ChanBeDu/relevant_section_length · Datasets at Hugging Face

10,462

138,708

22709

Discharge summary

report

Admission Date: [**2161-1-27**] Discharge Date: [**2161-2-3**] Date of Birth: [**2100-11-2**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 60 year old male transferred from [**Hospital3 45967**] in [**Doctor Last Name 792**]on [**2161-1-27**] for evaluation for coronary artery bypass grafting. He presented to the outside hospital on that day complaining of several hours of new-onset chest pain. He denied previous episodes of chest pain although had a stress test in [**2160-10-20**] which evoked some chest pain, increased heart rate which he did not have further testing for. Cardiac catheterization at the outside hospital showed a distal left main stenosis of 70 percent, proximal LAD of 50 percent, ostial circumflex of 50 percent, OM1 of 40 percent, proximal RCA of 50 percent and mid RCA of 50 percent. PAST MEDICAL HISTORY: Hypertension, diabetes type 2 for 17 years, peripheral vascular disease, gastroesophageal reflux disease and hyperlipidemia with a past surgical history of bilateral fem-[**Doctor Last Name **] grafts, iliac stenting, cholecystectomy and penile implant in [**2149**]. ALLERGIES: IV dye, penicillin, Toradol and Cipro. PHYSICAL EXAMINATION ON PRESENTATION: Height is 67 inches, weight 160 lb. Vital signs - heart rate 62 in sinus rhythm. Blood pressure is 140-160/50-70. General - not in acute distress. HEENT - normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular movements are intact, no JVD, positive carotid bruits bilaterally. Cardiovascular - regular rate and rhythm with a 2/6 systolic ejection murmur. Lungs are clear to auscultation bilaterally. Abdomen is soft, round and nontender and nondistended. Extremities with positive bilateral fem-[**Doctor Last Name **] well-healed incision lines, no varicosities with good DP and PT pulses distally. LABS ON DISCHARGE: WBC is 9.7, hematocrit 26.6, platelets 277, glucose 146, BUN 23, creatinine 1.2, sodium 142, potassium 4.7, chloride 104, bicarb 31. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**1-27**] as above. On day 1, he underwent some preop testing including carotid ultrasound showing only mild plaque on the right and left internal carotid arteries as well as bilateral lower extremity vein mapping showing patent right greater saphenous vein, ankle to mid calf and patent bilateral lesser saphenous veins. On [**2161-1-29**], he was taken to the Operating Room with Dr. [**Last Name (STitle) **] and underwent a CABG times three with a LIMA to the LAD, saphenous vein graft to OM and saphenous vein graft to the distal RCA. Total cardiopulmonary bypass time was 84 minutes and cross-clamp time of 64 minutes. He was transferred to the Cardiac Surgery Recovery Unit A-paced with a rate of 90 on Neo, propofol and insulin drips. His initial operative course was uneventful. He was weaned and extubated successfully. On postoperative day 1, he was transferred to the inpatient floor for continued rehabilitation, physical therapy and discharge planning. He had a significant amount of immediate postoperative pain for which he was started on a morphine PCA that significantly helped with his pain. [**Last Name (un) 3208**] was asked to see the patient by our team for uncontrolled diabetes. They recommended a change of his insulin regimen to Lantus and Humalog with follow-up plans with [**Hospital 3208**] Clinic including teaching. He was followed by Physical Therapy on postoperative day 4 and found to be safe for discharge home although he was kept for an extra 24 hours because of increased blood glucose levels and with better control, was discharged home on [**2161-2-3**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home with visiting nurses. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting, diabetes type 2, hypertension, peripheral vascular disease. DISCHARGE MEDICATIONS: Colace 100 mg po bid, aspirin 81 mg po daily, Percocet 5/325 one to two tablets po q4h prn for pain, Lipitor 10 mg po daily, Lexapro 20 mg po daily, nicotine patch 14 mg per 24 hour patch transdermally daily for 7 days, then decreased to 7 mg patch transdermally daily for 14 days, potassium chloride 20 mEq po daily for 7 days, Lopressor 75 mg po bid, Lasix 20 mg po daily for 7 days, trazodone 50 mg po qhs, Lantus insulin 22 units subcutaneously at bedtime and Lispro insulin subcutaneously four times daily per sliding scale. FOLLOW UP PLANS: The patient is to make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58805**] in [**12-21**] weeks, an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks, Dr. [**Last Name (STitle) **] in [**1-22**] weeks and with the [**Hospital 3208**] Clinic for diabetes management. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 25276**] MEDQUIST36 D: [**2161-2-3**] 14:18:37 T: [**2161-2-3**] 15:14:11 Job#: [**Job Number 58806**]

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icd9cm

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35183

Discharge summary

report

Admission Date: [**2132-8-16**] Discharge Date: [**2132-8-17**] Date of Birth: [**2057-1-28**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: rapid atrial fibrillation Major Surgical or Invasive Procedure: none History of Present Illness: This 75 year old black female underwent emergent asscending aortic replacement and resuspension of the valve on [**7-23**]. This was complicated by a prolonged time (7 days) to awaken and extubate. She had a seizure postoperatively and was treated with Dilantin. She did well from a hemodynamic standpoint and was eventually transferred to [**Hospital 100**] Rehab for further recovery. While here she failed a swallow study and tube feeding into the stomach were begun. She has continued Monday-Wednesday-Friday dialysis and has been being "dried'out over the last few weeks. Her Lopressor was held the day prior to transfer for BP in the 70s after dialysis and she developed rapid atrial fibrillation. This prompted transfer to [**Hospital1 18**]. Past Medical History: hypertension end stage renal disease on hemodialysis s/p failed renal transplant s/p replacement of aortic graft/resuspension of aortic valve abdominal hernia nephrolithiasis hemorrhoids arthritis Social History: Lives by herself at home, has homemaker who visits once weekly on Thursdays. Very independent but children help. Has 6 daughters and 2 sons. Smoked a couple cigarettes daily on-and-off x20years, quit in her 30s. EtOH: drinks a beer once in a while. Family History: Significant for HTN. Mother w/Alzheimer's. Brother w/CVA in 40s. Physical Exam: admission: Pulse:130 Resp: 22 O2 sat: 98% 4 l NC B/P Right: 94/58 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Sternal incision healing well, sternum stable Heart: RRR [] Irregular [x] Murmur Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds + [x] slightly distended Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Moves all extremities to command, A+Ox3, sl. weakness of L LE Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:tr Left:tr Radial Right:1+ Left:1+ Carotid Bruit Right: no Left: no Pertinent Results: [**2132-8-17**] 02:38AM BLOOD WBC-10.4# RBC-3.05*# Hgb-9.0*# Hct-27.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-19.7* Plt Ct-474*# [**2132-8-16**] 01:01PM BLOOD Hct-28.6*# [**2132-8-17**] 02:38AM BLOOD PT-17.3* PTT-44.6* INR(PT)-1.6* [**2132-8-17**] 02:38AM BLOOD Glucose-86 UreaN-35* Creat-3.7*# Na-136 K-4.0 Cl-101 HCO3-25 AnGap-14 [**2132-8-16**] 03:20AM BLOOD ALT-11 AST-22 AlkPhos-82 TotBili-0.1 [**2132-8-16**] 03:20AM BLOOD cTropnT-0.09* [**2132-8-16**] 03:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2132-8-16**] 04:06AM BLOOD Glucose-117* Lactate-1.7 Na-137 K-3.4* Cl-103 calHCO3-27 Brief Hospital Course: In the ED here labs indicated a hematocrit of 15, which was in error and was really ~24, near her baseline. She was in atrial fibrillation in the 120s with a BP of 94 systolic. She was transfused two units of PRBCs and begun on IV Amiodarone. A CTA demonstrated no changes in her descending dissection from her last study here. There was no evidence of new pathology or significant effusions. She was admitted to the ICU and converted to sinus rhythm quickly. She was briefly on a pressor. Her Amiodarone was changed to oral form and she remained in sinus. Tube feedings were resumed and a stool specimen was negative for c. difficile (she was being treated empirically on transfer with Flagyl). Flagyl was discontinued and she had formed stool. She was intact and the Nephrology service was notified of her readmission. they recommended changing the hemodilysate bath to 2.0 Ca and to target weight to 0.5-1 kg more than her post hemodialysis weight on [**8-15**]. She easily tolerated a puree/soft diet with a bedside evaluation here and a diet was begun, with tube feedings continued until oral intake is clearly adequate. The tube feeds can be decreased and discontinued in a few days if oral intake continues to go well. Then would change to a regular diet from puree. Medications on Admission: Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H as needed for temperature >38.0. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) ml PO BID B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID: subcutaneous. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO BID Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] as needed for oral care: oral [**Hospital1 **] care. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. Potassium Chloride 10 mEq / 100 ml SW IV PRN K<4.0 ** Concentrated KCL must be given via central line only ** Metoclopramide 5 mg IV Q6H:PRN nausea/vomiting Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg PO Q8H : for Dobhoff administration 22. Flagyl 500 mg PO TID Discharge Medications: 1. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fevers/pain. 2. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): mix as slurry for DHT. 11. Levetiracetam 100 mg/mL Solution Sig: Five Hundred (500) mg PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: rapid atrial fibrillation Chronic type B dissection s/p Ascending aortic graft/resuspension of aortic valve [**2132-7-23**] end stage renal disease on hemodialysis s/p renal transplant(failed) nephrolithiasis Discharge Condition: Alert and oriented x3, nonfocal Incisional pain managed with oral medications Incisions: Sternal - 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 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) **] on [**2132-9-3**] at 1pm ([**Telephone/Fax (1) 170**]) Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**] in [**2-14**] 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:[**2132-8-17**]

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icd9cm

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42175

Discharge summary

report

Admission Date: [**2183-12-6**] Discharge Date: [**2183-12-10**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1943**] Chief Complaint: Subdural Hematoma s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year-old woman with throat CA, HTN, a.fib, hyperlipidemia, DVT, CHF, mitral regurgitation with a mechanical fall at nursing facility secondary to attempted ambulation out support presenting to us from an outside hospital with concern for subdural hematoma. Onset was immediately prior to presentation. per report, the patient was attempting to ambulate without assistance but she is not capable of doing secondary to poor balance; she fell, striking her left forehead as well as left shoulder. No witnessed loss of consciousness. The patient complained of a headache, was evaluated at an outside hospital, and found to have a right occipital subdural hematoma. Neurosurgery saw and evaluated and felt no need for urgent intervention. Recommended Dilantin for 10 days and admit to medicine. While waiting for be she was significantly altered and became hypotensive to 70's SBP. Got 1 L NS and urinalysis was floridly positive. WBC was 17. Received Vancomycin, Ceftriaxone and haldol and calmed down. Was admitted to MICU for UTI with sepsis and hypotension where she got IVF but no pressors and urine grew out GNRs, not speciated. Also, via imaging lots of gastric and colonic distension and GI was called. CT scan showed lots of gas, no obstruction, no volvulus. Repeat kub, still lots of gas but marginally improved. She has afib, on dig, added metoprolol, not on aspirin or coumadin. Also, with h/o throat CA, has voice box to speak. Fluid Balance: +1L, got total 3L NS On arrival to the MICU, she was agitated and oriented x 0. Past Medical History: Dementia CHF SDH AFIB Hypothyroidism Breast ca HTN Skin CA Throat CA / with stoma Social History: From [**Location (un) 6598**] Manor. Otherwise unable to obtain Family History: Attempted to obtain but unable to due to altered mental status. Physical Exam: ADMISSION PHYSICAL EXAM VS: 98.9 84 97/44 97/TM(50%) GA: AOx3, NAD HEENT: PERRLA. MMM. stoma in neck. Cards: irreg irreg S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, ND Extremities: wwp, no edema. DPs, PTs 2+. Neuro/Psych: CNs II-XII intact. 5/5 strength in BUE and BLE extremities. Sensation intact to light touch DISCHARGE PHYSICAL EXAM VS: Tc 99.0, Tm 99.0, BP 110/70, P 85, R 26, O2 95 RA I/O MN 200/inc, 24h 880/1575Wt: 47.3kg GA: NAD, calm this AM HEENT: Stoma in neck. MMM. Cards: Irreg irreg S1/S2 heard. systolic murmur at LLSB. Pulm: CTAB, transmitted upper airway sounds Abd: Softly distended, hypoactive BS, NT Extremities: wwp, no edema. DPs 1+. Multiple bruises on BLEs that pt attributes to her falls. Pertinent Results: ADMISSION LABS [**2183-12-6**] 08:11AM LACTATE-1.7 [**2183-12-6**] 06:42AM GLUCOSE-77 UREA N-31* CREAT-1.0 SODIUM-139 POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-30 ANION GAP-14 [**2183-12-6**] 06:42AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.9 [**2183-12-6**] 06:42AM TSH-1.0 [**2183-12-6**] 06:42AM DIGOXIN-1.0 [**2183-12-6**] 06:42AM WBC-11.8* RBC-4.32 HGB-12.6 HCT-35.4* MCV-82 MCH-29.2 MCHC-35.6* RDW-16.1* [**2183-12-6**] 06:42AM PLT COUNT-181 [**2183-12-6**] 06:42AM PT-16.2* PTT-26.8 INR(PT)-1.4* [**2183-12-6**] 02:20AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011 [**2183-12-6**] 02:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG [**2183-12-6**] 02:20AM URINE RBC-8* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0 [**2183-12-6**] 02:20AM URINE WBCCLUMP-OCC MUCOUS-RARE [**2183-12-5**] 09:09PM GLUCOSE-98 UREA N-32* CREAT-0.9 SODIUM-135 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18 [**2183-12-5**] 09:09PM estGFR-Using this [**2183-12-5**] 09:09PM DIGOXIN-1.2 [**2183-12-5**] 09:09PM WBC-17.1* RBC-4.53 HGB-13.0 HCT-36.7 MCV-81* MCH-28.8 MCHC-35.5* RDW-16.1* [**2183-12-5**] 09:09PM NEUTS-81.8* LYMPHS-11.8* MONOS-5.3 EOS-0.7 BASOS-0.5 [**2183-12-5**] 09:09PM PLT COUNT-220 [**2183-12-5**] 09:09PM PT-16.1* PTT-26.3 INR(PT)-1.4* DISCHARGE LABS [**2183-12-7**] 02:40AM BLOOD PT-16.9* PTT-29.9 INR(PT)-1.5* [**2183-12-6**] 06:42AM BLOOD TSH-1.0 [**2183-12-6**] 06:42AM BLOOD Digoxin-1.0 [**2183-12-5**] 09:09PM BLOOD Digoxin-1.2 [**2183-12-6**] 08:11AM BLOOD Lactate-1.7 [**2183-12-6**] 02:20AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.011 [**2183-12-6**] 02:20AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG [**2183-12-6**] 02:20AM URINE RBC-8* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 [**2183-12-10**] 06:15AM BLOOD WBC-7.1 RBC-3.79* Hgb-11.0* Hct-31.7* MCV-84 MCH-29.1 MCHC-34.8 RDW-16.4* Plt Ct-183 [**2183-12-10**] 06:15AM BLOOD Glucose-84 UreaN-9 Creat-0.6 Na-135 K-3.7 Cl-103 HCO3-25 AnGap-11 [**2183-12-10**] 06:15AM BLOOD Calcium-8.6 Phos-2.2* Mg-2.2 MICROBIOLOGY [**2183-12-6**] URINE CULTURE (Final [**2183-12-9**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- 8 S AMPICILLIN------------ <=2 S =>32 R AMPICILLIN/SULBACTAM-- <=2 S =>32 R CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ <=1 S =>16 R MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S <=16 S TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=1 S =>16 R [**2183-12-6**] Blood Culture, Routine (Pending): [**2183-12-6**] Blood Culture, Routine (Pending): [**2183-12-7**] MRSA SCREEN (Final [**2183-12-7**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Imaging: CXR:IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Heart is severely enlarged. There is probably a large hiatus hernia, though lateral view would be helpful to confirm that. Pulmonary vasculature is engorged but there is no edema, pneumonia, or any pleural effusion. Limited imaging of the upper abdomen shows severe intestinal distention. Full abdominal view is recommended. CT HEAD W/O CONTRAST Study Date of [**2183-12-6**] 2:18 AM IMPRESSION: Accounting for changes in positioning and redistribution of blood products, no significant change in subdural hematoma. No shift of midline structures. ABDOMEN (SUPINE ONLY) Study Date of [**2183-12-6**] 7:26 AM IMPRESSION: Two supine views of the abdomen reviewed in the absence of any prior abdominal imaging. Severe intestinal distention is largely if not exclusively colonic. All segments of the colon are dilated, except the rectum. Diameter of the distended cecum is 10 cm, which appears to be greater than any of the other portions of the colon. When the patient can tolerate an upright view would be helpful in trying to define the orientation of the sigmoid to determine whether there are findings of volvulus. They are equivocal on this examination but that diagnosis is not excluded. An upright view would also detect pneumoperitoneum which would have to be substantial to appear on supine abdomen radiograph. CT ABD & PELVIS WITH CONTRAST Study Date of [**2183-12-6**] 2:33 PM IMPRESSION: Massively dilated, air-filled colon is in keeping with [**Last Name (un) 3696**] syndrome/pseudo-obstruction. No evidence of volvulus. RENAL U.S. Study Date of [**2183-12-6**] 2:47 PM Suboptimal exam due to patient's body habitus and technique. No hydronephrosis or perinephric collection. Known renal cysts seen on the CT exam of the same date are not well seen on the current ultrasound study. PORTABLE ABDOMEN Study Date of [**2183-12-7**] 11:24 AM IMPRESSION: A single overhead view of the supine abdomen shows persistent generalized distention of the colon, with some improvement. The diameter of the distended cecum is no more than 9 cm today, yesterday it was 10.4 cm. On the other hand, the sigmoid, previously 7.4 cm, is 8.4 cm today. Its orientation is not classic for sigmoid volvulus, although the definitive evaluation would require either sigmoidoscopy or a barium enema. I cannot be sure whether a rectal tube is in place. Findings and their clinical significance were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] at the time of dictation. Brief Hospital Course: [**Age over 90 **] year old female presented after a fall with head-strike and subsequently found to have an occipital subdural hematoma, initially admitted to the MICU after she became hypotensive in the setting of having UTI. She was transferred to the floor on [**12-7**]. She stayed in the hospital until urine culture results were available so that antibiotics could be tailored. ACUTE PROBLEMS: # Subdural hematoma: Pt initially admitted with history of fall to [**Hospital3 **] and found to have a subdural hematoma on CT and was transferred to [**Hospital1 **] for close monitoring. She was evaluated by neurosurgery who felt that neurosurgical intervention was not currently indicated and recommended the pt start on dilantin for a total of 10 days. Repeat Head CT showed no significant change in subdural hematoma and no shift of midline structures. She is set to have repeat Head CT in 8 weeks on [**2184-2-3**]. # UTI with sepsis: Patient had leukocytosis, AMS, and hypotension in the setting of positive UA concerning for evolving urosepsis vs pyelonephritis. Renal ultrasound showed no evidence of hydronephrosis or perinephric abscess and pt met criteria for sepsis. She was initially treated with Zosyn for her urinary tract infection/urosepsis and once cultures came back showing E. coli, the antibiotics were narrowed to Keflex to be continued for a total of 10 days. # Hypotension / history of hypertension: Pt initially had hypotension that resolved over the course of her hospitalization. This was likely due to hypovolemia in the setting of insensible losses, poor PO intake and concomitant infection. Her hypotension resolved with IV fluids and her home lasix and metolazone were held in this setting. Blood cultures (x2) were no growth at time of discharge, but still pending final results at time of discharge. # Abdominal distention: Pts abdominal distention was likely due to [**Last Name (un) 3696**] syndrome/pseudo-obstruction. There was no evidence of volvulus on KUB, and CT scan showed a massively dilated, air-filled colon is in keeping with [**Last Name (un) 3696**] syndrome/pseudo-obstruction, but there was still no evidence of volvulus. Pt felt symptomatically better and less distended once she was able to have a bowel movement (with the help of bowel medications). # Afib with RVR: She was continued on metoprolol and dose uptitrated to 25mg TID as her heart rate was beginning to run in the 120-130s on her home dose of 25mg [**Hospital1 **]. Pt was continued on metoprolol with uptitration to 25mg TID as above. Pt's aspirin was held due to her subdural hematoma. Okay to re-start aspirin on [**12-15**] as long as her INR is below 1.5. CHRONIC ISSUES: # Heart failure, unknown EF: Pt had no evidence of volume overload on exam. Her ejection fraction is unknown. In the setting of hypotension during this hospitalization, her lasix and metolazone were held. It is important that she gets daily weights in order to monitor her fluid status and it is recommended that she be restarted on her home lasix and metolazone once her blood pressures can tolerate it. Her digoxin level was 1.0 on [**12-6**] and she was continued on 0.0625 mg daily. # Hypothyroidism: Pt was continued on her home levothyroxine. TRANSITIONAL ISSUES # Pt's Abilify and Paroxetine were held in-house and pt did fine. These will be re-started upon discharge. # Pt's lasix and metolazone were also held while in-house due to pt's hypotension upon admission. These should be restarted as soon as her blood pressures can tolerate it so as not to exacerbate her heart failure. # Pt's aspirin was held due to her subdural hematoma. This is okay to re-start on [**12-15**] as long as her INR is below 1.5. Medications on Admission: Tylenol 650 Q4 hrs PRN Bisacodyl Deep sea saline mist Mylanta Milk of magnesia Compazine PRN nausea Megace 625 Daily Metolazone 2.5mg one tablet daily on Monday and Friday prior to lasix Metoprolol 25mg [**Hospital1 **] Multivitamin NTG prn Omeprazole 20mg PRN Oxybutin 15mg ER QD Paroxetine 30mg QD Abilify 2mg QD ASA 81mg QD Budesonide INH [**Hospital1 **] Digoxin 62.5mg QD Lasix 40mg PO qd tUSSIN 100MG qd lEVOTHYROXINE 88MCG qd Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for abd distention. 7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) neb Inhalation every six (6) hours. 8. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day) for 9 days: Please continue this through [**12-18**]. 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 9 days: Please continue through [**12-18**]. 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Abilify 2 mg Tablet Sig: One (1) Tablet PO once a day. 13. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO once a day. 14. oxybutynin chloride 15 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 15. multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. Tussin 100 mg/5 mL Liquid Sig: One Hundred (100) mg PO once a day as needed for cough. 17. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) neb Inhalation twice a day. 18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 19. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min up to three doses as needed for chest pain. 20. Daily Weights Please measure daily weights. If weight increases > 3 lbs, please alert MD. Consider restarting lasix and metolazone. Discharge Disposition: Extended Care Facility: [**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**] Discharge Diagnosis: PRIMARY DIAGNOSES: - Subdural hematoma - Urinary tract infection with sepsis - Hypotension - Atrial fibrillation with rapid ventricular response SECONDARY DIAGNOSES: - Chronic heart failure, unknown ejection fraction - Hypothyroidism - History of throat cancer, with stoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during your hospital stay at [**Hospital1 18**]. You were admitted because you had a fall and were found to have a head bleed by imaging. You were evaluated by neurosurgery and it was decided that there was no indication for surgery. The bleed in your head was stable on serial imaging and you were put on dilantin to help prevent seizures that may occur due to your head bleed. It is important that you complete the course of dilantin that is prescribed to you. You were also found to have a urinary tract infection. We have started you on an antibiotic called Keflex to treat this infection. It is important you complete the course of this antibiotic as it is prescribed to you. With regards to your medications, please make the following changes. Please START: 1. Dilantin 2. Keflex 3. Combivent inhaler Please STOP: 1. Aspirin -- You can restart this on [**12-15**] (10 days after your fall) as long as your INR < 1.5 Followup Instructions: Department: RADIOLOGY When: TUESDAY [**2184-2-3**] at 1:15 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage It is important that you are seen by a doctor shortly after your discharge from the hospital so that transitional issues may be followed upon. Completed by:[**2183-12-10**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15417, 15524

