positive for ESBL klebsiella. A sputum culture from [5-16] from here grew resistant Acinetobacter and ESBL Klebsiella. IV Bactrim was added to help cover the MDR Klebsiella and Acinetobacter. Given his complicated hx, ID was consulted to assist with management of his chronic infections. ID recommended continuing the Linezolid, Bactrim IV, and Meropenem as we were doing, and discontinuing the suppressive Doxycycline therapy. ID recommended draining R pleural effusion that was seen on a Chest CT that had been obtained during this admission. U/S guided drainage of the effusion did not grow any bacteria, although this was after 5 days of Abx therapy. Blood cx's drawn here remained negative to date. The left effusion was felt to be too small to tap per IR. In addition, In summary, after speaking with our infectious disease colleagues, they recommended the following. 1) Lifelong Linzeolid with weekly CBC monitoring 2) A total of 4 weeks of IV Bactrim; if patient remains stable clinically, ok to d/c 3) Would continue the Meropenem for at least a month as well. If able to d/c the Bactrim because of clinically stability, OK to d/c Meropenem a few days afterward. Would also consult ID at [Hospital1 ] on a as-needed basis. . 2) Ventilator-dependence: Given his lack of sternum, it was felt that likely would not be able to wean off the ventilator. Thoracic surgery was contact[Name (NI) ] and felt that the patient was not a candidate for further surgical interventions for his ventral hernia or chronic mediastinitis. Patient was left on his settings as from OSH, and he was transferred back to [Hospital1 ] for long term vent management. * 3) Adrenal Insufficiency: Patient with a hx of adrenal insufficiency and arrived on chronic Hydrocort 25 mg PO qD. He was placed on IV stress dose steroids on arrival which were slowly tapered over the ten days of his [Hospital Unit Name 153] admission. On discharge, his steroids were converted back to his standing PO dose. . 4) Anemia: Anemia of chronic disease, hct at baseline (20-24). Transfused prn during this admission to maintain hct >21. * 5) FEN: Continued on TFs by PEG tube to maintain nutrition. He was diuresed with lasix as needed. * 5) Ppx: No heparin products given history of HIT. Pneumoboots. Keep HOB elevated at 45 degrees. Lansoprazole. . 6) Code: DNR. Trached and intubated. Palliative care consult obtained in house. After several discussions with [Hospital1 18] [Hospital Unit Name 153] attending physician, [Name10 (NameIs) ] family, and accepting doctor [First Name (Titles) ] [Hospital1 31242], ultimate decision is to treat underlying PNA as we are doing, but that patient will remain both DNR/DNI and should he clinically decompensate, DNH with plans for hospice care at [Hospital1 ]. Medications on Admission: Bactrim 160 mg IV Q6 hours (changed from PO on [2110-5-16], started [2110-5-13] for ESBL Klebsiella in sputum) Doxycycline 100 mg PO Q12 hours Cipro 500 mg PO Q12 hours Amikacin 450 mg IV x1 Vancomycin 1 gm IV X1 Hydrocortisone 25 mg PO QD Insulin NPH 8U [Hospital1 ] with RISS TID ASA 81 Amiodarone 200 QD Klonipin 0.5 mg q8 hours Amitriptyline 25 qhs Lipitor 10 mg PO QD Singulair 10 mg PO QD MgOx 800 mg QD Senna/Colace Lunesta 2 mg PO QHS Bisacodyl 10 mg PR QD Benzonanate q8 hours prn Ondansetron 4mg IV q8 prn Protonix 40 QD Miconazole TP Lactulose prn Tylenol prn TPN Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: 1. ESBL Klebsiella pneumonia and bacteremia 2. Acinetobacter pneumonia 3. s/p sternectomy Discharge Condition: stable; note, Pt is DNR/DNH Discharge Instructions: Please follow up with the doctor [First Name (Titles) ] [Hospital3 ]. . Please take medications as listed below. . If develop chest pain, worsening secretions, fever, abdominal pain, or any other symptoms, please notify the rehab doctor. After speaking with our infectious disease colleagues, they recommend: 1) Lifelong Linzeolid with weekly CBC monitoring 2) A total of 4 weeks of IV Bactrim (dates below); if patient remains stable clinically, ok to d/c 3) Would continue the Meropenem for at least a month as well. If able to d/c the Bactrim because of clinically stability, OK to d/c Meropenem a few days afterward. Would also consult ID at [Hospital1 ] on a as-needed basis. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16881], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2110-7-31] 10:00 Name: [Known lastname 904],[Known firstname 126] A Unit No: [Numeric Identifier 5437] Admission Date: [2110-5-16] Discharge Date: [2110-5-29] Date of Birth: [2047-12-12] Sex: M Service: MEDICINE Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[First Name3 (LF) 5448] Addendum: What follows are specific recommendations regarding Mr [Known lastname 5449] [Last Name (NamePattern1) ] and length of treatment as discussed by Drs [First Name (STitle) 5450] and [Name5 (PTitle) ]. 1. The patient should NOT be on lifelong linezolid. 2. If the patient is doingwell at rehab over the 2 weeks following transfer, that the bactrim should be stopped and the patient should be watched closely. At 4 weeks after transfer, if he continued to do well, he should have a repeat CT of the chest to see if there was residual mediastinitis and effusions. If the scan looks ok, the meropenem (for Klebs pneumonia/bacteremia and possibly infected effusions) and the linezolid (for VRE mediastinitis) could be stopped, either together or one at a time. 3. There was no firm recommendation as to the exact stop date of antibiotics. He would need to be doing well (afebrile, normal wbc, etc) and the scan would need to be reassuring. If those criteria were met, it would be okay to stop and follow. 4. Someone at rehab should make the decision re d/c of the meds, since they would be seeing him daily. It would be irresponsible for the infectious disease team to make those recommendations since they are not seeing him daily. 5. Finally, the cardiothoracic surgeons consulted on this patient during his hospitalization and stated that he was no longer a surgical candidate, that surgical intervention would be unsafe and unfeasible, and that they would not intervene under any circumstances (for debridement, etc). Discharge Disposition: Extended Care Facility: [Hospital3 2215] - [Location (un) 42] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5451] MD [MD Number(2) 5452] Completed by:[2110-6-12]	[ "511.8", "428.0", "255.4", "482.83", "V15.1", "300.00", "707.03", "747.10", "785.52", "995.92", "518.83", "V44.0", "519.2", "038.49", "553.29", "285.29", "518.81", "482.0" ]	icd9cm	[ [ [] ] ]	[ "34.91", "96.72", "33.21", "96.6", "38.93", "00.14", "99.04", "93.90" ]	icd9pcs	[ [ [] ] ]	12430, 12659	5190, 8714	324, 331	9557, 9586	3822, 5167	10330, 12407	3030, 3068				9444, 9536		8740, 9329			9610, 10307								3083, 3803																					266, 286									359, 1856														1878, 2950	2966, 3014
56,128	127,394	33872	Discharge summary	report	Admission Date: [2139-6-16] Discharge Date: [2139-6-19] Date of Birth: [2094-6-5] Sex: F Service: MEDICINE Allergies: Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac / Potassium Attending:[First Name3 (LF) 348] Chief Complaint: chest pain, hypotension Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is a 45 year-old female with ESRD (on HD), chronic abdominal pain on narcotics, type 2 DM, HTN, HLD, CAD (h/o inferior MI, normal MIBI [11/2138]), h/o DVT, with extensive psychiatric history admitted on [2139-6-16] for chest pain and hypotension. She developed substernal chest pain the AM of admission at her Psychiatric group home which was not relieved with nitroglycerin. She also noted dizziness and lightheadedness while standing. She notes she may have syncoped, but this was unwitnessed and she denies LOC or head trauma. EMS arrived and administered ASA 325 mg. Of note, she reportedly has chronic dyspnea and often hyperventilates. . In the ED, VS 100.2 107 92/65 17 98% 2L NC. She was persistently hypotensive with SBP 73, which resulted in LIJ placement and initiation of Levophed gtt. EKG was concerning with new small TWI in lead I, aVL; Cardiology felt no urgent intervention was necessary given recent reassuring MIBI (1/[2138]). She was given Ativan 2 mg IV, Dilaudid 2 mg IV, Vancomycin 1 g IV, Zosyn IV, Benadryl 50 mg IV and 1L NS x 1. She had a CT abdomen/pelvis demonstrating an occlusion of the left subcalvian vein and collaterals to the LUE from the right with a thrombus in the right innominate vein graft with trace flow. There was no evidence of pulmonary embolus. An IVC filter was in place. There was a round structure in the anterior chest wall in the subcutaneous tissue could which was thought to be a sebaceous cyst. . Of note, the patient was seen in the ED on [2139-5-25] for a vulvar abscess which was I&D'ed with wick placement. Prior to that the patient was discharged on [2139-5-7] after admission for a viral-like syndrome with negative blood cultures. In discussion with [Location (un) ] dialysis of [Location (un) ], her last session was [2139-6-8] in which her post-weight was 91.3 kg (she had 3 kg removed) and she had an extra-HD/UF session Saturday ([2139-6-13]) for 2-hrs removing 2.5 kg. Her SBP has reportedly been 80-90s at baseline. . She was admitted to the MICU complaining of chest pain localized substernally with pain from the telemetry stickers on her chest; associated with generalized body pain. While in the MICU, she was continued on Levophed gtt with SBP of 100s, and upon cessation her pressures returned to 70 systolic. She received a dose of Kayexalate for a K+ 5.3 and her antibiotics were not continued. She received HD on Wednesday. Midodrine 2.5 mg PO TID was initiated given her tenuous SBPs. Given her hypotension, a random cortisol was found to be 22.2 on [2139-6-18] and Endocrinology was consulted and felt this value would be unlikely in the setting of adrenal insufficiency, thus [Last Name (un) 104]-stimulation was not recommended. . Currently, the patient denies chest pain or lightheadedness and dizziness. She has no vision changes or headaches; denies nausea or vomiting, currently she is without abdominal pain; she is anuric; denies numbness or tingling. She tolerated a diet today. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Hypotension (likely mineralocorticoid deficient, hypo-renin, hypo-aldosterone, not likely complete adrenal insufficiency vs. autonomic dysfunction on Florinef) 2. ESRD on HD M/W/F (RUE AV-fistula) 3. type 2 diabetes mellitus 4. coronary artery disease (inferior MI, cardiac cath [2129], EF 65%, inferior hypokinesis; MIBI [11/2138] no perfusion defects, no ischemic ST changes) 5. h/o LLE DVT (no longer on coumadin), popliteal DVT ([7-/2136]) s/p IVC filter placement 6. hypertension 7. GERD 8. h/o positive MRSA swab ([2138]) 9. hyperlipidemia 10. chronic abdominal pain (no etiology identified, extensive work-up including MRA abdomen, strongyloides serologies, RUQ U/S, multiple KUBs) 11. borderline personality disorder 12. drug-seeking behavior, ? suicidality 13. left eye prosthesis (followed by ophthalmology at [Hospital1 2177]) Social History: Born in [Country 2045] and moved from [State 108]; divorced, has two daughters who lives with their father; denies tobacco use, denies alcohol use and denies recreational substance use. Family History: Mother died from diabetes complications, brother died from the same as well; Sister and daughter have diabetes. Physical Exam: ON ADMISSION: VITALS: 98.2/98.2 78 102/61 14 94%RA HEENT: Normocephalic, atraumatic. EOMI on right, left eye prosthesis with minimal L>R periorbital edema. PERRL on right. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. No evidence of prior scars. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses NEURO: CN II-XII, DTRS 2+ throughout, strength 5/5 throughout, gait: deferred ON DISCHARGE: VITALS: 98.6/97.3 74 118/P 18 97%RA I/O: 380/HLIV \| HD BG: 149-322 HEENT: Normocephalic, atraumatic. EOMI on right, left eye prosthesis with minimal L>R periorbital edema. PERRL on right. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. No evidence of prior scars. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses; RUE fistula without bruit NEURO: CN II-XII, DTRS 2+ throughout, strength 5/5 throughout, gait: deferred Pertinent Results: [2139-6-18] 02:35AM BLOOD WBC-4.9 RBC-4.13* Hgb-12.7 Hct-38.4 MCV-93 MCH-30.8 MCHC-33.1 RDW-18.9* Plt Ct-125* [2139-6-17] 03:51AM BLOOD Neuts-73.6* Lymphs-17.3* Monos-5.2 Eos-3.2 Baso-0.7 [2139-6-17] 03:51AM BLOOD PT-13.8* PTT-34.7 INR(PT)-1.2* [2139-6-18] 02:35AM BLOOD Glucose-111* UreaN-19 Creat-6.6# Na-134 K-3.2 Cl-89* HCO3-33* AnGap-15 [2139-6-16] 09:27AM BLOOD ALT-20 AST-23 CK(CPK)-87 AlkPhos-280* TotBili-0.3 [2139-6-16] 12:23AM BLOOD Lipase-46 [2139-6-17] 03:51AM BLOOD CK-MB-6 cTropnT-0.10* [2139-6-16] 04:00PM BLOOD CK-MB-5 cTropnT-0.10* [2139-6-16] 09:27AM BLOOD CK-MB-4 cTropnT-0.08* [2139-6-16] 12:23AM BLOOD CK-MB-3 cTropnT-0.08* [2139-6-18] 02:35AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.5 . MICROBIOLOGY: [2139-6-16] Blood culture - pending [2139-6-16] Blood culture - pending [2139-6-16] C.diff toxin - negative . EKG: NSR 100, trifasicular block (RBBB and LAFB) with LAD, hyperdynamic T waves compared to previous EKG in [2-/2139] and TWI in I, aVL. . IMAGING: [2139-6-16] CT ABD & PELVIS WITH CO - Occlusion of the left subcalvian vein and collaterals to the LUE from the right (could be from an intercostal vein. Thrombus in the right innominate vein graft; however, there is a trace flow in a portion of the thrombus. No pulmonary embolus or thoracic aorta dissection. Normal appendix and gallbladder. No bowel obstruction. IVC filter in place. Small kidneys with no hydronephrosis. Increased density in the skeleton which could be from renal osteodystrophy. Round structure in the anterior chest wall in the subcutaneous tissue could be a sebaceous cyst, correlate with clinical exam. Brief Hospital Course: IMPRESSION: 45F with PMH significant for ESRD (on HD), chronic abdominal pain on narcotics, type 2 DM, HTN, HLD, CAD (h/o inferior MI, normal MINI [11/2138]), h/o DVT, with extensive psychiatric history admitted on [2139-6-16] to the MICU for chest pain and hypotension requiring pressors. . PLAN: # HYPOTENSION - The patient presented with a repored history of SBP 80-90s at baseline without symptoms and with good mentation. However, it appears that given her extra dialysis session prior to admission, she may have developed some pre-syncopal symptoms of lightheadedness and dizziness prior to her admission with hypovolemia. The patient was admitted to the MICU on admission because she transiently required Levophed gtt in the ED, and this was quickly weaned in the ICU. Per Endocrine, the patient was noted to have likely dysautonomia from her long-standing diabetes and a possible elements of mineralocorticoid deficiency. Her random cortisol in the MICU was 22.2 and she had no evidence of adrenal insufficiency. She was continued on Florinef, the dose was initially increased to 0.2 mg PO BID, and then was dropped to her home dosing of 0.1 mg PO BID. The patient was also started on Midodrine 2.5 mg PO TID in the ICU to support her pressure, but this was subsequently discontinued prior to discharge. Her vitals were supportive of orthostatic hypotension. It was felt that dysautonomia in the setting of an extra HD session may have precipitated her lower systolic pressures. She continued with HD sessions while hospitalized. She remained hemodynamcially stable on telemetry prior to discharge. She also had an infectious work-up with negative blood and urine cultures, C.diff was negative, with no PNA on imaging. We recommended that she consider outpatient tilt table testing, if a diagnosis of dysautonomia is in question. She was dialyzed before discharge and her systolic pressures improved. . # EKG CHANGES - The patient has baseline tri-fascicular block (RBBB and LAFB) and also LVH and therefore T wave changes were difficult to interpret and non-specific (furthermore, discordance between ST and T wave is normal with BBB's) - T wave prominance could have been exacerbated by K+ (received single dose of Kayexalate). She had serial EKGs which were reassuring and she was monitored on telemetry. She had a reassuring repeat EKG and her telemetry monitoring was not concerning. She had her troponins trended given some chest pain and the above EKG changes on admission, and these values were reassuring. Cardiology was notifie of the above findings and felt satisfied that active coronary involvement was unlikely. She had a MIBI perfusion study performed in [11/2138] without perfusion defect noted. . # HYPERKALEMIA - admitted with K+ 9.2(hemolyzed) in the setting of ESRD on HD and possible mineralocorticoid deficiency; received 30 gm Kayexalate x 1 with good response for repeat elevated potassium in the range of 5; EKG changes may have been augmented given hyperkalemia, but less likely. Again serial EKGs were reassuring and her potassium improved with dialysis sessions. . # LEFT SUBCLAVIAN VEIN OCCLUSION - left subclavian vein occlusion noted with collaterals from right, see on admission imaging; unlikely need for anticoagulation and patient compliance is a concern and the fact that collateral flow suggests chronic thrombus and no evidence of acute neurologic findings were noted. . # CHRONIC HYPONATREMIA - noted since [Month (only) 547] of this year; improved with HD; likely occurring in the setting of volume overload - no mental status changes or neurologic concerns. Improved with HD regimen. . # THROMBOCYTOPENIA - platelet trend 157 - 156 - 125; no evidence of petechiae or active bleeding; will follow-up as outpatient. Was receiving subcutaneous heparin prophylaxis. . # CAD - The patient is status-post inferior MI and MIBI in [11/2138] was reassuring without a perfusion defect. Her 2D echocardiogram demonstrated an EF > 55% - though she had complaints of diffuse chest discomfort which resolved. There was some concern that hypovolemia or hypotension may have precipitated demand ischemia, but her troponin and EKG findings were reassuring. We continued her statin and aspirin dosing. We avoided beta-blockade and ACEI in the setting of hypotension concerns. . # CHRONIC PAIN COMPLAINTS - suspect somatization or psychiatric component given poor history and vague complaints in the setting of multiple imaging modalities that have failed to yield an etiology. The patient has had reassuring abdominal imaging on this admission and we continued her medications including: Flexeril, Gapabentin, Seroquel, Ativan and her Dilaudid dosing. . # ESRD ON HEMODIALYSIS - continued on HD regimen per Renal recommendations - M/W/F - continued nephrocaps, sevelamer and monitoring electrolytes. She was dialyzed the day of discharge; her medications were all renally dosed and we avoided nephrotoxins. . # TYPE 2 DIABETES - Her last HbA1c 6.0% in [2135], has been on Levemir and sliding scale insulin at home; evidence of ESRD, peripheral neuropathy - we opted to maintain her on glargine 18 units QHS with plans to return to Levemir when she is discharged. TRANSITION OF CARE ISSUES: 1. blood and urine cultures negative from this admission 2. follow-up will be scheduled with PCP, [Name10 (NameIs) ] following given HD regimen 3. will continue with outpatient HD regimen M/W/F Medications on Admission: HOME MEDICATIONS: 1. Aspirin 81 mg PO daily 2. Lorazepam 1 mg PO 3x/weekly (M/W/F) 3. Lorazepam 1 mg PO Q6H PRN anxiety 4. Atorvastatin 40 mg PO QHS 5. [Name10 (NameIs) ] 10 mg PO QHS 6. Bisacodyl 10 mg EC PO daily 7. Dicyclomine 20 mg PO QID 8. Docusate sodium 200 mg PO BID 9. Bisacodyl 10 mg PR QHS PRN constipation 10. Dilaudid 1 mg PO 3x/weekly (M/W/F) 11. Dilaudid 1 mg PO Q6H PRN pain 12. Erythromycin 250 mg EC PO Q8H 13. Fludrocortisone 0.1 mg PO Q12H 14. Gabapentin 100 mg PO QHS 15. Insulin aspart SSI 16. Levemir 6 units SC QHS 17. Magnesium hydroxide 400 mg/5 mL (30 mL) PO Q6H PRN constipation 18. Miralax 17 g powder PO QID 19. B complex-vitamin C-Folic acid 1 mg PO daily 20. Omeprazole 20 mg EC PO daily 21. Tizanidine 1 mg PO QHS 22. Lidocaine 5 %(700 mg/patch) Adhesive Patch 1 patch TD daily 23. Tobramycin-dexamethasone 0.3/0.1% ointment 1 pp ophth TID 24. Sevelamer carbonate 800 mg (3 tbs) PO TID, w/MEALS 25. Latanoprost 0.005 % drops 1 gtt ophth QHS 26. Hydroxyzine 25 mg PO Q6H PRN itching 27. Seroquel 50 mg PO QHS 28. Nitroglycerin 0.4 mg SL PRN chest pain 29. Aranesp 40 mcg/0.4 mL IJ weekly Ophthalmic HS (at bedtime). Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 4. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 5. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 14. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) powder PO DAILY (Daily) as needed for constipation. 17. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 18. insulin aspart 100 unit/mL Solution Sig: sliding scale sliding scale Subcutaneous every six (6) hours. 19. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO 3 times weekly: M/W/F on HD days. 21. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal at bedtime as needed for constipation. 22. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) mL PO every six (6) hours as needed for constipation. 23. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 24. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. 25. lorazepam 1 mg Tablet Sig: One (1) Tablet PO M/W/F: three times weekly. 26. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: Forty (40) mcg Injection once a week. 27. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital 16662] Nursing and Rehab Center - [Street Address(1) ] Discharge Diagnosis: Primary Diagnoses: 1. Hypotension 2. Hyperkalemia and Hyponatremia 3. Chest pain . Secondary Diagnoses: 1. Coronary artery disease 2. Type 2 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the Internal Medicine service at [Hospital1 1535] to the medical ICU and then transfered to CC7 regarding management of your hypotension and chest pain concerns. You had a reassuring cardiac evaluation. Your hypotension was attributed to diabetes-induced dysautonomia (or dysfunction of your blood pressure-neurologic response). An endocrine/hormone evaluation revealed no acute abnormalitis. You were continued on dialysis while an inpatient. Your blood pressure improved and your chest pain resolved, thus you were discharged home. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: * Upon admission, the following medications were ADDED: Ferrous sulfate * The following medications were DISCONTINUED on admission and you should NOT resume until discussion with your primary care physician: [Name10 (NameIs) ], Nitroglycerin sublingual, and Lidocaine patch. * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Patient resides at psychiatric nursing facility and thus will have PCP [Name9 (PRE) 702] scheduled by that facility. She will continue with her dialysis regimen and be followed by [Name9 (PRE) ].	[ "287.5", "337.1", "412", "583.81", "V12.51", "276.1", "250.62", "338.29", "276.7", "414.01", "403.91", "255.42", "426.54", "250.42", "272.4", "585.6", "453.75" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.97" ]	icd9pcs	[ [ [] ] ]	16964, 17063	7876, 13321	360, 388	17266, 17266	6179, 7853	19343, 19550	4582, 4696		14525, 16941		17084, 17167		13347, 13347			17417, 19320								4711, 4711	17188, 17245		13365, 14502													5421, 6160					296, 322									416, 3436							4726, 5406		17281, 17393					3458, 4354	4370, 4566
11,218	119,049	1797+1803+55317	Discharge summary	report+report+addendum	Admission Date: [2138-3-21] Discharge Date: Date of Birth: [2076-4-18] Sex: M Service: VSU CHIEF COMPLAINT: Infected left foot ulceration. HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman with known type 2 diabetes and peripheral vascular disease who has undergone multiple surgeries on the right foot and status post right below-knee popliteal to PT bypass graft in [2135-2-21], now with a 3-day history of increasing redness, swelling, and drainage from the plantar left foot callous that has been developing and within the last several days has broken down and has become infected. The patient denies any constitutional symptoms. He was admitted to the podiatry service for management of foot ulceration. ALLERGIES: Tetanus toxoid. MEDICATIONS ON ADMISSION: Cozaar 25 mg daily, Protonix 40 mg daily, colchicine 0.6 mg daily, warfarin 4 mg daily, Plavix 75 mg daily, Coreg 50 mg b.i.d., Lasix 40 mg b.i.d., aspirin 81 mg daily, Zocor 40 mg daily, folic acid 400 mcg daily, multivitamin tablet, NPH insulin 32 units q.a.m. and 34 units q.p.m. with a regular insulin sliding scale. PAST MEDICAL HISTORY: Type 2 diabetes, insulin dependent, poorly controlled, hypertension, history of dyslipidemia, history of skin melanoma status post multiple excisions, history of coronary artery disease status post multiple coronary stenting over the last 10 years, history of atrial fibrillation with a defibrillator implant 1 year prior to admission, episode of TIA with no residual affects, remote history of multiple foot surgeries, peripheral vascular disease, status post right below-knee popliteal to PT bypass graft in [2135-2-21]. PHYSICAL EXAMINATION: Vital signs are stable. General appearance, no apparent distress. Alert and oriented times three. HEENT exam shows no lymphadenopathy. Sclera are clear. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Cardiac exam shows a regular rate and rhythm with no murmurs, rubs, or gallops. No JVD. Pulmonary exam shows clear to auscultation without adventitious sounds. Abdomen is soft, nontender, nondistended. Bowel sounds are present x 4 quadrants. Extremities with full-thickness ulcer along the plantar aspect of left fifth metatarsal head that probes to soft tissue covering bone. Wound base is moist, dark, fibrotic, with slough that mildly probes distal and dorsally. There is no evidence of purulent drainage but there is surrounding erythema progressing proximally on the dorsum of the foot. Pulse exam shows Dopplerable DP and PT of the left foot. Neurological exam is unremarkable, nonfocal. HOSPITAL COURSE: The patient was admitted to the podiatry service. He was placed on bed rest. Antibiotics with Unasyn were instituted. Wound cultures were obtained. White count was 12.8, hematocrit 31.2, platelets 241,000, BUN 46, creatinine 1.4, with a potassium of 3.8. Foot x-ray on admission was negative for foreign body. There was no air in the soft tissues. There was no plain film evidence of osteomyelitis. Medical service was consulted for a preoperative cardiac assessment and management of the patient's chronic medical issues. Last echocardiogram done was [2135-2-21] which showed an ejection fraction of 20%-25% with left ventricular hypertrophy and moderately dilated cavity. There was severe global left ventricular hypokinesis, overall left ventricular systolic function severely depressed. The aortic root was mildly dilated. The aortic leaves were mildly thickened and the mitral valve leaflets were thickened. There was 1+ MR. There was no pericardial effusion. The patient also had a Persantine MIBI in [2136-2-21] which showed a thick myocardial perfusion, defective volume in inferior wall and an ejection fraction of 34%. The patient is anticoagulated for his atrial fibrillation and his carvedilol was increased for better rate control. His renal insufficiency recommendations were to make sure the patient was adequately hydrated prior to any study requiring contrast and to renal dose all medications. For his leukocytosis, they recommended continuing his current antibiotic therapy and to consider starting iron supplement if the patient's iron studies showed iron deficiency anemia. The medicine service recommended a stress test if the patient would require peripheral bypass surgery. The patient would be at a higher risk given his cardiac history. The patient's antibiotics were changed to vancomycin and ciprofloxacin. The patient's arterial studies showed a patent right popliteal PT bypass graft. The arterial studies demonstrated a triphasic Dopplerable femoral and popliteal with the monophasic DP and PT. The lower left thigh was 25 mm, calf 29, ankle 12, and metatarsal 7 mm. Ankle brachial index could not be calculated secondary to noncompressive vessels. An arteriogram was recommended at this point. The patient underwent a diagnostic arteriogram on [2138-3-25], with left leg run-off via right femoral artery access. Study demonstrated patent aorta with brisk nephrogram, no renal artery stenosis. The common external and internal iliacs were patent bilaterally. The left SFA was patent with diffuse disease with a 50%-60% stenosis in the proximal portion with a patent profunda femoris. The AK popliteal and BK popliteal were patent. The tibial peroneal trunk was patent. The PT showed a proximal stenosis of 60%. The vessel was small caliber. The peroneal was patent with reconstruction of the distal AT. The DP was patent. The plantars were patent. The AT occluded at the midportion. The patient tolerated the arteriogram well. His renal function remained stable. He had been hydrated with bicarbonate and Mucomyst p.o. prior and post angiogram. The patient complained of some chest pain and an EKG was obtained on [2138-3-25], which was unremarkable. Vein mapping was obtained to assess for adequate conduit for bypass grafting. He had a patent left greater saphenous and a patent less saphenous vein. He had patent bilateral basilic veins. [Last Name (un) ] was consulted for glycemic management. His NPH insulin was adjusted to 35 units b.i.d. Cardiology was consulted for assessment of outside studies. They felt his left ventricular dysfunction is out of proportion to the report and coronary artery disease suggesting a contaminant dilated cardiomyopathy. The patient was placed at a high risk for revascularization. The patient proceeded to surgery on [2138-3-27]. He at induction went into cardiogenic shock and cardiac arrest. He was resuscitated and transferred to the coronary care unit. An intra-aortic balloon was placed via the left femoral artery. EP was requested to interrogate the patient's AICD and they felt that this was functioning appropriately. Cardiothoracic surgery followed the patient after placement of intra-aortic balloon. The patient was weaned in an attempt to maintain an arterial vein pressure of greater than 65 with the possibility of extubating. Intra-aortic balloon was discontinued on [3-28]. His INR was allowed to drift and heparin drip was instituted per protocol. The patient was placed on an amiodarone and the patient converted to normal sinus rhythm. Cultures were obtained for an elevated white count from 10- 29. Antibiotics were continued. The patient was weaned and extubated on [2138-3-28]. He was transferred to the VICU for continued monitoring and care. The patient's vancomycin and ciprofloxacin were discontinued on [3-29] and he was begun on Augmentin for a total of 10 days. The patient had a low-grade temperature of 100.2 to 99.1. White count improved to 13.9 with a hematocrit of 26.9 down from 29. He required transfusion at that time. BUN was 39 with a creatinine of 3.5 up from 2.8. They felt this was probably secondary to his vascular collapse and underlying chronic renal insufficiency. On postoperative day 3, [2138-2-27], the patient continued to show improvement from a clinical standpoint. White count was 11.5. Post-transfusion hematocrit was 27.7. BUN 46, creatinine 4.1. Renal function and urinary output were monitored. Dr. [Last Name (STitle) ] was consulted regarding advisement to an interventional approach to the patient's left lower extremity ischemia. [Last Name (un) ] continued to make adjustments in his insulin dosing with improvement in his glycemic control. He continued to be followed by podiatry. Diuresis was held secondary to the patient's increasing creatinine. Coumadin continued to be held at this point but aspirin and Plavix and subcu heparin were continued. Foot cultures showed no segs and no polyps on Gram stain. Augmentin was continued. The patient was transferred to the floor for continued monitoring and care. Podiatry continued to follow the patient and recommendations were that he would initially require a debridement at some point of the left heel. This could be done on an outpatient basis or once the patient returns for consideration for revascularization when he is medically stable. The remaining hospital course was unremarkable. The patient will be discharged to home when medically stable. DISCHARGE MEDICATIONS: Plavix 75 mg daily, aspirin 81 mg daily, simvastatin 40 mg daily, folic acid 1 mg daily, Protonix 40 mg daily, amiodarone 400 mg daily, carvedilol 3.125 b.i.d., acetaminophen 325 mg tablets [12-24] q.4-6 hours p.r.n. pain, hydromorphone 2 mg q.2 hours p.r.n. pain, Amoxicillin/clavulanate 5/125 mg tablets q.12 hours for a total of 1 week, glargine insulin 40 units at breakfast with a regular sliding scale before meals and at bed time, Coumadin addendum will be made regarding dosing of this medication at discharge. DISCHARGE DIAGNOSIS: Ischemic infected left foot ulcer on the plantar surface of the left foot, history of peripheral vascular disease status post multiple right foot surgeries and a right below-knee posterior tibial bypass graft in [2135-2-21] which is patent by ultrasound, history of type 2 diabetes, insulin dependent, uncontrolled, history of dyslipidemia, history of skin melanomas, history of coronary artery disease status post cardiac stenting with multiple stents over the last 10 years, history of atrial fibrillation status post automatic implantable cardiac defibrillator, history of transient ischemic attacks without residual, operative cardiac arrest, resuscitated, cardiogenic shock, operative intra-aortic balloon placement, resolved, postoperative acute tubular necrosis secondary to diuresis, postoperative fever with negative cultures, postoperative blood anemia, transfused. MAJOR SURGICAL PROCEDURES: Diagnostic arteriogram with left leg runoff via the right femoral access on [2138-3-25], an aborted left leg bypass on [2138-3-27], cardiac arrest with cardiogenic shock on [2138-3-27], left femoral intra-aortic balloon placement on [2138-3-27], left femoral intra-aortic balloon removal on [2138-3-28]. FOLLOW UP: The patient should follow-up with Dr. [Last Name (STitle) 1391] in 2 weeks' time to discuss appropriate management of his leg ischemia. He should follow-up with Dr. [Last Name (STitle) ] in 1 weeks' time for management of his left heel ulceration. DISCHARGE INSTRUCTIONS: The patient should continue all medications as directed. He should follow-up with the appropriate appointments as recommended. He should follow-up with his primary care physician and cardiologist after discharge from home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2138-3-31] 10:34:28 T: [2138-3-31] 12:06:38 Job#: [Job Number 10104] Admission Date: [2138-3-21] Discharge Date: [2138-4-2] Date of Birth: [2076-4-18] Sex: M Service: SURGERY Allergies: Tetanus Toxoid Attending:[First Name3 (LF) 4748] Chief Complaint: Left foot ulcer Major Surgical or Invasive Procedure: angiogram with left leg runoff via right femoral access [2138-3-25] aborted left leg [Month/Day/Year 10117] [2138-3-27] cardiac arrest with cardogenic shock [2138-3-27] left femnoral IABP placement [2138-3-27] left femoral IABP removal [2138-3-28] History of Present Illness: 61 y/o male patient with significant PMH for DM(II) presents to [Hospital ] Clinic with CC of left foot ulcer that has become infected. The patient states that over the past few days he's noticed increased redness/drainage from the area of the ulcer. The patient denies any fevers, chills, vomiting, nausea or night-sweats. The patient denies any trauma to left foot. Past Medical History: Type 2 diabetes; hypertension; dyslipidemia; history of skin melanomas, s/p mult cardiac stents over past 10 yrs, A-fib w/ defibrilator implant 1 year ago on ASA, coumadin, plavix, episode of TIA w/ no residual effects, s/p mult R foot surgeries and s/p R BK [Doctor Last Name ]-PT [Name (NI) ] Social History: Lives at home with wife Denies any EtOH, TOB, IVDU Family History: N/C Physical Exam: NAD AOx3 NC/AT MMM Neck Supple CTAB, no r/w/r RRR, no m/r/g Soft NT/ND, (+)BS Left foot: non-palpable pulses, (+)ulcer that probes to bone 5th met head no frank pus expressed, (+)peri-wound erythema. Pertinent Results: [2138-3-26] 05:35AM BLOOD WBC-10.7 RBC-4.13* Hgb-10.9* Hct-32.8* MCV-80* MCH-26.3* MCHC-33.1 RDW-16.6* Plt Ct-231 [2138-3-25] 05:25AM BLOOD WBC-10.1 RBC-4.04* Hgb-10.9* Hct-32.2* MCV-80* MCH-27.0 MCHC-33.9 RDW-16.4* Plt Ct-232 [2138-3-24] 05:30AM BLOOD WBC-11.0 RBC-4.27* Hgb-11.3* Hct-34.5* MCV-81* MCH-26.3* MCHC-32.7 RDW-16.5* Plt Ct-243 [2138-3-23] 05:30AM BLOOD WBC-13.8* RBC-4.31* Hgb-11.4* Hct-34.4* MCV-80* MCH-26.5* MCHC-33.2 RDW-16.3* Plt Ct-305 [2138-3-22] 05:45AM BLOOD WBC-12.8* RBC-3.94* Hgb-10.6* Hct-31.2* MCV-79* MCH-26.9* MCHC-34.1 RDW-16.4* Plt Ct-241 [2138-3-22] 01:36AM BLOOD WBC-14.4# RBC-3.96# Hgb-10.8# Hct-31.5# MCV-80* MCH-27.3 MCHC-34.3 RDW-16.4* Plt Ct-232 [2138-3-26] 05:35AM BLOOD Plt Ct-231 [2138-3-26] 05:35AM BLOOD PT-PND PTT-PND INR(PT)-PND [2138-3-25] 05:25AM BLOOD Plt Ct-232 [2138-3-25] 05:25AM BLOOD PT-21.3* PTT-36.8* INR(PT)-2.1* [2138-3-23] 05:30AM BLOOD Plt Ct-305 RADIOLOGY Final Report FOOT AP,LAT & OBL LEFT [2138-3-23] 2:16 PM FOOT AP,LAT & OBL LEFT Reason: osteo [Hospital 93] MEDICAL CONDITION: 61 year old man with infected plantar left 5th met head ulcer REASON FOR THIS EXAMINATION: please r/o OM EXAMINATION: Left foot. INDICATION: Infected left plantar surface near the fifth metatarsal head. Three views of the left foot are obtained and show evidence of moderate vascular calcification. No acute bony injury is identified. No plain film evidence of osteomyelitis is seen in the current views. A soft tissue ulcer is seen at the level of the fifth metatarsal distally. IMPRESSION: Soft tissue defect with no foreign body and no air seen in the soft tissues. No plain film evidence of osteomyelitis. If this remains a strong clinical concern, an MR [First Name (Titles) ] [Last Name (Titles) 10118] medicine should be considered. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Approved: SUN [2138-3-23] 8:13 PM Brief Hospital Course: Left foot infection: The patient was admitted to the Podiatry service and a wound culture was obtained of his wound site. The patient was started on IV abx. that consisted of Unasyn. A Vascular consult was placed and NIAS were ordered. The patient's NIAS showed in-adequate PVR's to heal a distal wound. The patient was then taken for Angio which showed patent inflow to bkpop, diseased tibials with patent distal AT/DP and PT. The patient was then transferred to the vascular surgery service. . ICU course: Patient became hypotensive during anesthesia induction (etomidate, succinylcholine, propafol) for PVD bypass. He had lost tracing on arterial line and rhythm was uninterpretable on cardiac monitoring due to artifact. AICD delivered anti-tachycardia pacing x 2, and defibrillation x 1 for what appeared to be Ventricular tachycardia. ECG tracings demonstrated wide-complex tachycardia, per EP represented atrial fibrillation with RVR and aberrancy. Patient subsequently received external defibrillation with 200J and reverted to sinus rhythm. He was simultaneously started on milrinone, epinephrine, and norepinephrine. Patient was intubated, PA catheter and IABP were inserted and he was transferred to CCU after blood pressure was stabilized. Nitro gtt was started for afterload reduction. Patient was subsequently extubated without incident, IABP, Swan were pulled. The nitro gtt and insulin gtt were weaned off, and patient was transfered back to the vascular service. . Medications on Admission: Cozaar 25mg qd, Protonix 40 qd, Colchine 0.6 qd, Warfarin 4mg qd, Plavix 75mg qd, Coreg 25 2 tabs [Hospital1 ], Furosemide 40mg [Hospital1 ], ASA 81mg qd, Zocor 40mg qd, Folic acid 400mcg qd, MVT, NPH 32U am, 34Upm, ISS Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 9. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous once a day: breakfast : 40 units. 10. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection four times a day: AC: glucoses <120 no insulin glucoses 121-160/2u glucoses 161-200/4u glucoses 201-240/6u glucoses 241-280/8u glucoses >281/10u HS: glucoses <160 no insulin glucoses 161-200/2u glucoses 201-240/3u glucoses 241-280/4u glucoses >280 /5u u=units. 11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 12. Outpatient Lab Work INR 2x/week x 1 week call resultts to patient's PCP 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q3-4 hrs prn as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: ischemic infected left foot ulcer of plantar surface history of perhperal vascular disease,s/p rt. foot surgeries,multiple,s/p rt. bkpop-pt [Hospital 10117] [2-23] history of DM2,insulin dependant,un controlled history of dyslipdemia-statin history of skin melenomas history of coronary artery disease,s/p cardiac stenting ,multiple over last 10 yrs. history of AF,s/p AICD, s/p interrogation [3-29]-functioning history of TIA ,without residual operative cardiac arrest with cardogenic shock posotperative ATN postoperative blood loss anemia, transfused cervical spine degeneative arthritic changes by x ray [3-29] Discharge Condition: stable Discharge Instructions: have your inr monitered regularly by your PCP Followup Instructions: 2 weeks Dr. [Last Name (STitle) 1391], call for appointment [Telephone/Fax (1) 1393] Please call your PCP for [Name9 (PRE) 702] and coumadin dose adjustments. Please follow-up with your PCP or with [Name9 (PRE) ] [Hospital 982] Clinic; you need excellent blood sugar control. Please follow-up with your cardiologist within 2 weeks. You will need a stress test in [2-23] weeks as part of preoperative testing if a bypass is to be performed. Name: [Known lastname 1395],[Known firstname ] P Unit No: [Numeric Identifier 1396] Admission Date: [2138-3-21] Discharge Date: [2138-4-2] Date of Birth: [2076-4-18] Sex: M Service: SURGERY Allergies: Tetanus Toxoid Attending:[First Name3 (LF) 231] Addendum: [2138-4-2] d/c to home with services. INR 1.7 cr 3.6 inmproved from 3.9 will have inr monitered and chemistries monitered and results call ed to PCP. Discharge Disposition: Home With Service Facility: [Hospital 1397] Home Health Care [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2138-4-2]	[ "707.15", "722.4", "584.5", "427.31", "682.7", "272.4", "V58.67", "785.51", "V45.82", "285.1", "414.01", "V10.82", "V12.59", "280.9", "250.72", "427.5" ]	icd9cm	[ [ [] ] ]	[ "99.07", "97.44", "88.49", "88.48", "99.62", "88.42", "89.49", "37.61" ]	icd9pcs	[ [ [] ] ]	20440, 20663	15371, 16859	12047, 12322	19344, 19353	13376, 14445	19447, 20417	13136, 13141		17138, 18583	14482, 14544	18690, 19323		16885, 17115	2665, 9164		19377, 19424								13156, 13357									10980, 11237				1708, 2647								11992, 12009	14573, 15348								12350, 12725														12747, 13052	13068, 13120
54,788	123,083	23564	Discharge summary	report	Admission Date: [2169-4-26] Discharge Date: [2169-5-12] Date of Birth: [2120-1-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1377] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Diagnostic and Therapeutic Paracentesis History of Present Illness: 49 year old man with a past medical history of HIV (on HAART, CD4 252 and VL UD [3-22]), HCV cirrhosis, Crohn's disease and gastroporesis who presented with abdominal pain. Has had 5 days of worsening abdominal pain. Started in RUQ and intermittent. Progressed to diffuse and constant abdominal pain. Denies fevers, having some chills. Some baseline diarrhea due to lactulose. New non-productive cough and shortness of breath. Pain became progressively worse so presented to the ED for evaluation. Of note, patient weighed 67.5 Kg on [4-12]. On arrival to ICU patient weighs 72.8 kg. . In the ED, initial vs were: T99.2 P153 BP144/93 R22 O2 97% sat. Well appearing but uncomfortable. Soft, moderately distended, tender in RUQ. Guaiac positive stool in ED. Mild b/l pitting edema. No asterixis. Lactate 3.1. Dx paracentesis -> no e/o SBP. Similar admission in [Month (only) 958] treated with large volume paracentesis. RUQ USD with patent portal vein. Patient was given 1L NS, now with mtce fluids running. ECG -> sinus tachycardia. Gotten 12mg IV morphine and 4mg zofran, pain is now well controlled. . Most recent VS were, T99.2, 113/74, HR 131, RR 21, 02 95%RA. Patient has two peripheral IV's. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias. Denies rashes or skin changes. Past Medical History: # HIV, CD4 116 - followed by [First Name8 (NamePattern2) ] [Doctor Last Name 4020] # systolic CHF, EF 55% on TTE [10-21] # hepatitis C - genotype 1, last VL [10-21] 4,000,000 IU/mL. - elevated AFP - negative MRI abdomen [3-18] and [12-20] # ? Crohn's disease - diagnosed at [Hospital1 336] around [2149] - diarrhea was initial presentation - treated with unknown medication for 1 month and sx resolved # htn # depression # condylomata, anal, penile, scrotal, L index finger - s/p Microscopically assisted transanal biopsy and laser destruction of anal condylomata [2168-2-5] - s/p microscopically assisted laser destruction of penile, scrotal and left index finger condylomata. # hemorrhoids # Verruca vulgaris, prurigo nodularis - followed by Dr. [Last Name (STitle) ] of Dermatology # h/o syphilis # gastroparesis Social History: Denies any tobacco, alcohol, or illicit drugs. Specifically, denies taking methadone. Family History: A number of relatives have had strokes or MIs in their late 40s or early 50s, including brothers, a sister, and father. Physical Exam: Exam on discharge [2169-5-12]: Vitals: Afebrile BP:90s-100s P: 70s-90s O2: 96RA, 72.4kg General: Alert, oriented, no acute distress HEENT: Sclera mildly icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTA b/l CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: distended but not firm, cellulitis at paracentesis site resolved Ext: 2+ pitting edema BLE-mostly in feet, no clubbing or cyanosis; RUE with 2+ edema R PICC removed before discharge. Pertinent Results: Labs on discharge [2169-5-12]: 6.9>-------< 35 27.9 135 100 11 --------------< 113 3.6 28 1.0 INR 3.3 T bili 8.0 Micro: [4-25] BCX: BETA STREPTOCOCCUS GROUP B \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G---------- 0.06 S VANCOMYCIN------------ <=1 S [4-26] Peritoneal fluid: B streptoccus group B [4-27] CMV not detected [5-4] DFA for HSV/Zoster uninterpretable due to inadequate specimen.; culture NGTD All subsequent Blood, Urine, Stool cultures negative. [2169-4-25]: RUQ Ultrasound 1. Portal vein is patent. Cirrhosis with moderate intra-abdominal ascites. 2. Cholelithiasis and gallbladder wall thickening. In the setting of liver disease, gallbladder wall thickening can be secondary to underlying liver disease. [2169-4-25]: CXR (PA & Lateral) Bibasilar linear compressive atelectasis and low lung volumes likely secondary to patient's known intra-abdominal ascites. No definite pneumonia or congestive heart failure. [2169-4-26]: HIDA Scan No evidence of cholecystitis. [2169-4-26]: CTA Abdomen/Pelvis IMPRESSION: 1. Cirrhosis and portal hypertension with moderate-to-large volume ascites and mild splenomegaly. No new focal concerning hepatic lesion. 2. No evidence for mesenteric ischemia or obstruction. While there is apparent narrowing at the origin of celiac axis, the remainder of the celiac axis and mesenteric vasculature appears widely patent. 3. Gallbladder distention has been present on priors with a few small gallbladder stones likely. 4. Diffuse colonic wall thickening most likely reflects third spacing. [2169-4-28]: TTE No vegetations seen (good-quality study). Normal global and regional biventricular systolic function. Mild to moderate regurgitation. Compared with the prior study (images reviewed) of [2169-3-8], the findings are similar. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. [4-30] US 1. Marked swelling of the scrotal skin with hypoechoic regions in both the right and left hemiscrotum. This may represent fluid from scrotal edema/third-spacing, but underlying infection cannot be excluded (though lack of significant associated vascularity argues against it). 2. No evidence of epididymo-orchitis. [4-30] CT 1. Marked interval increase in diffuse subcutaneous edema and slight interval decrease in moderate ascites. No organized fluid collection identified to suggest abscess. 2. Nodular liver and enlarged spleen consistent with cirrhosis and portal hypertension. 3. Diffuse colonic wall thickening likely reflecting third spacing. 4. Bibasilar airspace disease, likely atelectasis, and a tiny left pleural effusion. [5-3] US: 1. Unremarkable scrotal ultrasound with normal appearance of the testes. 2. Extensive subcutaneous edema unchanged [5-4] US Left lower quadrant abdominal wall edema, but no sign of abscess TEE [5-5]: No echocardiographic evidence of endocarditis. The catheter tip present in the right atrium in close proximity to the tricuspid valve. Recommend withdrawal of the catheter approximately 2 to 3 centimeters to avoid contact/mechanical irritation of the tricuspid valve. Aortic atheroma as described above. [5-11] CXR: Near complete resolution of left lower lobe pneumonia. [5-12] RUE US: No DVT Brief Hospital Course: Pleasant 49 yo M with HIV and HCV cirrhosis c/b cirrhosis, who was admitted with abdominal pain. He was found to have SBP and GBS bacteremia. . # SBP with bactermia- Pt completed 2 week course of ceftriaxone (ended [2169-5-10]). He completed albumin [4-30]. TTE and TEE without evidence of endocarditis. He was started on ciprofloxacin 500mg daily for SBP prophylaxis on [2169-5-11]. He remained afebrile for 24 hours after ceftriaxone was stopped. . # Cellulits at paracentesis site - No abscess by US. Pt was treated with 12 days of vancomycin (completed [2169-5-10]) and cellulitis was resolved at time of discharge. He remained afebrile for 24 hours after vanco was stopped. He was no longer requiring pain medications and none were given on discharge. . # Scrotal swelling/Anasarca - Pt had extremely swollen scrotum, which was determined to be an extention of his ascites. With supportive care (sheet under scrotum) and diuresis, it slowly improved. US and CT were negative for abcess/fourniers. His goal diuresis of losing 1 kg/day was achieve with lasix 120mg [Hospital1 ] and spironolactone 50mg daily. Weight on discharge was 72.4kg. . # Oral herpes - Pt had lesions concerning for oral herpes. DFA with insufficient specimen. He was treated with full course of acyclovir 400mg 5x/day for 10 days (completed [2169-5-12]). DFA caused lip bleeding that requried stitch. Stitch was removed after 9 days and there was no further bleeding. . # Low grade fevers - Pt had low grade fevers (99.1-99.7) after transfer out of MICU. They were attributed to cellulitis or HSV. He also had infiltrate on CXR concerning for pneumonia. Repeat CXR [5-11] (day after antibiotics were stopped) demonstrated imporovement and antibiotics were stopped as above. Fevers resolved and he remained afebrile for 24 hours off antibiotics. . # Skin care - pt had mild scrotal skin breakdown and complained of groin fungal infection. Supportive medications and topical anti-fungals were started during this hospitalization. Pt was instructed to see his PCP to determine if rashes had improved and if medications could be stopped. . # HCV cirrhosis- lactulose and diuresis as above. On discharge he was mentating well without signs of encephalopathy. He did not appear jaundiced but had mild scleral icterus. . # HTN: Pt had not taken metoprolol for several weeks prior to admission. His BP was normal in the hospital. This was held on discharge and pt was instructed to discuss with PCP regarding restarting this medication. . # HIV: continued HAART without change to regimen. . # Thrombocytopenia: Chronic and stable. . # Bone health - pt started on vitamin D 50,000 x 6 more weeks (1st two doses given [5-3], [5-10]); continued calcium. . # Full Code Medications on Admission: -Epzicom (abacavir/lamivudine) 1 tab daily -citalopram 20 mg daily -colestipol 4 or 6 grams [Hospital1 ] -vitamin D -furosemide 60 mg a day -lactulose 30ml TID -Reglan 5 mg three times a day -metoprolol 25 mg daily -Isentress (raltegravir) 400mg [Hospital1 ] -spironolactone 100 mg a day -tenofovir 300 mg a day -calcium -vitamin D -Ensure -omeprazole 20mg daily Discharge Medications: 1. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching skin. Disp:2 bottles Refills:0 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 9. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED): Apply once to twice a day for dry skin. Please stop when dryness resolves. Disp:1 bottle Refills:2 10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (WE) for 6 doses: Dose 1 = [2169-5-3] Dose 2 = [2169-5-10] . Disp:6 Capsule(s) Refills:0 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:1 bottle Refills:2 12. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for scrotum cellulitis for 2 weeks. Disp:1 tube Refills:0 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Outpatient Lab Work Please check weight (discharge weight 72.4 kg) and chem 7 on Monday [2169-5-15]. Please fax results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4427] (phone [Telephone/Fax (1) 250]; fax [Telephone/Fax (1) 6309]) AND Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] at [Telephone/Fax (1) 673]; fax [Telephone/Fax (1) 4400]). 17. Ensure Liquid Sig: One (1) can PO twice a day: Iron free formulation. 18. Colestipol 1 gram Tablet Sig: Four (4) Tablet PO twice a day. 19. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 20. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Spontaneous Bacterial Peritonitis, Cellulitis, Scrotal Edema Secondary Diagnosis: HIV, HCV cirrhosis, Crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: T 98.6 HR 94 (61-94) BP 86/52 (86-115/50-72) 100% RA Wt:72.4 kg Discharge Instructions: You were admitted with fevers and abdominal pain. We found that you had an infection in the fluid (ascites) in your abdomen. You also had a skin infection on your abdomen. We treated you with antibiotics. You are awaiting a liver [Hospital ]. . Changes to your medications (please see your discharge medication list for all your medications): 1. Increase Spironolactone to 150mg daily 2. Increase Lasix to 120mg twice a day 3. Increase Omeprazole to 20mg TWICE A DAY. 4. STOP Metoprolol as we are taking fluid off and your blood pressure was low to normal in the hospital. Discuss with your doctor if you need to continue this. 5. Start docusate 100mg twice a day to ensure soft stools. You can buy this over the counter. 6. Start ciprofloxacin 500mg daily to prevent infection. 7. We have started some skin medications (sarna lotion, lachydrin, miconazole powder, nystatin). As your skin improves, you may ask your doctor when you can stop these medications. 8. Take your vitamin D 50,000 units every WEEK on Wednesdays for 6 more weeks. Discuss with your doctor what you should take for vitamin D after this is completed. 9. Take calcium 600mg twice a day. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15398], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2169-5-16] 3:00 Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2169-5-17] 8:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15398], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2169-6-30] 3:00 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "571.5", "287.5", "428.22", "042", "038.0", "555.9", "995.91", "V49.83", "567.23", "572.3", "428.0", "054.9", "682.2", "608.86", "070.54", "998.59", "536.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "54.91", "88.72" ]	icd9pcs	[ [ [] ] ]	12631, 12689	6972, 9743	330, 372	12871, 12871	3526, 6949	14290, 14845	2879, 3002		10165, 12608		12710, 12710		9769, 10142			13090, 14267								3017, 3507																			1648, 1879		276, 292									400, 1629			12812, 12850			12729, 12791			12886, 13066					1901, 2759	2775, 2863
250	124,271	23313	Discharge summary	report	Admission Date: [2188-11-12] Discharge Date: [2188-11-22] Date of Birth: [2164-12-27] Sex: F Service: CSU BRIEF CLINICAL HISTORY: Ms. [Known lastname 59870] is a 23 year old Haitian woman who presented originally to the Medical Intensive Care Unit on [2188-11-12], with approximately two to three week history of mid sternal chest discomfort which had been treated with codeine. Circumstances surrounding the patient's presentation were somewhat confusion and contradicted at various times by the patient and various family members. What is known is that within three to four days of the patient's presentation to [Hospital6 649] she had arrived from [Country 2045] on apparently a legal visa. Soon after arriving she began experiencing shortness of breath, dyspnea and intermittent fever and chills. What is unclear is how long she had been having these problems. She had had a prescription for codeine which she had taken with her. While she did endorse that the symptoms became worse during her flight, it was generally agreed that there was a prodrome that superceded her flight. Upon her presentation to the Emergency Department on the afternoon of the 17th the patient was complaining of shortness of breath, dyspnea and increasing bilateral lower extremity swelling. She had had a productive cough for at least the last 48 hours, being described as yellow to green sputum. She did describe fevers and denied any night sweats. PRIOR MEDICAL HISTORY: Asthma. Unclear history of a resection of the neck mass, apparently in the [Country 13622] Republic although this was never entirely clear. ALLERGIES: Aspirin causes eye swelling in eyes. MEDICATIONS: Codeine exact prescription unknown. FAMILY HISTORY: The patient has a sister with [Name2 (NI) 14165] cell disease and is thought to have [Name2 (NI) 14165] cell trait. SOCIAL HISTORY: The patient was endorsed that she had been sexually active in the past but denies unprotected intercourse. Denies intravenous drug use, alcohol or tobacco. As previously mentioned, the patient is a recently emigrated Haitian. She joined her brother and sister here in the United States and leaves a mother in [Country 2045]. PHYSICAL EXAMINATION: Upon presentation to the Emergency Department, the patient is described as a somewhat frail- appearing Haitian woman in some distress. She had a temperature maximum and temperature currently of 97.8 degrees. She was extremely tachycardiac at 170 beats per minute. Blood pressure was 142/100. Respirations 30s, sating 100 percent on a nonrebreather mask but 91 percent on room air. In general, she was pale and cachectic using accessory muscles for breathing. Head, eyes, ears, nose and throat examination showed dry mucous membranes and unable to visualize posterior discs. Neck is supple, there is, however, a small 1 cm scar seen on the left side, no evidence of any thyromegaly or anterior or posterior lymph node chain adenopathy. Chest shows decreased breath sounds bilaterally but in particular on the left side. There are coarse crackles throughout bilaterally. Cardiac examination is tachycardiac, no evidence of any murmurs, rubs or gallops. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities, show 2 plus lower extremity edema. LABORATORY RESULTS ON PRESENTATION: Sodium 135, potassium 8.8, chloride 100, carbon dioxide 23, BUN 10, creatinine 0.5, glucose 92, white blood cell count 14.4, hematocrit 26.9, platelets 720, lactate 1.2, liver function tests pending at the time of admission. Radiology: The patient had a patchy interstitial infiltrates, left side greater than right with left pleural effusions as well as some poorly differentiated pleural thickening throughout. BRIEF HOSPITAL COURSE: Based on the patient's initial presentation, it was thought that her presentation was a most likely acute and chronic etiology. Scenarios considered were pneumonia, pulmonary embolism secondary to recent air travel, severe asthma. Given the tachypnea and poor oxygenation, the patient was admitted directly to the Cardiac Intensive Care Unit. There she was made a full code. Shortly after arrival, therapeutic thoracentesis was performed. This removed greater than 250 mm of serosanguinous fluid from the left side. There was some improvement in her pulmonary function thereafter. Within two hours of presentation to the Medical Intensive Care Unit the patient became tachypneic and arterial blood gases showed increasing difficulty with oxygenation. She was shortly intubated thereafter with confirmation of placement of an endotracheal tube via chest x- ray. Bronchoscopy performed soon thereafter likewise showed good placement of her endotracheal tube. Aspiration showed a large amount of purulent, sometimes bloody material within the lung parenchyma. Thereafter the patient's presentation became increasingly consistent with aseptic etiology. She was started on Zigress per the sepsis protocol. By morning, her respiratory status had worsened and again there became increasing problems with oxygenation. Initial consultation by Cardiac Surgery for possible extracorporeal membrane oxygenation was obtained and Cardiac Surgery deemed the patient an appropriate candidate and emphasized their readiness to perform procedure as necessary. This initial extracorporeal membrane oxygenation evaluation took place on [2188-11-13]. However, the decision was made to delay extracorporeal membrane oxygenation over night and to reassess in the morning. By hospital day Number 2, the patient's presentation had evolved to florid sepsis. Human immunodeficiency virus tests as well as critical stem tests had all come back negative. By mid morning, the patient had been maxing out all of her ventilation possibilities and oxygenation was still extremely challenged. Bedside echocardiogram showed evidence of a large pericardial effusion. It was not clear if this was secondary to the pneumonia, pulmonary embolism or other etiology. Cardiology was consulted and the decision was made to do a pericardiocentesis. The procedure was performed at the bedside under ultrasound guidance. During this maneuver, there was some damage noted to the right ventricle, most likely secondary to a large dilated ventricle in the setting of high right-sided pressures. The patient was taken emergently to the Operating Room. In the Operating Room a midline sternotomy was performed and a pericardial tamponade was repaired. During the course of this repair, several lesions in the surface of the heart and lungs were noted. These were biopsied intraoperatively. Initial intraoperative pathology showed pathology consistent with neuroendocrine carcinoma, again highly unusual for a woman of this age and this presentation. Given the unclear etiology of these lesions and the patient's overall presentation, decision was made to continue aggressive treatment and while in the Operating Room the patient was catheterized per the right femoral vein and artery and extracorporeal membrane oxygenation was started. The patient at that time was transferred to the Cardiothoracic Surgery Unit and her care team was transferred from the Medical Service to the Cardiac Surgery Service under the care of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70]. Over the next 48 hours, the patient remained reasonably stable on extracorporeal membrane oxygenation. Her oxygenation was maintained. A chest x-ray showed a gradually improving lung field, although the starting point from this was complete whiteout of both fields. A single sputum culture did show Streptococcus pneumonia. The patient was started empirically on Vancomycin, Ceftriaxone and Levofloxacin. While on extracorporeal membrane oxygenation, the patient's sedation was lightened intermittently and she was confirmed to be able to move all four extremities. She likewise underwent daily bronchoscopy and several mucous plugs and purulent material was removed from her lungs. On hospital day 5 through 7, intense review of the surgical samples was undergone by the Pathology Department in concert with the Oncology Group. Initial staining of the tissue likewise was thought to be neuroendocrine tumor, however, subsequent specialized staining with amino peroxidase showed this tumor to, in fact, to be consistent with a poorly differentiated large cell carcinoma. In further reviewing the patient's history, both by record and in discussion with her siblings and her mother in [Country 2045], it appears that the patient had a small lesion removed from her neck somewhere in the [Country 13622] Republic. The exact nature of this mass, its size, pathology and follow up was never obtained although it was thought to be quite suspicious. By hospital day 9 or postoperative day 6, final evaluation by Oncology had been completed and in discussion with the primary team, Oncology and the patient's family decision was made that attempt would be made to wean her from the extracorporeal membrane oxygenation machine, given that there was no clear interventions to be directed towards the cancer itself. On [11-21], [2187], after intensive optimization of her ventilator settings, fluid status and introduction of nitric oxide, attempt was made to wean the patient from extracorporeal membrane oxygenation. This was tried unsuccessfully during the course of the day and by late in the afternoon, the patient ultimately had to be returned to full extracorporeal membrane oxygenation support. By the following day after an additional review by the Cardiac Surgery Service, opinion rendered by the Ethics Support Service, Dr. [Last Name (STitle) 59871] [Name (STitle) 59872], and position taken by the [Hospital6 1760] Legal Department, decision was made for a final wean of the extracorporeal membrane oxygenation machine. Prior to this maneuver, the patient's brother and sister were intensively consulted, and indeed spent much of [Holiday 1451] Day in the patient's room. Several conference calls were initiated both directly and through a Creole translator to the patient's mother in [Country 2045]. Pastoral services as well as Ethics Committee were consulted throughout this and the patient's family was fully aware and in agreement of what was happening with the patient. At approximately 2 PM in the afternoon of [2188-11-22], the patient's ventilator settings were once again optimized. A surgical team was brought into her Intensive Care Room and after complete wean of the extracorporeal membrane oxygenation machine, Vascular Surgery Service decannulated intake and output catheters and closed the enterotomies in both vessels. Over the next two to three hours, the patient required increasing pressure support, maxing out Levophed, epinephrine, Natrecor, Neo-Synephrine and ventilator settings, none of which were to maintain a blood pressure compatible with life. Lactaid increasingly increased. Likewise pH dropped consistently to 7.1 despite several cycles of bicarbonate. At approximately 7 PM the patient became asystolic and unresponsive to further chemical interventions. There were several long discussions at that time with the patient's brother and sister as well as various members of the Creole community. Several hours later, a conference call was set up and in the company of the Intensive Care Unit staff, the patient's brother and sister informed the mother of the sister's passing. The patient's mother did appear willing and anxious to have an autopsy performed and this was arranged. The patient's case was presented to the medical examiners office and likewise was declined. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) 9178] MEDQUIST36 D: [2188-11-23] 01:23:31 T: [2188-11-23] 08:13:21 Job#: [Job Number 59873]	[ "584.9", "995.92", "785.52", "998.2", "423.9", "481", "518.81", "197.0", "285.9", "785.51", "038.2", "198.89" ]	icd9cm	[ [ [] ] ]	[ "33.24", "00.11", "33.23", "38.93", "96.72", "37.0", "96.6", "37.4", "34.91", "32.29", "34.1", "38.91", "00.13" ]	icd9pcs	[ [ [] ] ]		3835, 12056					1780, 1905																														2278, 3811																																1922, 2255
69,359	149,051	36107	Discharge summary	report	Admission Date: [2200-8-27] Discharge Date: [2200-9-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 53015] is a [Age over 90 ] yo F with history of hypertension and remote non-Hodgkin's Lymphoma who was admitted from the ED with delirium and hypotension with SBP's in 60's. She was recently discharged on [2200-8-25] after admission for delirium and acute renal failure [1-6] dehydration. Prior to that, she had been discharged on [2200-8-22] with failure to thrive, ARF, and CAP treated with a seven day course of levaquin (finished on [2200-8-26]). Today, she presents with worsening delirium. She had been at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] for the last 2 days and confusion was worsening. She was found wandering the halls, pulling at IVs and not answering questions appropriately, talking about the past. She was reported to be holding her abdomen, but no complaints from the patient on arrival here. According to family, she has no history of dementia and has not experienced delirium in the past. At baseline she is able to do her own ADLs including cooking and cleaning. She has been eating and drinking very poorly at home. . In the ED, initial vs were: T 96.5F BP 106/67 HR 93 RR O2 sat 93% on RA. She was confused. Her BP dropped to SBP 60s in setting of cont. delirium. She had a lactate of 4.0 and was given 3L of IVFs with complete normalization of her blood pressure. A bedside U/S was done and unremarkable. CXR showed a potentially worsening RUL infiltrate. She received vanco/zosyn/levo, tylenol PR. . On the floor, she continues to be confused but not verbalizing any acute complaints. . Review of systems: (+) Per HPI Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. h/o Non-Hodgkin's Lymphoma - s/p XRT at [Hospital1 2025] - currently in remission Social History: Home: Lives in [Location ] [Doctor First Name 12983] (elder housing), independent in all ADLs. Son/Daughter very involved in her care and see her on a daily basis. Was discharged from previous hospitalization on [2200-8-22] to home with services EtOH: Very rare social EtOH use Tobacco: Former smoker (quit 30 years ago, 30 pack per year history prior Drugs: Denies Family History: Mother - died of heart disease in her 70s. Physical Exam: Vitals: T: 96.3 HR 94 BP 149/71 RR 18 O2 98% on 3L General: Not oriented to place, time, not answering questions appropriately, speech is fluent. HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear - dentures in place Neck: supple, JVP not elevated, no LAD Lungs: Breath sounds clear b/l, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Orientation as above, poor attention. Able to follow commands - opens eyes, squeezes hand, toes downgoing. difficult to assess strength but moving all extremities. Pertinent Results: Labs on admission: [2200-8-27] 02:52PM LACTATE-4.0* [2200-8-27] 02:37PM GLUCOSE-146* UREA N-26* CREAT-1.6* SODIUM-141 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 [2200-8-27] 02:37PM ALT(SGPT)-22 AST(SGOT)-22 CK(CPK)-79 ALK PHOS-105 TOT BILI-0.7 [2200-8-27] 02:37PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.7 [2200-8-27] 02:37PM WBC-13.1* RBC-3.86* HGB-10.9* HCT-33.2* MCV-86 MCH-28.2 MCHC-32.8 RDW-14.9 [2200-8-27] 02:37PM NEUTS-84* BANDS-4 LYMPHS-5* MONOS-2 EOS-2 BASOS-1 ATYPS-1* METAS-1* MYELOS-0 [2200-8-27] 02:37PM PT-13.1 PTT-22.8 INR(PT)-1.1 [2200-8-27] 02:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Micro: [2200-8-28] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2200-8-28] URINE Legionella Urinary Antigen -POSITIVE [2200-8-27] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2200-8-27] URINE URINE CULTURE-PENDING EMERGENCY [Hospital1 ] [2200-8-27] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2200-8-27] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] Imaging: CHEST (PORTABLE AP) Study Date of [2200-8-27] 2:54 PM IMPRESSION: Chronic appearing interstitial lung disease with worsening in the right lung opacuity likely reflecting worsening of pneumonia. Followup to resolution. CT chest after resolution of acute symptoms can be done to assess the interstitial lung disease. CT HEAD W/O CONTRAST Study Date of [2200-8-29] 10:48 AM FINDINGS: There is no evidence of acute hemorrhage or shift of normally midline structures. The ventricles and sulci are prominent, consistent with age-related atrophy. There is a right lacunar infarct identified. There are extensive vascular calcifications of the cavernous portion of the internal carotid arteries. There is extensive periventricular white matter hypodensity, consistent with chronic small vessel ischemic changes. IMPRESSION: No evidence of acute hemorrhage. Please note that MRI is more sensitive in detection of acute ischemia. CT CHEST W/O CONTRAST Study Date of [2200-8-29] 10:48 AM IMPRESSION: 1. Pneumonic consolidation predominantly involving the right upper lobe and lesser involvement of right middle lobe lateral segment. No evidence of centrally obstructing mass. 2. Moderate bilateral effusions, right greater than left, with adjacent areas of atelectasis. Brief Hospital Course: [Age over 90 ] yo woman presented with Legionella pneumonia, altered mental status, acute on chronic renal failure. . # Pneumonia: RUL infiltrate seen on admission CXR. Patient has completed a 7 day course of levofloxacin prior to this admission. She was found to have positive Legionella urinary antigen and was treated with azithromycin, which was to be continued for 5 days after discharge. CT chest showed pneumonia consolidation of the right upper and middle lobes as well as moderate bilateral effusions. Patient continued to symptomatically improve on the azithromycin, now saturating well on room air. Patient was advised to follow up with PCP after discharge. . # Delirium: Most likely due to pneumonia. CT head was unremarkable. Her delirium resolved with treatment of pneumonia. # Acute on chronic renal failure: Likely a result of poor po intake and dehydration. Creatinine returned to baseline after IV fluids. . # Hypertension: Blood pressure was stable on this admission. Amlodipine was held due to concerns for worsening constipation with CCB contributing to delirium. HCTZ was discontinued on previous admission due to hyponatremia, now resolved. Not restarted durin gthis admission, although lower extremity edema was monitored and stable. HCTZ re-initiation should be considered as outpatient. Medications on Admission: -Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). -Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). -Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Levofloxacin (last dose 9/22) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 5 days. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 12.5 mg Tablet Sig: 1-2 Tablets PO once a day: Do NOT give on [9-2] or [9-3]. Rehab MD [First Name (Titles) ] [Last Name (Titles) ] to evaluate patient and consider starting on [9-4] given recent admission for hyponatremia. Previous dose 25mg daily. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Legionella Pneumonia Delirium Discharge Condition: Hemodynamically stable. Mental status at baseline. Discharge Instructions: You were admitted to the hospital due to confusion. An X-ray of your lungs showed that your pneumonia from a previous admission had not completely resolved. A test showed that you had Legionella Pneumonia and you were started on a different antibiotic. Your confusion improved with the treatment of your lung infection. Due to your recent hospitalizations, you will need rehabilitation to get your physical strength back prior to returning to your home. We have arranged for transfer to a rehabilitation facility. Please follow-up with your doctor when you complete your rehabilitation. CHANGES IN MEDICATION: START Azithromycin 500mg by mouth every day for 5 days (Last Day [9-7]) Continue all other medications as previously prescribed If you have a dryness in your throat, please take [12-6] sips of water, which should alleviate this symptom. If you experience fever, cough, shortness of breath, confusion, chest pain, pain with urination, loss of appetite or any other symptoms that concern you please contact your primary care physician or seek help at the nearest emergency room. Followup Instructions: Please follow-up with your primary care physician once you have completed rehabilitation.	[ "038.9", "202.80", "276.51", "038.8", "585.9", "482.84", "V15.82", "403.90", "995.92", "785.52", "272.0", "584.9", "285.9", "293.0" ]	icd9cm	[ [ [] ] ]	[ "99.21", "99.29" ]	icd9pcs	[ [ [] ] ]	8470, 8605	5809, 7136	282, 288	8679, 8733	3329, 3334	9885, 9978	2504, 2548		7605, 8447		8626, 8658		7162, 7582			8757, 9862								2563, 3310																			1924, 1938		221, 244									316, 1905							3349, 5786							1960, 2091	2107, 2488
28,508	115,622	19619	Discharge summary	report	Admission Date: [2158-3-31] Discharge Date: [2158-4-4] Date of Birth: [2102-1-24] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: BRBPR, anemia, chest pain Major Surgical or Invasive Procedure: EGD, flexible sigmoidoscopy History of Present Illness: Patient's H&P and hospital course reviewed. Briefly, this is a 56F w/ CAD, DM2, ESRD on PD sent to the ED for Hct of 15. She had LH for 5 days as well as chest tightness and dyspnea on exertion. She has had BRBPR for several days and has a prior diagnosis of hemorrhoids. She has not had abdominal pain, N/V, melena, diarrhea/constipation. In the ED she had a negative NG lavage, rectal exam was guaiac negative but external hemorrhoids were noted. Troponin was 0.07 and after discussion with cardiology in the ED, this was felt to be demand from severe anemia and not a primary cardiac process. She was transferred to the MICU for close monitoring and has so far received 4U PRBC. Hct was 20.6 after the first 2 units. She has remained hemodynamically stable. GI was consulted and felt that since this was likely a hemorrhoidal bleed, supportive care was warranted and that surgery should be consulted. Surgery consult recommended likely hemorrhoidectomy vs. banding but will staff with a colorectal surgeon on Monday. As she has been hemodynamically stable with no further bleeding, she was transferred to the floor. Past Medical History: 1) Type II diabetes mellitus 2) ESRD [1-21] diabetes, on hemodialysis since [2156-6-25] 3) HTN, benign essential 4) Anemia, chronic disease/iron deficiency 5) Diabetic Retinopathy, legally blind x 1 year 6) Eczema 7) s/p oophorectomy 8) CAD Social History: Patient is Cantonese and Mandarin speaking only, married, with husband at bedside. Denies alcohol, tobacco, or drug use. Family History: Strong family history of Type II DM. Brother deceased of renal failure. Physical Exam: Vitals- 96.8, 81, 125/58, 17, 100% RA Gen- NAD, appears fatigued but alert HEENT- sclerae anicteric, pale conjunctivae, MMM Neck- supple Pulm- CTAB CV- RR, 2/6 SEM heard throughout Abd- +BS, mildly distended with ?fluid wave, PD catheter in L lower abdomen, nontender Extrem- trace ankle edema Skin- scattered eczematous changes throughout Pertinent Results: [2158-3-31] 06:40PM GLUCOSE-80 UREA N-83* CREAT-13.7# SODIUM-133 POTASSIUM-4.2 CHLORIDE-94 TOTAL CO2-21* ANION GAP-22* [2158-3-31] 06:40PM POTASSIUM-4.0 [2158-3-31] 06:40PM ALT(SGPT)-26 AST(SGOT)-23 CK(CPK)-139 ALK PHOS-99 TOT BILI-0.1 [2158-3-31] 06:40PM LIPASE-111* [2158-3-31] 06:40PM cTropnT-0.07* [2158-3-31] 06:40PM CK-MB-3 [2158-3-31] 06:40PM CALCIUM-6.9* PHOSPHATE-6.7* MAGNESIUM-2.3 [2158-3-31] 06:40PM WBC-9.8 RBC-1.44# HGB-4.9# HCT-15.7# MCV-109# MCH-34.1* MCHC-31.3 RDW-19.1* [2158-3-31] 06:40PM NEUTS-75.9* LYMPHS-15.2* MONOS-4.9 EOS-3.5 BASOS-0.6 [2158-3-31] 06:40PM PLT COUNT-504* [2158-3-31] 06:40PM PT-12.3 PTT-26.4 INR(PT)-1.0 [4-3] EGD: Erosions in the antrum (biopsy) Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to second part of the duodenum [4-3] flex sig: Grade 1 internal & external hemorrhoids Normal mucosa in the sigmoid colon Otherwise normal sigmoidoscopy to 25 from the anus in the sigmoid colon Brief Hospital Course: 1. Lower GI bleed: NG lavage negative so most likley lower GI bleed. Colonoscopy recently demonstrated normal colon except for internal hemorrhoids, which is thought to be most likely source of this subacute bleed. Patient presented reasonably stable from hemodynamic standpoint, and received 4 units PRBC with improvement in her symptoms. Her hematocrit remained stable at ~30-31 for the remainder of her hospital course. GI was consulted and performed EGD and flex sig that showed no clear source of bleeding other than hemorrhoids. Colorectal surgery was consulted and recommended outpatient banding as well as a high fiber diet, fiber supplements, and steroid suppositories. The patient is to follow up with Dr. [Last Name (STitle) 1120] of colorectal surgery for this procedure. 2. CAD: Patient presented with chest tightness in setting of severe blood loss anemia, with negative CKs and elevated troponins. Symptoms resolved with correction of anemia. Medical therapy for coronary disease was continued, beta-blockers resumed, Aspirin and statin continued. 3. HTN: Metoprolol and valsartan were temporarily held and restarted after patient's tranfusions and hematocrits had remained stable. Metoprolol was changed to 100mg [Hospital1 ] and Lasix was changed to 80mg [Hospital1 ] in an effort to simplify her medication regimen. 4. ESRD on PD: Peritoneal dialysis per renal recommendations. Continued Sevelamer and lanthanum for phosphorus binding. Procrit dose was increased per renal and patient was started on iron. 5. DM2: Continued glargine + humalog sliding scale. Lantus was increased to 7 units daily due to increased blood sugars. 6. Prophylaxis: pneumoboots Medications on Admission: ASA 325mg daily Valsartan 40mg daily Lantus 5U QAM Humalog sliding scale Renagel 1600 TID w/ meals Simvastatin 40mg QHS Lasix 60mg [Hospital1 ] Metoprolol 75mg [Hospital1 ] Nephrocaps daily Fosrenol 1000mg QID Colace 100mg [Hospital1 ] Bisacodyl 10mg QHS Epogen Discharge Medications: 1. FiberCon 625 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 2. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) Units Subcutaneous qam. 3. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous see sliding scale. 4. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 14. Hemorrhoidal Suppository 0.25 % Suppository Sig: One (1) suppository Rectal at bedtime. Disp:30 suppository Refills:2 15. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] PRN (). Disp:1 tube Refills:2 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Epogen 20,000 unit/mL Solution Sig: One (1) mL Injection once a week. Disp:1 month supply Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: hemorrhoidal bleeding Secondary: end-stage renal disease, diabetes mellitus Type II, coronary artery disease, hypertension Discharge Condition: good, stable, no abdominal pain, no shortness of breath, no lightheadedness, no chest pain Discharge Instructions: You were evaluated for chest discomfort and found to have very low blood levels, likely from chronic hemorrhoidal bleeding. There was no evidence of a primary cardiac problem to explain your chest discomfort, and this was likely from being severely anemic. An upper endoscopy and flexible sigmoidoscopy did not show any evidence of other concerning sources of bleeding. You were evaluated by colorectal surgery, and Dr. [Last Name (STitle) 1120] will perform banding of the hemorrhoids as an outpatient. You should eat a high fiber diet with fiber supplements (FiberCon), which you may also get over the counter. You should use Anusol suppositories at night until you see Dr. [Last Name (STitle) 1120]. We have adjusted some of your medications in an effort to achieve better blood pressure and blood sugar control and to make it a little easier for you to take your medications. Your Lantus dose has been increased to seven units in the morning. We have increased your metoprolol dose to 100mg twice a day and your Lasix dose to 80mg twice a day. We have also increased your Epogen dose to 20,000 Units once a week and started you on iron. Followup Instructions: You have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120] (colorectal surgery) on [4-19] at 9am. You may call her office at [Telephone/Fax (1) 17489] with any questions. She will discuss the procedure with you at that time and will get informed consent for the procedure if you agree. Follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 714] [Doctor Last Name 29076]. You have an appointment with her this [Last Name (LF) 2974], [4-7] at 2:30pm. You may call [Hospital3 ] at [Telephone/Fax (1) 250] with any questions.	[ "362.01", "280.9", "285.1", "V58.67", "403.91", "414.01", "369.4", "585.6", "250.40", "250.50", "455.2", "285.21", "V45.82", "455.5" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.16", "96.07", "45.24" ]	icd9pcs	[ [ [] ] ]	7132, 7138	3443, 5146	340, 370	7314, 7407	2395, 3420	8606, 9252	1946, 2020		5471, 7109		7159, 7293		5172, 5448			7431, 8583								2035, 2376																					275, 302									398, 1518														1540, 1791	1807, 1930
15,726	198,066	28949	Discharge summary	report	Admission Date: [2146-1-28] Discharge Date: [2146-2-4] Date of Birth: [2097-5-1] Sex: M Service: SURGERY Allergies: Morphine Attending:[First Name3 (LF) 1390] Chief Complaint: trauma - MVC Major Surgical or Invasive Procedure: Epidural placement [2146-1-28] History of Present Illness: 48M s/p MVC, restrained driver, +air bag deployment, car rollover onto roof. +EtOH - fell asleep while driving. Found w/ R leg trapped under steering wheel. Past Medical History: PMH: - Renal insufficiency - HTN - EtOH cirrhosis - on liver transplant list - [Last Name (un) ] Gastric bypass - Hypothyroidism PSH: - humerus repair - [Last Name (un) ] gastric bypass - cholecystectomy Social History: Reportedly stopped drinking EtOH in [Month (only) ], but states he drank prior to this admission. Still smokes 10 cig/day but openly admits it is more than that. No drug use. Married with two kids. Family History: No family history of liver disease. Mother died from stroke at young age and history of alcohol abuse Father had urethral cancer and history of alcohol abuse. Physical Exam: Per Admission ED Note: PE: HR:101 BP:107/73 Resp:18 O(2)Sat:96 Normal Constitutional: Right eye periorbital edema. Ecchymosis of the right eye. No hyphema. No proptosis. Extraocular eye movements intact HEENT: C. collar in place. Chest: Clear to auscultation. Large area of ecchymosis over the right anterior chest wall. No crepitus. Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Extr/Back: Lacerations to the right hand and left ankle stable pelvis. Neuro: Speech fluent. GCS 15. Pertinent Results: IMAGING: - [1-28]: CT Head (wet read): No acute intracranial process - [1-28]: CT C-spine (wet read): 1. left clavicle fx 2. T1 body fx, likely chronic. 3. Old C7 spinous process fx. - [1-28]: CT Chest/Abd/Pelvis (wet read): 1. left clavicle fx. 2. sternal fx 3. acute left 7-10th rib fx, displaced from [9-21]. 4. Healed right and left rib fxs. 5. moderate-severe LLL atelectasis with a high riding left hemidiagphram. no diaphraghmatic defect seen. 6. s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] gastric bypass and cholecystectomy. - [1-28]: LEFT UE XRay: 1. Strong suggestion of a re-fracturing through what is thought to be a likely prior healed fracture of the proximal humeral diaphysis. 3. There is suggestion of an impacted non-intraarticular fracture of the distal radius. A more definite nearly nondisplaced transverse fracture of the ulnar styloid process is noted with associated soft tissue swelling. - [1-28]: L ankle XRay: There is no acute fracture or dislocation. - [1-28]: R Hand Xray: No acute fracture or dislocation is seen. - [1-29] CXR: Elevation of the left hemidiaphragm and left basilar atelectasis. Multiple rib fractures. - [1-29] CXR: Worsened LLL consolidation Brief Hospital Course: Patient admitted to trauma ICU after trauma evaluation/imaging revealed the following injuries: L 8-10th rib fx (displaced) L clavical fx; Sternal fx L prox humerus fx L distal radius fx He was admitted to trauma ICU for pain control and had an epiduralM (T6) placed on [1-28]. Orthopedic surgery was consulted and recommended a sling to his LUE and plan for casting on [2-1]. His epidural was removed on [1-30] without incident. On [1-31] he was transferred to the surgical floor for further care. While on the floor he contined to be confused due to hepatic encephalopathy due to known liver cirrhosis. He was seen by hepatology who made some pharmacologic recommendations and his confusion resolved over the following 2 days. At time of discharge he was alert and oriented to person, place and time and he was appropriately answering questions. He was seen by physical therapy while on the floor and they recommended discharge home with outpatient physical therapy. At time of discharge, the patient's pain was well controlled, he was voiding spontaneously and ambulating. He was not confused, affect was appropriate and he was alert and oriented. He was tolerating a regular diet. Medications on Admission: levothyroxine 50mcg daily, lasix 10 qAM & 5qPM, cialis prn, oxycontin 80mg tid, oxycodone 5mg TIDprn, gabapentin 200mg TID, lorazepam 1mg TID, Bactrim DS tab daily, cymbalta 60mg [Hospital1 ], combivent 2puffs daily, spironolactone 150mg daily, B12, mag, amitriptyline 50mg qHS Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. furosemide 20 mg Tablet Sig: 0.25 Tablet PO QPM (once a day (in the evening)). 5. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:7 Adhesive Patch, Medicated(s) Refills:2 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [2-13] Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheezes. 10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for encephalopthy. Disp:1000 ML(s) Refills:3 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 13. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: Five (5) Tablet Sustained Release 12 hr PO every twelve (12) hours. Disp:300 Tablet Sustained Release 12 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. L 8-10th rib fx (displaced) 2. L clavical fx 3. Sternal fx 4. L prox humerus fx 5. L distal radius fx 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 your car accident with multiple injuries including left rib fractures, left clavicle fracture, left proximal humerus fracture and left distal radius fracture You were seen by hepatology while you were admitted to the hospital and you have to follow-up with your hepatologist as an outpatient. You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus ). Followup Instructions: 1. Please call the Acute care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [3-17] weeks 2. Call the [Hospital ] Clinic at [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks with Dr. [Last Name (STitle) ] 3. Please call a physical therapist that is convenient for you to make an appoitment for outpatient physical therapy, which was recommended by the physical therapists in the hospital. You have been provided with a script for physical therapy.	[ "403.90", "585.9", "812.09", "244.9", "810.01", "V49.83", "572.2", "813.42", "V45.86", "E816.0", "807.02", "571.2", "305.00" ]	icd9cm	[ [ [] ] ]	[ "03.90" ]	icd9pcs	[ [ [] ] ]	6091, 6097	3000, 4213	279, 315	6246, 6246	1726, 2977	7803, 8309	974, 1134		4545, 6068		6118, 6225		4239, 4522			6397, 7780								1149, 1707																					227, 241									343, 501									6261, 6373					523, 737	753, 958
8,298	125,712	7338	Discharge summary	report	Admission Date: [2103-2-24] Discharge Date: [2103-3-5] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2698] Chief Complaint: transfer from OSH for complete heart block Major Surgical or Invasive Procedure: Temporary pacer wire placement under fluoroscopy ([2103-2-24]) . Permanent pacemaker placement ([2103-2-27]) History of Present Illness: Patient is an 85 y/o F patient with PMHx of DM, CAD, HTN, hypothyroidism who presents from OSH with acute pulmonary edema in the setting of complete heart block. Patient was transferred from NH to OSH 1 day PTA for symptoms of weakness and was found to be bradycardic 20s-40s. EKG showed initially first degree heart block with occasional complete heart block (by report). Also at OSH patient was in acute renal failure and was given fluids overnight. Patient was transferred to [Hospital1 18] for consideration of temp pacemaker. . When patient arrived to [Hospital1 18] her rhythm strip and 12 lead confirmed complete heart block with junctional escape rhythm in the 30-40s. Patient was short of breath on arrival with O2Sat in the 80s. She was given 40 IV lasix, started on nitro gtt and put on non-invasive ventilation. Decision made to place temp. pacer wire. Past Medical History: DM2 HTN CAD; ? silent MI in 20-50 years ago, was medically managed Hypothyroidism hyperlipidemia B/L CEA x 2 RAS Dementia Social History: nursing home resident no tobacco use no etoh use Family History: no history of CAD or early/sudden cardiac death Physical Exam: T 97.9 HR 30 RR 22 O2Sat 84% -> 100% on Bipap Gen: Patient pale, gasping for air, able to talk HEENT: PERRL, EOMI, OP clear, MMM Neck: no carotid bruits CV: RRR S1/S2 grade III/VI SEM Pulm: diffuse crackles 1/2 up lungs Abd: soft NT NABS Extr: +1 edema b/l; + erythema at shin b/l Neuro: AAOx2 Pertinent Results: [2103-2-24] 05:17PM BLOOD Glucose-127* UreaN-69* Creat-2.0# Na-140 K-4.6 Cl-102 HCO3-30 AnGap-13 [2103-2-24] 05:17PM BLOOD WBC-10.8# RBC-3.81 Hgb-12.2 Hct-35.0* MCV-92 MCH-31.9 MCHC-34.7 RDW-14.2 Plt Ct-230 [2103-2-24] 05:17PM BLOOD PT-11.3 PTT-25.7 INR(PT)-1.0 [2103-2-24] 05:17PM BLOOD CK-MB-3 cTropnT-0.07* . ECG ([2103-2-24]): complete heart block with junctional escape rhythm @ 30; nl axis . TTE ([2103-2-27]): The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Left ventricular systolic function is hyperdynamic (EF>75%). There is a moderate (42mmHg peak) resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification leading to mild functional mitral stenosis (area 1.7cm2). Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be quantified. There is a very small inferolateral pericardial effusion. Brief Hospital Course: Ms. [Known lastname ] was initially admitted to the CCU and found on admission to be severely hypertensive (SBP>200), hypoxic (O2Sat in mid-80%s on non-rebreather mask), and in complete heart block with a junctional rhythm. Her BP was controlled with a nitroglycerin drip and she was given IV Lasix with good brisk diuresis. She was also put on BiPAP while diuresing and was quickly weaned to 6L nasal cannula. Due to her instability, EP place temporary pacer wires under fluoroscopy shortly after admission. With the pacer wires in place, she remained stable over the course of the weekend and had a permanent pacemaker placed on [2103-2-27] and will follow up in device clinic one week later. . Also of note, she was found to be in acute-on-chronic renal failure upon admission, thought to be secondary to decreased renal perfusion in the setting of her complete heart block. Her ACEi was intially held for this reason. Once she was paced, her creatinine improved back to its baseline (1.3-1.5) and her ACEi was resumed and titrated up. . For the pacer placement, she was started intially on IV Ancef which was then switched to vancomycin post-procedure. This was switched to Keflex and she completed a course of antibiotics through [2103-3-4]. On chest x-ray, she was also noted to have a possibility of a community acquired pneumonia and was started empirically on PO levofloxacin on [2103-2-27]; she will complete a 10-day course of this (three more days). . She was evaluated by physical therapy who found her to be deconditioned and unsteady/unsafe on her feet; however she was not a candidate for acute rehab and will be discharged to skilled nursing facility with physical therapy. . She was found on physical examination to have a cardiac murmur which had not been documented on prior exams in our system. She had a TTE which showed mild MR and AS as well as outflow obstruction from LV hypertrophy. She will follow up in device clinic one week after pacer placement and will see Dr. [Last Name (STitle) ] for further cardiology follow up next month. . Her blood pressure was noted to be high, she was controlled on the following medications: amlodipine, Toprol XL, Hydralazine, Lisinopril, Isosorbide Mononitrate, and Hydrochlorothiazide. Medications on Admission: Novolog sliding scale insulin aspirin 325mg daily Colace 100mg daily Senna 2 tabs daily Travatan gtt daily Acular 0.5% gtt OU [Hospital1 ] Senna 2 tabs daily Tenex 3mg daily Imdur 60mg daily lisinopril 20mg daily MVI daily Norvasc 10mg daily Zoloft 25mg daily Toprol XL 100mg daily heparin sc tid Synthroid 100mcg daily atorvastatin 40mg daily Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<100. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Novolog 100 unit/mL Cartridge Sig: [1-9] units Subcutaneous QACHS: per patient's outpatient sliding scale. 10. Travoprost 0.004 % Drops Sig: 1-2 drops Ophthalmic daily (): to left eye. 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: to complete a ten day course (day 1 = [2103-2-27]). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection three times a day: inject SC tid. 14. Lisinopril 40 mg Tablet Sig: Two (2) Tablet PO once a day. 15. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. 16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 18. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 246] Nursing Center - [Location (un) 246] Discharge Diagnosis: Primary diagnosis: complete heart block Secondary diagnoses: type 2 diabetes mellitus, hypertension, diastolic heart failure Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with a disturbance in the conduction system of your heart known as a "complete heart block". For this, you had a pacemaker implanted and you will complete a 5 day course of prophylactic antibiotics (Keflex). You also were found to have a small pneumonia and will complete a ten day course of antibiotics (levofloxacin) for this. Please take all medications as prescribed and attend all follow up appointments. If you experience chest pain, shortness of breath, loss of consciousness, high fevers, or other concerning symptoms, then you need to seek medical attention. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2103-3-6] 11:00 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2103-4-5] 1:00 Completed by:[2103-3-5]	[ "585.9", "682.6", "426.0", "998.12", "584.9", "250.00", "428.0", "244.9", "E878.1", "599.0", "272.4", "403.91", "486", "414.01", "428.30" ]	icd9cm	[ [ [] ] ]	[ "37.83", "37.78", "37.72" ]	icd9pcs	[ [ [] ] ]	7511, 7602	3178, 5459	257, 376	7772, 7781	1895, 3155	8435, 8782	1512, 1561		5858, 7488		7623, 7623		5485, 5835			7805, 8412								1576, 1876	7685, 7751																				175, 219									404, 1285						7642, 7664								1307, 1430	1446, 1496
45,409	140,009	55118	Discharge summary	report	Admission Date: [2134-9-1] Discharge Date: [2134-9-6] Service: SURGERY Allergies: Penicillins / Heparin Agents / Aldactone / Aldomet / Actonel Attending:[First Name3 (LF) 598] Chief Complaint: trauma, found down Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] y/o M w/ CAD (s/p PCI LAD and RCA in [2120]), pacemaker (unclear indication), HTN, HLD, OA, who was initially transferred to [Hospital1 18] on [2134-9-1] after syncope/fall and pelvic fracture. Patient was found down at his nursing home. Patient reports sitting and watching TV, then lost consciousness. Next thing he remembered was waking up at [Hospital3 ]. He reported no chest pain, SOB, palpitation or dizziness prior to syncope. At [Hospital3 ], he was found to have pelvic fracture and sent to [Hospital1 18] for further management. En route, he was reported to have Vtach (no strips available), did not require intubation. Past Medical History: CAD s/p PTCA LAD and RCA stent in [2120] Diastolic dysfunction Aotrtic scloersis Pacemaker in [11/2129] St. [Male First Name (un) 1525] HTN Hyperlipidemia OA transverse colon carcinoma Addison's Gout DJD Social History: Former smoker, quit 40 years ago Denies EtOH No illicits Family History: No premature CAD Physical Exam: On arrival to [Hospital1 18]: Temp: Afebrile HR: 60 BP: 80/42 Resp: 18 O(2)Sat: 98 room air Normal Constitutional: He is awake and collared. HEENT: Extraocular muscles intact No C-spine tenderness Chest: Clear to auscultation without chest wall tenderness Cardiovascular: Normal first and second heart sounds Abdominal: Nontender GU/Flank: Foley catheter in place with clear urine Extr/Back: No edema Neuro: Speech fluent and he can move both sides equally Psych: Normal mentation Pertinent Results: CHEST (PORTABLE AP) Study Date of [2134-9-1] 9:46 PM IMPRESSION: No definite evidence of injury. Mild cardiomegaly. Convex contour to the right upper mediastinum, indeterminate, although most likely a normal variant; however, correlation of planned CT is recommended. CT ABDOMEN/CHEST W/O CONTRAST Study Date of [2134-9-1] 11:19 PM IMPRESSION: 1. Known comminuted left iliac fracture with associated increased left retroperitoneal hematoma. 2. Thyroid nodules measuring up to 2.2 cm on the right. 3. Wedge compression deformity at T10. This is age indeterminate; however, there is no paraspinal hematoma to suggest acute fracture. Cardiovascular Report ECG Study Date of [2134-9-2] 6:13:36 AM Atrial bigeminy. Right bundle-branch block with left anterior fascicular block. Intermittent atrial pacing. Left ventricular hypertrophy. Non-specific ST segment changes. No previous tracing available for comparison. Echo [2134-9-2]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate symmetric LVH with normal global and regional biventricular systolic function. Mild diastolic LV dysfunction with elevated filling pressures and moderate pulmonary hypertension. No clinically-significant valvular disease seen. CAROTID SERIES COMPLETE Study Date of [2134-9-3] 4:07 PM CONCLUSION: Less than 40% stenosis, bilateral internal carotid arteries. LAbs on admission: [2134-9-1] 10:06PM GLUCOSE-135* NA+-139 K+-3.0* CL--102 TCO2-26 [2134-9-1] 10:05PM UREA N-19 CREAT-1.7* [2134-9-1] 10:05PM ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-364* ALK PHOS-141* TOT BILI-0.6 [2134-9-1] 10:05PM LIPASE-25 [2134-9-1] 10:05PM cTropnT-0.19* [2134-9-1] 10:05PM ALBUMIN-3.6 [2134-9-1] 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-8* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2134-9-1] 10:05PM WBC-14.3* RBC-3.72* HGB-11.7* HCT-35.6* MCV-96 MCH-31.4 MCHC-32.8 RDW-16.6* [2134-9-1] 10:05PM PLT COUNT-142* [2134-9-1] 10:05PM PLT COUNT-142* [2134-9-1] 10:05PM FIBRINOGE-168* Brief Hospital Course: Mr. [Known lastname 112450] was admitted on [2134-9-1] under the Acute Care Surgical service. He was admitted to the trauma ICU given reported episode of vtach on transfer and elevated troponin and hypotension. His troponins were trended and peaked at 0.19 and decreased to 0.15. Cardiology was consulted and recommended continued resuscitation. He had a TTE that showed normal ejection fracture and normal wall motion. He was continued on metoprolol and home simvastatin. His diet was advanced to regular, which he tolerated well. His hematocrits were checked serially, due to his retroperitoneal bleed and pelvic fractures, and remained stable. His Cr improved from 2.0 to 1.7, which is his baseline. He was placed on his home dose of steroids for his adrenal insufficiency. In terms of his MSK injuries, for his pelvic fracture, orthopedic surgery was consulted and recommended non-operative management. He was to be weight bearing as tolerated in his lower extremities. On [9-3] he remained hemodynamically stable and was transferred to the floor. On the floor his vital signs were routinely monitored. He was noted to be persistently hypertensive and his morning dose of hydrocortisone was decreased from 20 mg to 15 mg. His home clonidine and lisinopril was restarted and his blood pressure normalized. Otherwise, his vital signs were within normal limits. His hematocrit was trended and remained stable. He required no further blood transfusions. His home aspirin was resumed on [9-6]. He was also started on fondaparinux at that time for DVT prophylaxis (pt with history of heparin allergy), with plans to discontinue when pt is more mobile. His I&O's were monitored and he made adequate amounts of urine. His creatinine returned to baseline at 1.7. He was tolerating a regular diet and was started on bowel regimen for prophylaxis. His pain level was routinely assessed. He was started on an oral pain regimen with standing tylenol and prn low-dose oxycodone and tramadol. Physical therapy was consulted who evaluated the patient and determined that he would benefit from ongoing physical therapy at rehab after discharge. On [9-6] Mr. [Known lastname 112450] is afebrile with stable vital signs. He is being discharged to rehab to continue his recovery. Medications on Admission: ALPRAZolam 0.25 mg PO BID Atenolol 25 mg PO BID Finasteride 5 mg PO DAILY FoLIC Acid 1 mg PO DAILY Hydrocortisone 10 mg PO QPM Hydrocortisone 20 mg PO QAM Simvastatin 20 mg PO DAILY Venlafaxine 75 mg PO BID Aspirin 81 mg PO DAILY CloniDINE 0.1 mg PO DAILY Clonidine Patch 0.2 mg/24 hr 1 PTCH TD WEEKLY Lisinopril 10 mg PO DAILY MethylPHENIDATE (Ritalin) SR 20 mg PO DAILY Tamsulosin 0.4 mg PO HS Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. ALPRAZolam 0.25 mg PO BID 3. Atenolol 25 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Finasteride 5 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Hydrocortisone 10 mg PO QPM 8. Hydrocortisone 15 mg PO QAM 9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain hold fro increased sedation, resp. rate <10 10. Senna 1 TAB PO BID:PRN constipation 11. Simvastatin 20 mg PO DAILY 12. Venlafaxine 75 mg PO BID 13. Aspirin 81 mg PO DAILY 14. CloniDINE 0.1 mg PO DAILY 15. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD WEEKLY 16. Lisinopril 10 mg PO DAILY hold for sbp<110 17. Tamsulosin 0.4 mg PO HS 18. Ferrous Sulfate 325 mg PO DAILY 19. TraMADOL (Ultram) 25-50 mg PO Q6H:PRN pain hold for increased sedation, resp. rate <10 20. Methylphenidate SR 20 mg PO DAILY 21. Fondaparinux Sodium 2.5 mg SC DAILY Discharge Disposition: Extended Care Facility: [Location (un) ] at [Location (un) 4693] Discharge Diagnosis: s/p trauma found down: Injuries: 1. Left iliac crest fracture 2. Left comminuted pubic ramus fracture 3. Retroperitoneal bleed 4. Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after a fall. You were found to have a left hip fracture which also caused some bleeding and your required a short stay in the intensive care unit. You blood levels are now stable. The orthopedic surgeons were consulted for the fracture this who recommended nonoperative management with physical therapy and pain management. You are now being discharged to rehab to continue this treatment. There was some concern over the reason for your fall and whether or not it was a syncopal episode. Cardiology was consulted for evaluation of this, who determined your pacemaker to be functioning normally and no evidence of cardiac event. You should follow up with your primary care provider after discharge from rehab for ongoing evaluation. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [2134-9-21] at 9:00 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2134-9-21] at 9:20 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2134-9-6]	[ "724.00", "V45.01", "427.1", "274.9", "272.4", "458.9", "V58.65", "868.04", "808.2", "E849.7", "401.9", "414.01", "V10.05", "733.90", "V45.82", "285.1", "808.41", "790.5", "E888.9", "255.41" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8359, 8434	4738, 7030	283, 289	8632, 8632	1872, 4062	9601, 10301	1329, 1348		7509, 8336		8455, 8611		7056, 7486			8808, 9578								1363, 1853																					225, 245									317, 998							4077, 4715		8647, 8784					1020, 1238	1254, 1313
26,827	116,000	31967	Discharge summary	report	Admission Date: [2146-9-12] Discharge Date: [2146-9-15] Date of Birth: [2073-4-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7223] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: implantable pacemaker placement History of Present Illness: Mrs. [Known lastname 12967] is a 73 yo woman from [Country 3587] with history of HTN who presented to a hospital in [Country 3587] about two weeks prior to admission with a heart block which she was told would require pacemaker implantation. She left the hospital without getting a pacemaker and travelled to the United States. Per chart, she reported that she had CP, palpitations and dyspnea 2 weeks ago when she was seen in [Country 3587]. She however reports that she has never had CP, palpitations or dyspnea and that when she was diagnosed with the "[Last Name ] problem" that she did not have any symptoms. She also reports having recent fevers and chills. No cough, rashes, arthralgia. . She reports that today, she came to the ED because she felt that her blood pressure was high. She says that when her blood pressure is elevated, she has "tongue heaviness" which she currently endorses. Otherwise she denies headache, weakness. She does report slurred speech which has been progressive for 1 month. . She presented to [Hospital1 18] and was found to have complete heart block on her initial EKG. Initial VSs were 96.8 HR 40 178/64 RR 16 97% RA . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Past Medical History: Hypertension Social History: Flew over from [First Name9 (NamePattern2) 74912] [Country ] last week, staying with family. Family History: non-contributory Physical Exam: VS: T Afebrile, BP 182/61 , HR 90, RR 22, O2 97% on RA Gen: WDWN elderly woman in NAD, resp or otherwise. Pleasant, appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Neck: JVP of 8 cm. CV: Bradycardic but regular, normal S1, S2. No S4, no S3. Chest: No crackles, wheeze, rhonchi anteriorly Abd: Obese, soft, NTND, No HSM or tenderness Ext: No c/c/e Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: [2146-9-12] ADMISSION LABS: CBC: WBC-16.8* RBC-4.66 Hgb-14.3 Hct-41.0 MCV-88 MCH-30.6 MCHC-34.8 RDW-13.8 Plt Ct-297 Neuts-58.0 Lymphs-29.4 Monos-5.2 Eos-7.1* Baso-0.2 . COAGS: PT-12.1 PTT-28.0 INR(PT)-1.0 . CHEM: Glucose-133* UreaN-18 Creat-1.1 Na-140 K-4.0 Cl-101 HCO3-27 AnGap-16 Calcium-9.9 Phos-4.2 Mg-2.4 . LFTs: ALT-28 AST-20 CK(CPK)-68 AlkPhos-98 Amylase-92 TotBili-0.5 Lipase-57 Albumin-4.1 . cTropnT-<0.01 . TSH-2.2 . COMPLETE HEART BLOCK AND EOSINOPHILIA WORKUP: RPR: negative [2146-9-13] 9:17 am STOOL CONSISTENCY: LOOSE Source: Stool. FINAL REPORT [2146-9-14] OVA + PARASITES (Final [2146-9-14]): NO OVA AND PARASITES SEEN. . Blood Cultures: negative Urine Culture: negative Toxo: IgG positive, IgM negative Lyme: negative Strongyloides: POSITIVE (result returned after discharge) Chagas: negative . [2146-9-15] DISCHARGE LABS: CBC: WBC-13.6* RBC-4.35 Hgb-13.3 Hct-38.4 MCV-88 MCH-30.5 MCHC-34.5 RDW-13.9 Plt Ct-213 Neuts-66.9 Lymphs-19.1 Monos-4.1 Eos-9.8* Baso-0.1 . CHEM: Glucose-98 UreaN-13 Creat-0.9 Na-139 K-4.2 Cl-102 HCO3-27 AnGap-14 Calcium-9.3 Phos-4.2 Mg-2.2 . STUDIES: CT head: no intracranial process . Admission EKG: Sinus rhythm, rate 95-100. There is high degree or complete A-V block with junctional pacemaker at rate 40. No previous tracing available for comparison. TRACING #1 . ECHO: Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . POST-PACEMAKER EKG: Normal sinus rhythm, rate 78, with ventricular synchronous pacing. Compared with tracing of [2146-9-13] the rhythm has changed from sinus at rate 70 with probable high degree A-V block to sinus at rate 78 with ventricular synchronous pacing. The ventricular rate has increased from 35 to 78. Brief Hospital Course: 75F with HTN presents with complete heart block. Hospital course by problem. . # CHB - patient was monitored on telemetry and was taken to the EP lab where a dual chamber pacmaker was placed. An echo showed a normal EF of 70%. Surveillence telemetry and CXR indicated a malpositioned atrial lead, and she was taken back to the EP lab for revision. Subsequent pacing was appropriate and leads were confirmed on CXR. She was discharged with follow up in the device clinic, and with 3 additional doses of post-procedure prophylactic Kefzol. Infectious etiologies for CHB including syphilis and chagas disease were negative. Of note, the patient's strongyloides antibody titer did return postitive (see "Eosinophilia" below), but strongyloides infection is not known to cause CHB. . # HTN - patient reported being on HCTZ in the past. Was restarted on HCTZ with only marginal BP control. Amlodipine 5mg was also begun prior to discharge. . # Eosiniophilia - ranged from 6.4 to 9% on differential. No known allergies or asthma. An infectious workup was pursued, including stool O+P, which was negative, and blood and urine cultures, which were also negative. A lyme antibody was negative. However, after discharge, her strongyloides antibody returned positive. Interestingly, the stronglyoides [Doctor First Name ] may be positive even when repeated examinations of stool samples have been unrevealing, as was the case in this patient. Also of note, rhe anti-strongyloides antibody assayed in the [Doctor First Name ] serology can persist for years after treatment. It is currently unknown whether or not the patient has ever been treated for strongyloides. However, given her high degree of peripheral eospinophilia, it is not unreasonable to assume that she may currently be infected. PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 11616] was notified via email, patient has appointment with him on [10-18] (in 12 days time). Medications on Admission: HCTZ 25mg daily occasional metaclopramide Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Keflex 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 doses. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary: complete heart block secondary: hypertension Discharge Condition: good, stable Discharge Instructions: You were admitted tot he hospital with an abnormal heart rhythm called complete heart block. You received an implantable pacemaker to treat this condition. After discharge, you will need to take 3 more doses of antibiotics to protect against infection. You will also need to follow up with the electrical device clinic to make sure the pacemaker is working properly. . You were also found to have high blood pressure. You are now taking 2 blood pressure medicines, called hydrochlorothiazide and amlodipine. . Please take all medications as prescribed. Please attend all follow up appointments. If you experience any chest pain, shortness of breath, lightheadedness, or other symptoms, please call your doctor or return to the ER. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2146-9-21] 9:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, MPH[MD Number(3) 708]:[Telephone/Fax (1) 7976] Date/Time:[2146-10-18] 4:15	[ "426.0", "996.01", "414.01", "288.3", "401.9", "E878.4" ]	icd9cm	[ [ [] ] ]	[ "37.75", "37.83", "37.72" ]	icd9pcs	[ [ [] ] ]	7265, 7271	4893, 6843	326, 360	7369, 7384	2443, 2459	8163, 8442	1955, 1973		6935, 7242		7292, 7348		6869, 6912			7408, 8140			3355, 3608					1988, 2424																					276, 288									388, 1785		3617, 4870			2475, 3339									1807, 1821	1837, 1939
74,935	118,102	38030	Discharge summary	report	Admission Date: [2162-6-7] Discharge Date: [2162-6-12] Date of Birth: [2111-7-6] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4616] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 50 F with hx of synovial carcinoma dx in [2159] on C1D5 2nd line gemcitabine/docetaxel w/ recent admission for uncontrolled abdominal pain managed with narcotics, who presents with AMS since Sunday. Pt and husband relayed the history together and reported that pt took 2 30mg tabs of morphine and 2 tabs 10mg oxycodone on Saturday night and slept through until Sunday morning. Husband reports that pt awoke before him and took 1 30mg tab of morhpine and 1 tab 10mg oxycodone and did ok for the beginning of the morning but when they went to watch tv, she fell asleep and he was unable to wake her. He called 911 and when the EMS came, they were also unable to wake her until they picked her up to move her. She then awoke and was taken to Good [Hospital 39887] Hospital, where he reports they gave her two "shots" of a medication he did not know and she awoke and improved, and subsequently was sent home. Additionally, she reports low urine output for a few days despite drinking a lot of water secondary to thirst, along with constipation. She also endorses dysuria and hematuria for the past few days, but denies any back pain. Husband reports a temperate at home to 100.9 yesterday and muscle jerks last night that lasted throughout the night, along with speaking non-sensical words and sentences. Otherwise, she denies chest pain, sob, vomiting, diarrhea. She reports her son has a dry cough at home, but no other sick contacts. Of note, pt had recent admission for abdominal pain after CT abd/pelvis on [5-31] showed large intra-abdominal mass with mass effect on the SMV and gallbladder, apparently new from [2162-2-22]. She was managed in conjunction with palliative care, and her pain was controlled with oxycontin 30mg in the AM, 60mg in the PM, and 60mg qHS, along with morphine PCA. She did not show any evidence of somnolence or AMS w/ this dosing. She was given MS Contin upon discharge, to be taken as 60mg in the morning, 60mg in the afternoon, and 90mg in the evening, along with Oxycodone 20-30mg q3h as needed for pain. Additionally, she was started on 2nd line chemotherapy for her synovial sarcoma and given 1 dose of gemcitabine on [2162-6-4], to which she had an expected fever, but otherwise tolerated well. She has had recent reports of suicidal attempts/ideation, though on her recent hospitalization, she denied suicidal ideation and voiced a safety plan prior to discharge. In the ED, initial VS were: 98.8 94 83/43 18 100% 2L. Patient was given 2 liters NS, and patient was started on Levophed with improvement in blood pressures. Labs notable for [Last Name (un) ] with BUN/Creatinine 42/5.1, hyponatremia 128, ALT/AST elevated to 302/761, Uric Acid 10.5, HCT down slightly from baseline. Blood cultures sent. CT head without evidence of intracranial mass or other acute process. CT abdomen per report with worsening liver and lung mets compressing SVC. CXR with left sided central line, unchanged left basal/apical masses, no interval change. Patient was given Naloxone 0.2mg without improvement in symptoms, Vancomycin/Zosyn. Vitals prior to transfer HR: 94, BP: 96/55, 94% on 2L. On arrival to the MICU, patient's VS were 99.4 99 88/48 20 96% 2L. She is resting in bed comfortably, drowsy but arousable and interactive. She reports [5-11] RUQ pain but otherwise is feeling okay. She endorses the symptoms described above, which is confirmed by her husband, who is at her bedside. Review of systems: (+) Per HPI (-) Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, diarrhea, dark or bloody stools. Denies rashes or skin changes. Past Medical History: --Type 2 Diabetes mellitus, insulin, followed at [Last Name (un) ]. -- Hypertension -- Asthma -- Anemia -- Arthritis -- Depression -- Status post posterior spinal fusion at L4-5 [2-/2159] at [Hospital1 2177] Hysterectomy and unilateral oophorectomy at age 32 for fibroids: pt was told she had a small foci of cancer but that it was completely resected and required no follow-up therapy -- Bladder suspension [2154] -- Tubal ligation -- Synovial Sarcoma (see ONC History Below) ONC HISTORY: Metastatic synovial sarcoma, left thigh, s/p resection [11/2159] and XRT, local recurrence and bilateral lung mets (2) [5-/2161], s/p resection of local recurrence and left upper lobectomy 5/[2161]. [2161-10-8] she underwent wedge resection of RUL nodule, path (+) for 0.5cm synovial sarcoma, margins (-). Restaging CT [2162-5-31] with significant progression of metastatic disease in chest with mult. new lesions and increasing size of existing lesions. - [2161-7-20]: Cycle #1 ifosfamide complicated by pulmonary edema. - [2161-8-10]: Cycle #2 ifosfamide given. - s/p 3rd cycle of doxorubicin [2162-1-12] - s/p 4th cycle of adriamycin on [2162-2-3] - currently C1D5 2nd line gemcitabine/docetaxel Social History: Pt lives in [Hospital1 1474], MA with her husband [Name (NI) 2319] of 31 years. They have 2 adult sons and grandchildren. She denies alcohol, tobacco, or illicits. She moved to the US from [Male First Name (un) 1056] as a teenager. She previously worked for the Department of Mental Health, has not worked since [2159]. Family History: Pt reports that a maternal aunt developed breast cancer and her son developed gastric cancer at a young age. No other history of malignancy. Her father died with CAD, HTN, DM. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T 99.4, BP 88/48, P 99, R 20, O2 96% on 2L NC General: Alert, oriented, calm, no acute distress, drowsy but arousable and interactive HEENT: Sclera anicteric, MM dry with two strips of white exudate on the lateral aspects of her tongue, oropharynx otherwise clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally w/ decreased breath sounds at b/l bases, but no wheezes, rales, ronchi Abdomen: softly distended w/ tenderness to palpation in the RUQ. Ecchymoses noted at RLQ and LLQ. Bowel sounds present but sluggish. GU: foley will be placed Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace edema on BLEs. DISCHARGE EXAM notable changes from admission: BP is 146-155/80-90 HR 88-95 The patient is awake, alert, interactive and appropriate. Distended and tender abdomen Pertinent Results: ADMISSION LABS [2162-6-7] 05:20PM BLOOD WBC-4.6 RBC-2.82* Hgb-7.3* Hct-23.5* MCV-84 MCH-26.0* MCHC-31.0 RDW-14.8 Plt Ct-240 [2162-6-7] 05:20PM BLOOD Neuts-86.8* Lymphs-11.2* Monos-1.0* Eos-0.7 Baso-0.3 [2162-6-8] 01:08AM BLOOD PT-20.3* PTT-30.7 INR(PT)-1.9* [2162-6-7] 05:20PM BLOOD Glucose-171* UreaN-41* Creat-5.2* Na-128* K-3.9 Cl-92* HCO3-24 AnGap-16 [2162-6-7] 05:20PM BLOOD ALT-302* AST-761* AlkPhos-188* TotBili-1.2 [2162-6-7] 05:20PM BLOOD Albumin-2.9* Calcium-8.2* Phos-4.5 Mg-1.9 [2162-6-7] 04:40PM BLOOD UricAcd-10.5* [2162-6-7] 05:35PM BLOOD Lactate-0.9 [2162-6-8] 01:56AM BLOOD O2 Sat-78 MIROBIOLOGY [2162-6-7] Blood Culture, (Pending): [2162-6-7] Blood Culture, (Pending): [2162-6-8] URINE CULTURE negative [2162-6-8] MRSA SCREEN negative IMAGING [2162-6-7] CHEST (PORTABLE AP): Little interval change from the prior study, with the basal and left apical masses. No definitive acute interval change. [2162-6-7] CT HEAD W/O CONTRAST: Stable extraxial lesion-likely meningioma. no evidence of intracranial metastatic disease, however, MRI is more sensitive for the detection of such lesions. [2162-6-7] CT ABD & PELVIS W/O CONTRAST: 1. Multiple pleural-based metastases in the left lung base, one abutting the left ventricle. If there is concern for hemodynamic abnormalities, an echocardiogram may be considered to evaluate functional mass effect on the heart. 2. Large infrahepatic metastasis with interval growth causing marked mass effect on adjacent structures. [2162-6-10] MRCP Extremely limited examination of the upper abdomen due to patient inability to complete the examination. There is however no gross intrahepatic biliary dilatation identified. Left sided pleural based and right upper abdominal masses consistent with metastases. The gallbladder cannot be seen separate to the subhepatic mass. RUQ US [2162-6-11] PRELIMINARY 1. Large mass within the right upper quadrant with significant mass effect Preliminary Reportover the liver. Preliminary Report2. The gallbladder cannot be identified. Preliminary Report3. The visualized liver parenchyma reveals no intra hepatic biliary duct dilation DISCHARGE LABS [2162-6-11] 05:30AM BLOOD WBC-4.9 RBC-2.77* Hgb-7.4* Hct-23.5* MCV-85 MCH-26.8* MCHC-31.5 RDW-15.3 Plt Ct-152 [2162-6-11] 04:55PM BLOOD Hct-25.9* [2162-6-11] 05:30AM BLOOD Neuts-79.2* Lymphs-12.0* Monos-8.3 Eos-0.2 Baso-0.3 [2162-6-11] 05:30AM BLOOD Glucose-125* UreaN-17 Creat-0.8 Na-137 K-3.9 Cl-102 HCO3-27 AnGap-12 [2162-6-11] 05:30AM BLOOD ALT-208* AST-343* LD(LDH)-437* AlkPhos-338* TotBili-6.1* [2162-6-11] 05:30AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.6 Brief Hospital Course: 50 F with hx of synovial carcinoma dx in [2159] on C1D5 2nd line gemcitabine/docetaxel w/ recent admission for uncontrolled abdominal pain managed with narcotics, who presents with AMS since yesterday. # Hypotension: SBP was initially in the 80s at admission and she was admitted to the [Hospital Unit Name 153] for management. Etiology was thought to be volume depletion given that she responded well to fluids and her BP improved. She was briefly on Levophed after transfer from the ED, however this was quickly weaned when she was adequately volume repleted. No source of infection was identified, however given her abdominal pain we considered cholangitis as a source, as discussed below. She was started on vanc/Zosyn empirically pending culture data. Vanc was discontinued after blood cultures were negative for 48 hours. Zosyn was then discontinued in favor of an oral regimen for ease of administration when the patient is at home on hospice. Cipro and Flagyl will be continued throughout hospice, as this is palliation. She likely does have biliary tract infection, but MRCP and RUQ US were technically unable to be done, so no definitive diagnosis was made. # Sedation - She was initially sedated at admission, thought to be due to the large amount of oxycodone she was using prior to admission for her abdominal pain. [Month (only) 116] have also been due in part to her volume depletion. She improved with cautious narcotic use and volume resuscitation. Palliative care was contulted for pain control as discussed below. # Acute Kidney Injury: Her Cr was 5.1 at admission and rapidly improved with to 0.9 prior to transfer to the floor. As discussed above, thought to be due to volume depletion at admission. She also had a large amount of urine released after Foley placement and it is thought that she may have had a component of urinary retention from her heavy use of narcotics. Her home lisinopril was held. Foley was removed and she urinated without difficulty for the remainder of her hospitalization, with post void residual on bladder scan being O. # RUQ pain and transaminitis: Patient had an elevated direct bilirubin with transaminitis at admission. There was some concern for cholangitis given her RUQ pain, mild fevers, and elevated direct bilirubin and she was empirically covered with Zosyn at admission. Another potential etiology was external compression of her biliary system from her abdominal malignancy with large intraabdominal masses. We attempted to obtain an MRCP, however she was unable to tolerate the test due to pain. A RUQ ultrasound was obtained instead which was also technically limited, so no definitive diagnosis was able to be made. # Synovial Sarcoma - Diagnosed in [2159], she is s/p chemo and XRT w/ tumor recurrence, metastases and large tumor burden. At admission, pt is currently C1D5 of 2nd line chemotherapy gemcitabine/docitaxel. Received 1 dose gemcitabine late last week and tolerated it well with the exception of 1 expected fever. Dr. [Last Name (STitle) ] is pt's primary oncologist who in discussion with the pt, decided to pursue this chemotherapy regimen last week. Pt is well-known to palliative care, who saw her on her last admission. Her pain was initially controlled with a Dilaudid PCA with fair control. Her nausea was controlled with Zofran and PRN Haldol. Palliative care was consulted and provided recommendations for her symptoms control. --Chronic issues-- # Asthma - Continued on home Advair and albterol. # DM II - Was continued on a lower dose of her home Lantus as well as a Humalog sliding scale. # genetics: notable fhx. outpatient genetics as per primary onc. # Depression - Continued on home citalopram # GERD -Continued on home omeprazole # Code status this admission: DNR/DNI (changed from Full at admission) --Transitional issues-- PENDING STUDIES - Blood cultures pending - RUQ US final read pending - FMLA forms filled out for patients' sons to enable them to provide care at home. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every six (6) hours as needed for shortness of breath or wheezing AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day DEXAMETHASONE - 4 mg Tablet - 2 Tablet(s) by mouth twice a day Days [8-9] of chemotherapy FILGRASTIM [NEUPOGEN] - 480 mcg/0.8 mL Syringe - 1 Syringe(s) once a day after chemotherapy, as directed. ICD9-171.9 FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 inhalation po twice daily rinse after each use FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth twice a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth in am and at 4pm, and 3 capsules at bedtime HAIR PROSTHESIS - - Please provide 1 hair prosthesis daily For chemotherapy induced alopecia. ICD9#171.9 INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 42 units twice a day INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - Dosage uncertain IPRATROPIUM BROMIDE - 21 mcg Spray, Non-Aerosol - 1 spray nasal four times a day LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily METHYLPHENIDATE - 20 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day In AM METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth four times a day MORPHINE [MS CONTIN] - (Prescribed by Other Provider) - 30 mg Tablet Extended Release - [3-5] Tablet(s) by mouth three times a day Please take 2 tablets in the morning, 2 tablets in the afternoon, and 3 tablets at nighttime NAPROXEN - (Prescribed by Other Provider) - 250 mg Tablet - 1 (One) Tablet(s) by mouth twice a day with food NYSTATIN - 100,000 unit/mL Suspension - 5 ml by mouth four times a day Swish and swallow OLANZAPINE - 15 mg Tablet - 0.5 (One half) Tablet(s) by mouth at night OMEPRAZOLE - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 84939] - 40 mg Capsule, Delayed Release(E.C.) - Capsule(s) by mouth ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8 hours chemotherapy induced nausea/vomiting. ICD9-171.9 OXYCODONE - (Prescribed by Other Provider) - 10 mg Tablet - [2-1] Tablet(s) by mouth q3h as needed for pain POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17 gram Powder in Packet - 1 Powder(s) by mouth DAILY (Daily) WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth every day as instructed . Medications - OTC CALCIUM CARBONATE - (Prescribed by Other Provider) - 200 mg calcium (500 mg) Tablet, Chewable - 1 Tablet(s) by mouth four times a day CIMETIDINE [TAGAMET HB] - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth as needed DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS SULFATE [SLOW FE] - (Prescribed by Other Provider) - 142 mg (45 mg iron) Tablet Extended Release - one Tablet(s) by mouth daily SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for constipation Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing. Disp:1 inhaler Refills:2 2. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:120 neb Refills:2 3. insulin glargine 100 unit/mL Solution Sig: Thirty (30) U Subcutaneous twice a day. Disp:1800 U Refills:0 4. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day: Per insulin sliding scale sheet, between 2-10U. Disp:qs Refills:2 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:30 Tablet(s) Refills:2 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. methylphenidate 20 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). Disp:15 Tablet Extended Release(s) Refills:0 9. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). Disp:60 Tablet(s) Refills:0 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. Disp:1 bottle Refills:0 12. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:0 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). Disp:30 Powder in Packet(s) Refills:0 15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:0 16. prochlorperazine maleate 10 mg Tablet Sig: 0.5=1 Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:60 Tablet(s) Refills:0 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 18. hydromorphone in 0.9 % NaCl 0.2 mg/mL Solution Sig: 0.5 mg Injection ASDIR (AS DIRECTED). 19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Indwelling Port (e.g. Portacath), non-heparin dependent: Flush with 10 mL Normal Saline daily, PRN, and when de-accessing, per lumen. 20. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 21. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 22. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 635] infusion Discharge Diagnosis: metastatic synovial carcinoma 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 Mrs. [Known lastname 61723], As you know, you were admitted to the hospital with altered mental status and low blood pressure. You have decided to go home to focus on comfort and being with your family. We wish you all the best. It was truly a pleasure taking care of you. Please note that your medications have been adjusted. You are on the PCA for pain control, and we encourage you to contine taking bowel medications to help prevent constipation. We have discontinued the following medications: Ondansetron 4-8 mg IV Q8H:PRN nausea Fentanyl Patch 75 mcg/hr TP Q72H Haloperidol 0.5-1 mg IV Q4H:PRN N/V (hasn't needed this) HYDROmorphone (Dilaudid) 0.5-1 mg IV Q1HR PRN pain Followup Instructions: Department: PSYCHIATRY When: TUESDAY [2162-6-15] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23908], MD [Telephone/Fax (1) 1387] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 551] Campus: EAST Best Parking: Main Garage	[ "V12.51", "197.0", "V49.86", "197.7", "250.00", "285.9", "276.50", "458.9", "493.90", "584.9", "V58.67", "401.9", "349.82", "276.1", "V15.3", "530.81", "V58.61", "V66.7", "V10.89", "V16.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	19736, 19795	9491, 13511	314, 320	19869, 19869	6765, 9468	20764, 21124	5657, 5835		16709, 19713		19816, 19848		13537, 16686			20052, 20741								5850, 6746																			3814, 4021		263, 276									348, 3795									19884, 20028					4043, 5287	5303, 5641
225	130,684	19653	Discharge summary	report	Admission Date: [2168-1-4] Discharge Date: [2168-1-13] Date of Birth: [2137-10-10] Sex: M Service: O-MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 30 year old male with a past medical history of pulmonic stenosis (now thought to be secondary to an anterior mediastinal mass), who presented with five weeks of progressive nonproductive cough, fever, and night sweats to an outside hospital on [2168-1-1], where a chest x-ray revealed an anterior mediastinal mass and a CAT scan showed the mass measuring at 11.3 by 14.4 by 12.0 centimeters, as well as small effusions. The patient was sent home with follow-up but over the weekend, he developed pleuritic left sided chest pain with mild shortness of breath. Again, he was evaluated at the outside hospital where the pericardial effusion now appeared large. He was therefore transferred to [Hospital1 69] where an echocardiogram revealed a 3.5 centimeter effusion with inferior vena cava inspiratory collapse and mitral inflow variability without increased jugular venous pressure or a pulsus. The patient was transferred to the CCU for close monitoring. PAST MEDICAL HISTORY: 1. Hernia repair at eight years old. 2. Lyme disease at ten years old. 3. Pulmonic stenosis diagnosed in [9-11], after a murmur and diagnosed by echocardiogram. 4. Shingles. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone. Negative tobacco. Three drinks of alcohol per month. The patient works as industrial designer, physically active. FAMILY HISTORY: Mother passed seven years ago from breast cancer. Grandfather with prostate carcinoma. PHYSICAL EXAMINATION: On admission, temperature 101.8, heart rate 105, blood pressure 130/70, respiratory rate 27 to 32, oxygen saturation 98% in room air. The patient is a well developed male who is thin and diaphoretic, anxious, in mild respiratory distress. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cranial nerves II through XII are intact. The oropharynx is clear. Negative anterior posterior lymphadenopathy. Neck is supple, negative axillary nodes. Lungs are clear to auscultation bilaterally. The heart was tachycardia, regular S1 and S2 with II to III/VI murmur at the left sternal border. The abdomen was soft, nontender, positive bowel sounds, no hepatosplenomegaly. Extremities were no cyanosis, clubbing or edema. No rashes. Strength was [4-13] in all four extremities. LABORATORY DATA: On admission, white blood cell count was 10.9, hematocrit 37.2, platelet count 381,000. INR 1.5. Chem7 was within normal limits. Echocardiogram revealed normal systolic function, 3.5 effusion at the largest diameter, inferior vena cava collapse with inspiration, question of pericardial studding, mild respiratory variation in mitral inflow consistent with some early signs of tamponade. CAT scan from [2168-1-1], heterogeneous mass in the left midline compressing the left pulmonary artery, right upper lobe pleural nodules, left pleural effusion, pericardial effusion. HOSPITAL COURSE: 1. Pericardial effusion at admission - The patient had signs for early tamponade physiology but was hemodynamically stable and was admitted to the CCU for close monitoring. Repeat echocardiogram showed increasing size of the effusion. The patient therefore underwent pericardial drain and 600cc of grossly hemorrhagic fluid were removed. Following the procedure overnight, there was no further drainage from the pericardial drain. Repeat echocardiogram showed decreasing pericardial fluid. Therefore on [2168-1-8], the pericardial drain was pulled. The patient had one further follow-up echocardiogram on [2168-1-11]. This revealed no effusion and it was felt the patient was stable from a cardiac standpoint. 2. Hematology/Oncology - The patient underwent a mediastinal biopsy to diagnose the large anterior mediastinal mass. The biopsy revealed nonseminomatous germ cell yoke sac tumor. The patient underwent two treatments of radiation therapy as well as a round of five days of chemotherapy with Etoposide and Cisplatin. Staging workup included a head magnetic resonance scan which revealed no lesions, as well as an ultrasound of the scrotum which was within normal limits. Fluid drained from the pericardial and pleural effusions were negative for malignant cells. The patient tolerated chemotherapy well suffering from nausea, relieved by Ativan. He was pretreated with Allopurinol and intravenous fluids to prevent tumor lysis. The patient completed his five days of chemotherapy. He will follow-up with Dr. [Last Name (STitle) ] in one week for continuation of his therapy with the possible addition of Bleomycin following pulmonary function tests. 3. Infection - During the [Hospital 228] hospital course, he continued to have shortness of breath as well as a cough with mild hemoptysis. On [2168-1-7], the patient spiked a fever. This was thought most likely secondary to the tumor burden, however, the patient was started on Vancomycin, Levofloxacin and Clindamycin as broad spectrum therapy with a question of postobstructive pneumonia. Subsequently, the patient did well with no further fevers. Vancomycin and Clindamycin were stopped and the patient will complete a ten day course of Levofloxacin. 4. Pleural effusion - The patient had a left sided chest tube placed for drainage of pleural fluid. Following the removal of the chest tube, the patient had continued drainage from the site of the tube. After a number of days, this slowly resolved. The patient's site was closed by CT surgery with a suture. The suture is to be removed in seven to ten days at a follow-up appointment with Dr. [Last Name (STitle) ]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with VNA services for dressing changes. FOLLOW-UP: The patient will follow-up on [2168-1-21], with Dr. [Last Name (STitle) ], as well as [2168-2-8], with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284] of cardiology. MEDICATIONS ON DISCHARGE: 1. Ativan 0.5 to 1 mg p.o. q3-4hours p.r.n. nausea. 2. Levofloxacin 500 mg p.o. once daily times three days. 3. Robitussin with Codeine p.r.n. FINAL DIAGNOSES: 1, Nonseminomatous germ cell anterior mediastinal tumor. 2. Pericardial effusion, status post drainage. 3. Left pleural effusion, status post drainage. 4. Postobstructive pneumonia. [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], M.D. [MD Number(1) 3218] Dictated By:[Name8 (MD) 13747] MEDQUIST36 D: [2168-1-13] 15:02 T: [2168-1-13] 18:18 JOB#: [Job Number 53226]	[ "164.2", "486", "197.1", "786.3", "423.0", "511.9" ]	icd9cm	[ [ [] ] ]	[ "34.25", "37.0", "37.21", "99.25", "92.29", "34.04" ]	icd9pcs	[ [ [] ] ]							1606, 1695					6207, 6354	1385, 1430	3174, 5852														6371, 6827									1719, 3157																	168, 1153														1175, 1358	1447, 1589	5877, 6181
23,438	166,483	44934	Discharge summary	report	Admission Date: [2200-11-22] Discharge Date: [2200-11-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13386] Chief Complaint: Coffee-ground emesis Major Surgical or Invasive Procedure: None History of Present Illness: 83F with history of dementia, chronic LE cellulitis, recent DVT and esophagitis/gastritis initially admitted to MICU with coffee-ground emesis and subsequently found to have urosepsis now transferred to floor. Pt's history dates back to admission in [8-15] for altered mental status where pt was found to have hypercalcemia and hypernatremia and was diagnosed with aspiration pneumonia and a UTI during that hospitalization. She was also found to have a LLE DVT and was anticoagulated with heparin. While supratherapeutic on heparin, she had am episode of coffee-ground emesis which resolved with a stable hematocrit. Pt had been discharged at that time with plans for outpatient EGD. Pt had been doing well until day PTA [11-21] when at nursing home (NH), pt developed a temp of 104.8 and three episodes of coffee-ground emesis. There was a question of an aspiration event and the patient's oxygen saturation was noted to drop. In the ED, the patient's temperature was 103.2 with heart rate 102. Oxygen saturation was 89% on RA and she was placed on a NRB mask. She refused an NG lavage, but while in the ED vomited ~100cc of brown/black liquid. She was given 3200cc of NS and subsequently noted to have audible wheezing with respiratory distress and was started on IV NTG, which was titrated up with improvement in respiratory status. She was given Vancomycin, levofloxacin, and metronidazole for presumed aspiration pneumonia. Over the course of her stay in the ED, her SBP progressively dropped to 70s-80s despite 3 L IVF and stopping nitro gtt and pt was then started on peripheral levophed (family refused central line). Pt was then admitted to MICU for further monitoring. . In MICU, blood cultures drawn [11-21] grew out GPC in clusters and GNR, +UTI on U/A (urine culture still pending). Pt was initially placed on Vanc/Levo/Flagyl, changed to Vanc/Zosyn/Levo [11-22]. Pressors weaned off last night but pt also developed IV infiltration secondary to peripheral levophed, given phentolamine overnight. BP has been stable with systolics 90s-100s. Respiratory status improved as well and NRB weaned down to 4 L NC with O2 sats 96%. Pt remains NPO for concern of aspiration risk. Now transferred to medicine floor for further management. Past Medical History: PMH: 1. Dementia. 2. Anxiety. 3. Depression. 4. Hypertension. 5. Colon cancer, status post resection in [2193-11-10]. 6. History of cellulitis of the left lower extremity and right lower extremity. 7. Gait disturbance. 8. Grade III Esophagitis 9. Gastritis 10. Hiatal hernia 11. Hypercalcemia [2-12] Primary Hyperparathyroidism 12. Hypernatremia, two previous admissions with AMS 13. LLE DVT [8-15] s/p IVC filter placement [2200-8-13] 14. Coffee-ground emesis [8-15] while supratherapeutic PTT Social History: The patient is a widowed [Hospital3 ] resident. The patient used to sell shoes. The patient denied any tobacco or alcohol use. Son has [Name2 (NI) ] syndrome. Daughter [Name (NI) ] used to take care of her. Family History: Noncontributory. Physical Exam: Vitals: T 98 BP 106/53 (92-106/48-53) P58-71 R20 Sat 95%4L NC, wt = 79 kg Gen: elderly woman, pleasant, breathing comfortably, follows commands, oriented x 1 (maiden name, knows she's in hospital, does not know year), asking repeatedly to be kissed HEENT: pupils 3mm and reactive bilaterally, dry mucous membranes, OP clear Neck: no JVD, no LAD Lung: coarse breath sounds bilaterally anteriorly, no wheezes Cor: RRR, nml S1S2 Abd: obese, soft NTND, NABS Rectal: guaiac positive (per ED initially in admisison), dark brown soft stool Ext: 2+ pitting edema bilateral lower extremities with chronic venous status changes; LUE with samll 4x4 cm area of purplish discoloration on forearm at previous PIV site which per nursing is significantly improved Pertinent Results: [2200-11-22] 06:34PM HCT-32.4* [2200-11-22] 11:34AM HCT-32.0* [2200-11-22] 05:55AM URINE COLOR-LtAmb APPEAR-Cloudy SP [Last Name (un) 155]-1.020 [2200-11-22] 05:55AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2200-11-22] 05:55AM URINE RBC-212* WBC->1000* BACTERIA-MANY YEAST-NONE EPI-<1 [2200-11-22] 05:55AM URINE WBCCLUMP-MANY MUCOUS-FEW [2200-11-22] 05:24AM TYPE-ART TEMP-37.9 PO2-153* PCO2-33* PH-7.37 TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [2200-11-22] 05:24AM LACTATE-6.3* [2200-11-22] 05:24AM O2 SAT-99 [2200-11-22] 05:05AM GLUCOSE-94 UREA N-30* CREAT-1.3* SODIUM-146* POTASSIUM-4.2 CHLORIDE-114* TOTAL CO2-17* ANION GAP-19 [2200-11-22] 05:05AM CALCIUM-9.8 PHOSPHATE-2.4* MAGNESIUM-1.8 [2200-11-22] 05:05AM WBC-9.3 RBC-3.78* HGB-10.1* HCT-31.7* MCV-84 MCH-26.7* MCHC-31.9 RDW-19.8* [2200-11-22] 05:05AM PLT COUNT-217 [2200-11-22] 01:00AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.024 [2200-11-22] 01:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2200-11-22] 01:00AM URINE RBC-[3-15]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-[6-20] [2200-11-22] 01:00AM URINE CA OXAL-MOD [2200-11-21] 11:00PM GLUCOSE-126* UREA N-30* CREAT-1.2* SODIUM-146* POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-25 ANION GAP-14 [2200-11-21] 11:00PM ALT(SGPT)-45* AST(SGOT)-51* ALK PHOS-151* AMYLASE-42 TOT BILI-0.4 [2200-11-21] 11:00PM MAGNESIUM-2.2 [2200-11-21] 11:00PM WBC-16.8# RBC-4.52 HGB-11.7# HCT-36.2 MCV-80* MCH-26.0* MCHC-32.5 RDW-18.9* [2200-11-21] 11:00PM NEUTS-87* BANDS-6* LYMPHS-1* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2200-11-21] 11:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2200-11-21] 11:00PM PLT SMR-NORMAL PLT COUNT-273# [2200-11-21] 11:00PM PT-13.5* PTT-27.1 INR(PT)-1.2 [2200-11-21] 11:00PM D-DIMER-2320* [2200-11-21] 10:26PM LACTATE-2.8* Brief Hospital Course: 83F with history of dementia, chronic LE cellulitis, recent DVT and esophagitis/gastritis admitted with coffee-ground emesis and UTI. . 1. Hypotension: Likely etiology was septic shock from UTI vs possible aspiration PNA va aspiration pneumonitis. Blood cultures now positive for Staph aureus (MRSA) and Proteus mirabilis sensitive. Source is likely the UTI with the Urine cultures from [2200-11-20] being positive for gram positive bacteria >100,000 and Proteus species 10,000-100,000. BP now improved after IV hydration and antibiotics, pressors were weaned off and the pt was maintaining adequate BP. The Staph aureus (MRSA) was sensitive to Vancomycin and the Proteus species was sensitive to Ceftriaxone. The pt was treated with the these antibiotics and will be given a total of 4 week course (Vancomycin) and 2 week course of Ceftriaxone. An ECHO done to rule out endocarditis showed: LV hypertrophy with LEVF 55%, while the technique was sub-optimal, no evidence of endocarditis was noted, 1+ aortic regurgitation and 1+ mitral regurgitation. Surveillance blood cultures should be continued in the rehab q4-5 days to ensure clearance of the bacteremia. At the time of discharge the pt was afebrile and the hypotension had resolved. . 2. Gastrointestinal bleed: Likely related to previously documented gastritis and/or esophagitis vs peptic ulcer disease, arterio-venous malformation. The pt has not had an EGD since [2197]. Pt did not tolerate NG lavage in ED and per daughter ([Name (NI) ]), does not want endoscopy. The pt was kept NPO until she was evaluated by speech and swallow. She was noted to be safe to tolerate supervised intake of soft PO pureed solids. Her hematocrit was followed [Hospital1 ] until it stabilized. A GI consult was not obtained per request from the patient's daughter ([Name (NI) ], the health care proxy) because she did not did not want any GI intervention per attending, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. The attending, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], discussed the therapeutic options with the patient's son-in-law (the daughter [[Doctor First Name ]] could not be contact[Name (NI) ] despite multiple attempts) and together they decided that the current infections (bacteremia and UTI) would be treated in the [Hospital 100] rehab but no attempt should be made to further workup the GI bleeding. . 3. Fever: As above, likely source is UTI, sepsis and possible aspiration pneumonia (bibasilar opacities on CXR) Blood cultures were positive for Proteus mirabilis and Staph aureus; urine cultures positive for Proteus mirabilis and Staph. aureus. The patient was treated with appropriate antibiotics and remained afebrile. . 4. Acute on chronic renal failure: Baseline creatinine 0.8-1.2. Initial acute renal failure likely secondary to prerenal failure from hypovolemia secondary to GI bleed and/or sepsis. The patient's creatinine was closely followed and was 0.7 at the time of discharge. . 5. Respiratory distress: Unclear etiology, ?CHF vs aspiration event in the setting of fluid resuscitation in ED and decreased mental status. Oxygen saturations were weaned off NRB to 2L. CXR revealed bibasilar opacities which may relate to aspiration or atelectasis. The patient was continued on Ceftriaxone and Vancomycin and remained afebrile. . 6. IV infiltrate of levophed: The patient was treated with peripheral Levophed (IV Norepinephrine) for pressor support in the MICU (the family refused a central line). The drip had to be due to subdermal infiltration of Levophed. The pt did not develop any signs of skin necrosis secondary to Levophed infiltration. . 7. Mental Status: Pt was noted to be responsive, though confused. She has baseline dementia and likely had delirium in the setting of fever and hypotension. [Hospital ] medical conditions were treated and her mental status was closely followed. A head CT to assess bleed or mass was negative. Her electrolyte derangements were corrected daily (hypercalcemia and hypernatriemia). The patient's family established that the current mental status was her baseline. . 8. Hypercalcemia: Likely secondary to primary hyperparathyroidism, has been on bisphosphonate as outpatient. Ca had been initially normal on admission, it trended upward and then resolved. The pt was treated with IV fluids (D5W) to improve her free water deficit. . 9. LFT elevation: Improved from previous measurements. . 10. FEN: Electrolytes were repleted as needed. . 11. Prophylaxis: Pneumoboots. Proton pump inhibitor PO BID. . 10. Code Status: DNR/DNI . 11. Access: PICC line . 12. Communication: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (daughter, HCP): [Telephone/Fax (1) 96104](home), [Telephone/Fax (1) 96105] (cell). [Name (NI) ] [Name (NI) ] (son-in-law): [Telephone/Fax (1) 96106]. Has confirmed DNR/DNI; will avoid central venous line and pressors if possible, but can place if reversible condition. Confirmed DNR/DNI. . 12. Dispo: to [Hospital 100] rehab Medications on Admission: MEDS as outpatient: Combivent Nebs q6h prn Fluoxetine 20mg daily Ferrous sulfate 330mg daily Acetaminophen 650mg q4h prn Lactulose 20g [Hospital1 ] Alendronate 70mg weekly Ascorbic acid 500mg daily Esomeprazole 40mg daily Magnesium Oxide 400mg [Hospital1 ] Sorbitol 30mL daily Vit D3-Cholecalciferol 400U daily . Meds on transfer: 1. Tylenol prn 2. Alb/Ipratropium IH q6hr prn 3. Levofloxacin 250 mg IV daily #3 4. Zyprexa [Hospital1 ] prn 5. Protonix 40 IV BID 6. Phentolamine x 1 last night 7. Zosyn 2.25 gm IV q6 day #2 8. Vancomycin 1 gm IV q48hr #2 . Allergies: NKDA Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-12] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:30 Refills:0 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Pantoprazole 40 mg IV Q24H 4. Ceftriaxone 1 g Piggyback Sig: One (1) gram Intravenous once a day for 12 days. Disp:12 grams Refills:0 5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous once a day for 28 days: 4 week course for MRSA positive urosepsis. Disp:28 grams Refills:0 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - 4 South Discharge Diagnosis: Urosepsis Upper GI bleed Discharge Condition: Stable Discharge Instructions: Please report to the nearest Emergency Department if you have vomiting (that resembles coffee-grounds), black ot tarry stool, shortness of breath, chest pain or fever. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14959] at the [Hospital 100] rehab for evaluation of your urine and blood infection. The [Hospital 100] Rehab has been made aware that you will be discharge today and that you will be followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14959]. Completed by:[2200-11-26]	[ "578.0", "785.52", "038.11", "599.0", "V12.51", "584.9", "V09.0", "682.6", "995.92", "294.8", "252.00", "507.0", "585.9", "403.91", "285.1", "276.0" ]	icd9cm	[ [ [] ] ]	[ "00.17", "38.93" ]	icd9pcs	[ [ [] ] ]	12854, 12923	6341, 10054	286, 292	12992, 13000	4185, 6318	13216, 13618	3381, 3400		12074, 12831		12944, 12971		11466, 11787			13024, 13193								3415, 4166																					226, 248									320, 2590									10069, 11440					2612, 3128	3144, 3365			11805, 12051
69,436	186,803	37405	Discharge summary	report	Admission Date: [2113-6-23] Discharge Date: [2113-6-28] Date of Birth: [2056-4-29] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Mitral valve repair and annuloplasty ring(28mm Future) [2113-6-23] History of Present Illness: This 56 year old white female has a 30 year history of mitral prolapse and has been followed with serial echocardiography. these have demonstrated worsening regurgitation, which is now 4+ with P2 prolapse. She is admitted for repair. Past Medical History: Hashimoto's thyroiditis hypertension hypothyroidism asthma alopecia s/p tubal ligation s/p sinus surgery s/p ovarian cystectomy Social History: works as nurse and lives with her husband smoked until a few years ago drinks several glasses of wine 4-5 times a week Family History: noncontributory Physical Exam: admission: Pulse: 75 Resp: 16 O2 sat: 98% B/P Right: 127/83 Left: 123/79 Height: 5' 6.5" Weight: 165# General: well-developed, well-nourished female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 3/6 systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: - Pertinent Results: [2113-6-23] 01:50PM BLOOD WBC-13.7# RBC-2.69# Hgb-9.1# Hct-27.4# MCV-102* MCH-34.0* MCHC-33.4 RDW-13.0 Plt Ct-134* [2113-6-23] 01:50PM BLOOD PT-13.9* PTT-35.0 INR(PT)-1.2* [2113-6-23] 03:21PM BLOOD UreaN-13 Creat-0.6 Na-142 K-4.2 Cl-113* HCO3-23 AnGap-10 [2113-6-27] 04:55AM BLOOD WBC-7.2 RBC-3.07* Hgb-10.2* Hct-30.1* MCV-98 MCH-33.3* MCHC-33.9 RDW-14.8 Plt Ct-118# [2113-6-27] 04:55AM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-30 AnGap-11 Intra-op Echo [2113-6-23] PREBYPASS: The patient is in sinus rhythm with some runs of atrial fibrillation during the pre-bypass study. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. The coronary sinus is not well seen. Infusion of fluid through a left antecubital IV was visualized in the right atrium coming from the SVC but not from the coronary sinus, effectively ruling out a persistent left SVC. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe prolapse of the posterior leaflet, primarily affecting P2. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Several attempts were made to pass a coronary sinus catheter from the right internal jugular vein into the coronary sinus without success - likely due to inability to optimally visualize the coronary sinus. POSTBYPASS: The patient is atrially paced on a phenylephrine infusion. The repaired mitral valve is well visualized. The anterior leaflet moves well and coapts well with the posterior leaflet, which has been largely immobilized. No mitral regurgitation is seen. There is no mitral stenosis. There is some chordal systolic anterior motion but is not flow restricting. Left ventricular function remains normal without wall motion abnormalities. The aortic, tricuspid, and pulmonic valves appear unchanged from prior. The aortic contour is normal. Brief Hospital Course: Following admission she was taken directly to the Operating Room where mitral repair was effected. See operative note for details. She weaned from bypass on Propofol alone and was weaned and extubated easily. She required neo synephrine for a couple of days for BP support, but this weaned off and she was transferred to the floor. Physical Therapy worked with her for strength and mobility. A sleep consult was called for apneic periods at night, BiPap was utilized in the ICU prior to a sleep consult. Sleep medicine evaluated the patient and recommended outpatient sleep study and follow-up. The patient will arrange for this locally. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was bradycardic and tolerated only very low dose beta blockade. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Synthroid 137mcg daily Lisinopril 10mg daily MVI daily Vitamin D3 1,000mg daily Albuterol PRN Flovent PRN Allergies: NKDA Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:1 * Refills:2 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever or pain. 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 1 Refills:2 4. Levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: mitral regurgitation/prolapse hypothyroidism Hashimoto's thyroiditis hypertension asthma s/p ovarian cystectomy s/p tubal ligation alopecia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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: Surgeon: Dr. [Last Name (STitle) ] on [2113-7-20], 9:00am at [Hospital3 ] [Telephone/Fax (1) 6256] Please call to schedule appointments with: Primary Care Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ([Telephone/Fax (1) 84087]) in [11-19] weeks Outpatient sleep study should be arranged through PCP for sleep apnea Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [11-19] 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:[2113-6-28]	[ "245.2", "493.90", "458.29", "780.57", "244.9", "704.00", "424.0", "401.9", "285.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.12" ]	icd9pcs	[ [ [] ] ]	6597, 6670	4082, 5380	341, 414	6854, 7065	1729, 4059	7904, 8599	981, 998		5554, 6574		6691, 6833		5406, 5531			7089, 7881								1013, 1710																					282, 303									442, 678														700, 829	845, 965
16,373	132,143	49996	Discharge summary	report	Admission Date: [2199-2-19] Discharge Date: [2199-2-19] Service: MEDICINE Allergies: Tetanus Antitoxin / Penicillins / Ethambutol Attending:[Last Name (NamePattern1) 495] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] yo F with PMHx of COPD, CHF and severe Aortic Stenosis who went home with hospice after last admission with respiratory distress during which she expressed clear wishes to be DNR/DNI. Over the last 24hrs, pt became progressively SOB and hospice nurse felt unable to make the pt comfortable with po oxycodone. Hospice nurse [First Name (Titles) 12690] [Last Name (Titles) ] and pt was started on non-invasive ventilation by paramedics on transfer to ED. On arrival to the [Name (NI) ], pt was on CPAP and responding intermittently. . VS on arrival to ED: HR 56 BP 121/34 RR 17 Sats 100% CPAP FiO2 60% and PEEP 6. Pt had a foley placed and there was scant dark uring return. She was given lasix 40mg IV and family was [Name (NI) 653], but was unable to come into the hospital until the am. Pt was transferred to the MICU for further management. . On arrival to the MICU, pt was on BiPAP sating 100% but unresponsive to verbal stimuli and did not respond to sternal rub or painful stimuli. Initial ABG was 7.04/95/326. Past Medical History: 1. COPD: Last spirometry [9-16]: FVR 78% pred, FEV1 74% pred, FEV1/FVC 95%. 2. Bronchiectasis: history of atypical mycobacteria on sputum culture in [2191]- followed by Dr. [Last Name (STitle) 21848]. 3. Aortic stenosis: moderate (area 1.0-1.2cm2 on [2199-2-1]) 4. Diastolic CHF: on home lasix 5. Cholelithiasis/cholangitis s/p cholecystectomy 6. Diabetes Mellitus: diet-controlled Social History: Pt was home with hospice, son [Name (NI) 2491] is HCP. From [Name2 (NI) 3155], moved to USA [2169]. H/o tob [2-12] cigs/day for 38 yrs, quit [2169]. No EtOH. Family History: NC Physical Exam: BP 135/33 HR 59 RR 14 Sats 100% on BiPAP Gen: Facemask inplace, no response to stimuli, pupils reactive CV: RRR harsh gr 3 SEM radiates across precordium & to carotids LUNGS: crackles bilaterally at bases ABD: NABS. Soft, NT, ND EXT: WWP, +1 pitting edema bilaterally NEURO: GCS of 3, pupils reactive, no response to pain Pertinent Results: [2199-2-19] 06:50AM BLOOD WBC-19.4# RBC-2.97 Hgb-9.6* Hct-29.6* MCV-99* MCH-32.2* MCHC-32.4 RDW-13.3 Plt Ct-489# [2199-2-19] 06:50AM BLOOD Neuts-86.3 Lymphs-9.4* Monos-3.0 Eos-1.2 Baso-0.2 [2199-2-19] 06:10AM BLOOD Glucose-176* UreaN-32* Creat-1.8* Na-130* K-6.3* Cl-98 HCO3-24 AnGap-14 [2199-2-19] 10:13AM BLOOD Type-ART Temp-36.1 pO2-326* pCO2-95* pH-7.04* calTCO2-28 Base XS--7 [2199-2-19] 10:13AM BLOOD Lactate-0.6 K-5.6* Brief Hospital Course: [Age over 90 ] y/o F with end stage AS, CHF, COPD who was transferred in from home hospice due to inability to control symptoms who arrived to the MICU obtunded on Bipap due to hypercarbic resp failure. Family meeting was held with son/HCP and in keeping with patients goals of care, there was no plan for intubation. Family was brought in and we explained the graveness of her respiratory failure and her worsened mental status which had failed to improve with BiPAP. Family was comfortable with removing Bipap and providing comfort care including morphine as needed. Pt expired on [2199-2-19] . Medications on Admission: Magnesium Hydroxide QID prn Acetaminophen 500 mg 1-2 tabs q6hr prn Bisacodyl 10mg Colace [Hospital1 ] Insulin Lispro sc QID Metoprolol Tartrate 25 mg [Hospital1 ] Quetiapine 25 mg [Hospital1 ] Senna 8.6 mg [Hospital1 ] prn Hydralazine 25 mg q6hr Albuterol q6hr Nifedipine 30 mg daily Aspirin 81 mg daily Omeprazole 20 mg daily Tiotropium daily Isosorbide Dinitrate 30mg TID Fluticasone [Hospital1 ] Polyethylene daily. Trazodone 50 mg qhs Multivitamin daily Furosemide 20 mg daily Oxycodone 20 mg/mL liquid Sig: 2-20 mg PO q1 hour prn Lisinopril 10 mg Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Expired Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none	[ "786.59", "401.9", "428.0", "250.00", "518.81", "496", "424.1" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	4080, 4089	2820, 3428	263, 269	4160, 4169	2346, 2797	4222, 4229	1983, 1987		4051, 4057		4110, 4139		3454, 4028			4193, 4199								2002, 2327																					220, 225									297, 1350														1372, 1771	1787, 1967
50,049	147,884	45779	Discharge summary	report	Admission Date: [2115-9-13] Discharge Date: [2115-9-24] Date of Birth: [2043-12-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2836] Chief Complaint: Abdominal pain - anastomotic leak 10 days after sigmoid colectomy Major Surgical or Invasive Procedure: Exploratory laparotomy, small bowel resection and sigmoid colostomy History of Present Illness: 71 year-old gentleman presents 10 days s/p sigmoid colectomy for sigmoid volvulus with abdominal pain and distention. Patient has been feeling distended for the past 2 days. He was seen in the ED on [9-10] for small wound infection and was discharged as he was still tolerating po diet and having BMs. However, patient came back to the ED [9-13] with abdominal pain and distention that has been progressive through the day. He had 3 formed BMs and tolerated lunch without vomiting. However, he had been having more frequent hiccups and he has noted his abdomen getting much larger through the day. He is finding it much harder to breath. He reports that he has had to sleep sitting upright the previous night. He denies fevers/chills. Past Medical History: PMH: Hypertension, Hypothyroidism PSH: Appendectomy, Shoulder Surgeries Social History: Lives by himself. Denies ETOH. Denies tobacco. Family History: non-contributory Physical Exam: On admission: VS: T 98.9, HR 84, BP 122/78, RR 14, 95%2L GEN: slightly anxious, A&O x 3 LUNGS: clear B/L CV: RRR, nl S1 and S2 ABD: soft, TTP diffusely - more so in LLQ, very distended, no guarding, slight rebound, incision healing well with slight erythema at inferior aspect EXT: no c/c/e At Discharge: Afebrile, vital signs are normal HEENT: PERRLA, sclera anicteric, EOMI CV: RRR no M/R/G Chest: Clear b/l without rhonchi or rales Abd: Incision with 2 small areas of wound breakdown, packed with moist gauze, staple line otherwise c/d/i and healing well. Colostomy pink, bag with stool and gas. J/P site c/d/i. GU: WNL. Ext: 2+ edema of LE (pt reports this is baseline) Pertinent Results: [2115-9-12] 10:15PM BLOOD WBC-17.3 RBC-4.90 Hgb-14.8 Hct-42.8 Plt Ct-494 [2115-9-14] 02:04AM BLOOD WBC-16.8 RBC-3.33 Hgb-9.9 Hct-29.2 Plt Ct-335 [2115-9-14] 02:46PM BLOOD WBC-12.2 RBC-3.17 Hgb-9.5 Hct-28.0 Plt Ct-312 [2115-9-15] 03:57AM BLOOD WBC-9.3 RBC-3.20 Hgb-9.4 Hct-28.4 Plt Ct-274 [2115-9-16] 03:38AM BLOOD WBC-8.2 RBC-3.31 Hgb-9.8 Hct-28.9 Plt Ct-281 [2115-9-17] 03:56AM BLOOD WBC-8.2 RBC-3.42 Hgb-10.1 Hct-29.7 Plt Ct-288 [2115-9-22] 05:17PM BLOOD WBC-10.8 RBC-3.85 Hgb-11.2 Hct-34.2 Plt Ct-415 [2115-9-12] 10:15PM BLOOD Glucose-139 UreaN-63 Creat-2.1 Na-134 K-4.2 Cl-90 HCO3-31 [2115-9-14] 02:04AM BLOOD Glucose-107 UreaN-36 Creat-1.4 Na-137 K-3.8 Cl-105 HCO3-27 [2115-9-14] 02:46PM BLOOD Glucose-97 UreaN-31 Creat-1.3 Na-137 K-3.7 Cl-103 HCO3-24 [2115-9-15] 03:57AM BLOOD Glucose-96 UreaN-27 Creat-1.3 Na-137 K-3.5 Cl-102 HCO3-29 [2115-9-15] 02:46PM BLOOD Glucose-94 UreaN-24 Creat-1.1 Na-136 K-3.5 Cl-102 HCO3-30 [2115-9-16] 03:38AM BLOOD Glucose-96 UreaN-23 Creat-1.2 Na-134 K-3.9 Cl-102 HCO3-26 [2115-9-17] 03:56AM BLOOD Glucose-98 UreaN-20 Creat-0.9 Na-134 K-3.7 Cl-101 HCO3-28 [2115-9-22] 05:17PM BLOOD Glucose-96 UreaN-11 Creat-1.2 Na-135 K-3.8 Cl-100 HCO3-26 Pathology Specimen: DIAGNOSIS: 1. Small bowel, resection (A-B): - Small intestinal mucosa with no diagnostic abnormalities recognized. - Mesentery with serositis and foreign body giant cell reaction. 2. Colostomy incision line (C): Fragments of intestine with acute and chronic inflammation, hemorrhage, and necrosis. Brief Hospital Course: The patient was admitted to the General Surgical Service on [2115-9-13] for treatment of an anastomotic leak POD 10 after a sigmoid colectomy for sigmoid volvulus. He presented to the ED with an acute abdomen and underwent an ex lap with a small bowel resection and sigmoid colectomy on [9-13]. He tolerated the procedure well. On POD 0 patient was initially well but developed hypotension and hypoxia and was re-intubated. There was concern for aspiration PNA and subsequent sepsis and he was started on antibiotics (cipro/vanc/flagyl/zosyn) and pressors. He stayed in the ICU while intubated and extubation occured on POD 2. At that time he was off of pressors and his respiratory status was significantly improved. He was transferred to the floor on POD 3 and had an uneventful recovery for the rest of his hospital stay. Neuro: The patient received fentanyl while in the ICU and was transitioned to morphine for pain with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to percocet without problem. CV: Aside from the aforementioned episode of hypotension on POD0, once the patient was transferred to the floor his cardiovascular status was stable, without episodes of hypotension. His home diuretics were restarted without event. Pulmonary: Aside from the re-intubation mentioned above, the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged immediately following his extubation. He was up and ambulating by POD 6 and was quite participatory in his own rehabilition. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. He received multiple fluid bolus in the ICU during his period of hypotension. Following his ICU stay he was slowly advanced in his diet, which was well tolerated. He began producing gas in his ostomy bag on POD 9 and stool on POD 10. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. He has baseline venous edema for which he takes diuretics at home. He received lasix on several occasions to diurese extra fluid. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. On POD 6 he was noted to have 2 small areas of wound breakdown - these were treated with wet-to-dry packing. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin sliding scale was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He will be discharged to [Hospital1 100] House rehab for ongoing wound/stoma care until he feels comfortable going home where he lives by himself. Medications on Admission: Alprazolam 0.5 mg Tablet 1 Tablet(s) by mouth three times a day as needed for anxiety [2115-9-12] Levothyroxine [Synthroid] 137 mcg Tablet 1 Tablet(s) by mouth daily [2115-7-2] Lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-14] Drops Ophthalmic TID (3 times a day). 2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) for 2 weeks. Disp:14 dose Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:40 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). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Small bowel obstruction s/p sigmoid colectomy with primary anastomosis on [9-3] and then take back for exploratory laparotomy, small bowel resection and sigmoid colostomy. Discharge Condition: good Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is 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 [4-21] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Monitoring Ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in the next 7-10 days. You can call ([Telephone/Fax (1) 6347] to confirm you appointment time.	[ "785.52", "557.0", "E878.2", "995.92", "997.4", "275.41", "V45.72", "560.89", "V45.79", "244.9", "518.5", "V10.83", "300.3", "569.89", "038.9", "311", "309.24", "507.0", "998.59", "401.9" ]	icd9cm	[ [ [] ] ]	[ "46.11", "45.62", "45.91", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	8217, 8302	3720, 7056	380, 450	8522, 8529	2132, 3697	10925, 11080	1404, 1422		7352, 8194		8323, 8501		7082, 7329			8553, 10000					10015, 10902			1437, 1437															1743, 2113						275, 342									478, 1225							1451, 1729							1247, 1322	1338, 1388
27,022	197,298	8985	Discharge summary	report	Admission Date: [2183-12-6] Discharge Date: [2183-12-8] Date of Birth: [2113-2-21] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1990] Chief Complaint: post ERCP pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 31164] is a 70 yo with ulcerative colitis x 10yrs and PSC who presents with abdominal pain post-ERCP. He was in his usual health until about 1-2 weeks ago when he developed night sweats and chills (no abdominal pain or jaundice) and he contact[Name (NI) ] his GI doctor because he knew this was a sign of recurrent biliary stricture. He underwent an ERCP this morning and underwent common hepatic duct balloon dilation and sludge removal without complications and was discharged home. A few hours later (around 1pm) he developed gradual onset of abdominal pain (in a circular peri-umbilical distribution) that he cannot describe in more detail, also associated with mild B flank/lower back pain, and minimal yellow emesis. He has had flatus and 1x BM. He presented to [Hospital3 ] where his Lipase was 1800 and his 79/55 with improvement to the 100's with 2L NS. CT scan showed peripancreatic stranding without clear obstruction. He was transferred to [Hospital1 18] for further evaluation. In our ED, he was afebrile with stable vitals (BP in 90's-100's) and he was given 1L NS and 4mg morphine. His abdominal pain has almost completely resolved now as has his nausea/vomiting. . ROS is negative for fevers, chills, SOB, jaundice, dysyuria, cough, Past Medical History: - CAD s/p MI with PTCA in [2167] and CABG in [2176] - CHF EF 30% - primary sclerosing cholangitis dx [2178] (s/p 3 ERCPs; atypical cytology in [2178], repeat neg for atypical cells in [2180] and [2181]) - ulcerative colitis x10-15 years - recurrent mild intermittent cholangitis - GERD - h/o Lyme disease [8-24] - hypercholesterolemia - hypertension - Raynaud's disease s/p multiple finger and toe amputations - OSAS on home BiPAP - esophageal stricture - depression Social History: He is a retired carpenter and married with 3 grown children. No Tob. 1-2 drinks per day until recently. Denies Illicit drug use. Family History: There is no family history of liver disease or liver cancer. There is no family history of colon cancer. His father developed diabetes and ischemic heart disease in later life. Physical Exam: Vital signs stable, afebrile G Pertinent Results: [2183-12-5] 09:00AM BLOOD WBC-5.6 RBC-3.63* Hgb-13.0* Hct-36.0* MCV-99* MCH-35.8* MCHC-36.0* RDW-14.4 Plt Ct-195 [2183-12-7] 05:29AM BLOOD WBC-8.9 RBC-3.53* Hgb-12.5* Hct-35.3* MCV-100* MCH-35.5* MCHC-35.4* RDW-14.4 Plt Ct-162 [2183-12-5] 09:00AM BLOOD Neuts-73.6* Lymphs-17.9* Monos-6.3 Eos-1.5 Baso-0.8 [2183-12-5] 09:00AM BLOOD PT-14.1* INR(PT)-1.3* [2183-12-6] 12:30AM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-139 K-3.9 Cl-109* HCO3-21* AnGap-13 [2183-12-7] 05:29AM BLOOD Glucose-101 UreaN-7 Creat-0.7 Na-137 K-3.4 Cl-105 HCO3-24 AnGap-11 [2183-12-5] 09:00AM BLOOD ALT-85* AlkPhos-245* Amylase-56 TotBili-2.1* DirBili-1.5* IndBili-0.6 [2183-12-7] 05:29AM BLOOD ALT-70* AST-66* AlkPhos-223* Amylase-205* TotBili-2.4* [2183-12-5] 09:00AM BLOOD Lipase-39 [2183-12-6] 12:30AM BLOOD Lipase-1161* [2183-12-6] 04:45AM BLOOD Lipase-800* [2183-12-7] 05:29AM BLOOD Lipase-118* [2183-12-6] 12:30AM BLOOD Albumin-2.7* Calcium-7.8* Phos-4.1 Mg-1.7 [2183-12-6] 12:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.018 [2183-12-6] 12:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: 1. acute pancreatitis -- post ERCP. Resolved quickly with IVFs, analgesics and supportive care. Tolerated regular diet prior to discharge without pain. 2. cholangitis from PSC/biliary strictures -- Bile duct dilated with baloon in ERCP. Prescribed 10 day total course of ciprofloxacin. Held aspirin for one week after dilation (to resume [12-13]). Medications on Admission: Asacol 1600 daily, baby aspirin (on hold x 1 week), folate 1mg, Simvastatin 10mg daily, Prilosec 20mg, Ursodiol 1200mg, Moexepril 7.5mg daily, Toprol XL 50mg daily, zoloft 50mg daily, levofloxacin Discharge Medications: 1. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 7 days. Disp:42 Tablet(s) Refills:0 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Disp:180 Tablet, Delayed Release (E.C.)(s) Refills:0 3. 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 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:0 7. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: START ON [12-13] - do not take any aspirin until [12-13]. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cholangitis ERCP with common hepatic duct dilation Post-ERCP pancreatitis and hypotension Discharge Condition: stable Discharge Instructions: Take all medications as prescribed. Return to the [Hospital1 18] Emergency Department for: Fevers and chills Nausea and vomiting Worsening abdominal pain Followup Instructions: Call your primary doctor for a follow up appointment for within 2 weeks of leaving the hospital: [Last Name (LF) ],[First Name3 (LF) 198] P. [Telephone/Fax (1) 19980] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2183-12-19] 10:40	[ "577.0", "311", "401.9", "E878.8", "576.1", "276.51", "272.0", "414.01", "997.4", "458.9", "556.9", "443.0", "327.23" ]	icd9cm	[ [ [] ] ]	[ "51.84" ]	icd9pcs	[ [ [] ] ]	5712, 5718	3772, 4131	295, 301	5852, 5860	2545, 3749	6068, 6405	2299, 2479		4378, 5689		5739, 5831		4157, 4355			5884, 6045								2494, 2526																					233, 257									329, 1616														1638, 2135	2151, 2283