9270, 11958

279, 285

15841, 15841

2932, 6473

17036, 17432

2068, 2133

13481, 15394

15545, 15691

13024, 13458

16017, 17013

2148, 2913

15712, 15820

6557, 9247

213, 241

313, 1866

15856, 15993

11974, 12998

1888, 1971

1987, 2052

56,502

122,047

42522

Discharge summary

report

Admission Date: [**2119-6-27**] Discharge Date: [**2119-7-4**] Date of Birth: [**2080-2-24**] Sex: F Service: MEDICINE Allergies: Wellbutrin / High Dose Steroids Attending:[**First Name3 (LF) 594**] Chief Complaint: Cough Major Surgical or Invasive Procedure: IP rigid bronch w/ stent removal [**2027-6-27**] History of Present Illness: 39 yo F h/o asthma, tracheobronchomalacia s/p y stent [**2119-6-22**] and anxiety here with tachypnea. Was recently hospitalized which required intubation on [**7-14**]/12 for worsening tracheobronchomalacia. This was followed up by IP placing a y stent [**6-22**]. Pt initially felt well for first 2 days. Following this developed progressively worsening shortness of breath x 2 days, couple episodes of scant hemoptysis. Noticed inhalers helped yesterday but no relief today. No wheezing. Has dry coughing fits while lying supine and improves when sits up. Talking makes SOB/cough worse. Does not endorse chest pain but has chest discomfort from coughing. Denies nightsweats, weight loss or fever/chills. No nausea/vomiting, abdominal pain. ED: Initial Vitals/Trigger: 98.6 85 130/96 16 99% IP saw in ED. blow by humidified air mask, on 2L sat 98-99%. Tachypneic to 30s initially but went down to 18-20. most recent vitals 98.7, rr 16, bp 109/53, 100% RA on humidifier Received ativan which alleviated tachypnea On arrival to the MICU, pt was saturating well in high 90s on RA. Boyfriend at bedside. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Asthma, multiple prior intubations 2. Tracheobronchomalacia, diagnosed on CT trachea [**2119-6-7**] 3. Possible inflammatory lung process such as hypersensitivity pneumonitis. (Had open lung biopsy in [**10/2118**] which was reviewed by [**Hospital1 18**] pathologists and showed undefined inflammatory process superimposed on normal lung,and poorly formed granulomas that seemed to be consistent with a hypersensitivity pneumonitis). Most recent CT trachea showed no evidence of hypersensitity pneumonitis. 4. History of positive PPD (the patient reports that it was borderline degree of induration for many years and has not received INH. She states the reason for no INH was a clear CXR 5. PCOS 6. Postpartum depression requiring psychiatric hospitalization 7. Multiple miscarriages requiring D and C 8. Status post multiple colposcopies and cervical LEEP procedure 9. Meningitis in [**2118-12-11**] 10. Status post tonsillectomy Social History: The patient is divorced and lives in a home with her 3 children. Works as a business analyst. Occasional etoh. Prior 1-1/2 pack per day smoking for 15 years, quit in [**2106**]. High likelihood of asbestos exposure according to the patient as she was a volunteer firefighter in the past. History of positive PPD. Has a dog, cat, a lizard and a hamster at home. Family History: Father alcoholic. [**Name2 (NI) **] family history of lung disease or DVTs Physical Exam: Admission exam: Vitals: T: 98.3F BP: 116/80 P: 101 R:22 O2: 96%RA General: Alert, oriented, no acute distress, sitting upright, speaking in full sentences, HEENT: MMM, oropharynx clear, EOMI, PERRL Neck: supple, no masses CV: tachycardic, regular rhythm, no murmurs, rubs, gallops Lungs: some accessory muscle use, Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge exam: Pertinent Results: [**2119-6-27**] 05:21PM TYPE-[**Last Name (un) **] PO2-53* PCO2-28* PH-7.49* TOTAL CO2-22 BASE XS-0 COMMENTS-GREEN TOP [**2119-6-27**] 02:25PM GLUCOSE-95 UREA N-7 CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 [**2119-6-27**] 02:25PM estGFR-Using this [**2119-6-27**] 02:25PM WBC-9.0 RBC-4.83 HGB-13.9 HCT-42.1 MCV-87 MCH-28.7 MCHC-33.0 RDW-14.4 [**2119-6-27**] 02:25PM NEUTS-65.3 LYMPHS-28.4 MONOS-3.9 EOS-1.6 BASOS-0.8 [**2119-6-27**] 02:25PM PLT COUNT-372 [**2119-6-27**] 02:25PM PT-10.1 PTT-25.3 INR(PT)-0.9 CXR: FINDINGS: The lungs appear clear. The cardiomediastinal silhouette and hilar contours are unremarkable. No pleural effusion or pneumothorax. IP Rigid Bronch Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A standard time out was performed as per protocol. The procedure was performed for diagnostic purposes at the operating room. A physical exam was performed. The bronchoscope was introduced through an endotracheal tube and advanced under direct visualization until the tracheobronchial tree was reached.The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. other findings: Following general anesthesia a yellow Dumon rigid tracheoscope was inserted with slight difficulty. The airway was examined with flexible bronchoscopy, there was minimal secretion in the stent, the distal airways were patent. Using rigid forceps the Dumon Y stent was removed. The airway was again examined, there was no granulation tissue, except a small rim at the distal end of the LMS limb of the Y stent. Impression: Severe Trachchiobronchomalacia Removal of Dumon Y stent with rigid forceps through a Rigid tracheoscope. Recommendations: Admit to ICU Will follow as inpatient Additional notes: Patient medication list was reconciled. Attending was present for the entire procedure. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology. Brief Hospital Course: Mrs. [**Known lastname 92011**] is a 39 woman who presents with shortness of breath x 2d, periodic hemoptysis with coughing since [**2119-6-27**]. Hx signficant for severe asthma, severe tracheobronchomalacia with air trapping treated with y stent on [**2119-6-22**]. She had her Y stent removed on [**2119-6-28**]. #Tracheobroncheomalacia: pt has a h/o tracheomalacia s/p y stent placement with IP on [**2119-6-22**] for worsening TCM which required hospitalization from [**Date range (1) 40836**] where pt required intubation. Due to recent placement of stent, this is most likely the cause of tachypnea and hemoptysis. Does have a h/o asthma requiring multiple intubations, but this does not seem likely to be an asthmatic exacerbation. Per pt, on MTX for sarcoidosis and this was held during hospitalization. Bronchoscopy was done on [**6-28**] with interventional pulmonology. Pt was tachypneic and distressed after bronch, and anxiety and coughing paroxysms could only be controlled with precedex drip initially. During this time, pt was still accepting lidocaine, albuterol and ipratropium nebs with morphine and benzodiazepines to control anxiety with coughing episodes. Anxiety and coughing paroxysms would worsen to the point where pt received multiple PRN doses of Ativan, morphine, Haldol and heliox. Of note, pt would not desaturate during coughing episodes. Throughout hospitalization, pt continued her home inhaled corticosteroids and oral asthma medications. Interventional pulmonology followed patient while in house and could not suggest other stents. Only BiPAP was recommended which patient refused on multiple occasions. CT surgery also assessed pt and found her to not be a good surgical candidate for tracheoplasty. Towards the end of her MICU course, the pt was transitioned off of the precedex drip to a low-dose of clonidine and Zyprexa [**Hospital1 **] (although the Zyprexa was not continued on discharge). Upon discharge, pt still had intermittent coughing paroxysms (which was her pre-hospitalization baseline) and still refused to use BiPAP. It was recommended that she pursue pulmonary rehab and she was amenable to consider this on an out-patient basis. Her pulmonologist, Dr [**Last Name (STitle) **], was contact[**Name (NI) **] with regard to potentially facilitating this. #Anxiety/depression: The pt was not on benzodiazepines pre-admission but had multiple episodes of extreme anxiety. Pt was emotionally labile in ICU and put on precedex drip to control anxiety associated with coughing paroxysms. The pt was continued on home SSRI throughout hospitalization and the dose was increased towards the end of her course. Standing Klonopin and PRN Ativan were also added to her regimen and anxiety was refractory to this. She also received Zyprexa during her hospitalization, but was not discharged on this medication as adequate clinical control was achieved with clonidine and symptomatic (anti-tussive) medications. Of note, the Precedex did not control her coughing, but blunted her supratentorial / affective / emotional response to her coughing episodes. She also responded to re-direction and distraction during episodes as a means of terminating a paroxysm of cough. She will likely benefit from the psychological coping skills taught during pulmonary rehabilitation is this is able to be established in the out-patient setting. Transitional Issues: Dr. [**Last Name (STitle) **] (IP) f/u Dr. [**Last Name (STitle) **] (pulm) f/u Could consider ENT referral per Dr.[**Name (NI) 84946**] recommendation Psych referral outpt highly recommend BiPAP to increase quality of life with severe TBM highly recommend pulmonary rehabilitation Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Benzonatate 100 mg PO TID:PRN cough 2. Guaifenesin [**4-20**] mL PO Q6H:PRN cough 3. budesonide-formoterol *NF* 160-4.5 mcg/actuation Inhalation Daily 4. methotrexate sodium *NF* 15 mg Oral weekly 5. ciclesonide *NF* 80 mcg/actuation Inhalation [**Hospital1 **] 6. Sodium Chloride 3% Inhalation Soln 4 mL NEB [**Hospital1 **] Supplied by Respiratory 7. Ipratropium Bromide MDI 1 PUFF IH QID sob/wheeze 8. traZODONE 75 mg PO HS 9. Terbutaline Sulfate 5 mg PO TID 10. Albuterol Inhaler [**12-12**] PUFF IH Q4H:PRN sob/wheeze 11. Montelukast Sodium 10 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler [**12-12**] PUFF IH Q4H:PRN sob/wheeze 2. Benzonatate 100 mg PO TID:PRN cough 3. Guaifenesin [**4-20**] mL PO Q6H:PRN cough 4. Montelukast Sodium 10 mg PO DAILY 5. Terbutaline Sulfate 5 mg PO TID 6. traZODONE 75 mg PO HS 7. budesonide-formoterol *NF* 160-4.5 mcg/actuation Inhalation Daily 8. ciclesonide *NF* 80 mcg/actuation Inhalation [**Hospital1 **] 9. Ipratropium Bromide MDI 1 PUFF IH QID sob/wheeze 10. Sodium Chloride 3% Inhalation Soln 4 mL NEB [**Hospital1 **] Supplied by Respiratory 11. Citalopram 20 mg PO DAILY RX *citalopram 20 mg 1 tablet(s) by mouth qday Disp #*30 Tablet Refills:*0 12. Lidocaine 1% 2.5 mL IH PRN wheezing/sob, cough [**Month (only) 116**] give up every 2 hours for cough. RX *lidocaine HCl 10 mg/mL (1 %) 2.5 mL q3 hrs Disp #*4 Vial Refills:*0 13. Codeine Sulfate 15-30 mg PO Q4H:PRN cough RX *codeine sulfate 30 mg/5 mL 5 mL by mouth q 6 hrs Disp #*1 Bottle Refills:*0 14. Lorazepam 1-2 mg PO Q4H:PRN anxiety RX *lorazepam 1 mg [**12-12**] pill by mouth q4hr Disp #*24 Tablet Refills:*0 15. CloniDINE 0.1 mg PO TID Hold for SBP<100 RX *clonidine 0.1 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 16. nebulizer & compressor *NF* Miscellaneous prn RX *nebulizer & compressor Use for nebulizing medications Disp #*1 Box Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Severe Tracheobroncheomalacia Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 92011**], You were admitted to the [**Hospital1 69**] for removal of your Y-stent. After removal of your stent with interventional pulmonology, we strived to control your persistent coughing and shortness of breath with numerous interventions including light sedation. After meeting with interventional pulmonology and cardiothoracic surgery, it was decided that surgery is not a viable option, and would not provide any relief of your symptoms. Therefore supportive care with BiPAP is best for your condition. We made the following additions to your medications to help with symptom control: Codeine Sulfate 15-30 mg orally every four hours as needed for cough Citalopram 20 mg oral daily for associated agitation with cough CloniDINE 0.1 mg oral three times a day for agitation with cough - do not take this if you are feeling dizzy or lightheaded. Lidocaine 1% 2.5 mL inhaled every 3 hours as needed for wheezing, shortness of breath, or cough--DO NOT EXCEED THIS DOSING AS IT CAN CAUSE FATAL CARDIAC RHYTHMS IF TAKEN IN EXCESS Lorazepam 1-2 mg oral every 4 hours as needed for agitation associated with cough. ***Do not take this before or while driving. Do not consume alcholic beverages. We have DISCONTINUED your methotrexate as it appears to be unneeded and can have very unfavorable side effects. Please take all your other medications as previously prescribed. Followup Instructions: You should schedule the following appointments: Interventional pulmonology- Dr. [**Last Name (STitle) **] Pulmonology- Dr. [**Last Name (STitle) **] Please call ([**Telephone/Fax (1) 513**] to schedule your follow up appointments.

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icd9cm

[ [ [] ] ]

[ "33.78" ]

icd9pcs

[ [ [] ] ]

12050, 12056

6312, 9688

296, 346

12137, 12137

4099, 6289

13717, 13954

3306, 3382

10710, 12027

12077, 12116

10018, 10687

12288, 13694

3397, 4063

4080, 4080

9709, 9992

1500, 1949

251, 258

374, 1481

12152, 12264

1971, 2911

2927, 3290

76,446

130,023

39880

Discharge summary

report

Admission Date: [**2145-3-30**] Discharge Date: [**2145-4-9**] Date of Birth: [**2058-12-29**] Sex: M Service: MEDICINE Allergies: Bee Pollens / Lisinopril Attending:[**First Name3 (LF) 11839**] Chief Complaint: hypotension/Tachycardia. Major Surgical or Invasive Procedure: RIJ placement rt thoracentesis [**2145-4-5**] History of Present Illness: 86M male with h/o of SCC of the tongue and mid-esophagus s/p hemiglossectomy and modified lateral neck resection now getting post-OP RT who presents with diarrhea, inability to take PO, and shortness of breath. He initially presented to radiation for treatment [**10-3**] today. He was noted to be orthostatic and tachycardic with O2 sats in the 80s-90s and sent to the ED. The patient reports diarrhea which started the night priot to admission. . In the ED, initial vitals were 99.4 99 111/53 24 97% 6L NC. He received 2500 cc IVF total. CXR showed multifocal PNA. ECG showed lateral ST depression in V5/V6 and AVL and he was given aspirin and started on a heparin gtt at 700 units/hr. Guaiac negative. Lactate 3.8, unchanged after 3L IVF. CTA showed no PE. He was given CTX and Azithro for CAP. T max: 103. Vitals prior to transfer: 99.3 87-130/65-77, NRB mask w/ sats 96-98%. 130/65, was not initally hypotensive in the ED, however developed hypotension with systolics in the 80s. An IJ was placed and he was started on levophed and last bp 92/47. He was expanded to levofloxacin prior to transfer to teh MICU. . Upon arrival to the MICU, patient feels well with no complaints. He is on NRB with appropriate saturations. . Review of sytems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: T2N0M0 SCC of the lateral tongue T1N0M0 SCC of the esophagus Hypertension GERD Polymyalgia rheumatica: Diagnosed about 2.5 years ago for the symptoms of hand swelling/stiffness. Started on steroid 15-20 mg daily and was slowly tapered off over couple years. Pt was on 1mg prednisone until [**Month (only) 359**] - then recently re-started last [**Month (only) **] admission. Social History: The patient performs his own ADL's. He used to drink about 4oz of alcohol a day and smoke a pipe, but quit both when he was diagnosed with cancer. He began smoking a pipe at the age of 17. Family History: No family history of oral or GI cancers. Physical Exam: On admission: Vitals: T:96.4 BP:116/66 P:101 R: 18 O2: 92% NRB General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi 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, G tube in place with bandage c/d/i GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On admission: [**2145-3-30**] 03:45PM BLOOD WBC-11.5* RBC-4.53* Hgb-14.6 Hct-43.4 MCV-96 MCH-32.2* MCHC-33.6 RDW-14.3 Plt Ct-229 [**2145-3-30**] 03:45PM BLOOD Neuts-84* Bands-4 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* [**2145-3-30**] 03:45PM BLOOD Glucose-159* UreaN-21* Creat-1.4* Na-143 K-4.0 Cl-101 HCO3-26 AnGap-20 [**2145-3-31**] 02:45AM BLOOD Albumin-3.3* Calcium-7.7* Phos-4.1# Mg-1.5* [**2145-3-30**] 03:45PM BLOOD ALT-14 AST-28 LD(LDH)-338* AlkPhos-54 TotBili-0.9 . [**2145-3-30**] 03:45PM BLOOD cTropnT-<0.01 [**2145-3-31**] 02:45AM BLOOD CK-MB-3 cTropnT-0.01 CK(CPK)-201 [**2145-3-31**] 08:13AM BLOOD CK-MB-5 cTropnT-<0.01 08:13AM BLOOD CK(CPK)-196 [**2145-3-31**] [**2145-3-30**] 03:45PM BLOOD proBNP-4386* [**2145-3-30**] 03:45PM BLOOD D-Dimer-2479* [**2145-3-30**] 03:56PM BLOOD Lactate-3.8* [**2145-3-31**] 05:33PM BLOOD Lactate-1.6 . [**2145-3-30**] Blood cultures x 2: ********** [**2145-3-30**] Urine culture: ********** [**2145-3-31**] 2:46 am URINE Source: Catheter. Legionella Urinary Antigen (Final [**2145-3-31**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . [**2145-3-30**] CXR: 1. Multifocal pneumonia or aspiration. 2. Emphysema. . [**2145-3-30**] CTA Chest: 1. Multifocal pneumonia. 2. Emphysema and mild cardiomegaly. 3. No evidence of PE. . [**2145-3-30**] CT head: 1. No acute intracranial process. Chronic involutional changes. 2. No significant mass effect identified. If there is clinical concern for intracranial metastases, MR would be a more sensitive examination. . [**2145-3-31**] TTE: The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild aortic dilation. Mild to moderate tricuspid regurgitation. . Brief Hospital Course: 86yo M w/hx of SCC s/p XRT who presents with shortness of breath, hypoxia and multifocal PNA. # Multifocal pneumonia: Pt started on vancomycin, unasyn, and levofloxacin to cover CAP v. aspiration pneumonia in an immunocompromised patient. Unable to obtain sputum for culture; urine legionella Ag neg. PCP considered due to prednisone use since [**10/2144**] but distribution of infiltrates on imaging not consistent. Pt was initially maintained on face mask overnight but weaned easily to NC, satting 92% on 4L on transfer to the floor.On the floor had episodes of desaturation to 80's. Repeat cxr showed development of pleural effusions,rt>lt and worsening of consolidation.Unasyn was switched to zosyn and pt also underwent a diagnostic and therapeutic rt sided thoracentesis. 1 lit of fluid was drained which was c/w a non-complicated parapneumonitic effusion. Speech & swallow consulted to evaluate aspiration risk he also underwent a video assisted swallow study. S&S services recommended a a diet of thin liquids and ground solids. On d/c pt started on bactrim prophylaxis as he is continued on prednisone 30 mg daily for PMR. . # Hypoxic Respiratory Failure: Attributed to multifocal PNA as above as well as volume overload which developed after INF hydration for hypotension. No PE seen on CTA chest. Initial concern for ACS leading to acute CHF (see below) but ruled out; echo showing normal EF. Hypoxia improved with treatment of pneumonia, thoracentesis and diureses.On d/c pt'd O2 sat 99 on 3 lit per NC.Pt also likely has COPD and was treated with nebs and started on advair. #. Shock: Likely combination of septic and hypotensive shock. Pt treated for pneumonia as above; cultures were all negative.He was also fluid-resuscitated and weaned off low-dose norepinephrine. Stress dose steroids were not needed. As above, no evidence of cardiogenic shock. However, other etiologies include cardiogenic in setting of NSTEMI. Also, hypovolemic from diarrhea. Right IJ pulled prior to floor transfer.On th efloor blood remained stable. #. NSTEMI: ECG with lateral ST depressions and mild ST elevation in v1/v2. Pt started on ASA and heparin gtt. However, Cards fellow felt this was more consistent with early repolarization from LVH. EKG normalized in AM and cardiac enzymes neg x 2. Echo with no wall motion abnormality and normal EF. Heparin gtt discontinued but aspirin continued. # New onset atrial fibrillation: Did not aggresively rate control for HR in low 100??????s initially given underlying hypotension. No evidence of PE on CTA. Left atrium markedly dilated and right atrium moderately dilated on TTE. Thought likely due to increased sympathetic tone in setting of illness and hypovolemia. Pt spontaneously converted back to a sinus rhythm in the MICU.On the floor pt had asymptomatic episodes of a.fib with RVR. He was initially treated with restarting metoprolol, however,given recurrent episodes of RVR and COPD , metoprolol was discontinued and pt started on a low dose of diltiazam. [**Name (NI) 87728**], pt converted back to sinus and remained in sinus. # Acute Renal Failure: Pre-renal in setting of hypovolemia and shock. Cr peaked at 1.4 but returned to baseline and remained stable. On d/c crea 1.2. #. Diarrhea: Unclear precipitant. Guaiac negative. Stool studies ordered, but pt without further diarrhea while in-house... #. SCC of tongue/esophagus: Stable. XRT held on day of admission but resumed [**2145-4-7**].Pt to continue radiation treatment adn f/u with Dr [**Last Name (STitle) 3929**]. #. GERD: Continued on omeprazole. Code: DNR/OK to intubate Medications on Admission: Atenolol 50mg PO daily Omeprazole 40mg PO daily Prednisone 30mg PO daily (increased from 1mg daily to 30mg daily [**10-14**]) Discharge Medications: 1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough for 7 days. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain for 7 days. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 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. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Multilobar pneumonia Sepsis Pleural effusion Acute renal failure Squamous cell cancer of the tongue-on radiation treatment Early stage cancer of teh esophagus s/p resection Atrial fibrillation Polymyalgia rheumatica-on [**Doctor Last Name **] term prednisone 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: Mr [**Known lastname 6955**], you were admitted with a multilobar pneumonia and hypotension. You were initially in the intensive care unit where you were treated with IV antibiotics and pressors. Yor were transferred to the Oncology floor and continued on antibiotics and treatment for pneumonia and also atrial fibrillation. Followup Instructions: 1. F/U with PCP at ECF with labs including cbc, chem 10 in 5 days to evaluate for any toxicities after starting bactrim prophylaxis. 2.Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2145-4-19**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage 3.Department: RADIOLOGY When: TUESDAY [**2145-5-25**] at 10:45 AM [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage 4.Department: VOICE,SPEECH & SWALLOWING When: TUESDAY [**2145-5-25**] at 10:45 AM With: [**Doctor First Name **] BAARS [**Telephone/Fax (1) 3731**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage 5. Please schedule a f/u with your rheumatologist in the near future.

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icd9cm

[ [ [] ] ]

[ "38.93", "34.91", "92.29" ]

icd9pcs

[ [ [] ] ]

10342, 10412

5558, 9159

311, 358

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386, 1613

4577, 5535

3260, 4568

10730, 10874

2006, 2382

2398, 2588

1,339

192,698

50584

Discharge summary

report

Admission Date: [**2138-9-11**] Discharge Date: [**2138-9-20**] Date of Birth: [**2071-3-16**] Sex: F Service: OTOLARYNGOLOGY Allergies: Heparin Agents / Percocet Attending:[**First Name3 (LF) 8480**] Chief Complaint: Tracheocutaneous fistula Major Surgical or Invasive Procedure: Closure of tracheocutaneous fistula History of Present Illness: 67F with extensive cardiac history and COPD with post-intubation tracheal stenosis, s/p tracheal decannulation and tracheocutaneous fistula. Here for fistula removal and closure. Past Medical History: -Coronary artery disease s/p CABG in [**2118**] and "recent" PCI -Left total hip replacement-[**1-27**], elective. Complicated postoperative course with post-operative atrial fibrillation wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE UT, and prolonged intubation leading to trach/PEG. Discharged to chronic wean facility but unable to decannulate. Bronchoscopy revealed tracheomalacia of subglottic region. -Supraglottic edema from GERD -Bipolar disorder -Depression -chronic atrial fibrillation, developed postop from THR, not anticoagulated -Chronic constipation -HIT during Fragmin therapy Social History: Married. Very supportive husband. When she is not hospitalized/in rehab, she lives with him. No ETOH or Family History: non-contributory Physical Exam: 99 98.8 81 120/62 20 94% 2L NC NAD, AAOx3 No stridor, breathing and comfortably Talking without problems Neck INC with some purulent discharge, no fluid collection Pertinent Results: Admission labs: [**2138-9-11**] WBC-9.9# RBC-4.33 Hgb-14.1 Hct-38.8 MCV-90 MCH-32.6* MCHC-36.4* RDW-13.8 Plt Ct-232 Neuts-85.5* Lymphs-9.2* Monos-2.9 Eos-1.2 Baso-0.1 PT-13.2 PTT-30.2 INR(PT)-1.1 Glucose-130* UreaN-28* Creat-1.0 Na-141 K-3.9 Cl-102 HCO3-26 AnGap-17 Calcium-10.0 Phos-4.5 Mg-1.7 Discharge labs: [**2138-9-20**] WBC-6.9 RBC-3.59* Hgb-11.4* Hct-33.1* MCV-92 MCH-31.7 MCHC-34.3 RDW-13.3 Plt Ct-239 Glucose-110* UreaN-16 Creat-0.9 Na-141 K-3.8 Cl-105 HCO3-27 AnGap-13 Calcium-8.8 Phos-2.9 Mg-1.9 Brief Hospital Course: 67 y/o F with CAD, COPD and respiratory failure was s/p trach wean with persistent tracheocutaneous air leak who presented for elective takedown of tracheocutaneous fistula, PACU course complicated by diffuse neck and face swelling [**2-22**] subcutaneous emphysema. Was transferred to the ICU for monitoring. Over the course of the evening, her subcutaneous emphysema slightly improved. At approximately 3am she developed acute respiratory distress and 02 sats in the 60s-70s. Her hypoxia did not respond to a non-rebreather and a code blue was called for emergent intubation. Initially, her skin sutures were taken down to see if she could be re-trached, but the tracheocutaneous fistula was too small. She was then intubated orally, but this was difficult given tracheomalacia. After being sedated with fentanyl and midazolam she became hypotensive 50s/30s. She was started on neosynepherine and her pressure responded appropriately and she was weaned down. A central line was placed and propofol was given for sedation. Again she became hypotensive and was started on neo which was weaned after 24 hours. She woke up, was alert and oriented, responded appropriately and had no focal neurological signs. However, she was difficult to oxygenate, on PEEP of 16 and Fi02 of 60-90%. She remained intubated to allow the trach site to heal and was weaned Fi02 to 40% and PEEP to 5. She did not have cuff leak during SBTs. She was also actively diuresed with lasix due to CHF history and BNP 1800. She was followed by ENT and interventional pulmonolgy who plan to extubate her in the OR under direct visualization. She spiked fever to 100.9 on POD2, and was started on vancomycin. Her blood cultures were positive for MRSA and her incsision started producing purulent discharge that also grew out MRSA. After starting Vanco treatment, repeat blood cultures had no growth to date. She spiked a fever again on POD3, had increased secretions and possibly worsening RLL infiltrate on CXR. She was started on Zosyn for concern for VAP and history of Pseudomonas (sensitive to zosyn). Mini-BAL grew coagulase postive staph aureus. Zosyn was discontinued after blood culture did not grow out gram negative rods or Pseudomonas on POD6. She did not have leukocytosis and she remained hemodynamically stable. The patient had daily CXR, which showed atelectasis and no evidence of PNA. Her subcutaneous emphysema continued to improve after intubation and facial swelling and upper toro crepitus resolved prior to discharge. After weaning down to minimal vent settings and having adequate oxygen saturations, the patient was extubated at bedside with anesthesia and respiratory therapy present to assist. Extubated was well tolerated and occurred without events on POD8. Patient was placed on BiPAP overnight and had desaturation to 88% in early morning of POD9, which warrented increasing oxygen. Saturations improved to 93% once oxygen was increased. Pt reports regular desats at home on CPAP. In the morning pt was placed on 2L NC and was sating >90%. Diet was advanced and patient tolerated advancing diet. Patient is being discharged: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, and ambulating well. Patient will follow-up in [**7-31**] days with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **], and PCP. Medications on Admission: ASA, Colace, Lactulose, lamictal, lasix, lipitor, lisinopril, MVA, nitroglycerin, potassium chloride, protonix, seroquel, vicodin, zoloft Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed. 2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-22**] Puffs Inhalation Q4H (every 4 hours) as needed. 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a day. 16. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for 2 weeks. Disp:*qs ML(s)* Refills:*0* 18. Bactroban 2 % Ointment Sig: One (1) Topical twice a day for 1 weeks: stop when skin forms scab. Disp:*qs * Refills:*0* 19. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: please take all pills on time and finish entire course. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Tracheocutaneous fistula Discharge Condition: Stable Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. OK to shower but do not soak incision until follow up appointment, at least. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Call your surgeon to make follow up appointment. Followup Instructions: Please call Dr.[**Name (NI) 18353**] office to schedule your follow up appointment within 1 weeks. [**Telephone/Fax (1) 2349**] Please call Dr.[**Name (NI) 14680**] office to schedule your follow up appointment within 1-2 weeks. [**Telephone/Fax (1) 3020**] Please make an appointment with PCP to follow up care and medication management within 1 week Completed by:[**2138-9-20**]

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icd9cm

[ [ [] ] ]

[ "93.90", "33.24", "38.93", "96.04", "96.71", "96.72" ]

icd9pcs

[ [ [] ] ]