26,462	105,124	16561	Discharge summary	report	Admission Date: [2178-10-17] Discharge Date: [2178-10-20] Service: MEDICINE Allergies: Augmentin Attending:[First Name3 (LF) 99] Chief Complaint: resp distress Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo female with recent dx of metastatic adenocarcinoma of the gallbladder with invasion of hte right colon and with liver metastasis now s/p ccy and right colectomy presents from her rehab facility with worsening resp status. Pt initally admitted to [Hospital1 18] [Last Name (un) 4068] on [2178-8-29] with abd pain. CT scan showed mass in BG. Pt underwent open laparotomy. Her post-op course was complicated by GI bleed felt to be [2-5] erosions at anastomotic site, CHF with labile BP after diresis, hypercarbic resp failure, PNA with highly resistent Enterobacter, Pseudomonas and MRSA, treated with 14 days of Vanc, Aztreonam and Flagyl. She was discharged to rehab facility on [10-12] with the regimen of 4 hours on Bipap and 4 hours off due to her hypercarbic resp failure. Over the last day, pt required continuous BIPAP and has had worsening resp status. . In [Name (NI) ], pt found to have ABG of 7.25/81/145. Pt received Vanc/Levo/Flagyl for presumed PNA and elevated WBC. Pt is DNR/DNI. Past Medical History: htn secondary av block s/p pacemaker avr tissue hypothyroidism s/p thryoidectomy polymyalgia rheumatica osteoarthritis GI bleed Social History: unable to obtain Family History: unable to obtain Physical Exam: 95.3 65 120/73 22 100% on BIPAP 50% GEN: somnelent but arousable; answers to name. Responds to yes, no. HEENT: MM dry NECK: supple, elevated JVD CV: distant heart sounds, regular, no murmurs PULM: difficult to assess due to bipap, no rales or rhonchi at bases ABD: well healed scar at midline; gtube intact EXT: anasarca, right arm more edematous than left; bilateral LE edema to knees NEURO: somnelent. Moving all ext. Pertinent Results: . 134 93 80 -------------< 154 4.7 32 1.1 14.4 > 11.7 < 290 35.8 N:88.8 L:8.0 M:2.6 E:0.1 Bas:0.4 PT: 11.7 PTT: 33.0 INR: 1.0 proBNP: [Numeric Identifier ] CXR: Cardiac failure. Small left pleural effusion with adjacent retrocardiac atelectasis/consolidation. UE US: No evidence of DVT in the right upper extremity. Brief Hospital Course: 89 yo f with metastatic cholangiocarcinoma p/w worsening hypercarbic resp failure. . # RESP FAILURE: Pt had ongoing hypercarbic resp failure requiring intermittent BIPAP at nursing home, then requiring full time bipap on admission. Resp failure was [2-5] decompensated CHF, which was evident on physical exam and on xray. Her BNP was over 60,000. The goal was to diurese her with IV lasix but this was limited by her low bp. . She was afebrile but she had leukocytosis with left shift, which raises the possibility of PNA also. She was pan-cultured and started emperically on vanc and meropenem. . She continued to decompensate, becoming acidemic, hypoxic and hypercarbic. She developed acute renal failure from diuresis and poor foward flow. The family decided, given the patients multiple medical problems including a poor prognosis from metastatic cholangiocarcinoma and end stage heart failure, to make the patient comfort measure only. . The patient expired on [2178-10-20] at 4:35 AM. . # UTI: culture sent. Covered emperically with vanc and meropenem. . # Cholangiocarcinoma: Pt has metastasis to liver and colon, s/p ccy and right colectomy. There were no futher plans for intervention. . # PMR: chronic steroids Medications on Admission: florinef 0.1 mg daily lopresor 12.5 daily lovenox 40 daily prednisone 5 daily lasix 40 [Hospital1 ] synthroid 125 daily mag-ox timoptic eye gtt Discharge Medications: Pt expired. Discharge Disposition: Expired Discharge Diagnosis: Pt expired. Discharge Condition: Pt expired. Completed by:[2178-12-14]	[ "585.9", "V45.01", "428.0", "518.84", "V10.09", "599.0", "584.9", "707.05", "250.00", "403.90", "725", "197.7", "197.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3813, 3822	2341, 3579	231, 237	3877, 3920	1978, 2318		1499, 1517		3777, 3790		3843, 3856		3605, 3754											1532, 1959																					178, 193									265, 1298														1320, 1449	1465, 1483
70,682	101,441	4405+55616	Discharge summary	report+addendum	Admission Date: [2169-2-10] Discharge Date: [2169-2-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: History obtained from medical records. This is a [Age over 90 ] year-old female with a history of dementia and HTN who presents with fever, tachycardia, and hypoxia from [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. Pt treated for bronchitis with levaquin 250 mg X 7 days starting on [1-29]. This am, not responding to stimuli and noted to be in respiratory distress. VS 100.1 (po) although ED reported up to 101F, HR 84, BP 131/57, RR 28, O2 sat 90% RA. Per PCP [Name9 (PRE) 7421], there was some concern for an aspiration event. Given tylenol 650 mg PR and albuterol nebulizer prior to being sent to ED. In the ED, T 99.8, BP 121/55, HR 95, RR 24, O2 sat 95% 6L NC --> 98% on 100% NRB --> 97% on 3L NC. Labs notable for WBC 30.1 without associated left shift or bands, Na 169, BUN 116, Cr 2.6, AG 18, and lactate 2.0. UA few bacteria, 0-2 WBC, mod LE. CXR with ? bilateral upper lobe opacities, final read pending. Pt DNR/DNI per NH records. Given Vancomycin 1 gm X 1, zoysn 4.5 gm IV X 1, 1L IVFs, and admitted to [Hospital Unit Name 153] for further mgmt. ROS: Unable to assess. Past Medical History: 1. Hypertension. 2. Grave's disease. 3. Dementia. 4. Depression. 5. Spinal stenosis. 6. Degenerative joint disease. 7. Status post multiple falls with a gait disturbance. Social History: Resides at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. Niece is HCP Family History: Unknown/Noncontributory Physical Exam: Vitals: Afebrile 132/55 p72 r20 100% 2L GEN: elderly female, non-toxic. HEENT: MM dry. COR: RRR, no M/G/R, normal S1 S2 PULM: Coarse wheeze throughout. ABD: Soft, NT/ND. EXT: No C/C/E, no palpable cords NEURO: +dementia, non-focal. PICC in place Pertinent Results: Admission Labs: [2169-2-10] 10:56AM WBC-30.1# RBC-4.07 HGB-11.2* HCT-34.9* MCV-86 MCH-27.5 MCHC-32.1 RDW-13.8 [2169-2-10] 10:56AM NEUTS-64.3 LYMPHS-33.9 MONOS-1.5* EOS-0.2 BASOS-0.2 [2169-2-10] 10:56AM PT-14.5* PTT-21.1* INR(PT)-1.3* [2169-2-10] 10:56AM PLT COUNT-406 [2169-2-10] 10:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-9.6 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2169-2-10] 10:56AM TSH-0.88 [2169-2-10] 10:56AM CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-2.9* [2169-2-10] 10:56AM ALT(SGPT)-12 AST(SGOT)-12 CK(CPK)-32 ALK PHOS-136* TOT BILI-0.2 [2169-2-10] 10:56AM GLUCOSE-262* UREA N-116* CREAT-2.6# SODIUM-169 POTASSIUM-4.0 CHLORIDE-130* TOTAL CO2-21* ANION GAP-22* [2169-2-10] 11:12AM LACTATE-2.0 [2169-2-10] 11:40AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.014 [2169-2-10] 11:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [2169-2-10] 11:40AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2169-2-10] 11:40AM URINE EOS-NEGATIVE [2169-2-10] 02:17PM TYPE-ART TEMP-36.2 PO2-116* PCO2-34* PH-7.41 TOTAL CO2-22 BASE XS--1 INTUBATED-NOT INTUBA . . CXR [2169-2-14]: FINDINGS: Persistent cardiomegaly and pulmonary vascular engorgement. Diffuse hazy opacities are again demonstrated in the right lung without substantial change. As noted previously, this could be due to resolving asymmetrical pulmonary edema or infection. New area of opacity has developed in the left retrocardiac region, and may reflect atelectasis, aspiration, or early focus of pneumonia. . [2169-2-20] 05:01AM BLOOD WBC-17.9* RBC-3.12* Hgb-8.8* Hct-26.8* MCV-86 MCH-28.1 MCHC-32.6 RDW-15.6* Plt Ct-365 [2169-2-14] 04:24AM BLOOD PT-13.8* PTT-31.9 INR(PT)-1.2* [2169-2-20] 05:01AM BLOOD Glucose-132* UreaN-16 Creat-1.3* Na-146* K-4.5 Cl-112* HCO3-24 AnGap-15 [2169-2-20] 05:01AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.5* (Note: Mg repleted after this result) [2169-2-15] 04:00AM BLOOD calTIBC-130* VitB12-[2137]* Folate-11.8 Ferritn-256* TRF-100* [2169-2-10] 10:56AM BLOOD TSH-0.88 . Micro: MRSA SCREEN (Final [2169-2-15]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . C-diff negative x 3 . URINE CULTURE (Final [2169-2-13]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- =>2 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R . Brief Hospital Course: Sepsis from left lower lobe pneumonia: treated with multiple antibiotics initially, but ultimately to complete a course of ceftriaxone and vancomycin. Leukocytosis initially improved, but recently has been trending up. Note patient has a history of CLL with persistent hx of leukocytosis, making WBC questionable as a marker for infection. Blood cultures negative, rapid resp viral screen negative, urine legionella antigen is negative. She received vancomycin and ceftriaxone for a total ten day course. Patient had a speech and swallow evaluation performed initially, which she failed, and was reattempted several days later, and again failed. After discussion with the family, decision was made not to place a PEG tube and she was permitted to eat for comfort. . Altered mental status: combination of sepsis and hypernatremia on baseline dementia. LFTs and TSH wnl, tox screens negative. Sedating medications held at admission Mental status improved quickly with correction of her multiple medical issues. - patient on D5W for mild hypernatremia and sl increased Cr. . Acute renal failure: peak at 2.9 at admission. Most likely pre-renal etiology given concurrent hypernatremia, story and exam. Urine eosinophils negative, renal ultrasound without obstruction. Lasix held at admission, and then restarted. Her creatinine improved with rehydration, now slightly increased to 1.3 from 1.1. Getting addt'l D5W today. . Hypernatremia: due to poor po intake and ongoing lasix prior to admission. Patient clinically dry on exam at admission. Treated with D5W with improvement in values, and sodium normalized at time of discharge. Getting addt'l D5W today. . Melena: She was also noted to have several episodes of melena. She received 1u pRBC, and remained hemodynamically stable. . Code: DNR/DNI, copy of form in chart. Confirmed with family that despite failing speech and swalloe evaluation, patient should be allowed to continue to eat for comfort. . Comm: next of [Doctor First Name ] listed in chart [Name (NI) ] [Last Name (NamePattern1) 18942], [Telephone/Fax (1) 18943] (h), [Telephone/Fax (1) 18944] (c). Access: PICC line. Will maintain on discharge for continued IV hydration as outpt for several days. DISPO: Discharge to day to [Hospital1 1501] Medications on Admission: Trazodone 25 mg daily Trazodone 25 mg qid prn for agitation Trazodone 75 mg qhs Dulcolax 10 mg qod Citalopram 20 mg daily Lasix 10 mg daily MVI daily Milk of magnesia 30 ml qod Nitrobid 2% ointment [2-17] inch prn for SBP > 170, DBP > 90 Flovent INH 2 puffs [Hospital1 ] Maalox prn Anusol-HC 2.5% cream [Hospital1 ] prn Guiafenesin 20 ml q6h prn Tylenol 650 PR q4h prn s/p Levofloxain 250 mg daily X 7 days Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Recommend hold until resumed by MD. 8. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection daily and prn. Discharge Disposition: Extended Care Facility: [Hospital3 ] Discharge Diagnosis: 1. Aspiration pneumonia 2. Altered mental status 3. Hypernatremia 4. Acute renal failure 5. Urinary tract infection 6. Acute blood loss anemia 7. Dementia Discharge Condition: Stable Discharge Instructions: You were admitted with an aspiration pneumonia and urinary tract infection, with associated dehydration. You were treated with antibiotics. Followup Instructions: Please follow up with your primary care doctor [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. Recommend feed patient at times when most awake (which may fluctuate according to parkinson medications) (per Speech and Swallow recommendations). Name: [Known lastname 3383],[Known firstname 2] Unit No: [Numeric Identifier 3384] Admission Date: [2169-2-10] Discharge Date: [2169-2-20] Date of Birth: [2065-12-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 128] Addendum: Updated Discharge Medication List: Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Recommend hold until resumed by MD. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection daily and prn. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 131] MD [Last Name (un) 132] Completed by:[2169-2-20]	[ "038.8", "288.60", "584.9", "294.8", "041.12", "715.90", "724.00", "204.10", "285.1", "514", "599.0", "578.9", "242.00", "401.9", "276.0", "311", "507.0", "995.91", "790.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04" ]	icd9pcs	[ [ [] ] ]	11222, 11422	5011, 5785	284, 306	9049, 9058	2101, 2101	9246, 11199	1791, 1816		7764, 8784		8871, 9028		7321, 7741			9082, 9223								1831, 2082																					223, 246									334, 1461					2118, 4988				5800, 7295					1483, 1662	1678, 1775
5,525	176,969	52634+52635	Discharge summary	report+report	Admission Date: [2109-8-5] Discharge Date: [2109-8-24] Date of Birth: [2050-4-3] Sex: M Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male with end stage renal disease who has been on peritoneal dialysis since [2106-7-8]. The patient was initially diagnosed with chronic renal failure in [2095] after returning from a trip from abroad and having experienced three days of anuria. His renal failure was thought to be secondary to an infection. The patient began hemodialysis on [11/2099], but because of difficulties in obtaining an adequate AVF, his dialysis was changed to peritoneal dialysis. The patient also has a history of bladder outlet obstruction with multiple urethral dilatations previously performed. His systolic blood pressures at home had been running in the 70s to 90s. The patient presented to the hospital for a cadaveric kidney transplant on [2109-8-5]. PAST MEDICAL HISTORY: 1. Relative hypotension (70s to 90s systolic blood pressure for several years) 2. Syncope x2 presumably secondary to hypotension 3. End stage renal disease of unclear etiology, but most likely infectious 4. Intermittent bladder outlet obstruction, status post multiple urethral dilatations. 5. Spontaneous bacterial peritonitis in [2109-4-8] 6. Gastroesophageal reflux disease MEDICATIONS: 1. Midodrine 5 mg 3x a day 2. Potassium chloride 10 milliequivalents qd 3. Neurontin 100 once a day 4. Epogen 4000 units twice a week 5. Tagamet prn 6. Tums 7. Nephrocaps ALLERGIES: No known drug allergies. SOCIAL HISTORY: No history of tobacco use. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3??????, heart rate 106, blood pressure 100/60, respiratory rate 18, 94% on room air. GENERAL: Obese male in no apparent distress. LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm, no murmurs. ABDOMEN: Obese abdomen, otherwise soft, nontender with peritoneal dialysis opening. EXTREMITIES: Warm, no edema. Pulses present bilaterally throughout. RECTAL: Guaiac negative. LABORATORY STUDIES: White blood cell count 8.8, hematocrit 34, platelets 149. Glucose 85, BUN 27, creatinine 9.1. Sodium 140, potassium 4.3, chloride 101. ALT 28, AST 29, LD1 56, alkaline phosphatase 39, total bilirubin 0.3, albumin 3.4, calcium 9.3, phosphate 6.5, magnesium 1.7. IMAGING STUDIES: Chest x-ray obtained on [2109-8-6] showed a left IJ Swan-Ganz catheter with the tip in the distal right pulmonary artery. The chest x-ray also showed satisfactory position of the endotracheal tube and the right IJ central line. Cardiomegaly and bilateral atelectasis. Chest x-ray obtained on [2109-8-7] showed continued widened mediastinum, bilateral atelectasis. Chest x-ray from [2109-8-9] showed stable mild congestive heart failure. Chest x-ray obtained on [2109-8-14] showed cardiac enlargement with evidence of mild congestive heart failure. The exam also showed patchy atelectasis at the right lower lobe, but no evidence of pneumothorax. Chest x-ray obtained on [2109-8-15] showed small right sided pleural effusion, as well as cardiomegaly with mild congestive heart failure. Ultrasound of the bladder obtained on [2109-8-17] showed multiple clots within the bladder. The renal transplant ultrasound obtained on [2109-8-20] showed mild hydronephrosis of the transplanted kidney, echogenic material in the collecting system of transplanted kidney which was thought to be consistent with blood clot, as well as mild elevation of the resistive index. SUMMARY OF HOSPITAL COURSE: On [2109-8-5], the patient underwent cadaveric renal transplant for chronic renal failure. The procedure was without any complications. Blood loss was 100 cc. The patient was transferred to the PACU intubated. Please see the full operative report for detail. In the PACU, the patient was noted to be hypotensive. In addition, the patient was noted to have poor urine output which was thought to be secondary to ischemic damage plus the hypotension. The patient had a Swan-Ganz catheter placed which demonstrated hyperdynamic hemodynamics and decreased systemic vascular resistance. The patient was transferred to the Surgical Intensive Care Unit for closer monitoring. The patient remained intubated. The patient was started on renal dopamine. On postoperative day 1, the patient continued to have low urine output but it was slightly improved. The patient received... DICTATION ENDS ABRUPTLY [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], MD [MD Number(1) 3599] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2109-8-23] 12:04 T: [2109-8-23] 12:10 JOB#: [Job Number 108625] Admission Date: [2109-8-5] Discharge Date: [2109-8-24] Date of Birth: [2050-4-3] Sex: M Service: TRANSPLANT SURGERY NOTE: This is an addenum to the previously dictated discharge summary which was cut off. On postoperative day 2, while in the Intensive Care Unit, the patient received MMF. The patient continued to be on cefazolin, Valcyte, Nystatin and Bactrim. The patient also receive Thymoglobulin. On postoperative day 2, the patient's creatinine still continued to be quite elevated at 8.9. Cardiology was consulted to evaluate a possible cardiac source of the patient's oliguria. The patient's cardiac function was thought to be normal with adequate preload. On [2109-8-7], the patient was extubated. However, soon after extubation, the patient became tachycardic and tachypneic. The patient was consequently reintubated. On [2109-8-8], ORL was consulted given patient's history of stridor post extubation attempt. The recommendation was to keep the patient intubated for the next 48 hours. On postoperative day 4, the patient's creatinine was still elevated at 9.1. On postoperative day 4, the patient continued to have inadequate urine output. He was also noted on physical exam to have small bowel protruding through the staple line of the original incision. The patient was thought to have wound dehiscence. The patient was transfused x1 for a hematocrit of 28.9. The patient was taken back to the Operating Room on [2109-8-10] for his incisional dehiscence. The patient underwent wound exploration and fascial closure using a mesh, as well as removal of the peritoneal dialysis catheter. The procedure was without complications. The patient was taken back to the Surgical Intensive Care Unit. Direct laryngoscopy also revealed severe edema of the epiglottis and pharynx. Please see the full operative report for details. The patient was continued on his immunosuppressive medication, which included ATG, MMF and Solu-Medrol. His urine output gradually improved. His hematocrit was noted to be 25.8 on [2109-8-11]. The patient's blood pressures were noted to be stable ranging from 100 to 150. The JP drain that was placed after the exploration remained in place, putting out a significant amount of serosanguinous fluid. The patient was gradually being weaned off of the respirator. The patient's urine output continued to improve. The patient's serum creatinine dropped to 5.0 on postoperative day 9. The patient was extubated on [2109-8-16]. The patient tolerated the extubation well. The immunosuppression medication which included MMF and steroids were changed to peroral. The patient was still being maintained on Midodrine for a history of hypotension. The patient was transferred to the regular floor on postoperative day 11. The patient's regimen included Solu-Medrol, CellCept, as well as Cyclosporin, Bactrim and Valcyte. The patient's serum creatinine decreased further to 2.3 on postoperative day 11. The patient's urine output was excellent. His JP drain continued to produce a significant amount of serosanguinous fluid. The patient's urine culture showed no growth. The patient was noted to have persistent hematuria in the Foley catheter. Hand irrigation of the catheter was performed with no significant results. No clots were withdrawn. On [2109-8-17], the patient underwent an ultrasound of his bladder. The bladder was noted to be distended with multiple clots within it. Urology was consulted again. Three-way irrigation system was placed for the Foley catheter. On postoperative day 14, the patient's hematocrit dropped further to 26.8. The patient was transfused with 1 unit of packed red blood cells. There was a concern for cyclosporin toxicity given an elevated cyclosporin level of 748 on [2109-8-16] and 708 and 633 on the following few days. The patient was given intravenous fluids. His cyclosporin was decreased to a smaller dose. On [2109-8-21], the patient underwent a cystoscopy to evaluate the ureters, the bladder and for clot evacuation in the patient's bladder. Prior to the cystoscopy, renal ultrasound of the transplanted kidney was performed which showed mild hydronephrosis of the transplanted kidney, as well as echogenic material in the collecting system of the kidney which was thought to be consistent with a blood clot. There was also mild elevation with a resistive index. The patient underwent a cystoscopy procedure the following day which showed normal urethra, a small prostate without active bleeding. There was also diffuse bladder edema consistent with postoperative changes and Foley catheter cystitis. There was also noted to be a bullous edema at the urethral anastomosis. However, there were no masses or tumors seen and there was no active bleeding seen. On [2109-8-22], the patient was again noted to be hypotensive with blood pressures dropping below 100 systolically. The patient was started on Florinef 0.1 mg qd. The Foley catheter was discontinued on [2109-8-22]. By that time, the urine and the Foley catheter was basically yellow without any evidence of bleeding. On [2109-8-23], the patient continued to do well. He was tolerating a regular diet without any complaints. He was able to void on his own x3. There was no blood noted. There was no burning with urination. There was some incontinence noted. The patient was being evaluated throughout his hospitalization by the physical and occupational therapy. It was agreed that the patient was not ready to be discharged to home. Consequently, the patient was discharged to a rehabilitation facility at [Hospital1 ] on [2109-8-24] in stable condition. DISCHARGE CONDITION: Good DISCHARGE DISPOSITION: [Hospital6 310] DISCHARGE INSTRUCTIONS: The patient was taught how to empty his JP drain. The patient will have to see his surgeon, Dr. [First Name (STitle) ] [Name (STitle) ], in clinic on Monday of next week for a follow up. The patient will continue on Keflex for at least two weeks until his JP drain is removed. DISCHARGE MEDICATIONS: 1. Cyclosporin (Neoral) 150 mg po bid 2. Fludrocortisone acetate 0.1 mg po qd 3. Midodrine 7.5 mg po tid 4. Prednisone 5 mg po qd 5. Clotrimazole 1 po tid 6. CellCept 1 gm [Hospital1 ] 7. Protonix 40 mg po qd 8. Albuterol 1 to 2 puffs inhalers q6h prn 9. Valcyte 450 mg po qd 10. Keflex 11. Iron 325 mg po qd 12. Bactrim 1 tablet po qd 13. Tylenol 650 mg po q 4 to 6 hours prn [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], MD [MD Number(1) 3599] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2109-8-23] 12:45 T: [2109-8-23] 13:29 JOB#: [Job Number 108626] cc:[Hospital6 ]	[ "591", "585", "998.3", "596.7", "518.5", "996.81", "285.1", "214.3", "599.7" ]	icd9cm	[ [ [] ] ]	[ "57.32", "96.6", "54.3", "57.0", "54.61", "54.92", "96.72", "96.04", "38.91", "55.69" ]	icd9pcs	[ [ [] ] ]	10610, 10631			10580, 10586					10966, 11653							10656, 10943																		3636, 10558			1676, 2394																	178, 969														991, 1609	1626, 1654					2412, 3607
779	197,527	48858	Discharge summary	report	Admission Date: [2152-10-25] Discharge Date: [2152-11-2] Date of Birth: [2077-3-13] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[First Name3 (LF) 898] Chief Complaint: upper gastrointestinal bleeding Major Surgical or Invasive Procedure: Intensive care unit, central line, total of 9 red blood cell transfusions. History of Present Illness: Pt is a 75 yo male with MMP including h/o PE, HTN, PAF on coumadin, recent workup of anemia with Hct in upper 20s who presents after went to PCP yesterday and found to have Hct of 18. Pt had a workup for anemia done. In [2151-10-28], Hct was 34, over time been in mid-upper 20s. Iron studies in [2152-6-27] showed iron 221, TIBC 221, Ferritin 25. Workup for anemia included BMBs in [2152-7-28] which showed no storage iron, small lymphoid aggregates, otherwise normal. Pt was started on iron tid. . Pt says that he has noticed that for the last week he has been SOB when moving only and not at rest. Whereas normally he can walk up and down the stairs, he has been having trouble walking a few feet before getting SOB. No CP. No BRBPR. +black stool since starting the iron many months ago. No Diarrhea. +chronic constipation. No abdominal pain. no cough. +subjective fever over the past few days. +Chills last night. No Night sweats. No lightheadness. No N/V. . In the ED, VS on arrival were: T: 97.4; HR: 76; BP: 116/42. He received Protonix 40 mg IV x 1, 2.5 mg vitamin K subcutaneous, and one unit FFP. NG LAVAGE showed mucus blood with lavage and pt was guauaic positive . Of note, Colonoscopy in [2149] showed Grade 2 internal hemorrhoids, otherwise normal colonoscopy to cecum . In MICU, did EGD which showed multiple erosions and a duodenal ulcer, but no active bleed. He had evidence of Barrett's esophagus as well as findings c/w H. pylori infection. Serologies were sent and came back positive for H. pylori. He has had serial Hct which have remained stable. He has had no episodes of hematemesis or melena, but he does have guaiaic positive stools. He is taking POs w/o any difficulty. Overnight ([10-26] -> [10-27]), he went into rapid afib and was given 5mg IV lopressor. His BP remained stable, but he became bradycardic w/ 5 sec pause. Currently HR is 58. Past Medical History: PE w/ 6mos anticoag [2122] DVT, PE, IVC filter [2144] htn increased chol neuropathy cerv spondylosis colon polyps ED hemorrhoids Social History: Married, lives with wife, retired, quit smoking [2127], 1 drink per day Family History: Non contributory Physical Exam: per admitting resident: VS: T: 98.1; BP: 123/54; HR: 71; RR: 14; O2: 98RA Gen: Slightly hard of hearing speaking in full sentences in NAD HEENT: PERRLA; EOMI; sclera anicteric; OP clear. Conjunctiva pale. Neck: No LAD. JVD hard to tell from carotid pulsations. CV: II/VI holosystolic at lusb. +II/VI apical murmurs. Lungs: Coarse rhonchorus sounds throughout. Abd: NABS. soft, NT, ND. No HSM. Back: No spinal, paraspinal tenderness Ext: trace-1+ edema. DP 2+ Neuro: CN II-XII tested and intact. MS [3-31] upper and lower. Reflexes: biceps, brachio, patellar [12-30]. Pertinent Results: [2152-10-25] 10:54PM HCT-24.9# [2152-10-25] 10:54PM PT-17.1 PTT-29.9 INR(PT)-1.6* [2152-10-25] 03:10PM CK(CPK)-89 [2152-10-25] 03:10PM CK-MB-NotDone cTropnT-<0.01 [2152-10-25] 03:10PM HCT-15.5* [2152-10-25] 03:10PM PT-20.3* PTT-31.3 INR(PT)-2.0* [2152-10-25] 02:20PM URINE HOURS-RANDOM [2152-10-25] 02:20PM URINE GR HOLD-HOLD [2152-10-25] 02:20PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2152-10-25] 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2152-10-25] 11:40AM GLUCOSE-115* UREA N-27* CREAT-1.2 SODIUM-141 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 [2152-10-25] 11:40AM estGFR-Using this [2152-10-25] 11:40AM CK(CPK)-93 [2152-10-25] 11:40AM CK-MB-NotDone cTropnT-<0.01 [2152-10-25] 11:40AM WBC-6.4 RBC-2.11# HGB-6.2# HCT-18.5# MCV-88 MCH-29.3 MCHC-33.4 RDW-14.3 [2152-10-25] 11:40AM NEUTS-62.5 BANDS-0 LYMPHS-24.2 MONOS-6.9 EOS-6.0 BASOS-0.4 [2152-10-25] 11:40AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [2152-10-25] 11:40AM PLT SMR-NORMAL PLT COUNT-205 [2152-10-25] 11:40AM PT-29.0* PTT-30.7 INR(PT)-3.0* Brief Hospital Course: 75 year old man with history of pulmonary embolisn, hypertension, paroxysmal atrial fibrillation on coumadin, presenting with drop in hematocrit. . 1) Anemia- Patient had upper gastrointestinal bleeding. He underwent upper endoscopy that showed multiple erosions and a duodenal ulcer, but no active bleed. He had evidence of Barrett's esophagus as well as findings consistent with H. pylori infection. Serologies were sent and came back positive for H. pylori. Patient was on [2152-10-27] started on a 14 day course of protonix, amoxicillin and clarithromycin. He transfused a total of 9 red blood cell packs. His hematocrit was stable at discharge. Needs to be rechecked in [1-29] days. He needs to have follow-up upper and lower endoscopy in [1-31] months. Warfarin is held because of bleeding risk. . 2) Atrial flutter (AF): Patient went into AF [2152-10-26] night with rate of 140s. He was given 5mg IV lopressor with resultant bradycardia and a 5sec pause. He was asymptomatic with no drop in blood pressure. Dr. [Last Name (STitle) ] recommended holding all beta-blockers, including any eye drops, and watching the patient on telemetry. The patient was seen by the cardiology service. It was decided that he needed ablation for his AF, probably without a pacemaker. The patient once reported an episode of chills and a temperature of 100.3. Workup for infection included negative urine and blood cultures and a negative chest xray. A mild left arm erythema (IV site) resolved quickly after the peripheral IV was pulled. Nevertheless, cardilogy felt that there is no urgent indication for ablation. Thus, the patient was discharged and in scheduled to follow-up as an outpatient in about 2 weeks. For now, coumadin has been held (bleeding risk) and metoprolol was not restarted. . 3) Dyspnea: Mild dyspnea at presentation, probably due to anemia. On exam, some crackles, but no congestion on chest xray. Increased Lasix to 20mg every day. Symptoms improved rapidly. Will need to monitor creatinine. Medications on Admission: Cymbalta 20mg PO QD Tylenol prn Coumadin 5/2.5mg Iron 325 mg PO QD Pepcid 40mg PO QD Terazosin 2mg PO QHS Folic acid 2mg PO QD Lisinopril 20mg PO QD Lasix 20mg PO QOD (for leg edema) Vytorin 10/20 mg PO QD Stool softener QD Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for prn back pain. 2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 8 days. Disp:16 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Start taking on [2152-11-10]. 9. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 8 days. Disp:32 Capsule(s) Refills:0 10. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days. Disp:32 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 13. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary - gastrointestinal bleeding - H. Pylori infection - Atrial flutter Secondary - Paroxysmal Atrial Fibrillation on coumadin - Tachy/brady syndrome - PE w/ 6mos anticoag [2122] - DVT, PE -> IVC filter [2144] - HTN - Hypercholesterolemia - Neuropathy - Cervical spondylosis - h/o colon polyps - hemorrhoids - s/p laminectomy L4, L5, superior S1 with decompression of lateral recess and bilateral foramina, L4-5 - Failed back surgery syndrome - Chronic leg pain Discharge Condition: Good. Discharge Instructions: Please take all your medications as prescribed. We changed your Lasix to 20 mg daily. We started you on an antibiotic regimen for H. Pylori infection. The course will end after 14 days ([2152-11-9]). Please do not stop your Amoxicillin, Clarithromycin and Protonix before that date. After this course, you will have to take omeprazole 20mg daily. We have stopped your coumadin because of bleeding risk. Please discuss with Dr. [Last Name (STitle) ] when to restart warfarin. . Please go to your follow-up appointments. You will need to check your hematocrit and creatinine when seeing Dr. [Last Name (STitle) 14069] on [Last Name (STitle) 766]. . Please call your doctor or go to the emergency department if you have nausea with bloody vomiting, black stools, fever >100.4 or any other concerning symptom. Followup Instructions: Provider: [Name10 (NameIs) 9894] [Name11 (NameIs) 7436] 7 PAIN MANAGEMENT CENTER Date/Time:[2152-11-8] 10:40 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2152-11-24] 1:20 . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 541] Date/Time:[2152-12-1] 3:00 . Dr. [Last Name (STitle) ], Tuesday [2152-11-14] 11:30 [Street Address(2) 3375] . Dr. [Last Name (STitle) 14069] [Name (STitle) 766] [2152-11-6] 1:00 PM . You will need to schedule a colonoscopy and upper endoscopy in 6 months. Please ask Dr. [Last Name (STitle) 14069] for a referral. Completed by:[2152-11-2]	[ "403.90", "532.40", "585.9", "280.0", "041.86", "V58.61", "427.32", "530.85", "272.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "99.07", "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]	8297, 8355	4507, 6536	302, 379	8872, 8880	3204, 4484	9750, 10551	2574, 2592		6811, 8274		8376, 8851		6562, 6788			8904, 9727								2607, 3185																					231, 264									407, 2304														2326, 2464	2480, 2558
4,974	115,247	29028	Discharge summary	report	Admission Date: [2185-2-17] Discharge Date: [2185-2-20] Date of Birth: [2119-1-11] Sex: F Service: NEUROLOGY Allergies: Penicillins / Dilantin Attending:[First Name3 (LF) 8850] Chief Complaint: Left flank pain and urosepsis. Major Surgical or Invasive Procedure: Percutaneous nephrostomy tube placement on [2185-2-17]. History of Present Illness: [Known firstname 1439] [Known lastname ] is a 66-year-old woman, with history of left temporal lobe glioblastoma, status post gross total resection, and currently on daily temozolomide chemotherapy and radiation therapy, who presented to [Hospital3 417] Hospital with left flank pain for one day duration. Yesterday afternoon, after her radiation treatment, she starting complaining of abrupt onset pain in her left flank with an intensity of [8-6], which was gradually moving up left side, worse with cough. By report, she was in her usual state of health until 1 day prior to presentation. She presented to [Hospital3 417] Hospital, where she developed temperature of 102 F, and underwent CT of the abdomen and pelvis showing mild to moderate left kidney hydronephrosis, pyelonephritis, UPJ obstruction and peri-renal stranding. She was given morphine 2 mg IV, Zofran 4 mg IV, Levaquin 750 mg IV and 1L normal saline. She was transferred to the emrgency department at [Hospital1 69] for further management, as she receives her oncology care here. In the emergency department, initial vitals were: Temperature 102.2 F, pulse 103, blood pressure 94/69, respiration 18, and oxygen saturation 94% in room air. Laboratory studies on arrival were significant for leukocytosis 16, Hct 34, lactate 1.4 and positive urinalysis. Shortly after arrival, the patient's blood pressure dropped to 80/50s, she was given Zosyn, Reglan, Tylenol 1 gm PO, Valium 5 mg PO and Ativan 1 mg IV for agitation, Hydrocortisone 100 mg IV, and 5 L IVF. Blood pressure transiently improved to low 100s, but again declined to 80s. A right subclavian was placed for central access. Patient was evaluated by urology, who suggested a percutaneous nephrostomy tube be placed by Interventional Radiology given her high grade obstruction and risk over lowering seizure threshold with general anesthesia. While in the emergency department, she was awake, alert, and oriented times 2, intermittently confused and forgetful (per husband, this is not her baseline - since surgery has been [Doctor Last Name 11506], but generally oriented). She was transferred to the [Hospital 332] Medical ICU for further management. Currently, patient complaining that she feels cold, but declining to answer other questions. States she does not know where she is or what the date is. Denies pain, difficulty breathing. Review of systems: Unable to obtain, patient refusing to answer most questions. Past Medical History: - Osteoporosis - Glioblastoma - resected in a gross total fashion from the left temporal lobe glioblastoma approximately 3 weeks ago, currently undergoing chemo and radiation (surgery at [Hospital3 2005], Dr. [First Name (STitle) ] [Doctor Last Name 60420]). - s/p hysterectomy in [2151] for fibroids and endometriosis Social History: She is retired. She smoked less than 1 pack of cigarettes per day for 38 years. She drank 1 pint of alcohol per day for 5 years until her seizure. She does not use illicit drugs. Family History: Her mother died at age 78 from pancreatic cancer. Her father died of complications from an abdominal aortic aneurysm. She has one sister and 2 brothers; one of the brothers had a stroke. She has 3 sons and they are healthy. Physical Exam: Physical Examination On Admission: Vital Signs: Temperature 97.8 F, pulse 78, blood pressure 85/42, respiration 18, oxygen saturation 97% on 2 liters via nasal cannula, and CVP 5 General: Somnolent, opens eyes to light physical stimuli, declines to answer orientation questions Skin: Fine papular rash over abdomen HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple Lungs: Unable to perform adequate exam [12-29] patient not cooperating. Generally clear anteriorly Cardiovascular: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, mildly distended, hypoactive bowel sounds present, no rebound tenderness or guarding Genitourinary: Foley in place draining clear yellow fluid, no left CVA tenderness (wouldn't roll over) Extremities: Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema Neurological Examination on Hospital Day 1 ([2185-2-17]): Her Karnofsky Performance Score is 90. She is awake, alert, and oriented times 3. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full; there is no nystagmus or saccadic intrusion. Visual fields are full to confrontation. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [3-31] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. Gait and stance are deferred. Pertinent Results: Labs On Admission: [2185-2-17] 04:45AM BLOOD WBC-16.0* RBC-3.23* Hgb-11.9* Hct-33.7# MCV-104 MCH-36.8* MCHC-35.4* RDW-12.0 Plt Ct-314 [2185-2-17] 04:45AM BLOOD Neuts-89.8* Lymphs-4.4* Monos-1.9* Eos-3.7 Baso-0.2 [2185-2-17] 05:54AM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2* [2185-2-17] 04:45AM BLOOD Glucose-85 UreaN-9 Creat-0.7 Na-136 K-3.5 Cl-103 HCO3-23 AnGap-14 [2185-2-17] 04:45AM BLOOD ALT-12 AST-21 LD(LDH)-154 AlkPhos-57 TotBili-0.7 [2185-2-17] 04:45AM BLOOD Albumin-3.1* [2185-2-17] 03:00PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.2* [2185-2-17] 04:45AM BLOOD Cortsol-26.8* [2185-2-17] 03:05PM BLOOD Type-[Last Name (un) ] pH-7.34* [2185-2-17] 04:45AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.035 [2185-2-17] 04:45AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [2185-2-17] 04:45AM URINE RBC-8* WBC-51* Bacteri-NONE Yeast-NONE Epi-<1 [2185-2-17] 04:45AM URINE Mucous-RARE DISCHARGE: [2185-2-19] 06:05AM BLOOD WBC-9.5 RBC-3.25* Hgb-11.4* Hct-33.4* MCV-103* MCH-35.0* MCHC-34.1 RDW-11.7 Plt Ct-296 [2185-2-19] 06:05AM BLOOD Glucose-83 UreaN-3* Creat-0.6 Na-138 K-3.5 Cl-105 HCO3-26 AnGap-11 Brief Hospital Course: The patient is a 66-year-old woman with recent diagnosis of left temporal glioblastoma, status post resection, currently undergoing temozolomide chemotherapy and radiation, who presented with UPJ obstruction, pyelonephritis, and hypotension suggestive of urosepsis, with improvement after percutaneous nephrostomy tube and antibiotics. Patient was intially admitted to the [Hospital 332] Medical ICU for management of septic shock. (1) Hypotension/Shock: The patient met criteria for septic shock on admission. She initially required norepinephrine for blood pressure support, but her blood pressure quickly improved after antibiotic treatment and fluid resuscitation of about 6 liter. She was weaned off pressors after several hours. She initially had significant mental status changes, suggesting end organ dysfunction, although other parameters such as lactate remained normal. This had improved by the next day. The most likely source remains urinary given her CT findings. Her urinary obstruction and pyelonephritis were treated with meropenem 500 mg IV Q6H and percutaneous nephrostomy tube placement. (2) Urinary Obstruction: She had a left percutaneous nephrostomy tube placed on [2185-2-17] with drainage of clear urine. Her creatinine was normal on admission and has remained stable. - The etiology of her obstruction remains unclear. She will have an outpatient CT abdomen and pelvis to evaluate the cause further. - She will follow up with Interventional Radiology and Urology for further management of her nephrostomy tube and potential for any further intervention. (3) Pyelonephritis: - Initially managed in the ICU setting with IV Meropenem - Urine culture from [Hospital3 417] was positive for E. Coli, sensitive with MIC <0.12 to levofloxacin. - She was transitioned to PO Levaquin on [2185-2-20] and given 3-day supply in the outpatient setting for a total course of 7 days. (4) Macrocytic Anemia: Her Hct has dropped from 44 to 33.7 in the past week with no current evidence of bleeding. Her Hct was 42.9 at OSH, so lower Hct could be secondary to hemodilution. She was continued on B12 and folate supplementation. (5) Glioblastoma: Patient currently undergoing temozolomide chemotherapy and radiotherapy. Per outpatient provider, [Name10 (NameIs) ] glioblastoma was completely resected and survival likely at least 2-3 years. She is planned for resuming radiotherapy on Monday. - She will follow up with Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 724] in the outpatient setting Medications on Admission: levetiracetam 500 mg PO BID oxycodone-acetaminophen 5 mg-325 mg [11-28] Tablet(s) PO qdaily prochlorperazine maleate 10 mg PO daily temozolomide 110 mg PO daily x45 days (from [2185-2-7]) cyanocobalamin 100 mcg PO daily docusate sodium 100 mg PO daily multivitamin 1 Tablet(s) PO daily thiamine HCl 100 mg PO daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 8. Percocet 5-325 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: [Hospital1 1474] VNA Discharge Diagnosis: Primary: Pyelonephritis, Uretero-Pelvic Junction Obstruction Secondary: Glioblastoma Multiforme Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs [Known lastname ], You were admitted to [Hospital1 18] for evaluation and treatment of a urinary tract infection near your kidney, a condition called pyelonephritis. You also underwent a percutaneous nephrostomy tube placement to relieve an obstruction in your ureter. You will take a medication called levofloxacin to finish your antibiotic course for pyelonephritis. You will follow up with the Interventional Radiologist tomorrow to discuss management of your percutaneous nephrostomy. You will have a CT scan as an outpatient on [2185-2-28] to evaluate your abdomen for a cause of the narrowing or blockage in your ureter. They will call you with a specific time to arrive. Medications: Added: Levofloxacin Changed: None Removed: None Followup Instructions: Interventional Radiology: Monday, [2-21] anytime between 7a and 1pm Call [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) 6745] [Telephone/Fax (1) 56404] or pager #[Numeric Identifier 5603] when you go for radiation treatment tomorrow and he will come meet you Department: MRI When: MONDAY [2185-2-28] at 1 PM With: MRI [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Hospital 1422] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: RADIOLOGY When: MONDAY [2185-4-4] at 11:15 AM With: RADIOLOGY MRI [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: MONDAY [2185-4-4] at 1 PM With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD [Telephone/Fax (1) 1844] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "995.92", "191.2", "V87.41", "785.52", "590.80", "V15.3", "593.4", "281.9", "733.00", "038.9" ]	icd9cm	[ [ [] ] ]	[ "55.03", "38.93" ]	icd9pcs	[ [ [] ] ]	10576, 10631	6910, 9508	315, 376	10773, 10773	5659, 5664	11720, 12742	3475, 3703		9881, 10553		10652, 10752		9534, 9858			10926, 11697								3718, 3739																			2840, 2902		245, 277									404, 2820							5678, 6887		10789, 10902					2924, 3260	3276, 3459
41,882	127,930	40517	Discharge summary	report	Admission Date: [2196-6-6] Discharge Date: [2196-6-22] Date of Birth: [2119-7-17] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain with NSTEMI Major Surgical or Invasive Procedure: [2196-6-7] Cardiac Cath [2196-6-17] Coronary [Last Name (un) ] bypass graft x 5 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending with y-graft to posterior lateral) History of Present Illness: 76 year old male s/p Right total hip arthroplasty [2196-6-2] that developed atrial fibrillation and ruled in for and NSTEMI with troponin peak to 11, with post operative anemia (hct 27 dropped from 34.9) on post operative day two. He did develop chest pain but unable to describe and is now transferred to [Hospital1 18] for cardiac workup including catheterization that revealed coronary artery disease and referred for surgical evaluation. Past Medical History: Right hip fracture [2-/2194] Atrial Fibrillation - new after arthroplasty Prostate cancer - seed implants [2190] Benign prostatic hypertrophy Tobacco abuse Past Surgical History Right hip fixation [2-/2194] Right Total hip arthroplasty [2196-6-2] Bilateral shoulder surgery appendectomy Discectomy [2160] Laminectomy [2180] and [2181] Social History: Race: caucasian Last Dental Exam: edentulous Lives with: Spouse Contact: [Name (NI) 8214] Phone # [Telephone/Fax (1) 88727] Occupation: retired maintenance worker Cigarettes: Smoked no [] yes [x] last cigarette - currentHx: 30 pack year history ETOH: < 1 drink/week [] [1-18] drinks/week [x] >8 drinks/week [] Illicit drug use denies Family History: Father died at age 82 of "old age" Mother died at age 54 of stomach cancer. No known family h/o of CAD, Stroke, CKD in parents, sister, or grandparents. Physical Exam: Pulse: 95 Resp: 16 O2 sat: 93% B/P Right: 112/76 Left: 118/72 Height: 183 cm Weight: 73.9 kg General: No acute distress sitting up in bed Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Expiratory wheezes throughout no rhonchi Heart: RRR [] Irregular [x] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: spider veins bilateral lower extremities Neuro: Alert and oriented x3 non focal Pulses: Femoral Right: +1 Left: cath site DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: ? bruit Left: no bruit Right forearm with PIV noted for phlebitis - warm red non tender Pertinent Results: [6-22] CXR: Pending [6-7] Cath: 1. Coronary angiography in this right-dominant system demonstrated three-vessel and left main disease. The LMCA had an ostial 80% stenosis. The LAD was heavily calcified and had a 80% proximal stenosis. The LCx had moderate diffuse disease with an 80% stenosis in its first obtuse marginal branch. The RCA was totally occluded and filled via collaterals. 2. Resting hemodynamics revealed elevated right- and left-sided filling pressures, with an RVEDP of 13 mm Hg and a PCWP of 20 mm Hg. There was moderate pulmonary arterial systolic hypertension, with a PASP of 49 mm Hg. The cardiac index was preserved at 2.7 L/min/m2. The systemic arterial blood pressure was normal. There was no gradient upon pullback of the catheter from the left ventricle to the aorta. [6-8] Carotid U/S: There is less than 40% stenosis within the internal carotid arteries bilaterally. [6-8] Chest CT: 1. Complete left upper lobe atelectasis with central obstructing lesion that potentially may represent obstructing tumor versus plaque and should be correlated with bronchoscopy. 2. Multiple mediastinal lymph nodes, but none of them specifically enlarged. 3. Right upper lobe and to a lesser extent right middle lobe opacity that most likely represent area of infection or aspiration and less likely asymmetric edema. 4. Bilateral moderate pleural effusion. 5. Extensive involvement of thoracic spine by multiple wedge compression fractures. Old fracture of the right humerus. Multiple rib fractures. [6-17] Echo: PREBYPASS: The interatrial septum is aneurysmal. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild inferior hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function remains unchanged. MR remains mild. Study otherwise unchanged from prebypass. [6-20] CXR: Moderate-to-large left pleural effusion has increased since [2196-6-18]. Generalized mediastinal widening, which developed between 7:30 a.m. and 10:45 a.m. on [2196-6-18] has changed in distribution but not in overall severity, concerning for mediastinal blood or other focal fluid accumulation. No pneumothorax. Mild pulmonary edema and small right pleural effusion have increased. Findings were discussed with the clinical care team member responsible for this patient, at the time of dictation. [2196-6-6] 09:40PM BLOOD WBC-5.9 RBC-3.59* Hgb-10.8* Hct-31.5* MCV-88 MCH-30.2 MCHC-34.4 RDW-14.1 Plt Ct-199 [2196-6-16] 08:05AM BLOOD WBC-6.1 RBC-3.54* Hgb-10.2* Hct-30.6* MCV-86 MCH-28.9 MCHC-33.5 RDW-13.5 Plt Ct-437 [2196-6-17] 12:14PM BLOOD WBC-8.1 RBC-2.69* Hgb-8.1* Hct-23.8* MCV-89 MCH-30.2 MCHC-34.2 RDW-13.7 Plt Ct-306 [2196-6-22] 04:55AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.4* Hct-27.1* MCV-86 MCH-30.0 MCHC-34.9 RDW-13.7 Plt Ct-353 [2196-6-6] 09:40PM BLOOD PT-13.2 PTT-42.0* INR(PT)-1.1 [2196-6-19] 01:59AM BLOOD PT-16.6* PTT-35.0 INR(PT)-1.5* [2196-6-20] 08:30AM BLOOD PT-62.4* PTT-38.5* INR(PT)-6.9* [2196-6-21] 04:45AM BLOOD PT-33.8* PTT-39.9* INR(PT)-3.4* [2196-6-22] 04:55AM BLOOD PT-17.8* PTT-32.0 INR(PT)-1.6* [2196-6-6] 09:40PM BLOOD Glucose-166* UreaN-17 Creat-0.7 Na-136 K-3.9 Cl-103 HCO3-24 AnGap-13 [2196-6-21] 04:45AM BLOOD Glucose-105* UreaN-18 Creat-0.6 Na-137 K-4.5 Cl-101 HCO3-27 AnGap-14 [2196-6-22] 04:55AM BLOOD Glucose-130* UreaN-18 Creat-0.7 Na-139 K-4.6 Cl-102 HCO3-29 AnGap-13 [2196-6-6] 09:40PM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9 Iron-14* [2196-6-22] 04:55AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 [2196-6-20] 08:30AM BLOOD ALT-14 AST-20 LD(LDH)-272* AlkPhos-68 Amylase-17 TotBili-0.8 [2196-6-9] 07:30AM BLOOD %HbA1c-5.6 eAG-114 [2196-6-9] 07:30AM BLOOD Triglyc-66 HDL-28 CHOL/HD-4.0 LDLcalc-72 Brief Hospital Course: Mr. [Known lastname 22627] is a 76 year old gentleman status post total hip arthroplasty ([2196-6-2]) at [Hospital6 ] who presents with Atrial fibrillation (HR 90-100)and post-op NSTEMI. He was found to have 3 vessel coronary disease demonstrated by catheterization ([2196-6-7]) and is on day [4-14] of empiric treatment for hospital acquired pneumonitis. Cardiac surgery was consulted and he was worked-up in the usual manner for coronary artery bypass grafting. He was noted to have left forearm phlebitis. An ultrasound revealed no evidence of deep vein thrombosis. Pulmonary function testing was obtained which showed an FEV1 of 1.57L. A carotid duplex ultrasound was also obtained which showed less than 40% stenosis within the internal carotid arteries bilaterally. Chest CT revealed new infiltrates and he developed a fever. Cefepime and vancomycin were started and surgery was delayed. In addition there was complete left upper lobe atelectasis with central obstructing lesion that potentially may represent obstructing tumor. Pulmonary was consulted and bronchoscopy was performed in the operating room at the end surgery. No official report but initial statement was mass seen in LUL/bronchus. On [2196-6-17], Mr. [Known lastname 22627] was taken to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative note for details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained intubated overnight and on post-op day one was weaned from sedation, awoke neurologically intact and extubated. Chest x-ray prior to extubation showed LUL open. Chest tubes and epicardial pacing wires were removed per protocol. Beta-blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the step-down unit for further recovery. He required blood transfusion for anemia, HCT 21 and had increase to 26. He also developed a brief episode of atrial fibrillation and was given amiodarone and beta-blockers. Given his pre-op history, he was also started on Coumadin. His INR quickly jumped to 6.3, Coumadin was stopped and FFP was given. Coumadin will continue on discharge given atrial fibrillation and recent right hip surgery (goal INR 2). He continued to make good progress while working with physical therapy for strength and mobility (decreased given recent hip surgery). On post-op day five he appeared to be doing well and was discharged to rehab with the appropriate medications and follow-up appointments. IV Lasix will continue given 10+ kg above pre-op weight and moderate-large left pleural effusion. He has multiple appointments in the beginning of [Month (only) 216] for further work-up of lung lesion. Dr. [Last Name (STitle) ] has asked to wait for cardiology clearance prior to undergoing any procedure by pulm/thoracic. Dr. [Last Name (STitle) ] will see him on [7-20] and will most likely clear him if he is doing well. Medications on Admission: Vancomycin 1 gram IV q12h Atrovent 0.5 mg nebulizer inhaled q6h p.r.n. shortness of breath aspirin 325 mg by mouth daily Celebrex 200 mg by mouth daily for four weeks Dilaudid 2-4 mg by mouth every three hours as needed for pain Flomax 0.4 mg by mouth daily Lopressor 50 mg by mouth every eight hours Lovenox 40 mg subcutaneous injection daily until last dose 7/10/2011multivitamin one tab by mouth daily Nexium 40 mg by mouth daily Senokot 2 tabs by mouth at bedtime Tylenol 975 mg by mouth every six hours as needed for pain Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing and sob . 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Please take 400mg daily for 7 days then decrease to 200mg daily until stopped by cardiologist. 18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for groin . 19. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please titrate for goal INR of 2 for AF and recent right hip surgery. INR [6-22] 1.6. 20. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection Q12H (every 12 hours): Please switch to PO once at pre-op weight of 73.9kg. 21. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [Hospital1 15331] TCU Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 5 Myocardial infarction Atrial Fibrillation - new after arthroplasty Left upper lobe pulmonary nodule Past medical history: Right hip fracture [2-/2194] Prostate cancer - seed implants [2190] Benign prostatic hypertrophy Tobacco abuse Past Surgical History s/p Right hip fixation [2-/2194] s/p Right Total hip arthroplasty [2196-6-2] s/p Bilateral shoulder surgery s/p Appendectomy s/p Discectomy [2160] s/p Laminectomy [2180] and [2181] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid/Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [7-14] at 1:00pm Cardiologist: Dr. [First Name4 (NamePattern1) 3979] [Last Name (NamePattern1) ] [7-20] at 12:30pm Pulmonary: Dr. [Last Name (STitle) ] [0-0-] on [2196-7-12] at 1:30pm in [Hospital Ward Name 23] 9A Thoracic: Dr. [Last Name (STitle) ] on [2196-7-12] at 2:30pm in [Hospital Ward Name 23] 9A CT of Head with Contrast on [2196-7-6] at 10:15AM in [Hospital Ward Name 23] 4 Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 19219] in [3-15] weeks To be scheduled by Chest disease center: Body PET/CT 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: AF/recent R hip arthroplasty Goal INR 2 First draw, 1 day after discharge, [6-23] Completed by:[2196-6-22]	[ "511.9", "V43.64", "427.31", "410.71", "486", "451.82", "414.01", "285.1", "997.1", "305.1", "E878.1", "518.0", "518.89" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.53", "36.14", "36.15", "39.61", "33.22", "88.56" ]	icd9pcs	[ [ [] ] ]	13119, 13171	7255, 10306	297, 604	13739, 13972	2871, 7232	14895, 15985	1860, 2014		10884, 13096		13192, 13353		10332, 10861			13996, 14872								2029, 2852																					235, 259									632, 1084														13375, 13718	1486, 1844
8,594	189,938	9311	Discharge summary	report	Admission Date: [2150-8-31] Discharge Date: [2150-9-3] Date of Birth: [2082-8-11] Sex: M Service: ENT [Doctor First Name 147] PRINCIPAL DIAGNOSIS: Recurrent aspiration and pneumonias requiring laryngectomy. HISTORY OF PRESENT ILLNESS: Mr. [Name14 (STitle) 31861] is a 68 year old male with severe mental retardation who is not verbal or communicative, who has had in the past few years, recurrent pneumonias and aspiration and readmissions to the hospital. He had a video swallow on multiple occasions attesting to his recurrent aspirations. He had a PEG placed and he continued to aspirate with PEG feeds and one of his few pleasures in life is eating per mouth. After assessment, the patient was brought in to the hospital and taken to the Operating Room on [8-31], for a total laryngectomy and stoma of the trachea out to the skin. HOSPITAL COURSE: The patient tolerated the procedure well and was taken up to the Intensive Care Unit with two [Location (un) 1661]-[Location (un) 1662] drains and a tracheostomy in place in the stoma. He did well following his surgery. He had calcium checks due to thyroid manipulation which needed to be occluded a couple of times but proved in the normal range. He was weaned from ventilator support on the following day and was on humidified oxygen via tracheostomy mask. On postoperative day two, the tracheostomy was removed and he was decannulated and his stoma is now wrapped with just a collar of humidified oxygen. He is as alert as he is per his assistant care givers, at his chronic care facility currently. In the Operating Room a Foley catheter could not be placed and Urology was consulted and they were not, at that time, able to place a wire or catheter. Under cystoscopic examination the following evening they did place a Foley catheter over a wire via cystoscopic examination and the Foley catheter has remained in place throughout his entire admission, and he will be discharged with that Foley catheter. It can be removed at any time so that a voiding trial is to be attempted. He is chronically incontinent outside of the hospital as well. He was restarted on his PEG tube feeds which were brought up to goal and cycled as they were at his care facility and he has been tolerating that without difficulty. On postoperative day two and three, his [Location (un) 1661]-[Location (un) 1662] drains were removed when they went down and he will be discharged back to his care facility in stable condition from our standpoint. PAST MEDICAL HISTORY: 1. Deafness with hearing aides. 2. Mental retardation. 3. Depression. 4. Recurrent otitis. 5. Recurrent aspiration. 6. Tachycardia. 7. Benign prostatic hypertrophy. MEDICATIONS: 1. Atenolol. 2. Calcium carbonate. 3. Iron sulfate. 4. Reglan. 5. Milk of Magnesia. 6. Multivitamin. 7. Zyprexa. 8. Aciphex. 9. Simethicone. 10. Trazodone. 11. Flagyl. 12. Keflex. 13. Debrox. 14. Several p.r.n. medications. ALLERGIES: Bactrim and Macrodantin. PHYSICAL EXAMINATION: The patient is awake and not oriented per his baseline, in no acute distress. His lungs are clear to auscultation bilaterally. His neck incision is healing well with staples with minimal swelling and good closure at the two [Location (un) 1661]-[Location (un) 1662] drain sites. His stoma is healing well with no swelling, minimal erythema, and no warmth to the area. His abdomen is soft and nontender. His PEG site is not irritated. Laboratory results as mentioned, his ionized calcium is normal at 1.18, and his hematocrit had fallen to about 28 but then remained stable thereafter. Operation was as stated above, total laryngectomy by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1837] on [8-31]. Complications were none. DISCHARGE MEDICATIONS: 1. Atenolol. 2. Calcium carbonate. 3. Iron sulfate. 4. Reglan. 5. Milk of Magnesia. 6. Multivitamin. 7. Zyprexa. 8. Aciphex. 9. Simethicone. 10. Trazodone. 11. Flagyl. 12. Keflex. 13. Debrox. 14. Several p.r.n. medications. 15. Addition of Roxicet p.r.n. pain. DISPOSITION: He was discharged in stable condition. DISCHARGE INSTRUCTIONS: 1. He is to remain NPO until follow-up with Dr. [Last Name (STitle) 1837]. 2. His tracheostomy collar oxygen is to be weaned as tolerated to room air. 3. No oxygen is needed for his stoma. 4. His staples will be removed in the office when he sees Dr. [Last Name (STitle) 1837] in follow-up. 5. Wound care is just Bacitracin to the wounds twice a day. 6. The Foley catheter can be removed per the Chronic Care Facility when they want to do a voiding trial. 7. He is discharged and his facility to call Dr. [Last Name (STitle) 1837] to schedule a follow-up appointment in one to two weeks. [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 6152], M.D. [MD Number(1) 6153] Dictated By:[Last Name (NamePattern1) 31862] MEDQUIST36 D: [2150-9-3] 18:10 T: [2150-9-3] 18:21 JOB#: [Job Number 31863]	[ "E911", "389.9", "318.1", "934.8", "296.7" ]	icd9cm	[ [ [] ] ]	[ "30.3" ]	icd9pcs	[ [ [] ] ]									3852, 4178					903, 2556		4202, 5086																					3060, 3829																	274, 885														2578, 3037
23,051	176,579	28072	Discharge summary	report	Admission Date: [2112-9-23] Discharge Date: [2112-10-1] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: Fall Major Surgical or Invasive Procedure: 1. Stent graft repair of ruptured descending thoracic aorta. 2. Right femoral artery exposure for delivery of stent graft and extensive femoral artery reconstruction. 3. Thoracic aortography. History of Present Illness: The patient is an 89 year-old male who fell 15 feet off a ladder. He was found by a passerby and taken to a hospital where he was found to have an aortic tear, multiple rib fractures with hemothorax, and was transferred to [Hospital1 18] for further care. Past Medical History: Dementia, prostate cancer, h/o kidney stones, right foot drop Social History: Widow, lives alone, has two sons close by. No EtOH or tobacco currently. Physical Exam: On admission to the T-ICU: Temp 99.3, HR 73, BP 146/43, RR 28, SaO2 97% on pressure support ventilation Neuro: not responding to commands HEENT: PERRLA CV: RRR Resp: CTAB Abd: Soft, NTND, +BS Ext: 1+ edema Pertinent Results: [2112-9-23] 06:15PM WBC-16.6* RBC-3.31* HGB-11.0* HCT-31.3* MCV-95 MCH-33.3* MCHC-35.2* RDW-14.4 Brief Hospital Course: The patient was taken emergently to the operating room for repair of aortic disruption (see operative note for details). Postoperative TEE showed the thoracic aortic stent graft in good placement with no aortic disruption visualized. The patient was taken to the CSRU for immediate post-op care. He was transferred to the Trauma ICU on post op day one. A CT scan of the head showed foci of intraventricular hemorrhage within the posterior horns of the lateral ventricles bilaterally. There were no c-spine fractures identified on imaging. Fractures of the right 1st rib and left 4th, 5th, and 12th ribs were seen as well as left transverse processes of T1 and T2. Neurosurgery, ortho-spine, vascular, and trauma surgery teams followed the patient's progress. The patient developed new onset atrial fibrillation and was treated with Amiodarone. He developed increasing O2 requirements requiring increased ventilatory support. He also developed a fever and underwent a fever workup while starting empiric antibiotic treatment. His neurologic status did not improve, and a neurology consult was obtained. The neurological consult impression was that MRI findings and clinical exam could be consistent with diffuse axonal injury. The patient remained in a comatose state. Attending physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], had extensive discussions with the patient's two sons who decided to withdraw care in accordance with the patient's advance directive. On hospital day 8, the patient was made "comfort measures only" as agreed upon by his two sons and attending physician. [Name10 (NameIs) ] patient expired at 1:30am on hospital day 9. Medications on Admission: Anacin prn Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Aortic disruption secondary to trauma, multiple rib fractures Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2112-11-29]	[ "V13.01", "853.05", "486", "860.2", "V43.65", "V10.46", "839.06", "807.04", "427.31", "901.0", "V66.7", "805.2", "E881.0", "294.8" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "39.73", "99.04", "33.24", "88.42", "88.44", "96.05", "96.6" ]	icd9pcs	[ [ [] ] ]	3093, 3102	1291, 3004	265, 458	3207, 3217	1164, 1268	3269, 3304			3065, 3070		3123, 3186		3030, 3042			3241, 3246								937, 1145																					221, 227									486, 747														769, 832	848, 922
53,014	100,039	43828	Discharge summary	report	Admission Date: [2174-4-18] Discharge Date: [2174-5-17] Date of Birth: [2135-11-15] Sex: F Service: MEDICINE Allergies: Prochlorperazine / Heparin Agents Attending:[First Name3 (LF) 3918] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Upper GI series with small bowel follow through Right heart catheterization IR guided paracentesis History of Present Illness: 38 yo F w/ h/o ALL in remission s/p cord transplant in [1-13], anthracycline-induced cardiomyopathy (EF 15-20% [1-14]) and recurrent nausea and vomiting who presents with abdominal pain, N/V x1 week Of note, the pt was admitted here from [Date range (1) ] with nausea and vomitting of unclear etiology. When discharged, she was tolerating good PO and had planned f/u with neuro for ? abdominal migraine and GI for possible other contributing factors including food sensitivities and gastroparesis. In the ED, VS: 98.8 94 138/100 16 100% and [10-15] pain. CT A/P showed a small umbilical hernia; interval increase in size and mild fat stranding and interval increase in ascites compared to recent prior imaging. WBC 12.4 with no left shift, bili 2.1 up from 1.1, Cr 2.7 up from 2.3. Surgery was consulted give CT finding and did not feel there was an indication for surgery. She received iv zofran and morphine 4mg iv and 1L IVF. On arrival to the floor, patient reports [11-14] total body pain and nausea. She has had ice chips today but threw them up in the ED. Review of Systems: (+) Per HPI (-) Review of Systems: Denies fevers, chest pain, SOB, diarrhea, constipation, dysuria, HA, change in vision or dizziness. Past Medical History: ONCOLOGIC HISTORY: ALL: - initially presented in [2172-8-5] right chest and right upper extremity pain and paresthesias and visual blurriness. WBC 149,000; received leukapheresis, started on hydroxyurea. Dx'ed with precursor B-cell ALL. - underwent phase I induction with daunorubicin, vincristine, dexamethasone, L-asparaginase, MTX; phase II with cyclophosphamide, cytarabine, mercaptopurine, MTX - Bone Marrow Aspirate/Biopsy on [2172-10-26] showed no morphologic evidence of residual leukemia - underwent allo double cord blood SCT [2173-1-11], course complicated by neutropenic fever and acute skin GVHD OTHER MEDICAL HISTORY: - Embolic stroke in [3-/2174] on coumadin - Cardiomyopathy due to early anthracycline-related cardiotoxicity [10/2172] - Chronic kidney disease stage III/IV, baseline creatinine ~2.0-2.2 - Asthma - HTN - Cervical Intraepithelial neoplasia - C-section in [2165] Social History: Smoke: never EtOH: Occasional in past, none currently Drugs: Never Lives/works: Single, has two children (ages 7 and 18). Lives in [Location 686]. Was previously employed at [Company 59330], hasn't been working since being diagnosed with ALL in [2172-8-5]. Family History: Mother with gastric cancer, passed at the age of 40 Father with HTN. Physical Exam: VS: 98 145/76 87 15 100% RA GEN: well appearing F in NAD HEENT: slight dry MM, sclera anicteric, PERRL Cards: RR S1/S2 normal. prominent S3 Pulm: CTAB Abd: Hyperactive BS. Initially soft when palpating with stethoscope over all 4 quadrants then suddenly exquisitely tender on right. No guarding initially. Unable to assess for HSM. Extremities: wwp, no edema. PTs 2+. Neuro: CNs II-XII grossly intact. normal gait Psych: overly dramatic affect Pertinent Results: On admission: [2174-4-18] 02:00PM BLOOD WBC-12.4* RBC-3.78* Hgb-11.4* Hct-36.3 MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-212 [2174-4-18] 02:00PM BLOOD Neuts-67.3 Lymphs-23.8 Monos-7.7 Eos-0.5 Baso-0.7 [2174-4-18] 04:30PM BLOOD PT-30.1* PTT-29.4 INR(PT)-3.0* [2174-4-18] 02:00PM BLOOD UreaN-30* Creat-2.7* Na-142 K-4.8 Cl-99 HCO3-31 AnGap-17 [2174-4-18] 02:00PM BLOOD ALT-15 AST-18 AlkPhos-127* TotBili-2.1* [2174-4-18] 02:00PM BLOOD Lipase-63* [2174-4-18] 02:00PM BLOOD cTropnT-<0.01 [2174-4-18] 02:00PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.8* Mg-2.0 On discharge: [2174-5-17] 12:00AM BLOOD WBC-19.1* RBC-3.86* Hgb-11.3* Hct-37.7 MCV-98 MCH-29.3 MCHC-30.0* RDW-17.8* Plt Ct-419 [2174-5-17] 12:00AM BLOOD Neuts-81.3* Lymphs-11.4* Monos-6.9 Eos-0.1 Baso-0.3 [2174-5-17] 12:00AM BLOOD PT-31.2* PTT-28.6 INR(PT)-3.1* [2174-5-17] 12:00AM BLOOD Fibrino-162 [2174-5-17] 12:00AM BLOOD Glucose-152* UreaN-78* Creat-2.9* Na-137 K-4.7 Cl-95* HCO3-31 AnGap-16 [2174-5-17] 12:00AM BLOOD ALT-51* AST-41* LD(LDH)-327* AlkPhos-107* TotBili-0.7 [2174-5-13] 12:11PM BLOOD cTropnT-<0.01 [2174-5-17] 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.1* Mg-2.7* UricAcd-8.7* [2174-4-27] 02:51AM BLOOD calTIBC-246* Ferritn-107 TRF-189* [2174-5-2] 05:55AM BLOOD [Doctor First Name ]-NEGATIVE dsDNA-NEGATIVE [2174-4-28] HHV-8 DNA, QL PCR Not Detected [2174-4-27] QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE [2174-4-29] ACE, SERUM 30 [10/2130] U/L Micro: [2174-4-25] 1:07 pm PERITONEAL FLUID GRAM STAIN (Final [2174-4-25]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2174-4-28]): NO GROWTH. ANAEROBIC CULTURE (Final [2174-5-1]): NO GROWTH. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2174-4-30]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [2174-5-13]): NO FUNGUS ISOLATED. [2174-4-29] 10:15 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. CMV Viral Load (Final [2174-5-6]): CMV DNA not detected. ECG [2174-4-18]: Sinus rhythm. Possible left atrial abnormality. Lateral ST-T wave abnormality. Cannot rule out myocardial ischemia. Poor R wave progression. Cannot rule out anterior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [2174-4-2] multiple described abnormalities persist. CT abdomen/pelvis without contrast [2174-4-18]: FINDINGS: There is a small-to-moderate right pleural effusion, smaller in size compared to last CT torso. There is a small pericardial effusion. Study is suboptimal for evaluation of solid organs due to lack of IV contrast. With this limitation in mind, there is no extra- or intra-hepatic biliary duct dilatation. Previously described presumably focal nodular hyperplasia in segment VI of the liver is not clearly visualized on a non-contrast CT. There is a presumably gallbladder wall edema from third spacing with moderate amount of ascites. There is likely gallbladder sludge. Pancreas and bilateral adrenal glands are within normal limits considering the limitation of no contrast administration. There is interval increase in size of a fat-containing umbilical hernia measuring 2 cm in transverse dimension with mild fat stranding(2:50), correlate with point tenderness/physical exam. The appendix is not dilated (2:49), contains air and there is a likely small appendicolith (2:53). There is no bowel obstruction. There is no evidence of colonic wall thickening, although evaluation is suboptimal given lack of IV or PO contrast and adjacent ascites.. The kidneys are normal in size. There is no evidence of hydronephrosis. Due to lack of oral contrast, evaluation for mesenteric lymph nodes is suboptimal. There are scattered lymph nodes in the retroperitoneum, however, do not meet the CT criteria for pathologic enlargement. CT PELVIS: There is free fluid in the pelvis - ascites. The uterus and urinary bladder appear normal. The rectum and sigmoid have scattered diverticula; however, no evidence of diverticulitis. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion. There is soft tissue stranding suggesting anasarca. IMPRESSION: 1. Mild-to-moderate right pleural effusion; however, interval decrease in size compared to prior. 2. Moderate ascites with interval increase. 3. No drainable fluid collection, however, evaluation is suboptimal due to lack of IV and oral contrast. 4. Diverticulosis. 5. Interval increase in size of a small fat-containing umbilical hernia with mild fat stranding, correlate with point tenderness. 6. No bowel obstruction. No definite bowel wall thickening, although the examination is suboptimal for such. 7. Pericardial effusion, similar to prior. RUQ ultrasound [2174-4-18]: FINDINGS: The liver is of normal echogenicity. Previously described presumably focal nodular hyperplasia in segment VI of the liver is not clearly visualized. There is no intra- or extra-hepatic biliary duct dilatation. The common bile duct measures 2 mm. There is ascites. There is gallbladder wall edema/thickening presumably from third spacing; the gallbadder is not distended. No convincing evidence of sludge on ultrasound. The main portal vein is patent. Pancreas is suboptimally evaluated due to overlapping bowel gas. There is a small-to-moderate right pleural effusion as seen on recent CT. IMPRESSION: 1. Ascites. 2. Gallbladder wall edema presumably from third spacing. 3. Small-to-moderate right pleural effusion. 4. No biliary duct dilatation. 5. Previously described presummed focal nodular hyperplasia in segment VI of the liver is not clearly visualized. Small bowel follow through [2174-4-20]: IMPRESSION: 1. Small, anterior cervical web that does not hinder the passage of a 13mm barium tablet. 2. Filling defect in the mid esophagus just below the carina appears to be either extrinsic compression versus a submucosal lesion. In correlation with the comparison CT torso, mediastinal lesion is less likely. Submucosal esophageal lesion remains within the differential, and direct visualization with EGD is recommended. Other possibility includes an aberrant vessel in this vicinity. 3. Mobile cecum which does not appear to be obstructive in any manner on today's examination. Renal ultrasound [2174-4-20]: FINDINGS: The right kidney measures 10.5 cm. The left kidney measures 9.7 cm. There is no evidence of hydronephrosis, stone or mass bilaterally. The bladder is unremarkable. Moderate amount of ascites is incidentally noted. IMPRESSION: No hydronephrosis, stone or mass within the kidneys. Peritoneal Fluid [2174-4-25]: ATYPICAL. Scattered atypical lymphoid cells in a background of reactive mesothelial cells IR guided paracentesis [2174-4-25]: IMPRESSION: Ultrasound-guided diagnostic paracentesis, with a total of 200 mL of ascites removed. TTE [2174-5-2]: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20 %). Systolic function of apical segments is relatively preserved. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is mildly increased with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Severe biventricular global hypokinesis. Severe tricuspid regurgitation. Pulmonary artery systolic hypertension. Small circumferential pericardial effusion without evidence of tamponade physiology. Compared with the prior study (images reviewed) of [2174-4-1], the findings are similar. TTE [2174-5-10]: The left atrium is dilated. A left-to-right shunt across the interatrial septum is seen at rest consistent with a stretched patent foramen ovale (or small atrial septal defect). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal with mildly impaired global left ventricular systolic function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is moderate (2+) tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [2174-5-6], ther pericardial effusion is now smaller. Biventricular sysotolic function appears slightly less vigorous compared to the prior study (on a lower dose of milrinone now than during the prior study). Cardiac cath [2174-5-5]: COMMENTS: 1. Hemodynamics measurements in this patient demonstrate low cardiac output. Following administration of milrinone, cardiac index increased to the low-normal range with 2.5 L/min/m2. 2. Moderate pulmonary hypertension with right atrial v-waves consistent with severe TR noted. Pulmonary vascular resistance is elevated at 280 dyne-cm-sec5. FINAL DIAGNOSIS: 1. Severe systolic ventricular dysfunction. 2. Moderate diastolic ventricular dysfunction. 3. Pulmonary hypertension LE ultrasound [2174-5-13]: IMPRESSION: 1. No evidence for deep venous thrombosis in either lower extremity. 2. 3.6 cm [Hospital Ward Name 4675] cyst in the right popliteal fossa as previous. Superficial soft tissue edema in the right mid thigh, may be related to partial rupture of [Hospital Ward Name 4675] cyst. TTE [2174-5-16]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [2174-5-10], biventricular systolic function is slightly worse. The size of the pericardial effusion is slightly smaller. Brief Hospital Course: 38 yo F w/ h/o ALL in remission s/p cord transplant in [1-13], anthracycline-induced cardiomyopathy (EF 15-20% [1-14]) and recurrent nausea and vomiting who presents with 1 week abd pain, acute on chronic renal failure and new hyperbilirubinemia. Unclear unifying diagnosis. # Acute on Chronic Abdominal Pain: Pt noted to have significant abdominal pain as well as increased [Month/Year (2) 4394] on admission. Of note, she had an extensive work up of her chronic abdominal pain in the past with no clear cause. Abdominal CT was unrevealing for any obvious source of her pain. GI was consulted who recommended a SBFT which did not reveal any significant pathology. GI recommended bentyl for antispasmodic effect. She was also continued on her home MS contin and IV morphine for breakthrough. Her pain persisted as did her [Last Name (LF) 4394], [First Name3 (LF) ] the decision was made to perform a diagnositc paracentesis under ultrasound guidance. 200ml peritoneal fluid was removed. This revealed 775 WBCs, but a lymphocytic/monocytic predominance with only 1% polys making SBP unlikely. Fluid was sent for culture which showed no growth and flow cytometry which showed no evidence of ALL recurrence. Despite lack of evidence for SBP, she was started on zosyn empirically which was stopped on [5-2]. She continued to have mild-moderate abdominal pain but was able to eat full meals and had BMs. She was continued on her home mscontin and morphine IR. . # Anthracycline-induced/ GVHD cardiomyopathy: EF <20% on echo from 2/[2174]. Pt was maintained on diuresis as above, which was subsequently held in the setting of rising creatinine with improvement in creatinine. Torsemide was slowly reintroduced and uptitrated to 40mg [Hospital1 ] which caused another bump in creatinine to 3.0, so renal and cardiology were consulted. Renal ultrasound was unrevealing. She was then taken to the Cath lab and placed on a milrinone/lasix gtt and transfered to the CCU. Her volume overload slowly improved and her peripheral edema/ascites slowly improved as well. A repeat echo showed improved EF to 40-45% on the milrinone gtt. She was then started on solumedrol 30mg IV due to a concern for GVHD directed towards myocardium. After further discussion between cardiology and her oncology team she was also started on cellcept for further management of her GVHD. She did well on milrinone and lasix drip, but the drip was stopped when her creatinine bumped to 3.0 and it was felt her volume status was near maximization. Her milrinone was then discontiued and she was then transferred back to [Hospital1 3242] for further management of her abdominal pain and GVHD. She was continued on torsemide for diuresis with close follow-up with her outpatient cardiologist. Of note, she had frequent alarms on telemetry for tachycardia that cardiologist felt was mostly due to artifact; her beta blocker was uptitrated. Repeat TTE prior to discharge showed an EF of 35-40%. She was discharged home on cellcept and prednisone for possible GVHD. # Acute Renal Failure: On admission Cr was 2.7 (recent baseline was 2), but at last discharge Cr was 2.3. Renal saw the patient who thought this was likely from overdiuresis (home torsemide regimen of 20mg [Hospital1 ]) in conjunction with her [Last Name (LF) ], [First Name3 (LF) ] recommended holding diuresis. Her Cr subsequently improved, but in the setting of her worsening [First Name3 (LF) 4394] and her cardiomyopathy, decision was made to slowly add back diuresis, and eventually she was up titrated to toresemide 40mg [Hospital1 ] and her [Last Name (un) ] was restarted. With this, however, her Cr began to climb again to 3.0. Given the delicate balance between her renal failure cardiomyopathy, cardiology/renal were consulted. Given her depressed EF, her rising Cr was thought to be [3-9] volume overload. She was sent to the cath lab and started on a milrinone/lasix gtt and transfered to the CCU with a goal diuresis of 1L per day. She was actively diuresed on her milrinone and lasix drip with a total net negative of close to 9L. Her Cr then returned to baseline by time of discharge and she was discharged home on torsemide. # Hyperbilirubinemia: Unclear cause, could have been related to a viral infection but no transaminitis to support this. RUQ u/s without cause for pain. This trended down to normal values and remained stable by time of discharge # Leukocytosis: patient had uptrending WBC in setting of starting solumedrol, clutures were sent which revealed no growth. . # H/O Embolic Stroke: Has new opening of PFO based on most recent echo which likely contributed to her recent stroke. She was maintained on coumadin 4mg daily, but anticoagulation was held on day of paracentesis and remained subtherapeutic for several days, so she was maintained on a heparin drip to bridge her to a therapeutic INR [3-10]. She was maintained on a decreased dose of coumadin throughout hospital admission with INR within goal between 2 and 3. She was arranged with follow-up at outpatient [Hospital3 ]. Medications on Admission: Carvedilol 25 mg [Hospital1 ] Fluticasone-salmeterol [Hospital1 ] Morphine 15 mg q6h prn pain Valsartan 40 mg qd Torsemide 20 mg [Hospital1 ] Multivitamin qd Albuterol prn Lorazepam 0.5 mg q6h prn nausea Warfarin 4 mg qd Ondansetron 8 mg tid prn Pentamidine 300 mg inhalation qmonth Colace 100 mg qd prn Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:60 Tablet(s) Refills:0 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob or wheeze. 5. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:0 8. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:60 Tablet Extended Release(s) Refills:0 9. dicyclomine 20 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:0 10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 14. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal pain or gas. Disp:120 Tablet, Chewable(s) Refills:0 15. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 16. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:500 ML(s) Refills:0 18. morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain. 19. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: -Abdominal Pain -Acute on chronic renal failure -Systolic Heart failure Secondary: -ALL -History of embolic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital for abdominal pain. Your pain was treated with pain medications, and a new medication called Bentyl. You were also switched to a longer acting form of your morphine. We did a test to look at your small bowel which was negative. At this point we are not sure what is causing your pain, but you had increased swelling of your abdomen which likely contributed to your pain. You underwent a right heart catheterization and [Known lastname 461] to assess your heart function because worsening heart failure can cause fluid in your belly and worsening kidney disease. You were at the cardiac intensive care unit and placed on a medication that improved your heart function. A repeat [Known lastname 461] prior to your discharge showed that your heart function has improved somewhat and is stable. You will follow up closely with your cardiologist as several of your heart medications have changed. You were started on steroids and mycophenolate mofetil because it was felt that you heart problems may be due to your leukemia. You also had some worsening of your renal failure. You were followed by our kidney consult team while you were in the hospital. Your kidney function was stable prior to discharge. We made the following changes to your medications: -Mycophenolate Mofetil 1000mg twice a day was started -Prednisone 60mg daily was started -Coumadin was decreased to 2mg daily -Torsemide was increased to 40mg daily -Please hold your valsartan until you see your cardiologist -Metoprolol succinate 100mg daily was started; please stop carvedilol -Bentyl (dicyclomine) was started for your abdominal pain -Simethicone was started for abdominal discomfort/gas -Your morphine was switched to long-acting Morphine 15mg twice a day -Bactrim single strength, 1 tablet daily, was started to help prevent infection -Acyclovir 400mg twice a day was started to help prevent infection -Allopurinol 100mg daily was started because your uric acid levels were high Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following appointments [Name8 (MD) 1988] for you. You will need to follow up at [Hospital3 ] on Thursday, [2174-5-19], for an INR (coumadin level) check. Please come to the [Hospital Ward Name 23] Center [Location (un) 895] for this lab test between 9am and 5pm. Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2174-5-20] at 3:30 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2174-5-20] at 3:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10565], NP [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] MD, Cardiology [Last Name (LF) 766], [2174-5-30] at 11:00AM SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2174-6-9] at 10:00 AM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] Completed by:[2174-5-26]	[ "787.01", "584.9", "428.0", "425.4", "425.9", "585.4", "622.11", "403.90", "428.43", "E933.1", "789.09", "416.8", "493.90", "204.01", "E849.8", "787.91", "782.4", "573.9", "V42.82" ]	icd9cm	[ [ [] ] ]	[ "37.21", "88.56", "54.91", "38.97", "89.64" ]	icd9pcs	[ [ [] ] ]	22819, 22825	15080, 20225	310, 411	22994, 22994	3486, 3486	25293, 26873	2931, 3002		20592, 22796		22846, 22973		20251, 20569		13655, 15057	23145, 24450								3017, 3467					5361, 5619			5652, 13638								4085, 5325		24479, 25270	1583, 1685		256, 272									439, 1529							3500, 4071		23009, 23121					1707, 2628	2644, 2915
10,394	192,972	23397	Discharge summary	report	Admission Date: [2176-3-20] Discharge Date: [2176-4-4] Date of Birth: [2123-3-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: 53 yr old male w/ severe tracheobronchomalacia s/p tracheoplasty [11-22] now w/ recurrent malacia on bronch [2176-2-19]. Presents for re-do tracheoplasty. Major Surgical or Invasive Procedure: RE-DO tracheoplasty via right thoracotomy History of Present Illness: 53 yr old male w/ severe tracheobronchomalacia s/p tracheoplasty in [11-22] w/ recurrent malacia [2176-2-19] Past Medical History: Emphysema, tracheobronchomalacia Social History: He is married, lives with his wife. [Name (NI) ] worked as a truck driver and has 1 child. He has a heavy smoking history having smoked 3 packs a day for 30 years and quit 10 years ago. Family History: Father died of lung cancer. Mother died of lung cancer. A brother died of brain cancer and has two healthy brothers and a sister. [Name (NI) ] has one son and no grandchildren. Physical Exam: General:In NAD. A+Ox3. PERRL, EOMI, RRR S1, S2 Lungs: CTA bilat ABD: soft, NT, +BS Extrem: no C/C/E Brief Hospital Course: Pt admitted for re-do tracheoplasty on [2176-3-20]. Post operatively patient remained intubated and was admitted to the surgical ICU. Epidural for pain management. POst op course complicated by agitation, Self- extubated, self removal of epidural on POD#1. On levo and vanco prophylactically. Intermittant serial bronchs were done for secretion management. Right surgical chest tube was removed POD# 4 c/b sucking chest wound resulting severe SQ emphysema over entire thorax anterior/posterior, facial, and bilat upper extremities. Chest tube was replaced but was in the fissure and failed to decompress. A second right chest tube was placed at the apex w/ gradual improvement in SQ air. Medications on Admission: Advair, combivent, Discharge Disposition: Home With Service Facility: [Hospital1 11485] VNA Discharge Diagnosis: RE-Do tracheoplasty Discharge Condition: good Completed by:[2176-4-8]	[ "V16.1", "496", "519.1", "293.0", "998.81", "518.5", "V15.82", "V16.8", "512.1" ]	icd9cm	[ [ [] ] ]	[ "33.22", "33.24", "34.04", "31.79", "33.21" ]	icd9pcs	[ [ [] ] ]	2045, 2101	1282, 1976	491, 534	2164, 2198			960, 1143				2122, 2143		2002, 2022											1158, 1259																					289, 453									562, 680														702, 736	752, 944
80,228	152,701	22076	Discharge summary	report	Admission Date: [2110-12-30] Discharge Date: [2111-1-10] Date of Birth: [2053-11-13] Sex: F Service: NEUROSURGERY Allergies: Codeine / Ciprofloxacin / Morphine Attending:[First Name3 (LF) 78] Chief Complaint: :"My neck and my back" / "the spasms in my upper back" Major Surgical or Invasive Procedure: C5 C6 corpectomies C45 C56 C67 discectomies C4-7 Fusion History of Present Illness: HPI:Asked to eval this 57 year old white female with extensive PMH for ? osteo in cervical spine. Note: pt has husband at bedside / both give conflicting stories of PMH and hospitalizations. Pt and husband describe that pt was hospitalized at [Last Name (un) 1724] in [Month (only) 205] of this yr for "perforated" vs "tear" in esophagus. Hospitalization lasted approx 5.5 wks at which time she was transferred to [Hospital ] rehab for an additional 5.5 weeks. While at [Hospital1 ] she had a PICC line placed for vancomycin x 4 weeks that was treating "gastric abscess and PNA". She was discharged to home with PICC line (but not on abx) and spent about 6 days at home. She then went back to [Last Name (un) 1724] for "fever and another esophageal tear". They removed the PICC line as possible fever source. The PICC cx was positive for MRSA. Note during that second hospitalization she was intubated in the ED and spent "[3-30]" days in the ICU on ventilatory support. She did not have surgery at any time for the esophageal tears. She describes coffee ground emesis during that time and was taken off of her Coumadin (which she was taking for a supraclavicular clot" that was ultimately treated by a "balloon breaking it up"). Her husband recalls an admission date of [11-8] because he had to miss [First Name (Titles) ] [Last Name (Titles) 648] and says she was complaining of neck pain a "few days after". She was ultimately released to home with PT. About 2 weeks after being discharged her neck pain was worse and she went to [Last Name (un) 1724] ED - had xrays and was sent home. She called her PCP and was prescribed Robaxin for muscle spasm which was increased from QD to TID. The pain was continuing and she states the PT refused to perform any further treatment b/c she was getting progressively weaker without explanation. She describes that PT called PCP and OSH MRI was ordered. She received this imaging on [12-29] and the radiologist wheeled her to the ER where she was placed in a collar and seen by Neurosurgery. She was sent here for further eval. Images are being uploaded to the system at this time. She admits to numbness and tingling to all finger tips and palms of both hands. She also admits to pain to dorsal and ventral surfaces of arms as well as pain down anterior thighs and legs. She denies MI, CVA, falls or hyperesthesias or bowel or bladder issues. Past Medical History: Past medical history: -Gastroparesis (likely narcotic induced vs idiopathic): History of TPN -Childhood constipation -History eating disorder -Narcotic induced ileus -History of laxative abuse and ? eating disorder -Supraclavicular clot -Chronic pain -History meningioma -Peripheral neuropathy -GERD -C. difficile colitis -Mild esophagitis -Cholecystitis -Hysterectomy for uterine cancer -Migraine headaches -Staph aureus bacteremia in setting of TPN Social History: She lives with her husband. History of tobacco abuse but quit 30-40 years ago after smoking [1-24] pack per day prior to that. Occasional alcohol. No illicit drugs. Has been on disability for years secondary to her chronic abdominal symptoms. Family History: Her father had diabetes and her mother died of colon cancer. Physical Exam: PHYSICAL EXAM: O: T: 98.7 BP: 110/ 62 HR:108 R 18 95 O2Sats Gen: Pale small framed female, comfortable, NAD at rest HEENT: NCAT Neck: Tender from occiput to upper thoracic region/ paraspinal regions bilaterally as well as to shoulders and ears. Abd: Soft, G-J tube noted with broth/ brown drainage noted / no coffee grounds Extrem: Warm and well-perfused./ no edema - note: husband feels that R hand is very swollen still "from clot" / no edema is appreciated by this examiner Neuro: Mental status: Awake and alert, attempts to cooperate with exam. Orientation: Oriented to person, place, and date. Motor: exam extremely limited [2-24] pain all over. At best participation pt is antigravity in the distal upper extremities. Resists examiners efforts to lift arms off of bed. Hoffmans negative however pt describes severe pain. Grips [3-27], bicep 4-/5 and breaking, triceps 4-/5 and breaking. LE's actively w/d to fully flexed during PR exam however at best IP [3-27], DF [3-27], PF [3-27]. Clonus appears to be negative however pt cries out in pain and w/d's away from examiner. Sensation: Intact to light touch Reflexes: unable to obtain / pt very limiting to exam / ON DISCHARGE: Full strength in BLE although [4-27] in uppers with very poor effort. She does not have any focal deficits. Incision, clean, dry, intact. Steri strips in place. Cervical collar in place. Pertinent Results: [2110-12-30] CT C-spine IMPRESSION: Chronic discitis/osteomyelitis at C5-6 with focal kyphosis and retrolisthesis at this level. Recent MRI showed severe canal stenosis at this level due to inflammatory epidural tissue. There is also extensive prevertebral soft tissue. [2111-1-2] CT C-spine IMPRESSION: 1. Note difference in levels from that given in the indication and wet read. 2. Satisfactory alignment of hardware with relative alignment of spine. However, disc-osteophyte complexes at multiple levels may efface thecal sac contact cord, though cord detail is limited at all levels given CT technique and streak artifact. CXR [2111-1-9]: The left PICC line tip is at the mid SVC level. There is new left basal opacity that might represent atelectasis or developing infection. The right basal linear opacity is also new and also might represent atelectasis. Close followup to these areas is recommended to exclude the possibility of developing infectious process. There is no pleural effusion. There is no failure. Cardiomediastinal silhouette is unremarkable. CXR [2111-1-10]: The left basal atelectasis is improved. The right basal atelectasis is improved. There is no evidence of pneumonia. [2111-1-6] 02:26AM BLOOD WBC-5.8 RBC-2.89* Hgb-8.5* Hct-26.0* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.9* Plt Ct-266 [2111-1-8] 05:22AM BLOOD WBC-3.4* RBC-2.90* Hgb-8.7* Hct-26.3* MCV-91 MCH-30.1 MCHC-33.2 RDW-15.7* Plt Ct-306 [2111-1-7] 04:38AM BLOOD WBC-3.5* RBC-2.80* Hgb-8.2* Hct-24.9* MCV-89 MCH-29.2 MCHC-32.9 RDW-15.7* Plt Ct-316 [2111-1-5] 02:28AM BLOOD PT-13.8* PTT-33.5 INR(PT)-1.2* [2111-1-6] 02:26AM BLOOD Glucose-123* UreaN-6 Creat-0.4 Na-140 K-3.7 Cl-106 HCO3-28 AnGap-10 [2111-1-7] 04:38AM BLOOD Glucose-105 UreaN-4* Creat-0.4 Na-144 K-3.5 Cl-108 HCO3-30 AnGap-10 [2111-1-8] 05:22AM BLOOD Glucose-93 UreaN-3* Creat-0.4 Na-144 K-3.3 Cl-106 HCO3-30 AnGap-11 [2111-1-6] 02:26AM BLOOD ALT-14 AST-19 LD(LDH)-125 AlkPhos-264* TotBili-0.3 [2111-1-8] 05:22AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8 Brief Hospital Course: 1) Osteomyelitis: Pt was transferred from the [Hospital3 ] emergency department for collapse of C56. She was maintained in a cervical collar. The pt was admitted to medicine service for clearance as well as to eval the integrity of the pts esophagus given her history of esophageal perforation x 2. She was initially started on vancomycin and ceftazidine in the OSH ED for empiric coverage of her osteomyelitis, however, after her initial dose her antibiotics were held per ID so that adequate biopsy specimens could be obtained for culture during her surgery. The patient was carefully monitored for any signs of neurological deterioration. Patient had UGI gastrograffin study that showed no evidence of esophageal perforation. The pt was medically cleared and taken to the OR on [1-2] for corpectomies at C5 C6 with fusion C4-7. No posterior fusion was performed. She was extubated the next morning and wound drain was removed. On [1-5] she was cleared to transfer to the step down unit but due to bed availability was unable. [1-6] Chronic Pain Service recommended that the patient continue with her Dilaudid PCA, and patient was transferred to the Step Down Unit. Her PCA was discontinued and she was transitioned to PO pain medication. She tolerated tube feeds however would complain of nausea when she was aware of rate being at goal. She did not have high residuals and have regular BMs. She worked with PT/OT and was OOB. PT/OT recommended rehab. She did c/o sl cough on [1-9] with vaigue adventitious sounds, although no elevated WBC, afebrile, no sputum. CXR was done showing some atelectasis. She had a repeat CXR on [1-10] showing that the atelectasis was resolving and there was no evidence of pneumonia. On [1-10] she was neurologically stable and was discharged to rehab. 2) Right hand swelling: The patient has a history of R brachial vein thrombosis, and on admission was noted to have right hand swelling and warmth. She reports chronic intermittent swelling since DVT. Right upper extremity ultrasound was performed that showed no evidence of clot. Probable etiology for her chronic swelling is post-DVT syndrome. 3) Migraine headaches: Patient has a history of chronic migraine headaches and experienced them nearly constantly during this admission. Her pain was well controlled with her home dose of fioricet. Medications on Admission: Medications prior to admission: Fentanyl 100mcg q 72 hrs senna two tabs po bid colace 200mg po bid scopolamine patch 1.5mg q 72 hours dicyclomine 20 mg q 6 hrs for stomach spasm Ativan 1 mg q 4 hours Nexium 40mg [Hospital1 ] (liquid) promethazine suppository 50mg q 4 hours reglan 40 mg daily hydromorphone 2mg po q 4 hours vivonex T.E.N. packet 20 ml / hr 8pm to 8am daily Coumadin 2mg (stopped last hospitalization to [Last Name (un) 1724]) potassium chloride 20meq [Hospital1 ] (powder) lactulose 15ml qd NTG fiorocet 1-2 tabs q 6 hours Discharge Medications: 1. Metoclopramide 10 mg Tablet [Hospital1 ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 2. Dicyclomine 10 mg Capsule [Hospital1 ]: Two (2) Capsule PO QID (4 times a day) as needed for stomach spasm. 3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 5. Multivitamin,Tx-Minerals Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Two (2) PO BID (2 times a day). 8. Trazodone 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. Fentanyl 75 mcg/hr Patch 72 hr [Last Name (STitle) ]: Two (2) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 11. Pregabalin 25 mg Capsule [Last Name (STitle) ]: Four (4) Capsule PO BID (2 times a day). 12. Ibuprofen 400 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours) as needed for fever. 13. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO BID (2 times a day) as needed for constipation. 14. Bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily). 15. Methocarbamol 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO QID (4 times a day) as needed for Pain. 16. Hydromorphone 4 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 17. Scopolamine Base 1.5 mg Patch 72 hr [Last Name (STitle) ]: One (1) Patch 72 hr Transdermal Q72 HOURS (). 18. Heparin, Porcine (PF) 10 unit/mL Syringe [Last Name (STitle) ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 19. Lorazepam 2 mg/mL Syringe [Last Name (STitle) ]: 0.5 Injection Q4H (every 4 hours) as needed for anxiety. 20. Heparin, Porcine (PF) 10 unit/mL Syringe [Last Name (STitle) ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 21. Sodium Chloride 0.9 % 0.9 % Syringe [Last Name (STitle) ]: One (1) Injection PRN (as needed) as needed for line flush. 22. Promethazine 25 mg/mL Solution [Last Name (STitle) ]: One (1) Injection Q6H (every 6 hours) as needed for Nausea. 23. Hydromorphone (PF) 1 mg/mL Syringe [Last Name (STitle) ]: One (1) Injection Q4H (every 4 hours) as needed for Breakthrough Pain. 24. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q 12H (Every 12 Hours). 25. Meds Patient has been on all of these medications while in the hospital and has not had adverse side effects even though several of them are reported to interract with each other. 26. Outpatient Lab Work You need weekly CBC with diff, BMP, vanco trough. You need ESR and CRP every other week. Please fax all labs results to Infectious Disease nurses at [Telephone/Fax (1) 1419]. Discharge Disposition: Extended Care Facility: [Hospital ] hospital [Hospital1 8] Discharge Diagnosis: C5 C6 cervical myelitis / discitis 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: ?????? Do not smoke. ?????? Keep your wound clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? You have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? You are required wear your cervical collar at all times for 3 months. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please call ([Telephone/Fax (1) 88] to schedule an [Telephone/Fax (1) 648] with Dr. [First Name (STitle) ] to be seen in 4 weeks. ??????You will need Ap/Lat x-rays of the cervical spine prior to your [First Name (STitle) 648]. You need to wear your cervical collar for 3 months. You will be contact[Name (NI) ] by the infectious disease office for a follow-up [Name (NI) 648]. If there are any questions regarding antibiotics please call the infectious disease nurses at [Telephone/Fax (1) 57729]. Completed by:[2111-1-10**]	[ "731.3", "730.18", "307.89", "536.3", "346.90", "722.71", "V12.51", "285.29", "V44.4", "V12.04", "530.81", "338.18", "041.12", "V10.42", "V85.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "81.02", "81.62", "80.99" ]	icd9pcs	[ [ [] ] ]	13455, 13524	7244, 9615	358, 416	13603, 13603	5174, 7221	15632, 16235	3655, 3717		10218, 13432		13545, 13582		9641, 9641			13780, 15609								3747, 4230											9673, 10195					4959, 5155					261, 320									444, 2896									13617, 13756					2940, 3371	3387, 3639
59,785	173,042	54718	Discharge summary	report	Admission Date: [2187-9-15] Discharge Date: [2187-9-20] Date of Birth: [2121-9-1] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2569] Chief Complaint: code stroke Major Surgical or Invasive Procedure: intubation History of Present Illness: CODE STROKE: Neurology at bedside for evaluation after code stroke activation within: 2 minutes Time (and date) the patient was last known well: 13:00 (24h clock) NIH Stroke Scale Score: 22 t-[MD Number(3) 6360]: No Reason t-PA was not given or considered: patient on pradaxa, last known well time >5hrs I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. * NEUROLOGY RESIDENT CONSULT NOTE * Reason for Consult: Code stroke unresponsiveness HPI: The pt is a 66yo F with hx of CAD, DVT, L MCA stroke ([2186]), ovarian ca (s/p chemo [2186]), SAH, dysphagia, presents to [Hospital1 18] with change in mental status (unresponsiveness). She was in her usual state of health at the [Hospital3 ] facility until earlier today when she complained of generally feeling unwell. She was able to eat breakfast and lunch and otherwise did not demonstrate any new deficits or problems. She was last seen normal at 1pm. At 4pm, an aide went in to check in on her and noted that she was sleepy and quite unarousable despite vigorous stimuli. She alerted EMS who found a normal FS (124) and otherwise normal vital signs (70 130/60 99% RA). At some point there was a concern for her eyes rolling back and given her overall condition and lack of responsiveness was intubated in the field and placed on propofol. She was brought to the ED in this condition and was noted on presentation to have eye deviation towards the right. She was diagnosed with LMCA in [2186] (unclear etiology of stroke) and was left with the following deficits: R hemiplegia, dysarthria and fluent aphasia, and limited ability to communicate verbally. She requires a walker but is independent in most ADLs (washing, eating). She has some dysarthria but is able to chew her food. She was never noted to have had a seizure while at this facility. She is on aspirin, fragmin and keppra (all of which she took today). On neuro ROS, pt intubated sedated Past Medical History: CAD DVT Depression L MCA stroke R Hemiparesis OA Ovarian CA (s/p chemo in [2186] - no further details at this time) Social History: Lives in [Hospital3 ] as noted above, independent of adls as above, no alcohol/cigarettes, Family History: non contributory Physical Exam: Physical Exam on Admission: Vitals: T: P: 71 R: 16 BP: 141/95 SaO2: 98% General: intubated sedated with ETT HEENT: NC/AT, no scleral icterus noted, MMM, tearing in both eyes Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregular, S1S2, Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Neurologic: (If applicable) NIH Stroke Scale score was 22: 1a. Level of Consciousness: 3 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 1 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 3 5b. Motor arm, right: 2 6a. Motor leg, left: 3 6b. Motor leg, right: 2 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: UN (intubated) 11. Extinction and Neglect: 0 -Mental Status: Intubated, off propofol for 10minutes did not respond to voice and did not open eyes to command or sternal rub, did grimace to noxious in all limbs, did not follow commands, -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VFF to confrontation. Funduscopic exam difficult with small pupils III, IV, VI: tonic deviation towards the right which could be overcome with VOR. VOR intact V: Facial sensation could not be assessed. VII: No facial droop, facial musculature difficult to assess with ETT. VIII: Hearing not assessed IX, X: + gag, -Motor: Normal bulk, increased tone on the right hemibody, increased tone on the left hemibody (arm was more flaccid than leg) No adventitious movements, such as tremor, noted. Spontaneous movements were noted in all extremities. -Sensory: withdrew to noxious in all limbs, possible extensor posturing on the left upper limb. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 1 2 2 0 R 3 2 3 3 1 Plantar response was extensor on the right. -Coordination/Gait: defered Physical Exam on Discharge: expired Pertinent Results: Labs on Admission: [2187-9-15] 05:53PM WBC-9.6 RBC-3.87* HGB-11.9* HCT-34.5* MCV-89 MCH-30.7 MCHC-34.4 RDW-14.1 [2187-9-15] 05:53PM PT-13.5* PTT-34.5 INR(PT)-1.3* [2187-9-15] 05:53PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2187-9-15] 05:53PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2187-9-15] 05:53PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2187-9-15] 05:53PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 [2187-9-15] 05:53PM URINE MUCOUS-RARE [2187-9-15] 06:43PM LACTATE-1.1 [2187-9-15] 06:08PM GLUCOSE-123* NA+-137 K+-3.7 CL--105 TCO2-20* [2187-9-15] 06:06PM CREAT-0.8 [2187-9-15] 05:53PM UREA N-18 Relevant Labs: [2187-9-16] 02:00AM BLOOD CK-MB-14* MB Indx-3.7 cTropnT-0.53* [2187-9-16] 10:45AM BLOOD CK-MB-12* MB Indx-2.5 cTropnT-0.54* [2187-9-16] 06:13PM BLOOD CK-MB-7 cTropnT-0.43* Imaging: CT/CTA head neck/CT perfusion 1. There is increased mean transit time with matched decreased blood volume and blood flow in the right frontoparietal lobes, with associated mild hypodensity, consistent with an acute infarction in this region. 2. Chronic left middle cerebral artery infarction involving the M1 segment on the left, with associated hypodensity in this region. 3. Hyperdense focus in the right occipital lobe is suggestive of hemorrhage or recanalized vessel. MRI head/MRA head and neck 1. Large right acute MCA territory infarct and left acute on chronic MCA territorial infarct with associated laminar necrosis and hemosiderin deposition. Multiple smaller acute infarcts in the supratentorial and infratentorial brain suggesting thromboembolic origin. 2. Left M1 occlusion, right MCA superior division occlusion and moderate to severe narrowing of the M2 segment of the right MCA. Chest-X-ray [9-17] FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. Newly appeared is a complete atelectasis of the middle lobe, causing enlarged right hemithorax basal parenchymal opacity. Brief Hospital Course: The pt was a 66 yo F with CAD, DVT, L MCA stroke [2186] who presented with decreased responsiveness and was found to have new bilateral MCA strokes. # Neuro: On admission exam, pt did not open eyes to voice or sternal rub. Her eyes crossed midline R to L and L to R, decreased tone and decreased spontaneous movements in the LUE and increased tone/reflexes in the right hemibody. Her combined -now bilateral- MCA strokes (one old, one new L MCA stroke) would likely have led to significant disability with increased weakness. The prognosis was unfavorable. The cause of her stroke was most likely embolic in the setting of a hypercoaguable state secondary to malignancy. She was continued on her antiplatelet [Doctor Last Name 360]. Fragmin was replaced by heparin sc at time of admission. Had BP goals autoregulate to <220 prn hydral. Continued Keppra at home dose (1000mg [Hospital1 ]). Was on aspirin 300mg PR qd. Family meeting was held on [9-17] with SICU and neurology teams present. Discussed that prognosis is quite poor without chance for meaningful recovery given b/l MCA strokes. On [9-18], had another discussion with the family and decided to extubate Ms. [Known lastname ] and transition to comfort care only as she had expressed in the past that she would not want to live in such a state. Ms. [Known lastname ] was extuabed on the evening of [9-18]. She passed away peacefully with family at bedside on the morning of [9-20]. # Resp: Was intubated on admission as above. # ID: Tm 102.5 on [9-17]. Urine cx final neg. WBCs 13 up from 9.7. Pneumonia on chest x-ray. Treated with Vanc/Cefepime for VAP (day 1 = [9-17]), then d/c'ed as pt was transitioned to CMO. # Cardio: On admission, pt had troponin elevation with peak of 0.54, down to 0.43 today. # Code: Transitioned to comfort measures only as above. Medications on Admission: aspirin 325mg bethanecol alendronate lorazepam prn tylenol omeprazole metoprolol 12.5mg [Hospital1 ] simvastatin tamsulocin keppra 1000mg [Hospital1 ] Fragmin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: R and L new MCA ischemic strokes Prior L MCA ischemic stroke Ovarian cancer Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2187-9-20]	[ "997.31", "183.0", "401.9", "V87.41", "434.11", "E879.8", "379.50", "438.11", "272.4", "793.0", "V12.51", "V49.86", "V66.7", "438.21", "276.3", "289.82" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.71" ]	icd9pcs	[ [ [] ] ]	8982, 8991	6853, 8732	316, 328	9111, 9121	4670, 4675	9177, 9327	2632, 2650		8950, 8959		9012, 9090		8758, 8927			9145, 9154				3727, 4614				2665, 2679														4642, 4651							265, 278									356, 2360							4690, 6830		3535, 3710					2382, 2504	2520, 2616
29,624	177,082	34806	Discharge summary	report	Admission Date: [2191-6-26] Discharge Date: [2191-7-7] Date of Birth: [2123-6-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8104] Chief Complaint: Compression fracture Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a 68yo woman w/ pmh of HTN, LE edema, DM2 presented to OSH w/ intractable low back pain and altered mental status. She had a fall [5-14] and was found to have compression fx T11, sent home on vicodin. Her daughter brought here to her PCP [12-25] decreased mobility and persistent back pain and she had an MRI on [6-6] (no report). Admitted on [6-25] to OSH and had CT TL spine, which showed burst fx at T11 with piece of bone sticking into central canal with what was thought to be an unstable spine. NSU consulted & recommended transfer here. She was also found to be in ARF (BUN 100/ creat 3.5) hyponatremia (120), hypokalemia 3.0. Received IVF and HCTZ held. Hemodynamically stable on regular floor. . Dr. [First Name (STitle) ] discussed case with Ortho Spine Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363] here, who recommended transfer here to Medicine due to metabolic derangements, with Ortho Spine following closely until she is medically stable for surgery. . On arrival to [Hospital1 18], she was initially a bit confused but cleared and was able to give some history. She denies any fevers/chills/cough/chest pain, diarrhea. She endorses [4-2] lower back pain w/o radiation. Her daughter and son-in-law were at her bedside and they state that she has been confused w/ slurred speech and increased urinary incontinence w/ [Month (only) ] po intake X 1 week (although she continued to take her pills). She has been completely bed-ridden over the past week. Not anuric. Her daughter states that she is the type of person who resists going to the doctor or having tests performed. . ROS: (+) as above; daughter endorses 20 lb wt loss in the past 2 months. (-) Denies fever, chills. 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. Ms. [Known lastname ] is a 68yo female with PMH significant for HTN, LE edema, and DM2 who is being transferred to the MICU for hypotension. The patient recently fell on [5-14] and was found to have a T11 compression fracture. She was sent home on Vicodin and since then has had persistent back pain and limited mobility. She was then admitted on [6-25] to an OSH and underwent a CT of the thoracic-lumbar spine which confirmed the T11 burst fracture but also showed a piece of bone protruding into the central canal. This was thought to be an unstable spine and she was transferred to the [Hospital1 18] for further work-up. . Upon transfer to the medical floor, the patient was slightly confused and admitted to decreased PO intake and urinary output over the past week. This morning the patient was noted to be hypotensive with SBPs in 80's. She was immediately given a fluid bolus with little improvement in her blood pressure. She was then transferred to MICU 7 for further management. Past Medical History: T11 burst fracture Hypertension Osteoporosis Gout Obesity Chronic lower edema s/p colostomy in [2171] for diverticular perforation s/p appendectomy s/p partial hysterectomy Social History: lives with her 18 year old granddaughter in [Name (NI) 1474] Family History: non contributory Physical Exam: Vitals: T: 95.8 P: 122 BP: 102/60 R: 16 SaO2: 97% on RA General: Awake, alert, NAD mildly confused. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: tachy, reg, nl. S1S2, no M/R/G noted Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l, + signs of arterial insufficiency Lymphatics: No cervical, supraclavicular lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor -DTRs: 1+ biceps, trace patellar and no ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: ================== RADIOLOGY ================== CTA CHEST: IMPRESSION: 1. Negative examination for PE or aortic dissection. 2. Narrowing of the right subclavian vein in the region underneath the right clavicle, resulting in extensive collateralization of veins in that area. 3. Bilateral bibasilar small to moderate pleural effusion. No evidence of pneumothorax. 4. T11 burst fracture with narrowing of the spinal canal at that level (please refer to the thoracic spine CT for better evaluation of the T11 vertebral body fracture). 5.A 3.5mm RUL nodule;for which either a 3 month follow up exam is recommended if the patient has risk factors for malignency or a one year followup if no risk factors are noted. RUQ U/S 1. No evidence for cholecystitis or biliary obstruction in this technically limited abdominal ultrasound. 2. Splenomegaly. Clinical correlation recommended. TTE The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Cannot exclude basal anteroseptal hypokinesis but views are technically suboptimal for assessment of regional wall motion. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. 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. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: 1)Hypotension: Patient was hypotensive with SBP~80's on the medical floor, and given difficulties with access she was transferred to the MICU. Differential included urosepsis vs. neurogenic shock (in the setting of burst fracture and bony fragment protruding into canal). She had good rectal tone on exam and no impairment of pain /temperature or motor ability, suggesting that this is less likely neurogenic shock. <br> Patient was fluid resusitated after an ultrasound guided right axillary/subclavian central line was placed. Although CVP improved with fluids, her systolic blood pressure remained low, averaging 90's to 100's. Echocardiogram was obtained and revealed preserved ejection fraction without focal wall motion abnormalities without pericardial effusion. Cortisol levels were checked and [Last Name (un) 104]-stim performed with adequate response. Although patient experienced episodes of atrial fibrillation (see below for details), these were independent of hypotension. UA obtained was concerning for urinary track infection and patient was treated with 3 days of Ciprofloxacin. Although etiology of relative hypotension is unclear, suspect that although on admission this was due to severe hypovolemia, this is now most likely secondary to poor vascular tone from prolonged bedrest (patient had not been out of bed for weeks prior to admission). She is mentating well and without complaints with SBP as low as mid 80's. <br> Given low voltages on ECG, unexplained conduction disorders, hypotension and fracture, we considered amyloidosis as a possible unifying diagnosis. Serum and urine electrophoresis was negative, with no monoclonal spike on immunofixation. A fat pad biopsy was obtained and the results from that test are still pending. TB was also a concern because it can increase the risk of amyloidosis and could also present a unifying diagnosis. A PPD was placed in the MICU and read as negative 48 hours later on the medicine floor. Back on the floor the patient maintained blood pressures that were appropriate and she did not have any symptomatic hypotension. <br> 2)T11 burst fracture: Some evidence of compression, however no deficits on exam. Differential included pathologic fracture (with high suspicion for multiple myeloma). Ortho spine team evaluated the patient but due to very difficult procedure for fixation, they would like to pursue conservative therapy at this time. Patient will need to wear TLSO brace when out of bed at all times. Has ortho surgery follow-up on [2194-7-20]:00 AM with Dr. [Last Name (STitle) 363] in [Hospital Ward Name 23] outpatient clinics. <br> 3)Atrial fibrillation: Noted during MICU admission. Patient however was asymptomatic during these episodes. Rate control was attempted with diltiazem, with good response but limited by hypotension as above. Amiodarone was started with IV load, and transition to oral dose at 200mg daily. Patient had baseline LFT's and TFT's. Will need PFT's in the near future. LFTs were up at one point and then trended down, but not to a normal level prior to discharge. The patient will be instructed to have her PCP drawn liver enzymes to follow-up from her hospitalization. Given lack of surgical intervention, anticoagulation was started with low dose coumadin, with care given relative thrombocytopenia, mild liver enzyme elevation and concurrent amiodarone use. INR trended up to 3.3 prior to discharge, likely in part due to concomitant use of Cipro the day prior to admission. <br> 4)Acute on chronic renal failure: Per PCP's office, baseline Cr appears to be 1.5, likely elevated [12-25] hypertension and DM2. Elevated to 3.2 at OSH and trended down to 1.0 during her stay in the MICU. Most likely represented pre-renal azotemia in the setting of hypotension and underlying infection. On the medicine floor, IVF were continued and Cr remained normal. <br> 5)Thrombocytopenia: Per PCP, [Name10 (NameIs) ] has not had low platelets in the past. Decreased to 112 on admission to OSH and decreased to 76 during hospital stay. Unsure if she received heparin products at the last hospital. HIT panel negative. Hematology / Oncology was consulted and felt that given her cholestatic picture, she may have an underlying chronic hepatitis. On discharge platelets were trending up and ended up being 161. <br> 6)Hyperbilirubinemia / Liver enzyme elevations: Bilirubin elevated to 2.9 and elevated alk phos. Question underlying process given hypotension. Right upper quadrant ultrasound without infiltration or fibrosis. Hepatitis panel was obtained and revealed: Hepatitis B Surface Antibody NEGATIVE Hepatitis B Virus Core Antibody NEGATIVE Hepatitis A Virus Antibody POSITIVE Hepatitis C Virus Antibody NEGATIVE <br> 7)Type 2 Diabetes: Unclear if patient is on oral regimen at home. In the MICU, her blood sugars were very well controlled. She was placed on an insulin sliding scale. This controlled the patient's blood sugars during this hospitilization. On discharge she had not required insulin by sliding scale for 5 days. She was not sent to the rehab facility with SSI discharge orders. <br> 8)Hypertension: Patient on Triameterene/HCTZ as an outpatient which was held given her hypotension. She can revisit this medication with her PCP as an outpatient. We will not discharge her on this medication. <br> 9)Hyperlipidemia: Patient on Gemfibrozil as outpatient; this was held given LFT abnormalities. She should consult with her PCP about restarting this medication once her LFTs are followed-up as an outpatient. <br> 10) Urinary tract infection: The day prior to being discharged from the hospital, patient had significant pain attributed to foley catheter. UA revealed likely UTI. Started on Cipro 500 mg Q12H for a total of 7 days with first day being [2191-7-6]. Medications on Admission: triamterene/HCTZ 37.5/25 allopurinol 300 mg daily gemfibrozil 600 mg po bid fosamax 70 mg weekly motrin 600 mg [Hospital1 ] prn Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain . 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [Hospital 39225] & Rehab Center - [Hospital1 1474] Discharge Diagnosis: PRIMARY DIAGNOSES 1) T11 Burst facture 2) Atrial Fibillation SECONDARY DIAGNOSES 1) Hypotension 2) Transaminitis 3) Hyperbilirubinemia Discharge Condition: stable, afebrile Discharge Instructions: You presented to the hospital with worsening back pain and were found to have a t11 burst fracture. Orthopedic Surgery was consulted and did not recommend surgery, but suggested conservative management with a back brace. Once you regain some of your strength in rehabilitation, you will need to follow-up with Dr. [Last Name (STitle) 363] ([Telephone/Fax (1) 3573]) on [2194-7-20]:00 AM at [Hospital Ward Name 23] building ([Hospital1 18] [Hospital Ward Name 516]) for further management of your spine fracture. You should wear your brace until that time. In the hospital you developed low blood pressure and needed to be transferred to the MICU. No reason was found for why you developed this low blood pressure, but it improved with IV fluids. In the MICU, you were found to have Atrial Fibrillation. You were started on medications to control your heart rate, as well as a medication to thin your blood called coumadin. Please continue amiodarone, metoprolol and coumadin after you leave the hospital and be sure to have your INR levels checked biweekly to determine the appropriate coumadin dosage. The day prior to being discharged from the hospital, you had significant pain attributed to your bladder catheter. You were found to have a urinary tract infection which is being treated with a 7 day course of a drug called Cipro. Your PCP should be aware that Cipro affects your blooding thinning and we have reduced the dosage of your coumadin while your are taking Cipro. We have held your home doses of triamterene/HCTZ and gemfibrozil due to low blood pressure and liver abnormalities while in the hospital. You should talk to Dr. [Last Name (STitle) 10740], your PCP about restarting these medications. Please have a repeat chest CT in 3 months to evaluate A 3.5 mm right upper lung nodule. Please seek immediate medical attention if you have any chest pain, palpitations, shortness of breath, loss of consciousnesses, weakness, dysarthria, loss of sensation or any other change in your condition. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 10740] within 1 week following your hospitalization. Dr. [Last Name (STitle) 10740] can decide about restarting your home antihypertensive medications. Please follow up with orthopedics Dr. [Last Name (STitle) 363] ([Telephone/Fax (1) 3573]) on [2194-7-20]:00 AM at [Hospital Ward Name 23] building ([Hospital1 18] [Hospital Ward Name 516]) for further management of your spine fracture. Completed by:[2191-7-7]	[ "996.64", "274.9", "571.40", "733.00", "276.8", "806.29", "E888.9", "276.2", "E879.6", "585.9", "427.31", "403.90", "293.0", "276.52", "584.9", "284.1", "518.89", "276.1", "272.4", "250.40", "V44.3", "599.0" ]	icd9cm	[ [ [] ] ]	[ "86.11", "38.93" ]	icd9pcs	[ [ [] ] ]	12805, 12890	6397, 12204	334, 341	13069, 13088	4704, 6374	15176, 15711	3648, 3666		12387, 12782		12911, 13048		12230, 12364			13112, 15153				4369, 4685				3681, 4273																					274, 296									369, 3349									4288, 4352					3371, 3550	3566, 3632
25,882	199,138	51645	Discharge summary	report	Admission Date: [2128-7-13] Discharge Date: [2128-7-16] Service: MEDICINE Allergies: Penicillins / Clarithromycin / Doxycycline Attending:[First Name3 (LF) 425] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Right heart catheterization Placement of a Swan Ganz catheter History of Present Illness: 85 yo male with severe CAD s/p CABGx2, bioprosthetic MVR, ischemic CM with EF 25% who presents with worsening shortness of breath. At baseline he is able to ambulate 1 block, drive, do his own grocery shopping and perform all of his ADL's when his heart failure is compensated. Four weeks ago he noticed increasing SOB and productive cough. His PCP started him on a 3 day course of azithromycin and his symptoms initially improved. He then began noticing increasing DOE, SOB, PND and orthopnea. He denied sick contacts, fevers, chills but cough was productive of yellow sputum. He was taking all of his medications, there was no dietary indiscretion, and he did not notice any increase in his weight or LE edema. He denied any chest pain, chest tightness or palpitations. Over the past week he has spent most of his time in bed with poor appetite. He had difficulty even getting to the bathroom so called his PCP who told him to present to [Hospital1 18]. Past Medical History: 1. CAD s/p CABG in [2102] with a redo in [4-/2121] - stent to LAD in [2122-1-26]. 3. Mitral valve replacement porcine [2121] 4. CHF with an EF of less then 20%. 5. Pacemaker/DDD for post surgical complete heart block [2121] 6. Atrial fibrillation - Anticoagulation stopped secondary to hemoptysis in [2121-7-26]. 7. CRI (baseline creatinine of 2.4 to 2.9) 8. Prostate cancer. 9. L eye lens replacement 10. Dyslipidemia 11. Hypertension 12. Anemia: baseline HCT 38-40 Social History: The patient lives lone and wife died 4 years ago. He had sons in [Name (NI) ] and [Name (NI) 3844]. Tobacco, he has a fifteen pack year history. He quit greater then 40 years ago. Occasional alcohol. No elicits. Independent in all of his ADLS with no help at home. Family History: all siblings and both parents have CAD. Physical Exam: VS: T 97.6 BP 135/48 HR 61 RR 12 O2 98% [Female First Name (un) ] Gen: Elderly cachectic male in mild resp distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. MMM. Neck: Supple with JVP to ear at 45 degrees CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [3-30] HSM at LLSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mod labored, no accessory muscle use. Crackles at left base Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Liver is pulsatile Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: 136 93 77 ---------------< 124 3.6 33 2.7 CK: 26 MB: Notdone Trop-T: 0.06 Ca: 8.6 Mg: 2.7 P: 3.9 Dig: 1.1 proBNP: 9217 . 11.9 6.3 >----< 151 34.2 N:85.0 L:9.5 M:3.4 E:1.4 Bas:0.7 PT: 13.2 PTT: 27.9 INR: 1.2 . Trends: WBC: 6.3-11.5-6.6 Hct 34-30 Creatinine 2.7-2.6 ALT-15 AST-19 LD(LDH)-258* AlkPhos-126* Amylase-186* TotBili-0.8 . Micro: [2128-7-14] 12:14 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [2128-7-14]): [11-18] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS, CHAINS, AND CLUSTERS. . Swan line placement [2128-7-13] - COMMENTS: 1. Resting hemodynamics revealed an elevated mean PCPW of 13mmHg with an elevated PAP of 50/11. Cardiac index was low normal at 2l/min/m2. FINAL DIAGNOSIS: 1. Moderate-severe pulmonary hypertension. 2. Mild elevation of PCW 3. Mild RV diastolic dysfunction . [2128-7-13] CXR compared to [2128-3-29] IMPRESSION: Reexpanded left lower lobe with residual atelectasis in bilateral lung bases. No acute pulmonary process. . [2128-7-14] CT CHEST W/O CONTRAST: IMPRESSION: 1. Right lower lobe consolidation, new from [2128-3-25], likely representing aspiration pneumonia. 2. Right infrahilar mass lesion is not excluded on this non-contrast exam. There is a rounded, bulging contour of the medial right major fissure, which raises the possibility of a hilar mass. A non-contrast CT could be repeated after treatment, to assess for clearing in this region. Alternatively, bronchoscopy could be performed. 3. Secretions within the bronchus intermedius and right lower lobe bronchi. 4. Chronic left lower lobe consolidation, which may be related to aspiration. 5. Moderately severe cardiomegaly. Brief Hospital Course: Pt is a 85 yo male with severe CAD s/p CABGx2, bioprosthetic MVR, ischemic CM with EF 25% who presents with worsening shortness of breath. Hospital course by problem: . #) CAD: No symptoms or signs suggestive of an ischemic event at this time. First set of CE is neg and there was no need to cycle. We continued the patient's aspirin, statin, B-blocker and held his ACE-I for the first night while diuresis was attempted. The patient is on standing lasix 80 [Hospital1 ] at home which was held in favor of PRN IV lasix here. We restarted the ACEI and the Lasix prior to discharge. . #) Rhythm: Patient was in known afib at the time of admission. Per Dr. [Last Name (STitle) 2357] the patient's amiodrone was held. The patient is well rate controlled and a beta-blocker was continued, however at a lower dose. The patient is not anticoagulated because of CHF and risk of hemoptysis, which has happend to him in the past. . #) Pump: Patient appeared to be in both left and right sided heart failure on initial exam. A swan line was floated. Wedge pressure of 13 suggests no severe back pressure although he does have poor cardiac output. High PA pressures suggest pulm HTN of unclear cause. BNP elevated. The patient was given lasix to remove 500cc per day. . #) Pneumonia: An alternative explanation of the patient's pulmonary symptoms was pneumonia. A sputum gram stain revealed gram positive cocci in chains, pairs and clusters. He was treated with levofloxacin. . #) Hyperlipidemia: we continued on outpatient statin dose. . #) CRI: patient's creatinine was near baseline. . #) Anemia: Patient is on q2week epogen for this. On the 3rd day of admission the patient was given 20,000 units of epogen. Medications on Admission: amiodarone 200 mg qd Captopril 3.125 mg [Hospital1 ] carvedilol 6.25 mg qam and 12.5mg qpm digoxin 0.125 mg Monday and thursday Imdur 90 mg a day Lasix 80 mg qam and 80 mg qhs Lipitor 10 mg three times a week. Coreg 12.5mg qd Nexium 40mg qd Albuterol MDI Epogen q3wks Flonase Flovent MDI [Hospital1 ] Discharge Medications: 1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO twice a day. 3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal DAILY (Daily). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: - community acquired pneumonia - moderate-severe pulmonary hypertension - systolic CHF - atrial fibrillation: not coumadin candidate given hx hemoptysis Secondary: - CRI with baseline creatinine 2.4-2.9 - s/p Mitral valve repair porcine [2121] - CAD s/p CABG in [2102] with redo in [2121]. s/p stent to LAD in [2122] - prostate cancer - dyslipidemia - hypertension Discharge Condition: baseline. Ambulating, tolerating POs. Discharge Instructions: You came in with shortness of breath and nausea. We did not believe that you had a heart attack. We performed a right heart cath which suggested that you were in slight cardiac failure. We diuresed you and your symptoms improved. You also were noted to have a pneumonia so we treated you with antibiotics. Please take your medications as instructed. We made some minor adjustments as follows: - stopped your amiodarone - continue levoflox (antibiotic) for 10 days - decreased carvedilol to 3.125 [Hospital1 ] . Please followup with your PCP and cardiologist. Please also contact them or the emergency department if you experience worsening shortness of breath, abdominal pain, chest pain, palpitations, fever, weakness. We performed a chest CT scan which demonstrated a possible mass in the right side of your lung. This likely is secondary to your infection but we recommend a followup CT scan once your infection resolves to assess for interval change. Followup Instructions: . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 94291], M.D. Date/Time:[2128-8-10] 12:00 . Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2128-8-16] 1:45 Please have nothing to eat or drink 3 hour prior to your CAT SCAN . Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2128-8-16] 3:00 . Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3512] Date/Time:[2128-8-16] 3:30 .	[ "414.01", "486", "428.20", "428.0", "427.31", "403.90", "416.0", "585.9", "V42.2", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "37.21" ]	icd9pcs	[ [ [] ] ]	8170, 8228	4923, 5063	269, 333	8663, 8704	3140, 3140	9719, 10297	2142, 2183		7003, 8147		8249, 8642		6669, 6980		3953, 4900	8728, 9696								2198, 3121																					210, 231							5091, 6643		361, 1322					3156, 3936									1344, 1836	1852, 2126
8,260	112,588	17545	Discharge summary	report	Admission Date: [2147-2-10] Discharge Date: [2147-3-14] Service: HISTORY OF PRESENT ILLNESS: The patient was transferred from [Hospital 1474] Hospital with a left brain tumor seen on CT scan today. The patient is an 83 year old male with a six week decline in language and motor coordination. Family first noticed some word finding difficulty around [Holiday 1451] but more concerned about confusion of his orientation starting four to six weeks ago. The patient also has headache and gait nystagmus thought to be secondary to his tumor, carotid stenosis and possible transient ischemic attack. He talked with his primary care physician yesterday and told to come to [Hospital 1474] Hospital today for CT scan. Large left hemispheric mass with edema and shift was noted. MRA was done at [Hospital 1474] Hospital. The patient loaded with Dilantin and given 10 mg of Decadron. There is concern of aphasia and the patient is unable to provide history. History is per family. PHYSICAL EXAMINATION: Heart rate in the 60s, blood pressure 162/70, respiratory rate 12, oxygen saturation 98% in room air. In general, the patient was awake and alert and attentive to examination. Speech is fluent yet unintelligible. The patient is able to follow simple two steps commands. The pupils are 3.0 to 2.0 and reacted to light symmetrically. Extraocular movements are intact. He has a right facial droop. Tongue is midline, palate elevates symmetrically. There is increased tone in the lower extremities bilaterally. Strength is [4-24] throughout except right interosseous in hands, [3-25]. There is a question of a slight right sided drift. Reflexes 2+ in the knees and ankles and 3+ in the left upper extremity and 2+ in the right upper extremity. Chest is clear to auscultation bilaterally. Cardiac is regular rate and rhythm, no murmurs. The abdomen is soft, nontender, nondistended. On MR, there is a large 4.0 by 6.0 centimeter mass left parietal temporal frontal lobe, appears to arise from meninges, minimal in appearance by T1, edema on T2 and FLAIR that is enhancing with an irregular shape, no cystic component, midline shift with edema throughout left hemisphere. HOSPITAL COURSE: The patient was admitted to the hospital and started on q1hour neural checks. His blood pressure was maintained less than 160. He was started on Dilantin 100 mg three times a day and Decadron 8 mg q6hours for the edema. Fluid was restricted to one liter. The patient was admitted to the Intensive Care Unit for close attention to all these things and availability of wider range of medicinal means to control blood pressure. Early on while in the Intensive Care Unit, the patient became delirious and concern of ethanol withdrawal was addressed. The patient was given Thiamine and Folate as well as Ativan p.r.n. The patient's operative procedure was initially delayed because there was concern the patient may have severe heart disease and arterial disease. The patient was seen by Cardiology but in the end, angiography and further intervention was held due to the feeling that the meningioma that the patient had was more important. As the patient's surgical procedure approached, the patient had an acute myocardial infarction, being ruled in with cardiac enzymes, which put off his surgery for some time while the patient was treated and allowed to improve post myocardial infarction. It was the impression of the neurosurgical team to transfer the patient to the floor post myocardial infarction for a period of convalescence until such time that he was able to go to surgery. However, the patient developed fever and was determined to have positive blood cultures and positive sputum, sputum positive for gram negative rods, blood for gram positive cocci in pairs and clusters. The patient was started on Vancomycin and Levofloxacin. The patient was then confirmed to have pseudomonas in his sputum. His blood had coagulase negative Staphylococcus and his urine had coagulase negative Staphylococcus. He also had a catheter tip with fifteen colonies of bacteria growing. His antibiotics were changed to Vancomycin, Ciprofloxacin and Ceftazidime. The patient remains in the Intensive Care Unit while on antibiotics and allowed to improve over time with regards to his myocardial infarction and pneumonia. While waiting for the surgery, the patient's mental status continued to decline and the patient appeared to become very depressed. Psychiatry was consulted. The patient was determined not to be an appropriate figure to make his own medical decisions at that time and that responsibility was left to the family. Finally on [2147-3-2], the patient went to the operating room where the left frontotemporal craniotomy was performed and resection of his meningioma was accomplished. The patient tolerated the procedure well and was returned to the Intensive Care Unit postoperatively. The patient had a slow recovery time as he remained very confused and somewhat somnolent postoperatively. The patient did, however, improve somewhat and his activity was advanced and he was able to sit up in a chair and subsequently began to walk with assistance. He has persistently failed swallow studies but at the family's request, he has been allowed to take small amounts of food by mouth. The patient is now transferred to the regular floor. He is receiving physical therapy and is being screened for rehabilitation and the patient will likely go to a rehabilitation facility. He will need to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1327] in one to two weeks. The patient may shower and observe regular activity. Prior to discharge, he will be evaluated again by speech and swallowing. Decision was to be made whether or not to give him a percutaneous endoscopic gastrostomy tube prior to discharge. Also, postoperatively, the patient suffered from a ventricular tachycardia for which cardiology was consulted. The patient was treated with Diltiazem drip and finally with Amiodarone 800 mg once daily times one week, 400 mg once daily times two months and 200 mg once daily thereafter. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern4) 8358] MEDQUIST36 D: [2147-3-13] 09:09 T: [2147-3-14] 19:22 JOB#: [Job Number 48947]	[ "038.19", "427.89", "482.1", "225.2", "599.0", "427.31", "410.71" ]	icd9cm	[ [ [] ] ]	[ "01.59", "43.11", "01.18", "96.6" ]	icd9pcs	[ [ [] ] ]														2246, 6457																							1039, 2228																	111, 1016
16,796	185,115	45546	Discharge summary	report	Admission Date: [2174-10-17] Discharge Date: [2174-10-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2605] Chief Complaint: large melanotic stool, nausea, vomiting, decr po intake and abd pain Major Surgical or Invasive Procedure: EGD [2174-10-18] History of Present Illness: 82 year old female with dementia, hx of CVA with right-sided weakness, progressive chronic kidney ds (BUN 90, Cr 2.4, not a candidate for Dialysis as per Dr. [Last Name (STitle) 1366], and gout who presents for evaluation of subacute abdominal pain, bilateral knee pain and hx of falls. This weekend, the pt had acute worsening of abd pain with n/v, myalgias, decr po intake and trace blood in stool. She also had orthostasis. . In ED, afebrile, VSS with mild hypertension and no tachycardia, inconsistent abd exam. The plan established with the geriatrics fellow was the discharge the patient back to [Hospital 100] Rehab and the patient was to have an outpatient EGD. 1.5L of normal saline was given. However, prior to departure, the patient had a large melanotic stool. A hematacrit was redrawn and showed a drop of 3pts. Her vital signs remained stable, however. She received 1.5L IVF in ED. Past Medical History: Irritable Bowel Syndrome Chronic anemia Constipation CVA with residual R-sided defecits Hypertension Gout h/o lower GI bleed (could not find old records to clarify further) Dementia Chronic acidosis Social History: [Hospital 100] rehab resident. Denies alcohol or tobacco use. Family History: NC Physical Exam: VS: T 97.6 HR 62 BP 165/49 RR 17 Sat 97-98% on RA Gen: Pleasant eldery female in NAD, lying flat, speaking in full sentences. HEENT: NC/AT PERRL slight anisocoria but both reactive, EOMI, no scleral icterus, mucous membranes moist without lesions, oropharynx clear CV: RRR S1 and S2 audible, with kyphosis so difficult to hear heart sounds Pul: CTAB anterior lung fields Abd: Tender on deep palpation of right lower and left lower quadrants. Positive bowel sounds, no masses felt. No rebound, no guarding. Ext: No cyanosis/clubbing/edema. 1+ peripheral pulses bilaterally. Neuro: tangential in conversation, able to answer questions, follow commands. Did not walk pt to assess gait. Pertinent Results: [2174-10-17] 11:00AM WBC-7.4# RBC-2.86* HGB-9.5* HCT-29.6* MCV-104* MCH-33.3* MCHC-32.1 RDW-15.7* [2174-10-17] 11:00AM NEUTS-73* BANDS-0 LYMPHS-23 MONOS-3 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2174-10-17] 11:00AM PLT COUNT-337 [2174-10-17] 11:00AM GLUCOSE-112* UREA N-78* CREAT-2.2* SODIUM-141 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-20* ANION GAP-16 [2174-10-17] 11:00AM CALCIUM-9.0 PHOSPHATE-2.7# MAGNESIUM-1.5* [2174-10-17] 11:00AM ALT(SGPT)-28 AST(SGOT)-33 ALK PHOS-62 AMYLASE-31 TOT BILI-0.3 [2174-10-17] 11:00AM LIPASE-29 [2174-10-20] 06:30AM BLOOD WBC-5.6 RBC-4.15* Hgb-13.2 Hct-39.2 MCV-95 MCH-31.9 MCHC-33.7 RDW-17.8* Plt Ct-316 [2174-10-20] 06:30AM BLOOD Plt Ct-316 [2174-10-20] 06:30AM BLOOD Glucose-87 UreaN-32* Creat-1.6* Na-145 K-4.0 Cl-115* HCO3-17* AnGap-17 [2174-10-20] 06:30AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.4* CT Abdomen: 1. Thickening of the wall stomach antrum and the first part of the duodenal. This could be consistent with gastro-duodenitis. There is no evidence of bowel obstruction or appendicitis. 2. Stable left adrenal adenoma. 3. Cholelithiasis without evidence of cholecystitis. EGD: evidence of gastritis and duodenitis with no active bleeding. Brief Hospital Course: # GI Bleeding: on admission, the pt had anemia in the setting of melena and guaiac positive stool that was likely [2-23] GI bleed. All NSAIDs and aggrenox were held. She was admitted to the ICU, where she required transfusion of 4 units PRBCs to reach HCT of 37-38. She was evaluated with EGD that demonstrated gastritis and duodenitis, with no evidence of active bleeding. This was likely [2-23] NSAID use, and explains the pt's abdominal pain. Treatment was started with protonix 40mg [Hospital1 ] and carafate 1gm qid. She was transferred to the medical [Hospital1 ] for ongoing care, where her HCT was observed to be stable and her abdominal pain improved. She will need to continue protonix and carafate for at least 6 weeks after discharge from the hospital, and perhaps longer depending on her symptom control. . # Orthostasis: on admission, she had orthostatic hypotension likely due to dehydration rather than acute bleeding. Pt reports very poor po intake over last several weeks. She was normotensive during her hospital stay, and was hydrated with normal saline until clinically euvolemic. At discharge, she is eating and drinking well and there is no evidence of dehydration. . # Renal: she has chronic renal insufficiency that remained at baseline during her admission. . # Dementia: she has dementia of the Alzheimer's type. She was conversational and attentive during her admission, with the exception of 2 episodes of delirium that resolved after treatment with haldol. At d/c, the pt is at baseline cognitive function, is attentive and conversational. . # Code status was DNR/DNI during this admission Medications on Admission: Aggrenox 25-200 1 tab qd Atenolol 25mg po qd Atorvastatin 40mg po qd Ca-Vit D 500mg [Hospital1 ] Vit B12 1000mcg Darbepoetin alfa 25mcg qWed 8:30am sc Docusate Vit B12 qMonth Darbepoetin 25mcg qWednesday Donepezil 5mg po qd Folic Acid 1mg po qd Lansoprazole 30mg po qd Senna 2tab qhs Sodium Bicarb 650mg po bid Traodone 50mg po qhs:prn Nephrocaps qd Oxycodone 2.5mg po q6:prn Loperamide 2mg q4:prn APAP 650 q6:prn Discharge Medications: Atenolol 25mg po qd Atorvastatin 40mg po qd Ca-Vit D 500mg [Hospital1 ] Vit B12 1000mcg Darbepoetin alfa 25mcg qWed 8:30am sc Docusate Vit B12 qMonth Donepezil 5mg po qd Folic Acid 1mg po qd Senna 2tab qhs Sodium Bicarb 650mg po bid Trazodone 50mg po qhs:prn Nephrocaps qd Oxycodone 2.5mg po q6:prn Loperamide 2mg q4:prn APAP 650 q6:prn Protonix 40mg PO BID Carafate 1gm PO QID Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: 1. Duodenitis and gastritis 2. Dehydration 3. Chronic renal insufficiency 4. Dementia of the Alzheimer's type Discharge Condition: Stable to go to [Hospital3 ] facility. At baseline mental status, eating and drinking, vital signs normal, no evidence of active bleeding. Discharge Instructions: You are being discharged after treatment for gastritis and duodenal ulcer with GI bleeding. Please take all medications as prescribed. Do not take aspirin or aggrenox unless you are instructed to resume these medications by your doctor. Call your doctor or present to the ED if you have uncontrolled pain, nausea and vomiting, bleeding, bloody stool, increased weakness, fever, chills, or other concerning symptoms. Followup Instructions: Follow-up with your primary care doctor ([Location (un) ],[Doctor First Name ] J. [Telephone/Fax (1) 14943]) in 1 week to check your blood count. Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 435] Date/Time:[2174-11-24] 4:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2608] MD, [MD Number(3) 2609]	[ "274.9", "401.9", "593.9", "276.5", "332.0", "532.40", "285.1", "535.50", "331.0", "294.10" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]	6136, 6201	3612, 5261	333, 355	6355, 6501	2344, 3589	6968, 7463	1618, 1622		5730, 6113		6222, 6334		5287, 5707			6525, 6945								1637, 2325																					225, 295									383, 1296														1318, 1518	1534, 1602
14,843	111,975	21225	Discharge summary	report	Admission Date: [2196-5-3] Discharge Date: [2196-5-16] Date of Birth: [2131-11-25] Sex: M Service: [Doctor First Name 147] Allergies: Heparin Agents Attending:[First Name3 (LF) 148] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 64 year old male with extensive past medical history tranferred from [Location 56198]hospital with pancreatitis. The pateient was in his usual state of health unitl 2 weeks prior to admission. He began to experience nausea vomitting and a diarrheal illnes as well as increased abdominal girth. He denied any pain, hematemesis, dysuria, hematuria, weight loss or similar epsisodes. He had instance of atrial fibrillation at the outside hospital as well bloody stools and was on TPN. He was placed on Imipenem and blood cultures were negative times 3. A CT scan on [4-29] demonstrated pancreatitis with surrounding small bowel inflammation. Past Medical History: 1. hypertension 2. Alcohol abuse No past surgeries Social History: alcohol Family History: Negative for cancer or coronary artery disease Physical Exam: Physical exam on admission was as follows: Temperature 102.2, Pulse 123, Blood pressure 184/75, Respirations 26, Pulmonary artery pressure 33/19, Central venous pressure 7, ABG 7.50/30/69/24/0 on Room air. General: alert and oriented times three in No apparent distress but patient was tremulous Neuro: cranial nerves 2 through 12 were grossly intact Neck: no jugular venous distention, no bruits Cardiac: regular rate and rhythm, no murmurs Lungs: Clear to ausculation bilaterally Abdomen: distended, nontender, tympanetic, no hernias, rectal exam guiac positive, NG output light green Extremities: palpable pulses bilateraly An EKG showed normal sinus rhythm Pertinent Results: ---[2196-5-4] CT abdomen: 1. Small, bilateral pleural effusions with reactive atelectasis. 2. Large amount of peripancreatic inflammation which extends from the transverse mesocolon to the left pericolic gutter. No distinct localized collections are seen. The body and tail of the pancreas appeared to enhance homogeneously. There is heterogeneous enhancement of the head of the pancreas. 3. Ascites and free-fluid within the pelvis. ---[2196-5-4]: echo: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There is a brief diastolic indentation of the right ventricular outflow tract without other evidence of right ventricular collapse or tamponade. ---CT abdomen [2196-5-15]: The pancreas remains edematous with a persistent slight heterogeneity of enhancement in the pancreatic head, without interval worsening. There is homogeneous enhancement in the body and tail of the pancreas. There are persistent fluid collections in the lesser sac and in the transverse mesocolon, as well as posterior to the gastroesophageal junction. Fluid is again noted tracking into the left paracolic gutter. There is no gas within the fluid collections. The pancreatic duct is not dilated. There is no intrahepatic or extrahepatic biliary dilatation. The liver, gallbladder, spleen, small bowel and colon appear unremarkable. There is fluid obscuring the right adrenal gland. The left adrenal gland is unremarkable. Bilateral renal cysts are again noted. Brief Hospital Course: The patient was admitted. He was placed on an amiodirone drip, and lopressor for atrial fibrillation. he was made NPO, and an NG tube was in place. His electrolytes were monitored closely and repleted as needed. He was placed on CIWA protocol for alcohol withdrawal. He was also continued on TPN. He was continued on his antibotics, which were discontinued on [2196-5-5]. He continued to be stable until hie had a temperature spike non [2196-5-7]. At this time it was noted that blood cultures and urine cultures taken to date were negative. Imipenem was restarted on hospital day 6 ([2196-5-8]). His NG tube was removed on Hospital day 7. Patient remained stable but had an illeus and was continued on TPN. Addiction services was consulted, but the patient had no interest in rehab after hospitalization. He was started on clears on Hospital day 9. Nutrition was also involved and suggested continuing TPN. The patient had a continuing benigh exam on Hospital day 11 and was passing flatus on a clear diet and on hospital day 12, the patient was changed to a regular diet and began taking his medications by mouth. He had a CT on [5-15] that wsa much improved. The patient was discharged home on Hospital day 14 ([2196-5-16]) in stable condition. Medications on Admission: -Atenolol 50 mg qd -Hydrocholorthiazide 25 mg once daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 4. MEDICAL ALERT BRACELET Have a medialert bracelet made stating "Heparin Antibodies - do not use heparin" and wear bracelet. Discharge Disposition: Home Discharge Diagnosis: pancreatitis PMH: HTN, ETOH abuse PSH: none Discharge Condition: good Discharge Instructions: Go to an Emergency Room if experience new and continuing nausea, vomiting, fevers (>101.5), chills. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 1231] Call to schedule appointment	[ "577.0", "560.1", "303.90", "401.9", "780.6" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	5869, 5875	4052, 5336	312, 319	5963, 5969	1880, 4029	6382, 6531	1132, 1180		5443, 5846		5896, 5942		5362, 5420			5993, 6359								1195, 1861																					254, 274									347, 1014														1036, 1091	1107, 1116
51,180	170,553	37518+37519	Discharge summary	report+report	Admission Date: [2174-6-25] Discharge Date: [2174-6-29] Date of Birth: [2108-5-14] Sex: F Service: MEDICINE Allergies: Banana / Melon Flavor / Avocado / IV constrast / Lorazepam Attending:[Last Name (un) 7835] Chief Complaint: Urinary Tract Infection, Developing urosepsis Major Surgical or Invasive Procedure: Nephrostomy tube change [2174-6-28] Flexible Sigmoidoscopy with cautery History of Present Illness: MICU HPI: This is a 66 year old female with a history of stage IV cervical cancer presenting with fever and urinary tract infection. Her history of cervical cancer includes chemotherapy and radiation therapy; her last dose of chemotherapy was in [2173] - her radiation therapy has left her with multiple complications including radiation colitis, a right ureteral stricture, and cystitis. Urology has been consulted for this stricture and had a nephrostomy placed last year; as a consequence, she has developed multiple urinary tract infections, including pan-sensitive E. Coli and Klebsiella. She takes macrobid for urinary tract infection suppression. Her urologist has been consulting for the possibility of a right nephrectomy in order to prevent recurrent urinary tract infections and as the definitive treatment for her stricture. Pt started EBRT [2173-2-19]. She was to start chemo [2173-2-25] but Cr was 2.3, she had b/l percutaneous nephrostomy tubes [2173-2-26] w/ improvement in Cr. Pt received 1st weekly cisplatin 40mg/m2 [2173-3-4]. She received #2 [2173-3-10], #3 [2173-3-15]. Her most recent admission in [2174-5-15] was for severe diarrhea - at times bloody - which was attributed to radiation colitis after colonoscopy was performed. She was started on anti-spasmodics; she also had a urinary tract infection during that admission for which she was treated with ceftriaxone. On the morning of this admission, she developed a fever to 102 - she had no other symptoms. She has been anorexic for the past several weeks with decreased PO intake. Denies dizziness or lightheadedness. She denies dysuria; her nephrostomy output has been normal and has not changed in color or output. Normal frequency. Denies cough, chills, sweats, chest pain, abdominal pain, nausea, or vomiting. In the emergency room, she was slightly hypotensive with BPs around the 90s - she received 2 L of fluid with improvement. A troponin was checked which was elevated at .23 with no EKG changes representative of ischemia. Her sodium was low and potassium was also depressed; she received potassium. She was transferred to the MICU given her transient hypotension. Floor HPI: Patient is a 66 year old female with a history of stage IV cervical cancer, currently inactive not on chemo-radiation, with history of nephrostomy tube for ureteral stricture with multiple prior admissions for urosepsis/UTIs with resistant GNRs who was admitted with fever and urinary tract infection. She was hospitalized in [2174-5-15] for diarrhea - at times bloody - found to be [3-17] radiation colitis based on colonoscopy. Also with UTI treated with Ceftriaxone during that admission (Klebsiella pan-sensitive). On the morning of admission, patient febrile 102 but asymptomatic otherwise. Denies dizziness or lightheadedness. She denies dysuria; her nephrostomy output has been normal and has not changed in color or output. Normal frequency. Denies cough, chills, sweats, chest pain, abdominal pain, nausea, or vomiting. In the MICU she was hemodynamically stable and never required pressors. Her UTI was treated with IV Ceftriaxone with defervescence. Additionally she was found to have a 10 point hct drop and a bowel movement with maroon colored stools. She was transfused 2 units PRBCs and she had no additional bloody bowel movements and her hct remained stable. Per GI consult, when she was last seen in [Month (only) 547] decision was made to repeat Flex Sigmoidoscopy with electro-cauterization of bleeding sites of proctitis. Given repeat episode of bloody diarrhea GI indicated she will have a Flex-Sig with cautery after patient transferred to the floor. Additional issues that were discussed included removal of nephrostomy tube. Patient and family frustrated with Nephrostomy and feel it is causing recurrent UTIs and sepsis, she would like it removed. Dr. [Last Name (STitle) ] indicated to patient that the only way to DC Nephrostomy tube would be to complete a right nephrectomy. The patient is agreeable with this plan. Patient would like to see Urology and Uro-Surgery while she is an inpatient. Patient also with history of pan-hypopituitarism for which she is on chronic Prednisone. She was not treated with Vit-D/Ca in the past and now has new pelvic fractures. Past Medical History: -Cervical cancer: followed by Dr. [Last Name (STitle) 4149], discovered after [1-23] post-menopausal vaginal bleeding/hematuria and was found to have a cervical mass w/ invasion of the posterior bladder wall. Biopsies revealed a locally advanced, stage [Doctor First Name ] squamous cell cervical carcinoma. Underwent nephrostomy tubes [2-23] for hydronephorosis. She initiated radiation therapy of pelvis on [2173-2-19] with her last session [2173-4-28]. She completed 6 sessions of weekly cisplatin on [2173-4-12]. -Status post resection of a benign pituitary adenoma at age 21 at [Hospital1 2025] with resultant hypopituitarism; she was previously followed at [Hospital1 2025], needs endocrine f/u (hasn't seen in some time) -Multiple UTIs since nephrostomy tube placement in [2172]: organisms including ENTEROCOCCUS (not VRE), MRSA, E.COLI (Pan-sensative) -Osteoporosis -Multiple food allergies Social History: She grew up in the West End of [Location (un) 86]. She lives in [Location 4628], MA with her husband [Name (NI) ]. They have two daughters, her eldest [Name (NI) 1785] lives nearby, her [Name (NI) 1685] daughter [Name (NI) 6480] lives in New [Name (NI) ]. Her sister from [Name (NI) 4565], [Name (NI) ], is back in [State 4565]. [Known firstname ] hopes to travel to [State 4565] later this spring. The patient smoked approximately one-third to [2-14] pack per day for 33 years, recently quitting. She had one alcoholic beverage daily until her illness. Family History: - [Name (NI) 1094] brother died of leukemia at age 64 in [2164]. Pt was a match, donated peripheral blood stem cells. Both parents had heart disease. Physical Exam: MICU Green Admission Exam Heart rate of 90 with BP of 108/54, RR of 12, O2 sat of 95% on 2 L, afebrile Gen: Caucasian female, in no apparent distress Cardiac: nl s1/s2 RRR no murmurs appreciable Pulm: lungs clear bilaterally Abd: soft, nontender, nondistended, no suprapubic tenderness Ext: no edema noted, nephrostomy tube draining slightly cloudy urine Rectal: Guiaic positive stool Transfer Exam VS - Afebrile, 130s/90s, 90s, 14, 98% RA GENERAL - Well-appearing, pleasant 66 yo F who appears comfortable, appropriate and in NAD HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Lungs are clear to ausculatation bilaterally, moving air well and symmetrically, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality without murmurs, rubs or gallops ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, no suprapubic tenderness. Right nephrostomy tube in right flank is C/D/I without surrounding erythema, exudate or tenderness, nephrostomy bag with pink tinged urine. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-18] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Discharge Exam: Afebrile, VSS GENERAL - Well-appearing, pleasant HEENT - NC/AT, PERRL, MMM, OP clear LUNGS - Lungs are clear to ausculatation bilaterally, moving air well and symmetrically HEART - RRR, S1-S2 clear and of good quality without murmurs, rubs or gallops ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, no suprapubic tenderness. Right nephrostomy tube in right flank is C/D/I without surrounding erythema, exudate or tenderness, nephrostomy bag with clear-yellow urine. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses Pertinent Results: Admission Labs [2174-6-25] 07:00PM BLOOD WBC-8.9 RBC-2.75* Hgb-8.2* Hct-25.0* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.3 Plt Ct-337 [2174-6-25] 07:00PM BLOOD Neuts-91.1* Lymphs-5.0* Monos-3.2 Eos-0.3 Baso-0.3 [2174-6-26] 04:38AM BLOOD PT-14.4* PTT-31.1 INR(PT)-1.3* [2174-6-25] 07:00PM BLOOD Glucose-90 UreaN-9 Creat-1.1 Na-126* K-2.6* Cl-89* HCO3-21* AnGap-19 [2174-6-26] 04:38AM BLOOD ALT-13 AST-24 LD(LDH)-154 CK(CPK)-130 AlkPhos-121* TotBili-0.6 [2174-6-25] 07:00PM BLOOD Calcium-8.0* Phos-1.7* Mg-1.7 [2174-6-25] 07:00PM BLOOD Lactate-1.9 Troponin Trend [2174-6-25] 07:00PM BLOOD cTropnT-0.23* [2174-6-26] 04:38AM BLOOD CK-MB-3 cTropnT-0.21* [2174-6-27] 06:00AM BLOOD CK-MB-3 cTropnT-0.18* Hct Trend: [2174-6-26] 04:38AM BLOOD WBC-6.4 RBC-2.74* Hgb-8.0* Hct-24.6* MCV-90 MCH-29.4 MCHC-32.7 RDW-14.9 Plt Ct-248 (received 2 units PRBCs) [2174-6-26] 08:18AM BLOOD Hct-29.4* [2174-6-27] 06:00AM BLOOD WBC-7.0 RBC-3.37* Hgb-9.6* Hct-29.8* MCV-88 MCH-28.6 MCHC-32.4 RDW-16.1* Plt Ct-255 [2174-6-27] 02:45PM BLOOD Hct-25.7* (Flex Sigmoidoscopy with cautery) [2174-6-28] 06:09AM BLOOD WBC-5.2 RBC-2.80* Hgb-8.2* Hct-25.3* MCV-90 MCH-29.4 MCHC-32.6 RDW-16.1* Plt Ct-212 [2174-6-28] 03:14PM BLOOD Hct-25.9* [2174-6-29] 05:45AM BLOOD WBC-5.1 RBC-2.93* Hgb-8.4* Hct-26.2* MCV-89 MCH-28.6 MCHC-32.0 RDW-15.4 Plt Ct-241 Discharge Labs: [2174-6-29] 05:45AM BLOOD WBC-5.1 RBC-2.93* Hgb-8.4* Hct-26.2* MCV-89 MCH-28.6 MCHC-32.0 RDW-15.4 Plt Ct-241 [2174-6-29] 05:45AM BLOOD Glucose-122* UreaN-7 Creat-0.8 Na-136 K-3.9 Cl-100 HCO3-22 AnGap-18 [2174-6-29] 05:45AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.5* Microbiology: - UCx Yeast - Repeat UCx NGTD - BCx NGTD x2 Reports: CT Head with contrast: [2174-6-29] PRELIM - No mass, edema or hemorrhage - Age related cerebral atrophy - No change from prior studies CXR [2174-6-25] IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: 66 year old female with a history of stage IV cervical cancer, not currently treated with chemo-radiation, with history of nephrostomy tube for ureteral stricture s/p radiation with multiple prior admissions for urosepsis/UTIs including resistant GNRs, also with history of radiation proctitis and GI bleeds who was admitted to MICU with fever and urinary tract infection concerning for sepsis also found to have GIB and 10 point hct drop. # UTI- Chronic UTIs related to nephrostomy tube. History of resistant organisms in past but recent Klebsiella pan-sensitive treated with Ceftriaxone [5-26]. UCx on this admission did not grow a pathogen but given her complicated history with recurrent episodes of sepsis, indwelling nephrostomy bag and fever on arrival to the ED she was treated with Ceftriaxone. After initiation of antibiotics she defervesced and never showed signs of sepsis. Negative UCx and BCx returned and she hemodynamically stable 48 hours after last fever so her antibiotic regimen was changed to Ciprofloxacin 500mg PO BID to complete a 14 day course. Her Neprhostomy tube was changed on [2174-6-28] and was uncomplicated. She wants a nephrectomy for definative treatment and final removal of nephrostomy tube. Patient will have outpatient follow up with Dr. [Last Name (STitle) ] and Uro-surgeon Dr. [Last Name (STitle) 3748] [Name (STitle) ]: Outpatient nephrectomy and removal nephrostomy. She will also follow up with ID as an outpatient regarding change in suppressive antibiotics given recent UTIs with Macrobid resistance. # Acute Blood Loss Anemia - Hct drop of 10 on admission from baseline and guiac positive stool in setting of patient with known radiation colitis/proctitis suggesting slow ooze from LGI track. Received 2 units PRBCs in the MICU and Hct remained stable therafter. Gastroenterology was consulted and completed a Flex Sigmoidoscopy with cautery on [2174-6-27]. She had loose stools with clots following completion of procedure but hematocrit remained stable and without tachycardia or hypotension. # Diarrhea: Patient with persistant loose stools following Flex Sig. Diarrhea likely related to GI ooze from practitis/colitis and recent cautery procedure, though hct stable so not actively loosing blood. She had no leukocytosis or fevers so C.Diff unlikely. Did order C.Diff on morning of discarge though patient no longer having loose stools so could not give a sample. Instructed patient to call her PCP or [Date Range ] if loose stools restart. Patient taking Ciprofloxacin anyway which would cover most enteric pathogens. # Headaches: Has been having hedaches for some time as an outpatient. During admission with persistant bilateral frontal headaches, severe [9-23] which was refractory to APAP-Caff-Butalbital. Only treatment which helped was low dose Dilaudid. Spoke to outpatient H/O fellow who reports HAs have been increasing in frequency over past 2 months. While rare for cervical cancer to metastasize to brain, favored caution and obtained CT Head with contrast to evaluate for a mass since patient cannot tolerate MRI. Has documented allergy to contrast on her medical record though patient has had multiple CTAs in our system and never had a reaction. Despite that she was pre-medicated prior to CT and received contrast load without reaction. # Troponin elevation - Likely demand from UTI and peri-sepsis. Troponin downtrending and CK-MB flat. Cardiology saw patient felt no acute ischemia/infarct and most likely demand in origin. Patient denies and chest pain or SOB type symptoms. Trops downtrended and she had no events on telemetry # Hyponatremia: Hypovolumic hyponatremia, resolved after IVFs # Stage IV cervical cancer - Chronic, inactive without current chemoradiation treatment. S/p chemoradiation with ureteral stricture and colitis/proctitis. Per report, Dr. [Last Name (STitle) 4149] aware of patient and in agreement with treatment plan. Recent CT scan showed no recurrence. # Known Pelvic Fractures: Appeared stable on imaging. Has chronic pelvic pain due to this and is on hydromorphone at home for the pain. Independent ambulation/ADLs. Continued on opiates for pain control. Started treatment with Vitamin D and Calcium while inpatient. Given known osteoporosis and pelvic fractures would recommend Bisphosphonate therapy to outpatient providers. # Pan Hypopituitarism. Hx benign pituitary adenoma s/p resection many years ago. Was on levothyroxine and low dose predisone for years as a result of hypopituitarism that followed. Continued Levothyroxine Sodium 125 mcg PO/NG DAILY and PredniSONE 5 mg PO/NG DAILY TRANSITIONAL ISSUES: - Follow up final CT Head read: Prelim no masses - Consider bisphosphonates as an outpatient - Patient discharged without obtaining C.Diff sample given no more loose stools. If patient begins having loose stools then would recommend C.diff testing - Patient will have outpatient follow up with Dr. [Last Name (STitle) ] and Uro-surgeon Dr. [Last Name (STitle) 3748] [Name (STitle) ]: Outpatient nephrectomy and removal of nephrostomy tube - Outpatient Infectious Diseaseto decide suppressive therapy given last UCx resistant to Nitrofurantoin and risk of resistance with Cipro suppressive therapy - Follow up pending urine and blood cultures Medications on Admission: ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s) by mouth qweek - No Substitution HYDROMORPHONE - 2 mg Tablet - [2-14] Tablet(s) by mouth every four (4) hours as needed for pain LEVOTHYROXINE - 125 mcg Tablet - one Tablet(s) by mouth daily LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - 2.5grams topically to PORT site as directed as needed for prior to accessing PORT NITROFURANTOIN MONOHYD/M-CRYST - 100 mg Capsule - 100mg Capsule(s) by mouth at bedtime OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - [2-14] Tablet(s) by mouth Q6 hours and QHS as needed for anxiety, insomnia POTASSIUM CHLORIDE [KLOR-CON] - 20 mEq Packet - 2 Packet(s) by mouth twice a day PREDNISONE - 5 mg Tablet - one Tablet by mouth daily Discharge Medications: 1. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vitamin D3 2,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for Pain: You should not drive or drink while taking this medication. Disp:15 Tablet(s) Refills:0 5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:30 Capsule(s) Refills:0 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. potassium chloride 20 mEq Packet Sig: Two (2) packets PO twice a day. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Active: - Urinary Tract Infection - Colitis-Proctitis, Radiation related - Ureteral stricture s/p nephrostomy tube Chronic: - Cervical Cancer - Chronic UTIs - Pan-Hypopituitarism Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Ms. [Known lastname 5936], It was a pleasure treating you during this hospitalization. Your were admitted to [Hospital1 69] because of a urinary tract infection and concern for sepsis. You were initially admitted to the medical ICU for monitoring. You were stable and so you graduated to the medical floor. You were treated with IV antibiotics which were changed to by mouth medications after improvement in blood pressure and with return of cultures. You also had some bleeding from your colon/rectum and had a flexible sigmoidoscopy by gastroenterology. Cautery during the procedure was completed to stop the bleeding, this was successful. You are being discharged in improved condition with plan to follow up with your primary care physician, [Name10 (NameIs) ] and infectious disease doctor. The following changes to your medications were made: - START Ciprofloxacin 500mg by mouth twice daily until [2174-7-8] - START Benzonatate (Tessilon Pearls) by mouth three times a day as needed for cough - START HYDROmorphone (Dilaudid) 1-2 mg by mouth every 4 hours as needed for pain. You should not drive or drink alcohol while taking this medication. - No other changes to your medications were made, please continue taking as previously prescribed. Other Instructions: - If you begin having loose stools, please see your primary care physician or [Month/Day/Year ] to have a C.Diff test completed. - You should discuss with your Infectious Disease doctor changing Macrobid to a different antibiotic for suppression of urinary tract infections. Followup Instructions: Department: GYN SPECIALTY When: [Month/Day/Year ] [2174-7-1] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], [First Name3 (LF) ] [Telephone/Fax (1) 5777] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: MONDAY [2174-7-4] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6887], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: SURGICAL SPECIALTIES When: THURSDAY [2174-7-7] at 8:30 AM 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 INFECTIOUS DISEASE DEPARTMENT [2174-7-15] 03:00p Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 111] ([Telephone/Fax (1) 17490] LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT ID WEST (SB) - Please discuss with your Infectious Disease Doctor about switching antibiotics from Macrobid to a different antibiotic to control urinary tract infections We are working on a follow up appointment with Dr. [Last Name (STitle) 4149] in the next 9-15 days. You will be called at home/rehab with the appointment. If you have not heard within 2 business days or have questions, please call [Telephone/Fax (1) 32192] Admission Date: [2174-7-3] Discharge Date: [2174-7-6] Date of Birth: [2108-5-14] Sex: F Service: MEDICINE Allergies: Banana / Melon Flavor / Avocado / IV constrast / Lorazepam Attending:[First Name3 (LF) 12131] Chief Complaint: Lower GI bleed/chest heaviness Major Surgical or Invasive Procedure: None History of Present Illness: EAST HOSPITAL ONCO-MEDICINE ATTENDING ADMISSION NOTE Date: [2174-7-3] Time: 03:30 The patient is a 66 year old female with a PMHx of stage IV cervical cancer, not currently treated with chemo-radiation, with history of nephrostomy tube for ureteral stricture s/p radiation with recent revision [2174-6-27], also with history of radiation proctitis and GI bleeds who was recently admitted to MICU with fever and urinary tract infection concerning for sepsis also found to have GIB requiring blood transfusion and endoscopy with cautery; who now presents with dark stools and fatigue. She reports 3 episodes of dark diarrhea since last night, constant [5-24] dull, pleuritic chest pain over the past day, which she attributes to "anxiety". She reports having an intermittent dry cough over the past two weeks, which is improved with benzonatate. She also reports pain "neuropathy" in her legs, which has been progressively worsening over the past several weeks. She endorses urinary frequency. She denies N/V, dysuria, hematuria, BRBPR, numbness/tingling of the arms/shoulders, exertional symptoms, palpitations, shortness of breath or dysuria. On review of OMR, she was admitted to ICU/Medicine service here [Date range (3) 84259] for lower GI bleed in relation radiation colitis, for which she received 2 units PRBCs in the MICU; GI performed a flex sig w/ cautery on [2174-6-27], w/ stable hematocrits thereafter. VS: 97.6 90 110/52 16 99% PX: a+ox3, 20g piv, port a cath-accessed; guiac positive stool Studies: WBC 7.5, HCT 23.9, PLT 302; Na: 126; U/A: RBC 19, WBC 52, Bact Few, Yeast Mod, Epi <1; Trop-T: 0.12 (stable from prior); D-Dimer: 2745; AP: 160, Tb: 0.4, Alb: 3.0, AST: 54 CTA w/ IV (PE Protocol) given elevated D-dimer-done -> given pleuritic chest pain -> negative for PE but showed metastatic disease in lungs Fluids given: ILNS Meds given: Aspirin 81mg, Morphine 5 mg IV, Ketorolac 15mg/mL, Ciprofloxacin IV 400mg & CeftriaXONE 1g IV (for UTI), Ondansetron 4mg x2, Pantoprazole gtt 8mg/hr; 1 unit pRBC (HCT lower than baseline) Consults called: GI aware VS prior to transfer to the floor: 97.9 72 118/49 100ra Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: -Cervical cancer: followed by Dr. [Last Name (STitle) 4149], discovered after [1-23] post-menopausal vaginal bleeding/hematuria and was found to have a cervical mass w/ invasion of the posterior bladder wall. Biopsies revealed a locally advanced, stage [Doctor First Name ] squamous cell cervical carcinoma. Underwent nephrostomy tubes [2-23] for hydronephorosis. She initiated radiation therapy of pelvis on [2173-2-19] with her last session [2173-4-28]. She completed 6 sessions of weekly cisplatin on [2173-4-12]. -Status post resection of a benign pituitary adenoma at age 21 at [Hospital1 2025] with resultant hypopituitarism; she was previously followed at [Hospital1 2025], needs endocrine f/u (hasn't seen in some time) -Multiple UTIs since nephrostomy tube placement in [2172]: organisms including ENTEROCOCCUS (not VRE), MRSA, E.COLI (Pan-sensative) and resistant GNRs -Osteoporosis Allergies: Banana / Melon Flavor / Avocado / ?IV constrast / Lorazepam Social History: She grew up in the West End of [Location (un) 86]. She lives in [Location 4628], MA with her husband [Name (NI) ]. They have two daughters, her eldest [Name (NI) 1785] lives nearby, her [Name (NI) 1685] daughter [Name (NI) 6480] lives in New [Name (NI) ]. Her sister from [Name (NI) 4565], [Name (NI) ], is back in [State 4565]. [Known firstname ] hopes to travel to [State 4565] later this spring. The patient smoked approximately one-third to [2-14] pack per day for 33 years, recently quitting. She had one alcoholic beverage daily until her illness. Family History: - [Name (NI) 1094] brother died of leukemia at age 64 in [2164]. Pt was a match, donated peripheral blood stem cells. Both parents had heart disease. Physical Exam: Admission Exam: GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no gallops/rubs, II/VI SEM PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound GU: nephrosomy tube draining yellow urine EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [6-18] motor function globally DERM: no lesions appreciated Discharge Exam: Unchanged except for the following Neuro: sleeping, but arousable to voice, AAOx3, appropriate Pertinent Results: [2174-7-2] 05:40PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.015 [2174-7-2] 05:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG [2174-7-2] 05:40PM URINE RBC-19* WBC-52* BACTERIA-FEW YEAST-MOD EPI-<1 [2174-7-2] 05:40PM URINE HYALINE-3* [2174-7-2] 05:40PM URINE MUCOUS-OCC [2174-7-2] 05:25PM LACTATE-1.0 [2174-7-2] 05:20PM GLUCOSE-107* UREA N-11 CREAT-0.7 SODIUM-126* POTASSIUM-3.5 CHLORIDE-89* TOTAL CO2-24 ANION GAP-17 [2174-7-2] 05:20PM ALT(SGPT)-37 AST(SGOT)-54* ALK PHOS-160* TOT BILI-0.4 [2174-7-2] 05:20PM cTropnT-0.12* [2174-7-2] 05:20PM ALBUMIN-3.0* [2174-7-2] 05:20PM D-DIMER-2745* [2174-7-2] 05:20PM WBC-7.5 RBC-2.65* HGB-7.7* HCT-23.9* MCV-90 MCH-28.9 MCHC-32.1 RDW-15.2 [2174-7-2] 05:20PM NEUTS-90.9* LYMPHS-5.9* MONOS-2.8 EOS-0.4 BASOS-0.1 [2174-7-2] 05:20PM PLT COUNT-302 CHEST (PA & LAT): Pending [2174-7-2] Radiology CTA CHEST W&W/O C&RECON: PRELIM IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic injury. 2. Moderate right pleural effusion. Additionally, there is mild ground-glass opacities as well as septal thickening suggestive of mild pulmonary edema. Correlation with BNP is recommended. 3. There are new bilateral pulmonary nodules in the right upper lobe and the left lower lobe. These findings are suspicious for metastatic disease. Additionally, the degree of peribronchovascular thickening appears slightly out of proportion for mild pulmonary edema and lymphangitic spread must be excluded. As a result, dedicated a chest CT is recommended after resolution of symptoms to assess the degree of metastatic disease. [2174-7-2] ECG: NSR 88 bpm, V1-V3 TWI Echo [2174-7-5]: The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild 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 no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The pericardium may be thickened. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. On subcostal supine and 45 degree head-up views, there is a <1 cm (in diastole) rim of pericardial fluid between the visceral pericardium/fat overlying the right ventricle and the diaphragm. A larger rim of pericardial fluid (upto ~1.7 cm in diastole ) is seen apical to the apical right ventricular free wall. Discharge Labs [2174-7-5] 05:01AM BLOOD WBC-10.6# RBC-3.76* Hgb-10.9* Hct-32.9* MCV-88 MCH-28.9 MCHC-33.0 RDW-15.0 Plt Ct-316 [2174-7-5] 05:01AM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-5 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [2174-7-5] 05:01AM BLOOD PT-15.1* PTT-33.7 INR(PT)-1.4* [2174-7-5] 05:01AM BLOOD Glucose-56* UreaN-5* Creat-1.1 Na-129* K-3.5 Cl-93* HCO3-20* AnGap-20 [2174-7-5] 05:01AM BLOOD Calcium-6.9* Phos-3.5 Mg-1.6 Brief Hospital Course: 66F with hx of stage [Doctor First Name ] squamous cell cervical cancer, s/p combined chemoradiation with nephrostomy tube and recent history of urosepsis from Klebsiella pan-sensitive and lower GI bleed related to radiation proctitis who presented with dark stools and 3 point drop in her Hct, now found to have new pulmonary metastases and early cardiac tamponade. # Goals of care discussion - After it was determined that the patient had signs of cardiac tamponade, family meetings were held with the patient, her husband, daughters, and palliative care. The patient made the decision that she did not want to undergo chemotherapy again and did not want invasive therapies such as a pericardiocentesis. The decision was made to move towards hospice care and the patient will be discharged to a hospice house with focus on comfort care. # Cardiac tamponade - Pericardial effusion noted on CT, then tamponade confirmed with echocardiography. Patient was never HD unstable - this finding prompted goals of care discussion as above given need of pericardiocentesis and then window if treatment desired. #. Headaches: Severe, somewhat responsive to narcotics - did not tolerate cyclobenzaprine. Differential included chronic daily headache vs tension. Pain service was consulted. They offered neck injection but patient declined. They recommended to try tizanidine 2mg TID prn headache for relief. # GI bleed - The patient initially presented with dark stool - she had no hematochezia so GI felt this was less likely related to her radiation proctitis. There was an initial plan to attempt further laser therapy, but this was decided against after the goals of care discussions. #. Chest pain, pleuritic: [Month (only) 116] have been related to pericardial effusion. Treated symptomatically. #. Cough/right pleural effusion: Likely due to new lung mets. Treated with anti-tussives and narcotics. #. Urinary tract infection: Completed 3 days of cipro. Culture returned positive for yeast as has priors - likely a colonization. #. Hyponatremia: Monitored, per family has been long term issue. #. Stage IV cervical cancer - CT on admission showed new metastatic lesions in the lungs. The patient stated she would not want to undergo further chemotherapy. Palliative Care was consulted and decision was made for hospice care. #. Pan Hypopituitarism. Hx benign pituitary adenoma s/p resection many years ago. Was on levothyroxine and low dose predisone for years as a result of hypopituitarism that followed. Continued home levothyroxine and prednisone 5 mg po daily until decision for hospice care. Medications on Admission: (Home medication list reconciled on this admission) Butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tab po q4 prn headache Ciprofloxacin 500 mg 1 Tablet PO Q12H for 10 days ([2174-6-29]) ergocalciferol (vit D2) 50,000 U 1 cap po qweek levothyroxine 125 mcg 1 po daily lidocaine-prilocaine 2.5% cream 2.5 gm topically to port site as directed prn prior to accessing port olanzapine (Zyprexa) 2.5 mg 1-2 tabs po q6h and QHS prn anxiety, insomnia potassium chloride 20 mEq 2 packets po BID prednisone 5 mg 1 po daily OTC: calcium carbonate 500 mg (1,250 mg) 1 tab po TID Discharge Medications: 1. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q2H (every 2 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 4. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for nausea. Disp:30 Tablet(s) Refills:0 5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO four times a day as needed for nausea/anxiety. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 6. tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for headache. Disp:90 Tablet(s) Refills:0 7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q4H (every 4 hours) as needed for cough. Disp:500 ML(s) Refills:0 8. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 656] Family Hospice Discharge Diagnosis: Primary: Metastatic cervical cancer, cardiac tamponade, headache Secondary: Urinary tract infection, Radiation proctitis, hyponatremia Discharge Condition: Level of Consciousness: Lethargic but arousable. Mental Status: Clear and coherent. Activity Status: Bedbound. Discharge Instructions: Dear Mrs. [Known lastname 5936], It was a pleasure getting to meet you and care for you during your hospitalization. You came in because of chest heaviness and dark stools. Unfortunately, a CAT scan of your chest showed new metastatic lesions from your cancer - it also showed fluid around your heart which was confirmed with an Echocardiogram. After discussion with you and your family, it was decided to focus on treating your symptoms and alleviating suffering. To that end, you will be going to a hospice house where they will focus on symptom management. You will have a new medication regimen that will be provided for you there. Morphine 7.5mg every 2 hours as needed for pain Benzonatate 100mg by mouth three times a dayAcetaminophen 650mg every 6 hours as needed pain/fever Prochlorperazine 5-10mg by mouth every 4 hours as needed for nausea Olanzapine 5mg 1 tablet by mouth every 6 hours as needed for nausea/anxiety Tizanidine 2mg by mouth three times a day as needed for headache/neck spasm Dextromethorphan-Guaifenesin 5ml by mouth every 4 hours as needed for cough Followup Instructions: None needed. Completed by:[2174-7-6]	[ "E878.6", "285.1", "909.2", "733.00", "V12.41", "558.1", "197.0", "E933.1", "276.1", "599.0", "511.89", "423.3", "412", "569.49", "V44.6", "253.7", "593.3", "569.85", "300.00", "V15.3", "780.52", "783.0", "198.1", "V15.82", "997.5", "E879.2", "V87.41", "784.0", "357.6", "V66.7", "E878.3" ]	icd9cm	[ [ [] ] ]	[ "45.43", "55.93" ]	icd9pcs	[ [ [] ] ]	34764, 34825	30363, 32990	21580, 21587	35005, 35054	27016, 30340	36256, 36299	26122, 26282		33617, 34741		34846, 34984		33016, 33594			35142, 36233			9848, 10403					26297, 26885							26901, 26997										15084, 15739		23785, 24451		21510, 21542									21615, 23766									35069, 35118					24473, 25480	25496, 26106