7407, 7456

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317, 355

7525, 7534

1558, 1558

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1870, 2068

1372, 1539

253, 279

383, 564

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586, 1198

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13,086

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53389

Discharge summary

report

Admission Date: [**2186-11-3**] Discharge Date: [**2186-11-14**] Service: MEDICINE Allergies: Penicillins / Metoprolol / Levaquin Attending:[**First Name3 (LF) 398**] Chief Complaint: Gross hematuria Major Surgical or Invasive Procedure: Central venous line placement. History of Present Illness: [**Age over 90 **] y/o man with PMH significant for Parkinson's disease, BPH, atrial fibrillation, CHF, and CRI admitted through the ED with gross hematuria, anemia, and hypotension. The patient self discontinued his Foley catheter yesterday resulting in traumatic bleeding. Today, a moderate amount of blood was noted in the Foley catheter bag. In the ED, VS were 95.8 67 106/48 100% RA. Labs were significant for a Hct of 22.6 (of note, his baseline is between 24-25). An urology consult was obtained in the ED. They placed a 22 French 3-way with continuous irrigation. There was initially some clearing of the urine then it turned more bloody again. The patient was given vancomycin and ceftriaxone. He also was transfused 1 unit of PRBC. The patient was kept in the ED for observation. . At 8:00 AM the morning of admission, the patient SBP decreased to 70. He was given 1 liter of IV fluids with an increase in his SBP to 90-110. At this time, he is being admitted to the medicine service for further care. . On his arrival to the floor, the patient repeatedly asked for food. He also reported that he was quite tired. Denied pain or any other concerns. Most of history obtained from his daughters. Past Medical History: 1. Recent [**Hospital1 18**] admission on [**2186-10-16**] for Staph aureus and Enterococcal bacteremia. At this time, the patient has completed 3 of 6 weeks of vancomycin. 2. Acute urinary retention with placement of a Foley catheter- [**6-/2186**] 3. [**Name (NI) 32951**] Pt with recent episodes of hematuria in [**7-/2186**] and [**2186-8-15**]. 4. Parkinison's disease 5. BPH 6. Large left hernia 7. S/P appendectomy 8. S/P hernia repair ~20 years ago 9. Atrial fibrillation- This was diagnosed in 02/[**2184**]. He is not anticoagulated. 10. CHF- TTE in [**12/2185**] showed moderate dilation of the RA, mild symmetric LVJ with a LVEF of 45 to 55%, RV depression, abnormal diastolic septal motion consistent with RV volume overload. [**11-28**]+ AR. [**11-28**]+ MR. 3+ TR. Mild PA systolic HTN. 11. Iron defficiency anemia 12. Hypothyroidism 13. CKD- Baseline creatinine is 0.9-1.0. 14. Left leg wound- VAC dressing in place. 15. PNA- [**12/2185**] Social History: Pt lives at home with his wife and daughter. [**Name (NI) **] is retired from work in construction, engineering, and real estate. No ETOH, tobacco, or drugs. Did occasionally smoke a pipe but quit greater than 20 years ago. The patient's daughter determines what foods he can eat. He will only take hot liquids (tea, coffee) by mouth and these must have thicket in them. Family History: [**Name (NI) 1094**] father had DM. Mother died of heart disease /rythm problems. She was over 90 at her death. Daughter (alive at 47) had Hodgkins many years ago. Physical Exam: On admission: Vitals: T 101.8 BP 87/57 HR 102-114 R 18 Sat 100% AC 450x14, 100%, PEEP 5; VBG: 7.29/48/48, mixed venous sat 79 Gen: Ill appearing elderly man, ventilated and sedated HEENT: NCAT, semi dry MM Cardiac: Distant heart sounds, regular, tachycardic, no m,r,g. Pulm: decreased breath sounds RLL Abdomen: Soft. NT. ND. Positive bowel sounds. G tube site c/d/i Extremities: No c/c/e. Bandage on left leg c/d/i with large ulcer down to fascia and clean base; L groin hernia Neuro: intubated Pertinent Results: [**2186-11-3**] 03:30AM WBC-9.2 RBC-2.82* HGB-7.4* HCT-22.6* MCV-80* MCH-26.1* MCHC-32.6 RDW-18.5* [**2186-11-3**] 04:45AM PT-12.6 PTT-25.0 INR(PT)-1.1 [**2186-11-3**] 07:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2186-11-3**] 09:37AM LACTATE-0.5 [**2186-11-3**] 06:20PM HGB-7.4* HCT-22.5* . [**11-3**]-Portable CXR- IMPRESSION: No acute cardiopulmonary abnormality. . [**11-6**]-CTA: IMPRESSION: 1. No evidence of pulmonary embolus. Heterogeneous flow to basilar segments of collapsed right lower lobe likely physiologic/artifactual. 2. Moderate right pleural effusion. Likely multifocal atelectasis in the right lung. Pneumonia cannot be excluded. 3. Near complete resolution of left upper lobe pneumonia. Residual left lower lobe minor atelectasis. 4. Findings consistent with congestive heart failure. . [**11-7**]-Renal U/S: IMPRESSION: Limited study demonstrating no hydronephrosis or gross renal calculi in either kidney. . [**11-8**]-Portable CXR: There has been interval improvement of the right upper lobe opacity most likely representing clearing of consolidation demonstrated on the previous chest CT; the right pleural effusion is increased which could be due to positional change of the patient. The left lower lobe retrocardiac atelectasis is unchanged. No evidence of failure is present. There are no new areas of consolidation. The ET tube tip is 2.5 cm above the carina. The right subclavian line tip is in the mid SVC. . Brief Hospital Course: This is a [**Age over 90 **] y/o man with PMH significant for Parkinson's disease, BPH, atrial fibrillation, CHF, and CRI initially admitted through the ED with gross hematuria, anemia, and hypotension. Hospital course summarized below: . Of note, the pt was just discharged from [**Hospital1 18**] on [**2186-10-16**] for Staph aureus and Enterococcal bacteremia (grown in blood and urine). He had completed 3 out of 6 weeks of Vancomycin for LLE ulcer and empiric endocarditis treatment. His recent history is notable for recent acute urinary retention after hospitalization for sepsis ([**7-2**]) at which point he was discharged with catheter (14F) in place. He was subsequently readmitted with gross hematuria about one month later; unclear precipitant, no clear trauma, however his catheter had been changed to an 18F PTA. He was later found to have a UTI, P. Aeruginisa, sensitive to Cipro and was discharged on this. He returned to the ED [**8-15**] with painless hematuria, was irrigated and discharged. . On this admission, the pt had hematuria thought to be due to pulling his foley catheter. The patient self discontinued his Foley catheter resulting in traumatic bleeding. He was found to have a hct of 22.6 (BL 24-25), and urology placed a 22 French 3-way with continuous irrigation. In the ED, the patient's BP dropped to SBP 70, and he was given 1L IVF with SBP increasing to 90-110. . Since admission to the medicine service, the pts hematuria had resolved. His hct had been stable at 31-33. He received 5 units PRBC over 3 days, and he had intermittent wheezing treated with atrovent nebs and prn Lasix 10 IV. . On [**11-6**], the pts HR increased from baseline of 100-110, up to 160. His RR also increased to 32. The pt was found to be satting 78% RA. On 100% NRB, his sats only increased to 85% NRB. He was given Lasix 10 mg IV x1 and he was intubated given his hypoxia. His SBP then droped to 74/60. He was then cardioverted with shock x1, and converted into NSR. Several minutes later he went back into afib with HR in 120s and then again spontaneously cardioverted to NSR upon transfer to the MICU. . In the MICU, the patient was initially unstable having hypotension and atrial fibrillation with [**Month/Year (2) 5509**]. He received 3 L of NS with initially some effect. Antibiotics were broadened to include cefepime and ciprofloxacin (for chronic LLE ulcer and empiric endocarditis treatment) and Cipro (h/o psuedomonas. He received a levophed bolus in the setting of hypotension, but his HR increased to 210 so levophed was turned off. The pts BP increased with neo and it did not seem to affect his HR. Again, his pressures decreased in the setting of [**Last Name (LF) 5509**], [**First Name3 (LF) **] he was given amiodarone 150 mg IVx1, but he had [**12-30**] second pauses thereafter. Levophed was resumed at a low dose in addition to the neo, and the pts BP stabilized. On HD 2 in the MICU, levophed was weaned off. His respiratory status also improved and the patient was extubated on HD 2. The patient remained hemodynamically stable with good respiratory status after this time. He remained afebrile and completed his course of antibiotics. Hematuria resolved He was discharged on HD 12 (MICU day 8) with two weeks left on his six week course of vancomycin. Creatinine trended toward baseline. His mental status was improved but not quite at baseline per the daughter In summary, this is a [**Age over 90 **] year old gentleman with Parkinson's disease, atrial fibrillation, CHF, L leg ulcer, and chronic kidney disease, and recent admission for enterococcal and staph aureus bacteremia. Admitted for hematuria believed secondary to traumatic foley. Transferred to MICU for fever, hypotension, and respiratory failure likely from combination of decompensated atrial fibrillation with [**Age over 90 5509**] and sepsis. Briefly intubated and maintained on pressors along with broad spectrum antibiotics. Afebrile and hemodynamically stable on discharge with antibiotics completed and maintained on long term vancomycin course. His admission had multple issues and these, along with the plan on discharge, are summarized below. . 1) Hypotension/question of sepsis: The etiology of the pts hypotension included septic, hypovolemic, and cardiogenic. Given the pts elevated WBC and fever, infectious etiology was believed to be playing a role. He appeared to have a possible RLL PNA on CTA and CXR. Cardiogenic cause was less likely given mixed venous Sat of 79%. CTA showed R pleural effusion and no PE, ?interstitial process. Ruled out for MI hree sets of cardiac enzymes were negative for infarction, and he had no EKG changes while in NSR. Cefepime was added for broader coverage in addition to Vanc ). Ruled out for influenza by DFA, blood, sputum, and urine cultures were negative. Likely hypotension was secondary to decompensated atrial fibrillation and sepsis with no known source other than possbile RLL PNA -cefepime and ciprofloxacin antibiotic course completed - continue vancomycin for two more weeks (total six weeks for staph/enterococcus bacteremia . 2) AF with [**Age over 90 5509**]: likely exacerbated by infection, PE ischemia unlikely cause. -continue aspirin - may consider outpt cardiology eval for rate control. Pt rate controlled adequately on discharge -hold on BB given history of block low BP -hold on using amiodarone given pauses and hypotension seen with bolus given in hospital. . 3) Hypoxic Respiratory Failure: Suspect combination of PNA and possible flash edema in the setting of afib/[**Age over 90 5509**]. The pt was intubated on the floor and maintained on AC. On MICU day 2, he was successfully extubated . 4) Hematuria, largely resolved: Pts hct remained stable s/p 5 units PRBC. BL Hct is 25, was 28 on dischage. Per daughter still had occasional clots passing through foley. -pt discharged on 22 Foley, will maintain for now to ensure any residual clots can pass, can change to 16 Coude after [**2186-11-20**] -outpt Urology follow up to be scheduled, per daughther she may have the pt's foley changed by urologist . 5) Left LE wound: Patient with an ulcerated stasis wound on his left lower leg. Had a Freecom VAC in place but the battery died in the ED. Was followed by plastics and wound care nurse using hospital VAC equipment (different equipment from that at home). Some confusion regarding best management of wound vac dressing changes, with differing plans from plastics, wound care, and the patients daughter. [**Name (NI) **] acute issues arose from the LE wound and there were no signs of infection on examination of the wound . The wound vac dressing was last changed [**11-8**], the pt was discharged with dressing in place and vacuum to resume on arrival to home. The following day, the wound vac dressing would be changed by VNA services using the Freecom system. The patient also had a L superficial ulcer on dorsum of L foot. On discharge, this did not appear infected. Aquacel was placed on the wound and dressing was placed. -continue wound vacuum care -continue zinc complete course of vancomycin. . 6) Hyperkalemia: Resolved s/p kayexalate. DDX included [**Doctor First Name 48**] and adrenal insufficiency. [**Last Name (un) **] stim WNL . 7) [**Doctor First Name 48**]: Pt is oliguric. BL Cr is 1.1, Cr rose to 2.3. Causes include poor forward flow, ATN, hypovolemia. Pts Cr rose s/p hypotension and IV contrast for CTA, so in part cause could be contrast related ATN as well as hypotension-related ATN. Renal US negative for obstruction. Cr 1.3 on discharge --renally dosed Vancomycin --monitor Cr one week after discharge . 8) Elevated INR/decreased plt: Pts plt decreased from 300s to 150 on [**11-8**]. His INR increased from Bl of 1 to 1.9 on [**11-8**]. All heparin products were held and HIT ab was sent. DIC labs were negative. . 9) Ileus: Pts pills were being regurgitated up through his G tube. AXR c/w stool in colon, lactulose and bowel regimen given -pt tolerating tube feeds by discharge, ileus resolved -continue outpt bowel regimen . 10) Parkinson's disease:The patient's neurologist is Dr. [**Last Name (STitle) **]. --continued carbidopa/levodopa, comtan,and mirapex. --of note, Of note, family wanted it to be known that pt received 2 out of the three antiparkinson's medications on an incorrect schedule. All medications were supposed to be schedule at 8 am 2 pm and 8 pm; however, for two days the patient received two of three medications at 10 pm instead of 8 pm. The other medication were received at the regular schedule. After this, medications maintained on regular schedule until discharge . 11) BPH: Continued finasteride; hold on alpha blockers . 12) Hypothyroidism: Continued levothyroxine. . 13) GERD: Continued lansoprazole . 14) Skin lesions: Pt with nodule on L shoulder which will needs dermatology biopsy as outpatient. . 15) FEN: Tube feeds with probalance as before . 16) Prophylaxis: Lansoprazole, colace, SC heparin . 17) ACCESS: PICC; quadruple R subclavian placed, removed on discharge . 18) DISP: Home with services. . Code status remains full. Medications on Admission: 1. Carbidopa-Levodopa 25-100 mg, 1.5 Tablets PO TID 2. Levothyroxine 12.5 mcg QD 3. Zinc Sulfate 220 mg QD 4. Furosemide 20 mg QOD 5. Pramipexole 3 mg TID 6. Finasteride 5 mg QD 7. Tamsulosin SR 0.4 mg QHS 8. Aspirin 81 mg QD 9. Lansoprazole, rapid dissolve 30 mg QD 10. Entacapone 200 mg TID 11. Docusate TID 12. Senna 8.6 mg, 2 tabs [**Hospital1 **] 13. Enulose QD 14. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop OU [**Hospital1 **] 15. Xenaderm 90-87-788 unit-mg-mg/gram ointment TID 16. Miconazole Nitrate 2 % Powder topical [**Hospital1 **] Discharge Medications: 1. Entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 2. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM (once a day (in the morning)). 3. Levothyroxine 25 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Brimonidine 0.15 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: One (1) tab PO Q4-6H (every 4 to 6 hours) as needed. 8. Pramipexole 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). 9. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment [**Telephone/Fax (3) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) g Intravenous Q48H (every 48 hours) for 2 weeks. Disp:*7 bags* Refills:*0* 11. Outpatient [**Hospital1 **] Work Please check vancomycin trough tomorrow. 12. Pramipexole 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times a day). 13. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO ASDIR (AS DIRECTED): please given 2 hours prior to dressing change. 14. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*90 Capsule(s)* Refills:*2* 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. . Disp:*100 ML(s)* Refills:*3* 16. 10 mL normal saline Please flush PICC catheter daily and PRN. Follow saline flush with heparin flush. 17. Entacapone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 18. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 19. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: Fifteen (15) mL PO TID (3 times a day). 20. Enulose Oral 21. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 22. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): Given at 8 AM, 2 PM, and 8 PM. 23. Probalance 6 cans a day for tube feeding. 24. Outpatient [**Hospital1 **] Work Please check blood chemistries, BUN and creatinine next week 25. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO every other day: hold for systolic blood pressure less than 100. 26. Outpatient [**Hospital1 **] Work Please check complete blood count next week Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary Diagnosis: 1. Hematuria secondary to traumatic foley 2. Atrial fibrillation Secondary Diagnoses: 1. Acute blood loss anemia 2. Chronic LLE venous stasis ulcer 3. Parkinson's disease 4. BPH 5. Hypothyroidism 6. GERD Discharge Condition: Stable, afebrile with vital signs within normal limits. Oxygen saturation nl on room air. Alert, vocalizes but doesnt form comprehensible words, intermittently follows commands. Pt not yet returned to mental baseline per family. Of note, family wanted it to be known that pt received 2 out of the three antiparkinson's medications on an incorrect schedule. All medications were supposed to be schedule at 8 am 2 pm and 8 pm; however, for two days the patient received two of three medications at 10 pm instead of 8 pm. The other medication were received at the regular schedule. Discharge Instructions: Weigh patient regularly. . Please make the follow-up appointments as detailed below. Dr [**Last Name (STitle) **] the primary care physician, [**Name10 (NameIs) 4801**] be seen shortly. Also make an appointment with urology to assist you with issues regarding the foley. . Continue the vancomycin for two more weeks. . The VNA will change the wound vac dressing tomorrow. . Maintain the 22 Foley catheter for now. After [**Holiday **] it should be safe to change this foley to a 16 gauge Cudahy catheter. . Call your PCP or return pt to the ED if you have: *fever/chills/night sweats *decreased urine output *increased blood in the urine *blood in the stools/dark stools *chest pain/difficulty breathing Followup Instructions: You should make a follow-up appointment within one week with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] by calling [**Telephone/Fax (1) 2936**]. . You will also need to follow-up with Dr. [**Last Name (STitle) **] in the urology clinic; you can make an appointment at your convenience by calling [**Telephone/Fax (1) 277**]. They will help you with issues regarding the indwelling foley. . Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2186-11-10**] 3:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2186-11-16**] 9:30 .

[ "454.0", "584.9", "285.1", "599.7", "995.91", "E928.9", "600.00", "332.0", "276.7", "530.81", "585.9", "038.9", "867.0", "458.9", "427.31", "560.1", "427.5", "428.0", "465.9", "244.9", "486", "287.5", "518.81" ]

icd9cm

[ [ [] ] ]

[ "93.57", "96.6", "96.71", "99.04", "96.04", "57.95" ]

icd9pcs

[ [ [] ] ]

17703, 17774

5151, 14288

259, 291

18041, 18626

3608, 5128

19380, 20073

2911, 3076

14897, 17680

17795, 17795

14314, 14874

18650, 19357

3091, 3091

17900, 18020

204, 221

319, 1526

17814, 17879

3105, 3589

1548, 2506

2522, 2895

6,255

171,214

10045

Discharge summary

report

Admission Date: [**2170-8-6**] Discharge Date: [**2170-8-14**] Date of Birth: [**2100-2-18**] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Tegretol Attending:[**First Name3 (LF) 1055**] Chief Complaint: Transfer for GI bleed Major Surgical or Invasive Procedure: Upper Endoscopy and cautery of the bleeding lesion s/p stenting of R arm arterio-venous fistula by interventional radiology -Upper Endoscopy with Biopsy and Pathology at OSH: no diagnostic abnormalities History of Present Illness: Pt is a 70 y/o male with CAD, CHF, PVD, COPD, ESRD, metastatic melenoma who was transferred from [**Hospital3 **] after being admitted there a week prior with a GI bleed. The night before he presented to [**Hospital1 **] (one week prior to transfer) he was in his usual state of health when he began to develop abdominal pain and nausea, with subsequent melena and eventual coffee ground emesis. He went to [**Hospital1 **] where he was admitted to the ICU and recieved 2-3 units of packed red cells daily. He [**Hospital1 1834**] EGD twice, the first time limited by active bleeding and the second revealing a hiatal hernia, duodenitis, and an ulcerated duodenal lesion in the third part of the duodenum. As it was felt he may need surgical intervention, he was transferred to [**Hospital1 18**] for further evaluation and management. At admission, he complained of mild lightheadedness and chest pain. He stated his last BM had been two days prior and without [**Hospital1 **]. He was afebrile with a bp of 82/36 and a hr of 76, satting 100% on 2Lnc. He was bolused one liter of IVF, resulting in a bp of 92/44 and a resolution of his symptoms. An initial hct was 27.2, not significantly different than his hct prior transfer. Past Medical History: 1.)Coronary artery disease s/p stent x 4 2.)CHF: EF unknown 3.)Peripheral vascular disease s/p stents to both legs and rue 4.)AAA s/p repair x 2 5.)Emphysema 6.)End-stage renal disease on HD MWF ([**Location (un) 2498**] dialysis, Dr. [**Last Name (STitle) **] x 4 years 7.)Metastatic melanoma s/p bilateral neck dissection and xrt Social History: Mr. [**Known lastname **] is a retired brick layer, divorced, lives alone, has supportive sister and brother-in-law. [**Name (NI) **] is actively smoking, with a 60 pack year hx. No etoh or illicit drug use. Family History: Father died of an MI at 59. 7 brothers with CAD/PVD. Mother died of breast cancer. Sister died of lung cancer. Physical Exam: gen- chronically ill appearing male, not acutely ill, pleasant and conversant, NAD heent- anicteric sclera, op clear with dry mucosa neck- bilateral well healed surgical scars with firm induration below each, left IJ in place cv- rrr, s1s2, [**2-4**] holosystolic murmur at ursb pul- moves air well, bibasilar rales [**1-2**] way up abd- soft, nt, multiple surgical scars, nd, nabs, no hepatomegaly back- no sacral edema, no cva tenderness extrm- no cyanosis, 2+ pitting edema throughout entire rue, otherwise no edema, warm/dry nails- moderate clubbing, no pitting/color changes/indentations neuro- a&ox3, no cn defects, motor [**5-3**] distally and proximally in all extremities, no focal sensory deficits, finger-to-nose exam with mild tremor but no major deficit Pertinent Results: [**2170-8-6**] 05:08PM PT-14.9* PTT-30.4 INR(PT)-1.5 [**2170-8-6**] 05:08PM PLT COUNT-122* [**2170-8-6**] 05:08PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ [**2170-8-6**] 05:08PM NEUTS-86.6* LYMPHS-4.5* MONOS-5.8 EOS-3.0 BASOS-0.1 [**2170-8-6**] 05:08PM WBC-5.7 RBC-3.19*# HGB-9.7*# HCT-27.2*# MCV-85# MCH-30.3 MCHC-35.5* RDW-17.9* [**2170-8-6**] 05:08PM ALBUMIN-2.4* CALCIUM-7.6* PHOSPHATE-3.0 MAGNESIUM-1.5* [**2170-8-6**] 05:08PM GLUCOSE-80 UREA N-32* CREAT-2.5*# SODIUM-132* POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-28 ANION GAP-12 Discharge Hct was stable at 32. ------------------- Shoulder X-ray for R shoulder Pain: Right shoulder 3 views on [**2170-8-13**]; the superior aspect of the glenoid demonstrates subchondral lucencies. The glenohumeral joint space is within normal limits. No dislocation or fracture. A subclavian stent is noted. There is a central venous catheter, incompletely imaged. IMPRESSION: Possible subchondral lucency of the superior aspect of the bony glenoid may be seen with degenerative changes. MRI or CT is recommended for additional evaluation. ------------------ A-V fistulogram . CONCLUSION: 1. Balloon angioplasty of the terminal, central portion of the right cephalic vein stenosis, using 6 mm, 8 mm and eventually 8 mm cutting balloons. Moderate angiographic improvement was noted, as well as reduction of mean pressure gradient from 20 to 10 mm Hg across this stenotic area. 2. Balloon angioplasty to 10 and 12 mm of the stenosis in the central portion of the right subclavian vein and the right innominate vein stent, with unsatisfactory angiographic and hemodynamic result. Successful deployment of a 14 x 60 mm Smart stent across that stenotic area, balloon-dilated to 12 mm, with moderate angiographic improvement in luminal narrowing and partial reduction in the degree of collateral venous opacification. The trans-stenotic mean pressure gradient remains unchanged (approximately 15 mm Hg). -------------------- EGD: [**2170-8-8**] Duodenitis of the bulb. Active bleeding site in the proximal descending duodenum, possibly from an erosion or a Dielafoye's lesion. Successful cautery and injection. Erythema and erosion in the antrum compatible with gastritis Erosions at the GE junction. Otherwise normal egd to fourth part of the duodenum Recommendations: continue IV Protonix 40mg [**Hospital1 **] If rebleeds, would get angiogram by IR to attempt embolization and surgery consult. Continue serial hct and transfuse as needed. Echo [**2170-8-9**]: The left atrium is elongated. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 70 y/o male with cad, chf, esrd, metastatic melanoma, s/p radical neck exploration and LN resection transferred from OSH with GI bleed, s/p . #GI bleed -- Ulcerated duodenal lesion seen on OSH EGD. Story consistent with UGI bleed. Does not appear to be actively bleeding. He denies NSAID use. Biopsies from OSH are pending. Concerns include duodenitis in setting of ASA/clopidogrel use, H. pylori, metastatic lesion. In the ICU the pt [**Month/Day/Year 1834**] an EGD that demonstrated a small bleeding area in the duodenum that was cauterized with good effect and was felt to be the main source of bleeding. His hematocrit remained stable subsequently and he was called out to the floor. . #Hypotension -- Likely [**1-31**] to hypovolemia and [**Month/Day (2) **] loss, responded to bolus. Other possibilities include sepsis (though does not fit SIRS criteria), cardiogenic (no ECG changes), and adrenal insufficiency. Exercising caution given CHF and ESRD. Hypotension was resolved on discharge . #RUE edema -- The first step in work-up was an ultrasound showing no DVT but a possibility of stenosis involving his AV-fistula. This was examined with a fistulogram, showing areas of stenosis at the cephalic vein and more proximally near the stent he had placed (brachiocephalic vein). As his CVP was 17, IR was concerned that opening these lesions could lead to excessive venous return and CHF, so an echo was obtained. . #Anemia -- Pt has some baseline anemia, likely from chronic disease but also now has acute [**Month/Day (2) **] loss anemia. Follow frequent hct's and txf for hct < 28, given CAD, PVD, COPD. . #CAD -- No evidence of active ischemia, holding asa, clopidogrel, and metoprolol in setting of GI bleed/hypotension. . . Medications on Admission: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inh* Refills:*0* 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 10 days. Disp:*40 Tablet(s)* Refills:*0* 8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. Disp:*90 Tablet(s)* Refills:*2* 10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. 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* 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inh* Refills:*0* 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 10 days. Disp:*40 Tablet(s)* Refills:*0* 8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. Disp:*90 Tablet(s)* Refills:*2* 10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] home care Discharge Diagnosis: Upper Gastro-Intestinal Bleed Anemia End Stage Renal Disease Discharge Condition: stable, afebrile, ambulating via walker Discharge Instructions: -if you exeperience any new pains, fevers, chills, please call your PCP immediately [**Name9 (PRE) 19288**] you continue seeing that your stools are black, tarry and malodourous and you are feeling weak, or you see bright red [**Name9 (PRE) **] per rectum, call your primary care physician immediately [**Name9 (PRE) **] follow up with your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) **], 1 week post-discharge, please have Dr. [**Last Name (STitle) **] check your chemistries and your complete [**Last Name (STitle) **] count -patient is to have dialysis in [**Location (un) 2498**] 3x/week, Mon, Wed, Friday. R arm arterio-venous fistula is ready to use for dialysis. -please take all medications as directed Followup Instructions: Provider [**Name9 (PRE) 11888**],MULTI CUTANEOUS ONCOLOGY Where: CUTANEOUS ONCOLOGY Date/Time:[**2170-10-24**] 9:15 . Provider [**Name9 (PRE) **],[**Name9 (PRE) 19848**] CUTANEOUS ONCOLOGY Where: CUTANEOUS ONCOLOGY Date/Time:[**2170-10-24**] 9:30 . -Dr. [**Last Name (STitle) **]: Patient was found to have a nodular opacity of the left upper lobe by CT scan. Follow up imaging is advised in 3 months. Completed by:[**2170-10-4**]