32,805	169,344	45857	Discharge summary	report	Admission Date: [2183-1-28] Discharge Date: [2183-2-17] Date of Birth: [2116-12-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: Cough, Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. [Known lastname 58143] is a 66 yo male with history of CAD s/p, CHF (EF 15-20%), diabetes type II, PVD, COPD who presents with cough and shortness of breath x 3 days. Patient states that he is able to ambulate around his house from room to room at baseline. On Saturday, he became dyspneic with exertion and noted reduction in his exercise tolerance. He states that he has been short of breath with any movement for the past few days. His VNA called his PCP on Saturday who started him on levofloxacin. He states that he has had a cough which is productive of brown/green blood-tinged sputum. He denies any fevers or myalgias at home. He endoreses chills and diarrhea since Saturday. He lives alone and denies any sick contacts. [Name (NI) ] states that he received both the flu vaccine and Pneumovax this year. . On arrival to the ED, T 98.3, HR 115, BP 110/60, RR 24, SpO2 90% on RA. He received 1L NS, combivent nebs x 2, azithromycin 500 mg PO x1 and ceftriaxone 1 g IV x 1. CXR and CTA chest were performed. He was enrolled in the NAC study. . Past Medical History: PAST MEDICAL HISTORY: 1) CAD: Recent anterior STEMI in [12-3] with stents x 2 to LAD, course c/b cardiogenic shock requiring balloon pump. - h/o BMS to proximal and distal LAD in [2174] 2) COPD: On 2L NC at home. PFT's [10-3]: Marked obstructive ventilatory defect. The reduced FVC is likely due to gas trapping but a coexisting restrictive defect cannot be excluded. Suggest lung volume measurements if clinically indicated. FVC 62% predicted, FEV1 39% predicted, FEV1/FVC 63% predicted. 3) Severe regional left ventricular systolic dysfunction, EF 15-20% 4) Hypercholesterolemia 5) Gout 6) Peripheral vascular disease s/p left iliac artery stent in [2174]. 7) Diabetes mellitus 8) Non-small-cell lung carcinoma, status post left pneumonectomy 9) Gastroesophageal reflux disease 10) Paroxysmal atrial fibrillation, chronically anticoagulated on coumadin Social History: h/o prior tobacco abuse x 60 pack years; quit in [2173]. There is no history of alcohol abuse. . Family History: There is no family history of premature coronary artery disease or sudden death. Father had CAD in old age. Sister with MVP. Physical Exam: VS: afebrile, BP 91/59 HR 102 RR 22 O2 100% 4L PULSUS 8 GEN: NAD, AOX3 HEENT: OP CLEAR, MM dry, JVP 15cm, no kussmauls CARDIAC: RR, tachycardic, [1-1] HSM at LLSB PULM: Left sided lung sounds are absent, Diffuse ronchi on R sided without rales ABD: soft, NT, ND, no masses, BS+ EXT: WWP, 2+ pitting pedal edema to knees NEURO: grossly normal Pertinent Results: [2183-1-28] 12:00PM BLOOD WBC-6.1 RBC-4.23* Hgb-10.6* Hct-35.2* MCV-83# MCH-25.0# MCHC-30.1 RDW-15.6* Plt Ct-408 [2183-1-28] 12:00PM BLOOD PT-60.7* PTT-59.3* INR(PT)-7.2* [2183-1-28] 12:00PM BLOOD Glucose-200* UreaN-36* Creat-1.6* Na-132* K-4.8 Cl-89* HCO3-25 AnGap-23* [2183-1-29] 03:02AM BLOOD CK(CPK)-27* [2183-1-28] 03:08PM BLOOD proBNP-[Numeric Identifier 97653]* [2183-1-29] 03:02AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2 [2183-1-28] 12:08PM BLOOD Lactate-3.7* [2183-1-28] 03:13PM BLOOD Lactate-3.8* [2183-1-29] 10:25AM BLOOD Lactate-2.9* [2183-1-28] 12:00PM WBC-6.1 RBC-4.23* HGB-10.6* HCT-35.2* MCV-83# MCH-25.0# MCHC-30.1 RDW-15.6* [2183-1-28] 12:00PM NEUTS-81.4* BANDS-0 LYMPHS-11.1* MONOS-7.1 EOS-0.2 BASOS-0.2 [2183-1-28] 12:00PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-1+ PAPPENHEI-OCCASIONAL [2183-1-28] 12:00PM PLT SMR-NORMAL PLT COUNT-408 [2183-1-28] 12:00PM PT-60.7* PTT-59.3* INR(PT)-7.2* [2183-1-28] 12:00PM GLUCOSE-200* UREA N-36* CREAT-1.6* SODIUM-132* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-25 ANION GAP-23* [2183-1-28] 12:00PM cTropnT-0.04* [2183-1-28] 12:00PM CK-MB-4 [2183-1-28] 12:08PM LACTATE-3.7* [2183-1-28] 03:08PM proBNP-[Numeric Identifier 97653]* . EKG: sinus tachycardia, normal axis, rate 115, Qwaves previous seen in V1-V4 . RADIOLOGIC DATA: CXR [2183-1-28]: Stable examination demonstrating post left pneumonectomy with no acute process in the right lung. . CT CHEST [2183-1-28]: 1. Moderate pulmonary edema superimposed on severe emphysematous changes in the right lung. New right-sided pleural effusion. 2. Post left-sided pneumonectomy changes appear stable. . TTE [2182-12-19]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is an apical left ventricular aneurysm. There is severe regional left ventricular systolic dysfunction with anterior/anteroseptal, apical and inferior/basal inferolateral akinesis (LVEF 15-20%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Moderate right ventricular systolic dysfunction. Moderate mitral regurgitation. Moderate pulmonary hypertension. . [2183-1-28] 9:06 pm SPUTUM Site: INDUCED FINAL REPORT [2183-1-31] GRAM STAIN (Final [2183-1-29]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2183-1-31]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . [2183-1-29] 9:47 am ASPIRATE Site: NASOPHARYNX R/O RESPIRATORY VIRUSES ADD ON RAPID RESPIRATORY VIRAL SCREEN PER DR. [Last Name (STitle) 24417]. FINAL REPORT [2183-1-29] VIRAL CULTURE (Final [2183-1-29]): TEST CANCELLED, PATIENT CREDITED. PLEASE REFER TO RESPIRATORY ID RESULT. Rapid Respiratory Viral Antigen Test (Final [2183-1-29]): Positive for Respiratory Syncytial viral antigen. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for direct detection of parainfluenza virus in specimens; interpret parainfluenza results with caution. REPORTED BY PHONE TO [First Name5 (NamePattern1) 22181] [Last Name (NamePattern1) ] (4I) [2183-1-29] AT 1637. . Brief Hospital Course: Mr. [Known lastname 58143] is a 66 yo male with CHF, CAD, COPD, remote h/o lung cancer s/p left pneumonectomy presents with respiratory distress x 3 days- found to have a RSV respiratory infection and subsequently MRSA pneumonia. In addition he was severely fluid overloaded and required much diuresis. . #.MRSA Pneumonia/RSV - The patient presented with a new productive cough in the absence of clear pulmonary infiltrate. He failed levofloxacin x 3 days at home as empiric treatment for community acquired pneumonia. On admission he was found to have an elevated lactate, chills, and sputum production. PE ruled out by CTA in ED. He was started on vanc/levo, but was found to have + RSV nasopharyngeal aspirate and antibiotics were DC initally discontinued, however on [1-28] sputum culutre was obatined and found to have MRSA. He was treated with a course of vancomycin, now completed. Urine legionella negative. He oxygen was weaned as tolerated and is currently afebrile and on his home rate of 2L NC. . #.COPD exacerbation - the patient has a long-standing history of COPD, admission exam consistent with a compenent of COPD exacerbation as a cause of dyspnea. He was treated with a prednisone taper, completed on [2-16]. He was also continued on Spiriva and albuterol as outpatient. #.Acute on Chronic Systolic Congestive Heart Failure - The patient has a history of severe systolic CHF s/p large anterior STEMI. EF 15% following a large anterior MI in [11-2]. Since that time he had been milrinone dependant and had previously been discharged on home milrinone at a rate of 0.5mcg. Upon this admission he was massively fluid overloaded and was diuresed with a lasix drip. His lungs remained relatively clear of edema on CXR and on exam but he did have significant dyspnea on exertion indicative of left sided heart failure which improved with diuresis. In addition he had very significant peripheral edema, with 3+ pedal edema to his upper thighs and also sacral edema, this also improved greatly with diuresis. During his diuresis hyponatremia down to 118 and renal failure were limiting factors but these improved eventually with further diuresis and uptitration of milrinone. Milrinone upon discharge is at 0.8mcg. He is on lasix 60mg po bid and digoxin 0.125mcg every other day. Multiple attempts have been made in the past with an ACE inhibitor, on this admission he was tried on 1.25mg of lisinopril daily which his blood pressure did not tolerate. Baseline SBPs is between 70-90 but his SBP dropped to the mid 60s with an ACEi. At his baseline SBP he is asymptomatic. He was continued on pseudoephedrine 30mg po q6hrs for BP augmentation and on spironolactone. His baseline BP is 80s systolic and he continues on a milrinone infusion at 0.8mcg/kg/min. He should continue to maintain a 1L fluid restriction daily. Please [Name8 (MD) 138] MD if weight increases greater than 3lbs as his lasix should be uptitrated if blood pressure allows. He continues on coumadin for his akinetic anterior wall as well as history of PAF. . #.CAD - The patient was admitted from [2182-11-14] - [2182-12-26] with a large anterior STEMI. He was found to have an LAD with a 70% stenosis after a proximal stent and then a total occlusion without collateral flow and stent was placed. His hospital course was complicated by cardiogenic shock requiring balloon pump. He has continued to be pressor dependent as above. He was continued on aspirin and plavix. . #.PAF - the patient has a h/o PAF. He was continued on amiodarone 200 mg daily, anticoagulated on coumadim, current dose 1.5mg daily. . #.ARF: On admission the patient presented with creatinine 1.8 up from baseline of 1.2. He improved to 1.4 with hydration, and believed to be likely prerenal in the setting of intravascular volume depletion, superimposed on mild chronic renal insufficiency. His Cr is now ranging from 1.2-1.4. . #.DM2: On admission his glyburide held in the setting of acute illness. He was maintained on SSI and Lantus. He is currently on Lantus 11 units dosed with breakfast and a SSI. His flingerstick should continue to be monitored four times daily and Lantus titrated as needed. . #.FEN: cardiac/DM diet. Fluid restriction 1L daily . #.PPx: PPI, systemically anticoagulated with coumadin . #. Full Code Medications on Admission: Amiodarone 200 mg daily ASA 325 mg daily Calcium carbonate 500 mg TID w/ meals Plavix 75 mg daily Senna 2 tabs [Hospital1 ] Colace 100 mg [Hospital1 ] Flonase 2 sprays each nostril daily Lasix 100 mg [Hospital1 ] Glyburide 5 mg qAM Milrinone gtt @ 200 mcg/mL daily MVI Protonix 40 mg daily KCL 10 meq [Hospital1 ] Aldactone 25 mg daily Spiriva 18 mcg daily Coumadin Simethicone 80 mg q6 hours PRN gas Tylenol PRN pain Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY16 (Once Daily at 16). 11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6HRS (). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [11-27] Sprays Nasal QID (4 times a day) as needed. 16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 18. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 19. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 24. Insulin Glargine 100 unit/mL Cartridge Sig: Thirteen (13) units Subcutaneous QAM at breakfast. 25. Insulin Lispro 100 unit/mL Solution Sig: One (1) Unit Subcutaneous four times a day: Per sliding scale provided. 26. Milrinone 1 mg/mL Solution Sig: 0.8 mcg/kg/min Intravenous INFUSION (continuous infusion). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: 1. MRSA Pneumonia 2. Rsepiratory Synctial virus 3. Acute on Chronic Systolic Heart Failure 4. Chronic Obstructive Pulmonary Disease Exacerbation Discharge Condition: Afebrile, VSS, BP at baseline 80s systolic Discharge Instructions: You were admitted with shortness of breath and were found to have pneumonia. You have completed your course of antibiotics for your pneumonia. You were also treated with steroids for an exacerbation of your chronic obstructive pulmonary disease which you have also completed. . You should continue to weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Please continue to adhere to 2 gm sodium diet. Restrict your fluid intake to 1L daily. You should continue to take lasix 60mg twice daily. You have also been started on digoxin 0.125mcg every other day and pseudoephedrine 30mg every six hours. You are also continuing on milrinone. Please continue to take the remainder of your medications as directed. . Please return or call Dr. [Last Name (STitle) ] if you experience chest pain, shortness of breath or worsening of your lower extremity edema. Please call with any questions. You are being disharged to acute rehab for continued care. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2183-2-26] at 3:00pm at [Doctor Last Name ] 430 [Last Name (NamePattern1) 14648] [Location (un) 86], [Numeric Identifier 8542]. Please call [Telephone/Fax (1) 7960] with any questions. . Please maintain your scheduled follow up listed below: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2183-3-27] 1:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2183-4-14] 1:10 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 612] Date/Time:[2183-4-14] 1:30	[ "482.41", "491.21", "428.0", "272.0", "707.03", "414.01", "250.00", "584.5", "V10.11", "427.31", "480.1", "V58.61", "585.9", "518.81", "403.90", "253.6", "530.81", "428.23", "507.0", "274.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	15277, 15348	8052, 12371	343, 350	15546, 15591	3001, 8029	16605, 17410	2488, 2615		12855, 15254		15369, 15525		12397, 12832			15615, 16582								2630, 2982																					277, 305									378, 1455														1499, 2353	2369, 2472
43,990	109,965	15220	Discharge summary	report	Admission Date: [2155-9-8] Discharge Date: [2155-9-10] Date of Birth: [2101-6-17] Sex: F Service: MEDICINE Allergies: aspirin Attending:[First Name3 (LF) 5893] Chief Complaint: Fevers, leukocytosis, tachycardia Major Surgical or Invasive Procedure: Ultrasound-guided percutaneous cholecystostomy with catheter placment History of Present Illness: 54yo female with T-cell lymphoma transferred from [Hospital ] Hospital with diagnosis of presumed cholecystitis. She was initially admitted [8-31] with fevers at home to 101.9 without localizing symptoms and was admitted overnight, labs drawn, negative CXR and discharged on [9-1] apparently without intervention. She was home for 5 days and continued to have fevers up to 103, and re-presented to [Hospital1 ] on [9-6]. Again she had no localizing symptoms. On the day of admission her WBC was found to be 21.8 (50% PMNs, 13% bands) up from WBC 0.8 two days prior. She was started on vancomycin and cefepime. She had a CXR on [9-7] which showed bilateral intersititial opacity slightly worse on the right. She was additionally found to have elevated LFTs with Tbili 2.4, Dbili 2.2, ALT initially 188, AST 130, increasing to 245 on day of transfer. Alk phos 521. Given the LFT abnormalities she had an abdominal ultrasound, which showed gallbladder wall thickening, distention of gallbladder and multiple 10mm mobile gallstones, trace pericholecystic fluid, but no CBD dilatation (4mm). This was thought to be consistent with cholecystitis. After the RUQ ultrasound, this was changed to Zosyn and vanc was dc'd. On exam she had a positive [Doctor Last Name 515] sign was tachycardic and initially borderline hypotensive (unclear exact pressures), however, received fluid resuscitation with an unclear amount of fluid and blood pressures responded, by report systolics in the low 100s (105/68) upon transfer, HR 140s regular sinus tach, RR 20, 95% on RA. On arrival to the MICU, patient's VS. T 97.8 HR 134 BP 85/58 RR 24 94% 2L NC Review of systems: (+) Per HPI, as well as nausea, new nonproductive cough, slightly short of breath (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ONCOLOGY: [11/2154]: Screening colonoscopy negative. [2154-12-10]: Screening PET showed no avid lesions though some low avidity uptake at surgical margins. [2-/2155]: Abdominal discomfort. [3-/2155]: CT demonstrated new liver lesions. A biopsy was performed which demonstrated a lymphoma. Limited tissue, a clear diagnosis was not possible but pathology was consistent with Hodgkin lymphoma. [2155-4-3]: Staging PET showed enlarged right subocciptal node, intensely avid, with avidity of the posterior paraspinal musculature. Multiple enlarged right supraclavicular nodes. Asymmetric thickening of right supraspinatus muscle. Multiple intensely avid masses within the liver. Enlarged and intensely avid aortocaval node and multiple enlarged left midabdomen mesenteric nodes. Circumferential masslike thickening of a portion of small bowel with an expanded lumen. Bone marrow biopsy demonstrated no disease. [4-/2155]: Right-sided neck pain; right arm pain, numbness and weakness; night sweats. Given rapid progression of symptoms, a second biopsy was performed on the neck lymph node and she was started on treatment with steroids and ABVD. Pathology from lymph node demonstrated a peripheral T-cell lymphoma. Chemo was changed for her second cycle to CHOEP. She received 3 cycles of CHOEP. CT following those scans demonstrates progression. [2155-7-28]: ICE cycle #1. [2155-8-6]: Admitted for neutropenic fever. [2155-8-18]: ICE cycle #2. . PMH: - Colon cancer s/p right hemicolectomy [2153]. 2 tumors. One 5cm, low grade through the muscularis propria into the pericolonic adipose tissue (t4), no lymphatic invasion. second tumor 4cm with some lymphatic invasion. 25 negative nodes. Microsatellite instability negative. No adjuvant treatment. - Celiac disease, dx at investigation of weight loss following colectomy. Managed with diet. PSX: - Hemicolectomy as above. Social History: Started smoking in her teens, quit 2 years ago /rare ETOH/no illicits. Works in IT. Family History: Mother died of breast cancer at 54. Grandmother died at 52. Father died in 80s with CAD. 2 healthy sisters. Daughter has celiac disease. Physical Exam: Admission: Vitals: T 97.8 HR 134 BP 85/58 RR 24 94% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles at bases bilaterally, breath sounds decreased [1-6] way up right lung field, no wheezes Abdomen: soft, minimally tender to palpation diffusely, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, no [Doctor Last Name 515] sign GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: Deceased Pertinent Results: Admission: [2155-9-8] 08:52PM BLOOD WBC-25.8# RBC-2.44# Hgb-7.8# Hct-23.1# MCV-94 MCH-31.8 MCHC-33.7 RDW-19.0* Plt Ct-129# [2155-9-8] 08:52PM BLOOD Neuts-83 Bands-1 Lymphs-9* Monos-5 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [2155-9-8] 08:52PM BLOOD PT-17.0* PTT-42.7* INR(PT)-1.6* [2155-9-8] 08:52PM BLOOD Fibrino-470* [2155-9-8] 08:52PM BLOOD Glucose-48* UreaN-11 Creat-0.8 Na-137 K-3.7 Cl-109* HCO3-11* AnGap-21* [2155-9-8] 08:52PM BLOOD ALT-145* AST-112* AlkPhos-520* TotBili-2.6* DirBili-2.4* IndBili-0.2 [2155-9-8] 08:52PM BLOOD Albumin-2.2* Calcium-7.3* Phos-2.1* Mg-2.0 [2155-9-8] 09:59PM BLOOD Type-MIX pO2-44* pCO2-24* pH-7.29* calTCO2-12* Base XS--12 [2155-9-8] 09:59PM BLOOD Lactate-7.4* Discharge: [2155-9-9] 06:45PM BLOOD WBC-62.5# RBC-2.58 Hgb-8.0* Hct-25.9* MCV-101* MCH-30.9 MCHC-30.7* RDW-20.5* Plt Ct-115* [2155-9-9] 02:41AM BLOOD Neuts-80* Bands-0 Lymphs-2* Monos-15* Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-1* NRBC-1* [2155-9-9] 06:45PM BLOOD PT-21.8* PTT-53.6* INR(PT)-2.1* [2155-9-9] 06:45PM BLOOD Glucose-145* UreaN-23* Creat-2.0* Na-133 K-4.5 Cl-98 HCO3-6* AnGap-34* [2155-9-9] 06:45PM BLOOD ALT-137* AST-186* LD(LDH)-4300* AlkPhos-478* TotBili-2.5* [2155-9-9] 06:45PM BLOOD Albumin-2.6* Calcium-7.5* Phos-5.1* Mg-2.1 [2155-9-9] 02:41AM BLOOD Cortsol-37.7* [2155-9-9] 07:25PM BLOOD Type-ART Temp-36.7 Rates-22/4 Tidal V-550 PEEP-10 FiO2-40 pO2-97 pCO2-26* pH-7.02* calTCO2-7* Base XS--23 -ASSIST/CON Intubat-INTUBATED [2155-9-9] 07:25PM BLOOD Lactate-15.1* Microbiology: [2155-9-8] 8:52 pm BLOOD CULTURE: pending [2155-9-9] 2:43 am MRSA SCREEN: pending [2155-9-9] 2:39 am URINE CULTURE: pending [2155-9-9] 11:15 am FLUID,OTHER GALLBLADDER DRAINAGE. GRAM STAIN (Final [2155-9-9]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): Pending ANAEROBIC CULTURE (Preliminary): Pending Imaging: [9-9] Liver/Gall Bladder Ultrasound: IMPRESSION: 1. Circumferentially thickened gallbladder wall in the setting of ascites. Tiny 5-mm gallbladder calculus. 2. Slightly prominent common bile duct, measuring 6 mm. 3. Small amount of ascites and right pleural effusion. [9-9] CT Abd/Pelvis w/ Contrast: IMPRESSION: 1. Circumferential wall thickening of the gallbladder in the setting of anasarca and free fluid within the abdomen and pelvis with no significant distension of the gallbladder. These findings are not classic for cholecystitis, however, if clinical suspicions remain high, an ultrasound and a HIDA scan is recommended to further evaluate for acute cholecystitis. No evidence of intrahepatic biliary dilatation. 2. Supraclavicular, mediastinal, and retroperitoneal lymph nodes, which are not particularly enlarged by CT criteria, however, demonstrate FDG avidity in a recent PET-CT, dated [2155-9-4]. 3. 1-cm hypoenhancing lesion within the segment VI of the liver, which has demonstrated FDG avidity on the prior PET-CT. 4. Mild splenomegaly. 5. Distal small bowel, eccentric, centrally hypoenhancing nodule, measuring 1.9 x 1.9 cm, which is suspicious for small bowel lymphomatous involvement or mesenteric implant. [9-9] CTA: No PE [9-9] Echo: IMPRESSION: Grossly preserved biventricular systolic function. No pericardial effusion seen. Limited study due to suboptimal acoustic windows and persistent tachycardia. [9-8] CXR: CONCLUSION: 1. New interstitial pulmonary edema is mild to moderate. 2. Bilateral mild-to-moderate pleural effusion is unchanged. Brief Hospital Course: Brief Course: 54yo female with T-cell lymphoma transferred from [Hospital ] Hospital for fever, tachycardia, leukocytosis, elevated LFTs with suspicion for cholecystitis vs. cholangitis. Patient developed septic shock and required 3 pressors. She also developed respiratory failure and was intubated and ventilated. She was covered broadly with antibiotics. She underwent ultrasound guided cholecystoscopy and catheter placement, however her lactate continued to increase and the patient continued to clinically decompensate. Her family was made aware, and decided to pursue DNR code status with comfort measures only. Patient was taken off pressors and antibiotics and was extubated. She expired the follwing morning. Active Issues: #Septic Shock: Patient was hypotensive requiring 3 pressors, tachycardic, and febrile with leukocytosis. Source is most likely acute cholecystitis. Patient underwent ultrasound guided cholecystostomy with catheter placement, as she was not stable enough to undergo cholecystectomy. Despite intervention and broad spectrum antibiotic coverage with meropenem and zosyn, patient's lactate continued to trend up to a peak of 15 and she continued to be tachycardic, hypotensive, and acidotic despite optimizing ventilator settings. In light of clinical decompensation, the family decided to make the patient DNR, with comfort measures only. Therefore she was extubated and pressors and antibiotics were stopped. She was made comfortable with morphine drip until she expired. #Respiratory failure: Likely secondary to fluid overload or flash pulmonary edema which is supported by bilateral pleural effusions seen on CT and crackles on exam. PE was ruled out with CTA. Patient's oxygenation was maintained on the ventilator, but she continued to be acidotic despite maximizing her settings. She was subsequenty extubated for comfort per the family's wishes. #Metabolic acidosis: Secondary to lactic acidosis in setting of sepsis. Patient could not compensate respiratory wise initially and was subsequently intubated. Acidosis could not be corrected despite optimizing vent settings and patient was subsequently extubated per family's wishes as mentioned above. #Coagulopathy: INR 1.5. No signs of active bleeding. [Month (only) 116] be secondary to malnutrition or liver dysfunction. #Elevated LFTs: CT very suggestive of acute cholecystitis. Direct bilirubinemia with elevated alk phos suggestive of obstruction. AST and ALT also elevated may be from adjacent gall bladder inflammation or cholangitis. Baseline at last check ALT 47, AST 22, Tbili 0.5. Patient underwent ultrasound guided cholecystostomy, however her lactate continued to trend up and she continued to be septic. Further intervention and antibiotics were withheld when the patient was made comfort measures only. # Hypoglycemia: Noted to be hypoglycemia in the 40s and 50s. She was replaced with D50 as needed. [Month (only) 116] be due to liver dysfunction and inadequate gluconeogenesis. #Anemia: Has been running baseline in range of Hgb [7-14], Hgb 24-26. This is likely to be related to chemotherapy or anemia of chronic inflammation in setting of cancer. #T cell lymphoma: Status post one cycle of ABVD and 3 cycles of CHOEP with progression and C2D9 from ICE salvage. PET showing multiple areas with lymphadenopathy and increased uptake in liver. Patient had expressed that she did not want to continue treatment. Inactive Issues: #Celiac disease: Controlled with diet. Transitional Care Issues: 1. Code Status: DNR 2. Contact: Sister [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 44304] 3. Pending studies: Blood and urine cultures, MRSA screen 4. Medication changes: N/A 5. Follow up: N/A Medications on Admission: Zosyn 3.375 gram q6h Acyclovir 400mg PO BID (prophylaxis) Bactrim SS one PO daily (prophylaxis) Advair 250/50 one inhalation daily Zofran 4mg q6h PRN nausea Acetaminophen 1000mg q6h PRN fever Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary: Septic Shock Respiratory failure Secondary: Acute cholecystitis Discharge Condition: Expired Discharge Instructions: Dear Ms. [Known lastname 11084], It was a pleasure taking care of you at [Hospital1 18]. You were admitted with a severe infection likely from your gall bladder. We supported you with antibiotics, and medications to help with your blood pressure. You also had difficulty breathing so we supported your breathing with a ventilator. We put a drain into your gall bladder, however your infection was very severe and all of our measures did not seem to be helping. Your family wanted to make you comfortable, so stopped the breathing machine. You passed away with your family at your bedside. Followup Instructions: None Completed by:[2155-9-11]	[ "V10.05", "518.4", "V87.41", "251.2", "785.52", "584.9", "276.2", "285.3", "V15.82", "579.0", "286.9", "V49.86", "574.01", "995.92", "202.70", "518.81", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.04", "38.97", "96.71", "51.01" ]	icd9pcs	[ [ [] ] ]	12987, 12996	8982, 9706	302, 374	13114, 13123	5374, 7262	13769, 13804	4546, 4687		12958, 12964		13017, 13093		12741, 12935			13147, 13746								4702, 5355									12710, 12715										2092, 2479	12692, 12699	228, 264		9721, 12425	12508, 12672						402, 2073				12442, 12482				7336, 8959						2501, 4427	4443, 4530		7291, 7303
9,270	171,336	21881	Discharge summary	report	Admission Date: [2194-10-26] Discharge Date: [2194-12-17] Date of Birth: [2173-10-16] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old, unrestrained driver in a motor vehicle accident car versus pole with intrusion. The patient was unresponsive at the scene and taken to an outside hospital where he was intubated and sedated. The CT scan from the outside hospital shows a left subdural hematoma, basal skull fracture, a left temporal contusion, right subarachnoid hemorrhage and multiple facial fractures. Chest, abdomen and pelvis films were negative. His chest x-ray showed left lower lobe atelectasis. He had no solid organ injuries and no vascular injuries. He was admitted to the trauma Intensive Care Unit and had a ventriculostomy drain placed. He had a repeat CAT scan on post hospital day number one that showed no interval change. He was monitored and given Mannitol 50 q.6h. intravenously for increased intracranial pressure. Facial fractures include left linear zygomatic fracture, bilateral nasal fracture, bilateral xiphoid fracture, right supraorbital commuted fracture, left temporal lobe contusion with fracture of the basal skull in that area. The patient remained in critical condition. Neurology was consulted for a possible question of seizure activity. EEG was done, and Neurology felt that his tremors the patient was having was likely either related to alcohol and drug withdrawal or coming off sedation medication and not seizure activity. On [2194-10-28], the patient had a repeat head CT that showed increased mass effect and edema. He was continued on Mannitol 50 intravenously every six hours, and a second ventriculostomy drain was placed at that time due to increased edema. On examination, he was intubated and sedated on propofol. He localized in the right upper to stimulation and attempted to withdraw his left upper. Repeat MRI and head CT show right frontal hyperdensities which are consistent with diffuse axonal injury, mild overall increase of edema. On [2194-10-31], the right ventricular drain was removed secondary to it not working. The left remained in place. Head CT showed mild increase in edema on [2194-10-29]. Neurology was re-consulted due to a non-movement of the left upper extremity. Neurology was unclear as to the cause of the left upper extremity weakness. However, it did improve with time. Neurologically on examination, the patient's pupils were 3 down to 2 mm and briskly reactive. He localized briskly on the right side. Grimace to pain on the left upper. Subtle rotation of the left arm antigravity in both lowers. Reflexes are 2 plus bilateral on the upper extremities. An MRI shows no evidence of stroke, and there is no spine trauma to explain the left upper extremity weakness. The patient had a CTA on [2194-10-31] which showed prominent vascular structures in the left sylvian fissure. An AV fistula cannot be excluded. On [2194-11-2], the patient had an IVC filter by Vascular Surgery without complication. On angio on [2194-11-3], the patient had evidence of injury to the vascular branches of bilateral vertebral arteries at the level of C1 with no evidence of dissection or AV fistula, but also evidence of left ICA vasospasm. The patient's blood pressure was kept 150-170. He remained on Mannitol and Depakote. He was intubated and sedated with increased ICPs and continued on Mannitol 50 intravenously every six hours. He had a repeat head CT on [2194-11-3] that was stable. On [11-5], the patient was paralyzed and sedated on cisatracurium for increased ICPs and also spiked to 101.2. ICP was still intermittently in the 30s when the cisatracurium was stopped on the 14th. Neurology was again re-consulted due to the left upper extremity weakness and the patient not waking up after being off sedation. Neurology felt the left upper extremity weakness was still difficult to explain and recommended a repeat MRI, and the patient needed longer to be off sedation to be examined. The patient's pupils were 4.5 down to 3 bilaterally localized in the right upper and lower extremities. There was still less localized in the left upper extremity to stimulation. The patient had a percutaneous endoscopic gastrostomy tube placed on [2194-11-7] without intraoperative complication. He also had a tracheostomy placed at that time as well. On [2194-11-9], the patient was off all sedations. ICPs remained below 20. His most recent CTs and MRIs were unchanged. The vent drain was weaned and removed on [2194-11-11], and the patient was off Mannitol by [2194-11-11]. He was trached and pegged. Neurologically, his left upper extremity resolved on its own. The patient was followed by physical therapy and occupational therapy. The patient was transferred to the step-down unit on [2194-11-12]. His hospital stay remained uneventful, and he remained in the hospital until [2194-12-17]. He was found to have an avulsion fracture of his left third finger. Plastic Surgery was consulted, the results of which are pending. He also had his percutaneous endoscopic gastrostomy tube removed by General Surgery. He was discharged to home on [2194-12-17] in stable condition. Global aphasia improving daily, speaking more and understanding more. Moving all extremities with good strength. He was discharged to home on [2194-12-17] for outpatient speech and occupational therapy and followup with Dr. [Last Name (STitle) 1132] in one month with a repeat head CT. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Valproic acid 750 p.o. t.i.d. 2. Trazodone 50 p.o. at bedtime 3. Fluoxetine 10 mg p.o. daily 4. Lansoprazole 30 cc p.o. once daily CONDITION ON DISCHARGE: Stable. He will followup with Dr. [Last Name (STitle) 1132] in one month with a repeat head CT. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 6583] MEDQUIST36 D: [2194-12-16] 12:33:26 T: [2194-12-16] 12:58:17 Job#: [Job Number 57382]	[ "112.89", "999.2", "348.5", "276.3", "305.00", "802.0", "851.84", "784.69", "802.8", "780.6", "E879.8", "816.00", "801.24", "305.60", "E816.0", "802.4", "451.82" ]	icd9cm	[ [ [] ] ]	[ "96.72", "88.41", "88.65", "43.11", "38.7", "31.1", "88.51", "33.22", "97.51", "99.04", "96.6", "02.2", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]																																																						168, 5775																5800, 6157
24,541	157,578	26478	Discharge summary	report	Admission Date: [2200-10-18] Discharge Date: [2200-10-22] Date of Birth: [2133-7-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2159] Chief Complaint: Alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 67 y/o M w/ h/o HTN, CAD s/p MI w/ stent placement [4-4] yrs back p/w chest pain while at detox facility for alcohol withdrawl. Patient exprienced sub-sternal chest pain, [3-9] in intensity non-radiating, not associated with any SOB, nausea /vomiting / palpitations / sweating. He says this was his chest pain from "panic" and he has experienced this in the past when he was panicky and in alcohol withdrawl. This pain is different from the pain that he had with his MI. The pain resolved on its own after 2-3 hours. . Patient was sober for almost 30 yrs after which he went on a 3 day binge of Vodka drinking 2 quartz vodka/day for 3 days. He says he started drinking because he ran out of vicodin which he has been taking for back pain. He was admitted to detox facility on the day prior to this admission and has been on CIWA scale. He reports a history of DTs in the past. . ED: on CIWA scale, got 30 mg valium; 1 L D51/2NS as he had dry MM ECG showed RBBB in TWI in III, AVF, biphasic in V4, V5 . The patient was initially admitted to the medical service, but was requiring large doses of valium per CIWA scale. Due to his valium requirement and the need for frequent nursing checks he is being transfered to the ICU. He received 360 mg of valium over 24 hours. In the ICU patient continued to require frequent doses of valium, however, the requirement significantly decreased by the team he was transferred to the floor. . Upon transfer to the floor, patient was feeling much better. At that time he was not complaining of any pain. No shortness of breath. No headaches, N/V, abdominal pain or diarrhea. He was feeling a little weak and unsteady on his feet. Past Medical History: PMHx: h/o Withdrawl Seizures CAD s/p MI [4-4] yrs back w/ stent placement HTN GERD Tremor Social History: Social Hx: He is a retired cab driver and is currently admitted to a detox facility after an alcohol binge. h/o alcohol abuse; 40 pack year history. Family History: Family Hx: Non-contributory Physical Exam: 99.3, 116, 149/95, 16, 95%/RA Gen: lying in bed, drowsy but awake, oriented, mild termors, fluent speech HEENT: PERRLA, EOMI, dry mucous membranes Lungs: CTAB Heart: S1/S2, RRR, no m/r/g Abd: soft/NT/ND, BS+, no hepatomegaly Ext: no edema, 2+ DP pulses Neuro: mild tremors, CN II-XII intact and symmetric bilaterally. Reflexes 1+ bilaterally. Moves all extemities. Pertinent Results: [2200-10-18] 06:25AM cTropnT-<0.01 [2200-10-18] 04:06PM BLOOD CK-MB-1 cTropnT-<0.01 [2200-10-18] 09:40PM CK(CPK)-115 [2200-10-18] 09:40PM BLOOD CK-MB-2 cTropnT-<0.01 [2200-10-19] 07:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2200-10-18] 06:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: 1. Chest Pain: Pt has a known cardiac history and had chest pain when he initially presented to the hospital. Cardiac enzymes were cycled and were negative. He had se rail EKGs which showed no change. He was monitored on telemetry with no evidence of arrhythmia. While on the floor he had one episode of chest tightness, which resolved quickly without any EKG changes. Chest tightness/pressure did not return during his stay. He will be discharged on his usual cardiac regimen of Inderal LA 80 QD, Plavix 75 mg QD, Lipitor 10 mg QD, and Lisinopril 20 mg QD. Patient was instructed to follow-up with his regular cardiologist in [12-1] weeks. . 2. Alcohol With drawl: Patient was admitted to [Hospital1 18] from [Hospital1 ] where he was undergoing detox from alcohol. Per the patient, he had been sober for 40 years and had only started to drink in the 3-4 days prior to his admission to [Hospital1 ]. Patient required very high doses of Valium and close ICU monitoring when he was initially admitted to [Hospital1 18]. This is suspicious as patient should not have had such severe alcohol withdrawal and require so much Valium if he had only been drinking for 3 days. We suspected more chronic alcohol abuse, although patient denies this. Given history of DTs and seizures patient was covered aggressively with Valium. He did not have any DTs or withdrawal seizures. He was also given folate, thiamine, and multivitamins. Patient was very adamant about not returning to [Hospital1 ]; he would not consent to admission to any in-patient facility. Patient was seen by our addictions specialists who recommended a partial hospital program, but the patient refused this as well. He was insistent upon going home and talking to his AA sponsor. He did not feel he would benefit from any additional interventions. We contact[Name (NI) ] his sister who was unhappy with this plan but agreed that we could not force him into a program as he was competent enough to make his own decisions. Patient was discharged with the understanding that if he started to drink again, he would seek out help from his existing support networks. He was also given prescriptions for thiamine, folic acid, and MVIs. Medications on Admission: Medications on admission: Inderal LA 80 QD Plavix 75 mg QD Lipitor 10 mg QD Lisinopril 20 mg QD Thiamine Folate MVT Haldol prn Ativan on ciwa scale Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Propranolol 80 mg Capsule, Sustained Action 24HR Sig: One (1) Capsule, Sustained Action 24HR PO DAILY (Daily). 9. Inderal LA 80 mg QD Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal Discharge Condition: good Discharge Instructions: Please follow-up with your PCP [Last Name (NamePattern4) ] [4-5] days. * Please return to the emergency department if you develop fever or chills, chest pain or pressure, shortness of breath, cannot eat or drink, or develop any other symptoms that are concerning to you. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 31446] [Name (STitle) 8521] in [4-5] days - # [Telephone/Fax (1) 54268]	[ "401.9", "412", "530.81", "V45.82", "414.01", "305.00", "291.81", "786.50", "333.1", "288.8" ]	icd9cm	[ [ [] ] ]	[ "94.62" ]	icd9pcs	[ [ [] ] ]	6386, 6392	3152, 5381	336, 343	6455, 6462	2781, 3129	6789, 6919	2352, 2381		5579, 6363		6413, 6434		5433, 5556			6486, 6766								2396, 2762																					278, 298									371, 2053														2075, 2170	2186, 2336
16,452	143,424	50537	Discharge summary	report	Admission Date: [2170-6-1] Discharge Date: [2170-6-2] Date of Birth: [2121-4-21] Sex: M Service: MED CHIEF COMPLAINT: Bleeding, status post bronchoscopy. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old man with renal cell carcinoma with metastases to the lungs and spine, who presented today to [Hospital1 18] for elective BAL bronchoscopy by IP to rule out infection. The patient had a CAT scan in [4-/2170], which showed interval progression of intrathoracic metastatic disease. Right paramediastinal mass to be associated with compression of the right upper lobe bronchus and associated atelectasis. There was also evidence of lymphangitic spread of tumor involving right upper lobe. The pulmonary team was aware of this, however, there was still a question of infection in this area. The patient had a baseline cough for approximately one year; however, his shortness of breath was increasingly worse over the past 2 weeks. He denied any hemoptysis. On bronchoscopy, the team found a right upper lobe endobronchial mucous plug. Up on suctioning of this plug, there was an underlying lesion which began to bleed. The patient had approximately 200 to 250 cc of blood loss. He was taken urgently to the OR for coagulation. The bleeding was successfully stopped. The patient was successfully extubated and transferred to MICU for overnight observation. REVIEW OF SYSTEMS: Negative for chest pain or shortness of breath. He had some chronic throat discomfort. PAST MEDICAL HISTORY: Renal cell carcinoma, diagnosed in [2166]. Status post left nephrectomy. Status post IL2 therapy and PIK 787. The patient also on [Initials (NamePattern4) ] [Last Name (NamePattern4) 1819] clinical trial. Coronary artery disease, status post myocardial infarction. Elevated cholesterol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg q.d. 3. Zocor 80 mg p.o. q.d. 4. Toprol-XL 300 mg p.o. q.d. 5. Enalapril 2.5 mg q.d. 6. Percocet 1 to 2 tablets q.4-6h. p.r.n. 7. Ibuprofen p.r.n. 8. Folic acid 1 mg q.d. SOCIAL HISTORY: The patient is a trial lawyer. [Name (NI) ] has a prior history of tobacco use. HOSPITAL COURSE: The patient was admitted to the MICU team status post bronchoscopy as described above. The patient felt well. He had no episodes of hemoptysis. He had no episodes of lightheadedness or dizziness. The patient stated that he felt at baseline and that his breathing was better than it had been prior to his elective bronchoscopy. Serial hematocrits were checked. The patient's initial hematocrit was 33; this dropped to 29, but then prior to admission had rose to 29.7. The medical team felt that this was acceptable given his known blood loss during bronchoscopy. The patient's Plavix and aspirin were held during his hospitalization for his increased risk of bleeding. His Plavix was only held because his coronary stent was placed greater than a year ago. In addition, the patient was instructed to restart his aspirin and Plavix on the day after discharge. There were no other events during this hospitalization. This is the consensus within the medical team that the patient was stable for discharge to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: Renal cell carcinoma with metastatic disease to lung and spine. Coronary artery disease, status post myocardial infarction. Status post left nephrectomy. Status post hemoptysis in the setting of bronchoscopy. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 2019] Dictated By:[Doctor Last Name 2020] MEDQUIST36 D: [2170-6-2] 11:38:53 T: [2170-6-2] 12:16:19 Job#: [Job Number ]	[ "272.0", "412", "198.5", "998.11", "414.01", "197.0", "V10.52" ]	icd9cm	[ [ [] ] ]	[ "33.24", "32.01" ]	icd9pcs	[ [ [] ] ]								3350, 3783						2244, 3268																													1438, 1527		152, 189									218, 1418														1550, 2123	2140, 2226	3293, 3328
57,139	155,470	42559	Discharge summary	report	Admission Date: [2185-12-7] Discharge Date: [2186-1-11] Date of Birth: [2126-1-11] Sex: F Service: MEDICINE Allergies: Keflex / Ciprofloxacin / Ertapenem Attending:[First Name3 (LF) 10293] Chief Complaint: ascites, hyponatremia, renal failure Major Surgical or Invasive Procedure: evacuation of History of Present Illness: 59 year-old woman with a history of cirrhosis with refractory ascites, s/p TIPS, and hyponatremia, who is transferred from her [Hospital3 ] facility for refractory ascites. She was recently discharged from [Hospital1 18] [11-24] after an admission for altered mental status, likely secondary to hepatic encephalopathy. In the intervening 2 weeks, her ascites reaccumulated and her sodium was as low as 121 (basline 128-130). She underwent a therapeutic tap 2 days prior to admission, removing 10 L of fluid. Also since that time, her diuretic regimen has been held. Labs on the day prior to admission were remarkable for creatinine of 2.0, elevated from her recent baseline of 1.3-1.5. . She denies mental status changes, abdominal pain, nausea, vomitting, fevers, chills, or change in her baseline [5-14] nonbloody daily bowel movements. She further denies any dysuria or change in the volume of urine. . Review of systems was otherwise negative. Past Medical History: Hepatitis C, Genotype 1: Diagnosed in [2185-1-8] with last VL 263,000 in [8-/2185] Cirrhosis (Methotrexate and Hepatitis C Induced) Portal Hypertension Chronic Kidney Disease with baseline Cr 1.8-2.0 Diastolic CHF: Grade I diastolic dysfunction [7-17], EF 75% Ascites Diuretic-Resistant Esophageal Varices per report; however, EGD [7-/2185] reports normal esophagus Psoriasis with Arthropathy - s/p Methotrexate x 15 years (MTX d/c in 12.07 when patient developed ascites and now uses halobetasol cream) Anemia with baseline Hct 25-30 Thyroid nodule 2.2cm identified on ultrasound [9-16], needs Bx (has f/u in Thyroid nodule clinic) Admission [Date range (1) 92102]: for elective TIPS for refractory ascites, also had UTI Admission [Date range (1) 92103]: for hyponatremia and ARF Admission [Date range (1) 78747]: for hepatic encephalopathy Foot drop from peroneal nerve injury during TIPS procedure (per DC summary) Hyponatremia with baseline Na 128-130 Social History: Quit smoking in [2184]. No alcohol problems, no drugs. Formerly taught hairdressing. Had been living with her son and father until recent admission after which she went to You-ville. Uses a cane and walker. Family History: no FH of liver disease Physical Exam: VS - Temp 98.6 F, BP 103/69 , HR 85, R 20 , O2-sat 100% RA GENERAL - uncomfortable appearing woman lying on her side HEENT - moist mucus membranes NECK - supple, no thyromegaly LUNGS - faint crackles at left base, otherwise clear HEART - RRR, 1/6 systolic murmur ABDOMEN - prominent umbilical veins. Tense, distended, nontender, + hepatomegaly on percussion, could not assess for shifting dullness as patient unable to lay on back ([3-12] leg discomfort) EXTREMITIES - warm. 1+ pitting edema bilaterally, exquisitely tender SKIN - diffusely scaling. Anterior chest wall with violaceous plaques. R leg recently bandaged, clean and dry. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-13] throughout, Pertinent Results: Admission labs: [2185-12-7] 03:30PM WBC-10.2 RBC-2.63* HGB-8.2* HCT-24.9* MCV-95 MCH-31.1 MCHC-32.9 RDW-17.0* [2185-12-7] 03:30PM NEUTS-73.1* LYMPHS-11.7* MONOS-6.5 EOS-8.4* BASOS-0.3 [2185-12-7] 03:30PM GLUCOSE-232* UREA N-27* CREAT-1.9* SODIUM-127* POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-18* ANION GAP-12 LFTs [2185-12-7] 03:30PM ALT(SGPT)-20 AST(SGOT)-25 LD(LDH)-188 ALK PHOS-79 TOT BILI-1.7* Other Pertinent Labs [2185-12-22] 05:13AM BLOOD WBC-7.7 RBC-3.16* Hgb-9.7* Hct-28.9* MCV-91 MCH-30.8 MCHC-33.7 RDW-18.3* Plt Ct-132* [2185-12-25] 01:04AM BLOOD WBC-11.1* RBC-2.15* Hgb-6.8* Hct-19.5* MCV-91 MCH-31.6 MCHC-34.7 RDW-18.2* Plt Ct-119* [2185-12-26] 03:32AM BLOOD WBC-12.7* RBC-2.64* Hgb-8.4* Hct-23.1* MCV-88 MCH-31.9 MCHC-36.5* RDW-17.6* Plt Ct-106* [2185-12-26] 12:08PM BLOOD WBC-8.9 RBC-2.04* Hgb-6.5* Hct-18.0* MCV-88 MCH-31.7 MCHC-36.1* RDW-17.5* Plt Ct-66* [2185-12-26] 04:08PM BLOOD WBC-14.0# RBC-3.57# Hgb-11.3# Hct-31.2# MCV-87 MCH-31.6 MCHC-36.1* RDW-16.2* Plt Ct-147# [2186-1-8] 05:30AM BLOOD WBC-16.1 RBC-3.67* Hgb-11.7* Hct-34.6* MCV-94 MCH-31.9 MCHC-33.8 RDW-18.9* Plt Ct-229 [2186-1-10] 05:41AM BLOOD WBC-15.8* RBC-3.34* Hgb-10.6* Hct-31.7* MCV-95 MCH-31.7 MCHC-33.4 RDW-19.2* Plt Ct-242 [2186-1-9] 04:30AM BLOOD Neuts-90* Bands-0 Lymphs-2* Monos-3 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 [2186-1-10] 07:00AM BLOOD PT-15.5* PTT-58.6* INR(PT)-1.4* [2185-12-27] 10:11PM BLOOD Fibrino-277# [2185-12-29] 02:19AM BLOOD Fibrino-187 [2185-12-26] 12:08PM BLOOD Ret Aut-3.6* [2185-12-18] 04:43AM BLOOD Glucose-100 UreaN-28* Creat-2.8* Na-136 K-3.8 Cl-105 HCO3-21* AnGap-14 [2185-12-19] 06:25AM BLOOD Glucose-124* UreaN-30* Creat-2.9* Na-135 K-4.0 Cl-103 HCO3-21* AnGap-15 [2185-12-12] 05:52AM BLOOD Glucose-118* UreaN-26* Creat-2.1* Na-136 K-3.9 Cl-106 HCO3-18* AnGap-16 [2185-12-26] 07:41PM BLOOD Glucose-140* UreaN-41* Creat-2.3* Na-144 K-2.9* Cl-110* HCO3-21* AnGap-16 [2185-12-28] 02:15PM BLOOD Glucose-77 UreaN-51* Creat-2.3* Na-143 K-4.0 Cl-110* HCO3-19* AnGap-18 [2186-1-3] 04:30AM BLOOD Glucose-146* UreaN-63* Creat-1.4* Na-137 K-3.8 Cl-109* HCO3-22 AnGap-10 [2186-1-5] 05:04AM BLOOD Glucose-185* UreaN-61* Creat-1.3* Na-132* K-3.8 Cl-105 HCO3-22 AnGap-9 [2186-1-7] 04:23AM BLOOD Glucose-187* UreaN-58* Creat-1.3* Na-129* K-3.8 Cl-102 HCO3-21* AnGap-10 [2186-1-10] 05:41AM BLOOD Glucose-141* UreaN-61* Creat-1.4* Na-130* K-3.7 Cl-101 HCO3-21* AnGap-12 [2185-12-17] 06:21AM BLOOD ALT-8 AST-17 LD(LDH)-149 AlkPhos-48 TotBili-2.9* [2185-12-23] 04:59AM BLOOD ALT-7 AST-18 LD(LDH)-130 AlkPhos-34* TotBili-3.9* [2185-12-28] 02:14AM BLOOD ALT-15 AST-26 AlkPhos-49 TotBili-9.1* DirBili-3.3* IndBili-5.8 [2185-12-30] 01:25AM BLOOD TotBili-6.1* DirBili-2.6* IndBili-3.5 [2186-1-6] 06:45AM BLOOD ALT-37 AST-62* LD(LDH)-193 AlkPhos-103 TotBili-4.8* [2186-1-10] 05:41AM BLOOD ALT-38 AST-55* LD(LDH)-194 AlkPhos-153* TotBili-2.9* [2185-12-27] 03:57PM BLOOD CK-MB-NotDone cTropnT-0.08* [2186-1-1] 02:01AM BLOOD CK-MB-NotDone cTropnT-0.03* [2185-12-30] 04:35PM BLOOD Calcium-11.2* Phos-3.2 Mg-1.8 [2186-1-2] 01:49AM BLOOD Albumin-3.9 Calcium-11.9* Phos-2.6* Mg-2.0 [2186-1-10] 05:41AM BLOOD Albumin-2.8* Calcium-10.8* Phos-3.8 Mg-2.3 [2186-1-1] 02:01AM BLOOD calTIBC-103* Ferritn-407* TRF-79* [2185-12-22] 05:13AM BLOOD Cryoglb-NEGATIVE [2185-12-28] 03:48PM BLOOD Ammonia-<6 [2185-12-17] 06:21AM BLOOD TSH-0.45 [2186-1-7] 03:00PM BLOOD PTH-76* [2185-12-7] 03:30PM BLOOD AFP-4.4 [2185-12-17] 06:21AM BLOOD PEP-HYPOGAMMAG IgG-715 IgA-203 IgM-96 IFE-NO MONOCLO [2186-1-7] 05:59AM BLOOD freeCa-1.45* MICRO Blood cx [12-8] [12-23], [12-25], [1-8] all no growth [1-8], [12-23], [1-2], [12-7] Ascitic fluid cx no growth to date [2186-1-8], [12-25] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST Negative [2186-1-8] URINE URINE CULTURE-FINAL {YEAST} [2186-1-6] URINE URINE CULTURE-FINAL {YEAST} [2186-1-2] Ascitic FLUID no growth [2185-12-25] URINE URINE CULTURE-FINAL {YEAST} [2185-12-23] URINE URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} [2185-12-16] URINE URINE CULTURE-FINAL INPATIENT [2185-12-10] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} I Discharge labs 128 99 63 -----------<155 4.0 20 1.6 Ca: 10.3 Mg: 2.2 P: 3.6 ALT: 41 AP: 159 Tbili: 2.8 Alb: 2.9 AST: 61 LDH: 220 Dbili: wbc 15.2 hgb 10.9 hct 31.9 plt 283 PT: 16.0 PTT: 59.6 INR: 1.4 IMAGING CXR [1-7] FINDINGS: Comparison is made to the prior study from [2186-1-3]. The Dobbhoff tube courses below the diaphragm, but the tip is not seen. A right PICC terminates in the superior vena cava. Heart is top normal in size. There is plate-like atelectasis at the left lung base and at the right lung base. The lungs are otherwise clear. CT Abdomen [12-25] 1. Relatively increased density of left abdominal wall musculature extending into the peritoneum, with relatively high density fluid layering dependently in the pelvis. Findings suggest small intraperitoneal bleed and/or retracted clot related to recent paracentesis. Please correlate clinically. 2. Significant increase in the degree of ascites. 3. Cirrhosis. 4. Gallstones. CT Abdomen [12-26] 1. Evidence of hemoperitoneum, with the greatest density fluid located in the left upper quadrant, likely indicating the area of recent bleeding. The proportion of simple ascites fluid to blood is difficult to assess, but there appears to be more hyperdense material layering dependently within the abdomen compared to yesterday. Hyperdense material also layers in the pelvis, consistent with blood or clot. 2. Cirrhosis. TIPS patency cannot be assessed. 3. Gallstones. 4. Increased opacity at the left lung base possibly representing atelectasis, aspiration, or pneumonia. Renal U/S [12-11] 1. No evidence of stone, mass, or hydronephrosis. 2. Borderline splenomegaly. 3. Large amount of ascites. PATHOLOGY [2185-12-22] Thyroid FNA FNA, Thyroid, left isthmus nodule: SUSPICIOUS for papillary carcinoma. Brief Hospital Course: 59 year-old woman with cirrhosis, with refractory ascites and hyponatremia, presents with hyponatremia, ascites, acute on chronic renal failure, and an elevated WBC. . # cirrhosis/ascites: Patient had known TIPS occlusion. Despite therapeutic tap removing 10 L just 2 days prior to admission, she had considerable ascites on admission. On the day of admission, she developed some mild abdominal pain, and a diagnostic paracentesis was done to rule out SBP, which it did. Lactulose and rifaxamin were continued. Diuretics were held given acute renal failure and hyponatremia (below). TIPS revision was considered but decided against given renal failure. She underwent therapeutic paracentesis of 8.5 L. . For the first 2 weeks of her hospitalization, INR was stable at baseline 1.7-1.9. Total bili was also at baseline. She was noted to be on the [Month/Day/Year ] list with a MELD of ~25. During the third week of her hospitalization, both INR and bilirubin crept up. . Lacutlose was continued; rifaximin was stopped because of concern for allergic interstitial nephritis given peripheral eosinophila and urinary eosinophils. . Tube feeds were initiated to optimize nutrition. . # intra-abdominal bleed - diagnostic paracentesis [12-23] in LLQ, then with steady downward trend of hct, then with acute hct drop to 18 on [12-26], requiring 10uPRBC with 4uFFP and 1u platelets. Repeat CT scan of abdomen showed intra-abdominal bleed. She was taken by surgery to [Hospital ] transferred to SICU. . In the SICU she had uneventful recovery from operation. Details of surgical ICU course not available at this time. # acute on chronic renal failure: Creatinine 2.0 on admission, up from recent baseline 1.5. Likely the recent large volume paracentesis contributed to this. She was given octreotide, midodrine, and albumin as treatment for presumed hepatorenal syndrome. Diuretics were held. Creatinine stabilized with this treatment. The renal consulting service was involved and agreed with the assessment that this was most likely hepatorenal syndrome. Octreotide, midodrine, albumin were stopped for 2 days, but because the creatinine started rising again, the medications were restarted. Creatinine continued to rise, and she was given pRBC with a goal to increase perfusion by keeping hematocrit >28. With this treatment, creatinine stabilized at 2.5. Octreotide, midodrine, and albumin were discontinued and creatinine trended down during admission to 1.2-1.4 but was slightly increased to 1.6 on [1-11] after diuretics restarted [1-11]. Diuretics consequently discontinued. . # metabolic acidosis: Likely secondary to worsening renal failure. Oral sodium bicarbonate treatment was begun and then discontinued as acid base status normalized. . # hyponatremia: Diuretics were held, and sodium rose into the 130s. . # anemia: Hct remained at baseline 24-27. Iron studies were consistent with underproduction secondary to renal failure. She initially received pRBC to keep Hct >28 as above. Subsequently her hematocrit was stable in the low 30s without any transfusion requirement. . # hypercalcemia: The patient had worsening hypercalcemia. Increasing albumin secondary to albumin therapy may have contributed; however, ionized calcium was also slightly elevated. PTH was elevated. The endocrine team saw her and commented that she likely had elements of both secondary hyperparathyroidism (from her renal disease) and primary hyperparathyroidism (given the elevated calcium). 24-hour urinary calcium was low. Vitamin D levels were checked and were still pending at time of discharge. She has endocrine follow-up to be scheduled. They will contact her. Calcium on discharge was 10.3. . # thyroid nodule: The patient had a previously noted thyroid nodule 08/[2185]. This was stable in appearance on repeat ultrasound but concerning for carcinoma. An FNA was performed and showed papillary carcinoma. The endocrinology team advised that this should not preclude liver [Year (4 digits) ] listing, as it had an excellent prognosis. Pt has a f/u appt with Dr. [Last Name (STitle) 5182] in [Month (only) 404] for evaluation for surgery. . # urinary tract infection: The patient had a urinary tract infection with ESBL-producing E Coli that was treated with 3 days of Bactrim. Follow-up cultures were negative. She had a recurrent UTI that was treated with meropenem. Follow up cultures only grew yeast. . # dermatologic abnormalities: Patient had scaling skin. Clobetasol was continued. Wound care assisted with dressing of a wound on her posterior leg. During the third week of her hospitalization, her lower extremity purpura worsened. The dermatology team saw the patient and recommended continuation of topical steroids. After her transfer out of the MICU, she had several hemorrhagic bullae. The dermatology team again saw her and thought this was likely secondary to trauma and fragile skin. Topical steroids were discontinued, and the lesions were dressed with vaseline and gauze. Adhesive dressings were avoided given sensitive skin. Urine phorphobilinogen was sent for possible PCT and was negative. Serum porphyrins were still pending at time of discharge. . # hyperglycemia: After tube feeds were initiated, the patient was hyperglycemic into the low 200s despite no history of diabetes. Regular insulin sliding scale and lantus were initiated and sugars were better controlled 140s-160s. Medications on Admission: Eucerin cream Lasix 40 mg daily (last [12-5]) Lactulose 30 cc [Hospital1 ] Metoclopramide 10 mg TID Nystatin 5 mL suspension QID Pantoprazole 40 mg daily Rifaxamin 400 mg TID (last [12-5]) Aldactone 25 mg qd (last [12-5]) Thiamine 100 mg qd Tylenol 650 mg PRN Clobetasol 0.05 % Cream [Hospital1 ] Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Octreotide Acetate 500 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 5. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Albumin, Human 25 % 25 % Parenteral Solution Sig: 12.5 grams Intravenous once a day. 7. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: primary: acute on chronic renal failure, hyponatremia, hepatitis C cirrhosis, anemia secondary: psoriasis Discharge Condition: hemodynamically stable, afebrile Discharge Instructions: You came to the hospital because you had problems with your kidneys and the sodium level in your blood was low. Your diuretics were stopped, and medications to treat your kidney problems were started. The sodium level improved. . The following medications were changed: lasix was stopped aldactone was stopped lactulose was decreased . Please call your physician or come to the hospital if you have chest pain or shortness of breath, high fevers and chills, nausea and vomitting, or other symptoms that are concerning to you. Followup Instructions: Please call [Telephone/Fax (1) 5189] to arrange follow-up with Dr. [Last Name (STitle) 5182], the thyroid surgeon. You will also follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16865] in [Hospital ] clinic. They will contact you with an appointment in the next 1-2 months to follow up your high calcium levels. If you have any questions, please call [Telephone/Fax (1) 9072]. Please follow up with your liver doctor, Dr. [Last Name (STitle) 696] on Friday [2186-1-19] at 4:40pm.	[ "285.1", "112.0", "553.1", "572.3", "789.59", "696.1", "041.4", "285.21", "276.2", "584.9", "193", "252.00", "E879.4", "427.61", "599.0", "276.1", "585.9", "518.81", "286.9", "428.0", "572.4", "998.11", "879.8", "571.5", "428.32", "E928.9", "070.70" ]	icd9cm	[ [ [] ] ]	[ "33.22", "96.04", "99.07", "99.05", "99.04", "54.19", "54.91", "06.11", "96.71", "53.49", "38.93", "99.14" ]	icd9pcs	[ [ [] ] ]	16238, 16317	9518, 15004	333, 348	16467, 16502	3382, 3382	17079, 17617	2596, 2620		15372, 16215		16338, 16446		15030, 15349			16526, 17056								2635, 3363																					257, 295									376, 1341					3399, 9495									1363, 2352	2368, 2580
23,391	134,102	13776	Discharge summary	report	Admission Date: [2170-12-20] Discharge Date: [2170-12-23] Date of Birth: [2118-4-15] Sex: F Service: Gynecology ADMITTING DIAGNOSIS: Ascites. DISCHARGE DIAGNOSIS: Ascites, status post total abdominal hysterectomy, salpingo-oophorectomy, omentectomy, peritoneal washings. HISTORY: The patient is a 52-year-old female with a history of mild asthma, hypertension, diabetes mellitus, obstructive sleep apnea, and chronic pain who presents with new onset of ascites and elevated CA125 level. Her evaluation in the outpatient setting included a CT scan of the abdomen and pelvis which confirmed a large intraperitoneal ascites without other abnormalities. The course and progression of the patient's ascites development was concerning for ovarian cancer. For this the patient was referred to gynecological oncology. For further evaluation and treatment of patient's condition, an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy was recommended. The patient consented to this treatment plan. When the patient presented on [2170-12-20] to the preoperative holding area, she complained of mild shortness of breath. She had recently been treated with antibiotics for a presumed upper respiratory tract infection and had continued her outpatient asthma care. The preoperative assessment was a mild asthmatic exacerbation. Though more aggressive care would be necessary to optimize the patient's pulmonary status intraoperatively and postoperatively, postponement of the surgery was not considered as the optimal treatment of the patient's acute condition of ascites requiring more immediate diagnosis and intervention given the high suspicion for ovarian cancer. The patient underwent an uncomplicated total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and peritoneal washing on [2170-12-20]. The estimated blood loss was 150 cc. The findings included the following: Large ascites, normal upper abdominal survey, normal omentum, normal bowel, normal uterus, tubes and ovaries, no peritoneal seedings, no palpable lymphadenopathy. The details of this operative procedure are provided in the dictated operative note. Immediately postoperatively extubation was not successful due to significant tachypnea in the setting of the patient's underlying pulmonary disease. Extubation was a completed successfully later that evening. The patient was admitted to the Intensive Care Unit overnight for observation and management of her pulmonary condition. She was treated with Albuterol nebulizer treatments on a regular basis and started on high dose steroids. The patient responded well to that therapy and by postoperative day #1 she was breathing comfortably on 3 liters of oxygen by nasal cannula. The patient continued to do well from a coronary standpoint. She was discharged on a Prednisone taper and continuation of her outpatient Advair and Combivent therapy. The patient's pain management was also closely attended to during her hospitalization. As an outpatient she was managed with 60 mg of OxyContin tid for her chronic pain condition. Once the patient was tolerating an oral diet and intravenous narcotics were discontinued, the OxyContin was restarted with Dilaudid provided as breakthrough. Non steroidal anti-inflammatories and Acetaminophen were continued as well. This regimen successfully controlled the patient's pain and she was discharged on this regimen. FOLLOW-UP: The patient will follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5166] in [5-29] days for a wound check and staple removal. DISCHARGE MEDICATIONS: The patient's outpatient regimen was continued. Additionally she was provided with Dilaudid and Motrin. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 26060] Dictated By:[Last Name (NamePattern1) 37772] MEDQUIST36 D: [2170-12-23] 17:10 T: [2170-12-26] 13:22 JOB#: [Job Number 41431]	[ "493.92", "789.5", "218.9", "780.57", "401.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "68.4", "65.61", "54.4" ]	icd9pcs	[ [ [] ] ]									3687, 4069		195, 3663																																																					163, 173
46,338	111,043	18091	Discharge summary	report	Admission Date: [2112-11-30] Discharge Date: [2112-12-5] Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Nitroglycerin / Naprosyn Attending:[First Name3 (LF) 3223] Chief Complaint: weakness and abdominal fullness on initial presentation then transferred with hypotension, tachycardia, intubated. Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ]F s/p AAA repair, patient brought to [Hospital3 ] following episode of weakness, and vomitted, followed by patient "slumping over" and becoming unresponsive. She was intubated and then transferred to [Hospital1 18] for tachycardia and hypotension to 70s sBP. She was, by report, pale, cool and diaphoretic). At [Location (un) 620] the patient's blood pressure reportedly responded to fluids and pressors. It is uncertain whether she experienced abdominal pain previously but on presentation to this hospital she was noted to have a positive FAST scan for fluid in [Location (un) 6813] pouch. Given her history of AAA repair, patient was assessed by vascular surgery. Patient was incontinent of large amounts of liquid stool which was guaiac negative. She was reportedly afebrile throughout. Patient's family reports that she had a ?septic joint for the past 10 days. Per report review of systems was otherwise negative. Past Medical History: PMH: Hypothyroidism Afib on Coumadin CHF Asthma Past MIs PSH: CABG AAA repair Social History: Lives in [Location 620]; daughter [Name (NI) 319] [Name (NI) ] [Telephone/Fax (1) 50063] No ETOH No tobacco Family History: non contributory Physical Exam: T 98.3 125 (Neo @ 2)137/95 20 97% (intubated CMV 100% 416 x 20 8/-) CVS: normal S1, S2, no murmurs Resp: mild bilateral coarse breath sounds [Last Name (un) ]: soft, no apparent tenderness, non-distended, patient otherwise intubated and sedated), not tympanitic Ext: cold, mottled, peripheral signals dopplerable Pertinent Results: [2112-11-29] 10:53PM WBC-17.3* RBC-4.03* HGB-10.7* HCT-33.8* MCV-84 MCH-26.6* MCHC-31.7 RDW-15.6* [2112-11-29] 10:53PM PT-64.3* PTT-37.0* INR(PT)-7.4* [2112-11-29] 10:53PM ALT(SGPT)-21 AST(SGOT)-40 CK(CPK)-185 ALK PHOS-113* TOT BILI-1.3 [2112-11-29] 10:53PM ALBUMIN-2.7* CALCIUM-7.2* PHOSPHATE-3.5 MAGNESIUM-2.3 [2112-11-29] 10:53PM GLUCOSE-194* UREA N-53* CREAT-1.9* SODIUM-132* POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-21* ANION GAP-12 [2112-11-30] 12:19PM WBC-14.5* RBC-3.36* HGB-9.2* HCT-27.2* MCV-81* MCH-27.3 MCHC-33.6 RDW-15.8* [2112-11-30] 12:19PM PLT COUNT-250 [2112-11-30] 12:19PM PT-15.2* PTT-27.9 INR(PT)-1.3* [2112-11-30] 12:19PM GLUCOSE-171* UREA N-44* CREAT-1.7* SODIUM-136 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15 [2112-11-29] CT Abd/pelvis : 1. Interval development of a small amount of intra-abdominal ascites in a perisplenic and perihepatic location with also ascites tracking down the paracolic gutters. 2. Segment of bowel wall thickening and associated colonic stranding and fluid, most indicative of a colitis involving the descending colon. The SMA/[Female First Name (un) 899] origins are heavily calcified. 3. Extensive atherosclerotic disease as detailed above with no evidence of acute rupture. Focal areas of outpouching do not demonstrate contrast within them and are likely related to prior post-surgical change/hematoma. [2112-11-29] Head CT : 1. No acute intracranial process. 2. Subcutaneous emphysema in the left masticator space of uncertain etiology, the majority immediately medial to the left temporal-mandibular joint. Clinical correlation with the findings in this region is advised. NOTE ADDED IN ATTENDING REVIEW: The abundant fluid and aerosolized secretions occupying the nasopharynx, nasal choanae and dorsal aspect of the nasal cavity likely relates to intubation and supine positioning. The pockets of subcutaneous emphysema, largely in the left masticator space, may reside in the pterygoid venous plexus and its tributaries, but should be correlated with history of recent placement of intravenous access, possibly of relatively large-bore. [2112-12-3] Right arm duplex scan : 1. No right upper extremity DVT. 2. Mild subcutaneous edema. Brief Hospital Course: Ms. [Known lastname 50064] was evaluated by the Acute care Service in the Emergency Room and her scans were reviewed. Based on her presenting symptoms to [Location (un) 620] and he CT scan she was admitted to the ICU for ischemic colitis, placed on broad spectrum antibiotics, hydrated and her blood pressure was supported with pressors initially. She was also evaluated by the Vascular Surgery service as there was some question of a possible pseudoaneurysm from her AAA repair in [2102]. The repair was intact, all arteries were patent and there was no evidence of any vascular events to explain her possible low flow state. Prior to admission her family remembered that she complained of large amounts of liquid stool. Her rectal exam was normal and her stool was guiac negative. A stool for C difficile was also negative. Her elevated WBC was gradually trending down and her abdominal exam improved daily. Her INR at [Location (un) 620] was 5.7 and she received 2 units of FFP to try to normalize it. Her hematocrit on admission was 29 and gradually decreased to 21 but she was asymptomatic and therefore not transfused. Prior to discharge her hematocrit was 23.8. She was easily extubated from the respirator on [2112-12-1] and remained free of any pulmonary complications during her stay. from a cardiovascular standpoint she was easily weaned off her pressors after she was fully fluid resuscitated. Her pre admission medications were resumed and her blood pressure was 140/80-90 without any hypotension. She was on an ACE inhibitor, beta blocker as well as Lasix for her chronic diastolic heart failure and she tolerated these medications well. Following transfer to the Surgical floor she continued to make good progress. Her abdominal pain resolved and she was working with the Physical Therapist daily to improve her endurance. Her appetite was only fair but she would gladly take protein shakes for supplementation. She had some right shoulder pain weeks prior to admission although no injury was noted on scans. The Physical Therapy service gave her some exercises to do to improve her ROM which she will continue with. On [2112-12-3] she had a duplex scan done of the right upper extremity to rule out DVT as she had noticible swelling in the lower arm and hand. She did have a right subclavian line in place in the ICU. The scan was negative and elevation helped a bit but she will need to continue that as well as staying off her right side. She will complete a 7 day course of Flagyl and Cipro on [2112-12-7] which she has done well with. Her Coumadin has been on hold since admission but there is no reason to withhold it any longer. Her home dose was 3 mg daily and can begin tonight. She was discharged to rehab on [2112-12-5] and will follow up in the Acute Care Clinic in [2-24] weeks. Medications on Admission: Lasix 80mg qod alt with 40mg qod Lovastatin 60 mg daily Lopressor 200 mg daily Moexipril 30 mg daily Coumadin 3mg daily Aspirin 81mg daily Vitamin D3 1000 units daily Discharge Medications: 1. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. moexipril 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. lovastatin 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: thru [2112-12-7]. 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: thru [2112-12-7]. Discharge Disposition: Extended Care Facility: [Location (un) 1036] Discharge Diagnosis: ischemic colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with colitis possibly due to poor circulation. Your symptoms improved with bowel rest, antibiotics and hydration. * You are now able to tolerate a regular diet and should try to have a little something at each meal. taking protein shakes will also help until your appetite improves. * You are being transferred to rehab for a short stay to increase your stamina and endurance with more physical therapy. * If your pain recurs or if you develop any other symptoms that concern you please return to the Emergency Room. * Your Coumadin has been held but you can safely resume it now. you will need to have your blood tested daily initially so that you will be on an appropriete dose. * You should elevate your right arm on pillows to decrease the swelling. Followup Instructions: Please follow up in [2-24] weeks in Acute Care Clinic Call [Telephone/Fax (1) 600] for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2112-12-5]	[ "244.9", "995.92", "412", "038.9", "428.0", "785.52", "V45.81", "493.90", "428.32", "557.9", "427.31", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.71", "38.91" ]	icd9pcs	[ [ [] ] ]	8058, 8109	4306, 7174	381, 388	8170, 8170	2011, 4283	9138, 9409	1640, 1658		7391, 8035		8130, 8149		7200, 7368			8321, 9115								1673, 1992																					227, 343									416, 1380									8185, 8297					1402, 1483	1499, 1624