[ "305.1", "729.81", "428.0", "996.1", "719.41", "457.1", "285.1", "V15.3", "286.9", "V10.82", "535.61", "496", "285.29", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.95", "44.43", "39.95", "39.50", "39.90", "99.04" ]

icd9pcs

[ [ [] ] ]

10853, 10910

6409, 8153

309, 514

11015, 11057

3285, 6386

11820, 12253

2370, 2482

9516, 10830

10931, 10994

8179, 9493

11081, 11797

2497, 3266

248, 271

542, 1773

1795, 2129

2145, 2354

16,881

147,845

3747

Discharge summary

report

Admission Date: [**2165-10-3**] Discharge Date: [**2165-10-9**] Date of Birth: [**2091-1-9**] Sex: M Service: GENERAL S. HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old male with a complex medical history including history of renal cell carcinoma for twelve years, status post bilateral nephrectomies. The patient presented for a routine colonoscopy, which showed carcinoma of the left colon above numerous diverticula. Of note, Dr. [**Last Name (STitle) 175**] removed a carcinoma from the right side of his chest as well. PAST MEDICAL HISTORY: 1. History is significant for bilateral nephrectomies. 2. Renal cell carcinoma, now on hemodialysis. 3. Coronary artery disease, status post myocardial infarction. 4. Insulin dependent diabetes mellitus. 5. Hypertension. 6. Coronary artery disease, status post coronary artery bypass graft times three. 7. Hypercholesterolemia. 8. Pacemaker status post right and left A-V fistulas. 9. Status post thoracotomy. MEDICATIONS: 1. Captopril. 2. Glyburide. 3. Prilosec. 4. Colace. 5. Aspirin. 6. Renagel. 7. Lipitor. 8. Plavix. SOCIAL HISTORY: The patient is a retired furniture dealer who lives with his wife. PHYSICAL EXAMINATION: Examination revealed the following: On examination, the pupils were equal and round. Teeth were normal. No Virchow nodes. Thyroid was nonpalpable. There were no bruits. Chest was clear to auscultation. Cardiac examination revealed a grade 2 apical systolic murmur with regular sinus rhythm. There was a well healed mediastinotomy scar. There was a pacemaker placed on the left chest and venous access catheter on the right chest. There is one testicle absent on examination. Stool guaiac was negative. HOSPITAL COURSE: Because of the known diagnosis of carcinoma of the left colon, the patient was admitted for an elective sigmoid and left colectomy with re-anastomosis. The patient underwent this procedure on [**2165-10-3**]. Please see the operative note for details. Postoperatively, the patient was taken to the Intensive Care Unit. The patient was noted to have tolerated the procedure well. Renal consultation was obtained due to the dependence on hemodialysis and coordination. Perioperative antibiotics included Vancomycin and Gentamicin for coverage of a Staphylococcus and ac Acetobacter bacteremia, which had recently been found as a result of outpatient blood cultures from the outpatient dialysis unit. On postoperative day #1, the patient was found to be doing well. The patient was extubated and had a temporary left groin line placed for dialysis access. On postoperative day #2, the patient continued to do well. The antibiotics were continued. On postoperative day #3, the patient continued to do well. Infectious Disease consultation had been obtained and the postoperative antibiotic regimen including Vancomycin, Gentamicin, and Levofloxacin dosed at dialysis. On postop day #4, the patient was found to be stable. He was transferred to the floor. It was noted that he had exhibited some nausea and emesis. Early on postoperative day #4 he was passing flatus. He had not passed a bowel movement. He was afebrile. The blood cultures taken here began growing gram negative rods. On this day, after hemodialysis, the temporary dialysis catheter in the groin was removed. On postoperative day #5, the patient underwent a tunnelled hemodialysis catheter placement by the Department of Interventional Radiology for continued long-term dialysis access. The Vancomycin, Gentamicin, and Levofloxacin were continued. The patient tolerated the placement of the catheter without incident. By postoperative day #6, the patient had remained afebrile. He had a bowel movement and he was generally feeling well. The Infectious Disease staff recommended outpatient treatment, which was to continue the Vancomycin, Levofloxacin, and Flagyl, as an outpatient with levels checked at outpatient dialysis. The patient was subsequently discharged home to follow up with Dr. [**Last Name (STitle) 957**]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to home. DISCHARGE DIAGNOSES: 1. Colon cancer. 2. Status post left hemicolectomy. 3. End-stage renal disease. 4. Non-insulin-dependent diabetes mellitus. 5. History of renal cell carcinoma. 6. Status post bilateral nephrectomies. 7. Coronary artery disease status post pacemaker placement. DISCHARGE MEDICATIONS: Preoperative medications with the addition of Vancomycin, Gentamicin, Levofloxacin to be doses at dialysis. FOLLOW-UP PLAN: The patient is to follow up in the clinic with Dr. [**Last Name (STitle) 957**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 16855**] MEDQUIST36 D: [**2165-10-30**] 12:26 T: [**2165-10-30**] 13:13 JOB#: [**Job Number 16856**]

[ "250.00", "153.1", "V10.52", "276.2", "V45.81", "996.62", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "45.75" ]

icd9pcs

[ [ [] ] ]

4180, 4448

4472, 4926

1764, 4072

1233, 1746

584, 1125

1142, 1210

4097, 4159

48,124

117,438

40780

Discharge summary

report

Admission Date: [**2165-6-18**] Discharge Date: [**2165-7-2**] Date of Birth: [**2091-5-3**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: Pleural effusion Major Surgical or Invasive Procedure: [**2165-6-21**]: Right VATS (video-assisted thoracic surgery) exploration, right thoracotomy and decortication, flexible bronchoscopy with bronchoalveolar lavage. History of Present Illness: Ms. [**Known lastname **] is a 74 year old woman who underwent RML sleeve resection on [**2165-5-31**] for carcinoid of the bronchus intermedius. She was sent home POD4 in stable condition with no specific complaints. She has been doing well at home and returns to clinc today for 2 week follow-up. She reports feeling well, that her cough is nearly gone and her pain is well controlled on <3 dilaudid tabs per day. Her CXR today shows right pleural effusion and small pneumothorax. She denies productive cough, pleuritic pain, fevers, chills or other concerning symptoms. Past Medical History: Right bronchus intermedius Carcinoid s/p sleeve resection [**2165-5-31**] Thyroidectomy for fetal adenoma [**2127**] Hyperlipidemia Asthma GERD Osteoporosis Social History: Married lives with spouse. Children. [**Name2 (NI) 1139**] never. ETOH social. Family History: Mother COPD died age 84 Father died of MI at age 48 [**2114**] Siblings MI younger brother died age 60 Physical Exam: VS: T: 99.8 HR: 78 SR BP: 140-170/78 Sats: 98% RA General: 74 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1.S2 no murmur Resp: clear breath sounds throughout GI: benign Extr: warm no edema Incision: Right thoractomy incision clean, dry intact no erythema Neuro: awake, alert oriented Pertinent Results: [**2165-7-2**] WBC-12.7* RBC-2.98* Hgb-9.1* Hct-27.3 Plt Ct-363 [**2165-7-1**] WBC-10.5 RBC-2.75* Hgb-8.3* Hct-24.8 Plt Ct-268 [**2165-6-29**] WBC-15.2* RBC-3.05* Hgb-9.4* Hct-27.9 Plt Ct-322 [**2165-6-28**] WBC-10.3 RBC-3.16* Hgb-9.5* Hct-28.5 Plt Ct-307 [**2165-6-21**] WBC-27.0* RBC-3.86* Hgb-12.5 Hct-34.9 Plt Ct-468* [**2165-6-18**] WBC-12.3* RBC-3.92* Hgb-12.2 Hct-35.1 Plt Ct-420 [**2165-7-2**] Glucose-96 UreaN-15 Creat-2.0* Na-142 K-3.8 Cl-103 HCO3-28 [**2165-7-1**] Glucose-93 UreaN-15 Creat-2.2* Na-139 K-3.5 Cl-105 HCO3-27 [**2165-6-30**] Glucose-86 UreaN-15 Creat-2.2* Na-139 K-3.6 Cl-104 HCO3-25 [**2165-6-27**] Glucose-90 UreaN-10 Creat-1.5* Na-137 K-4.0 Cl-101 HCO3-30 [**2165-6-21**] Glucose-102* UreaN-24* Creat-1.1 Na-126* K-4.1 Cl-88* HCO3-25 [**2165-6-18**] Glucose-124* UreaN-9 Creat-0.7 Na-140 K-3.8 Cl-103 HCO3-25 [**2165-7-2**] Calcium-8.7 Phos-3.9 Mg-1.9 Micro: [**2165-6-21**] TISSUE RIGHT PLEURAL DEBRIS. GRAM STAIN (Final [**2165-6-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. TISSUE (Final [**2165-6-24**]): STAPH AUREUS COAG +. SPARSE GROWTH. STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2165-6-25**]): NO ANAEROBES ISOLATED. [**2165-6-30**] C diff negative [**2165-6-29**] C diff negative [**2165-6-21**] PLEURAL FLUID + MRSA [**2165-6-21**] PLEURAL FLUID + MRSA [**2165-6-21**] BRONCHOALVEOLAR LAVAGE negative [**2165-6-21**] URINE CULTURE negative [**2165-6-21**] BLOOD CULTURE MRSA 4/4 bottles [**2165-6-18**] PLEURAL FLUID negative [**2165-6-18**] PLEURAL FLUID + MRSA IMAGING DATA: CT chest:[**2165-6-21**] 1. Large, probably loculated right pleural effusion and smaller volume of pleural air, projecting through the intercostal plane into the submuscular right chest wall, probably facilitated by separated surgical rib fractures. 2. Diffuse narrowing, right bronchial tree distal to the main bronchus, not due to hematoma. 3. Moderately severe atelectasis, right lung, probably due to a combination of bronchial narrowing and restriction by thickened pleura and pleural effusion. No right pleural drain is seen currently. CXR [**6-27**] There is no change from [**2165-6-26**]. The right chest tube remains in place. Small bilateral pleural effusions and associated atelectasis, right greater than left, are stable. The cardiac and mediastinal silhouettes and hilar contours are unchanged. A small right apical air collection is stable without evidence of tension. Subcutaneous air in the right chest wall is again noted. The left PICC ends in the mid to low SVC. Echogardiogram [**2165-7-2**]: A patent foramen ovale is present. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis. A patent foramen ovale was present. Brief Hospital Course: Mrs. [**Known lastname **] was admitted [**2165-6-18**] from the thoracic clinic following thoracentesis for 600 mL and placement of a right pigtail. Serial chest films revealed no change in right pleural effusion and pneumothorax. Chest CT [**2165-6-21**] revealed a loculated effusion and the patient had a rising white count. She was taken to the operating room for a Right VATS (video-assisted thoracic surgery) exploration, right thoracotomy and decortication, flexible bronchoscopy with bronchoalveolar lavage. Intraoperative she was found to a have a couple purulence pockets which was drained and cultures sent. She was started on Vancomycin and Zosyn. The cultures were MRSA vancomycin sensitive. The Zosyn was discontinued and a week course of Vancomycin was continued. She transfer to the PACU was hypotensive and tachycardic requiring pressors and volume and was transfer to the TICU with MAPs in the 70's. Overnight she improved titrated off pressors with MAPs > 60. She was given IV fluids. Her free water was restricted for hyponatremia and she normalized over the next 48 hrs. Her Lopressor was restarted for occasional ectopy. On [**2165-6-24**] she remained stable and was transfer to the floor. Below is a systems review of her hospital course: Respiratory: Nebulizers and incentive spirometry were continued, and she titrated off oxygen with saturations of 93-97% on room air. Chest tubes: She had right anterior and basilar chest tubes. Once the culture were finalized the anterior chest tube was removed on [**2165-6-26**] and the basilar converted to a Pneumostat and will slowly be removed over several weeks to prevent a pocket formation. Cardiac: The patient remained hemodynamically stable in sinus rhythm 80-90's with no further ectopy. Her Lopressor was continued. Blood pressures were 140-150's and her HCTZ was restarted. She continued to be hypertensive. Amlodipine 2.5 mg daily was started [**2165-7-2**]. GI: PPI and bowel regime Nutrition: tolerated a regular diet Renal: The patient developed climbing creatinine on [**2165-6-27**] plateau to 2.2 on discharge was 2.0. This was felt to be due to vancomycin which was discontinued [**2165-6-27**]. Her urine output was excellent. ID: She remained afebrile. Leukocytosis peak 27 which normalized following empyema drainage and antibiotics. She was initially started on vanc/Zosyn per above history but changed to ceftaroline 400mg IV bid on [**2165-6-28**] switched to 300mg IV bid (renal dosing). C.diff x 2 was negative. TEE on [**2165-7-1**] was negative for endocarditis. Pain: The patient had confusion with narcotics transition to Lidoderm patch, tramadol and acetaminophen with good pain control. Neuro: episode of confusion while in ICU which cleared once transfer to floor, limited narcotic use and a good night sleep. No further confusion occurred while on the floor. Disposition: She was seen by physical therapy and transfer to [**Hospital1 **] on [**2165-7-2**]. She will follow-up with Dr. [**Last Name (STitle) **] in 1 week for chest tube to be pulled back slowly and infectious disease. Medications on Admission: Albuterol IH, Atorvastatin 40 mg daily, Ezetimibe 10 mg daily, Fenofibrate 48 mg daily, HCTZ 25 mg daily, Levothyroxine 125 mcg daily, Metoprolol 50 [**Hospital1 **], Singulair 10 mg daily, Omeprazole 20 mg daily, Raloxifene 60 mg daily, Calcium Carbonate [**Telephone/Fax (1) 89122**] [**Hospital1 **], Fish Oil daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. montelukast 10 mg 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. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for stomach discomfort. 7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours). 10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL of NS followed by heparin. 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in [**1-13**] on either side of thoracotomy incision. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed for dyspnea. 15. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. ceftaroline fosamil 600 mg Recon Soln Sig: Four Hundred (400) mg Intravenous every twelve (12) hours for 4 weeks: continue until seen by ID [**2165-7-29**]. 17. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Right MRSA empyema s/p R VATS decortication [**2165-6-21**] Right middle lobe carcinoid s/p RML sleeve resection [**2165-5-31**] Thyroidectomy for fetal adenoma [**2127**] Hyperlipidemia Asthma GERD Osteoporosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience -Fevers greater than 101.5, chills, sweats -Increased shortness of breath, cough or chest pain Pneumostat (chest tube) -Empty daily. Change dressing daily Pain: -Acetaminophen 650 mg every 6 hours as needed for pain -Neurontin 100mg po tid -Ultram 25-50 mg mg take every 6 hours as needed for pain Activity -Shower daily. Wash incision with mild soap & water, rinse pat dry -No swimming, tub baths or hot tubs until incision healed Antibiotics: Ceftaroline 400 mg IV BID continue until seen by infectious diseae on [**7-16**] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2165-7-9**] 3:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray 4th Radiology 30 minutes before your appointment Follow-up with Dr. [**Last Name (STitle) **] Radiation oncology when the chest-tube has been removed. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2165-7-16**] 12:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Basement level Weekly CBC, Chem 7 LFTs, ESR, CRP fax to ID RN [**Telephone/Fax (1) 1419**] Completed by:[**2165-7-9**]

[ "272.4", "512.8", "995.91", "733.00", "276.1", "511.9", "510.9", "458.29", "998.31", "041.12", "209.61", "530.81", "E878.2", "584.5", "038.9", "493.90", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "34.03", "38.93", "34.04", "34.51", "34.09", "33.24" ]

icd9pcs

[ [ [] ] ]

10865, 10937

5541, 8646

326, 492

11193, 11193

1909, 5518

11982, 12669

1389, 1494

9015, 10842

10958, 11172

8672, 8992

11344, 11959

1509, 1890

269, 288

520, 1095

11208, 11320

1117, 1276

1292, 1373

12,351

178,821

20099

Discharge summary

report

Admission Date: [**2186-1-11**] Discharge Date: [**2186-1-15**] Date of Birth: [**2111-4-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Endoscopy blood transfusion History of Present Illness: 74 yo man with h/o CAD s/p MI x3, CHF (EF 40%), HTN, chronic a. fib (off coumadin since [**9-/2185**] [**2-3**] to GI bleed) who p/w melanotic stools for the 3rd time since [**Month (only) **]. . He reports that he noticed dark black stools since the morning 1 day PTA ([**2186-1-10**]). He denies diarrhea as well as any bright red blood. He further denies lightheadedness/dizziness even with ambulation. No chest pain/palpitations. He believes that his breathing is slightly worse than his most recent baseline on recent discharge from the hospital on [**2187-1-1**]. He has been ambulating with PT at home with dyspnea after approx 20 steps and after [**3-5**] stairs. He reported the dark stool to his daughter who is [**Name8 (MD) **] RN who then requested that VNA draw labs which revealed hct of 18. He was then brought to [**Hospital1 18**] ED for low hct in the setting of melanotic stool. . In the ED, vitals revealed HR 84, BP 88/42, T 96.9, RR 18 O2 sat 98% on 2L (his home O2 level). Hct in the ED was 21.7 (down from 24.9 on recent [**2186-1-1**] discharge). His pressure transiently dipped to 70s systolic and was responsive to 1L NS and returned to mid to high 90s systolic (recent baseline per daughter has been 100-110s systolic). NG lavage was negative for blood. He has had no further stools. He has MDS with assoc. anemia at baseline and hct appears to run 27-29 generally. . Per his daughter, EGD was performed at the time of his [**9-7**] bleed at OSH and revealed a large gastric ulcer. It is unclear whether this was biopsied and if H. pylori studies were sent, but it does not appear that he has been treated for H. pylori. Additionally he has been taking only once daily PPI. His coumadin (which he was on for chronic a. fib) was discontinued at that time. He was placed on ASA and plavis following his BMS which was placed in [**11-7**]. . ROS: No fevers/chills/URI sx/cough. No lightheadedness/dizziness, no changes in vision, no focal numbness/tingling/weakness, no CP/palpitations, no dysuria/hematuria/trouble starting/stopping stream. + urinary frequency [**2-3**] to lasix. He denies orthopnea/PND, does occasionally have LE edema, but not since his last admission and feels that his abdominal girth and weight is down if anything. . Past Medical History: 1. CAD status post MI [**2167**], s/p PTCA [**2167**], s/p 2-vessel CABG in [**12/2182**], with LIMA to LAD, SVG to OM1; s/p BMS to LCx in [**11/2185**] 2. CHF, [**2185-12-27**] echo EF 40%, No AR, 2+ MR, 4+ TR. 3. Aortic stenosis status post porcine AVR [**12/2182**] - normal AV gradient 4. Hypertension 5. Hypercholesterolemia 6. Chronic atrial fibrillation, Coumadin D/C'd [**2185-9-17**] secondary to GI bleed. 7. Bilateral fibrothoraces and history of recurrent pleural effusions. Status post right total decortication; pleural biopsies and fluid cytology benign. Status post left-sided decortication in [**11/2185**] complicated by hemothorax. 8. Thrombocytopenia, likely MDS. Baseline platelets 75-100K. Primary hematologist-oncologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4223**]. 9. Status post admission for UGI bleed [**9-/2185**], Coumadin D/C'd. 10. Pulmonary HTN Social History: Lives at home in [**Location (un) 17927**]. His daughter lives there as well and she is a nurse. He quit smoking in [**2167**], but prior to that has approx. 40pack yr smoking hx. He also rarely drinks EtOH, also since his MI in [**2167**]. Retired telephone technician. Family History: F d. 72 MI. M d. in 80s, uncertain cause. Physical Exam: Vitals: T 98.3 HR 84 A. fib BP 124/84 RR 20 O2 sat 100% 3lNC (80% RA) Gen: NAD, pleasant HEENT: MMM, EOMI Neck: JVP 7cm, supple, no LAD CV: Irreg. irreg. 3/6 systolic murmur heard best RUSB, but also appreciated diffusely. No radiation to the neck. Resp: decreased BS through apically as well as bibasilar. Abd: Obese, appears sl. distended, but pt. states his abd. girth has [**Month (only) **]. since his last admission. NTTP. No rebound/guarding. +BS. Ext: No C/C/E Neuro: A and Ox3, strength 5/5 throughout, sensation and CN 2-12 intact grossly. Pertinent Results: [**2186-1-11**] CXR: Persistent moderately sized left-sided pleural effusion. No evidence of acute interval change. . [**2185-12-27**] Echocardiogram: LVEF 40%, 2+MR, 4+TR, moderate pulmonary htn. . [**2182-12-31**] EGD: Esophagitis in the middle third of the esophagus and lower third of the esophagus. Food in the stomach body and antrum Erythema and friability in the fundus compatible with gastritis The stomach walls could not be completely visualized due to the food in the body. Otherwise normal EGD to pylorus. . [**2185-1-12**] EGD: mild gastritis. No clear source of bleeding to the 2nd portion of the duodenum. [**2186-1-11**] 06:40PM BLOOD WBC-5.2 RBC-2.21* Hgb-7.3* Hct-21.7* MCV-98 MCH-32.9* MCHC-33.4 RDW-22.5* Plt Ct-115* [**2186-1-12**] 02:57AM BLOOD WBC-5.0 RBC-2.36* Hgb-7.6* Hct-21.9* MCV-93 MCH-32.2* MCHC-34.7 RDW-21.6* Plt Ct-100* [**2186-1-12**] 07:48AM BLOOD Hct-23.6* [**2186-1-12**] 01:49PM BLOOD WBC-5.3 RBC-3.01*# Hgb-9.5* Hct-27.1* MCV-90 MCH-31.7 MCHC-35.2* RDW-21.2* Plt Ct-92* [**2186-1-12**] 09:59PM BLOOD Hct-25.9* [**2186-1-13**] 05:41AM BLOOD WBC-4.2 RBC-2.95* Hgb-9.2* Hct-26.9* MCV-91 MCH-31.2 MCHC-34.2 RDW-20.9* Plt Ct-82* [**2186-1-13**] 02:53PM BLOOD WBC-4.7 RBC-2.97* Hgb-9.4* Hct-27.5* MCV-93 MCH-31.5 MCHC-34.1 RDW-20.9* Plt Ct-80* [**2186-1-11**] 06:40PM BLOOD Neuts-76.3* Lymphs-15.5* Monos-5.5 Eos-2.4 Baso-0.4 [**2186-1-11**] 06:40PM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2* [**2186-1-12**] 02:57AM BLOOD PT-14.7* PTT-32.4 INR(PT)-1.3* [**2186-1-13**] 05:41AM BLOOD PT-14.6* PTT-31.9 INR(PT)-1.3* [**2186-1-11**] 06:40PM BLOOD Glucose-113* UreaN-29* Creat-0.8 Na-137 K-3.6 Cl-98 HCO3-30 AnGap-13 [**2186-1-12**] 02:57AM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-136 K-4.1 Cl-103 HCO3-26 AnGap-11 [**2186-1-13**] 05:41AM BLOOD Glucose-87 UreaN-22* Creat-0.7 Na-138 K-3.6 Cl-102 HCO3-29 AnGap-11 [**2186-1-11**] 06:40PM BLOOD ALT-12 AST-14 AlkPhos-85 Amylase-61 TotBili-0.6 [**2186-1-11**] 06:40PM BLOOD Lipase-23 [**2186-1-12**] 02:57AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.6 Mg-1.8 [**2186-1-13**] 05:41AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 EGD [**2186-1-12**]: Granularity, erythema and congestion in the antrum and stomach body compatible with gastritis Erosions in the antrum Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Per daughter's history, patient was found to have gastric ulcer on OSH EGD so this was considered a likely possibility. However, his gastric lavage was negative in the ED and repeat EGD in house showed only mild gastritis without evidence of active bleeding. A lower source seemed less likely given melanotic stools as well as a recent colonoscopy at outside hospital which showed multiple polyps which were removed at that time. Following EGD his PPI was decreased to once daily. His diet was advanced. He was restarted on once daily aspirin. However, as he had already received >4weeks of plavix following bare metal stent placement, his plavix was not restarted. This decision was discussed with his Cardiogist who was agreeable with that plan. He had no further melanotic stools. He received a total of 4 units PRBCs over the course of the admission with appropriate response in his hematocrit and no further evidence of bleeding. He was hemodynamically stable throughout his hospital course. His beta blocker and ace inhibitor were also held on admission in the setting of GI bleed, restarted prior to discharge. In the ICU He received 1.5L NS and 4U prbcs during his MICU course. He tolerated the volume well without evidence of volume overload on exam. He maintained O2 sats without any increase in dyspnea. As above, his beta blocker and ace inhibitor were held in the setting of GIB. Also held were his aldactone and lasix. Following his EGD, he was restarted on an IV dose of lasix equivalent to his po home dose. He diuresed well. However, his blood pressures became low. Patient remained asymptomatic. But it was thought that he was overly diuresed and his lasix were again discontinued. eventually restarted on the floor with normal BP. Patient on metoprolol and digoxin as an outpatient. Not anticoagulated with h/o GI bleed. He remained well rate controlled in the hospital. prior to discharge his statin was restarted as well. Pt to follow up with Dr. [**Last Name (STitle) **] for a small bowel capsule endoscopy per GI consult. He will make this apppointment as an outpatient. Medications on Admission: 1. ASA 81mg 2. Plavix 75mg daily 3. Zoloft 4. Colace 100mg [**Hospital1 **] 5. MVI 6. Iron 7. Folic acid 8. Zinc sulfate 50mg 9. Digoxin 125mcg 10. Aldactone 25mg 11. Zestril 5mg 12. Lopressor 50mg 13. Lasix 80mg [**Hospital1 **] 14. Nexium 40mg daily 15. Zocor 40mg daily 16. Albuterol prn 17. Magnesium hydroxide prn 18. Combivent MDI prn Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) puffs Inhalation twice a day. 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 11. Zestril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Acute Blood Loss Anemia Erosive Gastritis CHF Hypertension Atrial Fibrillation Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2000ml Return to the hospital if you experience black-tarry stools, abdominal pain, blood in your stool, nausea/vomitting, fever/chills Followup Instructions: You will need to make an appointment with your primary care doctor in the next 2-3 weeks ([**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 4475**]) Please schedule a Capsule Endoscopy to examine your small bowel by calling the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 2306**] in the next 2-3 weeks at the request of the gastroenterologist

[ "428.0", "V42.2", "416.8", "272.0", "535.41", "238.75", "427.31", "V45.81", "412", "401.9", "397.0", "285.1", "424.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

10243, 10294

6841, 8953

322, 351

10416, 10424

4532, 6818

10728, 11155

3898, 3942

9345, 10220

10315, 10395

8979, 9322

10448, 10705

3957, 4513

276, 284

379, 2666

2688, 3589

3605, 3882

26,124

189,432

48846

Discharge summary

report

Admission Date: [**2106-9-6**] Discharge Date: [**2106-10-28**] Date of Birth: [**2040-12-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 449**] is a 65 year old gentleman who was treated at [**Hospital6 2018**] for gallstone pancreatitis leading to necrotizing pancreatitis. PAST MEDICAL HISTORY: Prior medical history includes hypertension, noninsulin dependent diabetes mellitus, hypercholesterolemia, status post open appendectomy and status post hernia repair. MEDICATIONS AT HOME: Undocumented. ALLERGIES: No known drug allergies. NOTE: Due to a medical records error, Mr. [**Known lastname 60659**] [**Hospital 33930**] medical records were not located at the time of this dictation. Records reviewed for this dictation included the immediate postoperative period and the final two weeks of his hospitalization. [**Hospital 1739**] medical records, should they become available, will be added as an addendum to this dictation. CLINICAL COURSE: Mr. [**Known lastname 449**] is a 65 year old gentleman who was admitted from home with a 2 1/2 hour history of acute abdominal pain. He has had several episodes of vomiting, flank pain and pain radiating to his back. The diagnosis soon after admission was made of pancreatitis with a gallstone traveling from the gallbladder to the common bile duct. At the time of admission, his amylase was noted to be [**2027**]. In the first days of his hospitalization his abdominal pain, discomfort improved with Demerol and Vistaril, and it was felt that through intravenous fluid resuscitation, conservative management would be sufficient. In the following days, the patient's clinical course continued to decline with evidence of increasing abdominal tenderness, abdominal distention and on hospital day #4 darkened urine. The patient was soon started on prophylactic antibiotics and was kept in conservative treatment on the medical service for the next seven days. On hospital day #7 the patient began having increasingly frequent febrile episodes and had an increase in white blood cell count. Computerized tomography scan at that time was consistent with acute pancreatitis with increased peripancreatic inflammatory changes. There were also areas of low density within the body and tail of the pancreas and there was increasing concern for necrosis. Antibiotic coverage was then increased and the patient was transferred to the Medical Intensive Care Unit for resuscitation. On [**2106-9-25**], the patient went to the Operating Room for the first of two operative procedures. During that case, the patient underwent an extensive removal of dead tissue, and was returned to the Intensive Care Unit intubated. Following this, the patient was again taken to the Operating Room for re-look exploratory laparotomy, necrotic tissue debridement and placement of a feeding jejunostomy. The procedure proceeded without any complications and the patient was returned to the Intensive Care Unit. Intensive Care Unit course was as follows (reviewed by systems - 1. Neurologic - The patient's neurological status showed poor recovery from sedation. On [**2106-10-14**], neurology consult was requested which showed no focal lesions, however, some evidence of encephalopathy. Magnetic resonance imaging scan of the brain as well as lumbar puncture were all shown to be inconclusive. Electroencephalogram likewise was shown to show no definitive diagnosis. Over the subsequent two weeks, sedation continued to be weaned and at the time deficits continued to improve. There was persistent weakness in all extremities. The patient remained disoriented, however, became increasingly responsive and able to follow commands. 2. Cardiovascular - During his intensive care course, the patient had multiple episodes of tachycardia and hypertension. The tachycardia was ultimately rate-controlled with Lopressor and hypertension was controlled with intravenous Hydralazine. 3. Respiratory - The patient's respiratory status was a persistent problem during his Intensive Care Unit time and underwent several workups for possible pulmonary emboli. All of these episodes were shown to be negative for embolism and throughout he has responded to pulmonary toilet. 4. Gastrointestinal - At initial presentation, the patient was on total parenteral nutrition. This was gradually replaced with tube feeds. The tube feeds were at goal until it was found that the patient had positive cultures for Clostridium difficile colitis. Tube feeds were stopped and the patient was returned to total parenteral nutrition during antibiotic course for Clostridium difficile colitis. Following appropriate antibiotic course surveillance cultures confirmed negative Clostridium difficile. 5. Abdomen - The patient had multiple intraoperative as well as percutaneously placed drains. These drains maintained purulent drainage throughout his course in the Intensive Care Unit. On two occasions, drains fell out during transfer of the patient and he required replacement while in Interventional Radiology. On [**10-20**], the patient was transferred from the Intensive Care Unit to the normal surgical floor. Shortly thereafter hi clinical condition deteriorated once again with febrile episodes up to 103.2 and hypertensive episodes. After a full septic workup it was found that the patient had positive blood cultures for coagulase negative Staphylococcus. An additional percutaneous drain was placed by Interventional Radiology and the patient was again started on intravenous antihypertensives and returned to the Intensive Care Unit. On postoperative day #31 and 29, the patient was again deemed to be a good candidate for transfer to the Surgical Floor. At that time, the antibiotics included Vancomycin, Levofloxacin, Fluconazole and Flagyl. He was maintaining appropriate fluid and calorie goals on Peptamine tube feeds at a rate of 80 with the addition of 250 cc of water q.i.d. He had a Foley catheter in place. He also had a percutaneously placed pigtail catheter in place, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain in place and a gastrostomy tube in place. Once out of the Intensive Care Unit the patient's cognitive skills and attention level improved dramatically. He then became alert and oriented times three and was able to follow commands. Given the prolonged periods without temperatures and decreasing white count, his antibiotic coverage was narrowed to Vancomycin and Fluconazole. On postoperative day #33-31, the patient had a double lumen pigtail catheter placed in interventional radiology and efforts were began to find suitable placement for him. On postoperative day #34-32, the patient was on a stable tube feed diet, having begun to tolerate a soft diet by mouth and had been afebrile for over 72 hours. At that time he was screened for placement for rehabilitation and seemed to be a suitable candidate. DISCHARGE MEDICATIONS: 1. Oxymetazoline spray for nasal congestion b.i.d. 2. Viokase one to two tablets p.o. q.i.d. with tube feeds 3. Potassium chloride 20 mEq p.o. q. day 4. Lasix 20 mg p.o. q. day 5. Insulin per sliding scale 6. Hydralazine 20 mg intravenously q. 6 7. Fluconazole 400 mg intravenously q. day 8. Vancomycin 1 gm intravenously q. day 9. Ibuprofen 400 mg p.o. q. prn 10. Metoprolol 125 mg p.o. t.i.d. 11. Zinc sulfate 220 mg p.o. b.i.d. 12. Ascorbic acid 500 mg p.o. q. day 13. Lansoprazole oral suspension 30 mg per tube q. day 14. Amlodipine 10 mg p.o. q. day 15. Albuterol 10 puffs q. 4 hours prn for congestion CONDITION ON DISCHARGE: The patient is stable, beginning to tolerate a full diet, meeting adequate nutrition goals via tube feeds. DISPOSITION: The patient will be discharged to [**Hospital3 7558**] Facility. DISCHARGE DIAGNOSIS: Status post gallstone pancreatitis with subsequent necrotizing pancreatitis, requiring multiple debridements and washouts. FOLLOW UP: The patient will go to skilled nursing care facility where his weights should be followed on a daily level to assess fluid balance. He will be maintained on diuretic, Lasix 20 mg q. day in addition to potassium 20 mEq q. day. His potassium level should be assessed within one to two weeks of his transfer to skilled nursing facility to assure that he does not become hyperkalemic. The patient should plan to visit Dr. [**Last Name (STitle) **] in his office one to two weeks following discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) 6825**] MEDQUIST36 D: [**2106-10-27**] 14:44 T: [**2106-10-27**] 16:34 JOB#: [**Job Number 102621**] cc:[**Hospital3 102622**]

[ "567.2", "997.09", "560.81", "518.84", "008.45", "574.80", "577.0", "996.62", "789.5" ]

icd9cm

[ [ [] ] ]

[ "51.22", "38.93", "99.15", "54.59", "43.19", "96.04", "46.39", "52.22", "96.6", "54.25", "96.72", "54.91", "33.22", "96.08" ]

icd9pcs

[ [ [] ] ]

7017, 7636

7871, 7995

535, 6994

8007, 8814

160, 321

344, 513

7661, 7849

5,867

192,421

5115

Discharge summary

report

Admission Date: [**2139-9-30**] Discharge Date: [**2139-10-3**] Date of Birth: [**2088-7-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5119**] Chief Complaint: Chest pain /DKA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 19407**] is a 51 yo F with Type I DM, CAD s/p CABG who presented with nausea, vomiting and chest pressure. Her symptoms started at 5:30 pm with nausea and vomiting which is similar to her anginal equivalent. She later developed substernal chest pressure, [**4-28**] at rest which persisted until she came to the ED and was given NTG x2. She denies any associated dyspnea, light headeness, diaphoresis, arm/jaw pain. She had not taken Levemir in 2 days because she had lost a bottle and her insurance would not allow her to fill it early. She reports that for two days her glucometer was [**Location (un) 1131**] as high which likely is >500-600. She was taking increased humalog at home with meals however her glucose was still running hight. She takes 325mg ASA daily. . On ROS she endorses increased leg swelling over the past several weeks as well as increased fatigue with exertion. Otherwise she denies fevers, abdominal pain, cough, dysuria, hematuria, skin ulcers or wounds. . In the ED T 97.2 HR 55 BP 160/71 100% RA. Glucose was elevated at 522 with an anion gap of 22 and positive urine ketones. She was initially given reular insulin 10 units x 2 with decrease in her glucose to 439 and persistant anion gap so she was started on insulin gtt at 5 units/hour. She also had an EKG which showed increased ST depressions and T wave inversions in V3-V6 and new T wave inversions in III and aVF. She was given NTG x1 and morphine 2mg IV with resolution of her chest pain. First set of cardiac enzymes with CK of 93 and troponin of 0.04. She was also given zofran 4mg IV x2, compazine 10mg IV x1 and reglan 10mg IV x1 for nausea. She was given 3L NS prior to transfer. Past Medical History: DM1 Diastolic heart failure (normal EF) CAD s/p CABG [**2132**] CKD (bl cr 1.3) HTN Hyperlipidemia s/p L BKA [**2-24**] s/p cataract surgery Social History: lives alone, works as computer operator, non-smoker, past tobacco 1PPD x5 years from 16-21, social ETOH, denies any drug use. Family History: NC Physical Exam: vitals: 123/43 HR 66 RR 19 98% RA General: resting comfortable, A&O x3, +vomiting x1 HEENT: NC AT EOMI, left pupil post surgical, right pupil reactive Neck: obese, appears to have elevated JVP at angle of jaw CV: RRR s1 s2 no appreciable murmur Lungs: decreased breat sounds at the bases, otherwise CTA Abdomen: soft, diffuse mild tenderness, no rebound/guarding, hypoactive bowel sounds Ext: left leg s/p BKA, 1+ edema of right lower leg, trace right DP, no lesions or skin breakdown Neuro:grossly intact Pertinent Results: [**2139-9-30**] 01:50AM WBC-7.6 RBC-3.77* HGB-11.5* HCT-34.0* MCV-90 MCH-30.6 MCHC-33.9 RDW-13.4 [**2139-9-30**] 01:50AM NEUTS-86.6* LYMPHS-11.2* MONOS-1.8* EOS-0.2 BASOS-0.2 [**2139-9-30**] 01:50AM PLT COUNT-172 [**2139-9-30**] 01:50AM GLUCOSE-522* UREA N-56* CREAT-1.9* SODIUM-132* POTASSIUM-4.3 CHLORIDE-86* TOTAL CO2-26 ANION GAP-24* [**2139-9-30**] 01:50AM ALT(SGPT)-26 AST(SGOT)-23 CK(CPK)-108 ALK PHOS-124* TOT BILI-0.5 [**2139-9-30**] 01:50AM LIPASE-16 [**2139-9-30**] 01:50AM cTropnT-0.03* [**2139-9-30**] 01:50AM CK-MB-5 proBNP-2772* [**2139-9-30**] 01:50AM ALBUMIN-4.3 CALCIUM-9.4 MAGNESIUM-2.6 [**2139-9-30**] 01:50AM OSMOLAL-324* [**2139-9-30**] 06:00AM CK(CPK)-93 [**2139-9-30**] 06:00AM cTropnT-0.04* . [**2139-9-30**] CXR TWO VIEWS: There has been previous CABG with midline sternotomy wires and vascular clips in unchanged position. There are no pleural effusions, but there is mild pulmonary edema. No focal consolidation is identified. Osseous structures are unremarkable. IMPRESSION: Cardiomegaly with mild pulmonary edema. . [**2139-10-1**] KUB - IMPRESSION: No radiographic evidence for ileus or obstruction. Extensive vascular calcifications. Brief Hospital Course: Ms. [**Known lastname 19407**] is a 51 yo F with DM1, CAD s/p CABG presenting with diabetic ketoacidosis and chest pressure with ischemic EKG changes. . #Diabetic Ketoacidosis - The patient's DKA was most likely due to missing her levemir for 2 days prior to admission. She missed this medication secondary to difficulties getting insurance to cover this medication. She did not have any evidence of infection. She was transferrred to the MICU and treated with an insulin drip and intravenous fluids. The [**Hospital **] clinic was consulted to help manage her blood sugars. Her blood sugars stablized quickly and the patient was transistioned to subcutaneous dosing, and was transferred out of the ICU after a day. On the floor, she continued to have nausea/vomiting and had difficulty tolerating foods. She did not have any evidence of bowel obstruction. It was felt that her nausea may have been secondary to constipation. Her nausea was improved with reglan and an enema. . #Chest Pain/ischemic EKG changes: She developed substernal chest pressure shortly after admission. She was monitored on telemetry without any arrhythmias. Her cardiac enzymes did not increase on serial testing. However, she did have some non-specific EKG changes possibly secondary to demand ischemia. She was treated with an aspirine, lipitor and metoprolol. She was hypotensive on admission, but eventually her blood pressure normalized and she was restarted on the rest of her home anti-hypertensives (valsartan, amlodipine and lasix). Recommend outpatient cardiology follow up and possible perstantine MIBI. . #Acute on Chronic kidney disease - The patient presented with acute renal failure secondary to dehydration in the setting of DKA. Her creatinine returned to [**Location 213**] after fluid repletion. . #Diastolic heart failure - Patient had a mild increase in lower extremity edema and fatigue with exertion as well as CXR with pulmonary edema and elevated JVP. Patient required diuresis after fluid repletion. . #Hyperlipidemia - stable. continue atorvastatin . #Hypertension - continued outpatient medications as listed above. . #Anemia - mild anemia at baseline for which she takes iron supplementation. HCT stable. Medications on Admission: AMLODIPINE 5 mg Tablet daily FUROSEMIDE 40 mg Tablet [**Hospital1 **] LEVEMIR 20 units [**Hospital1 **] HUMALOG as instructed by Dr. [**Last Name (STitle) **] 4-10U 3-4 times a day METOPROLOL SUCCINATE 50 mg daily OMEPRAZOLE - 20 mg daily lipitor 40 mg Tablet qhs VALSARTAN - 40MG Tablet daukt ASPIRIN [ECOTRIN] - 325 mg daily FERROUS SULFATE - 325 mg daily Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at [**Last Name (STitle) 21013**]. 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at [**Last Name (STitle) 21013**])) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous At breakfast. Disp:*qs units* Refills:*2* 13. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous At dinner. 14. Humalog 100 unit/mL Solution Sig: Per sliding scale units Subcutaneous four times a day. 15. Outpatient Physical Therapy Patient should continue outpatient physical therapy for help with use of left lower extremity prosthesis. Discharge Disposition: Home with Service Discharge Diagnosis: 1) Diabetic ketoacidosis 2) Chest pain Secondary: 1) Coronary artery disease 2) Insulin dependent diabetes mellitus Discharge Condition: afebrile, displaying normal vital signs, tolerating a regular diet Discharge Instructions: You were admitted to the hospital for chest pain, nausea and vomiting. You were found to have a severe electrolyte disorder called diabetic ketoacidosis that may have occurred as a result of missing insulin doses. You were treated with intravenous fluids and an insulin drip. Your insulin dose was then changed back to a long-acting and short-acting insulin. You were also treated with medications to help control nausea. After discharge it is very important to continue to take your insulin as prescribed, and call your doctor if you are feeling poorly or not able to eat and drink normally. Continue to take all medications as prescribed and keep all scheduled health care appointments. If you experience chest pain, shortness of breath, abdominal pain, nausea, vomiting, confusion, lightheadedness, or if you feel worse in any way, seek immediate medical attention. Followup Instructions: You have a follow-up appointment Monday, [**10-12**] at 4:00pm with your cardiologist, Dr. [**Last Name (STitle) **] on [**Hospital Ward Name 23**] 7. You have a follow-up appointment with your primary care doctor, Dr. [**First Name (STitle) 1022**] on Thursday, [**10-8**] at 3pm. Provider: [**First Name8 (NamePattern2) 21015**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-10-8**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2139-10-12**] 4:00 Provider: [**First Name8 (NamePattern2) 21015**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2140-1-28**] 2:00 [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2139-10-6**]

[ "428.0", "584.9", "276.51", "V58.67", "403.90", "733.00", "272.4", "428.32", "585.2", "250.13", "285.21", "411.1", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8311, 8330

4164, 6393

331, 338

8490, 8559

2948, 4141

9478, 10368

2400, 2404

6802, 8288

8351, 8469

6419, 6779

8583, 9455

2419, 2929

275, 293

366, 2075

2097, 2240

2256, 2384

12,733

176,695

6460

Discharge summary

report

Admission Date: [**2188-10-29**] Discharge Date: [**2188-11-3**] Date of Birth: [**2128-7-16**] Sex: M Service: MED Allergies: Penicillins Attending:[**First Name3 (LF) 613**] Chief Complaint: "Black stools" Major Surgical or Invasive Procedure: Blood transfusion History of Present Illness: 59yo M with ESRD on HD, CAD s/p CABG s/p stenting to LMCA in [**6-26**], presented to the [**Hospital1 18**] on [**2188-10-29**] with dizziness with black stool. . Pt was in his USOH until [**2188-10-29**] when he returned from HD to home at 6pm. Experienced nausea, ate "spicy schezuan" meal, then had abd upset and passed brown/black stools. Went to bed and at MN awoke and passed black diarrhea. Felt dizzy and felt that BS might be low; on way to fridge, collapsed with LOC, with sudden feeling of dizziness and weakness. Denies CP, palps, SOB. Regained conciousness and called EMS. This was pt's first episode of melana. Denies GERD. . Pt takes aspirin and plavix. Sigmoidoscopy 2mo ago was unremarkable. . While in [**Name (NI) **], pt rec'd R femoral line, a-line, and 2 U pRBC's. Had episodal emesis trace. Vitals on presentation to ER: 98.4 91 104/91 10 100%FM Pt noted to have ST depressions on presentation. Past Medical History: 1. Cardiac - CAD s/p CABG [**2171**] (LIMA --> LAD, SVG --> OM). - NSTEMI in [**6-26**] s/p left main stent, PTCA x 2. - Nuclear stress test in [**4-27**] with reversible defects in the LAD and PDA territories. 2. CHF - H/o systolic and diastolic HR. Echo [**2-27**] showed EF 30%. 3. PVD s/p R TMA. 4. DM. 5. HTN. 6. Hypercho. 7. ESRD on HD since [**2188**], [**2-25**] to DM2. S/p insertion of RIJ permacath and [**2-27**] placement of L brachiocephalic fistula. 8. H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10834**] 4 melanoma, s/p right shoulder ressection in [**Month (only) **] [**2188**], no reccurence. Social History: Lives with mother in [**Name (NI) 4628**]. 20 py smoking history but quit in [**2187**]. No EtOH. No IVDU. Family History: Mother - recent stroke. Physical Exam: Morbidly obese, well-appearing, NAD, talkative, A+Ox3 MMM, o/p clear EOMI, PERRL RRR, 2/6 SEM loudest at LUSB Lungs CTA bilaterally Abd Soft, distended, obese, +BS Extr 2+ pitting edema bilaterally Pertinent Results: [**2188-10-29**] 10:45AM WBC-16.5*# RBC-3.29* HGB-10.6*# HCT-31.8* MCV-97 MCH-32.3* MCHC-33.4 RDW-15.3 [**2188-10-29**] 10:45AM PLT COUNT-259 [**2188-10-29**] 10:45AM NEUTS-80.1* LYMPHS-14.3* MONOS-4.5 EOS-0.5 BASOS-0.6 [**2188-10-29**] 01:23PM LACTATE-2.9* . [**2188-10-29**] 10:45AM GLUCOSE-377* UREA N-100* CREAT-8.7*# SODIUM-140 POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-25 ANION GAP-27* [**2188-10-29**] 10:45AM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-3.3# MAGNESIUM-1.8 [**2188-10-29**] 10:45AM ALT(SGPT)-38 AST(SGOT)-26 LD(LDH)-226 CK(CPK)-57 ALK PHOS-131* AMYLASE-57 TOT BILI-0.3 . CK 57 --> --> 209 --> --> 57 CKMB 15 --> --> 5 cTnT .16 --> --> 1.14 Brief Hospital Course: 1. GIB: Pt seen by GI who did not want to emergently scope pt since he was having an NSTEMI. He recieved 1 unit PRBCS in the ED and another 2 overnight within 12 hrs of his arrival to the unit. His vitals signs remained stable and Hct bumped appropriately to the mid 30's after the two units (29.8 --> 34.5). He arrived with a femoral cordis, which later was displaced, so two periperhal IVs were started. Protonix IV. Q6h hcts were done, and then decreased to q8 and then q12. He was called out on the morning of his first hopsital day since he was stable and was transferred to the [**Hospital Ward Name **] on HD #2. The pt had no further episodes of melena in the hospital and was entirely asymptomatic. Diet was adv as tolerated, and plan was for outpt EGD and colonoscopy in 2-3wks. Plavix and beta-blocker were held in hospital. Transfusion goal was hct>30; pt did not require further transfusion. After discussion with GI, pt was discharged on aspirin and on a [**Hospital1 **] PPI (new) prior to the procedure. Pt was instructed to hold plavix at home until the colonoscopy. . 2. NSTEMI: In the [**Last Name (LF) **], [**First Name3 (LF) **] EKG showed ST segment depressions and TWI in the lateral leads which were different from prior EKG. His troponin was 0.16 in the ED but increased 8 hours later, along with a rise in his CK and MB. These continued to climb over the next 24 hours, but plateued by the second hospital day. Serial EKG's were checked which showed no new change. Cardiology consult obtained in the ED; decision was to defer intervention as this was likely demand ischemia, hold plavix since he had been 1 yr out form his stnet placement. Pt placed on tele with no events and he never had chest pain or other anginal symptoms. On the floor, pt had several brief episodes of asymptomatic bradycardia to 30's with increased ectopy. An EKG showed no changes. Echo showed: EF > 60%. No AS, no AR. Mild PA HTN. Suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. . 3. ESRD: Renal consult obtained in ED did not find a need for emergent HD. Pt had HD on ICU day 1. Pt's home HD is Tu/Th/Sat. . 4. DM: On home regimen with good control. . 5. Hyperchol. Increased lipitor to 40qd. . 6. Proph: PPI, OOB . 7. Pt discharged to home with very close follow-up: PCP, [**Name10 (NameIs) 2085**], GI Medications on Admission: Insulin 70/30, 30qAM 30qPM Aspirin 325 Nephrocaps Lisinopril 10 Lipitor 10 Plavix 75 Tums Lopressor 5 [**Hospital1 **] Discharge Medications: 1. 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* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*0 * Refills:*0* 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 8. Insulin 70/30 70-30 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: Take 20 units in am and 20 units in pm. Discharge Disposition: Home Discharge Diagnosis: 1. GI bleed 2. Diabetes mellitus 3. Hypertension 4. Elevated cholesterol 5. Coronary artery disease 6. History of myocardial infarction 7. End stage renal disease on hemodialysis Discharge Condition: Good Discharge Instructions: Call or return if you develop chest pain, shortness of breath, lightheadedness, or dizziness. Call or return if you develop nausea, vomiting, abdominal pain, black stools or bloody stool. * Please DO NOT take your plavix until you have either spoken with Dr. [**Last Name (STitle) 911**] or had your colonoscopy and spoken with the gastroenterologist. * You will receive receive a prescription for protonix, which is important after your GI bleed. Followup Instructions: 1. Follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week. 2. Follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]. Please call [**Telephone/Fax (1) 62**] for an appointment. 3. Follow-up with a gastroenterologist for an outpatient colonoscopy in two weeks. Call [**Telephone/Fax (1) **]. 4.Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-1-7**] 10:00. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "272.0", "412", "428.0", "410.71", "250.00", "285.1", "V45.81", "578.9", "458.9", "428.42", "V10.82", "403.91" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