12,041	105,267	6910	Discharge summary	report	Admission Date: [2137-5-27] Discharge Date: [2137-6-6] Date of Birth: [2095-5-8] Sex: M Service: UROLOGY HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 26022] is a 42 year old white male with a history of metastatic testicular carcinoma diagnosed in [2125] status post left radical orchiectomy followed by four cycles of Bleomycin, Etoposide, and Cisplatin. Mr. [Known lastname 26022] was also diagnosed with HIV in [2123] and has been on long standing anti-retroviral therapy since that time. His recent CD4 count was 702 and his viral load was 1060. The patient had been free from recurrence of his testicular cancer until approximately six months ago when he presented with low back pain after going on an HIV "drug holiday". At the time of his presenting low back pain, the patient also had symptoms of malaise and a low grade fever. His work-up at the time was notable for significant retroperitoneal lymphadenopathy by CT scan. Multiple CT guided percutaneous biopsies were performed and these were not diagnostic revealing follicular hyperplasia. With a continuously rising alpha fetoprotein level, last measured at 214, open surgery was recommended. PAST MEDICAL HISTORY: 1. Metastatic non-seminoma testicular carcinoma. 2. Human Immunodeficiency Virus. 3. Noninsulin dependent diabetes mellitus. 4. Depression. PAST SURGICAL HISTORY: 1. Left radical orchiectomy in [2125]. 2. Status post lipectomy. 3. Status post atypical nevus excision. MEDICATIONS ON ADMISSION: 1. Flonase. 2. Zantac. 3. Acyclovir. 4. Kaletra. 5. Epivir. 6. Effexor. 7. AndroGel 8. Chloral hydrate. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Temperature 95.9 F.; blood pressure 126/68; pulse 72; respiratory rate 16; oxygen saturation 98% on room air. In general, the patient is a pleasant, moderately obese white male in no apparent distress. HEENT: Clear oropharynx, moist mucous membranes. Anicteric sclerae. Neck: Soft, no masses, no lymphadenopathy, no bruits. Lungs are clear to auscultation and percussion bilaterally. Heart is regular rate and rhythm, normal S1, S2, no murmurs. Abdomen soft, obese, nontender. Left abdominal scar, well healed. No hepatosplenomegaly. Normoactive bowel sounds. No cyanosis, clubbing or edema. Two plus dorsalis pedis pulses bilaterally. LABORATORY: The white blood cell count was 9.6, hematocrit 40.2, platelet count 325, INR 1.0. CD4 count 702. Glucose 93. BUN 18, creatinine 0.6. AST 14, ALT 18; alkaline phosphatase 89, amylase 55. Total bilirubin 0.4, direct bilirubin 0.1, indirect bilirubin 0.3. His AFP was 214.3, which was up from 199.7 in [2137-2-9], and 110.7 in [2137-1-12]. The HIV viral load was 1,060. IMAGING: CT scan study obtained in [2137-3-12], revealed significant retroperitoneal, inguinal and pelvic lymphadenopathy. The lymphadenopathy has been overall stable, although there has been one para-aortic lymph node which increased in size from 2.6 by 2.1 centimeters to 3.4 by 3.2 centimeters. The preoperative chest x-ray was within normal limits. The preoperative EKG demonstrated normal sinus rhythm at a rate of 78 beats per minute. HOSPITAL COURSE: On the date of admission, the patient was taken to the Operating Room where he underwent a bilateral retroperitoneal pelvic lymph node dissection. The estimated blood loss from the procedure was 1500 cc. The specimens sent included the lymph nodes as well as the left gonadal vein. Intraoperatively, a Foley catheter was placed along with an nasogastric tube. Postoperatively, the patient was admitted to the surgical Intensive Care Unit intubated and sedated. His postoperative creatinine was 0.8; his postoperative hematocrit was 37.7. The following morning, postoperative day one, the patient was extubated and subsequently transferred to a regular hospital floor the following afternoon. The patient had adequate urine output, but did have significant pain issues necessitating a pain service consultation to manage this. Thereafter, the patient's pain was tolerable. The nasogastric tube was removed on postoperative day five, along with the Foley catheter. The patient began eating at that time and Physical Therapy and Occupational Therapy were consulted to [Year (4 digits) ] with transferring and personal care needs. The patient was becoming increasingly depressed at this time, concerned that he was not able to care for himself, and mobilize as easily as he had been prior to his surgery. On postoperative day seven, the patient was ready to be discharged when a large amount of serous fluid began draining from his inferior abdominal incision. Approximately 700 cc of serous fluid were expressed and the patient was sent for a CT scan to evaluate fascial dehiscence. Abdominal examination at this time revealed that the staples were intact, that the abdomen was soft, and that there was no erythema nor palpable masses at the incision site. The CT scan did not suggest evidence of fascial dehiscence, although it did indicate that there were was a moderate amount of intra-abdominal ascites present. The serous fluid was sent for evaluation, revealing a creatinine level of 1.0 and amylase level of 35 and a triglyceride level of 23. The patient was diuresed with Lasix as needed and a rectal bag was secured over the abdominal incision to collect the drainage. The abdominal drainage persisted throughout postoperative day eight and postoperative day nine, although it diminished significantly on postoperative day ten. At this time, it was felt that a repeat CT scan was not necessary and the patient was sent home on postoperative day ten with the visiting nurse [First Name (Titles) ] [Last Name (Titles) ] with wound care and care of the abdominal drain and collection of the abdominal drain contents. DISCHARGE DIAGNOSES: 1. Recurrent metastatic left testicular carcinoma. 2. Postoperative ascites and incisional drainage 3. Postoperative ileus 4. Human Immunodeficiency Virus. 5. Depression. 6. Obstructive sleep apnea. 7. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Furosemide 40 mg p.o. q. day times seven days. 2. Potassium chloride 40 mEq p.o. q. day times seven days. 3. Ibuprofen 400 mg p.o. q. eight hours p.r.n. pain. 4. Kaletra as directed. 5. Epivir as directed. 6. Acyclovir as directed. 7. Ranitidine as directed. 8. Effexor as directed. 9. Chloral hydrate as directed. 10. AndroGel as directed. 11. Flonase as directed. DISCHARGE INSTRUCTIONS: 1. The patient was told to follow-up with Dr. [Last Name (STitle) 9125] in one to two weeks for staple removal. 2. He was told to see Dr. [Last Name (STitle) 9125] earlier if there was significant output from the abdominal drainage bag. 3. The patient was also told to follow-up with his primary care physician regarding his HIV issues as needed. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home with services. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [MD Number(1) 13269] Dictated By:[Last Name (NamePattern1) 26023] MEDQUIST36 D: [2137-6-27] 11:18 T: [2137-7-4] 23:12 JOB#: [Job Number 26024]	[ "789.5", "250.00", "780.57", "V08", "196.2", "518.81", "311", "530.81", "285.1" ]	icd9cm	[ [ [] ] ]	[ "40.3" ]	icd9pcs	[ [ [] ] ]								5917, 6161	6184, 6563				1543, 1711	3245, 5896		6587, 6946						1404, 1517															1735, 3227																	164, 1214														1236, 1381		6972, 7326
11,342	154,014	49016	Discharge summary	report	Admission Date: [2181-10-15] Discharge Date: [2181-10-23] Date of Birth: [2130-4-3] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Optiray 350 Attending:[First Name3 (LF) 668] Chief Complaint: Reason for Admission/CC:[CC Contact Info 102888] Major Surgical or Invasive Procedure: none History of Present Illness: 51F pmhx HCV/HCC cirrhosis now POD10 s/p OLT discharged to rehab 5 days prior to readmission with post-operative course remarkable for acute renal insufficiency and hyponatremia which were resolving at time of discharge. Per report, pt with acute change in mental status this morning at rehab facility described as confusion without agitation. Pt reportedly had adequate pain control, tolerating PO without nausea/vomiting, voiding without difficulty, and ambulating with assistance. Direct admission given temporal association with OLT and acute altered mental status. No reported ingestion, abdominal trauma or head trauma. At time of admission, pt coherent, NAD, A/Ox3, but some word-finding difficulty and distractability without focal neurologic deficits. AFVSS without abdominal pain or signs of wound infection. Past Medical History: - COPD - Cirrhosis c/b variceal bleed, hepatic encephalopathy, and ascites s/p TIPS procedure and embolization of duodenal varix - History of Heavy ETOH abuse - HCV (antibody postive, RNA negative) - Celiac: diagnosed with bx, noncompliant to gluten free diet - Chronic LE neuropathy - ?Diastolic CHF - Depression - Osteopenia - Hypothyroidism - s/p CCY - s/p TAH for endometrial hyperplasia Social History: Lives with husband. [Name (NI) ] 1 son. Previously worked as an accountant but is not currently working. Former smoker, quit in [2175], has 30 pack year smoking history. Was drinking alcohol [12-10] gallon of vodka until [2175] when she quit. Denies IVDU. Family History: Father died of MI in 80s. Many alcoholics in family. One cousin with celiac sprue. Physical Exam: VS: T 97.6, HR 87, BP 138/73, RR 26, SaO2 100%3Lnc GEN: NAD, A/Ox3, confused, stuttering words but easily directable NEURO: CN2-12 intact, no facial droop, tongue midline, no obvious asymmetry on exam. Extremity strength/sensation intact without focal deficits. HEENT: PERRL, no scleral icterus CV: RRR, no M/R/G, nl s1s2 PULM: CTAB, no W/R/R BACK: no CVAT ABD: soft, nontender, nondistended. Extended subcostal staple line intact without fluctuance/drainage/erythema. Punctate ecchymoses at staple line and former drain insertion sites, no underlying fluctuance/tenderness. PELVIS: deferred EXT: WWP, 1+ pedal edema, 2+ distal pulses LABS: 7.7 19.4 >------< 243 ∆ 23.3 121 / 86 / 67 ---------------<183 AGap=19 5.0 / 21 / 2.1 estGFR: 25/30 Ca: 8.0 Mg: 2.5 P: 5.3 ∆ ALT: 60 AST: 42 AP: 104 Tbili: 0.7 Alb: 3.0 PT: 11.6 PTT: 20.8 INR: 1.0 IMAGING: Liver Duplex [prelim, verbally communicated] Hepatic artery: Portal System: Peak RI Main - 50 0.69 Main - ?turbulent flow v artifact Left - 29.6 0.63 Left - patent Right - 27.8 0.57 R ant - patent R post - patent Hepatic Veins: Patent Fluid collections: None Pertinent Results: [2181-10-15] 07:25PM BLOOD WBC-19.4# RBC-2.61 Hgb-7.7* Hct-23.3* MCV-89 MCH-29.6 MCHC-33.1 RDW-15.7* Plt Ct-243# [2181-10-16] 05:06AM BLOOD WBC-16.2* RBC-2.35* Hgb-7.0* Hct-21.6* MCV-92 MCH-29.9 MCHC-32.4 RDW-16.0* Plt Ct-240 [2181-10-17] 02:16AM BLOOD WBC-15.6* RBC-2.98# Hgb-8.8# Hct-26.3* MCV-88 MCH-29.6 MCHC-33.6 RDW-15.9* Plt Ct-208 [2181-10-23] 05:14AM BLOOD WBC-11.2* RBC-3.35* Hgb-10.2* Hct-30.4* MCV-91 MCH-30.6 MCHC-33.8 RDW-15.7* Plt Ct-240 [2181-10-18] 02:20AM BLOOD PT-12.4 PTT-21.3* INR(PT)-1.0 [2181-10-23] 05:14AM BLOOD Glucose-112* UreaN-21* Creat-0.8 Na-136 K-3.8 Cl-104 HCO3-21* AnGap-15 [2181-10-15] 07:25PM BLOOD ALT-60* AST-42* AlkPhos-104 TotBili-0.7 [2181-10-16] 05:06AM BLOOD ALT-50* AST-37 AlkPhos-84 TotBili-0.7 [2181-10-23] 05:14AM BLOOD ALT-64* AST-46* AlkPhos-207* TotBili-0.7 [2181-10-21] 05:50AM BLOOD Albumin-3.1* Calcium-8.3* Phos-4.3 Mg-1.5* [2181-10-22] 05:30AM BLOOD tacroFK-7.7 Brief Hospital Course: 51F with h/o HCV/HCV cirrhosis POD10 from liver transplant admitted with AMS, no clinical or radiographic evidence of graft rejection / portal vein compromise in setting of leukocytosis, renal insufficiency,and anemia. She was admitted to Transplant Surgery (Dr. [First Name (STitle) ]and pan cultured. IVF resuscitation for hyponatremia was administered. Broad spectrum antibiotics were given. CT abd/pel was done to assess for intraabdominal pathology. This demonstrated a lesser sac fluid collection adjacent to the pancreas. A smaller fluid collection was seen anterior to the stomach deep to the left anterior abdominal wall, which did not communicate with the lesser sac collection. Dilated loops of small bowel with no focal transition point were noted. Fluid collection was unable to be drained by radiology. Post-transplantation immunosuppressive regimen continued. Hct was 21. She was transfused with HCT increase to 27. This remained stable. Sodium was 125. IV NS at 75 was continued with improvement of serum sodium to 130. An NG was placed for emesis and KUB demonstrated dilated small bowel. TPN in addition to NS was started. Feeding tube was placed. Neuro was consulted for confusion, insomnia, hallucinations and twitching. Head CT was done and was negative for acute intracranial abnormality. Neuro status was most likely a metabolic/toxic encephalopathy with features of an agitated delirium. Steroid psychosis was suspected that may have been exacerbated by SSRI. Effexor was stopped and Zyprexa given. The twitching/myoclonus could not be explained by steroid side effects. Tacrolimus was a potential culpert and dose was lowered. Mental status improved. Nausea/vomiting resolved. Diet was advanced and tolerated. Appetite and po intake were excellent. TPN was stopped and feeding tube feeds was removed. [Last Name (un) ] was consulted and recommended continuing NPH 10 units qam with humalog sliding scale. Vanco & Zosyn were given [10-16] thru [10-22]. Cultures (blood/urine and stool)remained negative. PT declared her safe for home with rolling walker. She was discharged to home. Care Group VNA 1-[Telephone/Fax (1) 14297] for NSG, PT, OT, HHA was arranged. Medications on Admission: Albuterol 2.5 mg/3 mL (0.083 %)prn, Fluticasone-Salmeterol 250/50'', Ibandronate 3mg/3mL 1inj q3mo, Levothyroxine 50, Omeprazole EC 20, Pregabalin 50'', Tiotropium 18, Venlafaxine 75, Zolpidem 10qHS, NPH14u qAM/LisproRISS, Valcyte 450, Fluconazole 400, Bss, Prednisone 20, MMF 1000'', Tacrolimus 1'', Oxycodone 5prn Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Telephone/Fax (1) ]:30 Tablet(s) Refills:2 4. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): follow taper. Decrease dose to 17.5mg on [10-25]. 5. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). [Month/Year (2) ]:60 Capsule(s) Refills:2 6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [Month/Year (2) ]:30 Refills:2 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). [Hospital1 ]:1 Disk with Device(s) Refills:2 11. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. [Hospital1 ]:30 Tablet(s) Refills:0 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:8 Tablet(s) Refills:0 14. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day. [Hospital1 ]:1 bottle Refills:2 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day. [Hospital1 ]:1 bottle Refills:2 16. syringes Low dose insulin syringes for daily nph and sliding scale humalog qid 25-26 gauge needles supply: 1 box refill: 2 17. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 18. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 19. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 1 months. [Hospital1 ]:30 Capsule, Delayed Release(E.C.)(s) Refills:1 20. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous four times a day. [Hospital1 ]:1 bottle Refills:2 21. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous once a day. [Hospital1 ]:1 meter Refills:0 22. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four times a day. [Hospital1 ]:1 box Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Acute mental status changes likely r/t steroid psychosis, resolved h/o liver transplant abdominal collection DM 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: -Care Group VNA 1-[Telephone/Fax (1) 14297] has been arranged to see you at home -Please call the Transplant Office [Telephone/Fax (1) 673] if you have any of the warning signs -You will need to have blood drawn for labs every Monday and Thursday for lab monitoring at [Hospital1 18] lab on [Location (un) 453] of [Hospital ] Medical Office Building -you may shower -check your weight daily and call if you have a 3 pound/day weight gain or you feel dizzy/thirsty or legs look less swollen -You may shower -No heavy lifting/straining Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2181-10-31] 9:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2181-11-7] 9:40 Completed by:[2181-10-23]	[ "780.1", "250.00", "579.0", "E932.0", "733.90", "311", "781.0", "496", "V42.7", "567.22", "349.82", "293.0", "244.9", "780.52", "276.1" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	9386, 9444	4266, 6482	348, 355	9600, 9600	3277, 4243	10362, 10737	1933, 2017		6850, 9363		9465, 9579		6509, 6827			9783, 10339								2032, 3258																					256, 310									383, 1208									9615, 9759					1230, 1624	1640, 1917
653	155,866	11127	Discharge summary	report	Admission Date: [2117-3-3] Discharge Date: [2117-3-18] Date of Birth: [2040-3-14] Sex: M Service: MEDICINE Allergies: Angiotensin Receptor Antagonist / Ace Inhibitors Attending:[First Name3 (LF) 783] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Electric Cardioversion. History of Present Illness: Mr [Known lastname 35869] is a 76 year old gentleman with a history of CAD s/p stenting of RCA in [2113], hypertension, hypercholesterolemia, and new-onset atrial fibrillation, presenting with progressive shortness of breath. His problems started a few months ago. He started to feel more short of breath, especially with exertion/walking, and he would experience left-sided sharp chest pain (non pleuritic, no radiation or associated symptoms) with severe episodes. Of note, he was diagnosed with new atrial fibrillation in [11-14], and was started on coumadin at this time (and was on beta blocker already). He went to Floriday in [Month (only) 956], and while on the plane, he had increased shortness of breath with the associated chest pain. He also noted the onset of new bilateral LE swelling. When he got off the plane, he went to a hospital in [State 108] where he was admitted for 2 days, a CXR showed LLL infiltrate, and he was started on antibiotics (completed a 7-day course of a fluoroquinolone). A BNP was normal at 50, he was given 40 mg IV lasix, and discharged on PO Lasix. His symptoms did not improve and in fact, worsened. He denied any fever/chills/abdominal pain/bowel or urinary symptoms, but said he was experiencing PND/orthopnea (states he hardly sleeps at night, can only sleep at 60-90 degree angle) which had been getting progressively worse. He denied palpitations, light headedness, or dizziness, but he stated that he had had episodes in the past few months where he would just pass out/thought he suddenly fell asleep. He denied any prodromal symptoms before these episodes and denied any tongue biting, loss of bowel or bladder function. He does not think he lost consciousness with these episodes. He was hospitalized this second time from [Date range (1) 35870], and at this time, he was treated with rocephin/azithro, V/Q was low prob, bilateral LENI's were negative, BNP was 126. To work up these ?syncopal episodes, neuro was consulted, and CT of the head was negative, bilateral carotid US showed only 30% stenosis, EEG was negative, and TTE showed EF=60% with trival PR, borderline concentric LVH. He was discharged and returned to [State ] on the day of admission. He came right to the hospital, stating that he had no improvement in his symptoms of shortness of breath. In the ED, he was afebrile, 92% on room air, found to have BNP of 1386. He was given 40 mg IV lasix with good diuresis. CTA could not be performed, for he couldn't lie flat due to his SOB. He was admitted for further workup of this shortness of breath. Past Medical History: 1. CAD, s/p stenting of RCA in [2113] TTE at OSH: EF=60% as above 2. Atrial fibrillation, diagnosed [11-14], on coumadin 3. HTN 4. Hypercholesterolemia 5. Gout 6. s/p Spinal fusion 7. Benign tumor of Left breatst 6 yrs ago 8. Left knee TKR 9. Benign tumor of spine 10. Appendectomy Social History: Lives with wife who is paraplegic, retired machine store owner. Quit smoking 50-60 yrs ago (smoked 1 [12-13] pack/wk x 1yr), drinks 1-2 drinks/d Family History: Non-contributory. Physical Exam: PE: VS: 96.3 78 153/50 20 97% 2L Gen: very pleasant gentleman, speaking in short sentences, using accessory muscles to breath, working hard to breath HEENT: PERRL, OP clear Neck: no LAD, JVD to ear at 90 degrees CV: irreg irreg s1/s2, no m/r/g appreciated Lungs: crackles 1/3 up lungs bilaterally but distant breath sounds, no wheezes/rhonchi Abd: protuberant, soft, nt/nd, nabs Extr: [12-13]+ pitting edema to mid calf bilaterally, DP 1+ bilaterally Pertinent Results: ECHO/TTE ([2117-3-4]): The left atrium is normal in size. The left ventricular cavity size is normal. Views are technically suboptimal for assessment of ventricular systolic function. Left ventricular function is probably mildly impaired with inferior/inferolateral hypokinesis. Estimated ejection fraction ?50%. Right ventricular chamber size is normal. Right ventricular systolic function is probably normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. There is at least mild pulmonary artery systolic hypertension. ECHO/TTE ([2117-3-16]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2117-3-4], the findings are similar (trace aortic regurgitation is now seen - may be due to technical differences). CXR PA/LAT ([2117-3-2]): The heart is of normal size for technique. The pulmonary vascularity is difficult to evaluate due to very low lung volumes. There are bibasilar atelectases. There is a left retrocardiac opacity that most likely represents atelectasis. There are no obvious pleural effusions. There are degenerative changes of the thoracic spine. The patient is status post posterior spinal fusion of the lumbar spine. There is no pneumothorax. CXR PA/LAT ([2117-3-16]): IMPRESSION: Persistent patchy bibasilar opacities, most likely due to atelectasis. Underlying infection in the left lower lobe cannot be fully excluded. [2117-3-3] 05:13PM BLOOD freeCa-1.26 [2117-3-3] 05:13PM BLOOD O2 Sat-97 [2117-3-8] 05:22PM BLOOD O2 Sat-60 [2117-3-3] 01:16PM BLOOD Lactate-1.2 [2117-3-3] 05:13PM BLOOD Lactate-0.9 [2117-3-3] 01:16PM BLOOD Type-ART pO2-44* pCO2-81* pH-7.31* calHCO3-43* Base XS-10 [2117-3-3] 05:13PM BLOOD Type-ART pO2-92 pCO2-81* pH-7.31* calHCO3-43* Base XS-10 Intubat-NOT INTUBA [2117-3-4] 08:00PM BLOOD Type-[Last Name (un) ] pO2-44* pCO2-80* pH-7.31* calHCO3-42* Base XS-9 [2117-3-8] 05:22PM BLOOD Type-ART pO2-34* pCO2-71* pH-7.33* calHCO3-39* Base XS-7 Comment-QNS TO [Last Name (un) ] [2117-3-9] 05:06AM BLOOD Cortsol-29.8* [2117-3-7] 05:00AM BLOOD TSH-2.0 [2117-3-7] 05:00AM BLOOD VitB12->[2111] Folate-10.2 [2117-3-12] 05:00AM BLOOD calTIBC-252* Ferritn-1088* TRF-194* [2117-3-2] 03:00PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9 [2117-3-3] 04:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.9 [2117-3-2] 03:00PM BLOOD CK-MB-4 proBNP-1386* [2117-3-2] 03:00PM BLOOD cTropnT-<0.01 [2117-3-2] 09:50PM BLOOD CK-MB-NotDone [2117-3-2] 09:50PM BLOOD cTropnT-<0.01 [2117-3-3] 04:00AM BLOOD CK-MB-NotDone [2117-3-3] 04:00AM BLOOD cTropnT-<0.01 [2117-3-8] 06:10AM BLOOD proBNP-1365* [2117-3-2] 03:00PM BLOOD Lipase-23 [2117-3-2] 03:00PM BLOOD CK(CPK)-132 [2117-3-2] 09:50PM BLOOD CK(CPK)-87 [2117-3-3] 04:00AM BLOOD CK(CPK)-92 [2117-3-8] 06:10AM BLOOD ALT-20 AST-32 LD(LDH)-267* AlkPhos-87 TotBili-0.8 [2117-3-2] 03:00PM BLOOD Glucose-98 UreaN-28* Creat-1.1 Na-132* K-5.4* Cl-91* HCO3-36* AnGap-10 [2117-3-3] 04:00AM BLOOD Glucose-99 UreaN-22* Creat-1.0 Na-137 K-4.1 Cl-91* HCO3-40* AnGap-10 [2117-3-16] 05:00AM BLOOD Glucose-122* UreaN-30* Creat-0.8 Na-133 K-4.3 Cl-86* HCO3-42* AnGap-9 [2117-3-17] 05:10AM BLOOD Glucose-117* UreaN-35* Creat-1.0 Na-133 K-4.6 Cl-87* HCO3-41* AnGap-10 [2117-3-2] 03:00PM BLOOD PT-19.6* PTT-32.2 INR(PT)-2.4 [2117-3-2] 03:00PM BLOOD Plt Ct-225 [2117-3-16] 05:00AM BLOOD PT-19.7* INR(PT)-2.4 [2117-3-16] 05:00AM BLOOD Plt Ct-303 [2117-3-17] 05:10AM BLOOD PT-17.1* INR(PT)-1.9 [2117-3-17] 05:10AM BLOOD Plt Ct-274 [2117-3-2] 03:00PM BLOOD Neuts-70.6* Lymphs-20.8 Monos-6.6 Eos-1.7 Baso-0.3 [2117-3-15] 05:00AM BLOOD Neuts-87.2* Lymphs-5.7* Monos-6.8 Eos-0.3 Baso-0.1 [2117-3-2] 03:00PM BLOOD WBC-4.9 RBC-3.81* Hgb-13.2* Hct-38.9* MCV-102* MCH-34.6* MCHC-33.8 RDW-13.3 Plt Ct-225 [2117-3-3] 04:00AM BLOOD WBC-5.4 RBC-3.90* Hgb-13.5* Hct-40.4 MCV-104* MCH-34.6* MCHC-33.5 RDW-13.5 Plt Ct-220 [2117-3-16] 05:00AM BLOOD WBC-12.8* RBC-3.62* Hgb-12.1* Hct-37.1* MCV-103* MCH-33.5* MCHC-32.6 RDW-12.7 Plt Ct-303 [2117-3-17] 05:10AM BLOOD WBC-9.6 RBC-3.56* Hgb-12.1* Hct-36.9* MCV-104* MCH-34.0* MCHC-32.8 RDW-13.1 Plt Ct-274 Brief Hospital Course: Mr [Known lastname 35869] is a pleasant man with a history of known CAD, OSA and new-onset AF who was first admitted to [Initials (NamePattern4) ] [Last Name (NamePattern4) 108] hospital with subacute on chronic (2-3 months) dyspnea. He was treated for pneumonia and then was treated for CHF. He was then admitted to [Hospital1 18] Medicine for a further evaluation of his breathing difficulty. The cause of his symptoms was likely a diastolic heart failure (dCHF), given his chest-xray findings, normal LVEF on ECHO, elevated BNP and clinical findings and history. An etiology of his dCHF was not found, but was possibly ischemic. Early in his course, he underwent successful electric cardioversion of his atrial fibrillation. This occurred in the CCU given his progressively falling systolic blood pressures, in the setting of heart failure and [Last Name (un) ] initiation. Fluid removal, via Nesiritide and Lasix was continued for a brief time in the CCU. He remained in sinus rhythm for most of the remainder of his course, with paroxysms of atrial fibrillation. His symptoms slowly improved and success was achieved in lowering his weight and oxygen requirement. Nevertheless, on discharge he still required low-level nasal cannula supplemental oxygen and was somewhat breathless on exam. 1. Dyspnea: As mentioned, the likely etiology of his symptoms was dCHF, but an alternate etiology possible. His initial CXR and BNP, along with his increasing weight, lower extremity edema, orthopnea, and PND all pointed towards CHF. He improved somewhat with diuresis (via Lasix and Nesiritide), beta-blockade (Metoprolol 25 mg PO BID) and then cardioversion from AF to sinus rhythm. of note, a work-up for pulmonary embolism via CTA at the [Hospital 108] hospital was negative. A persistent atelectasis versus infiltrate of his left lower lobe in the lung was observed. He was treated for pneumonia at the outside hospital and also received a five-day course of Levofloxacin at [Hospital1 18] (for a UTI). 2. CHF: The admission ECHO showed an EF of 50%. Again, the cause of his dysfunction was not known, but was likely diastolic, but the exact etiology was unknown. He was ruled out for acute myocardial infarction on admission. He had an isolated elevation of his ferritin level, but had no other signs of systemic hemochromatosis. Futher, systemic amyloid was not apparent on exam, but was certainly a possible cause for his diastolic dysfunction. Follow-up ischemic and cardiac imaging (ie. MIBI, catheterization, or MRI) was deferred to his new outpatient cardiologists. As mentioned, he improved somewhat with beta-blockade, a one liter fluid restriction, NaCl restriction, and fluid removal via Lasix and Nesiritide. He was to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from EP Cardiology. 3. PAF: He presented with recent onset of atrial fibrialltion. He underwent electric cardioversion in the CCU given low SPBs, as mentioned. He was started on Amiodarone HCl 400 mg PO TID, which was decreased to DAILY given a new-onset tremor. He then remained in sinus rhythm with rare, brief episodes of PAF. Coumadin was initially held because of a supratherapeutic INR. It was later reinitiated at 2 mg PO QHS for an INR goal of [1-14]. He was to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2357] from EP Cardiology. 4. UTI: He had an initial leukocytosis, peaking at 15.6. He had no fever or systemic symptoms, but a urinalysis minimal cystitis (WBC 11) with few bacteria. He was started empirically on Levfloxacin for 5 day course for UTI. 5. Hypotension: The patient had low SBPs over his course, mainly ranging from the 90s-110s. However, upon initittion of ACE-i or [Last Name (un) ] (one dose of Losartan 50 mg and then 25 mg on two separate occasions) he had a relatively acute drop of his SBPs to the 70s-80s. He was asymptomatic and his mentation remained intact. His SBPs normalized to his to his new (low) baseline after cardioversion and discontinuation of the [Last Name (un) ]/ACE-i. 6. CAD: He was continued on ASA, BB, and Statin. His nitrates were held given low SBPs. He ruled out for MI as above. 7. RUE/RLE Pain: The patient had intermitted pain of his right elbow, hand, and knee along with associated decreased range of motion, tenderness and warmth. There were no effusions or erythema. The etiology was unclear, but was possibly pseudogout (given his x-ray findings) or gout. His clinical picture was consistent with crystalline diseases in the setting of diuresis. He was seen by Rheumatology and was continued on Allopurinol QOD given his known gout history. It was noted that increasing or decreasing his allopurinol in the setting of a possible acute exacerbation may have worsened his symptoms. Conditions associated with pseudogout were sought: he had an elevated ferritin, and a normal calcium, phosphate and TSH. He was discharged with Rheumatology follow-up. His pain was controlled with Percocet, as NSAIDs were avoided given his renal dysfunction. 8. ARF/CKD: The patient had marked renal sensitivity to both NSAIDS and [Last Name (un) ]/ACE-i. His creatinine throughout most of his course was less than 1, but climbed to the low 2.0's upon administration of these agents. Medications on Admission: Isordil 20 mg [Hospital1 ] Tenormin 50 mg daily Mucinex Ceftin Vasotec 2.5 mg daily Coumadin 7.5/5 mg Detrol 2 mg qhs Mevacor 20 mg daily Allopurinol 300 mg daily ASA/Plavix held at OSH NKDA Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. 10. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please check INR daily and adjust dosing for goal of INR of [1-14]. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Please follow I/O's and weights, along with creatinine and adjust PRN. 12. BiPAP IPAP 9 cm H20. EPAP 6 cm H20. O2 at 2L/min. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Primary Diagnosis: 1) Diastolic Heart Failure. 2) Atrial Fibrillation. 3) Hypotension. Secondary Diagnosis: 4) Urinary Tract Infection. 5) Coronary Heart Disease. 6) Likely Crystalline Joint Disease Exacerbation. Discharge Condition: Fair/Stable. Discharge Instructions: 1) Please contact your doctor or return to the ER if you have increased shortness of breath, fatigue, fevers, chills, or any other concerning symptoms. 2) Use your BiPAP every night. 3) Take your medications as instructed. Followup Instructions: 1) Please contact your new heart failure doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 3512]) a appointment: Provider [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2117-4-27] 9:00 2) Please see your new EP (electrophysiology) heart doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 285]) for the following appointment. Your amiodarone dosing will be adjusted. Dr. [Last Name (STitle) ] will check your [Doctor Last Name ] of Hearts monitoring: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2117-5-11] 12:30 3) Please contact the Rheumatologists at [Telephone/Fax (1) 2226] for a new appointment in regards to your joint pain. They will discuss treatment options with you. Repeat uric acid and ferritin levels will be checked at that time. 4) Please see your primary doctor ([Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 3183]) in the next 4-6 weeks. Contact your doctor [Last Name (Titles) 2678] (ie. the day you leave the Rehab facility) to arrange correct dosing of your Coumadin. Your INR levels need to be checked frequently while you are on your new medication regimen. 5) Speak to your cardiologists and primary care doctor [First Name (Titles) ] [Last Name (Titles) 11370]g your Plavix. 6) Follow-up with your own pulmonologist or make an appointment with the [Hospital1 18] pulmonologists at the Sleep Clinic at ([Telephone/Fax (1) 35871] in regards to your CPAP use for your OSA. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "V43.65", "V45.82", "401.9", "599.0", "274.0", "584.9", "458.9", "414.01", "428.31", "427.31", "780.57" ]	icd9cm	[ [ [] ] ]	[ "93.90", "99.62", "00.13" ]	icd9pcs	[ [ [] ] ]	15933, 16030	9270, 14610	327, 353	16288, 16302	4016, 9247	16575, 18524	3497, 3516		14857, 15910		16051, 16051		14636, 14834			16326, 16552								3531, 3997																					268, 289									381, 2990			16160, 16267			16070, 16139								3012, 3314	3330, 3481
53,876	106,315	263+55198	Discharge summary	report+addendum	Admission Date: [2164-10-22] Discharge Date: [2164-10-30] Date of Birth: [2095-10-16] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2164-10-22]: Emergency repair of type-A ascending aortic dissection with ascending aortic and hemiarch replacement with a size-28 Gelweave graft. History of Present Illness: 69 year old male woke up this am with acute epigastic pain, chest pain, shortness of breath and diaphoresis. He called EMS and was brought to ED and was found to have type A dissection and is going emergently to OR with Dr. [First Name (STitle) ]. Past Medical History: Hyperlipidemia Hypertension BPH right superior cerebellar artery stroke prostate cancer s/p brachytherapy 5 years ago gout Afib Past Surgical History: s/p lumbar laminectomy s/p tonsillectomy Social History: Lives with wife, Ex [Name (NI) 2570], quit smoking 25 years ago, drinks a glass of wine on occasions, no drug abuse Family History: Strokes in both parents Physical Exam: Admission: Pulse:58 Resp:18 O2 sat:97 B/P 206/72 Height:6'1" Weight:220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] 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:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [10-22] Echo: Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior wall.. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. A mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) to Moderate [2+] aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [2164-10-22] at 1715. Post bypass: Patient is A paced. LVEF= 40%. 2+ aortic insufficiency present. (2 jets seen - one central and the other eccentric. Mild mitral regurgitation present. [10-22] Chest CT: 1. Type A aortic dissection with involvement of the entire thoracic aorta and abdominal aprta as well as multiple abdominal aprtic branches, described in detail above. No evidence of aortic rupture. 2. Infrahilar lymphadenopathy, unclear etiology, may be reactive. 3. Multiple pancreatic hypodense lesions. Recommend further evaluation with non-emergent MRCP. 4. Pulmonary, hepatic, and splenic calcifications suggestive of granulomatous disease. 5. Diverticulosis without evidence of diverticulitis. [10-23] Renal U/S: 1. No hydronephrosis. Simple bilateral renal cysts. 2. Arterial and venous flow is seen bilaterally within the kidneys. [2164-10-30] 03:56AM BLOOD WBC-9.2 RBC-2.97* Hgb-8.9* Hct-26.5* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-313 [2164-10-29] 03:43AM BLOOD WBC-10.2 RBC-2.96* Hgb-8.8* Hct-26.4* MCV-89 MCH-29.8 MCHC-33.3 RDW-15.1 Plt Ct-245 [2164-10-28] 05:00AM BLOOD WBC-10.2 RBC-2.85* Hgb-8.7* Hct-25.4* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.9 Plt Ct-184 [2164-10-30] 03:56AM BLOOD PT-15.2* INR(PT)-1.4* [2164-10-29] 03:43AM BLOOD PT-14.8* INR(PT)-1.4* [2164-10-28] 05:00AM BLOOD PT-15.5* INR(PT)-1.5* [2164-10-27] 05:12AM BLOOD PT-15.3* INR(PT)-1.4* [2164-10-30] 03:56AM BLOOD Glucose-109* UreaN-66* Creat-2.2* Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 [2164-10-29] 03:43AM BLOOD Glucose-116* UreaN-70* Creat-2.6* Na-136 K-3.8 Cl-98 HCO3-29 AnGap-13 [2164-10-28] 05:00AM BLOOD Glucose-105* UreaN-61* Creat-3.1# Na-135 K-4.0 Cl-97 HCO3-27 AnGap-15 [2164-10-27] 05:12AM BLOOD Glucose-131 UreaN-87* Creat-5.2* Na-134 K-4.4 Cl-97 HCO3-25 AnGap-16 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 2572] was transferred to the ED by EMS presenting with acute epigastric pain, chest pain, shortness of breath and diaphoresis. He was found to have a type A aortic dissection and was emergently transferred to the operating room for repair. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained intubated for several days due to respiratory failure and worsening hypertension during extubation trial. Finally on post-op day two he was weaned from sedation, awoke neurologically intact and extubated. In addition on post-op day two, nephrology was consulted for decreasing urine output and acute kidney injury. He eventually required hemodialysis and was followed closely by nephrology throughout his hospital course. Atrial fibrillation was noted post-operatively (has history of) and he was appropriately treated with beta-blockers and Amiodarone. Chest tubes and epicardial pacing wires were removed per protocol. He had a swallow study performed due to a history of CVA which he passed for a regular diet, thin liquids. On post-op day four he was transferred to the step-down unit for further recovery. Blood pressure medications were titrated to keep SBP<140. Coumadin was eventually started for his atrial fibrillation and history of CVA and his home dose was resumed. He is to be followed by the [Hospital3 2576] [Hospital 197] Clinic. Over the next several days he remained stable while receiving hemodialysis. Renal continued to follow, urine output slowly increased and renal function was improved to a creatinine of 2.2 at the time of discharge (peak cratinine 5.7.) Renal signed off with the thought that renal function would continue to inprove, although it may not return to baseline (1.5-1.6.) Physicial therapy worked with him for strength and mobility. On POD 8 he was ambulating without difficulty, tolerating a full oral diet and his incisions were healing well. It was felt that he was safe for discharge home at this time with VNA services. Medications on Admission: famotidine 20 mg [Hospital1 ] labetalol 200 mg- 2 Tablet(s) Twice Daily Benicar 40 mg- 1 Tablet Once Daily methocarbamol 750 mg- 1 Tablet TID warfarin Unknown Strength 1 tablet daily allopurinol 300 mg Daily simvastatin 40 mg Daily prednisone 5 mg Tab Oral PRN- last dose 1 week ago (has only taken a few times for gout) Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed for INR goal 2.0-2.5. Disp:90 Tablet(s) Refills:2 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:30 Tablet(s) Refills:0 6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 Tablet(s) Refills:0 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 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:0 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 12. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Aortic Dissection s/p Emergent repair Past medical history: Hyperlipidemia Hypertension Benign prostatic hypertrophy Right superior cerebellar artery stroke Prostate cancer s/p brachytherapy 5 years ago Gout Atrial fibrillation s/p lumbar laminectomy s/p tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Ultram Sternal Incision - healing well, no erythema or drainage Edema: 1+ LE edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] on [11-6] at 10:45 AM in [Hospital Unit Name ] [Hospital Unit Name ] Surgeon: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2164-11-27] 1:30 Location: [Last Name (un) 2577] Building [Last Name (NamePattern1) ] Cardiologist: Please get referral to cardiologist from Dr. [Last Name (STitle) 2578] Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 2578] [Telephone/Fax (1) 2579] in [2-21] 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 Coumadin for Atrial Fibrillation Goal INR: 2.0-3.0 First draw [2164-10-31] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Mass [Hospital 2580] [Hospital 197] Clinic Results to phone [Telephone/Fax (1) 2581] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2164-10-30] Name: [Known lastname 262],[Known firstname 263] Unit No: [Numeric Identifier 264] Admission Date: [2164-10-22] Discharge Date: [2164-10-30] Date of Birth: [2095-10-16] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 265] Addendum: VNA instructed to check K/BUN/Crea and call results to cardiac office on Thurs [11-1]. At wound check appointment next week, consider resuming Lasix if renal function stable and edema persistent. Discharge Disposition: Home With Service Facility: [Location (un) 42] VNA [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2164-10-30]	[ "287.5", "274.9", "V12.54", "285.9", "427.31", "530.81", "V10.46", "272.4", "424.1", "584.5", "403.90", "276.7", "V58.61", "518.51", "441.03", "585.3" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.44", "38.45", "38.93", "38.95", "39.61", "96.71" ]	icd9pcs	[ [ [] ] ]	11902, 12080	4716, 6838	324, 477	9051, 9217	1815, 4693	10088, 11879	1126, 1151		7213, 8659		8760, 8798		6864, 7190			9241, 10065						931, 973		1166, 1796																					273, 286									505, 758														8820, 9030	989, 1110
80,745	168,076	5915+55711	Discharge summary	report+addendum	Admission Date: [2186-2-16] Discharge Date: [2186-2-24] Date of Birth: [2139-11-3] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7733] Chief Complaint: Post traumatic amputation of right index finger at phalangeal level. Major Surgical or Invasive Procedure: [2-16] OPERATION PERFORMED: 1. Ipsilateral microvascular second toe transfer to right index finger. 2. Local flap closure of toe. 3. Local flap closure on index finger. 4. Split-thickness skin graft right index finger. 5. Application short-arm splint. 6. Application short leg splint. [2-22] OPERATION PERFORMED: 1. Debridement, right foot. 2. Split-thickness skin graft, right foot. 3. Short leg cast, right lower extremity. 4. Debridement, right index finger. 5. Advancement flap, right index finger, with stump revision. 6. Application short-arm splint. History of Present Illness: Mr. [Known lastname 23345] is a middle-aged man who sustained a much earlier traumatic amputation of his index finger, distal to the PIP joint. The extrinsic flexors and extensors were intact in the joint where he had excellent flexion and extension. He wished to have a distal finger with sensation and a pulp surface with a nail, strictly for functional purposes. He is an excellent candidate for a second toe transfer. His medical history was significant in that he had had arrhythmias. He is presently being treated with beta blockers. He is being brought to the operating room today for elective second toe transfer. Past Medical History: HTN, traumatic amputation distal R index finger Social History: Lives at home with wife and 4 children. No smoking, occassional ETOH, no drugs. Family History: n/a Physical Exam: D/C PE: gen: pt anxious, otherwise NAD VS: AF/VSS CV: RRR no murmurs Resp: CTA B/L R hand; dressing and splint CDI. R foot; cast CDI Pertinent Results: [2186-2-23] 10:50AM BLOOD PT-17.2* PTT-32.3 INR(PT)-1.6* [2186-2-23] 10:50AM BLOOD Plt Ct-225 [2186-2-20] 12:47AM BLOOD WBC-10.5 RBC-3.82* Hgb-12.9* Hct-34.6* MCV-91 MCH-33.9* MCHC-37.4* RDW-12.7 Plt Ct-170 [2186-2-20] 12:47AM BLOOD Glucose-112* UreaN-10 Creat-1.0 Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [2186-2-20] 12:47AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 Brief Hospital Course: Patient was admitted post-operatively to the TSICU for Q1h checks of perfusion to the transplanted digit. Of note, during the surgery, the patient was seen to have sluggish return of circulation to his foot when the tourniquet was released to the R foot after partial toe removal. Post-operatively, the patient was started on ASA and Heparin at 500cc/hr as per the [Last Name (un) 5884] flap protocol, and he had a bear hugger around the digit. Immediately post-operatively he had an episode of fever to 102.5, which resolved spontaneously. During the following days, the patient's tranferred digit remained relatively underperfused however some capillary refill was still appreciated. On [2-18] (POD2) botox was injected into the proximal digit. On POD4 there was some darkened blood flow to the digit for which transient leech therapy was trialed. Unfortunately, demarcation continued throughout this time period, perfusion dwindled, and by POD6 the digit was clearly non-viable. Therefore, on POD6, the patient was brought back to the OR for amputation of the transplanted digit and debridement of the foot wound. He tolerated this procedure well and was brought back to the general floor for wound care and pain control. Medications on Admission: Metoprolol XR Discharge Medications: 1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, HA. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:60 Tablet(s) Refills:0 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety for 2 weeks. Disp:60 Tablet(s) Refills:0 6. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Failed free transfer of right 2nd toe to right index finger s/p transfered digit amputation. Wound dehiscence, right foot. Discharge Condition: stable Discharge Instructions: You will have a visiting nurse to help you with your dressing changes. Between changes, please keep the dressings clean and dry and try to keep both your arm and leg elevated as much as possible. Please resume all regular home medications and take any new meds as ordered. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * You have increasing pain, redness along your hand, arm, or leg, or blood that soaks your dressings. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please call Dr[Name (NI) 23346] office at ([2186] today to schedule a follow up appointment for next week. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 7738] Name: [Known lastname 3984],[Known firstname 3985] Unit No: [Numeric Identifier 3986] Admission Date: [2186-2-16] Discharge Date: [2186-2-24] Date of Birth: [2139-11-3] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3987] Addendum: Discharge instructions were changed before giving them to the patient to read as follows: Please take care not to get your casts wet. They will stay on at least until your follow up visit with Dr [Last Name (STitle) ] in [12-9] weeks. Please to not attempt to walk on your right leg. You can help yourself balance by using your heel but do not put full weight on this leg. Please resume all regular home medications and take any new meds as ordered. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * You have increasing pain, redness along your hand, arm, or leg, or blood that soaks your dressings. * Any serious change in your symptoms, or any new symptoms that concern you. Discharge Disposition: Home [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 3988] Completed by:[2186-2-24]	[ "736.29", "E929.9", "V49.62", "427.9", "401.9", "996.93", "459.81", "906.4", "998.32", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "86.73", "86.69", "86.22", "84.3", "84.11", "03.90", "82.81" ]	icd9pcs	[ [ [] ] ]	7624, 7781	2375, 3615	384, 960	4570, 4579	1975, 2352	5707, 7601	1800, 1805		3679, 4374		4424, 4549		3641, 3656			4603, 5684								1820, 1956																					275, 346									988, 1616														1638, 1687	1703, 1784
72,764	139,759	36884	Discharge summary	report	Admission Date: [2138-7-1] Discharge Date: [2138-7-2] Date of Birth: [2061-7-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: SAH and facial bone fractures s/p syncopal even Major Surgical or Invasive Procedure: none History of Present Illness: 76 M with metastatic colon cancer undergoing neupogen treatment was on his way to his oncologist's office when he felt lightheaded, ? syncopized and fell face first onto pavement with + LOC x 30-40sec. Past Medical History: metastatic colon cancer to lung and liver CABG [2129] chemo x 4 years Social History: quit Tobacco 20 years ago, occasional EtOH, lives with wife Family History: NC Physical Exam: A&O X 3, NAD PERRLA, EMOI, significant right sided facial and periorbital edema and ecchymosis; no malocclusion of his teeth; R. eye swollen shut RRR CTAB Abdomen soft, NT, ND, no abrasions Pelvis stable extremities neurovascularly intact x 4 rectal guaiac neg, normal tone Pertinent Results: [2138-7-1] 04:30PM cTropnT-<0.01 [2138-7-1] 04:30PM CK(CPK)-36* [2138-7-1] 04:30PM WBC-1.8* RBC-3.22* HGB-10.2* HCT-29.7* MCV-92 MCH-31.6 MCHC-34.2 RDW-17.4* [2138-7-1] 04:30PM NEUTS-36* BANDS-4 LYMPHS-12* MONOS-0 EOS-0 BASOS-2 ATYPS-2* METAS-4* MYELOS-0 OTHER-40* [2138-7-1] 04:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [2138-7-1] 04:30PM PLT SMR-NORMAL PLT COUNT-214 [2138-7-1] 04:30PM PT-12.9 PTT-24.5 INR(PT)-1.1 CT Head [7-1]: Bilateral subarachnoid hemorrhage with intraventricular extension and likely intraparenchymal blood as well, overall appearing minimally changed from outside hospital films. Facial fractures and their sequelae are characterized on a concurrent facial bone CT CT C-spine: no fractures CT Maxillofacial: Multiple bilateral facial fractures involving the maxillary sinuses and right inferior orbital wall with hemorrhage into the maxillary sinuses. Nondisplaced fractures of both greater wings of the sphenoid. CT Head [7-2]: no change CTA Head [7-2]: no aneurysm Brief Hospital Course: Md. [Known lastname 14887] was admitted on [2138-7-1] after being transferred from [Hospital6 33] after sustaining a fall with likely + LOC and a syncopal event. His injuries are as follows: 1. Bilateral subarachnoid hemorrhage with intraventricular extension 2. Multiple bilateral facial fractures involving the maxillary sinuses and right inferior orbital wall with hemorrhage into the maxillary sinuses. Nondisplaced fractures of both greater wings of the sphenoid. He was evaluated by trauma surgery, neurosurgery, opthalmology, and plastic surgery. Neurosurgery follwed the SAH with repeat CT of his head and evaluated for an aneurysm with a CTA of his head. They placed him on Keppra. Plastic surgery said that his facial fractures do not require surgery and he doesn't have any entrapment of his extra-occular muscles. Mr. [Known lastname 14887] is being discharged home with an appointment to follow up with his cardiologist at [Hospital6 33] (Dr. [Last Name (STitle) 2077] on [2138-7-3] at 2:45 PM. He will talk to his oncologist today and reschedule his appointment with him (Dr. [Last Name (STitle) 58562]. Medications on Admission: ASA 81' Lopressor 25' HCTZ 12.5' Accupril 20' Zocor Neupogen 480 micrograms SQ x 5 days Discharge Medications: 1. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection 1X (ONE TIME) for 1 doses. 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 7 days. Disp:21 Capsule(s) Refills:0 7. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: for the first 2 doses, only take 500mg (1 pill at a time). Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage Multiple facial bone fractures Discharge Condition: Good Discharge Instructions: Call your doctor or go to the ER if you experiece high fever >101.5, severe pain or headache, another syncopal event, or any other concerning symptoms. Followup Instructions: Follow up with Dr. [Last Name (STitle) 2077] (cardiology at [Hospital6 33]) [2138-7-3] at 2:45 PM Call your oncologist (Dr. [Last Name (STitle) 58562] at [Hospital6 33]) to schedule an appointment. Call the plastic surgery office for follow-up regarding your facial bone fractures. Call the opthalmology office to schedule a follow-up appointment in [1-3] weeks.	[ "401.9", "E888.9", "197.0", "V45.81", "801.22", "197.7", "802.8", "V10.05", "780.2", "285.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4242, 4248	2274, 3429	359, 365	4346, 4352	1100, 2251	4552, 4943	787, 791		3567, 4219		4269, 4325		3455, 3544			4376, 4529								806, 1081																					272, 321									393, 596														618, 694	710, 771
55,143	140,274	41608	Discharge summary	report	Admission Date: [2164-8-17] Discharge Date: [2164-8-21] Date of Birth: [2111-8-26] Sex: M Service: NEUROLOGY Allergies: Advil Attending:[Last Name (NamePattern1) 11784] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 57M w/hx of HTN, afib, CKD p/w decrease appetite, nausea and vomiting for three days. Yesterday developed headache and photophobia and increasing lethargy. At that time he denied blurry vision, numbness, tingling or weakness of his lower extremities. Presented to [Hospital3 ] where he was found to have sbp 180s and posterior fossa brain mass found on CT head. Patient given zofran and lopressor and transferred to [Hospital1 ]. pt seen by Neurosurg in ED and found to have normal neuro exam, however previous CThead was concerning for possible compression of 4th ventricle with concern for pending hydrocephalus. Pt was started on decadron and blood pressure goal was sbp 140. However bp difficult to treat and bp liberalized to 160. Neurological exam remained stable and MRI then read as ischemic stroke with hemorrhagic conversion. Decadron discontinued. Given significant hypertension and relative young age, pt underwent CT torso with contrast to look for possible Renal /adrenal mass which was unrevealing on wet read Patient underwent bedside swallow exam and allowed to eat, his home atenolol was restarted at half his regular dose. Neurology then consulted from transfer to neurological-stroke service. Past Medical History: Htn -difficult to treat, typically 180s systolic, on several meds simultaneously, Paroxysmal a fib on aspirin given difficulties with med compliance in past [Name (NI) 90455] unclear baseline, creatinine on admission was 1.3 Social History: Works with rats, independent, lives at home with his brother and brother's wife, separated from his wife currently, travels frequently to the [Country 13622] Republic. Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: T: Afebrile; 168/103; 82; 26;98%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregular rhythm, nl rate, S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: (done with nurse interpreter) -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and [Country 19912]. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No Drift, no tremor 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, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: ([Name2 (NI) 19912] throughout) [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Plantar response was flexor bilaterally. -Coordination: FNF and HSK without deficits, rapid alternating movements, -Gait: nl, narrow based, romberg negative DISCHARGE PHYSICAL EXAM: VS: 98.2, 130-140/80's, HR 80's, 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregular rhythm, nl rate, S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and [Last Name (un) 19912]. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No Drift, no tremor 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, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: ([Name2 (NI) 19912] throughout) [Hospital1 ] Tri [Last Name (un) 1035] Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Plantar response was flexor bilaterally. -Coordination: FNF and HSK without deficits, rapid alternating movements, -Gait: nl, narrow based, romberg negative Pertinent Results: ADMISSION LABS: [2164-8-17] 08:40PM BLOOD WBC-12.9* RBC-4.68 Hgb-15.3 Hct-44.4 MCV-95 MCH-32.8* MCHC-34.5 RDW-13.7 Plt Ct-212 [2164-8-17] 08:40PM BLOOD Neuts-91.2* Lymphs-5.9* Monos-2.2 Eos-0.6 Baso-0.1 [2164-8-17] 08:40PM BLOOD PT-13.8* PTT-22.6 INR(PT)-1.2* [2164-8-17] 08:40PM BLOOD Glucose-122* UreaN-21* Creat-1.3* Na-139 K-3.0* Cl-94* HCO3-30 AnGap-18 [2164-8-19] 04:12AM BLOOD ALT-46* AST-32 LD(LDH)-276* AlkPhos-56 TotBili-0.8 [2164-8-17] 08:40PM BLOOD Calcium-9.4 Phos-3.5 Mg-1.7 [2164-8-19] 04:12AM BLOOD %HbA1c-5.6 eAG-114 [2164-8-19] 04:12AM BLOOD Triglyc-82 HDL-50 CHOL/HD-4.7 LDLcalc-170* DISCHARGE LABS: [2164-8-21] 06:15AM BLOOD WBC-9.5 RBC-4.79 Hgb-15.5 Hct-45.7 MCV-95 MCH-32.3* MCHC-33.9 RDW-13.6 Plt Ct-259 [2164-8-21] 06:15AM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-139 K-3.4 Cl-101 HCO3-28 AnGap-13 [2164-8-21] 06:15AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9 IMAGING: MR HEAD [2164-8-17]: IMPRESSION: 1. Large acute infarction with hemorrhagic transformation in the right posterior inferior cerebellar artery territory, involving both the cerebellar hemisphere and the vermis within this territory. No evidence of an enhancing mass. 2. Considerable effacement of the fourth ventricle, without dilatation of the third and lateral ventricles at this time. Recommend close follow-up of ventricular size. CT ABDOMEN PELVIS [2164-8-18]: IMPRESSION: 1. No adrenal mass lesions. 2. No evidence of renal artery stenosis. 3. Minimal atherosclerotic calcification of the abdominal aorta. 4. 4mm gallbladder polyp. 5. Small hiatus hernia. 6. Linear atelectasis at the left base. 7. Small bilateral renal cysts. MRA HEAD AND NECK [2164-8-19]: IMPRESSION: 1. Overall unremarkable appearance to roughly co-dominant distal V4 segments of both vertebral arteries; however, there is flow-signal in only the proximal portion of the right PICA vessel with no flow-signal more distally, in the region of acute infarction. 2. Otherwise unremarkable appearance to the posterior circulation. 3. Azygos anterior cerebral artery originating from a robust A1 segment on the right. 4. Unsuccessful cervical MRA, due to apparent patient intolerance of gadolinium contrast material. TTE [2164-8-20]: IMPRESSION: Marked symmetric left ventricular hypertrophy with normal cavity size and mild global hypokinesis c/w diffuse process (toxin, metabolic, etc.; multivessel CAD less likely given distribution of dysfunction). Mild mitral regurgitation. Dilated ascending aorta. These findings are c/w hypertensive heart. Brief Hospital Course: [Known firstname ] [Known lastname ] is a 52 yo male with HTN, CKD, paroxysmal afib (not on coumadin) found to have posterior fossa hemorrhage and R PICA infarct. . # NEURO: patient had a R PICA infarct with posterior fossa hemorrhage, however had minimal neurological deficits, with exam only notable for very mild dysmetria on the R on admission which since improved. We started pt on 81 mg of aspirin on [8-20]. Patient will need anticoagulation for his afib to prevent further strokes. Per his PCP he has skipped many appointments and may not be reliable with follow-up. Therefore it was determined, through planning with pt's PCP that he will be started on dabigatran rather than coumadin when he sees her on [8-28]. She will obtain prior authorization between discharge and pt's follow-up appointment. # CARDS: We initially put pt only on atenolol at 50mg (half of pt's home dose) and allowed BP to autoregulate, but pt's SBP's then regularly in the 160-180's. On day prior to discharge we restarted pt on his home lisinopril 40mg QD, HCTZ 25mg QD and clonidine 0.1mg [Hospital1 ]. In addition, we started pt on simvasatin 40mg QD for an LDL of 170. At discharge we also increased his atenolol back to 100mg QD. Patient's TTE on [8-20] showed LV hypokinesis and LA enlargement, both of which puts pt at increased risk of clot, and therefore as above, decided to put pt on anticoagulation with dabigatran after discharge. # ID: pt initially presented with a leukocytosis at 12, which increased to 18.8 after receving a dose of steroids when it was initially suspected that his PICA infarct was a mass (later proved false by further imaging). His WBC then trended down throughout his admission once the steroids were stopped. He remained afebrile throughout this hospitalization. # ENDO: we put pt on an ISS throughout this admission, but his FSBG were WNL. # CODE: Full Code PENDING RESULTS: None TRANSITIONAL CARE ISSUES: Patient will need to be started on dabigatran when he sees his PCP on [8-28]. He will need to be monitored for change in his neurological exam to ensure the medication does not precipitate bleeding. Medications on Admission: Atenolol 100 mg p.o. daily Hydrochlorothiazide 25 mg p.o. daily Lisinopril 40 mg p.o. daily Clonidine 0.1mg [Hospital1 ] Loratadine 10 mg p.o. daily, although pt reports he no longer takes this med. Discharge Medications: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): Please stop this medication the day after you start dabigatran. Disp:30 Tablet, Chewable(s) Refills:0 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: posterior fossa hemorrhage, PICA infarct Secondary: atrial fibrillation, Hypertension, Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were seen in the hospital for a stroke that then bled. We monitored your condition, and were able to send you home when you were stabilized. You will need to start a medication call dabigatran when you see your PCP on [8-28]. This medication is very important to prevent future strokes. We made the following changes to your medications: 1) We STARTED you on ASPIRIN 81mg once a day. HOWEVER WE WANT YOU TO STOP ASPIRIN the day after you are started on Dabigatran, because if you are on both, your blood may be too thin. 2) We STARTED you on SIMVASTATIN 40mg once a day. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: You have an appointment with your PCP [First Name4 (NamePattern1) 402] [Last Name (NamePattern1) 35914] at 12:20pm on [8-28]. It is VERY IMPORTANT that you attend this appointment as she will be starting a new medication at this visit that will help prevent new strokes. Department: NEUROLOGY When: TUESDAY [2164-10-23] at 2:30 PM With: [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], MD, PHD [Telephone/Fax (1) 657] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "425.4", "431", "403.90", "434.91", "585.9", "427.31" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11904, 11910	8910, 10851	292, 299	12073, 12073	6314, 6314	13119, 13716	2013, 2022		11336, 11881		11931, 12052		11108, 11313			12224, 12577			6968, 8887	5035, 6295				2077, 2627																		12606, 13096			237, 254			10877, 11082						327, 1554					6331, 6951				12088, 12200					1576, 1808	1824, 1997				4211, 4728
17,267	174,218	43421	Discharge summary	report	Admission Date: [2185-6-13] Discharge Date: [2185-7-5] Date of Birth: [2123-7-8] Sex: M Service: MEDICINE Allergies: Flagyl / Iodine; Iodine Containing / Keflex Attending:[First Name3 (LF) 348] Chief Complaint: Bright red blood per ostomy Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 61 year old male with past medical history significant for rectal cancer s/p LAR with end colostomy ([2174])and XRT, CAD s/p CABG ([2172]), CHF (EF=25%) s/p placement of PPM, HTN and DM who presents to ED with complaints of bloody output from ostomy accompanied by dizziness. Patient reports the first episode occurred about 10:00 this a.m. This was then followed by an additional output around 10:30a.m. The patient described the output as dark red and "jelly" like. In the setting of this bloody output, the patient reports that he feels tired and lightheaded. He denies however any associated chest pain or shortness or breath. The patient reports that he takes aspirin daily, which he has been doing for 10+ years, but otherwise has not added any additional NSAIDs or anti-platelet drugs to his daily regimen. . The patient reports that he has been eating and drinking well at home without any associated nausea, vomiting, or abdominal pain currently. However, the patient does reports dull abomdinal pain for 1-2 days preceeding the current episode. . In the ED, the patient was evaluated and a gastric lavage was negative for acute bleeding. The patient was additionally seen and evaluated by surgery. Since his presentation to the ED to his evaluation by surgery, the patient had decreased bloody output and more normal appearing stool. The decision was made at that time to admit the patient to medicine, assess the patient again in the morning, and make possible plans for colonoscopy. In the evening, around 8:00 pm, the patient again began to have bloody output, with 425cc documented in the ED nursing chart. 50 minutes later there was an additional 225cc of maroon, partially clotted bloody output. The patient reported that he still felt lightheaded, but denied any chest pain or shortness of breath. The patient was non-orthostatic at this time with a lying BP of 105/27 and HR of 62; sitting BP of 111/41 with a HR of 64; and a standing BP of 114/23 with a HR of 65. Pt will be admitted to medicine for further care. Past Medical History: 1. DM 2. CHF, EF=25% 3. CAD s/p CABG, [2174] 4. Rectal Cancer, s/p LAR and XRT, [2174] 5. HTN 6. Back surgery [2182] 7. Anemia 8. Chronic draining sacral ulcer Social History: Social History: Pt is a retired elctronic engineer. Remote smoking history. Denies ETOH and drugs. Family History: Noncontributory Physical Exam: Physical Exam: 98.2 61 110/86 95% RA Gen: Tired man resting on strecher. Reports that he is very tired of answering questions. HEENT- NC AT. Anicteric sclera. Mildly dry mucous membranes. Cardiac- RRR. S1 S2. No m,r,g. Pulm- CTAB. No wheezes, rales, rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Small amount of blood in the ostomy bag. Extremities- 2+ pitting edema bilateral LE. No c/c. Pt with chronic changes of venous stasis on the bilateral LE and ulcer on the anterior right LE. Pertinent Results: [2185-6-13] CXR - No evidence of congestive heart failure [2185-6-15] ECHO - The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe hypokinesis of the inferior and lateral walls including the apex. The anterior wall is not weel seen. Overall left ventricular systolic function is moderately depressed. No masses or thrombi are seen in the left ventricle. There is mild global right ventricular free wall hypokinesis. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-5]+) mitral regurgitation is seen. There is no pericardial effusion. [2185-6-20] LE Doppler (R) - No deep venous thrombosis within the right common femoral, superficial femoral, deep femoral, or popliteal veins [2185-6-21] GI Bleeding Study - No evidence of active bleeding. [2185-6-21] UGI SGL W/ SBFT - No reason for bleeding identified in this study. [2185-6-27] GI Bledding Study - No evidence of active bleeding [2185-6-28] CXR - Interval development of congestive heart failure with perihilar and basilar edema and new small right pleural effusion. [2185-7-3] CXR - The patient is status post sternotomy with mediastinal clips. There is mild cardiomegaly. A left-sided dual lead pacemaker is present, with lead tips over right atrium and right ventricle. A third lead may also be present, not well visualized here. There is minimal upper zone redistribution, but no overt CHF. There is a small-to-moderate right effusion with underlying collapse and/or consolidation. The left costophrenic sulcus is clear. Aside from the right base, no focal infiltrate is identified. There is mild diffuse parenchymal scarring. Compared with [2185-6-13], the right pleural effusion is new. Compared with [2185-6-28], there has been improvement in the CHF findings and the left base has cleared. [2185-7-4] CXR - There has been interval right thoracentesis with near complete resolution of a previously noted right pleural effusion. No pneumothorax is identified, and there is otherwise no significant change since the recent chest radiograph of 1 day earlier. [2185-7-4] Pleural Fluid - NEGATIVE FOR MALIGNANT CELLS. Cultures: [2185-7-4] Pleural Fluid - GRAM STAIN (Final [2185-7-4]): 2+ ([12-8] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2185-7-7]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH [2185-6-16] Wound Culture - WOUND CULTURE: CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE RODS. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. (MRSA) Labs: [2185-6-13] 03:00PM BLOOD WBC-9.4 RBC-3.20* Hgb-8.6* Hct-27.0* MCV-84 MCH-27.0 MCHC-32.0 RDW-16.1* Plt Ct-138* [2185-6-14] Hct-25.6* [2185-6-14] Hct-30.3* [2185-6-14] Hct-29.4* [2185-6-14] Hct-30.0* [2185-6-15] Hct-30.0* [2185-6-15] WBC-8.8 RBC-3.24* Hgb-9.2* Hct-27.0* MCV-83 [2185-6-15] Hct-30.1* [2185-6-16] WBC-8.4 RBC-3.47* Hgb-9.7* Hct-29.6* MCV-85 Plt Ct-148* [2185-6-17] WBC-8.1 RBC-3.61* Hgb-9.8* Hct-31.0* MCV-86 Plt Ct-155 [2185-6-18] Hct-29.5* [2185-6-18] WBC-9.1 RBC-3.65* Hgb-10.2* Hct-32.2* MCV-88 Plt Ct-150 [2185-6-18] WBC-10.2 RBC-3.66* Hgb-10.3* Hct-32.4* MCV-89 Plt Ct-148* [2185-6-18] Hct-31.9* [2185-6-18] Hct-30.2* [2185-6-19] WBC-9.1 RBC-3.38* Hgb-9.7* Hct-30.0* MCV-89 Plt Ct-122* [2185-6-19] Hct-34.4* [2185-6-20] Hct-31.4* [2185-6-22] WBC-10.1 RBC-3.16* Hgb-9.0* Hct-27.0* MCV-85 Plt Ct-129* [2185-6-22] Hct-30.3* [2185-6-23] Hct-31.0* [2185-6-24] WBC-7.4 RBC-3.18* Hgb-9.0* Hct-27.3* MCV-86 Plt Ct-139* [2185-6-25] WBC-9.0 RBC-3.60* Hgb-10.2* Hct-31.6* MCV-88 Plt Ct-159 [2185-6-26] Hct-31.9* [2185-6-27] WBC-8.0 RBC-3.61* Hgb-10.2* Hct-30.8* MCV-85 Plt Ct-135* [2185-6-28] Hct-34.5* [2185-6-29] WBC-9.4 RBC-4.19* Hgb-11.8* Hct-36.9* MCV-88 Plt Ct-150 [2185-6-30] WBC-6.7 RBC-3.49* Hgb-9.9* Hct-30.3* MCV-87 Plt Ct-126* [2185-7-3] WBC-6.2 RBC-3.42* Hgb-9.6* Hct-29.7* MCV-87 Plt Ct-145* [2185-7-3] Hct-31.7* [2185-7-4] Hct-30.5* [2185-7-5] WBC-7.2 RBC-3.57* Hgb-10.2* Hct-31.1* MCV-87 Plt Ct-160 [2185-6-13] PT-13.9* PTT-27.3 INR(PT)-1.3 [2185-7-5] PT-14.0* PTT-29.2 INR(PT)-1.3 [2185-6-13] Glucose-151* UreaN-140* Creat-4.0# Na-128 K-4.7 Cl-91* HCO3-22 AnGap-20 [2185-7-5] Glucose-71 UreaN-30* Creat-1.2 Na-135 K-5.0 Cl-101 HCO3-27 AnGap-12 [2185-7-4] proBNP-9539* [2185-7-4] Calcium-8.9 Phos-4.3 Mg-1.9 Iron-28* [2185-7-4] TIBC-248* Ferritn-253 TRF-191* [2185-6-26] Triglyc-81 HDL-26 CHOL/HD-3.7 LDLcalc-55 [2185-6-14] Digoxin-2.2* (Admission) [2185-7-4] Digoxin-0.9 (Discharge) Brief Hospital Course: 1. GI Bleed - The patient was initially admitted to the floor for active fluid resusitation and work-up. He was in and out of the MICU for an episode of active bleeding and was then sent out to the floor again on [2185-6-16]. On [6-26], the patient was noted to have had a hematocrit drop from 31.6 to 27.5 and so was transfused one unit of PRBC with an appropriate bump to 31.9. The night float resident was called to the floor on the evening of [6-26] due to a finding of 300 cc of BRB in the ostomy bag - MICU evaluation was called - pt found to have bled a total of 550 cc by 1 am [6-27], although he remained hemodynamically stable. A second unit of PRBC was transfused given the witnessed blood loss (in the ostomy bag). On evaluation by the MICU resident, he was initially found to have a pressure in the 140's, and a HR in the 80's, although he is on a beta blocker. His pressure soon dropped to the 90's, and the unit of blood was put in as quickly as possible (wide open). Additionally, he complained of syptoms of dizziness and was transported to the MICU expeditiously. During his hospital stay the patient underwent upper and lower endoscopy, and both were essentially unremarkable. Colonoscopy reveals some angiodysplasia and laceration in ostomy. He subsequently underwent capsule endoscopy which revealed multiple AVM's of the small bowel. So far, however, no active bleeding detected by EGD, colonoscopy, or tagged red blood cell scan. The patients Hct again stabalized and he was transferred to the floor. His hct remained stable after this point in time. 2. ARF - It was also noted on admission, that the patient had a creatinine of 4.0. This was likely prerenal secondary to hypovolemia in the setting of active GI bleeding. It slowed trended down on the course of the patients hospitalization. He was discharged with a creatinine of 1.2. 3. CHF - The patient has a history of CHF, but on admission had denied any SOB and a CXR had shown no signs of fluid overload. After the patients episode of active bleeding and time in the MICU, the patient became fluid overloaded, secondary to aggressive fluid resusitation and s/p 10 units of PRBC. The patient began to experience increasing SOB. A subsequent CXR showed: "Interval development of congestive heart failure with perihilar and basilar edema and new small right pleural effusion." The patient was placed on nasal canula and diuresed. The patient was still having SOB so a subsequent CXR was ordered. It showed a worsening pleural effusion. The pleural effusion was tapped and the patient was continued on lasix. The patient symptoms then began to improve. The patients Hct remained stable, and his SOB resolved. . The patient was discharged home with serives on [2185-7-5]. Medications on Admission: MVI Arginine 500 mg PO BID Vitamin C 500 mg PO BID ASA 325 mg PO QD Neurontin 300 mg PO TID Iron 325 mg PO TID Digoxin 0.125 mg PO QD Folic acid 2 mg PO QD Coreg 12.5 mg PO BID Demadex 20-30 mg PO BID Hydralazine 10 mg PO QID Tolvaptan (Heart Failure Study at [Hospital1 2025]) Aranesp (injection preloaded) Insulin - Lantus, 20 units QHS Insulin - Nova, 7 units breakfast/lunch, 4 units snack, 9 units dinner Pain med preference: 30 units oxycontin, 2 percocets . Allergies: 1. Iodine 2. Cephalexin 3. Flagyl Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 capsules Refills:2 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:30 bottle Refills:2 7. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:12 preloaded Refills:2 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 tube Refills:0 10. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) milliliters PO BID (2 times a day). Disp:600 milliliters Refills:2 11. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:30 Tablet Sustained Release 12HR(s) Refills:0 12. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1468] VNA Discharge Diagnosis: Primary diagnosis: GI bleed- Pt had bleeding into his ostomy. Secondary diagnosis: Acute renal failure Type 2 diabetes mellitus CAD Hypertension Anemia Congestive heart failure Discharge Condition: Stable. Patients hct has been stable. His renal function has improved. Vital signs are within normal limits. Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. 4. Please monitor daily weights. 5. Return immediately if dizzy and lightheaded, and/or you notice blood in your ostomy. Followup Instructions: 1. Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 24253]. Call [Telephone/Fax (1) 93432]. 2. Follow up with cardiologist Dr. [First Name (STitle) ] in 2 weeks. We had recommended to patient that he be started on a statin and beta blocker but he refused on multiple occasions.	[ "428.20", "285.1", "511.9", "569.69", "537.82", "584.9", "V10.06", "250.92", "569.85", "401.9", "707.03", "356.9", "V45.81", "V45.01", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "96.34", "45.13", "34.91", "45.19", "45.22", "99.04" ]	icd9pcs	[ [ [] ] ]	13461, 13520	8330, 11120	329, 335	13742, 13855	3298, 5951	14247, 14595	2747, 2764		11685, 13438		13541, 13541		11146, 11662			13879, 14224								2794, 3279																					262, 291									363, 2418			13625, 13721			13560, 13604		5987, 8307						2440, 2614	2646, 2731
60,383	173,706	34294+57912	Discharge summary	report+addendum	Admission Date: [2111-11-30] Discharge Date: [2111-12-12] Date of Birth: [2048-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: atrial fibrillation Major Surgical or Invasive Procedure: Maze procedure via bilateral mini-thoracotmomies [2111-12-2] History of Present Illness: This 63 year old white male developed atrial fibrillation 8 years ago. He was successfully converted to sinus rhythm. His paroxysmal fibrillation has become chronic, having been cardioverted three times this year, with persistent dysrhythmia now. He has been on Coumadin for this. The Coumadin was discontinued four days ago and he was admitted for Heparin therapy as a bridge peroperatively. A cardiac MRI has been performed to delineate his pulmonary vein anatomy previously. Past Medical History: Hypercholesterolemia s/p partial gastrectomy for peptic ulcer disease gastric reflux chronic brochitis s/p left shoulder surgery s/p hip surgery hypertension paroxysmal atrial fibrillation s/p transurethral prostatectomy Social History: Exsmoker, stopped a year ago. Social ETOH use. Lives alone. Is a retired maintenance worker. Family History: Father died of MI age 57, had MI previously. Physical Exam: At discharge: AVSS Gen: [Male First Name (un) 4746] in NAD HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy Lungs: Clear to A+P, bilat. thorocotomy incisions healing well CV: IRRR without R/G/M Abd: soft, nontender without masses or hepatosplenomegaly Ext: bilat. LE edema Neuro: non focal Pulses: 1+=bilat throughout Pertinent Results: [2111-12-12] 07:15AM BLOOD WBC-8.7 RBC-4.28* Hgb-9.7* Hct-31.8* MCV-74* MCH-22.7* MCHC-30.6* RDW-16.6* Plt Ct-328 [2111-12-12] 07:15AM BLOOD PT-20.1* INR(PT)-1.9* [2111-12-12] 07:15AM BLOOD Glucose-96 UreaN-21* Creat-1.2 Na-136 K-3.7 Cl-96 HCO3-31 AnGap-13 [2111-12-10] 04:00AM BLOOD ALT-93* AST-48* LD(LDH)-258* AlkPhos-127* Amylase-49 TotBili-0.7 [Known lastname 78926],[Known firstname ] [Medical Record Number 78927] M 63 [2048-6-14] Radiology Report CHEST (PA & LAT) Study Date of [2111-12-10] 9:44 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2111-12-10] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 78928] Reason: r/o inf, eff Preliminary Report !! PFI !! Small bilateral pleural effusions are greater on the right side. Bilateral discoid mid-lung atelectases are larger on the right. Mild cardiomegaly is unchanged. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] PFI entered: [Doctor First Name ] [2111-12-10] 10:34 AM Imaging Lab Brief Hospital Course: Heparin was begun after admission. On [12-2] he went to the operating room where bilateral thoracoscopic Mazes with ligation of the left atrial appendage was performed. Marcaine infusion pumps and bulb drains where placed bilaterally. He remained stable and was extubated easily and transferred to the floor on POD 1.He was atrially paced, Sotalol was resumed. His underlying rhythm was sinus bradycardia, however, he returned to AF on POD2. His chest drains were removed on POD4. AF persisted, Sotalol was discontinued and dofetilide was begun. DCSCV was planned and anticoagulation was continued. He spontaneously converted to sinus rhythm on [12-9]. He was prepared for discharge. Dofetilide was continued as was diuresis. Arrangement were made for Coumadin monitoring as he was on preoperatively. Medications, instruction and precautions were discussed with him prior to discharge. On the day of discharge his Lopressor was increased and he was given an extra dose of 12.5 mg. He was discharged to rehab on POD#10 in stable condition. Medications on Admission: Coumadin 5mg m/w/f:2.5mg t/th/s/s Prilosec 20mg/D Zocor 20mg/D Tricor 145mg/D Xalantan Ophth. Diovan 80mg/D Sotalol 80mg [Hospital1 ] ASA 81mg/D Lasix 80mg/D KCl 20 mg/D Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metoprolol Tartrate Oral 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 13. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime: Titrate for INR of [3-14].5. 14. Latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime: Both eyes. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 6598] ManorExtended Care Facility Discharge Diagnosis: s/p bilateral thoracoscopic Maze procedures with ligation of left atrial appendage Atrial fibrillation hypercholesterolemia Gastric reflux peptic ulcer disease s/p hemigastrectomy chronic brochititis s/p cholecystectomy hypertension s/p transurethral resection prostatectomy s/p herniorraphies s/p shoulder surgery s/p right hip surgery glaucoma Discharge Condition: good Discharge Instructions: No driving for 4 weeks and off all narcotics. No lifting more than 10 pounds for 10 weeks. Shower daily, no baths or swimming. No creams, lotions or powders to incisions. Report any weight gain greater than 2 pounds a day or 5 pounds a week. Report any redness of, or drainage from incisions. Take all medications as directed. Followup Instructions: Dr.[Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) Dr [Last Name (STitle) 3003] in 1 week ([Telephone/Fax (1) 14916]) call for appointments Dr. [Last Name (STitle) ] in 4 weeks. Completed by:[2111-12-12] Name: [Known lastname 12711],[Known firstname 1558] Unit No: [Numeric Identifier 12712] Admission Date: [2111-11-30] Discharge Date: [2111-12-12] Date of Birth: [2048-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1543] Addendum: Pt. also needs to be on Potassium Chloride 40 mEq [Hospital1 ]. Discharge Disposition: Extended Care Facility: [Location (un) ] ManorExtended Care Facility [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2111-12-12]	[ "E879.8", "997.1", "V58.61", "512.1", "V15.82", "530.81", "280.9", "496", "365.9", "V12.71", "420.90", "272.0", "V17.3", "338.12", "401.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "37.33", "37.27", "03.90", "37.26" ]	icd9pcs	[ [ [] ] ]	7171, 7406	2916, 3970	342, 409	6053, 6060	1733, 2893	6435, 7148	1290, 1336		4194, 5561		5684, 6032		3996, 4171			6084, 6412								1351, 1351															1365, 1714						283, 304									437, 920														942, 1164	1180, 1274
1,804	157,298	25074	Discharge summary	report	Admission Date: [2150-8-23] Discharge Date: [2150-9-7] Date of Birth: [2075-1-5] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 5880] Chief Complaint: perforated duodenal ulcer Major Surgical or Invasive Procedure: Exploratory laparotomy and gram patch repair of posterior duodenal penetrating ulcer. Left laparotomy, evacuation of clot, ligation of bleeding. History of Present Illness: The patient is a 35 year-old male who has recently undergone a CABG. He is now postoperative day 10. He presented with acute onset of abdominal pain, increased LFTs and focal abdominal tenderness in the right upper abdomen. He had an elevated white blood cell count of 33. He underwent a CT scan of the abdomen which showed a fluid collection in the upper abdomen, with an air fluid level. This was highly suggestive of a perforated viscous. He was taken emergently to the operating room for exploration. Past Medical History: CAD, a-fib CABG [2150-8-13] Social History: no etoh no tobacco Physical Exam: alert, anxious, no acute distress anicteric pulses irrgularly irregular clear to auscultation bilaterally, well healing sternotomy abdomen soft, focal right upper quadrant tenderness with guarding and no rebound warm extremities, + pulses bilaterally Pertinent Results: [2150-8-22] 08:40PM BLOOD WBC-33.0# RBC-4.17 Hgb-11.7* Hct-35.9* MCV-86 MCH-28.2 MCHC-32.7 RDW-16.7* Plt Ct-555# [2150-8-23] 01:30PM BLOOD WBC-17.6 RBC-3.10* Hgb-9.0* Hct-26.6* MCV-86 MCH-29.0 MCHC-33.8 RDW-16.3* Plt Ct-306 [2150-8-24] 03:00AM BLOOD WBC-21.1* RBC-3.14* Hgb-9.1* Hct-27.8* MCV-88 MCH-28.9 MCHC-32.8 RDW-16.1* Plt Ct-287 [2150-8-25] 06:58AM BLOOD WBC-18.3* RBC-3.23* Hgb-9.2* Hct-28.0* MCV-87 MCH-28.4 MCHC-32.7 RDW-16.0* Plt Ct-340 [2150-8-27] 08:12AM BLOOD WBC-12.8* RBC-3.45* Hgb-9.7* Hct-29.6* MCV-86 MCH-28.1 MCHC-32.6 RDW-15.7* Plt Ct-412 [2150-8-29] 05:20AM BLOOD WBC-11.7* Hct-30.0* Plt Ct-397 [2150-9-1] 06:30AM BLOOD WBC-8.0 RBC-3.78* Hgb-10.3* Hct-32.6* MCV-86 MCH-27.3 MCHC-31.7 RDW-16.2* Plt Ct-424 [2150-9-5] 01:30PM BLOOD WBC-6.5 RBC-3.37* Hgb-9.2* Hct-28.8* MCV-86 MCH-27.3 MCHC-31.9 RDW-16.1* Plt Ct-399 [2150-8-22] 08:40PM BLOOD Neuts-89* Bands-9* Lymphs-1* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2150-8-22] 08:40PM BLOOD PT-21.7* PTT-35.0 INR(PT)-3.4 [2150-8-23] 02:05AM BLOOD PT-18.9* PTT-35.6* INR(PT)-2.5 [2150-8-24] 06:53AM BLOOD PT-17.4* PTT-33.4 INR(PT)-2.1 [2150-8-27] 08:12AM BLOOD PT-33.6* PTT-43.0* INR(PT)-8.6 [2150-8-27] 10:30PM BLOOD PT-17.2* PTT-32.0 INR(PT)-2.1 [2150-8-29] 05:20AM BLOOD PT-13.8* PTT-23.3 INR(PT)-1.3 [2150-9-5] 01:30PM BLOOD PT-13.8* PTT-24.6 INR(PT)-1.3 [2150-8-22] 08:40PM BLOOD Glucose-130* UreaN-20 Creat-1.1 Na-139 K-4.6 Cl-103 HCO3-25 AnGap-16 [2150-8-27] 01:51PM BLOOD Glucose-127* UreaN-25* Creat-1.0 Na-145 K-3.3 Cl-111* HCO3-24 AnGap-13 [2150-9-3] 06:20AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-142 K-3.1* Cl-107 HCO3-24 AnGap-14 [2150-9-5] 01:30PM BLOOD Glucose-131* UreaN-13 Creat-0.9 Na-137 K-3.9 Cl-103 HCO3-23 AnGap-15 [2150-8-22] 08:40PM BLOOD ALT-61* AST-37 CK(CPK)-59 AlkPhos-173* Amylase-38 TotBili-1.6* [2150-8-29] 05:20AM BLOOD ALT-28 AST-37 AlkPhos-92 Amylase-68 TotBili-11.1* [2150-8-31] 06:40AM BLOOD ALT-37 AST-48* LD(LDH)-372* AlkPhos-166* Amylase-81 TotBili-7.4* [2150-9-3] 06:20AM BLOOD ALT-41* AST-45* AlkPhos-172* Amylase-91 TotBili-4.9* [2150-9-7] 06:50AM BLOOD ALT-41* AST-36 AlkPhos-207* Amylase-91 TotBili-2.7* [2150-8-22] 08:40PM BLOOD Lipase-23 [2150-9-1] 06:30AM BLOOD Lipase-100* [2150-9-7] 06:50AM BLOOD Lipase-85* [2150-8-23] 03:52AM BLOOD Calcium-8.2* Phos-5.6# Mg-1.6 [2150-8-28] 04:08AM BLOOD Albumin-2.7 Phos-3.0 Mg-2.0 [2150-9-5] 01:30PM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.7 Mg-2.3 [2150-8-23] 05:30AM BLOOD freeCa-1.11* [2150-8-27] 11:21AM BLOOD freeCa-1.06* [2150-8-22] 10:26PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [2150-8-22] 10:26PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [2150-8-23] 1:00 am SWAB Site: PERITONEAL Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. FINAL REPORT [2150-8-25] GRAM STAIN (Final [2150-8-23]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2150-8-25]): [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE GROWTH. [2150-8-26] 12:40 pm SEROLOGY/BLOOD FINAL REPORT [2150-8-28] HELICOBACTER PYLORI ANTIBODY TEST (Final [2150-8-28]): POSITIVE BY EIA. Reference Range: Negative. RADIOLOGY Final Report CT RECONSTRUCTION [2150-8-22] 11:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: aorta, obstruction, liver, appy Field of view: 40 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 75 year old man with diffuse and RUQ pain, inc lfts, US pos gallstones but no wall/ fluid REASON FOR THIS EXAMINATION: aorta, obstruction, liver, appy CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 75-year-old male status post CABG, presenting with abdominal pain today. COMPARISONS: No comparisons are available. TECHNIQUE: 64-MDCT axial images of the abdomen and pelvis were obtained with IV contrast only. CT OF THE ABDOMEN WITH IV CONTRAST: There is marked inflammation in the right upper quadrant and right flank with a significant amount of mesenteric fluid and stranding. There is a focal loculated area of air-fluid level in the anterior mesentery measuring 3.5 x 4.4 cm that most likely represents extraluminal air and fluid. In this collection, there is also hyperdense area seen on series 2, image 37, of unclear significance. It could represent a small amount of oral contrast since the patient received a minimal amount of oral contrast per NG tube. It could also represent extravasation of IV contrast. Due to localization of the inflammation findings and fluid around the stomach and proximal duodenum, these findings are most likely secondary to perforated duodenal ulcer or distal gastric ulcer. There is mild inflammation in the ascending colon and hepatic flexure, likely secondary to the process. The cecum and the rest of the colon are otherwise unremarkable. The liver and gallbladder are within normal limits. Fluid around the gallbladder is likely due to the inflammatory process. The pancreas appears unremarkable. There are multiple simple cysts in the kidneys bilaterally. There is no evidence of hydronephrosis. There is a 3.5 cm AAA of the infrarenal abdominal aorta. This contains mural thrombus. There is also dilatation of the proximal right common iliac, measuring up to 1.8 cm (consistent with aneurysmal dilatation). Extensive calcification of the remaining vessels. No retroperitoneal mass is seen. Imaging of the lower lungs demonstrate a moderate-sized left pleural effusion. There are also patchy opacities in the lung bases that could represent atelectasis. Pneumonia or aspiration, however, cannot be excluded. CT OF THE PELVIS WITH IV CONTRAST ONLY: There is a small amount of fluid in the pelvis. The urinary bladder, distal ureters, intrapelvic bowel loops are unremarkable. There is calcification of the prostate. BONE WINDOWS: There are no suspicious lytic or blastic lesions in the bones. There are degenerative changes of the lumbar spine. CT reformations were very important to confirming the above-mentioned findings and to evaluate the presence for free extraluminal air. IMPRESSION: 1. Acute inflammatory changes in the right upper quadrant, likely secondary to perforation of the duodenum or distal stomach. There is an extraluminal mesenteric collection of air and fluid, likely secondary to the perforation. 2. Small amount of free fluid in the pelvis. 3. Infrarenal AAA measuring 3.5cm. Right common iliac artery aneurysmn 4. Left pleural effusion. Also multifocal opacities in the lung bases, likely due to atelectasis. However, possibility of aspiration cannot be excluded. 5. Calcification of the right lung base, likely due to granulomatous disease. Brief Hospital Course: After Ct showed concern for perforated viscous, patient was immediately taken to the OR for an ex-lap and exploration with [Location (un) ] patch of duodenal ulcer perforation. Patient received 6U FFP intra-op and was then taken to the SICU post-op, intubated. Received 3 U pRBCs Was started on UNASYN ([2065-8-22]) and wound cx showed [Female First Name (un) ]. Patuebt was extubated on POD 1 and transferred to the floor on POD 2 in good condition. NGT/NPO was kept unti POD 5. H pylori serology was perofrmed POD 4, which was positive. On POD 5 patient was taken back to the OR for ex-lap because of [Doctor Last Name ] hct and large amount of JP output where a large clot was found in the abdomen but no active bleeding. 2U pRBCs given post-op, heparin held. Diflucan was started on POD 4([8-26]), Triple tx for H pylori started on POD [8-16] ([8-31]) - to be continued for 2 weeks. POD [5-13] U/S GB showed stones, subsequent HIDA was equivocal. Clears were started POD [7-15]. Soft solids started POD [8-16] and po meds and then regular diet. NGT placed POD [9-16] because with a return of bilious liquid after problems breathing and gas pains, with subsequent improvement. NGT was kept until POD [11-18]. [9-2] UGI c SBFT some narrowing in 2nd protion of duodenum, but no obstruction. POD 13/8 restarted and tolerating reg diet. [9-5] CXR: RLL opacity, cardiomegaly, prom pulm vasc c/w CHF. Did have some asymptomatic nonsustained runs of v-tach. Hepatitis panel was also ordered and d/c planning was initiated. Cardiology saw the patient and recommended to change metoprolol form [Hospital1 ] to tid. Patient was discharged home with VNA in good condition. Medications on Admission: Lasix 20", captopril 25"', KCl 20, Lopressor 50", ASA 81, oxycodone, Lipitor 10, Coumadin 3 Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 3. Amoxicillin 500 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day) for 7 days. Disp:14 Capsule(s) Refills:0 4. Clarithromycin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 5. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 6. Captopril 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 7. Oxycodone-Acetaminophen 5-325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:48 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: perforated duodenal ulcer Discharge Condition: good Discharge Instructions: 1. please seek medical attention if you experience fever > 101.5, severe nausea, vomitting, pain 2. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. 3. Adhere to 2 gm sodium diet 4. Fluid Restriction: 5. may shower 6. no driving while on narcotic pain meds 7. please take new meds as directed and resume home meds Followup Instructions: please call dr.[Hospital Ward Name ] office for an appointment [Telephone/Fax (1) ] Completed by:[2150-9-7]	[ "V45.81", "998.59", "496", "574.20", "412", "428.0", "V45.01", "998.11", "560.1", "427.31", "V58.61", "532.20", "442.2", "041.86", "285.9", "441.4", "997.4", "V17.3", "682.2", "414.01", "401.9", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "87.63", "44.42", "54.64", "54.12", "87.62", "39.31", "99.04", "99.07" ]	icd9pcs	[ [ [] ] ]	11306, 11365	8417, 10145	304, 451	11435, 11442	1363, 5126	11828, 11949			10287, 11283	5163, 5253	11386, 11414		10171, 10264			11466, 11805								1092, 1344																					239, 266	5282, 8394								479, 986														1008, 1041	1057, 1077