6420, 6426

2995, 5345

282, 302

6649, 6655

2306, 2972

7152, 7861

2048, 2073

5514, 6397

6447, 6628

5371, 5491

6679, 7129

2088, 2287

228, 244

330, 1255

1277, 1908

1924, 2032

17,904

166,593

46890

Discharge summary

report

Admission Date: [**2176-5-25**] Discharge Date: [**2176-5-29**] Date of Birth: [**2112-11-25**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Toradol / Talwin Nx Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: This is a 63-year-old woman with tracheal stenosis status post laryngeotracheal resection x2 following recent revision surgery who presents with recurrence of tracheal stenosis. The patient also notes hemoptysis, which has occurred infrequently, last occurring 2 weeks ago appearing as clots mixed with sputum, which resolved spontaneously. Patient had stent placement by interventional pulmonology [**5-22**] due to worsening stenosis. Patient was discharged, and shortly returned complaining of shortness of breath and neck pain. Past Medical History: Carotid stenosis and cerebrovascular accident, diabetes mellitus, lupus, hypothyroid, bilateral mastectomies for cystic disease Social History: The patient is married and lives with her husband. She is a former office secretary. She is a former smoker with 60 pack year history who quit 10 years ago. She has no known asbestos exposure. Family History: Her mother died due to complications related to coronary artery disease, and her father of cerebrovascular accident (CVA). Physical Exam: gen: anxious, but comfortable. no acute distress vs: 98.7 91 131/67 29 95% 2L chest: clear to auscultation cv: regular rate and rhythm ab: soft nontender nondistended ext: no clubbing or edema Pertinent Results: [**2176-5-25**] 07:40PM BLOOD WBC-14.8* RBC-4.30 Hgb-11.1* Hct-34.9* MCV-81* MCH-25.7* MCHC-31.6 RDW-13.9 Plt Ct-280 [**2176-5-28**] 07:45AM BLOOD WBC-12.6* RBC-4.70 Hgb-12.3 Hct-38.0 MCV-81* MCH-26.3* MCHC-32.5 RDW-13.6 Plt Ct-333 [**2176-5-27**] 05:52AM BLOOD PT-13.4* PTT-26.5 INR(PT)-1.2 [**2176-5-27**] 05:52AM BLOOD Plt Ct-306 [**2176-5-27**] 05:52AM BLOOD Glucose-250* UreaN-12 Creat-0.9 Na-137 K-4.0 Cl-102 HCO3-27 AnGap-12 [**2176-5-27**] 05:52AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8 RADIOLOGY Final Report **ABNORMAL! CT CHEST W&W/O C [**2176-5-25**] 10:22 PM CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Reason: eval for possible abscess in trachea, eval for narrowing of Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with recent tracheal stent placement REASON FOR THIS EXAMINATION: eval for possible abscess in trachea, eval for narrowing of trachea CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 63-year-old woman with recent tracheal stenting, distant partial tracheal resection and multiple biopsies, evaluate for possible abscess or peritracheal fluid collection. COMPARISON: Chest x-ray done the same day. TECHNIQUE: Axial MDCT images through the chest with and without IV contrast. Coronal and sagittal reformats were performed. CT CHEST WITH AND WITHOUT IV CONTRAST: At the superior portion of the trachea imaged, there is moderate narrowing and a focal soft tissue density along the right lateral aspect of the trachea. Tracheal stent is identified and appears well positioned. Tiny anterior tracheal diverticulum noted at the level of the stent. The trachea is grossly patent from this point more distally. There is a small- to- moderate amount of peritracheal inflammatory changes, which is likely post- surgical/procedural. No focal fluid collection or abscess is identified. There is no evidence of tracheal perforation. No abnormal lymph nodes are identified. The vasculature is within normal limits. The heart and pericardium are unremarkable. The lungs are clear. A tiny 5-mm nonspecific nodular opacity in the right mid lung along the course of the major fissure. Limited axial images through the upper abdomen demonstrate no gross abnormalities. Bone windows demonstrate no suspicious lytic or blastic lesions. MULTIPLANAR REFORMATS: Only sagittal reformats were available for interpretation at this time. They helped to better delineate the tracheal stent, which appears in place and maintaining a grossly patent trachea at its mid and distal aspect. The superior aspect of the tracheal stent is not imaged. IMPRESSION: 1) Indwelling tracheal stent, with a small soft tissue lesion causing mild- to-moderate stenosis superiorly. Distal to this, the airways are patent. The superior aspect of the stent is not visualized on this study. If clinically warranted, a dedicated CT trachea may be useful. 2) Nonspecific soft tissue stranding surrounding the trachea about the course of the stent, likely postoperative/procedural in nature. No focal abscess, fluid collection, or hematoma is identified. 3) No evidence of pneumonia. Tiny nonspecific nodular opacities in the right mid lung zone, nonspecific in nature, possibly related to recent surgery. Brief Hospital Course: Patient was admitted from the ED to the SICU for worsening shortness of breath and pain. SHe was started on levofloxicin and azithromycin for bronchitis, multiple nebs/inhalers to maximize oxygen status, as well as morphine for pain. After 2 days, wHen patient was stable and breathing comfortably, was transferred to the floor. Underwent rigid brnochoscopy on [**5-28**], showed patent stent, and was prepared for discharge. HOspital course was uncomplicated once started on appropriate meds. Patient will go home with tylenol and ibuprofen for pain. Medications on Admission: Ditropan, trazodone, ranitidine, Plavix (held for the past 1 week), Ativan, Protonix, Glucovance, atenolol, Levoxyl, Effexor, aspirin 81 mg per day, Humulin, Lipitor, Zonegran, and prednisone taper (ended today with 4 mg dose). Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 6. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Insulin NPH Human Recomb Subcutaneous 9. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*11 Tablet(s)* Refills:*0* 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: tracheal stenosis Discharge Condition: good Discharge Instructions: 1. call the office for [**Telephone/Fax (1) 99471**] is have fever,chills, shortness of breath, chest pain, priductive cough 2. resume home meds 3. no drving if taking narcotic pain meds Followup Instructions: call interventional pulmonology [**Telephone/Fax (1) 99472**] for f/u appt Completed by:[**2176-5-29**]

[ "250.00", "490", "244.9", "519.1", "V12.59", "710.0" ]

icd9cm

[ [ [] ] ]

[ "33.22" ]

icd9pcs

[ [ [] ] ]

6977, 6983

4900, 5453

325, 340

7045, 7051

1632, 2358

7286, 7393

1279, 1404

5732, 6954

2395, 2450

7004, 7024

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1419, 1613

266, 287

2479, 4877

368, 901

923, 1052

1068, 1263

31,441

145,118

50327+59248

Discharge summary

report+addendum

Admission Date: [**2121-7-1**] Discharge Date: [**2121-7-24**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: [**2121-7-1**] - Aortic Valve Replacement utilizing a 23mm [**Company 1543**] Mosaic Porcine Valve History of Present Illness: This is an 87-year-old male with a history of hypertension, hyperlipidemia, with known aortic stenosis with some dyspnea on exertion. He was diagnosed with a heart murmur approximately 2 years ago and followed by serial echoes. He is a very active 87-year-old and asymptomatic until approximately 1 month ago when he started to experience some exertional chest tightness and shortness of breath. He underwent an echocardiogram on [**2121-5-29**] that showed an ejection fraction greater than 55% with an aortic valve area of less than 0.8 cm as well as some left ventricular hypertrophy. Based on these findings, he underwent cardiac catheterization which showed no coronary artery disease and based on the findings from the echocardiogram, the patient was scheduled to undergo an aortic valve replacement. The patient understood the risks and benefits of the procedure including, but not limited to, bleeding, infection, myocardial infarction, stroke, death, renal or pulmonary insufficiency as well as the possibility of blood transfusion and future revascularization procedures. Past Medical History: Aortic Valve Stenosis Hypertension Hypercholesterolemia Diabetes Mellitus Type II History of Prostate Cancer Social History: Lives with his wife. Quit tobacco 60 yrs ago, drinks one glass wine/day. No other drug use. Family History: Non-contributory Physical Exam: V: 99.6F HR 82 BP 143/65 RR 20 Gen: awake, alert NAD, WDWN HEENT: PERRL, anicteric sclera, OP clear, MM dry, no erythema or exudate Neck: supple, no JVD CV: RRR, Normal S1, soft S2, 2-3/6 harsh systolic murmur RUSB Pulm: CTA-ant Abd: Normoactive BS, soft, NT, ND Ext: WWP, no edema, 2+ Pulses NEURO: Nonfocal Pertinent Results: [**2121-7-1**] INTRA OP TEE: PRE-CPB: The left atrium is markedly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. LVEF=45-50%. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is moderate to severe aortic valve stenosis (area 0.8 -1.0cm2). Mild (1+) aortic regurgitation is seen. The aortic annulus measures 2.5 cm. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. There is severe mitral annular calcification. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. POST-CPB: On infusions of epinephrine, phenylephrine. Well-seated bioprosthetic valve in the aortic position. Trivial AI, no paravalvular leak. Mild AS. MR is improved post bypass, now mild. Aortic contour is normal post decannulation. LVEF is 50%. [**2121-7-6**] Discharge chest x-ray: There is a small right-sided effusion and a small amount of fluid in the major fissures. There is subsegmental atelectasis in both lower lobes. There is some prominence to the pulmonary vessels that is slightly increased compared to the prior and may represent some mild failure. [**2121-7-7**] 06:30AM BLOOD WBC-7.4 RBC-3.12* Hgb-9.8* Hct-27.5* MCV-88 MCH-31.5 MCHC-35.6* RDW-14.2 Plt Ct-193 [**2121-7-6**] 05:30AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.8* Hct-29.2* MCV-91 MCH-30.5 MCHC-33.4 RDW-14.2 Plt Ct-172 [**2121-7-5**] 05:30AM BLOOD WBC-7.3 RBC-3.07* Hgb-9.6* Hct-26.7* MCV-87 MCH-31.2 MCHC-35.9* RDW-14.2 Plt Ct-141* [**2121-7-7**] 06:30AM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-144 K-4.2 Cl-102 HCO3-36* AnGap-10 [**2121-7-6**] 05:30AM BLOOD Glucose-129* UreaN-12 Creat-0.9 Na-143 K-3.7 Cl-103 HCO3-35* AnGap-9 Brief Hospital Course: Mr. [**Known lastname 104934**] was admitted to the [**Hospital1 18**] on [**2121-7-1**] for surgical management of his aortic valve stenosis. He was taken directly to the operating room where Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacement. Please refer to operative note for surgical details. Following the operation, he was taken to the cardiac surgical intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He experienced some mild confusion which quickly resolved over the next 24 hours. His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day one. Low dose beta blockade was resumed and advanced as tolerated. He remained mostly in a normal sinus rhythm - one short burst of paroxysmal supraventricular tachycardia was noted on postoperative five. Over several days, he continued to make clinical improvements with diuresis and made steady progress with physical therapy. Medical therapy was optimized and he was cleared for discharge to rehab on postoperative day six. At discharge, his BP was 125/54 with a HR of 77. His oxygen saturations were 96% on room air and his discharge chest x-ray was notable for only small bilateral pleural effusions. All surgical incisions were clean, dry and intact. Medications on Admission: Lupron Aspirin 81 qd Univasc 15 qd Nifedical XL 30 qd Atenolol 50 qd Zocor 40 qd Glyburide/Metformin 5/500 [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Titrate accordingly, preoperative weight 165 lbs. 7. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day for 7 days: Please take with Lasix. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day: take every evening. 9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO TID as needed as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic Valve Stenosis - s/p AVR Hypertension Hypercholesterolemia Diabetes Mellitus Type II History of Prostate Cancer Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 58**] (PCP) in [**1-25**] weeks. [**Telephone/Fax (1) 3329**] Follow-up with Dr. [**Last Name (STitle) 696**] (Cardiologist) in [**1-25**] weeks. [**Hospital Ward Name 121**] 2 wound clinic in 2 weeks. Please call all providers for appointments. Schedule Appointments: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2121-8-21**] 8:00 Completed by:[**2121-7-7**] Name: [**Known lastname 17061**],[**Known firstname **] Unit No: [**Numeric Identifier 17062**] Admission Date: [**2121-7-1**] Discharge Date: [**2121-7-24**] Date of Birth: [**2034-1-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 674**] Addendum: Mr [**Known lastname **] was initially scheduled to be discharged on [**7-7**] but developed a fever with elevated LFT's and was worked up appropriately. Major Surgical or Invasive Procedure: [**2121-7-1**] - Aortic Valve Replacement utilizing a 23mm [**Company 1331**] Mosaic Porcine Valve [**2121-7-8**] - ERCP [**2121-7-11**] - PICC line placement [**2121-7-15**] - ERCP [**2121-7-17**] - Exploratory laparotomy; attempted laparoscopic cholecystectomy conversion to open cholecystectomy. Past Medical History: Aortic Valve Stenosis Hypertension Hypercholesterolemia Diabetes Mellitus Type II History of Prostate Cancer Social History: Lives with his wife. Quit tobacco 60 yrs ago, drinks one glass wine/day. No other drug use. Family History: Non-contributory Physical Exam: see previous report Pertinent Results: [**7-18**] CXR: There is no definite evidence of an effusion on the current study, though a lateral view would be more sensitive for a small amount of posterior pleural fluid. Sternotomy wires, cardiomegaly, and a heavily calcified aorta are unchanged. The prominent right superior mediastinal contour is related to fat and tortuous vessels as seen on CT. [**7-8**] Abd U/S: Sludge and gallstones again seen in the gallbladder, however, no evidence of cholecystitis. Incidentally noted is a right pleural effusion. [**7-1**] Echo: PRE-CPB:1. The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. LVEF=45-50%. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The aortic annulus measures 2.5 cm. 6. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. There is severe mitral annular calcification. Mild to moderate ([**12-24**]+) mitral regurgitation is seen. POST-CPB: On infusions of epinephrine, phenylephrine. Well-seated bioprosthetic valve in the aortic position. Trivial AI, no paravalvular leak. Mild AS. MR is improved post bypass, now mild. Aortic contour is normal post decannulation. LVEF is 50%. Surgical staples overlie the right upper quadrant soft tissues. [**2121-7-6**] 05:30AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.8* Hct-29.2* MCV-91 MCH-30.5 MCHC-33.4 RDW-14.2 Plt Ct-172 [**2121-7-9**] 09:35AM BLOOD WBC-7.3 RBC-2.80* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.1 Plt Ct-261 [**2121-7-9**] 08:31PM BLOOD Hct-21.9* [**2121-7-10**] 05:02PM BLOOD WBC-7.3 RBC-3.57* Hgb-10.5* Hct-31.0* MCV-87 MCH-29.5 MCHC-34.0 RDW-15.7* Plt Ct-239 [**2121-7-14**] 11:13AM BLOOD WBC-18.4*# RBC-4.20* Hgb-12.4* Hct-37.6* MCV-90 MCH-29.5 MCHC-32.9 RDW-15.4 Plt Ct-362 [**2121-7-1**] 12:20PM BLOOD PT-15.6* PTT-33.8 INR(PT)-1.4* [**2121-7-13**] 05:39AM BLOOD PT-12.8 PTT-27.0 INR(PT)-1.1 [**2121-7-7**] 06:30AM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-144 K-4.2 Cl-102 HCO3-36* AnGap-10 [**2121-7-14**] 11:13AM BLOOD Glucose-209* UreaN-8 Creat-0.9 Na-139 K-3.6 Cl-100 HCO3-29 AnGap-14 [**2121-7-7**] 10:40PM BLOOD ALT-258* AST-607* AlkPhos-479* Amylase-59 TotBili-3.1* [**2121-7-8**] 12:35PM BLOOD ALT-408* AST-708* LD(LDH)-534* AlkPhos-501* Amylase-35 TotBili-3.1* [**2121-7-14**] 11:13AM BLOOD ALT-52* AST-29 LD(LDH)-322* AlkPhos-265* Amylase-24 TotBili-1.0 [**2121-7-21**] 06:45AM BLOOD WBC-8.4 RBC-3.57* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.5 MCHC-32.9 RDW-15.1 Plt Ct-589* [**2121-7-17**] 08:57AM BLOOD PT-13.8* PTT-29.8 INR(PT)-1.2* [**2121-7-19**] 05:57AM BLOOD Glucose-145* UreaN-9 Creat-0.8 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [**2121-7-22**] 06:40AM BLOOD WBC-7.6 RBC-3.71* Hgb-10.8* Hct-32.3* MCV-87 MCH-29.1 MCHC-33.4 RDW-15.0 Plt Ct-553* [**2121-7-22**] 06:40AM BLOOD Glucose-109* UreaN-5* Creat-0.7 Na-141 K-3.9 Cl-105 HCO3-27 AnGap-13 [**2121-7-19**] 05:57AM BLOOD ALT-19 AST-22 AlkPhos-147* TotBili-0.7 Brief Hospital Course: As mentioned in the addendum, Mr [**Known lastname **] was initially scheduled to be discharged on [**7-7**] but developed a fever and he was eventually worked-up for this. It was noted that he had an elevated LFT's and total bilirubin. Then underwent an ultrasound which revealed sludge and gallstones again seen in the gallbladder, however, no evidence of cholecystitis. He was started on antibiotics and surgery was consulted. On post-op day seven he underwent an ERCP. Please see ERCP report for details. Following procedure he was transferred back to the cardiac surgery telemetry floor. ID was consulted d/t blood cultures came back positive for Klebsiella Pneumoniae. On post-op day eight patient developed a GI bleed with a significant drop in HCT. General surgery was immediately contact[**Name (NI) **] d/t recent ERCP procedure. Pt was transferred to the CSRU and had multiple blood transfusions. He also had an urgent endoscopy at bedside which revealed no active bleeding from yesterdays procedure. Patient remained stable in the CSRU for several days with a rise in her HCT. Once stable, a PICC line was placed (on post-op day ten) for long-term antibiotic therapy. Later on this day pt appeared clinically stable and was transferred back to the telemetry floor. He remained stable over the next several days while receiving antibiotics and awaiting another ERCP for removal of pancreatic duct stent. On post-op day fourteen he had another ERCP where the pancreatic duct stent was removed. On post-op day thirteen his WBC became quite elevated and blood cultures were taken. Additional antibiotics were started. Increased WBC was felt related to his cholecystitis. On post-op day fourteen his pancreatic duct stent was removed. On post-op day sixteen he was brought to the operating room where he underwent a cholecystectomy by Dr. [**First Name (STitle) **]. Please see operative report for surgical details. Of note, lap cholecystectomy was converted to open. Following surgery he was transferred to the CSRU. On post-op day seventeen (one from the cholecystectomy) he required a blood transfusion and was later transferred to the telemetry floor for further care. Over the next several days he continued to improve and transplant/general surgery followed him for his gallbladder surgery. Electrolytes were repleted and beta blockers/ace-inhibitors were titrated for maximum hemodynamics. Finally on post-op day twenty-three he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. during this time he will receive to weeks of antibiotics. Medications on Admission: Lupron Aspirin 81 qd Univasc 15 qd Nifedical XL 30 qd Atenolol 50 qd Zocor 40 qd Glyburide/Metformin 5/500 [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*1* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Titrate accordingly, preoperative weight 165 lbs. 5. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day for 7 days: Please take with Lasix. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day: take every evening. Disp:*30 Tablet(s)* Refills:*1* 7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO TID as needed as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 8. Glyburide-Metformin 5-500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 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. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 weeks. Disp:*14 * Refills:*0* 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 12. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*1* 15. Heparin Flush 100 unit/mL Kit Sig: Two (2) Intravenous once a day for 2 weeks: 2ml via PICC daily and prn. 10ml NS followed by 2ml of 100u/ml Heparin (200units Heparin) each lumen daily and prn. Disp:*28 * Refills:*0* 16. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection once a day for 2 weeks: 10ml NS followed by 2ml of 100u/ml Heparin (200units Heparin) via PICC line daily and prn. Disp:*14 * Refills:*0* Discharge Disposition: Home with Service Facility: [**Location (un) 4641**] - [**Location (un) 407**] Discharge Diagnosis: Aortic Valve Stenosis - s/p Aortic Valve Replacement Cholecystitis s/p Cholecystectomy (s/p ERCP x 2) GI Bleed Bacteremia PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitus Type II, History of Prostate Cancer Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 4294**] at ([**Telephone/Fax (1) 2092**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 676**] in [**3-27**] weeks ([**Telephone/Fax (1) 2092**] Dr. [**Last Name (STitle) 2222**] (PCP) in [**1-25**] weeks. [**Telephone/Fax (1) 17063**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 11112**] Appt on [**2121-8-21**] @ 8:00 Please call Dr [**First Name (STitle) **] (transplant) and schedule an appointment for 2 weeks after discharge. He can be reached at ([**Telephone/Fax (1) 17064**]. [**Hospital Ward Name **] 2 wound clinic in 2 weeks. Provider: [**First Name8 (NamePattern2) 17065**] [**Name11 (NameIs) 6300**], MD Phone:[**Telephone/Fax (1) 496**] Date/Time:[**2121-8-14**] 10:30 Provider: [**First Name11 (Name Pattern1) 1198**] [**Last Name (NamePattern4) 14090**], M.D. Phone:[**Telephone/Fax (1) 17066**] Date/Time:[**2121-8-7**] 10:00 Provider: [**Name10 (NameIs) 13443**] Phone:[**Telephone/Fax (1) 10708**] Date/Time:[**2121-8-7**] 9:00 [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2121-7-24**]

[ "V43.65", "293.0", "576.1", "401.9", "272.4", "998.11", "V64.41", "424.1", "997.4", "V10.46", "790.7", "574.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "51.88", "97.56", "51.87", "35.21", "89.60", "45.13", "51.22", "51.85", "38.93", "51.10", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

18219, 18300

13375, 15991

8945, 9245

18560, 18566

9577, 13352

19280, 20350

9504, 9522

16165, 18196

18321, 18539

16017, 16142

18590, 19257

9537, 9558

228, 264

431, 1514

9267, 9377

9393, 9488

18,846

186,928

6074

Discharge summary

report

Admission Date: [**2136-6-7**] Discharge Date: [**2136-6-15**] Date of Birth: [**2074-2-1**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1828**] Chief Complaint: Fever Major Surgical or Invasive Procedure: HD line removal History of Present Illness: 62 yo F with PMH of ESRD on HD, DM, diastolic CHF, history of multiple line infections who presents with fevers from rehab. Patient reports she was in her usual state of health. For last couple weeks has been having mid-flank back pain. Per patient not further evaluated at rehab as attributed to muscle pain. Reports decreased appetite last several days. Patient went for regular HD today where she reported chills. T99.9 at HD and later spiked to 100.8 and referred to ED for further evaluation. . In the ED, her vitals were rectal temp 38.9, SBP 60s, HR 116. She complained of her chronic back pain and some mild abdominal pain. A foley was placed and frank green pus came out per report from the ED. She was given 4L NS with initial lactate of 2.4. Blood cultures and urine culture was sent. Patient was initially given levo, flagyl and vanc and then was given cefepime to cover for pseudomonas given green pus. They tried to place a left IJ but could not thred the wire. The patient refused a femoral CVL and refused an aterial line per the ED report. Patient was to have a CT abdomen/pelvis to evaluate for abscess prior to admission to ICU. . Currently, she reports of mild bitemporal HA, but no back or abdominal pain. During interview developed throbbing r-flank pain again, non-radiating, no nausea/vomitting, +constipation - but just had BM, no change in vision, SOB, c/p. normally anuric but with occasionaly UOP. noted that her abdominal pain/constipation improved with urine output this AM. Chronic LE ulcers - pain controlled and wounds appear to be improving. c/o thirst at this time. Past Medical History: # ESRD on HD (T/H/Sat) # DM2 - last A1c 8.6% # diastolic CHF - EF > 55% # Hypercholesterolemia # BLE DVTs, was on warfarin - recently discontinued in [**5-24**] b/c developed bleeding at ulcer site. Leni's in [**1-24**] w/o e/o DVT. # OSA - intolerant of CPAP mask at home # OA # Multiple line infections/Bacteremia -[**2136-1-17**] Strep viridans simple bacteremia with negative TTE and TEE. -[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin and gentamicin -[**4-23**] Excision of left upper arm infected AV graft; associated MRSA bacteremia treated with 6 weeks vancomycin. -Providencia bacteremia [**2135-12-20**]- treated with 4 weeks aztreonam # h/o C. Diff # GERD # Depression # Morbid obesity # L forearm radial-basilic AV graft, s/p infection, thrombosis and abandonment ([**12-21**]) # Multiple lines in L upper arm with AV graft # 1/07 L femoral PermaCath placed # L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**]) # Right upper extremity AV fistula creation [**10-23**] s/p revision [**2135-12-14**]-? infection per notes from [**Hospital 1474**] hospital. # [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring and IVC filter removed # Admission for aflutter in [**3-24**] with DCCV Social History: Patient denies a tobacco, alcohol or illicit drug use. She lives in a nursing home ([**Hospital3 2558**]) since [**12-23**] Family History: NC Physical Exam: HR: 99 (99 - 100) bpm BP: 93/46(56) {93/44(56) - 100/46(58)} mmHg RR: 16 (16 - 19) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) T: 101.0 General Appearance: No acute distress, Overweight / Obese, No(t) Thin, Not Anxious, Not Diaphoretic Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No Endotracheal tube, No NG tube, No OG tube, no teeth Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), HD line in place on right upper chest Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : anterior and lateral, No Crackles : , No Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese, tender in right flank/lateral mid right back Extremities: Right: Trace, Left: Trace Musculoskeletal: Unable to stand Skin: two dressed wounds on right leg. C/D/I dressings and non-tender around area Neurologic: Attentive, A&O x3. Pertinent Results: [**2136-6-7**] CTU IMPRESSION: 1. No acute intra-abdominal process. 2. Multiple bilateral nonobstructing renal stones. 3. Fibroid uterus, with prominent ovaries bilaterally, largely changed from as far back as [**2127**]. 4. Unusual appearance of the right common femoral vessels, with asymmetric enhancement of the right common femoral vein relative to the left. This raises the suspicion for whether there is an underlying AV malformation in this area. 5. Marked stool impaction within the rectum with stable circumferential rectal wall thickening of unclear etiology. [**2136-6-8**] The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2136-2-15**], the findings are similar. IMPRESSION: no obvious vegetations seen [**2136-6-8**] RIGHT UPPER EXTREMITY NON-VASCULAR ULTRASOUND: The hemodialysis catheter is visualized but no abscess or fluid collection is seen in the surrounding tissues. 5/22 [**6-22**] blood cx bottles with staph aureus [**6-8**] blood cx positive with gram + cocci Brief Hospital Course: 62F with PMH ESRD on HD with history of multiple line infections, now with bacteremia and acute bacterial cystitis # Staph Aureus bacteremia: [**6-22**] blood cultures with GPCs in clusters, all speciated to coag + staph aureus -vancomycin dosing was performed by levels with dialysis -TTE had no evidence vegetations -Her HD line was removed on [**6-8**] and left out for a "line holiday" until Tuesday [**6-12**] -Because of persistent complaints of back pain, an MRI of the spine was ordered. This revealed findings consistent with osteomyelitis at the T9 Vertebrae. This obligates her to receive a 6 week course of antibiotics. -The infectious disease service consulted and agreed with plan of care, but noted that the MIC to vancomycin for her isolate was rising. I.D. thus made very explicit recommendations re: vancomycin dosing to occur with every hemodialysis, so as to maintain trough levels above 20. # Acute bacterial cystitis: E. coli on culture, sensitivities showing resistance to multiple agents, including ciprofloxacin. -cefepime was given, and then changed to ceftriaxone, and she completed a 7 day course. -Per urology recs: instilled bladder with NS flushes during the first 5 days of therapy. # Hypotension: She is known to medical service as having low cuff pressure readings despite normal mentation/ UOP. Her blood pressures normalized with treatment of infection, remaining in the range of 90-100 systolic # ESRD on HD -As dialysis was held off during the line holiday, she was on a fluid restriction. The nephrology service followed her course and she did well, tolerating dialysis well when it was reinstituted. # Leg ulcers: -A wound care consultation made recommendations for local management, but felt her wounds were improving. She received daily dressing changes and wounds continued to look clean. # Hx DVT She was maintained off coumadin but received sq heparin and pneumoboots # CHF: chronic diastolic dysfunction, TTE with EF 70% she remained stable and continued on asa and a statin. # DM her insulin regimen (glargine and sliding scale) as she was receiving at [**Hospital3 **] was maintained. #Mobility -While in the hospital, she stated that she was unable to walk although there is no clear reason why she should not ambulate. She related a history of a prior fall, occurring when her weight was much higher. She was assessed by physical therapy who found her to be severely deconditioned but no specific deficit was identified. This was discussed with her primary providers at [**Hospital3 4262**] who state that they have been making persistent efforts to increase her ambulation at [**Hospital3 2558**], with limited success. Medications on Admission: Home meds: renal meds, nebs, paxil, bowel regimen, NPH 10U in am, RISS, oxycodone, morphine Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: regular insulin per sliding scale. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) for 5 weeks: 500 mg with every dialysis. Completes 6 week course on [**2136-7-21**]. Questions contact [**Name (NI) **] [**Last Name (NamePattern1) 7443**], ID, Fax number [**Telephone/Fax (1) 1419**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Staph aureus Line sepsis End Stage renal disease Diabetes Mellitus CHF Discharge Condition: Stable Discharge Instructions: You are being treated with antibiotics for Staph aureus infection of your hemodialysis catheter, which has also led to an infection of a bone in your spine (T9 vertebrae). Vancomycin with dialysis should continue for 6 weeks from [**6-8**], or until [**2136-7-21**] Followup Instructions: You will be followed by Dr. [**Last Name (STitle) 23834**] (nephrology) and by [**Hospital 7200**] Group who will see you at [**Hospital3 2558**].