82,040	103,716	4172	Discharge summary	report	Admission Date: [2108-11-22] Discharge Date: [2108-11-26] Date of Birth: [2034-6-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: Fatigue and abdominal pain Major Surgical or Invasive Procedure: EGD History of Present Illness: 74 yoM w/ a h/o ETOH related cirrhosis presents with coffee ground emesis (few episodes) and black stools x 3 weeks. He had been taking 6 ASA per day for a few weeks. He also has not been taking his nexium for the past 3 weeks. The patient went to [Hospital6 12112] where his hct was found to be 18, he was then transferred to [Hospital1 18]. Prior to transfer he was given Protonix 40 mg IVx1, and morphine 2 mg IVx1. In addition the patient complains of fatigue, nausea, and abdominal pain for the past 2-3 weeks. In the ED, initial VS: T 96.9 HR 95 BP 125/67 RR 22 O2 sat: 96% on RA. He rec'd 1 uPRBC in the ER. He was guaiac +, dark stool. NG lavage negative. He rec'd 2 liters of fluid. He was given 40mg IV protonix (in addition to the 40mg IV protonix). He was started on an octreotide drip after a bolus. BP 122/56 HR 93 100% on 3L RR 12. Past Medical History: COPD Cirrhosis (GI f/u @ [Last Name (un) 4199]) Gastric PUD 10 years ago Variceal bleed in past (10 years ago) h/o GI bleed HTN ETOH abuse COPD DM c/b neuropathy DJD OA anemia Social History: h/o ETOH abuse. No ETOH recently (x10 years) w/ the exception of "sneaking" some ETOH recently. Family History: Non contributory Physical Exam: Vitals - T: 96.6 BP: 122/57 HR: 96 RR: 12 02 sat: 96% 2L GENERAL: Oriented x1, Sleeping but arousable HEENT: PERRL, no scleral icterus, dry MM CARDIAC: tachy, regular, no murmurs rubs or gallops LUNG: Clear bilaterally ABDOMEN: + BS, soft, nt, no hsm, dull to percussion bilaterally in flanks EXT: WWP, 1+ pedal edema, no c/c NEURO: No asterxis Pertinent Results: [2108-11-23] 09:24AM BLOOD Hct-23.7* [2108-11-23] 02:47AM BLOOD WBC-5.7 RBC-2.58* Hgb-7.8# Hct-24.0 MCV-93 MCH-30.2 MCHC-32.4 RDW-18.1* Plt Ct-213 [2108-11-22] 12:53PM BLOOD WBC-7.0 RBC-2.08# Hgb-6.1# Hct-20.1# MCV-97# MCH-29.1 MCHC-30.2 RDW-18.9* Plt Ct-201 [2108-11-23] 02:47AM BLOOD Neuts-83.3* Bands-0 Lymphs-8.9* Monos-6.7 Eos-0.7 Baso-0.5 [2108-11-23] 02:47AM BLOOD PT-17.3* PTT-32.9 INR(PT)-1.5* [2108-11-22] 12:53PM BLOOD PT-17.4* PTT-32.0 INR(PT)-1.6* [2108-11-23] 02:47AM BLOOD Glucose-42* UreaN-28* Creat-0.8 Na-145 K-3.4 Cl-112* HCO3-20* AnGap-16 [2108-11-22] 12:53PM BLOOD Glucose-147* UreaN-33* Creat-0.9 Na-143 K-3.9 Cl-106 HCO3-23 AnGap-18 [2108-11-23] 02:47AM BLOOD ALT-82* AST-175* AlkPhos-103 TotBili-3.1* DirBili-1.2* IndBili-1.9 [2108-11-22] 12:53PM BLOOD ALT-100* AST-248* AlkPhos-121* TotBili-1.4 [2108-11-23] 02:47AM BLOOD Albumin-2.6* Calcium-7.6* Phos-2.2* Mg-1.6 [2108-11-22] 12:53PM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.7 Mg-1.8 [2108-11-22] 12:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2108-11-22] 12:53PM BLOOD AFP-153.2* [2108-11-22] 12:53PM BLOOD Lipase-24 GGT-550* [2108-11-22] 12:53PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE [2108-11-22] 12:53PM BLOOD tTG-IgA-21* [2108-11-22] 12:53PM BLOOD HCV Ab-POSITIVE* [2108-11-26] 05:30AM BLOOD WBC-3.4* RBC-3.11* Hgb-9.2* Hct-29.0* MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-213 [2108-11-26] 05:30AM BLOOD Glucose-110* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-108 HCO3-22 AnGap-15 [2108-11-25] 06:55AM BLOOD Ret Aut-1.9 [2108-11-26] 05:30AM BLOOD Glucose-110* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-108 HCO3-22 AnGap-15 [2108-11-26] 05:30AM BLOOD ALT-55* AST-84* AlkPhos-97 TotBili-2.6* [2108-11-26] 05:30AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.4* Mg-1.8 EGD [2108-11-22]: Varices at the lower third of the esophagus and gastroesophageal junction Ulcers in the antrum Three non bleeding AVM's found in the stomach Erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Villous blunting noting diffusely in first and second portion of the duodenum Varices at the fundus Otherwise normal EGD to second part of the duodenum [2108-11-22] RUQ ULTRASOUND: 1. Cirrhotic shrunken liver, with a mass in the right lobe, which is worrisome for the presence of HCC. Recommend a multi-phasic CT or MRI of the liver to further evaluate the mass in the right lobe. 2. The main portal vein, right and left portal vein are patent with hepatopetal flow. 3. There is extensive ascites and splenomegaly in keeping with portal hypertension. 4. The right hepatic vein is not visualized. Brief Hospital Course: UPPER GI BLEED: Given his symptoms of coffee ground emesis, dark stool and low hematocrit, the patient was assumed to have suffered an upper GI [Last Name (un) ]. He underwent an upper endoscopy in the medical ICU which revealed no active bleeding but multiple sources including grade II varicies, AVMs and peptic ulcer disease. The patient was started on an octreotide and protonix drip initially; eventually the octreotide was discontinued and the protonix changed to oral dosing. The patient was instructed to avoid NSAIDs, ASA, and ETOH. He was transfused 2 units of pRBCs and his hematocrit rose to the upper 20s and was stable. LIVER CIRRHOSIS: The patient has known alcoholic cirrhosis as per HPI. During this admission, he was started on spironolactone, lactulose, and nadolol for his cirrhosis/varices, ciprofloxacin for SBP prophylaxis, and folic acid and thiamine for nutritional deficits, but he refused to take most of these medications during his stay. After discussion with his wife, we will prescribe these medications at transfer with the intent for patient to take prescriptions with him when departing rehab. His wife understands the the priority order (if patient wishes to limit number of medications) is lactulose > nadolol > spironolactone > cipro/folic acid/thiamine. He will continue to take Nexium as before. HEPATIC MASS: This is likely HCC based on ultrasound findings, and his AFP was markedly elevated. This finding was discussed at length with Dr. [Last Name (STitle) 497] (hepatology attending), the patient and his wife, and a decision was reached to pursue no further work-up or treatment for this mass. In addition, the patient has elected to change his code status to DNR/DNI. PAIN CONTROL: The patient was reportedly taking [4-30] aspiring per day prior to admission, which may have caused or exacerbated his upper GI bleed. He has been on tramadol 50 mg PO TID at home as well as percocet, which seem effective for his pain and are safer than NSAIDs or aspirin. His total acetominophen intake should be limited to 2 g daily given his liver disease. Additional narcotic medication may be required in this patient with likely cancer in the future. DIABETES MELLITUS: Per the patient's wife, he was taken off of insulin in [Month (only) 547] of this year, and since then has largely refused to allow her to check his fingersticks. During this admission, he was placed on a humalog sliding scale with blood sugars ranging in the 100s (range 145-202 on the day prior to discharge). Given the relatively low sugars and the patient's preference to stay off of insulin, we are not continuing his fingersticks or humalog sliding scale at discharge. OTHER CARE: Also, patient was discharged with foley catheter in place. As soon as possible, please remove foley and do voiding trial. Medications on Admission: Nexium 40 mg PO daily Percocet PRN (patient has taken 9 tabs since [Month (only) 359]) Tramadol 50 mg PO TID PRN (patient typically takes TID) Ambien 10 mg PO QHS PRN insomnia ASA PRN (up to 6-8 tablets per day, per his wife) [Name (NI) ] supplement Discharge Medications: 1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Hold for > 3 bowel movements per day. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: OK for patient to take this medication 3 times daily at times of his choice. 8. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: Please do not drive or operate machinery while taking this medication. Please keep your total daily acetominophen use to less than [2098] mg daily (325 mg per Percocet tablet). 13. [Year (4 digits) ] (Ferrous Sulfate) 325 mg (65 mg [Year (4 digits) ]) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] - [Location (un) ] Discharge Diagnosis: Primary: - Upper gastrointestinal bleed (source unknown - esophageal varices vs. ulcer vs. AVM) - Alcoholic cirrhosis of the liver - Liver mass (probable hepatocellular carcinoma) - Esophageal varices - Ulcers in antrum Secondary: - Diabetes mellitus type II (diet-controlled) - COPD Discharge Condition: Mental Status:Confused - sometimes (at the time of discharge, patient is coherent, but had episodes of confusion throughout this admission) Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) - this is his baseline; he is currently deconditioned and only able to walk very short distances Discharge Instructions: You were transferred to [Hospital1 69] with weakness, fatigue, dark stool, and a low hematocrit (red blood level). You were admitted to the intensive care unit and you underwent an upper endoscopy procedure. This showed esophageal varices (distended veins), ulcers in the stomach, and some arteriovenous (vascular) malformations, but there was no active bleeding seen. You received 2 units of packed red blood cells and your hematocrit (blood level) improved and remained stable. You were re-introduced to a regular diet, and you appeared much improved. However, because you are still very weak and it will be difficult for your wife to care for you alone at home, you will be discharged to a rehab facility where you can focus on re-gaining your strength. While you were here, an imaging study of your liver showed a new liver mass. This most likely represents a type of liver cancer called hepatocellular carcinoma. You discussed this finding with Dr. [Last Name (STitle) 497] and your wife, and a decision was made not to pursue further work-up or treatment for the mass at this time. We have made the following changes to your medication regimen: - STOP TAKING aspirin and do not take any other over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen). These medications could cause a life-threatening bleed given the findings on your endoscopy study. - CONTINUE TAKING Percocet as needed for pain. Please keep your total acetominophen (Tylenol) level to < [2098] mg (2 g) per day. Each Percocet contains 325 mg of acetominophen. - BEGIN TAKING acetaminophen (Tylenol) for pain not controlled by the tramadol and Percocet you already use, up to [2098] mg (2 g) a day as above. Note that each Percocet tablet contains 325 mg of acetaminophen that must be counted toward the total daily dose. It is important that you not take more acetominophen than this as it may worsen your liver disease. - BEGIN TAKING Lactulose 30 ml by mouth three times daily (unless having more than 3 bowel movements daily; then scale back). This medication will help to keep your mind clear by preventing confusion caused by liver disease. This is the MOST IMPORTANT medication for you to take as prescribed. - BEGIN TAKING nadolol 40 mg by mouth daily. This medication will help to prevent bleeding complications from esophageal varices. This is the SECOND MOST IMPORTANT medication for you to take as prescribed. - BEGIN TAKING spironolactone 100 mg by mouth daily. This medication will prevent complications from fluid build-up caused by your liver disease. This is the THIRD MOST IMPORTANT medication for you to take as prescribed. - BEGIN TAKING ciprofloxacin 500 mg by mouth daily. This medication will help to prevent abdominal infections caused by your liver disease. - BEGIN TAKING folic acid 1 mg by mouth daily - BEGIN TAKING thiamine 100 mg by mouth daily If you have to prioritize your medications, the most important ones by order are 1. lactulose 2. nadolol 3. spironolactone Followup Instructions: Please follow up with your primary care doctor as below. You do not require specific liver clinic follow up at this time. If you are unwilling or unable to make these appointments, please call ahead to cancel. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time: Tuesday [2108-12-11] 11:00 AM Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2109-2-19] 10:00 AM Completed by:[2108-11-26]	[ "571.2", "537.83", "305.02", "537.89", "799.4", "401.9", "280.0", "572.2", "578.9", "496", "456.20", "579.0", "531.40", "250.60", "357.2", "572.3", "789.59" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	9344, 9409	4803, 7642	343, 348	9738, 9738	1985, 4780	13173, 13739	1583, 1601		7950, 9321		9430, 9717		7668, 7927			10121, 13150								1616, 1966																					277, 305									376, 1250									9752, 10097					1272, 1453	1469, 1567
70,872	130,833	5875	Discharge summary	report	Admission Date: [2172-10-30] Discharge Date: [2172-11-2] Date of Birth: [2094-3-27] Sex: F Service: MEDICINE Allergies: Morphine / Codeine / Percocet / Bactrim Attending:[First Name3 (LF) 1990] Chief Complaint: fever, malaise Major Surgical or Invasive Procedure: none History of Present Illness: 78F h/o urinary retention, urosepsis presenting with fever and malaise. She presented to her PCP yesterday after several days of foul smelling urine and one day of chills and was sent home on Bactrim. She experienced one episode of severe midline back pain radiating to her neck while making dinner which and began to feel fatigued and nauseous and was brought to the ED by her daughter. In the ambulance, she had several episodes of non-bloody, non-bilious emesis. She reports some shortness of breath x 24h and chronic dry cough. She denies diarrhea or abdominal pain, no hematuria, dysuria, urgency or frequency. No cold symptoms or skin changes. Her daughter states her presentation similar to that for prior admission for urosepsis. In the ED, initial VS were 102.3 107 119/87 18 96%. Her blood pressure dropped as low as 80s/50s in the ED and she received a total of 5L NS with SBP mostly 90s-low 100s. Labs were notable for K 3.2 and elevated lactate (5.3), transaminases, Alk phos and LDH. Initial concern for pleural effusion on CXR but final read negative. CT chest performed and negative on prelim read. CT abd/pelvis wet read showed no gallbladder distention. On arrival to the MICU, patient's VS 97.7 P 79 102/46 R 24 98% 3L NC. Past Medical History: -urosepsis: Hospitalized [7-/2171] with urosepsis. Urine cx showed E. coli sensitive to ciprofloxacin. [4-/2171] pansensitive pseudomonas -urinary retention: Urodynamics study and cystoscopy performed for urinary frequency, urgency, urge incontinence in [Month (only) 547] and [2172-6-9] showed partial urinary retention with PVRs 270-480cc. -spinal stenosis: on flexeril -ABNORMAL LIVER FUNCTION TESTS -s/p bilateral knee replacements -HYPERTENSION -OSTEOARTHRITIS -HYPOTHYROIDISM -PERIPHERAL NEUROPATHY -GERD Social History: Lives alone in [Initials (NamePattern4) ] [Last Name (NamePattern4) ] which she recently sold to be able to move in with her son's family. Never smoked. [3-13] alcoholic drinks per week. No illicits Family History: Negative for heart disease, cancer, diabetes Physical Exam: admission PE: Vitals: 97.7 P 79 102/46 R 24 98% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, EOMI Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, +tenderness to palpation epigastrium and LLQ, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, well healed ulceration R shin Neuro: moving all 4 extremities equally Pertinent Results: Admission Labs: [2172-10-29] 10:50PM BLOOD WBC-4.5 RBC-4.42 Hgb-13.0 Hct-38.0 MCV-86 MCH-29.5 MCHC-34.3 RDW-13.0 Plt Ct-207 [2172-10-29] 10:50PM BLOOD Neuts-84* Bands-3 Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2172-10-29] 10:50PM BLOOD PT-12.0 PTT-22.1* INR(PT)-1.1 [2172-10-29] 10:50PM BLOOD Glucose-87 UreaN-23* Creat-0.9 Na-135 K-3.2* Cl-97 HCO3-22 AnGap-19 [2172-10-29] 10:50PM BLOOD ALT-74* AST-166* LD(LDH)-338* AlkPhos-142* TotBili-0.8 [2172-10-29] 11:00PM BLOOD Type-[Last Name (un) ] pO2-57* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 Comment-GREEN TOP RUQ US [2172-10-30]: Cholelithiasis and adenomyomatosis of the gallbladder wall. There is no evidence of biliary obstruction. Brief Hospital Course: 78F with h/o urinary retention and urosepsis p/w fever, malaise, hypotension x 24 hours. #SIRS: Febrile to 102.3 in ED with tachypnea, tachycardia. Lactate 5.3 on admission. Suspect sepsis with unclear source but most likely urinary vs biliary. Pt has h/o urosepsis and urinary retention and reports several day h/o foul smelling urine although UA is negative. Pt has had nausea/vomiting and epigastric tenderness and transaminases, alk phos and LDH all elevated, although close to baseline prior values. CT ABD/PEL in ED indicated cholelthiasis without gallbladder distention or wall edema, confirmed with RUQ US. She was covered broadly in the ICU with vanc/Zosyn. SBP improved with agressive volume resuscitation, 5L in the [Hospital Unit Name 153]. Of note, hypotension happened after exposure to Bactrim, and similar reaction may have happened with prior exposure to Bactrim, so could be distributive picture from allergic rxn, although this does not explain her initial symptoms clearly. Her syndrome resolved, cultures remained negative, antibiotics were discontinued. She was monitored on the medical [Hospital1 ] for 48 hours for recurrent symptoms/fevers, and she continued to improve. She developed symptoms of a viral URI (coryza, low grade fever) which also resolved. In the final 24 hours of hospitalization, pt. had no fevers or significant symptomatic complaints. She appeared well and reported feeling well, she was independently ambulatory, voiding regularly, and tolerating a regular diet. She was discharged to home with the instructions below. #Abnormal liver function tests: Pt appears to have chronically elevated transaminases, AP and LDH for the last several years but now with marked elevation compared to prior labs in [2171]. As noted above, choletlithiasis without cholecytitis on RUQ US. These resolved to normal by discharge, they may have been elevated due to relative hypotension on presentation with mild hepatic injury, or, this may have been representative of a passed gallstone although given CT imaging, this appears unlikely. #Back Pain: Chronic -continued home meds #Urinary retention, chronic, stable. #HTN: On atenolol-chlorthalidone at home resumed after volume resuscitation #OA: -continued nsaids prn: pain. #Hypothyroidism -continued home levothyroxin #GERD: -continued home omeprazole Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. atenolol-chlorthalidone NF 100-25 mg Oral daily 2. Cyclobenzaprine 10 mg PO HS:PRN back pain 3. Gabapentin 100 mg PO TID 4. Gabapentin 400 mg PO HS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lorazepam 1 mg PO HS:PRN insomnia 7. Omeprazole 20 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Vitamin D Dose is Unknown PO DAILY 10. tolmetin NF 400 mg Oral [Hospital1 ] PRN pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cyclobenzaprine 10 mg PO HS:PRN back pain 3. Gabapentin 100 mg PO TID 4. Gabapentin 400 mg PO HS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Lorazepam 1 mg PO HS:PRN insomnia 7. Omeprazole 20 mg PO DAILY 8. tolmetin NF 400 mg Oral [Hospital1 ] PRN pain 9. Vitamin D 800 UNIT PO DAILY 10. atenolol-chlorthalidone NF 100-25 mg Oral daily Discharge Disposition: Home Discharge Diagnosis: possible allergic reaction to bactrim possible viral upper respiratory tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after presenting to the ED with back pain, nausea, vomiting, and a high fever. The source of this remains unclear. [Name2 (NI) ] cultures and imaging studies here were negative for infection. You may have passed a gallstone, however, there was no definitive evidence for this on imaging or laboratory analysis. You had some symptoms of a viral illness (a 'cold') however, this would not explain your initial syndrome on presentation. There was mention in the ICU of this being a reaction (allergic-type) to Bactrim, however, this remains uncertain. Although you reported being treated emperically for a UTI from your primary care MD, again, our urinalyses and urine cultures reveal no evidence of any urinary tract infection. Your CT of the chest reveals several pulmonary nodules, which, as we discussed, will need repeat imaging in one year by repeat CT scan. I have sent Dr. [First Name (STitle) ] a letter outlining this recommendation. Followup Instructions: Department: RADIOLOGY When: TUESDAY [2173-1-12] at 1:15 PM [Telephone/Fax (1) 590] Building: Gz [Hospital Ward Name 2104] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Department: SURGICAL SPECIALTIES When: TUESDAY [2173-1-12] at 2:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 11307], MD [Telephone/Fax (1) 3752] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: [Hospital Ward Name ] [2177-8-1] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "715.90", "465.9", "356.9", "276.8", "794.8", "995.0", "401.9", "244.9", "E931.0", "530.81", "458.29", "287.5", "995.91", "V43.65", "793.11", "275.2", "038.9", "788.29", "574.20" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7105, 7111	3821, 6181	316, 322	7241, 7241	3064, 3064	8389, 9286	2393, 2440		6708, 7082		7132, 7220		6207, 6685			7391, 8366								2455, 3045																					262, 278									350, 1597					3080, 3798				7256, 7367					1619, 2148	2164, 2377
22,874	156,009	23381	Discharge summary	report	Admission Date: [2195-1-12] Discharge Date: [2195-1-15] Service: MEDICINE Allergies: Biaxin / Lipitor Attending:[First Name3 (LF) 2880] Chief Complaint: CAD here for pre-hydration before cath Major Surgical or Invasive Procedure: Bilateral baloon valvuloplasty History of Present Illness: 81 yr old male with class 4 CHF, CAD s/p CABG, severe aortic stenosis, severe PVD, HTN, high cholesterol who is admitted today for pre-hydration before cardiac cath and aortic valvuloplasty. Pt states that he has been experiencing worsening dyspnea on exertion over the past 3-4 years. Currently, he can only walk about 20 feet or a couple minutes before becoming short of breath. He has lost approximately 75lbs over the past 4-5 years due to fatigue and dyspnea while eating. Also over the past few years, he has been complaining of burning leg pain on walking. He sleep on 2-pillows because of his hiatal hernia; he denies PND and lower ext swelling. He denies fevers, chills, abd pain, n/v/d; he states that he gets up multiple times during the night to urinate. He has a hx of an MI several years ago and his angina was described as neck pain. He denies frequent chest pain but does feel a discomfort in his chest when he exerts himself too much. Past Medical History: ~class IV CHF ~HTN ~High cholesterol ~tobacco abuse ~CAD s/p CABG in [2176], s/p PTCA in [2182] ~severe Aortic stenosis with aortic valve area of 0.7 cm2 (echo [2192]) ~severe PVD ~hiatal hernia Social History: tobacco: 38 pack-year history; quit 44 years ago EtOH: occasional lives alone but can stay with daughter if needed Family History: mother and father with CAD no DM Physical Exam: temp 97.4, BP 138/90, HR 68, RR 20, O2 97% 2L Gen: NAD, pleasant HEENT: PERRL, EOMI, dry MM, anicteric sclera Neck: no JVD, no bruits CV: RRR, 3/6 systolic murmur heard best at RUSB and apex Chest: crackles at bases to [12-28] way up Abd: +BS, scaphoid, nontender, no renal bruits Groin: no femoral bruits Ext: no edema, nonpalp pulses, warm, sensation intact Neuro: AO x 3 Pertinent Results: [2195-1-12] 06:38PM GLUCOSE-102 UREA N-48* CREAT-2.5* SODIUM-142 POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-38* ANION GAP-12 [2195-1-12] 06:38PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.3 [2195-1-12] 06:38PM WBC-8.5 RBC-3.27* HGB-10.4* HCT-31.7* MCV-97 MCH-31.8 MCHC-32.8 RDW-17.5* [2195-1-12] 06:38PM NEUTS-69.7 LYMPHS-21.8 MONOS-4.8 EOS-3.1 BASOS-0.7 [2195-1-12] 06:38PM ANISOCYT-1+ MACROCYT-2+ [2195-1-12] 06:38PM PLT COUNT-160 [2195-1-12] 06:38PM PT-12.2 PTT-28.2 INR(PT)-0.9 . EKG: Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Left ventricular hypertrophy. There are ST segment depressions in II, III, aVF and leads V4-V6 as well as T wave inversions which may be secondary to left ventricular hypertrophy and/or the repolarization abnormalities with right bundle-branch block. However, ischemia cannot be excluded. Clinical correlation is suggested. . CXR:Diffuse interstitial pulmonary fibrosis with peripheral and somewhat basilar predominance. This is most likely due to a cause of UIP, which may be idiopathic, related to drug toxicity, collagen vascular disease, or asbestos-related lung disease. Small left apical and lateral pneumothorax. In the absence of recent intervention, this may be spontaneous as a complication of chronic interstitial lung disease. Patchy peripheral apparent consolidative changes in the right lung, which may reflect confluent areas of fibrosis or an acute infectious process. . CATH: 1. Coronary arteries not evaluated. 2. Severe aortic stenosis. 3. Normal filling pressures. 4. Aortic valvuloplasty. 5. Bilateral perclose. * ECHO: Severely thickened/deformed aortic valve with at least moderate aortic valve stenosis and mild aortic regurgitation. Regional left ventricular systolic dysfunction c/w CAD. Right ventricular free wall hypokinesis. Mild mitral regurgitation. Brief Hospital Course: A/P: 81 yr old male with CAD s/p CABG, HTN, high cholesterolemia, class IV heart failure, PVD and severe aortic stenosis who was admitted for pre-hydration prior to cath and aortic valvuloplasty. . 1. CAD: s/p CABG in [2176] and PTCA in [2182]; diseased vessels unknown, but remained stable and assymptomatic and followed by outpatient cardiologist. He was continued on ASA, imdur, coreg, but not on a statin because of history of liver toxicity secondary to lipitor. His coronary arteries were not evaluated during the procedure. . 2. CHF: class 4 by report; likely secondary to aortic stenosis, symptoms of dyspnea with exertion improved after valvuloplasty. Not on an ace-inhibitor because of renal failure. Otherwise continued on home regimin of carvedilol and lasix. Continue to follow daily weights at home. . 3. Rhythm: remained in normal sinus rhythm and continued on a betablocker. . 4. Aortic Stenosis: severe, sympomtatic aortic stenosis with valve area 0.7cm2, he had dual bilateral baloon valvuloplasty to open his aortic stenosis with resultant 1+ aortic regurgitation following procedure and good symptomatic improvement. . 5. PVD: known symptomatic peripheral venous insufficiency in bilateral lower extremeties with MRA done in [11-29] which showed moderate to severe PVD in both lower extremities. He will return in future for LE stenting with Dr [Last Name (STitle) ]. . 6. Renal: per patient has had known renal insuffciency and is followed by nephrologist in [Location (un) 3844] who is following his renal function and administering procrit. He was pre-hydrated and given mucomyst pre-cath for renal protection. . 7. Anemia: stable here- was transfused one unit PRBC during this stay. His iron studies, folate and B12 were normal. At time of discharge his hematocrit was 32. he will follow up with his nephrologist for continued procrit injections. He remained guiaic negative and last had a colonoscopy in [2190] per discussion with his PCP with diverticuli and one polyp. . 8. Chronic interstitial lung disease: discussed with PCP and has had known intersitial disease without a known source. He remained stable and this is consistent with his lung disease prior to admission and remains on home oxygen as prior to admission. His metabolic alkalosis on chemistries is consistent with long stabding pulmonary disease. Medications on Admission: Ranitidine 300mg [Hospital1 ] Temazepam 30mg qd Imdur 30mg qd Lasix 40mg [Hospital1 ] Coreg 12.5mg [Hospital1 ] ASA 325mg qd MVI Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed. 3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Severe aortic stenosis Class IV heart failure Hypertension coronary artery disease peripheral vascular disease chronic intersitial lung disease on home oxygen Discharge Condition: Continued on home O2 and able ambulate to bathroom with minimal difficulty. Discharge Instructions: Please call or return if become more short of breath or develop any pain or bleeding from groin site. Please take all medicines as prescribed. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ] [7-5] days. Please follow up with your Cardiologist Dr [Last Name (STitle) 60004] in [7-5] days. Please follow up with your nephrologist Dr [Last Name (STitle) ] in [12-28] weeks. [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883] Completed by:[2195-1-20]	[ "424.1", "403.91", "414.00", "V45.82", "285.9", "799.4", "428.0", "515", "276.4", "V45.81", "272.4", "413.9", "276.5" ]	icd9cm	[ [ [] ] ]	[ "35.96", "37.78", "99.04" ]	icd9pcs	[ [ [] ] ]	7219, 7225	4006, 6382	263, 296	7428, 7505	2109, 3983	7697, 8125	1662, 1696		6573, 7196		7246, 7407		6408, 6550			7529, 7674								1711, 2090																					185, 225									324, 1283														1305, 1513	1529, 1646
23,455	172,250	3581	Discharge summary	report	Admission Date: [2169-1-17] Discharge Date: [2169-1-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: worsening dyspnea on exertion and LE edema Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 6512] is a [Age over 90 ] yo F with h/o CHF (EF=55%), valvular disease (AS & MR), and Afib admitted overnight with complaints of worsening dyspnea on exertion and LE edema. Admission note comments that patient was unable to provide a history. Per ED notes, caretaker reported pt has had worsening LE swelling over the last 2 weeks (L>R), decreased activity, and decreased PO intake. Also reports of increased left breast edema. Report of patient being on a diuretic, but unsure of name or dose. Caretaker says for the past several days pt has c/o DOE and decreased activity. On admission, patient denied recent F/C/cough, CP/SOB/trauma. EMS notes indicated pt was found with O2 of 89% on RA, rales on exam. EMS also indicated that she was A&Ox4, but ED note states had altered mental status. CT head was performed in the ED which showed no acute bleed. . In the ED she received 500cc NS IV. CXR showed CHF, effusions, and posterior opacity c/w ?pneumonia. ceftriaxone 1g IV x 1 and azithromycin 500mg IV x 1 given in ED. Bilateral LENI's negative in the ED. . This morning patient found by medicine team to be minimally reponsive; was opening eyes to command, but not answering all questions. Low BP (88/palp), normal pulse, RR high 20's, 94% on 4L O2. Also did not make any urine overnight. ABG attempted, but only able to get VBG (7.18/93/36). MICU called for eval and transfer. . Past Medical History: - CHF, EF >55% - AS/MR ([12-18]) - HTN - AFib Social History: - Lopressor - Digoxin - ASA Family History: NC Physical Exam: VS: T= 92.2 (ax); HR = 73; BP = 94/56; RR = 16-30; O2 = 90-92% 3L NC. GEN: sleeping, arouses to voice; able to answer some questions. falls back asleep quickly. HEENT: anicteric, surgical pupil OS, Pinpoint pupil OD, OP slightly dry, no erythema NECK: supple, prominent EJ, JVP not elevated. CV: irregularly irregular, II/VI systolic crescendo-decrescendo murmur at LUSB, [1-17] sys M at apex. No R/G ABD: NABS, soft, ND, some tenderness to palpation diffusely. +reducible ventral hernia LUNGS: bibasilar crackles, no wheezes, poor air movement. EXT: 1+ pitting edema to thighs bilaterally (L>R). 1+ LUE edema. No tenderness to palpation. SKIN: erythematous rash on left breast w/ swelling/warmth NEURO: arousable, answering some questions; will not follow commands for neuro exam. Moving all extremities spontaneously. Pertinent Results: [2169-1-16] 07:35PM BLOOD WBC-12.5* RBC-4.82 Hgb-11.8* Hct-38.8 MCV-80* MCH-24.4* MCHC-30.3* RDW-14.7 Plt Ct-303 [2169-1-16] 07:35PM BLOOD Neuts-82.2* Lymphs-13.1* Monos-4.1 Eos-0.2 Baso-0.2 [2169-1-16] 07:35PM BLOOD PT-14.0* PTT-27.5 INR(PT)-1.2* [2169-1-16] 07:35PM BLOOD Plt Ct-303 [2169-1-17] 05:11PM BLOOD Fibrino-231 D-Dimer-1499* [2169-1-16] 07:35PM BLOOD Glucose-158* UreaN-55* Creat-1.9* Na-132* K-4.7 Cl-96 HCO3-28 AnGap-13 [2169-1-16] 07:35PM BLOOD CK(CPK)-16* [2169-1-17] 01:20AM BLOOD ALT-16 AST-17 LD(LDH)-178 CK(CPK)-16* AlkPhos-85 [2169-1-17] 05:11PM BLOOD Lipase-34 [2169-1-16] 07:35PM BLOOD CK-MB-NotDone cTropnT-0.12* [2169-1-17] 01:20AM BLOOD CK-MB-NotDone cTropnT-0.10* proBNP-[Numeric Identifier 16350]* [2169-1-17] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.11* [2169-1-17] 05:40AM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.8* Mg-2.0 [2169-1-17] 01:20AM BLOOD TSH-1.3 [2169-1-17] 05:11PM BLOOD Hapto-103 [2169-1-17] 05:40AM BLOOD Digoxin-1.7 [2169-1-17] 05:11PM BLOOD HEPARIN DEPENDENT ANTIBODIES- HIT . CXR [2169-1-16] 1. Congestive heart failure with moderate effusions. 2. New posterior opacity, on the lateral view, which may relate to edema, but in the appropriately clinical setting raises concern for infection. . CT HEAD [2169-1-16] No evidence of acute intracranial hemorrhage. MRI with diffusion-weighted images is more sensitive in the evaluation for acute ischemia/infarct and for vascular detail . R LE doppler [2169-1-16]: No evidence of right lower extremity DVT. . CT head [2169-1-16]: no evidence of hemorrhage. . ECHO [2168-12-19]: elongated LA. mild symmetric LVH w/ normal cavity size; normal systolic function (LVEF>55%). RV chamber size and free wall motion are normal. aortic valve leaflets are moderately thickened; mild aortic stenosis (area 1.2-1.9cm2) Trace aortic regurgitation. Mild to moderate ([12-13]+) mitral regurgitation. moderate pulmonary artery systolic hypertension. trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2166-7-24], moderate pulmonary artery systolic hypertension and increased mitral regurgitation are now seen. The severity of aortic stenosis is similar. Brief Hospital Course: . MICU COURSE: . # HYPERCARBIC RESPIRATORY FAILURE: The etiology for her respiratory failure was unclear. Differential diagnosis of her respiratory failure in this patient: CHF, mucous plug. Echo shows new right ventricular hypokinesis and EF 60%, this in conjunction with elevated d-dimer and clinical picture makes PE more likely. Patient was empirically anticoagulated. Hypoventilation due to sedating meds possible, but patient did not receive narcotics, benzos, or other sedatives since admission. Bicarb appears chronically elevated (~28-29) over the last month. Possibly acute on chronic resp failure; ?neuromuscular or obstructive disease. After discussion with the patient, she refused bipap and intubation. Initially family requested that patient be full code; however, after patient refused all intervention, including CPR, intubation, and BiPAP, family agreed to DNR/DNI status. . # ALTERED MS: Patient was reportedly functional at baseline with intact MS. Only A&Ox2 on this admission. CT negative for ICH. Confusion likely secondary to hypercarbia. Could be also be due to infection (possible pneumonia). Dig level was normal at 1.7. She was treated empirically with vanco, ceftriaxone, and azithro for presumed pneumonia and mastitis . # PNEUMONIA: Posterior opacity on CXR. Continued on antibiotics mentioned above . # MASTITIS: Patient had rash on L breast and swelling, consistent with mastitis. She was continued on vancomycin for this issue. . # CHF: Patient likely with CHF exacerbation on admission supported by elevated JVD, rales on lung exam, peripheral edema reported by ED note. Appeared to be more euvolemic to dry at the time of MICU admission. Patient received lasix, without urine output. Echo showed EF 60%, new right ventricular hypokinesis. BNP was elevated around [Numeric Identifier 16351]. . # ACUTE ON CHRONIC RENAL FAILURE: Cr 1.9 on admission, now 2.9. Oliguric. Increased from 1.4-1.6 prior to admission (though has been up to 1.9 before). Urine Na<10. Right kidney showed no hydronephrosis. Left kidney not imaged due to patient not compliant with exam. Creatinine continued to trend up during admission. Patient did not respond to IVFs. . # A FIB: Patient in AFib this admission. This was monitored and she was continued on digoxin. Dig levels were followed closely given ARF. . # ELEVATED TROP: Troponin had been elevated before. Patient was not complaining any chest pain. CKs flat. This was possibly elevated [1-13] to renal failure or demand from CHF. . # DECREASED PLATELETS: plts noted to drop from 200->100 while on heparin SC during prior admission, plts appropriately increased off heparin. HIT antibody negative. . # H/O HTN: BP currently slightly low; Lopressor held. . # CODE: DNR/DNI, no Central line, no pressors, no BiPAP (confirmed with patient and family) . # DISPO: Her respiratory and renal functions continued to decline while in the MICU. After discussion with her family, patient was made comfort care measures. She expired on [2169-1-20]. Family was notified at that time. . Medications on Admission: - Lopressor - Digoxin - ASA Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2169-1-31]	[ "780.97", "276.2", "782.3", "611.0", "403.90", "486", "276.7", "518.84", "428.0", "276.51", "585.9", "428.30", "424.90", "584.9", "427.31" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8222, 8231	5072, 8143	304, 310	8282, 8291	2751, 5049	8344, 8379	1887, 1891				8252, 8261		8169, 8199			8315, 8321								1906, 2732																					222, 266									338, 1751														1773, 1825	1841, 1871
76,219	166,623	38596	Discharge summary	report	Admission Date: [2172-6-8] Discharge Date: [2172-6-11] Date of Birth: [2093-2-2] Sex: F Service: NEUROLOGY Allergies: Hydroxyzine / Codeine / Lorazepam Attending:[First Name3 (LF) 5018] Chief Complaint: IPH, unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: HPI; 79 yo F with hx HTN and afib on coumadin, transferred from [Hospital6 302] with IPH. She was last seen normal by her family last evening and this AM was found on the floor of her house, unresponsive. She was initially taken to OSH where she was noted to have "pinpoint pupils, not following commands, withdrawl to noxious on the left, and no movement on the right." BP was 118/64, INR 1.8, and CT head showed large L temporoparietal IPH as well as L SDH. She was believed to have had seizure activity and was given fosphenytoin 1g as well as 10 mg vitamin k, 2 units FFP, ativan 1 mg, paralyzed and intubated for airway protection, and transferred to [Hospital1 18] for further care. She became transiently hypotensive while on propofol, requiring levophed. Past Medical History: afib, htn Social History: Social History; -unable to be obtained Family History: Family History; -unable to be obtained Physical Exam: VS; BP 132/78 P 56 RR 14 100% on vent Gen; intubated, NAD HEENT; c-collar in place. CV; bradycardic, distant S1,S2 Pulm; CTA anteriorly Abd; soft, nt, nd Extr; no edema Neuro; Mental Status; Eyes closed, intubated, off sedation. Minimal grimace to noxious stimuli on left hemibody. CN; Pupils 3mm, surgical pupil on left, and nonreactive. Eyes conjugate in midposition. Weak corneals bilateral. Gag present. Face obscured by vent but no major asymmetries noted. Motor; normal bulk, increased tone in legs bilaterally. No spontaneous movement. Withdraws to noxious stimuli to left arm. Triple flexion in legs bilaterally. Reflexes; 2+ and symmetric at biceps, brachioradialis, and patellars. 0 at achilles. Toes are upgoing bilaterally. Pertinent Results: [2172-6-8] Radiology CT HEAD W/O CONTRAST IMPRESSION: Large left cerebral intraparenchymal hemorrhage with small left SDH and small intraventricular component. Significant midline shift and early left uncal herniation noted. Brief Hospital Course: Ms. [Known lastname 29721] is a 79 yo F with hx HTN and afib on coumadin, transferred from [Hospital6 302] with IPH. She was last seen normal by her family last evening and this AM was found on the floor of her house, unresponsive. Prior to transfer she was found to have a large L temporoparietal IPH with 1.3 cm shift in setting of INR 1.8. She received vitamin K and FFP as well as fosphenytoin after concern for seizure activity prior to transfer. Possible etiologies include amyloid angiopathy, hypertensive hemorrhage, underlying mass or AVM. Currently, her examination is notable for weak corneal and gag reflexes, minimal withdrawl of left arm to noxious stimuli, and triple flexion in the legs. Based on the size and location of the hemorrhage, her chance of survival or any meaningful recovery is extremely low. This was discussed with her son, [Name (NI) 401] [Name (NI) 29721], [Telephone/Fax (1) 85802], who expressed clear understanding of the situation and that his mother would not want to be kept alive with this unfortunate prognosis. Patient was initially admitted to the Neuro ICU under attending Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] Patient was placed on palliative therapy and expired on [2172-6-11]. Medications on Admission: coumadin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: IPH AFib HTN Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2172-6-17]	[ "427.31", "348.4", "431", "V58.61", "401.9", "348.5", "458.29" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	3670, 3679	2306, 3582	311, 317	3735, 3744	2050, 2283	3800, 3953	1228, 1269		3641, 3647		3700, 3714		3608, 3618			3768, 3777								1284, 2031																					254, 273									345, 1122														1144, 1155	1171, 1212
26,914	161,085	31663	Discharge summary	report	Admission Date: [2116-8-3] Discharge Date: [2116-8-10] Date of Birth: [2056-3-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3326] Chief Complaint: Metastatic Melanoma requiring IL-2 therapy Persistent acidemia, AG acidosis & ARF Major Surgical or Invasive Procedure: - Central line placement [2116-8-7] - Central line placement [2116-8-8] - CVVH dialysis beginning [2116-8-8] History of Present Illness: Pt is a 60 yo man with history of metastatic melanoma (primary in foot, known mets in pelvis, liver, lungs who initially presented on [2116-8-3] to biologics service for IL-2 therapy. Since admission, pt has been stable, receiving IL-2 therapy. Of note, hospital course to this point has been complicated by diarrhea, developement of acute renal failure with Cr increased to 2.8 from baseline of 0.9, felt secondary to IL-2 therapy. Today, pt received his 13th out of 14 doses of IL-2 therapy at 5pm. During the day, he had been noted to have persistent acidemia (low HCO3) and had been treated with total of 5 amps bicarb throughout the day without much improvement of his HCO3. This evening, pt was noted to be tachypnic in respiratory distress, as well as tachycardic to 200's. At this time, pt c/o SOB, no other complaints. Labs at this time demonstrated persistent acidemia, with ABG: 7.19/32/158/13. Other labs drawn at this time as below - notable for worsening ARF (Cr 5.1), AG acidosis. The patient was transferred to the ICU for closer monitering. On arrival in the ICU, pt was noted to be tachypnic to 30-40's, O2 sats 90-100% on NRB, hypotensive with SBP 60's, tachycardic 180-210, and again, complained only of SOB. He was intubated for airway protection, initially started on levophed gtt for pressure support. Cardioversion was attempted but was unsuccessful. He was therefore switched from levophed to neosynephrine and was bolused amiodarone and started on amio gtt. Currently pt remains intubated/sedated. Past Medical History: Metastatic Melanoma S/p Appy Migraine Social History: - Married with 3 children - He is a retired truck driver and lives in [Location 74394]. - He hasn't smoked for ten years and drinks approximately one beer per day Family History: - There is no family history of melanoma. - He has an uncle with [Name2 (NI) 499] cancer and a brother with prostate cancer. Physical Exam: Vitals - T , HR 190, BP 73/37, RR 36, O2 99% on NRB -> AC/FiO2 1.0/TV 500/RR30/PEEP 5 Gen - awake, alert, able to answer questions, visibly tachypnic with use of abdominal muscles HEENT - scleral icterus Lungs - slight wheezing at bases, otherwise CTA b/l CVS - tachycardic, irregular Abd - soft, use of abdominal muscles with breathing, no noted tenderness to palpation; tympanic in upper region Ext - [1-14]+ LE edema b/l Neuro - A+O initially, became more lethargic Skin - cool extremities, flushed appearance to limbs Pertinent Results: [2116-8-8] CXR - prelim read low lung volumes, ? mild CHF [2116-8-8] Rpt CXR - prelim worsening CHF Brief Hospital Course: This patient is a 60 yo male with h/o metastatic melanoma, who was undergoing IL-2 therapy (s/p 13 out of 14 doses), now with severe multi-organ failure; ?r/t to IL-2 toxicity. . # Respiratory Failure: Patient was initially intubated for work of breathing/tachypnea, resp distress. There was a significant acidemia as well as CXR which indicated pulm edema. Etiology was unlikely to be CHF as the patient had no history of CAD. Presentation was more consistent with an ARDS picture, given bilateral pulm infiltrates as well as PaO2/FiO2 < 200, or IL-2 therapy adverse event as this can cause a capillary leak syndrome. Other possibilities of pulm edema include volume overload [2-14] renal failure, less likely CHF related to heart disease/MI. Hypoxia may be secondary to shunt ([2-14] likely atelectasis) as well as likely increased intrathoracic pressures secondary to ascites. The patient was continued on AC ventilation following ARDSnet protocol--> increase PEEP 12 to 15, decrease VT 600 to 550, wean oxygen as able. An esophageal balloon was used to measure pleural pressures to aid in target CVP assessment. The patient was maintained on CVVH to help with acid/base disorder with pt. IL-2 therapy was held. . # Atrial Fibrillation: No known history of CAD; the patient had afib on admission to ICU but converted to NSR after shocks x2 & amiodarone IVP x1; o/n, converted back to Afib, requiring cardioversion as well as amiodarone without success. Hypotensive, thus requiring levophed, neosynephrine & vasopressin. Amiodarone infusion was not used because of hypotension as well as liver failure. . # Sepsis/Shock: The patient met criteria for SIRS, however there was no clear source of infection. The patient was pancultured, the R subclavian CVL was d/c'ed & tip cultured. The patient was hypothermic and hypotensive, requiring 3 vasopressors with SBP still 90's; hypotension was thought to be a side effect of IL-2 therapy, unsure if it was related to IL-2 toxicity. CT abd unremarkable for lactic acidosis or any ischemic process, however, clinical picture was consistent with shock liver. It was attempted to wean vasopressors to keep MAP>60, especially levophed given dusky distal extremities. Support was given with fluids, both colloid and crystalloid. The patient was started on IV solumedrol, which was changed to standing hydrocortisone for treatment of IL-2 related adverse effects. Antibiotic therapy for broad spectrum coverage was continued throughout admission. . # Acute renal failure: The patient had rising Cr during hospital course, intially attributed to IL-2 therapy on the floor. IL-2 known to cause renal failure, perhaps indirectly due to vasodilation/capillary leak and hypotension. Creatinine had elevated to ~5, also with multiple electrolyte abnormalities & in the setting of not wean vasopressors to keep MAP > 60. Medications were renally dosed and nephrotoxins were avoided. . # Severe Acidemia/AG-Acidosis: The patient had severe lactic acidosis in the setting of hypotension SBP 60's on arrival to ICU & occasionally overnights, also with triple vasopressor use-vasoconstriction, ?abd compartment syndrome (however CT scan does not support this), shock or ischemic liver were also included in the differential. Acidemia is a known effect of IL-2 therapy/?toxicity, however unsure if it can account for the extent of acidosis in this patient. The patient was taken off IL-2 and was receiving thiamine and steroids. Also the patient had evidence of renal failure. As mentioned above, the patient was started on CVVH to correct acid/base abnormality. Acid/base status and lactate levels were monitored. . # Fulminant liver failure: the patient presented with severely elevated transaminases, also with coagulopathy (see below). Initially, mild transaminatis due to IL-2 therapy ?toxicity of IL-2. Also receiving 4gm Acetaminophen while on the floor, however standard during IL-2 therapy & unlikely to cause such fulminant failure; it was felt that the etiology was most likely shock liver. Coagulopathy and LFTs were monitored, and a hepatology consult was obtained for further management. . # Coagulopathy: The patient appeared to be DIC based on labs, however difficult to differentiate in the setting of severe liver failure. [Month (only) 116] also be r/t IL-2 toxicity. Received 4U FFP & Vit K x 1 dose. On [8-10] INR values returned at 22.8 (from baseline 7) with fibrinogen < 35 and PTT > 150. 3units FFP were transfused with plan to transfuse if platelets < 20 without bleeding or platelets < 50 with bleeding. HIT Ab was checked, and the patient was monitored for bleeding. . # Metastatic Melanoma:Mets to multiple sites; s/p IL-2 therapy. Oncology was following along. Initiated steroids to reverse effects of IL-2 currently. No melanoma treatment for now. Oncology recommendations were followed. . The patient was maintained on PPI and pneumoboots for prophylaxis (no SC hep b/c plt low). During the admission a high-dose insulin drip was started up to 23 units/hr for FS up to 600s; however, the patient became hypoglycemic with FS (60s). There was a concern for hypoglycemia in the setting of liver failure and possibly retained insulin given renal failure. . On [8-10] the team was called to the bedside for an acute change in VS: pt became tachycardic briefly before becoming bradycardic and hypotensive and ultimately going into asystole. CPR was attempted with chest compressions for approximately 25 minutes without a return of pulse; the code was terminated because of persistent asystole with the time of death at 9:25pm on [8-10]. The family was notified at this time. They elected not to proceed with an autopsy or liver biopsy. . Discharge Disposition: Expired Discharge Diagnosis: Metastatic melanoma - s/p IL-2 therapy SIRS Respiratory failure Liver failure Renal failure DIC Acidemia Discharge Condition: Expired	[ "E933.1", "787.01", "698.9", "V16.42", "782.4", "198.89", "570", "V10.82", "790.5", "V58.12", "197.0", "995.90", "V16.0", "286.6", "584.9", "276.2", "458.29", "787.91", "275.3", "276.8", "518.82", "197.7", "285.22" ]	icd9cm	[ [ [] ] ]	[ "00.15", "38.93", "96.04", "99.07", "39.95", "96.71" ]	icd9pcs	[ [ [] ] ]	8910, 8919	3164, 8887	396, 518	9068, 9078	3031, 3141		2339, 2469				8940, 9047													2484, 3012																					275, 358									546, 2076														2098, 2138	2154, 2323
49,580	114,163	51776	Discharge summary	report	Admission Date: [2199-8-14] Discharge Date: [2199-8-19] Date of Birth: [2160-5-7] Sex: F Service: NEUROLOGY Allergies: Ampicillin / Penicillins / Morphine Hcl Attending:[First Name3 (LF) 8850] Chief Complaint: EBV+ CNS lymphoma, requiring methotrexate and dialysis. Major Surgical or Invasive Procedure: Methotrexate dose with leucovorin rescue on CVVH stereotactic biopsy of brain [2199-8-1] Lumbar puncture [2199-8-13] History of Present Illness: [Known firstname 1439] [Known lastname 106990] is a 39-year-old right-handed woman with type I diabetes mellitus, glomerulonephritis and renal/pancreas transplant with EBV-driven CNS lymphoma presenting for high-dose IV methotrexate. Please see initial history and physical by Dr. [Last Name (STitle) ] for admission details. Hospital course: the patient was initially admitted to the OMED service, but was transferred to [Hospital Ward Name 332] ICU for CVVH after her high dose methotrexate. Her dose was administered at 1:00 a.m. on [2199-8-15] and she was started on high-flow hemodialysis and then transitioned to CVVH, per renal. She was given leucovorin rescue and bicarbonate. Her liver function tests increased following therapy and the leucovorin dose was increased. On [2199-8-17], her methotrexate level was < 0.1 uM and she was transitioned to the medical floor for disposition planning. She tolerated the treatment well with minimal side effects. Currently, she feels well and has no complaints. She is anxious to go home. She denies pain and is breathing comfortably. She has been eating and going to the bathroom normally. She has no rash and no tenderness over her line sites. Past Medical History: -IDDM diagnosed at age 14 months -Hypertension -Crescentic glomerulonephritis at age 14 which progressed to renal failure, requiring dialysis s/p deceased donor renal transplant [2174] c/b graft rejection, s/p second cadaveric renal transplant [2177], and s/p cadaveric kidney/pancreas transplant in [10/2188], s/p bilateral nephrectomy of her native kidneys [3-/2185] due to hypertension, on immunosuppression -s/p ligation of arteriovenous fistula, left antecubital space -Ventral/incisional hernias (times 4) s/p repair [5-/2190] -Anemia -Polycystic ovarian syndrome -Chronic pancreatitis -Renal osteodystrophy Oncological History: The patient initially presented with mood changes. She was admitted to [Hospital1 18] [2199-5-28] for elective ventral hernia repair with mesh and work up of altered mental status. MRI brain without gadolinium wiht moderate atrophy and mild periventricular hyperintensities and hydrocephalus. A spinal tap performed on [2199-6-3] showed 2 WBC, 49 protein, and 72 glucose, but she was positive for EBV PCR in the CSF. But HHV-6, HSV1 and 2, and [Male First Name (un) 2326] virus PCR were all negative. She was placed on 15 days of IV ganciclovir for meningoencephalitis with positive EBV PCR in CSF. A repeat lumbar puncture on [2199-6-21] yield negative EBV PCR, both qualitative and quantitative, in the CSF. But her memory function improved but it was still off. A repeat head MRI without gadolinium showed 3 hyperintense FLAIR lesions in the left caudate, right parietal periventricular region, and left frontal region near the surface of the brain. She underwent a stereotaxic brain biopsy by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. on [2199-8-1] and the pathology showed EBV-driven CNS lymphoma. Her cyclosporin was taken off subsequently. She still has short-term memory problems and psychomotor slowing. Social History: She denies cigarette or illicit drug use. She drinks a glass of wine/month. She has a boyfriend, [Name (NI) ], but she lives with her sister. She reports that she was in special education classes but is college educated. Family History: Her grandfather had NIDDM and her great grandmother apparently had IDDM. Physical Exam: VITAL SIGNS: Temperature 98.0 F, Blood Pressure 120/80, Heart Rate 90, Respiration 20, Oxygen Saturation is 100% in room air. SKIN: Full turgor. GENERAL: Sitting in bed, poor eye-contact, NAD [Name2 (NI) 4459]: PERRL, [Name (NI) 3899] but with several beats of nystagmus with gaze in both directions, O/P clear NECK: supple, no LAD, no JVD CARDIOVASCULAR: RRR no m/g/r PULMONARY: CTAB no w/r/r ABDOMEN: Soft, non-distended, and non-tender, with normoactive bowel sounds EXTREMITIES: No c/c/e, fistula in LUE, no palpable thrill NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 60. She is awake, alert, and oriented times 3. Her language is fluent with good comprehension. Her recent recall is good. Cranial Nerve Examination: Her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [3-26] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are absent. Her right toe is down but the left one is up. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. Her gait is normal. She can do tandem. She does not have a Romberg. Pertinent Results: [2199-8-13] 03:30PM (CSF) WBC-6 RBC-1* POLYS-0 LYMPHS-92 MONOS-0 MACROPHAG-8 (CSF) PROTEIN-61* GLUCOSE-56 LD(LDH)-15 [2199-8-14] 04:27PM WBC-8.9 RBC-3.06* HGB-9.5* HCT-29.5* MCV-96 MCH-31.1 MCHC-32.3 RDW-15.6* GLUCOSE-86 UREA N-68* CREAT-2.6* SODIUM-141 POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-15* ANION GAP-23* ALT(SGPT)-52* AST(SGOT)-52* LD(LDH)-310* ALK PHOS-80 TOT BILI-0.4 PT-12.5 PTT-26.9 INR(PT)-1.1 PET-CT ([8-14]) Focal increased uptake in known right parietal (SUVmax 5.0) and left basal ganglia lesions (SUVmax 6.8). There is no FDG avid disease outside the brain. MRI: IMPRESSION: Limited study, performed without contrast enhancement, due to the patient's significant renal insufficiency, with: 1. Normal spinal cord caliber and intrinsic signal intensity, through the level of the conus medullaris. 2. No discrete epidural or paraspinal soft tissue mass. 3. Normal vertebral height and alignment, with heterogeneous intrinsic signal intensity, which may represent red marrow reconversion and/or response to chemotherapy, but should be correlated clinically. There is no focal STIR-signal abnormality to specifically suggest marrow replacement. COMMENT: Though there is a grossly normal appearance to the conus medullaris and distribution of cauda equina nerve roots, leptomeningeal, nerve root, and, even, intramedullary tumor involvement cannot be the excluded in the absence of intravenous contrast. Labs at discharge: Lumbar Puncture: Many lymphocytes with rare atypical forms and monocytes present. Clonality could not be assessed in this case due to insufficient numbers of B cells. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells. WBC RBC Hct MCV MCH MCHC RDW Plt 5.7 2.20* 27.2 95 31.0 32.5 15.3 321 Glucose UreaN Creat Na K Cl HCO3 AnGap 126* 27* 2.4* 137 4.2 108 21* 12 ALT AST AlkPhos TotBili 204* 123* 62 0.2 Calcium Phos Mg 8.2* 3.0 1.5* Brief Hospital Course: (1) EBV-Derived CNS Lymphoma: Identified by biopsy. She is being treated per plan by Drs. [Last Name (STitle) 724] and [Name5 (PTitle) ]. Patient received IV high-dose methotrexate, and leucovorin rescue was started on the onc floor; patient received CVVH after HD was done on the floor. Leucovorin rescue was continued per heme/onc orders and bicarbonate per heme/onc orders. Per renal, discontinued bicarbonate on day of transfer. Leucovorin was then increased per onc recs. Upon discharge, VNA services will flush dialysis line with saline and heparin. Patient will then have continued line care during subsequent scheduled admissions. (2) Encephalopathy: Some of her neurological impairment was thought to be due to residual effects of EBV meningoencephalitis, but outpatient note suggested more likely to be lymphoma effects. Dr.[Name (NI) 94547] outpatient note suggests prominent features are memory impairment and emotional lability. Dr. [Last Name (STitle) 724] suggested methylphenidate as a possible aid to improved cognition. Her encephalopathy did not progress and remained at baseline throughout her stay. (3) s/p Pancreas-Kidney Double Transplant: Transplanted kidney had marginal function. Estimated creatinine clearance has been 20-25 cc/min/m2. Diabetes no longer an issue. We held CellCept during course, which was restarted upon discharge. Other anti-rejection meds were continued, including prednisone. (4) Hypertension: This was reasonably controlled during admission on atenolol 100 daily and amlodipine 5mg daily. (5) Full Code. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) ARANESP SURECLICK -POLYSORBATE - 100 mcg/0.5 mL Pen Injector - IM/Subq weekly ATENOLOL - (update) - 100 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] - 50,000 unit Capsule - 1 Capsule(s) by mouth qweek x 3 months FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth as needed MYCOPHENOLATE MOFETIL [CELLCEPT] - 500 mg Tablet - 2 Tablet(s) by mouth twice a day PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 1437] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day PICC LINE - - please discontinue PICC line once PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth once a day SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider) - 400 mg Tablet - 2 Tablet(s) by mouth three times a day Medications - OTC FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth DAILY (Daily) SODIUM BICARBONATE - (Dose adjustment - no new Rx) - 650 mg Tablet - 3 Tablet(s) by mouth twice a day only taking 1300mg qd Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. CellCept [Pager number ] mg Tablet Sig: One (1) Tablet PO twice a day. 6. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:180 Tablet(s) Refills:2 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for swelling. 12. Renagel 400 mg Tablet Sig: Three (3) Tablet PO three times a day. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA SouthEastern Mass Discharge Diagnosis: CNS lymphoma Chronic Renal Insufficiency s/p renal transplant Discharge Condition: Stable, methotrexate level < 0.1 uM, Creatinine:1.0 Discharge Instructions: You came to the hospital for chemotherapy treatment. You required dialysis while getting this treatment. You tolerated your treatment well, without complication. We made the following changes to your medications: Start taking Leucovorin 60 mg q4h If you have fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath, swelling in your legs, headache, confusion, slurred speech or any other symptoms that are concerning to you please call your doctor or come to the emergency room. Please keep all your appointments as below. Please keep your catheter dressing dry, no showers. Baths are fine, just please keep the dressing dry. A wet dressing increases the risk of infection Followup Instructions: [Name6 (MD) 2341] [Last Name (NamePattern4) 2342], M.D. Phone:[Telephone/Fax (1) 2343] Date/Time:[2199-8-21] 1:30 [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2199-9-27] 10:10 please call and f/u with liver clinic within 1 month: [Telephone/Fax (1) 2422]	[ "V42.83", "V42.0", "403.90", "272.0", "348.39", "585.9", "V58.11", "200.50" ]	icd9cm	[ [ [] ] ]	[ "38.95", "39.95", "99.25", "38.93" ]	icd9pcs	[ [ [] ] ]	11880, 11932	7694, 9285	357, 484	12037, 12090	5685, 7118	12843, 13201	3956, 4030		10739, 11857		11953, 12016		9311, 10716	869, 1741		12114, 12301								4045, 5666																		12331, 12820			261, 319						7138, 7671			512, 852														1763, 3694	3710, 3940
64,230	119,573	30063	Discharge summary	report	Admission Date: [2120-7-30] Discharge Date: [2120-8-15] Date of Birth: [2049-3-15] Sex: M Service: MEDICINE Allergies: Unasyn Attending:[First Name3 (LF) 4327] Chief Complaint: "Cardiogenic Shock, CHF, Critical AS" Major Surgical or Invasive Procedure: Cardiac catheterization Attempted balloon angioplasty CVVH Intubation History of Present Illness: 71-year-old man with AS undergoing CoreValve eval for critical aortic stenosis, s/p complicated cardiac cath on [7-10] (hematoma) groin p/w with CP and SOB s/p Intubation Was at rehab after [Hospital1 18] admission (see below). On [7-28] he was combative, delirious. On [7-29] he c/o CP and SOB. Sent to NVMC ED with t98.3, HR 108, RR 18, BP 117/47, 84% on RA. He received 60mg IV lasix and BiPap. Admitted to a telemetry float. IV dapto (600) and Gent (120) given. On [7-30], at 0120, he received 40mg IV lasix for SOB and was intubated at 2am and started on propofol. No vasopressors. CXR with "extensive fluffy infiltrates that appeared nodular". ABG showed 7.35/40/94 on 100%Fi02, PEEP 5, TV 700 on AC at RR12. Net fluid balance was 800 negative. Cultures were drawn. WBC 6.7, Hbg 9.3, HCT 26.3, plt 312. Na 132, K 3.6, Cl 94, HCO3 26, BUN 33, Cr 2.28 (from 1.86 overnight. ACE and BB were held due to "soft" blood pressures. He was transferred to the [Hospital1 18] CCU intubated on propofol. In the CCU, he was tachy to 130 and hypotensive to 90's. His CXR yielded a diffuse patchy infiltrate. His PICC line transduced a CVP of 9. He received 2.5 mg of metoprolol tartrate to bring rate to 100. EKG was unchanged despite rate decrease with precordial ST-depressions, AVR elevation. He received 500cc of NS bolus (250 x 2). Propofol was dc'd. LAST ADMISSION Was admitted on [7-10] with Hematoma following cardiac catheterization which disclosed RCA disease. He had ecchymoses throughout right groin, including swelling and discoloration of genitals. Ultrasound revealed pseudoaneurysm of the femoral artery with bleeding resolved by thrombin injection, confirmed by US. The patient developed fever on [2120-7-15] and increased oxygen requirement. 8/8 bottles were growing Enterococcus faecalis as was his urine. TTE was without vegetation. He was treated as endocarditis. WBC scan showed a single focus near posterior liver, may also be in pleural space, but no reason to believe AAA graft was infected by scan. Infectious Disease was consulted and started patient on regimen of daptomycin (patient had anaphylaxis to Unasyn) and gentamicin. Within 48 hours, the patient had defeveresced. His blood cultures from [2120-7-16] onward were negative. ASSORTED PROBLEMS DURING LAST ADMISSION During an episode of oxygen desaturation, an EKG was checked, which showed no ST or T wave changes. The patient had troponin elevation (0.57), but CK-MB (2) resolved. Patient's Cr rose to 1.6 from 1.2 and later fell to 1.3 on discharge. Cardiac surgery has declined AV replacement. Patient underwent CTA chest/CT cardiac and PFTs as part of CoreValve work-up. Episodes of abdominal pain with negative bloodtests. RUQ ultrasound ordered for unclear indications and showed cholelithiasis without cholecystitis. Past Medical History: -Peripheral vascular disease: s/p endovascular AAA repair with a [Doctor Last Name ] EXCLUDER device on [2116-5-4]. 23 x 160 mm main body device and a 12 x 100 mm right iliac contralateral limb device CTA post implantation have failed to show any evidence of endoleak. Non healing ulcer [2118-3-22]. He underwent left femoral to posterior tibial bypass graft with nonreversed saphenous [Year (4 digits) 5703] graft and angioscopy by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391]. Following surgery, his left leg ulcer had improved. -s/p right carotid endarterectomy with patch angioplasty [2116-5-18]. -Hypertension, essential -Hyperlipidemia -Right eye cataract last year; left cataract is pending. -Chronic renal insufficiency -History of osteomyelitis -OSA -History of GI bleed [12/2115] -Chronic back pain -Chronic tremor Social History: He has been living with his sister since [2115] with his medical disability. He does not currenly smoke but did smoke 3 packs per day for 20 years. He does not drink alcohol. Family History: There is a family history of diabetes and heart disease. There is no history of hypertension or strokes. His mother died at age [Age over 90 ] years of Alzheimers and his father died at 69 of diabetes and coronary artery disease. He has three healthy children. Physical Exam: Admission Exam T 97.2 BP 134/53 HR 63 RR 18 96% RA [7-25]: Tm 99.0 BP 104-134/61-71 HR 78-99 RR 16-18% RA Gen: NAD, intubated, sedate. Responded to questions, squeezed hand. HEENT: NCAT PERRLA, intubated Resp: Lungs rhonchorous with diffusely decrease sounds, crackles. CV: Tachy, S1/S2, [4-14] holosystolic murmur that radiates to carotids. Abd: Soft, non-tender, protuberant, bowel sounds positive. No tenderness to palpation. EXT: slighlty mottled L>R leg, thready DP bilaterally. Edematous (mild pitting) . DISCHARGE EXAM: Temp current: 98.4 HR: 80-81 RR: 18 BP: 128-132/44-64 O2 Sat: 98% RA Gen: NAD, appears comfortable HEENT: NCAT, MMM, no JVP elevation CV: RRR, crescendo/decrescendo murmur at RUSB Resp: CTAB anteriorly and upper post Abd: soft, NT/ND, pos BS Ext: no LE edema, DP pulses 2+ Neuro: moves all extremities, follows commands, responds with yes/no Skin: warm, dry, no open areas noted (back not assessed) Pertinent Results: ADMISSION LABS: [2120-7-30] WBC-9.8# RBC-3.55* Hgb-10.5* Hct-30.9* MCV-87 MCH-29.4 MCHC-33.8 RDW-14.2 Plt Ct-557# Neuts-75 Bands-1 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* PT-14.3* PTT-27.9 INR(PT)-1.2* Glucose-204* UreaN-40* Creat-2.7# Na-137 K-4.2 Cl-95 HCO3-27 AnGap-19 Calcium-8.5 Phos-7.6# Mg-2.2 Gentamycin-5.5 Type-ART pO2-51 pCO2-65* pH-7.23* calTCO2-29 Base XS--1 Lactate-3.0* [2120-7-31] WBC-5.5 RBC-3.38* Hgb-9.7* Hct-29.4* MCV-87 MCH-28.8 MCHC-33.1 RDW-14.2 Plt Ct-595* Glucose-270* UreaN-51* Creat-2.9* Na-134 K-4.9 Cl-97 HCO3-23 AnGap-19 Glucose-298* UreaN-63* Creat-3.7* Na-131* K-4.5 Cl-94* HCO3-19* AnGap-23* CK-MB-3 cTropnT-0.13* Calcium-8.0* Phos-6.8* Mg-2.2 Lactate-6.7* [2120-8-1] 04:00AM BLOOD WBC-6.4 RBC-2.91* Hgb-8.6* Hct-25.0* MCV-86 MCH-29.7 MCHC-34.6 RDW-14.5 Plt Ct-483* ALT-447* AST-685* AlkPhos-56 TotBili-0.7 [2120-8-2] Gentamycin-0.5* [2120-8-4] Lactate-1.8 [2120-8-8] ALT-51* AST-34 LD(LDH)-278* AlkPhos-73 TotBili-0.3 DISCHARGE LABS: [2120-8-13] WBC-7.5 RBC-3.89* Hgb-10.9* Hct-34.8* MCV-90 MCH-28.1 MCHC-31.4 RDW-17.1* Plt Ct-406 Glucose-205* UreaN-54* Creat-2.3* Na-140 K-4.1 Cl-104 HCO3-27 AnGap-13 Calcium-8.6 Phos-4.1 Mg-2.3 [2120-8-14] WBC-8.1 RBC-3.79* Hgb-10.5* Hct-33.8* MCV-89 MCH-27.8 MCHC-31.2 RDW-17.0* Plt Ct-452* Glucose-176* UreaN-49* Creat-2.4* Na-140 K-4.5 Cl-104 HCO3-26 AnGap-15 Calcium-8.7 Phos-3.6 Mg-2.3 [2120-8-15] WBC-9.3 RBC-4.03* Hgb-11.3* Hct-35.9* MCV-89 MCH-28.1 MCHC-31.6 RDW-16.9* Plt Ct-464* PT-26.9* PTT-30.5 INR(PT)-2.6* Glucose-158* UreaN-38* Creat-2.0* Na-142 K-4.1 Cl-108 HCO3-28 AnGap-10 Calcium-8.7 Phos-3.6 Mg-2.2 MICROBIOLOGY: BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Final [2120-8-5]): NO GROWTH. SPUTUM Source: Endotracheal. GRAM STAIN (Final [2120-7-30]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2120-8-1]): SPARSE GROWTH Commensal Respiratory Flora. STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2120-7-31]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). URINE Source: Catheter. URINE CULTURE (Final [2120-8-6]): PROTEUS MIRABILIS. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING TTE ([2120-7-31]): FOCUSED VIEWS PRE/POST AORTIC VALVULOPLASTY. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen prior to valvuloplasty. Mild (1+) aortic regurgitation is seen after valvuloplasty. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. KUB ([2120-8-7]): 1. No evidence of obstruction or ileus. 2. No evidence of free air on these supine radiographs. CT HEAD ([2120-8-8]) IMPRESSION: Left parietal hypodensity extends to the cortex and has an appearance of subacute infarct of few days' duration. However, clinical correlation recommended. No hemorrhage seen EEG ([2120-8-9]) IMPRESSION: This is an abnormal EEG due to the presence of a background frequency asymmetry suggesting a large area of subcortical abnormality involving the left hemisphere. Additionally, the presence of a slower than normal background with bursts of generalized slowing is consistent with a mild to moderate encephalopathy of toxic, metabolic, or anoxic etiology. CTA HEAD/NECK ([2120-8-11]) IMPRESSION: Subacute-appearing infarct with some blood products in the left parietal lobe. No acute infarct is seen. No mass effect or hydrocephalus. Note is made of decreased flow void in the right cavernous carotid artery. IMPRESSION: Right internal carotid artery has markedly diminished flow. The internal carotid was described to be normal on a previous duplex ultrasound on [2120-7-15]. Axial source images do not give appearance of a dissection, but further evaluation with CTA is recommended after consideration of patient's renal insufficiency. MPRESSION: Diminished flow signal in the right cavernous and petrous carotid could be due to occlusion or markedly slow flow. CAROTID U/S ([2120-8-13]) Right - nice brisk upstoke, minimal diastolic flow, diminuitive ICA and potential dissection versus intracranial carotid disease- CTA and clinical correlation is suggested. Brief Hospital Course: 71 M with AS (0.8) and One vessel CAD p/w resp. distress that prompted intubation. He is presently hypotensive, tachycardic and profoundly hypoxic. . ACUTE ISSUES: # Hypoxia - Patient arrived intubated after presenting to OSH with SOB. Bilateral pulm infiltrates were severe and most radiologically c/w pulm edema. However, the patient had fluid responsive tachycardia and a low CVP (through the PICC). His resp distress progressed despite lasix diuresis at NVMC. Accordingly, initial differential included ARDS from sepsis (see below), DAD, multifocal pna, flash pulmonary edema and daptomycin pneumonitis. He was ventilated with ARDSnet settings. Pt was able to be weaned to minimal ventilator settings by day 8 of intubation. However, extubation was delayed due to pt's mental status. Despite holding sedation for several days, pt remained non-responsive. He was successfully extubated on day 11 of intubation. He successfully transitioned from nasal canula to room air and has an oxygen saturation of 97-100% on room air at time of discharge. . # Hypotension - Inital presentation with low CVP implies poor preload implicating aortic stenosis as a cause. Tachycardia improved with fluid boluses supporting poor preload. Differential also included cardiac event, sepsis, PEEP effect and propofol. Fluids and pressors were administered with goal MAP > 60. Palliative valvuloplasty was attempted. TTE showed post-valvuloplasty aortic valve area of 0.8cm2. He was pan-cultured and initially continuted on vancomycin (gentomycin was held given [Last Name (un) ]). He was successfully weaned off pressors and maintained MAP >65. . # E. Faecalis infection: Pt diagnosed with E.Faecalis on previous admission and was discharged on dapto/gentamycin. In interim, pt developed [Last Name (un) ] that was attributed to gentamycin toxicity. Dapto/gent was discontinued and he was started on vancomycin (vanc sensitivity MIC of 2). Infectious Disease team was consulted and per their recommendations, vancomycin was discontinued due to risk of increasing kidney injury. Pt was resumed again on daptomycin. Blood cultures remained negative during this hospitalization. He is to complete a 6 week course of daptomycin for bacteremia (should be discontinued around [2120-8-28] - however exact date of discontinuation should decided at follow-up ID appointment on [2120-8-20]). . # UTI: Pt developed fever and leukocytosis during his ICU stay. A UA demonstrated pyuria, and he grew Proteus resistant to cipro but sensitive to ceftriaxone. He was started on ceftriaxone 1gm daily for a 14 day course which should be completed on [2120-8-29]. . # Atrial Fibrillation: Pt developed new onset paroxysmal atrial fibrillation during hospitalization with heart rates up to 150s. He was rate controlled with IV and PO metoprolol. He was loaded with amiodarone and was started on anticoagulation with heparin and coumadin. He spontaneously converted back to sinus rhythm and has remained in sinus for several days without any recurrence of afib. He was taken off heparin drip once INR was theraputic at 2.0-3.0. He should be continued on amio 400 mg PO daily for 1 week, and then decreased to maintenance dose of amio 200 mg PO daily. His INR has been theraputic on coumadin 5mg PO daily. . # Renal Failure - Pt presented with acute renal failure, thought to be secondary to gentamicin use with a creatinine that peaked at 3.7. Pt' severe respiratory distress was thought to be due to volume overload so CVVH was initiated. There were issues of kinking with the CVVH catheter and the line had to be replaced two times in order to achieve adequate flow. Pt tolerated CVVH well with only one episode of hypotension thought to be related to excessive fluid shifts during the CVVH. CVVH was discontinued on [8-5] when pt began putting out good urine to IV Lasix. By the end of his stay, pt was euvolemic, his creatinine was trending down and he no longer required lasix. . # Altered Mental Status/Stroke - There was difficulty extubating patient due to persistent mental status alteration. He was inconsistently responsive to painful stimuli and failed to respond to simple commands even though he had been quite alert and interactive prior to his hospitalization. This altered mental status was initially attributed to oversedation during intubation so sedation was withheld for several days without any improvement in mental status. Concern was then raised for ischemic stroke given his recent episodes of atrial fibrillation (see below). On exam, it was noticed that he seemed to had clonus on his right side and appeared to have gaze preference to the left. Neurology was consulted who recommended a CT Head and MRI/MRA of the Head. CT Head showed left parietal hypodensity extending to the cortex with an appearance of subacute infarct of few days' duration. Follow-up MRI/MRA confirmed these findings but also showed diminished flow in the right ICA. F/u ultrasound of the carotids demonstrated intracranial dissection on the right but per vascular surgery, no intervention is needed and he can follow-up with vascular surgery in six months for interval evaluation of any changes. However, he should be further evaluated with CTA once his renal function improves. Most likely etiology of the stroke is thrombus dislodged during valvuloplasty or during pt's episodic episodes of atrial fibrillation. After patient was successfully extubated, his mental status improved significantly. He was alert and able to follow commands consistently. He had a tremor in his face and extremities (though this was present at baseline) and pt has an expressive aphasia, able to answer questions only in short sentences. Per neurology, pt is now exhibiting symptoms of Parkinsonism but would defer treatment at this point. . # Diabetes: Pt continue to have elevated BG to 300s during ICU stay. He required insulin drip to manage his sugars. [Hospital ] Clinic was consulted and pt was started on Lantus 45 units along with sliding scale insulin as attached. . CHRONIC ISSUES: # Aortic stenosis: Prior to admission pt was being evaluated for CoreValve procedure, however evalution was complicated by enterococcus infection. Because of hypotension on presention, palliative valvuloplasty was attempted but was not successful because of technical difficulties. Post-valvuloplasty aortic area was 0.8cm2. Volume status was monitored closely during admission because pt is very preload depended. Even if deemed an appropriate candidate, he will not be eligable for CoreValve for at least 6 months now given acute CVA. . # CAD: Pt continued on aspirin, metoprolol, and rosuvastatin during hospitalization. . # Hypertension: Pt resumed on metoprolol once hypotension resolved. . # Hyperlipidemia: Continue Rosuvastatin . TRANSITIONAL ISSUES: He remained full code this admission. Acute parietal infarct has left pt with many residual deficits and will require intense rehab and close follow-up with many specialties. Medications on Admission: 1. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxazepam 10 mg TID 3. Klor-Con 10 10 mEq qd 4. gabapentin 800 mg TID 5. metoprolol tartrate 50 mg [Hospital1 ] 6. rosuvastatin 5 mg daily 7. glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily (). 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. docusate sodium 100 mg [Hospital1 ] 10. insulin aspart sliding scale (GENT AND DAPTO) Discharge Medications: 1. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: [2-11] PO BID (2 times a day). 3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 50 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. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS ([Doctor First Name ],MO,TU,WE,TH,FR,SA). 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). 10. daptomycin 500 mg Recon Soln Sig: Six Hundred (600) mg Intravenous Q24H (every 24 hours). 11. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 12. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 13. insulin glargine 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous once a day: at lunch. 14. oxazepam 10 mg Capsule Sig: Ten (10) mg PO three times a day as needed for anxiety. 15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Acute renal failure requiring CVVH Acute respiratory distress requiring intubation Stroke Critical Aortic Stenosis Urinary Tract Infection Discharge Condition: Mental status: minimally interactive due to expressive aphasia Level of Consciousness: alert Ambulatory: out of bed with assistance Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You were hospitalized for acute shortness of breath likely related to an antibiotic you were taking that lead to acute kidney injury. You required intubation, mechanical ventilation, and initiation of hemodialysis. You were also found to have suffered a stroke during your hospitalization for which you will need rehab. . Please call your doctor if you notice any increased shortness of breath or notice any weight gain. . Please note that you are currently taking antibiotics for an infection in your urine and an infection in your blood. Stop taking the daptomycin on [8-28] and stop taking the Ceftriaxone on [8-18]. . The following medications were changed during your hospitalization: 1. Stop taking Aspirin 325mg and instead take Aspirin 81mg by mouth daily. 2. Stop taking lasix. 3. Continue taking oxazepam 10mg by mouth up to 3 times a day for anxiety 4. Stop taking gabapentin 800 mg three times a day and instead take 800mg by mouth twice a day. 5. Stop taking glimepiride and instead take Lantus 45 units with sliding scale insulin following scale provided. 6. Continue taking Daptomycin 600 mg IV daily - end date to be set during ID appointment on [8-20] 7. Continue taking CeftriaXONE 1 gm IV daily until [2120-8-29] 8. Take amiodarone 400mg daily for 1 week, then decrease to 200 mg by mouth daily. 9. take coumadin 5mg by mouth daily Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [2120-8-20] at 2:30 PM With: [Name6 (MD) 1423] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: CARDIAC SERVICES When: FRIDAY [2120-8-23] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Also, please set-up follow up appointments with neurology (Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2574]) for your stroke, and [Last Name (un) ] (Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 12648]) for your diabetes, renal (Dr. [Last Name (STitle) 14005] at [Telephone/Fax (1) ]) for your kidney and Dr. [Last Name (STitle) 1391] (Vascular Surgery)at [Telephone/Fax (1) 1393] for your carotid artery disease.	[ "440.20", "332.0", "276.0", "996.64", "E879.8", "997.1", "785.51", "285.1", "443.21", "997.02", "E879.6", "790.7", "428.0", "V09.80", "424.1", "585.3", "428.23", "403.90", "518.81", "041.6", "784.3", "427.31", "434.91", "790.4", "250.00", "041.04", "E879.0", "E930.8", "584.5" ]	icd9cm	[ [ [] ] ]	[ "39.95", "35.96", "57.95", "96.72", "38.95", "99.61" ]	icd9pcs	[ [ [] ] ]	19707, 19781	10844, 16915	305, 376	19964, 19964	5604, 5604	21575, 22696	4365, 4633		18348, 19684		19802, 19943		17897, 18325			20122, 21552			6626, 10821					4648, 5167							5183, 5585										17694, 17871				228, 267									404, 3248					5620, 6610				19979, 20098			16931, 17673		3270, 4150	4166, 4349