[ "038.11", "707.11", "428.0", "995.91", "996.62", "599.0", "272.0", "403.91", "250.00", "428.32", "041.4", "V12.51", "V58.61", "585.6" ]

icd9cm

[ [ [] ] ]

[ "86.05", "38.95" ]

icd9pcs

[ [ [] ] ]

10654, 10724

6399, 9093

276, 293

10839, 10848

4481, 6376

11163, 11313

3355, 3359

9236, 10631

10745, 10818

9119, 9213

10872, 11140

3374, 4462

231, 238

321, 1925

1947, 3197

3213, 3339

73,425

130,193

38050+58188

Discharge summary

report+addendum

Admission Date: [**2101-9-16**] Discharge Date: [**2101-9-20**] Date of Birth: [**2075-2-4**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Found down, unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: Pt is 20 y/o F found down at bottom of 5 steps. Pt unresponsive at the scene with GCS 3, found to have some bleeding from right ear canal. Pt transferred to ED and intubated. Unclear how long pt was down. Past Medical History: depression Social History: unknown Family History: unknown Physical Exam: On admission: T 96.8 P 83 BP 135/86 R 17 SaO2 100% Gen: intubated, sedated Mental status: minimally responsive, does not open eyes, withdraws to pain on occasion Cranial Nerves: I: Not tested II: Pupils equal round and reactive to light, 4mm-2 bilaterally. III, IV, VI: not able to be tested V, VII: not able to be tested IX, X: Gag intact [**Doctor First Name 81**]: not tested XII: not tested MOTOR: not able to be tested SENSATION: not able to be tested Babinski sign: negative Pertinent Results: CT head [**9-16**]: 1. Right parietal posterior soft tissue swelling with left temporoparietal subarachnoid hemorrhage suggesting contre-coup injury. 2. Probable subarachnoid blood overlying the right temporoparietal region. 3. Longitudinal fracture through the right temporal bone. 4. Fracture through the right occiput towards the skull base extending through the condylar canal, to the foramen magnum. There is likely early hemorrhagic cortical contusion involving the superficial left temporal lobe, with adjacent edema and effacement of overlying sulci. CT head [**9-17**]: Expected evolution of left temporal hemorrhagic contusion, with increased parenchymal edema compared to study performed one day prior. Small amount of overlying subarachnoid blood here, as well as likely in the right parietal region. There is no new focus of intracranial hemorrhage, and no other new acute intracranial process. Right temporal bone fracture is not well characterized in this study. [**2101-9-16**] 12:40AM BLOOD ASA-NEG Ethanol-249* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG FINDINGS: Partially imaged are longitudinal fracture of the right temporal bone and likely separate and distinct fracture through the right occiput, posterior to the occipitomastoid suture. There is no fracture of the cervical vertebrae. There are orogastric and endotracheal tubes in situ, and assesment of the prevertebral soft tissues is limited, secondary to intubation. However, there is no discrete hematoma, and the retropharyngeal fat plane appears preserved. Atlantodental and craniocervical junction appear normal. Facet joints are normally aligned. Lateral masses of C1 are well seated on C2. The dens appears normal. The thyroid appears normal. The lung apices appear clear, without pneumothorax. IMPRESSION: 1. No acute cervical fracture or alignment abnormality. 2. Partly imaged longitudinal fracture of the right temporal bone and hairline fracture of the right occiput are better visualized on the concurrent head CT. If warranted on clinical grounds, these could be better-assessed by dedicated thin-section MDCT of the temporal bones. CT HEAD [**2101-9-16**] FINDINGS: There is a slight increase in the left temporoparietal subarachnoid hemorrhage, compared to the prior study. There is a 1.4 x 1.3 cm cortical hemorrhagic contusion in the left temporal lobe with surrounding edema. There is no significant shift of midline structures. Ventricles are of normal configuration and size for age. Preservation of the [**Doctor Last Name 352**]- white matter differentiation. Mild effacement of the sulci noted. The basal cisterns are patent. Bones are better assessed in the prior study where dedicated thin-section bone algorithm reconstruction was performed. There is longitudinal right temporal bone fracture, involving the external auditory canal. The ossicles appear normally-aligned. The right external auditory canal shows some soft tissue density material, likely blood, and there is partial opacification of the right mastoid air cells. The left mastoid air cells appear clear. There is mild opacification of the ethmoid sinuses bilaterally. Soft tissue swelling noted on the right posterior parietal region. IMPRESSION: 1. Interval slight increase in the left temporoparietal subarachnoid hemorrhage and emergence of a hemorrhagic left temporal contusion. 2. Longitudinal fracture of the right temporal bone extending into the external auditory canal, better CT HEAD [**2101-9-17**] NON-CONTRAST HEAD CT: There is likely a small amount of subarachnoid blood again appreciated in the right parietal region. There has been expected evolution of the left temporal hemorrhagic contusion with overlying subarachnoid blood, with increased parenchymal edema compared to study performed one day prior. There is no new focus of hemorrhage identified. There is effacement of the adjacent sulci, with no significant midline shift and no evidence of herniation syndromes. The ventricles, sulci, and cisterns are normal in size and appearance. Remote from the hemorrhagic contusion, the [**Doctor Last Name 352**]-white matter differentiation is preserved. There is partial opacification of the right mastoid air cells. The previously characterized right temporal bone fracture is not well seen on the current study (2:2). There is slight mucosal thickening in the ethmoid air cells. The globes and orbits appear unremarkable. IMPRESSION: Expected evolution of left temporal hemorrhagic contusion, with increased parenchymal edema compared to study performed one day prior. Small amount of overlying subarachnoid blood here, as well as likely in the right parietal region. There is no new focus of intracranial hemorrhage, and no other new acute intracranial process. Right temporal bone fracture is not well characterized in this study. CT Head [**2101-9-19**] FINDINGS: Noted is a stable subarachnoid hemorrhage in the left parietal and left frontal regions. There is a hemorrhagic contusion in the left temporal cortex, with surrounding edema, stable since the prior study. Small temporal subarachnoid hemorrhage is also stable since the prior study. There is no new hemorrhage identified. There is effacement of the adjacent sulcal spaces in the left cerebral hemisphere. Tiny sliver of Sub dural hematoma noted in bilateral parietal regions,without mass effect. The basal cisterns are widely patent. The ventricles appear normal in size and appearance. The rest of the brain parenchyma shows normal [**Doctor Last Name 352**]- white differentiation. Again noted is partial opacification of the right mastoid air cells.The temporal bone fracture not clearly visualized in the current study and better visualized in the prior study with bone reformats. Minimal mucosal thickening in bilateral ethmoid air cells. The external auditory canals bilaterally and the rest of the paranasal sinuses and the orbits appear unremarkable. IMPRESSION: 1.Left temporal hemorrhagic contusion with subarachnoid hemorrhage in the left frontoparietal and right occipital regions,stable since the prior study. 2.Tiny sliver of biparietal Subdural hematoma without mass effect,stable. 3.No new hemorrhage. No hydrocephalus. Brief Hospital Course: The patient arrived to the emergency room unresponsive. She was intubated for airway protection. Ct imaging revealed a right parietal posterior soft tissue swelling with left temporoparietal subarachnoid hemorrhage suggesting contre-coup injury. There was a longitudinal fracture through the right temporal bone. There also was a fracture through the right occiput towards the skull base extending through the condylar canal to the foramen magnum. There was early hemorrhagic cortical contusion involving the superficial left temporal lobe, with adjacent edema and effacement of overlying sulci. She was admitted to the ICU for continued monitoring. She was loaded with Dilantin loaded and it was continued at 100 mg TID. She was getting hypertonic saline. She was moving all extremities without deficit when off sedation. She was extubated on [**9-17**] and she was without neurologic deficit. Serial CT's were stable. She was safe for trasnfer to the floor on [**2101-9-19**]. She was discharged to home without services on [**9-20**]. Medications on Admission: Zoloft Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 5. Sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: left parietal SAH, right temporal/parietal SAH, rt temporal bone fx, & rt occipital fx(non-displaced). Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2101-9-20**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13494**] Admission Date: [**2101-9-16**] Discharge Date: [**2101-9-20**] Date of Birth: [**2075-2-4**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 599**] Addendum: Cerebral edema that was resultant from closed head injury; required close neuromonitoring in the ICU for several days. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2101-9-23**]

[ "311", "348.5", "E880.9", "305.00", "787.01", "801.26" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

11172, 11315

7421, 8465

343, 349

9262, 9286

1195, 4697

10281, 11149

662, 671

8522, 9086

9136, 9241

8491, 8499

9310, 10258

686, 686

279, 305

377, 587

870, 1176

4706, 7398

700, 766

781, 854

609, 621

637, 646

7,666

197,926

383

Discharge summary

report

Admission Date: Discharge Date: [**2155-6-13**] Date of Birth: [**2099-4-13**] Sex: M Service: PROCEDURES PERFORMED: Cadaver kidney transplant. ADMISSION DIAGNOSES: 1. Endstage renal disease secondary to diabetes mellitus. 2. Peripheral vascular disease. POSTOPERATIVE DIAGNOSES: 1. Endstage renal disease secondary to diabetes mellitus. 2. Peripheral vascular disease. HOSPITAL COURSE: Mr. [**Known lastname 3419**] is a 56-year-old male with endstage renal disease secondary to diabetes mellitus who after listing for cadaver kidney transplant, an organ become available. He was taken to the operating room on [**2155-2-24**], where he underwent placement of a cadaver kidney in the left iliac fossa. His posttransplant course was uncomplicated. The kidney began making urine almost immediately after implantation. He did not require dialysis in the postoperative period. He was started with usual induction immunosuppression, which includes 3 doses of Thymoglobulin followed by introduction of calcineurin inhibitors namely tacrolimus when the renal function improved. He also received steroid taper and CellCept. On postoperative day 2, he was started on a clear liquid diet, which was advanced to the rest of his hospital stay. His [**Location (un) 1661**]-[**Location (un) 1662**] drain and Foley were removed on postoperative day 4 and on postoperative day 5, he was certainly ready for discharge. He achieved a satisfactory prograf levels. Was able to demonstrate understanding and knowledge of his immunosuppression regimen after teaching from the transplant coordinators. He was discharged home on [**2155-2-28**], and he will follow up with the transplant service in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern4) 3433**] MEDQUIST36 D: [**2155-6-13**] 08:48:39 T: [**2155-6-13**] 10:53:16 Job#: [**Job Number 3434**]

[ "272.0", "244.9", "V49.72", "250.40", "443.9", "070.54", "403.91" ]

icd9cm

[ [ [] ] ]

[ "55.69" ]

icd9pcs

[ [ [] ] ]

425, 2000

198, 407

29,913

197,045

10698

Discharge summary

report

Admission Date: [**2147-10-26**] Discharge Date: [**2147-10-31**] Date of Birth: [**2081-3-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin Attending:[**First Name3 (LF) 898**] Chief Complaint: Hypoxia/hypotension. Most of HPI is adopted from Dr.[**Name (NI) 35037**] admission note. Please refer to his note for details. Major Surgical or Invasive Procedure: none History of Present Illness: 66 y/o F with frequent UTIs, HTN, h/o kidney stones who was admitted to the floor on [**10-26**] for RLL pneumonia is transferred to MICU for hypoxia/hypotension. She initially presents with acute onset of sharp, burning right flank pain since 4am on [**10-26**] which woke her from sleep. She noted some SOB but may have been from splinting due to pain. She also noted the onset of dry cough shortly thereafter. She took her temp at 7am and was 101.6 with associated chills and rigors. She did note increasing urinary but no dysuria/hematuria. She denies CP, abdominal pain, N/V/D. Moved her bowels this morning. . In ED, vitals were: T: 101.3 P: 104 BP: 134/70 O2: 98% 4L. Initial concern was kidney stone vs. pyelo. U/A negative and CT abdomen showed no stone but clear RLL infiltrate not seen on CXR. She was given one dose of CTX/Azithromycin, 1gm Tylenol, 600mg Ibuprofen and 1L NS. . Upon arrival to the floor, her BP was initially T 99.7, 100/60, HR 106, O2 sat 93% on 3L. Then, she started c/o feeling not feeling well with Bp in 80/d. Pt was also noted to have O2 sat of 82 on 3L via NC which went upt to 91-92% after 6L and then was placed on NRB. Pt was still mentating well. ABG at 5L O2 via NC was 7.46/30/50 (blind stick but Dr. [**First Name (STitle) 1887**] says pulsatile blood). Her SBP improved to 90s with after ~500cc NS. . On arrival to the unit, she no longer c/o dizziness but still similar sob with R flank pain. Denies cp, fevers, abdominal pain, nausea, vomiting, dysuria, or urgency. Past Medical History: HTN Kidney Stone in '[**40**] Narrow urethra with frequent UTIs GERD Osteoporosis Hyperlipidemia Genital Herpes Social History: Distant small tob.hx. EtOH only on holidays. No illicits. Lives by herself in apartment. Idependent in IADLs. Retired economist. Family History: Mother had DM and HTN Physical Exam: T: 97.4, 95, 102/57, 22 100% on NRB Gen: AOX3, pleasant, in mildly tachypneic but speaking in full sentences without difficulty HEENT: PERRL, EOMI, MM dry, no LAD CV: distant heart sound due to body habitus but RRR, no MRGs appreciated Resp: bronchial BS at R base with decreased BS, mild wheezes, + egophony and possible increased fremitus. Abd: Obese, soft, NT/ND, +BS, no masses or HSM appreciated Ext: no edema. warm extremities. DP [**12-13**]+ R>L. Skin: no rash Brief Hospital Course: A/P:66 yo female with HTN, kidney stones, UTIs presents with RLL infiltrate/R flank pain transferred to MICU for hypoxia/hypotension. . # PNA/Hypoxia: The patient was intially admitted to the floor and started on Ceftriaxone and Vancomycin. The pneumonia was likely the cause of her R flank pain by regional irritation. However, the patien was transferred to the MICU because she had some hypoxia and hypotension. In the MICu, she was given an additional 1gm of CTX and 1gm of vancomycin to cover possible community acquired MRSA. Her hypoxia improved and did not require any intubation or non-invasives. Her O2 was weaned to NC and at the time of c/o to the floor, her O2 sat is 92-95L on 4L. On right lateral decub film, she has a small effusion that was felt to too small to tap. Given how clinically stable she was, she was transferred back out to the floor. Sputum cultures were sent and were contamined, legionella was negative. Blood cultures had no growth. The patient was continued on IV Vancomycin, Ceftriaxone and Azithromycin. IV Vanc was dicontinued on [**10-30**]. She was subsequently changed to oral antibiotics upon discharge as she continued to improve. . # Hypotension: On the floor, patient had hypotensive episode which was initially was concerning for sepsis/shock in the setting of PNA. Pt responded to 500cc of NS bolus and her MAP remained >65. She was transferred to the MICu. She was given additional 1L NS. All her antihypertensives were held. At time of call-out of MICU, SBP 120-140s. She had no further episodes of hypotension, and in fact her systolic was 150-160s on the floor; her atenolol was restarted. . # Anemia: Her initial admission hct was 41. Her hct dropped to 31.9. Pt only received a total of 2L NS (1L in ED and 1L here in MICU). Likely [**1-13**] bone marrow suppression from pretty severe pneumonia. Her guaiac is negative and her repeat hct was 33.1 which is stable. It continued to rise and remained stable throughout her stay. . # History of Compression fx: Patient was continued on actonel and Ca/Vitamin D supplements. . # GERD: Prilosec was held and Protonix given in house. This was changed back to her home prilosec on discharge. . # Hyperlipidemia: Continued on home Lipitor. . # Herpes: Continued on home Valtrex and Zovirax ointment . Medications on Admission: Actonel 35mg po qWk Atenolol 25mg PO daily Lipitor 10mg PO daily Enablex 7.5mg PO daily Valtrex 1gm PO daily Prilosec 20mg PO daily Diovan 80mg PO daily ? Zovirax ointment Nifedipine 30mg qday . MEDS at transfer: Ceftriaxone 1gm iv q24h Azithromycin 500mg po q24h Atenolol 25mg qday Nifedipine 30mg qday Atorvastatin 10mg qday Enablex 7.5mg qday Acyclovir ointment 5% appl TP daily Valtrex 1gm po daily Protonix 40mg qday Valsartan 80mg qday Heparin 5005 units sc TID Albuterol neb q6H Ipratropium neb Q6H Tylenol Ibuprofen Guaifenesin-dextromethrophan 10mg po q6h/prn Zolpidem tartate 5mg po qhs/prn Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acyclovir 5 % Ointment Sig: One (1) Appl Topical DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal ONCE (Once). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 7. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 10. Cepacol 5.4 mg Lozenge Sig: One (1) Mucous membrane every 4-6 hours as needed for sore throat. Disp:*20 lozenges* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Pneumonia Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital with flank pain and fever. You were found to have a pneumonia in your right lung. You were treated with antibiobics. You intially had some difficulty breathing from the pneumonia and briefly went to the intensive care unit. You subsequently did well and required some oxygen. You will go home and continue a course of antibioitics. You will continue Cefpodoxime for 6 more days Your blood pressure medications were held because of hypotension. You will continue the Atenolol but the diovan and nifedipine were held. You will need to follow up with your PCP. [**Name10 (NameIs) 357**] call and make an appointment this week. If you have any worsening symptoms of cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, or any other concerning symptoms, please call your PCP or return to the ER. Followup Instructions: Please call Dr [**Last Name (STitle) 5102**] and make a follow up appointment this week. [**Telephone/Fax (1) 35038**]

[ "285.9", "272.0", "V13.01", "275.3", "458.9", "530.81", "486", "054.9", "272.4", "511.9", "401.9", "799.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6653, 6739

2795, 5100

415, 421

6793, 6804

7705, 7827

2263, 2286

5752, 6630

6760, 6772

5126, 5729

6828, 7682

2301, 2772

248, 377

449, 1964

1986, 2100

2116, 2247

32,762

101,480

21109+57219

Discharge summary

report+addendum

Admission Date: [**2148-7-17**] Discharge Date: [**2148-8-8**] Date of Birth: [**2082-9-12**] Sex: F Service: MEDICINE Allergies: Antihistamines Attending:[**First Name3 (LF) 16983**] Chief Complaint: recurrent pneumonia Major Surgical or Invasive Procedure: PICC, left arm History of Present Illness: Briefly, this is a 65 year-old F with COPD who has been admitted to an OSH 3 times in the past 2 months for a RLL pneumonia/ consolidation. She initially presented 2 months ago with RLL PNA, and returned one month ago with RLL and lingular PNA. She underwent bronchoscopy on [**7-2**] at which time BAL cultures were negative and cytology from the washings was negative. A CT of the chest was reportedly without malignancy. She most recently returned to [**Hospital3 **] Hospital 8 days after discharge ([**7-12**]) with increasing cough, sputum production, and left sided rib pain which started two days prior to presentation. A CT again showed mass-like consolidation in the lingula with interval increase in size since the previous film, RLL atelectasis and dense consolidation which is unchanged, stable mediastinal adenopathy, and an acute left 7th rib fracture. A PPD placed at [**Hospital3 **] was negative according to their records. She was started on zosyn on [**7-12**]; after sputum cx grew out MRSA she was started on vancomycin on [**7-15**]. She was transferred to [**Hospital1 18**] on [**7-18**] for further work-up and management of her recurrent pneumonias. She had a repeat bronchoscopy on [**7-22**], cytology from which revealed BAC. While her current exacerbation was considered to be due to infection, the pt was felt to have poor underlying lung function from involvement of her tumor and therefore was started on tarceva. . In the MICU the patient had waxing and [**Doctor Last Name 688**] respiratory status and required a NRB. SHe was never intubated. Currently she is on 70% face mask. She continued to be treated for hospital acquired pna with vanc/levo/flagyl. While the bronchoal lavage cx was negative but a sputum cx grew MRSA. The pt was also found to have new ARF with a creatinine of 1.5, which was thought to be prerenal and resolved with IVF. Her chest pain was felt to be due to a rib fracture and was treated with dilaudid. . The pt is now transfered for further management of her BAC. She is currently on 6L NC with intermittent episodes of SOB and a dry cough and denies CP, nausea, vomiting Past Medical History: Hypertension MRSA pneumonia in [**2138**] GERD Dyslipidemia Depression Anxiety Social History: Patient lives a alone in [**Hospital3 **]. She had previous worked in retail. She quit smoking in [**Month (only) 547**] and now uses nicorette gum. She had smoked approximately 0.5 packs a day for 45 years. She drink alcohol only socially. She reports no use of recreational drugs. Family History: Mother (former smoker) is [**Age over 90 **] years old and carries a diagnosis of "asthma". Mother had breast cancer. Father had liver disease. Not family history of lung disease. Physical Exam: Vitals: t 96.6 bp 122/62 P 93 RR 20 97 70% mask Gen: mildly tachypneic when moving around, NAD HEENT: MMM, op clear, perrl Neck: no LAD, no thyromegaly, no JVD Pulm: decreased breath sounds at the bases Heart: RRR, no m/r/g Abdomen: soft, NT/ND Extr: no cyanosis , no edma, no clubing Neuro: AxO3, cranial nerves grossly intact Pertinent Results: [**2148-8-8**] 12:00AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.7* Hct-28.8* MCV-97 MCH-32.8* MCHC-33.8 RDW-12.7 Plt Ct-422 [**2148-8-8**] 12:00AM BLOOD Plt Ct-422 [**2148-8-8**] 12:00AM BLOOD Glucose-126* UreaN-19 Creat-1.2* Na-138 K-4.2 Cl-97 HCO3-27 AnGap-18 [**2148-8-8**] 12:00AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2 [**2148-8-4**] 01:30AM BLOOD Hapto-312* [**2148-8-2**] 12:00AM BLOOD calTIBC-203* Ferritn-408* TRF-156* [**2148-8-1**] 12:27AM BLOOD VitB12-590 Folate-10.5 [**2148-8-6**] 07:10PM BLOOD Vanco-5.2* [**2148-7-23**] 12:19AM BLOOD Type-ART pO2-84* pCO2-44 pH-7.35 calTCO2-25 Base XS--1 [**Date range (1) 56011**] C. Diff Assay: Negative x3 . GRAM STAIN (Final [**2148-8-6**]): [**11-28**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | Bronchial lavage:[**7-23**] Suspicious for non-small cell carcinoma. Scattered single cells and loose clusters of cells with high nuclear cytoplasmic and nuclear membrane irregularity, nucleoli and chromatin clearing. These findings are suspiciuos for non-small cell carcinoma, possibly bronchioloalveolar type . Chest CT w/ contrast [**8-6**]: IMPRESSION: 1. Improving right lower lobe consolidation and lymphadenopathy. 2. Improving left basilar atelectasis. 3. Stable suspicious mass in the lingula. A nearby area of well-marginated ground-glass opacity may be inflammatory or also raises suspicion for malignancy. The opacities are unchanged. 4. New mixed patchy ground glass and consolidative opacity in the superior segment of the left lower lobe, which could be infectious, inflammatory or due to aspiration. 5. No evidence of bony metastases, but several rib fractures, which are unchanged in retrospect. 6. Pneumobilia, which could be seen in prior sphincterotomy. 7. Suspicious renal lesion not imaged. . Brain MRI:IMPRESSION: Mild-to-moderate brain atrophy. No evidence of acute infarct or abnormal enhancement. No evidence of mass effect or hydrocephalus. . Bone Scan: IMPRESSION: 1. Two adjacent areas of focal increased tracer uptake in the left lateral 7th and 8th ribs consistent with fractures. 2. Nonspecific increased tracer uptake within the right 6th posterior and 7th lateral ribs. Given the findings in the contralateral ribs, this tracer uptake may also be due to a trauma; however, correlation with cross-sectional imaging (CT scan) could be used for further evaluation if clinically indicated. . CT Abdomen/pelvis: [**7-26**] IMPRESSION: 1. Complete consolidation of the right lower lobe, which may be filled with fluid (perhaps related to recent lavage), hemorrhage, or tumor. This appearance is rather extensive for BAC, however, it is possible. No focal masses are identified within the consolidated lobe. 2. Spiculated mass within the lingula with associated left hilar lymphadenopathy is highly concerning for malignancy. 3. Vague airspace opacities at the left posterior lung base and medial aspect of the right middle lobe may represent infection or less likely tumor. 4. 1.3 cm soft tissue lesion within the right kidney which may represent a hemorrhagic cyst, or renal cell carcinoma. Recommend further evaluation with MRI. 5. Three hypoattenuating lesions within the liver are likely cysts, however, attention should be paid to these on future exams to ensure stability. 6. Diverticulosis without diverticulitis. 7. Moderate centrilobular emphysema. . TBBX: Atypical mucinous glands, highly suspicious for bronchiolo-alveolar carcinoma, mucinous type. Brief Hospital Course: 63F with recurrent pneumonias, htn was transfered on [**7-17**] from an OSH after 3 hospitalizations for RLL pneumonia in the last 2 months. The next hospitalization found RLL and Lingular PNA. A BAL on [**7-2**] was negative for bacteria or atypical/malignant cytology. On the most recent admission, Ms. [**Known lastname 56012**] was found to have sputum positive for MRSA. The patient was at home for 8 days with 2.5 L continous oxygen requirement with dyspnea on excertion. On [**7-12**] the patient returned to the hospital with excruciating laft sided rib pain that developed over 3 days that was though to be secondary to severe coughing. Admission CT was postive for RLL a persistent RLL consildation, left lingular process, and 7th rib fracture. Ms. [**Known lastname 56012**] was treated with Zosyn starting [**7-12**] and vancomycin on [**7-15**] following a sputum positive for MRSA on [**7-15**]. was found to have have a positive MRSA result cultured from sputum. She underwent bronch at OSH which revealed no evidence of tumor. She was transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**], she underwent work-up for the hypoxia which involved pulmonary consult which recommended repeat bronch. The patient underwent bronch with biopsies on [**7-22**]. Bronch was remarkable for abundant secretions. . Negative PPD at OSH . Studies from OSH: [**7-12**] CXR PA/lat [**Last Name (un) **] improvemtn of RLL consolidation, resolving [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 56013**] in LLL . Left rib films [**7-12**] on fracture . CTA chest [**7-12**] no PE, unchaged RLL atelectasis with dense consliation interal increase in mass like lingular consliation stable , medistial adeopathy, acute left 7th [**Last Name (un) **] fracture. . A/P: 63F with recurrent pneumonias, htn p/w hypoxia s/p bronch . # Acute hypoxia; Patient experienced multiple episodes of acute hypoxia most concerning for mucous plugging given the abundant secretions on bronch. No evidence of CHF. Patient never intubated throughout ICU stay, was able to be maintained on NRB and then titrated as secretions improved to Face Mask and 6L NC. Two febrile episodes with rising white count and worsening respiratory status treated empirically for post-obstructive PNA with course of vanco and zosyn. Patient to complete a ten day course of IV Vancomycin and Zosyn (total of 7 days post-dsicharge). . # Bronchoalveolar Carcinoma, mucinous type: Persistent RLL cosolidation and cough over months despite treatment, BAL demonstrated bronchorrhea from bronchoavelolar cancer, mucinous type on pathology. CT chest also demonstrated spiculated mass in the lingula. Patient started on 60mg prednisone and Tarceva daily with improvement in brochorrhea. Nebs given standing. Patient to continue with Tarceva until she is evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] ([**Telephone/Fax (1) 56014**]) as outpatient for further management of BAC. She also will continue with a Prednisone taper over 30 days for bronchorrhea. Chest CT prior to discharge showed resolving areas of consolidation suggesting improved control of mucinous secretions. . # Pain: Left Rib Fracture c/o pathologic fx -Contolled on MsContin and prn oxycodone . # ARF: Cr 1.5 on admission, was 0.9 on [**7-18**]. Prerenal state. Stabilized with IVF at 1.0-1.2. . # Anxiety Depression: - Continued buspar, celexa, seroquel, trazadone - prn ativan for an acute anxiety attack . # HTN: -continued norvasc, diovan Medications on Admission: Medications at home: Buspirone 10 Qid Diovan 160 mg qd FemHRT 1/.005 qd [**Doctor First Name **] D 1 tab Protonix 60 mg qd Celexa 60 mg qd Seroqul 200 mg qhs potassium chloride 10 to 20 meq qd trazonde 50 to 100 mg PO qhs prn Albuterol prn . Medications on transfer: PredniSONE 60 mg PO DAILY Erlotinib (Tarceva) *NF* 150 mg PO DAILY Start Morphine SR (MS Contin) 60 mg PO Q12H Clonazepam 0.25 mg PO BID Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Acetaminophen 650 mg PO Q6H:PRN Lidocaine 5% Patch 2 PTCH TD QD Guaifenesin [**6-13**] ml PO Q4H Vancomycin 1000 mg IV Q 12H HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg(s) MetRONIDAZOLE (FLagyl) 500 mg PO TID Levofloxacin 250 mg PO Q24H [**7-23**] @ 0937 View Fexofenadine 60 mg PO DAILY [**7-23**] @ 0409 View Lorazepam 0.5 mg PO/IV Q4-6H:PRN anxiety Aspirin 81 mg PO DAILY Senna 1 TAB PO BID:PRN Quetiapine Fumarate 200 mg PO QHS Docusate Sodium 100 mg PO BID Heparin 5000 UNIT SC TID traZODONE HCl 50 mg PO HS:PRN [**7-23**] @ 0409 View Amlodipine 10 mg PO DAILY Citalopram Hydrobromide 60 mg PO DAILY Pantoprazole 40 mg PO Q12H Femhrt [**2-9**] *NF* 5-1 mcg-mg Oral QD BusPIRone 10 mg PO QID Discharge Medications: 1. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 17. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 19. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H (every 4 hours) as needed. 20. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 22. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN For PASV Picc flush before and after each use Inspect site daily 23. Heparin Flush (10 units/ml) 2 ml IV PRN 24. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 25. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 7 days. 26. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 30 days: Please take 6 pills x5 days, 5 pills x5 days, 4 pills x5 days, 3 pills x5 days, 2 pills x5 days, 1 pills x5 days. Tablet(s) 27. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day for 30 days: Please take 6 pills x 5 days then taper to 5 pills x5days, 4 pills x5 days, 3 pills x5 days, 2 pills x5days, 1 pill x5 days. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 23638**] Discharge Diagnosis: Bronchoalveloar Carcinoma Post-Obstructive Pneumonia in MRSA carrier Chemotherapy-induced diarrhea Acute Renal Failure Normocytic Anemia of Chronic Disease Vitamin K deficiency Coagulopathy Stress Urinary Incontinence Anxiety Depression Benign Hypertension Vaginal Candidiasis Discharge Condition: Stable, requiring 6L of NC to maintain oxygen saturation. Discharge Instructions: You have been treated for Bronchoalveolar carcinoma and associated bronchorrhea and post-obstructive pneumonia. Please complete a 7 day course of IV Vancomycin and Zosyn for empiric treatment of MRSA post-obstructive pneumonia. Please continue a one month taper of your prednisone. You are to follow-up once discharged from the rehab facility with an oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**], MA. In the interim, please continue with Tarceva for the next month until otherwise instructed by Dr [**Last Name (STitle) 20889**]. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20889**] [**Telephone/Fax (1) 56014**] in [**Location (un) 15566**], MA for further management of your lung cancer. Rahbilitation facility is to call to schedule an appointment prior to discharge home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**] Name: [**Known lastname 10499**],[**Known firstname 1365**] A Unit No: [**Numeric Identifier 10500**] Admission Date: [**2148-7-17**] Discharge Date: [**2148-8-8**] Date of Birth: [**2082-9-12**] Sex: F Service: MEDICINE Allergies: Antihistamines Attending:[**First Name3 (LF) 10501**] Addendum: Please forward a copy of this discharge summary to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 10502**], MA [**Telephone/Fax (1) 10503**] Discharge Disposition: Extended Care Facility: [**Hospital1 170**] Senior Healthcare - [**Location (un) 10504**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10505**] MD, [**MD Number(3) 10506**] Completed by:[**2148-8-8**]