9,016	119,034	11092	Discharge summary	report	Admission Date: [2180-10-14] Discharge Date: [2180-11-1] Date of Birth: [2103-10-20] Sex: M Service: NMED Allergies: Aspirin Attending:[First Name3 (LF) 618] Chief Complaint: Right hand weakness, slurred speech. Major Surgical or Invasive Procedure: Angiography with unsuccessful recanalization of left ICA; pt received 10 mg t-PA and 0.75 of Abciximab. History of Present Illness: Patient is a 76 year old right-handed male with past medical history of coronary artery disease status post CABG and stenting, chronic renal insufficiency, vertebrobasilar aneurysm, peripheral vascular disease, mitral regurgitation status post mitral valve replacement, hypertension, hypercholesterolemia, and congestive heart failure who presented to the [Hospital3 ] [Hospital 1225] Medical Center on [2180-10-14] with right hand weakness and slurred speech. Patient was in his usual state of health until 14:00 on the day of admission. At that time, he was writing a letter and noted that his right hand was weak; he was unable to fully grasp his pen. He tried to talk to his daughter. His speech was garbled and he had difficulty getting words out. He was able to comprehend speech. Family noted his face was drooping on the right side. He felt like his gait was weak and unsteady. These symptoms lasted 10 minutes and then resolved. He took an aspirin at home, then his family took him to the Emergency Department for evaluation. He arrived in the Emergency Department by 15:00. Initial vitals of temp 98, HR 72, BP 161/75. His symptoms then recurred, in that his right hand dropped his cane. On initial exam in the ED, he had an NIH stroke scale of 4. He was unable to correctly name the year, had right lower facial droop, and decreased sensation to pin and touch on his right arm and leg. Finger stick blood glucose testing was 90. CT head with no acute intracranial hemorrhage, left vertebrobasilar aneurysm. Initial MRI showed an area of restricted diffusion in the left subcortical parietal region in area supplied by superior division of MCA, absent left ICA and poor filling of left MCA with collaterals from right ACOM. Examination after MRI showed NIH stroke scale of 2 with right lower facial droop. Due to the improvement in his symptoms, small size of stroke, and presence of vertebrobasilar aneurysm, thrombolysis with tPA was not pursued. He was admitted to the neurology service. On initial review of systems, he denied fevers, chills, sweats, chest pain, shortness of breath, palpitations, headaches, visual changes, numbness, weakness, paresthesias, abdominal pain, dysuria. No recent of history of surgery or trauma. Past Medical History: 1. Mitral valve replacement with porcine valve, [2179]. Course complicated by respiratory failure. 2. Left vertebrobasilar artery aneurysm found during follow-up for mitral valve replacement. Failed to follow-up with Dr. [Last Name (STitle) 1132] as an outpatient for evaluation of aneurysm. 3. Stroke, 20 years ago. Unclear what his symptoms were at that time, but no residual deficits. 4. Coronary artery disease s/p CABG 5-6 years ago with LIMA to LAD, SVG to distal circumflex marginal and SVG to PDA. Also with multiple stents. 5. Congestive heart failure 6. Rectal cancer status post resection with resultant colostomy, [2177] . No history of chemotherapy or radiotherapy. 7. Hypercholesterolemia 8. Hypertension 9. Gout 10. Status post burn injury to hands as child, status post grafting 11. MRSA positive 12. Chronic renal insufficiency 13. Peripheral vascular disease 14. 50-79% left ICA stenosis on ultrasound 15. History of bacterial endocarditis 16. Degenerative joint disease 17. Hypothyroidism All: Aspirin results in rash, but he reported taking it nevertheless. Social History: Retired construction worker. Emigrated from [Country 2559] as a young adult. Moved to [Location (un) 86] at age 30. Smoked 1.5 pack cigarettes daily for 40 years; quit 25 years ago. No alcohol or drug use. Lives with wife. Daughter and son in area and actively involved in care. Speaks English but Italian in primary language. Family History: Brother deceased from stroke at age 77. Coronary artery disease in brother and father. Mother with stroke in her 80s. Physical Exam: Tm: 98.6 Tc: 98.2 BP: 155/57 (132-179/51-90) HR: 75 (62-75) RR: 23-33 O2Sat.: 95-100/3L Gen: WD/WN, comfortable appearing, NAD. HEENT: NC/AT. Right eye chemosis. Mild scleral icterus. MMM. +Nasogastric tube. Neck: Supple. No masses or LAD. Unable to assess JVP. No thyromegaly. No carotid bruits. Lungs: Coarse breath sounds anterolaterally. Cardiac: RRR. S1/S2. No M/R/G. Abd: +Colostomy. Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Left knee edematous, warm. Tender to palpation. Neuro: Mental status: Awake and alert, cooperative with exam. Nod yes/no to simple questions. Intermittently follows [1-14] steps midline and appendicular commands. He occasionally answers back with simple sentences or words; repeats his name. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2.5 mm bilaterally. Does not blink to threat on right. Unable to appreciate fundi. III, IV, VI: Left gaze preference but will track past midline. V, VII: Right facial UMN paresis. VIII: Hearing intact grossly. IX, X: +Gag. [Doctor First Name 81]: Did not assess. XII: Tongue midline without fasciculations. Motor: Moves left side spontaneously. Withdraws right LE to pain. Right UE plegic. Sensation: Grimaces to pain x4. Unable to assess sensation adequately. Reflexes: Present and symmetric. Grasp reflex absent. Right toe upgoing, left downgoing on Babinski. Coordination: Did not assess. Gait: Unable to assess. Pertinent Results: [2180-10-14] 11:30PM CK(CPK)-83 [2180-10-14] 11:30PM CK-MB-NotDone cTropnT-<0.01 [2180-10-14] 03:30PM GLUCOSE-87 UREA N-56* CREAT-2.2* SODIUM-138 POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20 [2180-10-14] 03:30PM CK(CPK)-109 [2180-10-14] 03:30PM CK-MB-5 cTropnT-<0.01 [2180-10-14] 03:30PM WBC-9.5 RBC-4.85# HGB-14.9# HCT-44.7# MCV-92 MCH-30.8 MCHC-33.4 RDW-14.4 [2180-10-14] 03:30PM PLT COUNT-181 [2180-10-14] 03:30PM PT-13.4 PTT-27.7 INR(PT)-1.1 [2180-11-1] 03:47AM BLOOD WBC-9.5 RBC-4.62 Hgb-14.1 Hct-43.4 MCV-94 MCH-30.5 MCHC-32.5 RDW-13.9 Plt Ct-310 [2180-11-1] 03:47AM BLOOD Plt Ct-310 [2180-11-1] 03:47AM BLOOD Glucose-153* UreaN-61* Creat-1.5* Na-142 K-4.7 Cl-102 HCO3-30* AnGap-15 [2180-10-15] 11:26AM BLOOD Triglyc-167* HDL-52 CHOL/HD-3.5 LDLcalc-98 [2180-10-15] 11:26AM BLOOD %HbA1c-5.3 Brief Hospital Course: Patient was stable overnight from [2180-10-14] to am of [2180-10-16]. At approximately 6am on [2180-10-16], noted by nurse to be in respiratory distress, aphasic, and not moving right side at all. NIH stroke scale 19. Felt to be in congestive heart failure by exam and chest x- ray. Treated with IV lasix. Stat head CT showed no evidence of hemorrhagic transformation. Taken for MRI/MRA. MRI demonstrated restricted diffusion in entire left MCA territory; lesion not yet visible on FLAIR. Patient was taken to angiography suite emergently for attempt at intraarterial tPA thrombolysis. However, left ICA was totally occluded and unable to access left sided circulation via ACOM. Neurointerventionalist was able to traverse the left ICA occlusion and five 10.5 mg of intraarterial tPA and 1mg of Reopro. Multiple attempts to open left ICA via balloon angioplasty were undertaken. However, flow was poor and vessel reoccluded. Post-procedure, patient taken to ICU intubated. Hospital course has been remarkable for difficulty weaning from ventilator due to volume overload, difficulty handling secretions and aspiration pneumonia. He received a course of levofloxacin and metronidazole for aspiration. He has been treated with IV Lasix for CHF. He was successfully extubated on [2180-10-23]. He was transiently on vancomycin for sputum culture with S. aureus. After extubation, he was tachypneic and had several episodes of respiratory distress which responded to IV lasix. He developed a painful left knee effusion. Arthrocentesis was performed and revealed an inflammatory artritis. Since the patient had been on antibiotics for PNA, it was immpossible to rule out a partially treated septic arthritis. He was therefore treated with Vancomycin for several days until knee joint fluid culture was negative. For inflammation, he was started on IV methylprednisilone taper, he was changed to po prednisone on the day of discharge per rheumatology. His knee was re-tapped x2 by rheumatology service; both subsequent taps revealed negatively birefringent crystals c/w gout. For stroke prevention, he was started on ASA and Aggrenox. He has been evaluated and treated by PT and OT while in the hospital, his deficits have remained largely static, but he has had some improvement in the last several days in terms of increased speech production and decreasing right neglect. He failed swallow evaluation on [10-26] and subsequently had a PEG placed on [10-30]. He was seen by the CHF service while in the hospital for episodes of respiratory distress due to CHF. He was started on Lisinopril, lasix and beta blocker. His respiratory status has improved. His echo was technically limited, but revealed LVH and dilated LA (EF could not be assessed). He also had several runs of V tach (longest 42 beats) during his hospitalization. EP service was [Month/Year (2) 4221] and recommended continuing telemetry, electrolyte repletion and continuing beta blocker. He should continue to have cardiac telemetry while in rehab for the next seven days. Follow up with Dr. [Last Name (STitle) ] in stroke clinic has been arranged for [1-2]. Medications on Admission: plavix 75 pravastatin 20 levothyroxine 25 mcg MVI metoprolol (either 12.5 [Hospital1 ] or 25 [Hospital1 ]) calcium carb 500 tid aspirin 325 mg a day ipratropium inhaler lisinopril 2.5 mg a day lasix 20mg a day Discharge Medications: 1. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q8H (every 8 hours) as needed for sob, wheeze. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO qd. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 14. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release Sig: One (1) Cap PO BID (2 times a day). Cap(s) 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 16. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO QD (once a day). 17. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QD (once a day). 20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Take 1 Prednisone tablet 20 mg PO qd for 3 days. Then take 1 Prednisone tablet 10 mg PO qd for 3 days. Then take 1 Prednisone tablet 5mg PO qd for 3 days. 21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Take 1 prednisone tablet 10 mg po x 3 days. 22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Take 1 prednisone tablet 5 mg po qd x 3 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 76 y/o white Italian male, h/o CHF, hypertension, with Left MCA stroke (superior division). Discharge Condition: Broca's aphasia, Right hemiparesis (0/5 strenght RUE and RLE), improving right hemineglect. Discharge Instructions: Please continue your current medications. Continue prednisone taper as prescribed. Return to ER or contact Dr. [Last Name (STitle) ] if you experience new weakness, numbness, dizziness, double vision, or any worrisome symptom. Followup Instructions: [Name6 (MD) ] [Name8 (MD) ], M.D. Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 2574] Date/Time:[2181-1-2] 2:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "427.1", "784.3", "V02.59", "V15.82", "440.20", "593.9", "428.0", "507.0", "414.01", "272.0", "437.3", "401.9", "274.0", "V44.3", "V45.82", "V42.2", "244.9", "433.11", "453.8", "V45.81", "V10.06", "V09.0", "342.91" ]	icd9cm	[ [ [] ] ]	[ "88.41", "96.72", "99.20", "38.93", "88.91", "81.91", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	12318, 12397	6726, 9900	303, 409	12533, 12626	5830, 6703	12905, 13143	4181, 4301		10169, 12295		12418, 12512		9926, 10146			12650, 12882								4316, 4858																					226, 265									437, 2697	5116, 5811								4873, 5100					2719, 3812	3828, 4165
24,951	190,200	29843	Discharge summary	report	Admission Date: [2166-1-8] Discharge Date: [2166-1-21] Date of Birth: [2106-10-9] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1974] Chief Complaint: Fever, weakness, neck pain Major Surgical or Invasive Procedure: Cervical decompression with epidural abscess and fusion of C6-7. History of Present Illness: 59 y/o M hx of CAD s/p stent, hypercholesterolemia, and gastroesophageal reflux recently s/p uncomplicated endoscopy on [12-13] who presented to ED with fevers, progressive weakness/paraplegia found on MRI to have epidural abscess and now s/p urgent evacuation. He was in his USOGH (works as tennis pro) until 1 wk ago when he developed fevers, back pain, neck pain and progressive LE weakness. He had been seen previously by PCP for back pain, who thought there may be UTI/prostatitis. He had been taking ibuprofen and percocet for pain. . In the ED, neurology evaluated him and noted plegia in his legs, perhaps a flicker of trace movement in adduction and abduction, no sensation below T3 to pinprick. Rectal tone was not tested. Reflexes were 3+ in the biceps and brachioradialis, 2+ in the triceps, 3+ in the knees, 2+ in ankles with silent toes. MRI revealed anterior cervical epidural collection, largest at C6/7, but extending both laterally and caudally (to T2/T3) with severe compression of the spinal cord at C6/7, likely representing abscess. . He was sedated and intubated, started on Vanc/Gent and taken urgently to OR for anterior cervical decompression and fusion C6-7 with left iliac crest bone graft and instrumentation. Per Op report, he recived 4 liters IVF, EBL 75 cc, UOP 200cc and procedure was uncomplicated. However, he did receive phenylephrine intraoperatively to maintain his blood pressure in the systolic 160's to perfuse his spinal cord. Specimens consistent with frank pus were sent for micro and path. . Blood cx and wound cx growing MSSA, switched to Nafcillin on [1-10]. Post op, he has continued to spike high fevers to 103 with minimal maintenance fluids. ID was consulted. Repeat MRI of c-spine showed "increased signal of the spinal cord from C5-T3 with cord swelling and effacement of the subarachnoid space" concerning for infectious, ischemic, or a combination of both. It also showed "significant increase in size of an enhancing prevertebral soft tissue swelling" that enhanced making a worsening infectious phlegmon more likely. . On POD# 3 ([1-11]), he developed ARF cre 1.9 (baseline 0.8) as well as elevated LFTs and medicine was consulted. Past Medical History: CAD-x2 stents following chest pain [2162], and [2163]. GERD Hypercholesterolemia . Denies HTN, DM, lung diseas Social History: married, no tobacco. Drinks 1 beer per week. Family History: unknown Physical Exam: initial medicine exam: 102.7 103.9 100/54 78 20 94%RA O2 Sats Gen: pleasant cooperative NAD, surrounded by family, joking HEENT: Clear OP, slightly MM NECK: c collar in place CV: RR, NL rate. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTA anteriorly, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. No sensation below T4. 0/5 strength in legs, [1-17] finger extensors, flexors. 4/5 strength biceps. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission labs: 138 100 21 ------------<168 4.0 28 1.0 estGFR: >75 (click for details) . 13.1 9.7>----<115 38.1 N:85.8 L:8.4 M:5.0 E:0.4 Bas:0.3 . PT: 12.0 PTT: 25.5 INR: 1.0 . UA: Color Amber Appear Clear SpecGr >1.035 pH 6.5 Urobil 8 Bili Lg Leuk Tr Bld Sm Nitr Neg Prot 30 Glu Neg Ket Tr RBC [3-17] WBC [3-17] Bact Few Yeast Mod Epi 0 . blood cx: [1-8]: [2-16] MSSA [1-9]: NG x4 [1-11]: NGTD x4 [1-12]: NGTD x2 [1-13]: NGTD x4 [1-14]: NGTD x2 [1-18]: NGTD x4 Urine cx: NG [1-11], [1-12], [1-16] Wound cx: [1-8]: MSSA . Imaging: ABDOMINAL ULTRASOUND [2166-1-11]: The liver is normal in contour and echotexture. No focal lesions are identified. There is no intra- or extrahepatic biliary ductal dilation. The portal vein is patent with flow in the appropriate direction. The gallbladder is not dilated, and there are no stones or sludge demonstrated within its lumen. The right kidney measures 11.7 cm. The left kidney measures 12.1 cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal mass. The kidneys are not abnormally echogenic. The spleen is not enlarged. The pancreatic head and body appear unremarkable. The abdominal aorta is not dilated. There are small bilateral pleural effusions seen. . TTE [2166-1-10]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. No vegetation seen. . LE US [2166-1-15]: 1. No evidence of DVT in the common femoral veins bilaterally. . CXR [2166-1-14]: Development of bilateral pleural effusions blunting the lateral pleural sinuses and extending in the posterior pleural compartments. Cause unknown. To exclude coinciding significant pulmonary abnormalities, a CT may be helpful. . Renal US [2166-1-15]: Lesion in question in the upper pole of the left kidney does not meet ultrasound criteria for a simple cyst. Further evaluation with MRI without and with gadolinium is recommended. . CT neck [2166-1-20]: Three radiographs of the cervical spine demonstrate C1-C7. Patient is status post anterior cervical fusion at C6-C7. There is narrowing of the C5-C6 intervertebral body disc space. Prevertebral soft tissues are unremarkable. Radiopaque tubing projects over the left hemithorax. The visualized lung apices are unremarkable. No hardware loosening. Grade I retrolisthesis of C5 on C6 seen on [2166-1-13] is not apparent on the current exam. . CT chest [2166-1-18]: There is dense consolidation with volume loss of the entire right lower lobe as well as of the anterior, lateral and posterior segments of the left lower lobe. Air bronchograms are visualized within both these collapsed lower lobes. There are moderate overlying pleural effusions. Remainder of the lung parenchyma is clear. Noncontrast evaluation of the mediastinum is unremarkable, except for a stent visualized within the right coronary artery. Evaluation of the osseous structures is unremarkable aside from degenerative changes of the thoracic spine. Limited evaluation of the upper abdomen is unremarkable demonstrating unremarkable liver, gallbladder, pancreas, spleen and adrenal glands. . ECG [2166-1-15]: Sinus bradycardia (55) Prolonged Q-Tc interval (468) - clinical correlation is suggested No previous tracing available for comparison Brief Hospital Course: ASSESSMENT: The patient is a 59 y/o M hx CAD s/p stent, GERD s/p endoscopy, hyperlipidemia who presented with C6 epidural abscess s/p decompression with C6-C7 fusion with persistent postoperative fevers, trending down, improving ARF and stable transaminitis. . 1. Epidural abscess w/paresis: MSSA in blood and wound, s/p decompression and fsion [2166-1-8] emergently with residual fluid, spinal cord swelling, followed by ortho spine, neurology, infectious disease. He was initially started on vanco and gent but switched to Nafcillin on [1-10] (s/p vanco/ceftaz [Date range (1) 62834], gent d/c'd [1-11], naf day 1=[1-10], 42 day course). After surgery he was noted to have continuing but slightly improved neurologic deficits related to cord compression. Surveilance cultures have all been negative. Unclear initial portal of entry for MSSA, possibly [2-14] pruritis leading to excessive itching with skin break down, also consider given renal fx/back pain ? multiple myeloma making him more susceptible though UPEP negative, SPEP pending at time of discharge. No indwelling hardware, no IVDU, no significant valvular abnormalities on TTE, no vegitations identified, no other stigmata of endocarditis identified, imaging of chest/abdomen/pelvis has not identified nidus for infection. Urine negative to date. LE US negative (only assessed common femorals). Fevers continued post-operatively but generally trending ddown, with improved bandemia. Given no changes on ECG c/w significant perivalvular abscess no further cardiac imaging Had chest CT [2166-1-18] to eval effusions given fever [2166-1-18], ? RLL process but ID felt not significant enough to treat given lack of pulmonary symptoms. Over 48 hours prior to discharge, his temp curve came down with a T max of 100.0. ID felt there was no evidence of persistent infection and low grade temp may have been from atelectasis. He will follow-up with orhtopedic surgery and neurology and needs hard C-collar for 8 weeks post operatively. Currently on oxycontin 20mg po bid with oxycodone ir 5mg po q 4-6 hours prn for breakthrough, with neurontin 300mg po q8 and cyclobenzaprine 10mg qhs for pain relief which may need to be uptitrated in rehab. . 2. ARF: Creatinine went from 0.8 to 1.9 [1-11], peaked at 2.1 [1-12], then slowly trending down to 1.4. Most likely [2-14] ATN (given muddy brown casts in urine, also given minimal IVF post op and restriction of PO [2-14] paresis in the setting of high fevers) vs prerenal vs interstitial nephritis [2-14] gentamycin (though initially no peripheral or uine eos noted, elevated % eos [1-16]->decreased [1-17]). No evidence on ultrasound to suggest obstruction. He has not received contrast (GAD for MRI rarely causes ARF). FeNA 1.06, so ATN vs prerenal. Has recieved aggresive IVF and was anasarcic on imaging with pleural effusions (improving, in the setting of albumin 2.1). Out of concern for post-ATN diuresis PO was supplemented with IVF through [1-20] when this was stopped and he was able to keep up with oral hydration. We avoided Nsaids or nephrotoxic agents. Monitored Factor Xa levels on lovenox, recommend continuing this until renal function stabilizes. . 3. Increased LFTs: All LFT's elevated on admission, albumin noted to be low (2.1), coags WNL [1-17]. These increased to max ALT 125 AST 102 alk phos 332 and bili 3.6 but then trended down below admission levels, to normal ([2166-1-21] ALT 33, AST 17 AP 149 Tbili 0.6). Picture was slightly more consistent with obstructive process but RUQ ultrasound without stone. Given paralysis, unable to detect acute processes based on symptoms. No evidence of hemolysis. Lastly, one report of nafcillin causing cholestatic jaundice is in micromedex. Abdominal CT not helpful, liver parenchyma c/w fatty infiltration. Hep serologies all negative. Unclear etiology, ? EToH contributing, consider further w/u when more stable (though could all be related to acute process) for hemochromatosis (though ferritin elevated as acute phase reactant), ceruloplasmin, alpha-1 antitrypsin, anti LKM, anti SMAb, though now that most LFT's normal likely will not need. . 4. Anemia: HCT dropped from 38 to 28 post operatively. Hct has been stable, so less concerned for acute bleed. Most likely iron deficiency anemia from procedural losses coupled with hemodilution (given 4L intraop). Iron studies, B12, folate show anemia of inflammation, no evidence of hemolysis; hapto, LDH normal. Retic inappropriately low, ? BM suppression (especially since he has never mounted a leukocytosis to bacteremia, but did have bandemia). This hct remained stable and has not required transfusion. . 5. Fevers: Last 0800 [2166-1-18], most likely [2-14] continued infection. Based on MRI read, there may be a continuing process in neck/C-spine. Ortho does not favor surgical intervention. All fevers >101.5 cultured but no growth. Chest CT showed possible RLL process but ID not favoring this as culprit, no treatment currently for pna, they recommended tap L AC joint given TTP over this however IR unable to do so given size. Also ortho tapped his let [Hospital1 ] joint which was dry and thought to communicate with the AC given rotator cuff tears so thought less likely to be infected based on that. TEE, US LE (complete), w/u for PE (though ECG without changes) were all considered if he were to be febrile again. PICC placed [2166-1-20] once afebrile. He will need to continue Nafcillin on discarge for total course 42 days (through [2-22]) and have labs monitored (by Infectious disease) while on it. He will follow up with infectious disease. . 6. Constipaiton: Developed over [Date range (1) 71361], uptitrated on senna/colace, some improvment with enemas/lactulose, may need to continue those on discharge. . 7. Hyperglycemia: No hx of DM, BS in 200's most likely [2-14] infection and recent OR (stress) though could have underlying impaired fasting glucose not yet diagnosed, started will need to contiue insulin with 8units glargine qhs and adjust this as necessary. Hemoglobin A1C 5.9. . 8. Hypoxia: This occured 3-4 days post-operatively but resolved. At risk for PE as he's had cord infarct, on lovenox ppx, ortho considering filter placement ppx-favoring hold on that for now given fevers but likely will need ultimately. Hypoxia likely due to atelectasis. Encourage IS, OOB. . 9. Quadriplegia: some UE motor function returning, none in LE, working with PT/OT, in hard cervical collar post-op (8 weeks), monitor neuro exam closely, guarded prognosis, will need PE ppx: filter vs. anticoagulation, risk of PE very high but as pt still had low-grade temp, did not favor placing foreign body. . 10. Wound care: Stage II decubitis ulcer developing over buttocks/gluteal/sacral area, wound care evaluated [1-14] and [1-17], appreciate recs, maintained on air matress, with washing and dressing changes (q48 hours to sacrum per wound care), freqeunt monitoring, OOB to chair. . 11. PPX: on lovenox, consider filter as above, BR, pantoprazole, air mattress, wound care. . 12. Code: full. Medications on Admission: Crestor 20mg po qd Nexium generic equivalent 1 po qd Aspirin 325mg po qd Motrin prn pain Percocet prn pain occ. allergy pills steroid cream prn for eczema occ. B vitamin Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) units Subcutaneous Q12H (every 12 hours). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO every eight (8) hours. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: to groin/buttocks. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 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. Insulin Glargine 100 unit/mL Cartridge Sig: Eight (8) units Subcutaneous at bedtime. 9. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 10. Docusate Sodium 100 mg Capsule Sig: [2-15] Capsules PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 12. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 33 days: to be given through [2166-2-22]. 13. Outpatient Lab Work Please check CBC with differential, ESR, CRP, AST, ALT, Alkaline phosphotase, total bili once per week and forward results to [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) ]: fax ([Telephone/Fax (1) 1353]. 14. Outpatient Lab Work We recommend following weekly Factor Xa levels on enoxaparin for anticoagulation as your renal function improves to ensure adequate anticoagulation and adjusting enoxaparin as appropriate. 15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 16. Lactulose 10 g Packet Sig: [1-14] packets PO three times a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Epidural abscess with T4-T5 partial quadriplegia. . Acute renal failure [2-14] acute tubular necrosis, anemia, transaminitis, hyperglycemia. Discharge Condition: Good. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your providers or contact your primary care doctor if you experience fevers, chills, nausea, vomitting, diarrhea, constipation, shortness of breath, headache, worse neck or shoulder pain, cough, worsening weakness or numbness or any symptoms that concern you. Followup Instructions: You have been arranged to start primary care with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3649] in [Location (un) 620] but her next available appointment is not until [5-28], [2166] at 10:45am. Her office number is ([Telephone/Fax (1) 3650]. . Please follow-up with infectious disease on [2166-2-14] at 9:30am, please call ([Telephone/Fax (1) 4170] with questions. You should have your blood drawn once per week while at rehab and these results will go to Dr. [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) ] of infectious disease for monitoring while on nafcillin. . Please follow-up with neurology, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [3-12], [2166] at 4:00pm. Please call ([Telephone/Fax (1) 2528] with questions. . Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352] of orhtopedics on [2166-2-14] at 2:00pm, please arrive 20 minutes prior (1:40pm) for xrays. You should wear your hard cervical collar for 8 weeks after your surgery (date [2166-1-8]).	[ "790.4", "344.04", "324.1", "272.0", "780.6", "998.89", "V09.0", "997.5", "584.5", "041.11", "707.09", "238.71", "730.28", "530.81", "414.01", "707.03", "280.8", "997.3", "V45.82", "707.05", "576.8", "790.29", "799.02", "564.00", "518.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "93.90", "81.91", "81.02", "81.62", "77.79" ]	icd9pcs	[ [ [] ] ]	16595, 16665	7255, 14001	307, 373	16854, 16862	3460, 3460	17267, 18398	2827, 2836		14616, 16572		16686, 16833		14422, 14593			16886, 17244								2851, 3441																					241, 269								14013, 14396	402, 2606					3476, 7232									2628, 2749	2765, 2811
7,786	164,229	17911	Discharge summary	report	Admission Date: [2128-12-15] Discharge Date: [2129-1-4] Date of Birth: [2056-3-24] Sex: F Service: MEDICAL ICU HISTORY OF THE PRESENT ILLNESS: The patient is a 72-year-old female with multiple medical problems who was brought to the Emergency Department on the day of admission from [Hospital ] Rehabilitation Facility for evaluation of a cold left foot. The patient had recently been discharged approximately one month prior to this visit from [Hospital6 2018] after having a low anterior resection for rectal cancer. Her postoperative course has been complicated by deep venous thrombosis for which the patient remained on Coumadin. She reported left leg swelling and pain intermittently since that operation but reported increasing pain, changing color, and temperature over the prior 24 hours. The patient denied fevers, chills, chest pain, shortness of breath, or change in her fingerstick blood glucose. PAST MEDICAL HISTORY: 1. Nonsmall cell lung cancer, status post chemotherapy and XRT. 2. Bladder cancer, locally invasive. 3. Diverticulitis, status post sigmoid resection. 4. Rectal cancer, status post low anterior resection with ileostomy. 5. DVT, status post [Location (un) 260] filter placed in [2109] with recurrent extensive left lower extremity DVT seen on admitting ultrasound. 6. Paroxysmal atrial fibrillation. 7. Chronic renal insufficiency. 8. Anemia. 9. Hypertension. ALLERGIES: The patient is allergic to penicillin. ADMISSION MEDICATIONS: 1. Insulin. 2. Humalog sliding scale. 3. Digoxin. 4. Iron sulfate. 5. Folate. 6. Ativan. 7. Atenolol. 8. Nortriptyline. 9. Actos. 10. Coumadin. 11. Lasix. 12. Percocet p.r.n. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.7, heart rate 108, blood pressure 113/22, respiratory rate 20, saturating 95% on room air. General: The patient was an uncomfortable appearing elderly lady in no acute distress. HEENT: The mucous membranes were dry. The neck was supple. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, II/VI systolic murmur at the left sternal border. GI: Soft, nontender, well-healed surgical scars, and a ileostomy bag. Extremities: There was 1+ bilateral femoral pulses. Chronic venous stasis changes of the bilateral lower extremities to the shin. Cool left foot, decreased sensation in a stocking-like distribution of the bilateral feet. No palpable or Dopplerable pulses bilaterally in the Emergency Department on the dorsalis pedis. There was 3+ edema of the bilateral lower extremities. LABORATORY/RADIOLOGIC DATA: On admission laboratory studies that were pertinent include CBC with a white count of 5.8, 90% polys, hematocrit 28 down from baseline of 30. Chemistry panel revealed a sodium of 128, potassium 6.1, chloride 98, bicarbonate 22, BUN 57, creatinine 1.6, glucose 102. PTT 2.7. Bilateral lower extremity ultrasound revealed large clot burden in the left lower extremity venous system. HOSPITAL COURSE: The patient was admitted to the Vascular Surgery Service with a medicine consult. She was placed on a heparin drip for the deep venous thromboses and conservative measures were utilized to improve the bilateral lower extremity edema. Subsequently, the patient was transferred to the [Hospital 1739] Medical Service on [2128-12-16] and an arterial Doppler of the lower extremities on [2128-12-17] revealed a significant flow deficit to both ankles. Subsequently, the patient was known to have decreasing platelet counts and was switched from heparin to lepirudin on [2128-12-18]. On the following day, [2128-12-19], the patient was found hypotensive in respiratory distress and was intubated on the floor and transferred to the Medical Intensive Care Unit for further management. Her initial ICU course was notable for CT of the chest revealing right lower lobe consolidation, bronchoscopy with bronchial alveolar lavage yielding methicillin-resistant Staphylococcus aureus for which she was started on vancomycin and levofloxacin. The patient required inotropes during her ICU stay which were finally weaned off on [2128-12-22]. The patient was transferred back out to the general medical floor on [2128-12-26] for continued management of her pneumonia and deep venous thromboses. However, the patient was again transferred back to the Medical Intensive Care Unit the following day for hypercarbic respiratory distress that was initially responsive to noninvasive positive pressure ventilation. On [2128-12-29], the patient again required noninvasive positive pressure ventilation for an additional attempt for persistent desaturations. The patient did not tolerate this procedure and required endotracheal intubation. The remainder of the [Hospital 228] Medical Intensive Care Unit course was significant for repeat bronchoscopy that yielded similar findings to prior with Staphylococcus aureus islet. Repeat blood cultures that were final were negative on final determination. Chest x-ray revealed diffuse bilateral opacifications. The patient's ICU course was further complicated by acute renal insufficiency and GI bleeding requiring transfusion of packed red blood cells while anticoagulated for the previously identified deep venous thromboses. After ongoing discussions with the family regarding the patient's wishes for care, the severity of the ongoing illness despite the current aggressive level of care and the potential prognosis of inability to return to baseline given her prolonged hospital course. The health care proxy, in discussion with the remainder of the family, decided to make the patient comfort measures only on [2129-1-4]. At that time, all aggressive measures were stopped. The patient was extubated and comfort was ensured. Later on that same day, the ICU team was called to see the patient for pronouncement of death. The time of death was pronounced to be 20:55. CONDITION ON DISCHARGE: Expired. DISCHARGE DIAGNOSIS: 1. Respiratory failure. 2. Acute renal failure. 3. Gastrointestinal bleed. 4. Deep venous thromboses. 5. Bladder cancer. 6. Nonsmall cell lung cancer. 7. Rectal cancer. 8. Paroxysmal atrial fibrillation. 9. Hypertension. 10. Obesity. 11. Diabetes mellitus type 2. 12. Anemia. 13. Hyponatremia. 14. Thrombocytopenia. 15. Hospital-acquired cellulitis. 16. Vascular insufficiency. 17. Hematuria. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 28700] MEDQUIST36 D: [2129-2-25] 12:18 T: [2129-2-26] 17:50 JOB#: [Job Number 49627]	[ "453.8", "578.9", "162.9", "427.5", "038.10", "707.0", "518.81", "289.82", "482.41" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.91", "96.72", "96.6", "33.24", "99.10", "99.04", "96.04" ]	icd9pcs	[ [ [] ] ]											6047, 6678			3036, 5991				1526, 1732																																											1747, 3018							974, 1503		6016, 6026
12,026	153,758	1552	Discharge summary	report	Admission Date: [2127-12-12] Discharge Date: [2128-1-5] Date of Birth: [2068-7-23] Sex: F Service: CARDIOTHORACIC Allergies: Heparin Agents / Amoxicillin Attending:[First Name3 (LF) 922] Chief Complaint: acute MR transferred from OSH with hypotension. c/o neck pain and slight SOB. Major Surgical or Invasive Procedure: [2127-12-12] Mitral Valve replacement ([Street Address(2) 7163]. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 9041] porcine valve) [2127-12-12] and [2127-12-28] Cardiac Catherization [2127-12-28] [2128-12-27] Temporary Transvenous pacemaker History of Present Illness: 59 yo female transferred in from OSH with one week history of neck and hip pain with ? fever/chills. Acute nausea/vomiting/SOB evening prior to admission and went to local ER. She presented in respiratory distress and was intubated there prior to being trasnferred to [Hospital1 18] ER. Past Medical History: hypothyroid overactive bladder Social History: unable Family History: unable Physical Exam: HR 133 BP 66/30 RR 20 pulse ox 85% sat intubated on exam/sedated on vent RRR 4/6 holosystolic murmur extremities mottled, but warm dobutamine 60 mcg/kg/min levophed 0.6 mcg/kg/min no palpable distal pulses 2+ bil. femoral pulses luns rales bil. throughout hypoactive BS, soft, NT Pertinent Results: [2128-12-11] Cath: 1. Selective coronary angiography in this right dominant system revealed no obstructive CAD. The LAD, LMCA, RCA, and LCx were free of angiographically appartent stenoses. 2. Central aortic pressure was low with an SBP of 70 mmHg and DBP of 30 mmHg. 3. Successful placement of an intra-aortic counterpulsation balloon via the left femoral artery with position confirmation by floroscopy. The position was stabilized by multiple subcutaneous suture anchors prior to transport. Adequate augmentation noted on the balloon pump console. [2128-12-11] Echo: PRE-CPB: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, 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. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A mass or vegetation on the mitral valve cannot be excluded. Torn mitral chordae are present. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. POST-CPB: Sinus Tach on Epi,Levo drips. 1. Well-seated bioprosthetic valve in the mitral position. No MR. [Name13 (STitle) ] paravalvular leak. 2. LVOT obstruction is mild with strut of St [Name13 (STitle) 923] valve present in the outflow tract with mild turbulent flow seen. 3. Hyperdynamic LV systolic function. Normal RV systolic function. 4. Mild to Moderate (2+) TR unchanged from pre-CPB. 5. Bilateral pleural effusions are diminshed post Bypass. [2128-12-16] Chest/Abd CT: 1. Multifocal pneumonia. 2. Status post median sternotomy with a pericardial drain and a small amount of intrapericardial gas, but no pericardial effusion. 3. Edema in the subcutaneous soft tissues of the abdomen and pelvis. 4. Uterine fibroids. [2128-12-16] UE U/S: Superficial vein thromboses of the right basilic and cephalic vein. Please note that the right subclavian is not viewed in its entirety secondary to the patient's central line; however the vein distal to the line is patent. No evidence for deep vein thrombosis within the visualized deep venous structures. [2128-12-22] Abd U/S: 1) No gallstones, or evidence of cholecystitis. [2128-12-27] Cath: 1. Selective coronary angiography of this right dominant system revealed no angiographically apparent disease. The LMCA, LAD, and LCx were all patent. The RCA was not injected. 2. Resting hemodynamics revealed elevated filling pressures with a mean RA of 19mmHg and a mean PCWP of 24mmHg. 3. The procedure was complicated by dislodgement of the RIJ venous sheath and temporary pacing wire during patient transfer. A second temporary pacing wire placed via the left femoral vein and the original pacemaker was removed. [2127-12-31] UE U/S: Right internal jugular acute appearing nonocclusive thrombus. Right cephalic occlusive thrombus. Left axillary chronic nonocclusive thrombus. [2128-1-5] CXR: The patient is status post median sternotomy. Cardiomediastinal contour is unchanged from previous study. Small bilateral pleural effusions are present, but slightly improved from previous study. There is also slightly better aeration of the lung bases on current study. Pulmonary vasculature is within normal limits. [2127-12-12] 03:15AM BLOOD WBC-17.8# RBC-4.53 Hgb-13.8 Hct-39.4 MCV-87 MCH-30.4 MCHC-35.0 RDW-13.1 Plt Ct-250 [2127-12-18] 03:31AM BLOOD WBC-33.6 RBC-3.14* Hgb-9.5* Hct-26.2* MCV-84 MCH-30.4 MCHC-36.3* RDW-17.2* Plt Ct-90* [2127-12-29] 02:39AM BLOOD WBC-14.1* RBC-2.73* Hgb-8.3* Hct-23.9* MCV-87 MCH-30.4 MCHC-34.8 RDW-16.8* Plt Ct-298 [2128-1-3] 05:55AM BLOOD WBC-6.1 RBC-3.32* Hgb-9.9* Hct-28.6* MCV-86 MCH-30.0 MCHC-34.8 RDW-15.8* Plt Ct-326 [2127-12-12] 03:15AM BLOOD PT-20.7* PTT-39.9* INR(PT)-2.0* [2127-12-16] 02:16AM BLOOD PT-17.0* PTT-31.2 INR(PT)-1.6* [2128-1-5] 04:30PM BLOOD PT-22.8* PTT-36.8* INR(PT)-2.3* [2127-12-12] 03:15AM BLOOD Glucose-138* UreaN-28* Creat-2.0* Na-140 K-5.1 Cl-104 HCO3-18* AnGap-23* [2127-12-22] 08:16AM BLOOD Glucose-139* UreaN-53* Creat-7.4* Na-139 K-5.0 Cl-103 HCO3-26 AnGap-15 [2128-1-5] 05:50AM BLOOD Glucose-88 UreaN-25* Creat-2.5* Na-138 K-4.3 Cl-111* HCO3-17* AnGap-14 [2127-12-12] 03:15AM BLOOD ALT-1179* AST-1557* CK(CPK)-303* AlkPhos-94 Amylase-197* TotBili-0.6 [2127-12-31] 04:13AM BLOOD ALT-28 AST-18 AlkPhos-79 Amylase-196* TotBili-0.6 [2128-1-5] 05:50AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.7 Brief Hospital Course: Admitted from ER to cath [Year/Month/Day ], hypotensive on significant pressors. Echo showed acute flail mitral valve leaflet seen with ? papillary muscle rupture and ? vegetation. Cardiology consult done and pt had cath which showed clean coronaries/IABP inserted for wide open MR. [First Name (Titles) 9042] [Last Name (Titles) 9043] to OR where she underwent a MVR done by Dr. [Last Name (STitle) 914] in the early AM [12-11]. Please see operative report for surgical details. Transferred to the CSRU in critical condition for invasive monitoring. Renal consulted for acute renal failure with ? cortical necrosis of her kidneys due to shock. Also had shock liver with very high LFT's post-op that slowly trended back to normal by discharge. CVVH started and her chest was opened at bedside after she developed high airway pressures, low C.O. and difficult ventilation that afternoon on [12-11]. IABP removed that evening. Steroids were started for concern for septic shock and stopped on post-op day 4. She remained stable over the next couple of days and her chest was re-closed on [12-14] in the OR. All cultures were negative and abx discontinued on POD #4. Amiodarone was started for atrial fibrillation and her chest tubes and epicardial pacing wires were removed over the next couple of days. Heparin was started for DVT prophylaxis. All drips were weaned and she was started on beta blockers. On post op day six she was weaned from sedation, awoke neurologically intact and extubated. Over the next week her WBC remained elevated. ID was consulted and multiple cultures were taken. Cultures were negative and she remained afebrile. WBC trended down and no ABX were started. On post-op day 12 a left thoracentesis was performed for a large left pleural effusion. She awaited a PermCath placement which was deferred until her WBC came down. During this time she remained in the CSRU and continued to receive dialysis. Finally on [12-25] she was transferred to the telemetry floor and on [12-27] she was taken to the OR for a IJ PermCath placement. Procedure was complicated by complete heart block and PEA arrest. An urgent temporary pacemaker was inserted and she subsequently underwent a TEE which revealed anterior LV dysfunction. She then underwent a cardiac catheterization to rule out acute coronary plaque rupture. Please see results for details. Following this she was transferred back to the CSRU for invasive monitoring on pressors and intubated. The following day she was weaned from pressors and mechanical ventilation and was extubated neurologically intact. The following day she appeared to be doing well and was transferred back to the SDU. UE U/S performed d/t swelling which showed several different thrombus (see pertinent results). On [1-1] she was started on Heparin and Coumadin for DVT prophylaxis with a goal INR of 2. Following day HIT panel was positive and Heparin was stopped. ID and dermatology were consulted for rash and fevers. Treatment done per derm. and Argatroban was started for HIT+. Rash improved over next couple of days. Argatroban was stopped. INR appeared to be at therapeutic level on [1-5] and she was discharged home with VNA services. Medications on Admission: (home ) synthroid, ditropan ER- levophed, dobutamine drips as noted above Discharge Medications: 1. Outpatient [Name (NI) ] Work PT/INR as needed first draw [2128-1-7] with results to Dr [Last Name (STitle) ] office #[Telephone/Fax (1) 1579] 2. Outpatient [Telephone/Fax (1) ] Work SMA 7 with results to renal clinic [Hospital1 18] [Telephone/Fax (1) 9044] fax # ([Telephone/Fax (1) 8387] 3. Outpatient [Telephone/Fax (1) ] Work fingerstick INR - as needed first draw [2128-1-7] with results to Dr [Last Name (STitle) ] office #[Telephone/Fax (1) 1579] 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. 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 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 days: please take 3 mg [1-6] and have INR checked [1-7] with results to Dr [Last Name (STitle) ] for further dosing . Disp:100 Tablet(s) Refills:0 9. 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 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Lactaid Fast Act 9,000 unit Tablet Sig: One (1) Tablet PO q4 hours PRN (). 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:2 bottles Refills:0 13. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:2 tubes Refills:2 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 15. Benadryl 50 mg Capsule Sig: One (1) Capsule PO three times a day as needed for itching. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Acute papillary muscle rupture s/p Mitral Valve Replacement Acute renal failure Asystole Arrest PMH Hypothyroid Overactive Bladder Discharge Condition: Good Discharge Instructions: [Month (only) 116] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions Continue with Sarna cream to rash and call if worsens No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 9045] Date/Time:[2128-1-26] 10:30 [Hospital 2793] clinic in 1 week [Telephone/Fax (1) 60] - please call for appt Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] in 4 weeks - [Telephone/Fax (1) 170] please call for appt Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in 2 weeks [Telephone/Fax (1) 1579] please call for appt and referral to cardiologist Please follow up with own Ophthamology Completed by:[2128-4-1]	[ "584.5", "453.8", "785.51", "280.9", "244.9", "996.74", "511.9", "577.0", "518.81", "794.8", "E947.9", "427.5", "429.6", "428.0", "693.0", "596.51", "287.5", "424.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "78.41", "38.95", "39.61", "88.56", "37.61", "00.17", "37.78", "96.6", "88.72", "99.04", "35.23", "89.64", "34.03", "96.72", "99.07", "39.95", "34.91", "34.09", "37.22", "38.93" ]	icd9pcs	[ [ [] ] ]	11856, 11914	6461, 9697	372, 660	12089, 12095	1401, 6438	12614, 13165	1074, 1082		9822, 11833		11935, 12068		9723, 9799			12119, 12591								1097, 1382																					255, 334									688, 980														1002, 1034	1050, 1058
77,241	166,501	38671	Discharge summary	report	Admission Date: [2194-3-24] Discharge Date: [2194-3-26] Date of Birth: [2116-6-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mrs. [Known lastname ] is a 77 year old female with a PMH significant for chronic chest pain, HLD, HTN whow as admitted to the CCU s/p cardiac cathterization with [Known lastname ] to RCA complicated by hematoma formation and hypotension. The patient initially presented on [3-21] to an OSH with acute onset of chest pain radiating to her throat while having dinner and lasting for 10 minutes. She denied any other associated symptoms including shortness of breath, diaphoresis, nauasea, vomiting, palpitations, or pain radiating to her jaw or arm. At the OSH, ECG demonstrated non-specific ST-T wave changes, with a peak TnT of 0.06. She has remained pain free since admission to the OSH, and a TTE performed at the OSH demonstrated a LVEF 60%, trace MR, and no WMA. She was then transferred to [Hospital1 18] for cardiac catheterization. . On arrival, the patient underwent cardiac catheterization which demonstrated an 80% RCA stenosis confirmed by IVUS s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) 5175] with cardiac catheterization complicated by groin hematoma and hypotension requiring transient dopamine in the setting of groin cath site pressure. The patient underwent an urgent CTAP that was negative for an RP bleed, and the patient was admitted to the CCU for further management. Currently denies any CP/SOB, n/v/d, abd pain, groin pain, back pain, orthopnea, PND, diaphoresis, palpitations, pain radiating to arm or back. . ROS: As above, otherwise 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. CARDIAC RISK FACTORS: HTN, HLD, glucose intolerance 2. OTHER PAST MEDICAL HISTORY: Angina Hypertension Hyperlipidema Glucose intolerance Gastritis b/l cataract surgery s/p hysterectomy Social History: lives in a single family home with a son. Remote [Name2 (NI) ] use. No ETOH use. Family History: premature CAD Physical Exam: VS: 96.2 57 139/55 75 98%RA Gen: Somnolent in NAD. HEENT: Perrl, eomi, sclerae anicteric. Neck supple. CV: Nl S1+S2, no m/r/g. No precordial heave or laterally displaced PMI. JVP flat. Pulm: CTAB anteriorly. Abd: S/NT/ND +bs Ext: 2+ dp/pt bilatrally. Right groin with 3x3 cm marked site with hematoma spreading just beyond borders. Neuro: Oriented to hospital, year, name. Follows simple commands. Pertinent Results: Admission labs: [2194-3-25] 07:54AM BLOOD WBC-8.4 RBC-3.97* Hgb-12.2 Hct-34.6* MCV-87 MCH-30.8 MCHC-35.3* RDW-12.9 Plt Ct-223 [2194-3-24] 09:05PM BLOOD Hct-34.3* [2194-3-24] 04:30PM BLOOD Hct-36.3 [2194-3-25] 07:54AM BLOOD PT-11.7 PTT-21.8* INR(PT)-1.0 [2194-3-25] 07:54AM BLOOD Glucose-129* UreaN-13 Creat-0.8 Na-142 K-3.6 Cl-106 HCO3-30 AnGap-10 [2194-3-25] 07:54AM BLOOD CK(CPK)-40 [2194-3-25] 07:54AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 . Discharge labs: [2194-3-26] 04:00AM BLOOD WBC-6.6 RBC-3.75* Hgb-10.9* Hct-33.0* MCV-88 MCH-29.2 MCHC-33.2 RDW-13.0 Plt Ct-197 [2194-3-26] 04:00AM BLOOD PT-11.8 PTT-22.3 INR(PT)-1.0 [2194-3-26] 04:00AM BLOOD Glucose-118* UreaN-17 Creat-0.8 Na-142 K-4.2 Cl-108 HCO3-27 AnGap-11 [2194-3-26] 04:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9 . Cardiac catherization [2194-3-24]: 1. Coronary angiography in this right dominant system demonstrated single vessel CAD. The LMCA, LAD, and LCx were patent. The RCA had an 80% ostial stenosis confirmed with IVUS (see below) but was otherwise patent. 2. Limited resting hemodynamics revealed severely elevated systemic arterial systolic hypertension with an SBP of 171 mmHg. 3. IVUS of the RCA showed revealed a tight ostial RCA stenosis with a 3.5 mm vessel diameter. 4. The ostial RCA lesion was stented directly using a 3.5x12 mm Promus drug-eluting stent post-dilated with a 3.5 mm balloon, with no residual stenosis, no apparent dissection, and almost normal flow (see PTCA Comments). 5. There was oozing around the 6 French RFA sheath during the IVUS and PCI. A 6 French Mynx device was deployed successfully following limited femoral angiography that showed mild plaquing and an arteriotomy site at the femoral bifurcation. Post-Mynx gentle compression was complicated by hypotension and bradycardia in the setting of urinary retention consistent with a vasovagal response. The systolic blood pressure improved after atropine IV, insertion of an urinary drainage catheter and low dose dopamine. 6. Left ventriculography was not performed. . FINAL DIAGNOSIS: 1. Single vessel CAD. 2. Successful placement of [Month/Day/Year ] to ostial RCA. 3. Vasovagal event related to groin hematoma and compression. . CT abdomen/pelvis w/o contrast [2194-3-24]: Large right femoral hematoma from femoral vascular access site. There is no retroperitoneal hematoma. . Right femoral ultrasound [2194-3-24]: 1. Right groin hematoma measuring up to 3.4 cm. 2. Limited evaluation of the right groin vessels due to body habitus and surrounding soft tissue changes from the hematoma. Turbulent flow in the right SFA without discrete pseudoaneurysm seen. Follow up ultrasound can be performed if clinically indicated. No evidence of fistula. Brief Hospital Course: 77 yo F with HTN, hyperlipidemia presents with chest pain, thought to be anginal. Now s/p drug-eluting stent to RCA. . #Coronary Artery Disease/Unstable Angina: The patient initially presented to an outside hospital with 10 minutes of chest pain. She was transferred to [Hospital1 18] for further management. Here, cardiac catherization showed 80% occlusion of the RCA. The patient was treated with a drug-eluting stent. Catherization was complicated by hypotension (likely vagal) and a groin hematoma. The patient was discharged on aspirin, Plavix, pravastatin, metoprolol, diltiazem, lisinopril, and nitroglycerin. Cardiology follow-up was arranged. . #Groin hematoma: The patient's cardiac catherization was complicated by a right groin hematoma. CT abdomen/pelvis (performed without contrast) was negative for retroperitoneal bleeding. Ultrasound revealed a possible reversal of flow without obvious pseudoaneurysm. Reimimaging was considered, but the patient was improving clinically and hemodynamically, so this was not pursued. The patient's hematocrit remained stable throughout her hospital course. . #Hypotension: The patient's catheterization was complicated by hypotension, likely related to inreased vagal tone. Consequently, the patient required transient pressor support with dopamine. This was quickly weaned. . #Hypertension: The patient's antihypertensive regimen was adjusted. Specifically, metoprolol was added, diltiazem CR was decreased to 120 mg daily, Maxzide was stopped, and lisinopril was decreased to 5 mg daily. The patient will follow up with her cardiologist and her primary care doctor for further titration of her blood pressure medications. . #Delirium: The patient became disoriented and confused in the late evening/early morning of [3-24]. She was given haldol 0.25 mg x 5 with decreased agitation. The patient was alert and oriented at the time of discharge. Medications on Admission: MEDICATIONS (Transfer): Lovenox 40 mg daily Aspirin 325 mg daily Plavix 75 mg daily Lisinopril 10 mg daily Lopressor 25 mg [Hospital1 ] Pracachol 20 mg daily Diltiazem CR 180 mg daily MVI 1 tab daily Caltrate 500mg [Hospital1 ] nitropast [1-4]" q6 hrs . MEDICATIONS (Home): Aspirin 325 mg daily Lisinopril 10 mg daily Pravastatin 80 mg daily Maxzide 37.5/25 mg [1-4] tab daily Diltiazem CR 240 mg daily Fosamax weekly MVI 1 tab daily Caltrate 600mg [Hospital1 ] SL NTG prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed: For chest pain, place one tablet under your tongue. If the pain persists, may repeat up to two more times at five minute intervals. Go to the emergency room if you still have chest pain after 2 tablets. 9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. unstable angina 2. groin hematoma 3. delirium . Secondary: 1. hypertension 2. hyperlipidemia Discharge Condition: Alert and oriented. Hemodynamically stable. Chest-pain free. 3x3 cm hematoma in right groin, stable in size and appearnace. Hematocrit stable. Discharge Instructions: You came to the hospital to undergo cardiac catheterization. You were found to have a blockage in the right coronary artery, which was stented in the catheterization lab. . Your cardiac catherization was complicated by a bruise in your right groin. At the time of discharge, this bruise had been stable for 48 hours. . There are some changes in your medications: START Plavix (clopidogrel) START metoprolol STOP Maxzide DECREASE lisinopril to 5 mg daily DECREASE Diltiazem CR to 120 mg daily . It is very important that you take aspirin and Plavix every day. You should not stop taking aspirin or Plavix, unless directed to do so by your cardiologist. Followup Instructions: You have a follow-up appointment scheduled with your Cardiologist, Dr. [Last Name (STitle) 5686], on Tuesday [2194-4-8] at 11:15am. If you have any questions or need to reschedule, you can call Dr. [Name (NI) 85913] office at [Telephone/Fax (1) 11554]. . You should also follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 1968], within [1-4] weeks of discharge. You should call Dr.[Name (NI) 11632] office at [Telephone/Fax (1) 27093] to schedule an appointment.	[ "272.4", "V45.61", "401.9", "788.20", "414.01", "V17.49", "530.81", "780.2", "E937.9", "V15.82", "411.1", "998.12", "292.81", "997.2", "E879.0", "997.5", "458.29" ]	icd9cm	[ [ [] ] ]	[ "37.22", "00.66", "00.45", "00.40", "88.56", "36.07" ]	icd9pcs	[ [ [] ] ]	9383, 9389	5655, 7561	326, 351	9538, 9683	2869, 2869	10383, 10908	2421, 2436		8104, 9360		9410, 9517		7587, 8081		4957, 5632	9707, 10360			3355, 4940					2451, 2850																					276, 288									379, 2091					2885, 3339									2199, 2303	2319, 2405
48,372	133,301	2553	Discharge summary	report	Admission Date: [2194-10-27] Discharge Date: [2194-10-28] Date of Birth: [2155-8-15] Sex: M Service: MEDICINE Allergies: Penicillins / Pollen Extracts / Mold Extracts Attending:[First Name3 (LF) 398] Chief Complaint: Chest burning Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 39 yo M with HIV CD4 354, viral load <75 as of [10-9], recent diagnosis of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP [10-17] s/p elective admission for penicillin desensitization [10-23] who presented to ED complaint of chest burning and throat tightness. He had been getting home infusions of pcn and doing well. He started taking benadryl prophylactically 2 days ago because of fleeting chest burning that would come with each transfusion of pcn and then would go away after the transfusion was finishing. Today he noticed 2 red spots on his arm the were itching. He woke up feeling off and then when his transfusions started he felt chest burning that progressed to throat tightness that would not remit so he came to the ED. Of note, while in the MICU on prior admission patient experienced fleeting chest pain and burning in vein with PCN infusion. He also had a panic attack with PICC placement on his panic attacks who prescribed him ativan. . In the ED, initial VS: 97.8 108 144/89 16 100% on RA. Given 4mg IV morphine. His PCP, [Name10 (NameIs) ] and ID was consulted. . Currently, patient endorsed the same chest burning and throat tightness but it had improved slightly. He denied SOB, lightheadness, or tongue swelling. He endorsed anxiety and chest flushing but not facial flushing. He endorsed sensitivity at the PICC site and a rash that consisted of 2 red papules, one on his right hand and one near his PICC site that were pruritic. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -HIV last CD4 count 354 -anal HSV [10-9] -central serous retinopathy [10-9] therefore stopped intranasal steroids -Impetigo -Condyloma acuminatum -allergic rhinitis -esophageal reflux -sinusitis [7-24] -hypertriglyceridemia -molluscum contagiosum -cellultis of finger -pterygium -Anal CIS -elbow pain/fracture -rective airway disease -chronic leg pain -back pain Social History: Currently works for [University/College ] in systems managing, non smoker, ETOH 3times/month, admits to occasional recreational drug use. Not currently in a relationship but MSM not always using protection. Family History: Father with CAD, aunt and uncle with diabetes Physical Exam: Vitals: 96.5 80 127/87 16 97% RA Gen: Well-appearing, NAD HEENT: NC, AT, MMM, EOMI RESP: CTAB, moving air well CV: RRR, no MRG ABD: soft, NT, ND, BS+ EXT: warm, well-perfused, no edema Pertinent Results: Admission Labs: [2194-10-27] 09:00PM WBC-5.6 RBC-5.13 HGB-14.6 HCT-41.7 MCV-81* MCH-28.5 MCHC-35.0 RDW-14.7 [2194-10-27] 09:00PM NEUTS-46.2* LYMPHS-44.2* MONOS-5.7 EOS-3.0 BASOS-0.8 [2194-10-27] 09:00PM PLT COUNT-210 [2194-10-27] 09:00PM CK-MB-NotDone [2194-10-27] 09:00PM cTropnT-<0.01 [2194-10-27] 09:00PM CK(CPK)-57 [2194-10-27] 09:00PM GLUCOSE-101 UREA N-13 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12 . STUDIES: EKG: NSR at 85, NA, NI, no acute STTW changes . CXR: [10-27] PA and lateral views of the chest are obtained. A right upper extremity PICC line is seen with its tip in the expected location of the right atrium. Lungs are clear bilaterally. Cardiomediastinal silhouette is stable. No pneumothorax or pleural effusion is seen. Bony structures appear intact. No free air is seen below the right hemidiaphragm. Brief Hospital Course: 39 yo M with HIV CD4 354, viral load <75 as of [10-9], recent diagnosis of anal HSV s/p treatment and recent diagnosis of neurosyphillis on LP [10-17] s/p elective admission for penicillin desensitization [10-23] who presented to ED complaint of chest burning and throat tightness. . # Throat/chest tightness: Given [Month/Day (4) ] to penicillin and cephalosporin patient was admitted out of concern for anaphylaxis however has completed a desensitization protocol without complication and tolerated infusions while in-house without evidence of anaphylaxis. In addition, symptoms atypical even for early anaphylaxis. No peripheral eosinophilia. Likely anxiety component as patient had his symptom of chest burning in the absence of an infusion and patient was recently started on ativan for panic attackes. EKG unchanged and enzymes unremarkable make ACS unlikely. Pt premedicated with benadryl, ativan and famotidine. . # Neurosyphilis: Found on screening labs which prompted LP, asymptomatic, started penicillin on [10-23] for a 14 days course. Penicillin was continued without evidence of anaphylaxis. Patient had his symptom of chest burning in the absence of an infusion. . # Anxiety: Patient was recently diagnosed with panic attacks and started on ativan on [10-24]. Ativan was continued in-house and recommended prophylactically with antibiotic infusions. . # HIV: CD4 count 354 in [9-24]. Continued HAART. . Medications on Admission: -Viread 300mg PO daily -Ziagen 600mg PO daily -Reyataz 300mg PO daily -Norvir 100mg PO daily -Astelin 137 mcg/spray [Hospital1 ] -Guaifenesin 100mg PO BID -zyrtec 10mg PO daily -epipen -ativan prn -PCN G 3mil unit Iv q4 hrs day 6 of 14 Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO at bedtime: Must be taken separately from HIV medications. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: Do not drive or drink alcohol while taking this medication. Disp:30 Tablet(s) Refills:0 3. Diphenhydramine HCl 25 mg Capsule Sig: [1-17] Capsules PO Q6H (every 6 hours) as needed for itching. 4. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 9. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback Sig: Fifty (50) mL Intravenous every four (4) hours for 8 days: Last Day [11-4]. Please infuse over 1 hour. Disp:1600 mL Refills:0 Discharge Disposition: Home With Service Facility: INFUSION SOLUTION INC Discharge Diagnosis: Neurosyphilis Panic disorder HIV Discharge Condition: Clinically improved with stable vital signs. Discharge Instructions: You were admitted to the hospital for monitoring while on IV antibiotics. You are NOT allergic to penicillin any longer following your desensitization procedure. Please take Penicillin G Potassium 3 million units IV q4 hours (last day [2194-11-4]) through your PICC line. You may take ativan as needed for anxiety or insomnia. Do not drive or drink alcohol while taking this medication. Please call your physician or return to the Emergency Department if you experience fever, chills, headache, confusion, weakness, numbness, tingling, chest pain, or shortness of breath. Followup Instructions: Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6164] on Wednesday, [10-29] at 12:40 PM.	[ "300.01", "094.9", "V08" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6753, 6805	3942, 5397	321, 329	6882, 6929	3017, 3017	7557, 7695	2741, 2788		5687, 6730		6826, 6861		5423, 5664			6953, 7534								2803, 2998																					268, 283									357, 2098					3034, 3919									2120, 2496	2512, 2725
24,746	157,301	43582	Discharge summary	report	Admission Date: [2168-10-20] Discharge Date: [2168-11-29] Date of Birth: [2098-3-29] Sex: M Service: MED Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 689] Chief Complaint: recent falls Major Surgical or Invasive Procedure: mechanical ventilation swan ganz catheter placement History of Present Illness: 70yo male hx htn, cad s/p cabg [2162], dm2, afib, cri, depression with recent suicide attempt with Klonipin [10-6], p/w recent falls. First fall last week after suicide attempt, seemed mechanical fall. This week more LE weakness, no strange movements, no incontinence/ CP/ lightheadedness/ n/v. In [Name (NI) ], pt with unresponsive episode with rhythmic jerking movements of left arm and leg and fixed stare, no incontinence. Sats 90% NRB, intubated for airway protection and impaired mental status. BP dropped to 60s/40s after propofol gtt. Repeat CXR with worsening CHF (s/p 3L NS). BP recovered after 3L NS to 110s/80s. Febrile to 102 rectally, ?sepsis vs meningitis, LP done. Ceftriaxone, levo, flagyl, ativan, dilantin. Head CT negative. EKG Afib 110s, no ST/T changes, first two enzyme sets with elevated CK but flat CKMB. Transferred to MICU for further evaluation Past Medical History: -Pulmonary Sarcoid dx'd [2155], remote hx of prednisone, never biopsy proven -HTN -CAD s/p cabg [2162], echo [12-29] 50%EF, MIBI neg [5-31] -Cardiac MRI [2168-7-14]; ?patchy very focal hyperenhancement of midmyocardium of basal anteroseptal and midanterolateral walls c/w local scarring or infiltrative dz -cath [2162]; wedge 22, PAP 44/30, CO 5.3 -DM2 diet controlled -Afib -CRI (baseline 1.5 to 1.8) -Depression (suicide attempt with Klonipin [10-6], seen at [Hospital1 336]) -Inverted papilloma R maxillary sinus, removed 12 yrs ago -Acute sinusitis [10-14] ENT, MRSA final [10-16] Social History: no tobacco, alcohol. married lives with wife Family History: father mother sister died of lung cancer Physical Exam: 100.6, Tm 103.6, 60-166/40-64 current 118/65, 85-113, 16-20, 96-100% Gen intubated sedated responds to deep physical stimuli HEENT ncat, L TM obscured/ R TM clear, Nares patent/ R erythematous/ L eryth with yellow green discharge from ostia of middle turbinate, PERRL, anicteric Pulm CTAB in anterior lung fields CVS irreg irreg Abd soft nt mod distended BS wnl Ext 2+ edema of calves B/L, nonedematous ankles/ feet Brief Hospital Course: A/P: 1. AMS: On admission, pt presented with lower extremity weakness and increased falling which according to the wife was chronologically related to his sinusitis diagnosed and treated with bactrim on [10-14]. In ED,pt with witnessed activity c/w seizure and pt was loaded with dilantin and given 2mg Ativan. Lumbar puncture was performed, fourth tube of CSF with 1 wbc/ 500 rbc (increased over tube #1) so patient was started on empiric acyclovir for herpes simplex encephalopathy awaiting further culture results. EEG on admission consistent with encephalopathy, no evidence of active seizure. Pt not known to be immunocompromised. Also on admission, concerning for possible ingestion and toxic encephalopathy with recent suicide attempt two weeks prior. Also, with hx of sinusitis inappropriately treated and seizure on presentation, concerning for cavernous sinus thrombosis, so patient started on vanco for MRSA sinusitis and MRI/MRA headindicated when stable off of pressors (ENT consult obtained, agree with plan). CT of sinuses shows changes c/w prior surgery, no bony penetration, 'underwhelming' for source of infxn as per ENT. HSV PCR/final negative, and Acyclovir D/C'd. MRI/MRA of brain did not show evidence of cavernous sinus thrombosis or any acute abnormality. The patient was intubated, during which time assessment of his mental status was hindered secondary to sedation. Post extubation, he remained alert and awake, however with a clouded sensorium, lethargic, and increased agitation - delerium waxed and waned. Neuro and Psych following, with ddx's including toxic-metabolic [2-29] uremia, infectious, or ischemic processes. Cx's were all negative, and pt was unable to get a repeat head MR [2-29] inability to lie flat. He continued to be therapeutic on Dilantin/Phenytoin. Once transferred to floor, continued phenytoin, TID holding for supratherapeutic doses and checking levels daily with goal 15-20 after Phenytoin levels corrected for low albumin. Once transferred to floor, pt's mental status improved everyday. Began to orient better to both time and place. Eventually grew quite agitated, requiring medication for his anxiety, pt known in past to have anxiety disorder. Haldol used at doses of 2.5 to acutely calm pt down, but not effective as desired. Pt tolerated trazodone, but this too did not effect tranquility. Psych consult recommended seroquel/quetiapine 25mg am, 50mg evening dose to help pt sleep, and 25mg qhs:prn if continued difficulty sleeping. Quetiapine can be titrated up by 25 mg each day up to a maximum of 200mg total in one day should patient continue to have difficulty sleeping and/or day time agitation. 2. RESP - likely [2-29] edema of sepsis. Required ventilatory support. 1st extubation attempt failed [2-29] inc WOB and/or aspiration, reintubated [11-2] for increase wob/fatigue. Weaned to PS, and re-extubated on [11-8] - with persistent AG acidosis (pH 7.26-7.30) from renal failure. Started on 14 day course of Levoflox/Flagyl for presumed asp. PNA. Developed increased WOB and fatigue on [11-11], placed back on Bipap with good response. Received standing HCO3 replacement to correct acidemia. Decision to undergo dialysis made on [11-11], in hopes that resolving uremia and acidosis will help alleviate resp depression. Pt underwent multiple failed S/S evaluations for aspiration. Cleared for thin PO's on [11-10]. Had PPFT placed for TF's. Was weaned to 35% FM on [11-13] and tolerated it well, but then developed hypotension, CO2 retention, and hypoxia on [11-15]. Was placed back on Bipap with improvement of oxygenation and ventilation. Respiratory status remained tenuous, with low threshold for intubation. Possibilites for resp failure and difficulty weaning to FM at this time included volume overload and PNA.Started on Vancomycin again on [11-15] for sputum growing MRSA. After transfer to floor, CXR showed LLL infiltrate vs atelectasis, ?effusion. Pt continued to improve respiratory status, weaning O2 supplement by face mask from 40% to _____2L NC?. Pt desaturated after 10 minutes to an oxygen level of 90% on [Last Name (LF) ], [First Name3 (LF) ] O2 was continued. Lungs sounding clearer each day with decreased sputum and coughing, cough reflex intact. Needs chest physical therapy and incentive spiromety to prevent mucus plugging. 2. Shock: Pt hypotensive requiring Levophed pressor on admission. Pt in most lkley septic shock, with low grade temps escalating to temps of 103 and witnessed seizure. Pt with sinusitis dx'd by ENT on [10-14], history of papilloma removed from the sinuses, and cultures from the 17th positive for MRSA although pt only treated with Bactrim. [10-22] Blood cultures positive for GPC in clusters. While sinusitis is rare cause of sepsis, it is most likely source of bacteremia c/w mrsa-- Vancomycin dosed appropriately for renal failure (cking troughs). Also restarted Ceftriaxone on [10-24]. CT of/sinus not showing obvious source for seeding; pt currently off levophed, with good pressure. On [11-2], after 1st extubation, pt with septic picture (hypotension, hypoxia, intubated), treated on MUST, cultures sent. Pt failed [Last Name (un) 104]-stim, on steroids with improvement of bp, now off pressors. Received 7 day course of stress dose steroids, then switched to quick Prednisone taper. Became hypotensive after Prednisone tapered off, and failed another [Last Name (un) 104] stim. Was started on standing Dexamethasone 1mg [Hospital1 ] for presumed adrenal insufficiency. Other than MRSA in sputum, no infectious etiology found. Once transferred to floor, began prednisone taper [2091-11-21]: 10mg; [11-24]: 5mg, [11-25]: 2.5 mg, [11-26]: 0 mg and [11-27]: 2mg then off prednisone. Prednisone taper tolerated well on 2nd day off steroids, no hypotension seen, looks clinically stable. Be wary if pt does eventualy show hypotension within a week or so. This could be related to adrenal insufficiency. 4. ARF: Acute on chronic (baseline 1.5 to 1.8) renal failure likely secondary to hypoperfusion from sepsis leading to ATN and intrinsic renal failure. Acyclovir likely contributed. Was initially improving, then worsened after second hypotensive episode post-extubation. Post-extubation, has had a persistent AG acidosis, likely [2-29] renal failure, and a mild respiratory acidosis. BUN/Cr were very slow to improve, around ~3.8-4.2 for over 1 week with marked volume overload, acidemia, and signs of uremia (MS changes, clonus). Pt received standing doses of Bicitra to correct acidemia. UOP remained adequate, supplemented with Lasix to keep negative daily balance. On [11-11], decision with Renal team to initiate dialysis was made, given marked vol overload, acidemia, and uremia. Received dialysis qd and qod with gradual improvement in BUN/Cr, and acidemia. Delerium still waxed and waned, making it difficult to ascribe to uremic encephalopathy alone. Once transferred to floor, BUN continued to decrease, Cr hovered at 2.1 (2.0-2.2) for the week. Delirium persisted, but improving throughout week. Began speaking more and more coherently and in full sentences. Volume overload was treated with furosemide and nutrition. Furosemide was tapered from 80mg [Hospital1 ] to 60 mg qd for a more gentle diuresis with goal diuresis of 1 liter negative per day, as kidneys regain better functioning. UOP good all week on floor ([Date range (1) ]/04) with use of furosemide; putting out over 2.5 L each day. Still 5L or so over admission weight, not considering myopathy/ deconditioning. Returned patient to 60mg PO BID to reach home dose. 5. Hypernatremia: Pt hypernatremic throughout ICU stay [2-29] free water losses. Free water defecit was calculated and corrected. Pt kept on maintenence of 250cc water boluses per NGT qid. Once transferred to floor, hypernatremia began to be easier to control given PEG tube placement and 250 cc free water boluses. Na decreased from 149 on [11-22] to 137 on [11-27]. 6. GI-patient had G tube placed for feeds and tolerated 40 cc/hour. Has been evaluated by speech and swallow and is cleared for pureed and solids one bite at a time. 7. CAD: Pt with mild elevation of troponins but flat CKs on admission, likely from myocardial suppression of sepsis with renal failure contributing. Pt had negative mibi 4 months prior to admission and echocardiogram during admission with EF 50%. EKG on second intubation with some initial precordial ST changes that resolved once intubated. ?remains of septic vs. cardiogenic shock. With reintubation, no EKG changes or enzyme leak. On ASA, Lopressor. Once on floor, metoprolol titrated up to 50 mg TID and added diltiazem on [11-25] to reduce HR and workload of tachycardia. [Month (only) 116] consider further increases in diltiazem as needed to control tachycardia, as tachycardia was persistent throughout the last week on the floor, but resolved on his last 2 days here in hospital with HR in 80's-90's. Converted him to long acting rate control meds which will need titration s/p discharge. 8. AFib - On Lopressor for rate control. Anticoagulation held during [Hospital ] hospital course [2-29] HCT drop of unknown etiology. Once on floor, received coumadin, titrated up to 10mg qd to maintain goal INR [3-1]. Heart rate well controlled in 80's with Metoprolol and Diltiazam. Also given heparin and ASA on floor. [Month (only) 116] consider cardioversion once stablized and anti coagulated for >1month. Follow up with cardiology (Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911]) who knows patient well. 9. Anemia - HCT dropped ~6 points - unknown etiology. Since has been stable at >32. Holding anticoagulation. Once transferred to floor, pt recieved 2 units of blood after HCT dropped to 26 after it had been stable in 28-29 during the week. Now stable in 30's. 10. Coagulopathy: Inc PT/INR c/w coumadin, but inc PTT worrisome for DIC, however DIC labs remained negative and INR/PT/PTT remained stable. Pt required FFP for procedures on admission. Are monitoring this increasing INR and DIC labs as necessary. Improving; with coffee ground emesis from OG tube [10-26] but stable HCT. INR continues to improve with stable HCT, no more coffee grounds. Once transferred to floor, coagulopathy was less of an issue. HCT did drop to 26.6 which prompted 2 units of pRBCs. Blood product also given to aid fluid shift and improve diuresis as well as patient's overall energy level. 11. LFTs: increased transaminases and total bilirubin likely secondary to hypoperfusion from sepsis. RUQ u/s with right liver lobe cyst, no evidence for cholecystis or liver disease. Abd CT from [10-24] showing only possible mild sigmoid diverticulitis, no fluid collection. Pt with elevated amylase and lipase; thought to be [2-29] TPN. Pt also with elevated total bilirubin; possibly [2-29] TPN but should get a liver consult to evaluate these LFT abnormalities. LFT's followed qod throughout ICU stay -gradually trending down as BP stablized. Once transferred to floor, LFT's continued to trend downward, approaching normal values on discharge date. Albumin still low @ 2.5-2.7. (Adjusting Dilantin appropriately). 12. DM2: On insulin SS and insulin drip in ICU. On NG TF's. [Last Name (un) ] following. Once transferrered to floor, received a PEG for improved nutrition as patient not able to maintain sufficient PO's. Regular insulin sliding scale adjusted for continuous tube feeds and NPH for longer acting control of blood sugars. Endocrinology suggested timing RISS with intermittent tube feed boluses, if we use intermittent tube feeds. 12. ICU: FEN Currently NPO, TF(with insulin as nec), s/s eval Access R triple lumen (SCL) Code full Communication Wife Dispo: will continue PT and eventual placement in rehab 13: PT/deconditioning: Once transferred to floor, obtained PT consult consult Pt evaluated and recommended for rehab. 14: Nutrition: Speech/swallow consult obtained and evaluation: PASS, as he is able to swallow well while sitting upright. S/S recommends alternating between 1 sip and 1 bite of food and to maintain PO intake with thickened liquids in addition to meeting goal tube feeds of 40mL/hour. 15: ICU myopathy: continue with rehabilitation, diuresis. Increase activity as tolerated. No frozen shoulder, but still quite weak and debilitated, likely from disuse. Further goals attainable at rehab, as patient has high potential for recovery and success, given proper motivation/support and attention to psychiatric care. Medications on Admission: atenolol, lipitor, lasix 80, lisinopril, neurontin, coumadin, remeron, glyburide Discharge Medications: Metoprolol extended release 100 mg PO qd Phenytoin 200 mg PO TID acetaminophen 325-650 mg prn pain Aluminum Magnesium hydroxide-simethicone 15-30mL PO qid: prn ASA 325mg qd Bisacodyl 10mg pr qd Calcium Acetate 1334mg PO TID with meals Diltiazem long acting 240mg po qd Erythromycin ophthalmic ointment 0.5% OU qid quetiapine 25 mg po qm, 50 mg qhs, 25mg qhs:prn agitation after 50 mg not enough regular insulin sliding scale per protocol NPH insulin per protocol Lansoprazole 40mg oral suspension PO/per PEG qd KCL 60 mEq po qd:prn repleting low K<3.5 Coumadin 10mg qd (dose according to INR goal [3-1]) Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: seizure disorder Coronary artery disease had Bypass in [2162] for 3vessel disease atrial fibrillation hypertension diastolic dysfunction chronic renal insufficiency baseline Creatinine at 2 now depression diabetes type 2, insulin dependent sarcoidosis anasarca/chronic edema Malnutrition Discharge Condition: stable and improving; to rehabilitation. Discharge Instructions: Continue prednisone, as well as all medications you have been prescribed. Your rehabilitation facility will be aware of all of your prescribed medications. Try to increase activity levels as tolerated. Be sure to move arms around, especially increasing shoulder motion. Continue Chest PT, suctioning of secretions. Followup Instructions: With primary care physician, [Name Initial (NameIs) 3390]: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 9347] within 1-2 weeks after discharge from rehabilitation. Also follow up with [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911]. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time: after discharge from rehabilitation.	[ "584.5", "250.00", "276.2", "428.0", "359.81", "576.8", "507.0", "518.82", "293.0", "038.8", "473.9", "995.92", "255.4", "427.31", "785.59", "780.39" ]	icd9cm	[ [ [] ] ]	[ "03.31", "46.32", "39.95", "96.72", "99.04", "96.04", "38.93", "89.64", "96.6", "93.90", "99.15", "38.95" ]	icd9pcs	[ [ [] ] ]	15998, 16070	2493, 15233	291, 344	16405, 16447		16810, 17339	1995, 2037		15365, 15975		16091, 16384		15259, 15342			16471, 16787								2052, 2470																					239, 253									372, 1268														1290, 1917	1933, 1979
16,382	131,104	43230	Discharge summary	report	Admission Date: [2170-7-6] Discharge Date: [2170-7-12] Date of Birth: [2092-10-11] Sex: F Service: MEDICINE Allergies: Colchicine / Sulfonamides / Augmentin / Penicillins Attending:[First Name3 (LF) 898] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: TEE History of Present Illness: 77 yoF w/ ESRD on HD, CAD s/p CABG X 2, HTN, Type II DM, hypercholesterolemia presents with GPC bacteremia. Pt reports intermittent fevers (to 100.8), general fatigue, decreased appetite/poor PO intake, loose stool (1 BM/day, no BRBPR, no melena) for the last 2 days. 2 days ago, she had an episode of N/V. She presented to dialysis yesterday; her RUE AVF was noted to be mildly erythematous and blood cultures were drawn, which grew [1-17] GPC in pairs and clusters. She was instructed to come to the ED by ambulance today. She received 1L NS by EMS. In ED, T 101.5, HR 45, bp 89/30, resp 32, 97% 2L NC. Her EKG was notable for [Street Address(2) 4793] elevation in V1 and diffuse anterolateral ST depressions. She received Tylenol 1 g X 1, ASA 81 mg X 3, Vancomycin 1 g IV X 1, gentamycin 80 mg IV X 1, and 1 L NS with improvement in sbp to 100s. Currently, the patient denies headache, sore throat, nausea, vomiting, chest pain, shortness of breath, palpitations, abdominal pain, rashes. No LE edema, orthopnea, or PND. Past Medical History: 1) CAD s/p CABG X 3 [2163] - [9-18] PMIBI, uninterpretable EKG changes, EF 38%, no perfusion defects - [2-17] TTE: mild LA enlargement, mildly dil RA, mild sym LVH, LVEF >55%, mild AS, 1+ MR, [12-17]+ TR, mod PA systolic HTN 2) HTN 3) Type II DM 4) Thoracic aortic aneurysm 5) ESRD on HD T/Th/Sat - right arm AVF (~ 7 yrs old) 6) Hypercholesterolemia 7) h/o CVA 8) PVD - s/p left fem-[Doctor Last Name ] bypass and right fem-fem bypass - [2-17] s/p open translumenal arthrectomy of left fem-[Doctor Last Name ] bypass graft 9) Gout 10) Chronic anemia: baseline HCT 29-31 11) Diverticulosis s/p sigmoid colectomy 12) left intertrochanteric fracture s/p ORIF 13) h/o MRSA from furuncle, treated with vancomycin 14) h/o MSSA endocarditis [2168] 15) Hyperparathyroidism Social History: Lives alone, walks with a walker, independent in ADLs, 40 pk-yr smoking history, quit [2149]. No EtOH or other drug use Family History: CAD, ESRD (father) Physical Exam: T 100.5, pc 66, bpc 106/76, resp 20, 97% 2L NC Gen: elderly female, alert, tired appearing, NAD HEENT: PERRL, EOMI, anicteric, nl conjunctiva, OMM dry, OP clear, neck supple Cardiac: RRR, III/VI SM heard throughout the precordium, no R/G appreciated Pulm: CTA bilaterally Abd: NABS, soft, NT/ND, no HSM noted Ext: No C/C/E, well-healed left great toe amputation, warm, nonpalpable DP bilaterally, right upper extremity AVF with thrill/bruit, no erythema or tenderness Skin: No rashes noted, thick toenails bilaterally, some cracking of skin between toes. Pertinent Results: wbc 13.5 (PMN 87.9 Band 0 L 9.2 M 2.4 E 0.2 Bas 0.3), Hgb 10.7, HCT 31.8, plt 167, MCV 95 . Na 138, K 4.4, Cl 94, HCO3 29, BUN 45, Cr 5.2, glc 189 Ca 8.6, P 6.8, Mg 1.8 . lactate 1.8 . CK: 388 MB: 21 MBI: 5.4 Trop-T: 11.68 LDH 1299, Fbg 624 . ALT 356, AST 616, Alk phos 186, TBili 0.7, lip 19, amyl 73, alb 3.4 . PT 15.3, INR 1.5, PTT 27.9 . EKG: SB @ 59 bpm, first degree AVB, [Street Address(2) 4793] elevations in V1, 1.5-[Street Address(2) 1766] depressions I, II, V4, V5, [Street Address(2) 4793] depressions avL, V6, avF (new since [2-17]) . CXR: L SC tip in mid SVC. No pneumothorax. Stable appearance of descending aortic andurysm, cardiomegaly. No acute cardiopulmonary process. . RUQ U/S: 1. Cholelithiasis, without evidence of acute cholecystitis. 2. Coarsened liver echotexture. This finding is commonly seen in patients with hepatitis or other forms of liver disease. Correlate with patient's history and laboratory values. 3. Bilateral renal atrophy, with simple cysts, _____, consistent with medical renal disease. Brief Hospital Course: 1) MSSA endocarditis: The patient responded well initially to fluid boluses, and was no longer hypotensive on transfer to the floor. The most likely source of infection is her AVF. [1-17] bottles positive for GPC, ultimately growing out MSSA. She was treated with gentamycin and vanocmycin given PCN allergy and ease of dosing at diaylsis. TTE revealed calcification on AV suggestive of prior endocarditis. TEE showed possible aortic vegitation with mural thrombus in aorta and aneurysm and possible left atrial clot. Chest CT was perfermed to evaluate aneurysm and showed no change in aneurysm from prior studies. Pt was noted to have this in past and has refused any surgery or stenting. RUE ultrasound showed no evidence of clot in AV fistula to suggest source of infection. Pt refused anti-coagulation for [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] despite risk for CVA and hence MRI head was defered. She was dischared on 6 weeks of vancomycin and gentamycin until cultures of [2170-7-9] are negative. . 2) NSTEMI: The patient had a NSTEMI on admission, with peak troponin of 11.68. This NSTEMI was likely related to her sepsis. Her troponin then trended down. Cardiology was consulted and recommended conservative managment with ASA and beta blocker. Pt was not anti-coagulated. . 3) TRANSAMINITIS: etiology of transaminitis was unclear. viral serologies were negative but likely [1-17] to some enzyme leakage from her myocardial injury as well as sepsis. The enzymes continued to trend downward during the hospital course. . 4) DNR/DNI. Confirmed with patient. . 5) Communication: patient, HCP [Name (NI) ] [Name (NI) 93137] (H: [Telephone/Fax (1) 93138], C: [Telephone/Fax (1) 93139]) Medications on Admission: 1) Metoprolol 25 mg PO TID 2) Lisinopril 10 mg PO daily 3) Hydralazine 25 mg PO q6h 4) Zoloft 50 mg PO daily 5) ASA 325 mg PO daily 6) Fosamax 7) Fosrenal 500 mg PO TID w/ meals 8) Sensipar 30 mg PO daily 9) Allopurinol 100 mg PO daily Discharge Medications: 1. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q Hemodialysis for 6 weeks: please redose for random level<15. Disp:20 bags Refills:0 2. Gentamicin 10 mg/mL Solution Sig: Eighty (80) mg Intravenous Q Hemodialysis for 4 days: may discontinue on [2170-7-15] if blood cultures from [7-7], [7-8], and [7-9] are negative (not pending). . Disp:3 doses Refills:0 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:30 Tablet(s) Refills:2 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:30 Tablet, Chewable(s) Refills:2 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: MSSA bacteremia and endocarditis Discharge Condition: Good Discharge Instructions: Call 911 or go to the nearest ER if you experience fevers/chills, nausea, vomiting, chest pain, or feel unwell. Followup Instructions: 1. please see your nephrologist Dr. [Last Name (STitle) 1860]; you are scheduled to get your dialysis at [Hospital 4265] Healthcare, you should receive antibiotics there after each session for the next 6-8 weeks. * 2. Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2170-8-6] 3:30 * 3. Provider: [Name10 (NameIs) ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2170-8-6] 2:30 * 4. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2934] Date/Time:[2170-8-3] 1:00 * 5. Inectious Disease: Dr. [First Name (STitle) ] on [8-5] @11:30 AM; call [Telephone/Fax (1) 457] to confirm appointment. * 6. Please call your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 931] to follow up your blood pressure and progress with anti-biotics.	[ "787.91", "790.4", "995.92", "424.90", "440.0", "785.52", "272.4", "414.00", "V09.0", "410.71", "V45.1", "285.9", "276.5", "V45.81", "250.40", "038.11", "403.91", "421.0", "440.20", "441.2" ]	icd9cm	[ [ [] ] ]	[ "38.95", "88.72", "39.95" ]	icd9pcs	[ [ [] ] ]	7458, 7498	4055, 5802	323, 329	7575, 7582	2979, 4032	7742, 8841	2368, 2388		6088, 7435		7519, 7554		5828, 6065			7606, 7719								2403, 2960																					272, 285									357, 1389														1411, 2211	2227, 2352

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