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icd9cm

[ [ [] ] ]

[ "38.93", "33.27", "96.56" ]

icd9pcs

[ [ [] ] ]

16900, 17151

7286, 10840

295, 312

15176, 15236

3441, 4220

15919, 16877

2896, 3077

12146, 14743

14876, 15155

10866, 10866

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3092, 3422

4261, 7263

236, 257

340, 2477

11133, 12123

2499, 2580

2596, 2880

43,052

103,454

35144+57979

Discharge summary

report+addendum

Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-6**] Date of Birth: [**2128-2-1**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: Tremor Major Surgical or Invasive Procedure: Attempt at Stage 1 DBS, Stereotactic frame and burr hole placement History of Present Illness: Mr. [**Known lastname 80234**] is a 69 year old gentleman with a 20 year history of Parkinsons disease. Presenting symptom, right arm tremor. Now things are progressed and they are still strongly asymmetric with the right side still being the worse. Major problems are tremor, rigidity, muscle cramping, bradykinesia, and dyskinesias as well. Gait is not as bad. Freezing is an issue as well. Poor balance and dysarthria is also a problem. [**Name (NI) 28118**] problems are stooped posture and swallowing trouble, whereas he has [**Last Name **] problem with memory loss or hallucinations. He needs assistance when he is walking and he is off. He has to to use a walker. The difference between his best on and worst off is extreme and he thinks he spends at the most about 50% on during the day. He takes Sinemet six times a day. Past Medical History: PD, R>L tremor, gait Ds, mild hypothyroidism, knee surgery, pilonidal cyst surgery Social History: Lives with family Family History: Non contributory Physical Exam: Upon discharge: Patient afebrile and heamodynamically stable. He is oriented to person, place, day, date, time of the day. Mild difficulties in obeying commands. But otherwise no clear cranial nerve deficits. Able to move all 4 limbs. Power grossly normal in all 4 limbs. Motor: Appears dyskinetic all over, hypomimic and hypophonic. There was no rest, action, or postural tremor. He had mild cogwheeling bilaterally, right more than left Pertinent Results: [**2197-4-4**] CT Head FINDINGS: The patient is status post cannulation of the left frontal bone for deep brain stimulation procedure. A small amount of subarachnoid hemorrhage adjacent to the surgical defect interdigitates along left frontal sulci, which demonstrate mild cortical swelling. A small subdural hemorrhage may be present in this location as well. A moderate amount of expected pneumocephalus is seen. As seen on prior MR, there is moderate dilatation of the ventricles. A small hypodense area in the left temporal lobe ( se 2, im 6) is likely artifactual. Basal cisterns appear patent. The visualized paranasal sinuses are clear. Globes and orbits are intact. IMPRESSION: Status post aborted DBS with small amount of subarachnoid hemorrhage, mild cortical swelling, and possibly a small subdural hematoma present adjacent to the surgical site. [**2197-4-5**] CT Head FINDINGS: Small left frontal subarachnoid hemorrhage with minimal associated sulcal effacement adjacent to craniotomy due to aborted attempt of place deep brain stimulator is stable. Previously suspected thin left frontal subdural hematoma is more evident on current study, but measures only 2-3 mm at greatest depth (2:21). Stable moderate amount of post-procedural pneumocephalus evident. Moderate ventriculomegaly is unchanged. The mastoid air cells and middle ear cavities are clear. Minimal mucosal thickening identified within the ethmoid air cells. IMPRESSION: Status post aborted DBS, with stable small amount of subarachnoid hemorrhage layering in the left frontal sulci with mild sulcal effacement; there is a very thin subdural hematoma at the surgical site, minimally-increased and measuring only [**2-17**] mm in maximal thickness. Brief Hospital Course: 69M elective admission for stage 1 DBS which was aborted secondary to bleeding. Post-op head CT showed a small SAH on the left side. He was admitted to the Neuro ICU. He had a repeat head CT for an episode of freezing/ increased tremor/ unresponsive. CT head was stable. Heme was called to consult. On [**4-5**] his exam was stable and appeared at his baseline. Heme felt the increased bleeding could be from a platelet dysfunction secondary to herbal supplements and recommended that patient discontinue taking these supplements. On [**4-6**], PT evaluation was obtained and they recommended home. Additionally, a CXR and UA was obtained to ensure that is post op confusion was not infectious. This was essentially negative. Now DOD, he is afebrile, VSS, and neuro stable. He is ambulating at baseline. He is set for d/c home in stable conditon and will follow-up accordingly. Medications on Admission: Sinemet 25/100 two tablets six times per day ReQuip XL 2 mg at 8:00 a.m. and 10:00 a.m Discharge Medications: 1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO 6 TIMES DAILY (). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/ha. 4. Requip XL 2 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO daily (). Discharge Disposition: Home With Service Facility: [**Hospital 269**] Healthcare of [**Location (un) **] CT Discharge Diagnosis: Parkinson's Disease SAH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please remove your dressing on [**2197-4-6**]. Keep sutures clean and dry until they are removed. Followup Instructions: Please call [**Telephone/Fax (1) 1272**] to re-schedule your surgery and for a suture removal appointment in [**7-25**] days from the date of your surgery. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2197-4-6**] Name: [**Known lastname 12896**],[**Known firstname **] Unit No: [**Numeric Identifier 12897**] Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-6**] Date of Birth: [**2128-2-1**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1698**] Addendum: added: Tramadol 50mg PO Q6h prn for pain, dispense 40 pill no refills Discharge Disposition: Home With Service Facility: [**Hospital **] Healthcare of [**Location (un) 12898**] CT [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2197-4-6**]

[ "244.9", "781.3", "430", "997.02", "E878.8", "784.51", "332.0" ]

icd9cm

[ [ [] ] ]

[ "39.98", "01.24", "93.59" ]

icd9pcs

[ [ [] ] ]

6228, 6441

3648, 4532

312, 381

5202, 5202

1894, 3625

5476, 6205

1398, 1416

4670, 5024

5155, 5181

4558, 4647

5353, 5453

1431, 1431

266, 274

1448, 1875

409, 1241

5217, 5329

1263, 1347

1363, 1382

28,909

145,746

33492+57851

Discharge summary

report+addendum

Admission Date: [**2172-2-29**] Discharge Date: [**2172-3-11**] Date of Birth: [**2108-1-29**] Sex: F Service: CARDIOTHORACIC Allergies: Glucophage / Amoxicillin Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p Aortic Valve Replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Regent Mechanical) [**2172-3-5**] History of Present Illness: 64 year old female with increasing shortness of breath with aortic stenosis, referred for cardiac surgery Past Medical History: Aortic Stenosis Breast Cancer Pulmonary embolism Elevated cholesterol Diabetes mellitus Osteopenia Social History: Lives alone Does not currenlty work Tobacco denies ETOH [**11-27**] year Family History: brother deceased at 42 from MI Physical Exam: General NAD Skin unremarkable HEENT unremarkable Neck supple Full ROM Chest CTA bilat Heart RRR murmur Abdomen soft, obese, NT, ND Extremeties warm well perfused +1 edema (RUE +2), pulses palpable Pertinent Results: [**2172-3-11**] 05:30AM BLOOD WBC-5.8 RBC-3.19* Hgb-10.2* Hct-30.0* MCV-94 MCH-31.9 MCHC-33.9 RDW-14.5 Plt Ct-318 [**2172-2-29**] 03:58PM BLOOD WBC-7.6 RBC-4.29 Hgb-13.6 Hct-39.1 MCV-91 MCH-31.8 MCHC-34.9 RDW-13.8 Plt Ct-182 [**2172-3-5**] 10:55AM BLOOD Neuts-61 Bands-11* Lymphs-24 Monos-2 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2172-3-11**] 05:30AM BLOOD Plt Ct-318 [**2172-3-11**] 05:30AM BLOOD PT-23.5* PTT-30.3 INR(PT)-2.3* [**2172-2-29**] 03:58PM BLOOD Plt Ct-182 [**2172-2-29**] 03:58PM BLOOD PT-14.1* PTT-22.6 INR(PT)-1.2* [**2172-3-11**] 05:30AM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-140 K-4.8 Cl-102 HCO3-25 AnGap-18 [**2172-2-29**] 03:58PM BLOOD Glucose-155* UreaN-13 Creat-0.9 Na-140 K-3.4 Cl-100 HCO3-27 AnGap-16 [**2172-2-29**] 03:58PM BLOOD ALT-12 AST-13 LD(LDH)-203 AlkPhos-125* TotBili-1.0 [**2172-2-29**] 03:58PM BLOOD %HbA1c-7.5* [**2172-3-1**] 10:04 am URINE Site: CLEAN CATCH **FINAL REPORT [**2172-3-4**]** URINE CULTURE (Final [**2172-3-4**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. [**2172-3-9**] 11:00 am URINE Source: CVS. **FINAL REPORT [**2172-3-10**]** URINE CULTURE (Final [**2172-3-10**]): NO GROWTH. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77657**] (Complete) Done [**2172-3-5**] at 8:54:02 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2108-1-29**] Age (years): 64 F Hgt (in): 69 BP (mm Hg): 124/74 Wgt (lb): 255 HR (bpm): 76 BSA (m2): 2.29 m2 Indication: Intra-op TEE for AVR ICD-9 Codes: 786.05, 440.0, 424.1 Test Information Date/Time: [**2172-3-5**] at 08:54 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2008AW04-: Machine: Echocardiographic Measurements Results Measurements Normal Range 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: 4.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: *0.28 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *79 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 37 mm Hg Aortic Valve - LVOT pk vel: 0.87 m/sec Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2 Aortic Valve - Pressure Half Time: 750 ms Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild to moderate ([**11-27**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**11-27**]+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. 7. Physiologic mitral regurgitation is seen (within normal limits). 8. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in Sinus rhythm 1. Mechanical prothesis is well seated in the Aortic Position. Leaflets open well. Peak gradient is 17 mm of Hg with CO of 5 l/min. No significant AI is seen. 2. LV functions is preserved. RV function is marginally decreased. 3. Aorta is intact post decannulation. 4. Other findings are unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2172-3-5**] 13:08 CHEST (PA & LAT) [**2172-3-9**] 11:33 AM CHEST (PA & LAT) Reason: evaluation pneumomediastinum - [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with s/p avr REASON FOR THIS EXAMINATION: evaluation pneumomediastinum - STUDY: PA and lateral chest radiograph. INDICATION: Status post aortic valve replacement, evaluate for pneumomediastinum. COMPARISON: [**2172-3-6**]. FINDINGS: Pneumomediastinum detected on previous radiographs are not apparent on today's study. Median sternotomy wires remain intact. Aortic valve replacement device noted. Right internal jugular central venous catheter tip overlies the cavoatrial junction. Small bilateral effusions are again noted. No focal consolidation or pulmonary edema is detected. IMPRESSION: 1. Resolved pneumomediastinum. 2. Cardiomegaly without acute pulmonary edema. Small bilateral effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2172-3-10**] 9:17 AM Sinus rhythm. Non-specific lateral T wave abnormalities. Compared to the previous tracing of [**2172-3-5**] the sinus rate is slower and left bundle-branch block is no longer present. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 136 82 428/443 57 0 76 Brief Hospital Course: Admitted for anticoagulation with heparin drip. On admission labs was found to have urinary track infection and she was treated with antibiotics. Surgery was delayed due to urinary tract infection and she was continued on heparin drip. On [**3-5**] she went to the operating room for aortic valve replacement and received vancomycin periop due to hospitalization. Please see operative report for further details. She was transferred to the intensive care unit for hemodynamic montioring. In the first 24 hours she was weaned from sedation, awoke neurologically intact, and was extubated without difficulty. She was transferred to the floor on POD 1, started on beta blockers and diuretics. Physical therapy worked with her for strength and mobility. Continued on heparin until therapuetic with coumadin and was ready for discharge home with services POD 6. Follow up for coumadin with Dr [**Last Name (STitle) **]. Medications on Admission: Paxil 37.5 daily Coumadin 3 daily Glipizide 10 daily Lipitor 10 daily Arimidex 1 daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Paxil CR 37.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0* 10. Outpatient [**Name (NI) **] Work PT/INR mon/wed/fri and prn results to Dr [**Last Name (STitle) **] fax # [**Telephone/Fax (1) 70142**] 11. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2 days: please take 7.5mg wed and thrus - INR check fri am and further dosing with Dr [**Last Name (STitle) **] . Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] Discharge Diagnosis: Aortic Stenosis s/p AVR Diabetes Mellitus Elevated cholesterol Osteopenia Pulmonary embolism ([**2167**]) IVC filter Breast cancer s/p lumpectomy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] PT/INR monday-wednesday-friday for mechanical AVR with goal 2.5-3.0 - results to Dr [**Last Name (STitle) **] fax # [**Telephone/Fax (1) 70142**] Followup Instructions: Dr [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) **] in 1 week - please call for appointment Dr [**Last Name (STitle) 5874**] in [**12-29**] weeks - please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Labs: PT/INR for coumadin dosing - goal INR 2.5-3.0 for AVR Results to Dr [**Last Name (STitle) **] #[**Telephone/Fax (1) 43460**] Fax # [**Telephone/Fax (1) 70142**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2172-3-11**] Name: [**Known lastname **],[**Known firstname 1940**] Unit No: [**Numeric Identifier 12559**] Admission Date: [**2172-2-29**] Discharge Date: [**2172-3-11**] Date of Birth: [**2108-1-29**] Sex: F Service: CARDIOTHORACIC Allergies: Glucophage / Amoxicillin Attending:[**First Name3 (LF) 265**] Addendum: Spoke with Dr [**Last Name (STitle) **] office, will follow up on coumadin and LUL nodule noted on preop cxr. Discharge Disposition: Home With Service Facility: [**Last Name (un) 11596**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2172-3-11**]

[ "E878.1", "V12.51", "272.0", "041.3", "998.81", "250.00", "599.0", "V10.3", "518.89", "424.1", "733.90" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

13620, 13797

8979, 9905

310, 446

11806, 11813

1075, 7610

12470, 13597

811, 843

10042, 11537

7647, 7678

11637, 11785

9931, 10019

11837, 12447

858, 1056

251, 272

7707, 8956

474, 581

603, 704

720, 795

25,225

143,004

3975

Discharge summary

report

Admission Date: [**2180-6-23**] Discharge Date: [**2180-7-6**] Date of Birth: [**2147-8-13**] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin / Heparin Agents / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2181**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 14323**] is a 32 y/o female with a h/o SLE Nephritis w/ ESRD on HD, HTN, MSSA endocarditis, H/O Line Sepsis, s/p R BKA, seizure d/o, and restrictive lung disease presenting with pain from sacral decubs and fever. Per transfer notes, the patient had fevers 2 days prior at [**Known lastname 2286**] and was given Vancomyocin. Over the past few months she has had pain at the site of her decubitus which has escalated. She has pain throughout her body, and decreased PO intake. She has not had a bowel movement in several days. She reported no chest pain, pleuritic pain, palpitations, or shortness of breath. She feels "fluid overloaded". . She has a recent admission at [**Hospital 1263**] Hospital from [**Date range (1) 17594**] with SOB after [**Date range (1) 2286**]. She had a debridement of her hospital and was emperically covered with Vanco and Ceftaz with subsequent coverage with just Ceftaz for RLL PNA. She also had left shoulder pain which was diagnosed as supraspinatus tendonitis which was treated with prednisone and dilaudid. . Of note: Her CXR was unchanged from prior studies, and a CT ABD, Pelvis demonstrated air tracking from her decub site. She had an episode of hypotension (SBP 80's, baseline 90s) which was treated with IVF fluids. Past Medical History: #. Systemic Lupus Erythematosus: diagnosed [**2166**] complicated by lupus nephritis, anemia, serositis and ascites, vascular stenosis resulting in facial edema and subclavian steal #. Pulmonary HTN #. ESRD s/p failed renal transplant in [**2174**] requiring explant -HD T/Th/Sat #. HTN #. GERD #. Multiple hospitalizations for line sepsis #. S/p R BKA for chronically infected non-healing fracture (R Tib-fib fracture in [**2176**]) #. H/o MSSA endocarditis c/b embolic stroke and resultant seizure disorder #. Seizure disorder- complication of embolic strokes from mitral valve endocarditis in [**2177**] #. H/o VSD s/p surgery at age 13 #. HTN #. ITP #. Sickle cell trait #. S/p left oophorectomy related to IUD associated infection, s/p TAH/RSO for right pelvic abscess #. Restrictive lung disease Social History: Lives at home with husband and 16 year old son. Denies any past history of smoking, alcohol or other drugs. Originally from [**Country **]. Used to work at [**Hospital1 18**] as a patient care technician, currently on disability. She has used a walker for about 2.5 years since amputation of her right foot. She lives in an apartment on the [**Location (un) 448**], has to climb about 15 stairs to get to the apartment. Family History: Brother with SLE and DM Physical Exam: Admission Physical Exam: Gen: Uncomfortalble, sensitive to touch in lower legs. Swollen face with cachectic arms and legs. Neuro: Responsive. Alert and Oriented. Moving arms, not moving legs [**1-11**] to pain. CV: Normal S1 and S2, no S3 or S4. No rub. Res: CTA anteriorly ABD: Soft, NT, ND. Hypoactive bowel sounds. No hepatosplenomegaly apprecated. Ext: R, BKA, sensitive to touch. No erythema. L Bandage across lower leg. Brace in place. No edema. Discharge Physical Exma: Gen: Resting comfortably. Swollen lips, with periorbital swelling. Cachectic arms and legs. Neuro: Alert and Oriented. Moving arms and legs. She moves her legs with limited ROM due to pain. CV: Normal S1 and S2, no S3 or S4 appreciated. No rubs or murmurs. Res: Speaks in full sentences on NC 2L O2. Shallow breaths, with basilar crackles but no rubs or rhonchi. ABD: Midline surgical scar. Slight distention of abdomen, no hepatosplenomegaly appreciated. Ext: R BKA. Non-sensitive. L leg. Mobile fluid above knee with tender quadriceps tendon. Point tenderness over the medial and lateral aspect of the elbow. Large 2-4 cm dark spots across the L leg. Pertinent Results: [**2180-6-23**] 12:55PM BLOOD WBC-7.4 RBC-3.33* Hgb-8.6* Hct-29.3* MCV-88 MCH-25.8* MCHC-29.3* RDW-21.0* Plt Ct-136* [**2180-6-23**] 12:55PM BLOOD Neuts-71.9* Lymphs-22.1 Monos-4.6 Eos-0.7 Baso-0.7 [**2180-6-23**] 12:55PM BLOOD Plt Ct-136* [**2180-6-26**] 08:00AM BLOOD ESR-98* [**2180-6-23**] 12:55PM BLOOD Glucose-75 UreaN-13 Creat-3.2*# Na-136 K-3.6 Cl-94* HCO3-34* AnGap-12 [**2180-6-28**] 07:00AM BLOOD CK(CPK)-65 [**2180-7-5**] 07:24AM BLOOD CK(CPK)-22* [**2180-6-24**] 09:28AM BLOOD Albumin-2.9* Calcium-7.5* Phos-1.9* Mg-2.2 [**2180-6-30**] 06:36AM BLOOD PTH-[**2176**]* [**2180-6-26**] 08:00AM BLOOD CRP-54.6* Relevent Imaging: MR PELVIS WITHOUT IV CONTRAST: As seen on CT from six days prior, gas is seen in the gluteal muscles, especially along an apparent sinus tract adjacent to the gluteal crease on the right (6:31). There is generalized marrow signal abnormality throughout the pelvis and heterogenous marrow re-conversion sparing the epiphyses and apophyses, related to the patient's debilitated state. Even allowing for this background abnormal marrow signal, there is focally increased marrow signal on fluid-sensitive sequences at the sacrococcygeal junction, especially at S4-5 and the proximal coccyx (9:30). There is also fluid surrounding the sacrococcygeal junction, with pre-sacral fluid in contiguity with background ascites also seen on recent CT. Diffuse anasarca, and soft tissue edema are also again seen. Bowel loops are not well evaluated due to patient motion, but the rectum appears unremarkable. The pelvic muscles elsewhere also appear unremarkable. The vertebral discs demonstrate slight degenerative signal and endplate irregularity at the lumbosacral junction. IMPRESSION: 1. Sacral decubitus ulcer with gas in the gluteal muscles and possible right paramedian sinus tract. 2. Sacrococcygeal junction marrow abnormality and overlying edema without osseous erosion, but highly concerning for osteomyelitis. Findings conveyed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10919**] the morning of [**2180-6-30**]. The study and the report were reviewed by the staff radiologist. CT LEFT ELBOW WITHOUT INTRAVENOUS CONTRAST. INDICATION: 32-year-old female with left elbow joint effusion and left lateral elbow pain. COMPARISON: Left elbow radiograph dated [**2180-6-29**]. TECHNIQUE: MDCT axial images of the left elbow were obtained without administration of intravenous contrast. Coronal and sagittal reformatted images were obtained. FINDINGS: The osseous structures are severely demineralized. There is no definite fracture and no dislocation, bone erosion, or focal osteolysis. There is an equivocal subtle lucency through the anterior aspect of the radial head, extending to the articular surface, likely representing a nondisplaced fracture, best seen on the sagittal series 702A images 106-111. No other fractures are seen, generalized osteopenia limits evaluation. Effusion previously appreciated on the radiograph is not seen on today's study. There is generalized soft tissue edema, consistent with anasarca. There are vascular calcifications. IMPRESSION: 1. Subtle nondisplaced radial head fracture. 2. Anasarca. Findings of fracture were discussed with Dr. [**Last Name (STitle) 17595**] on [**2180-7-3**] at 12 p.m. MMD Addendum [**2180-7-4**] by Dr. [**Last Name (STitle) **] - There is possible linear lucency, but no definite fracture and no displaced fracture. Demonstration of a possible nondisplaced fracture is markedly limited by the surrounding osteopenia. Possibilities for further assessment include follow-up radiographs 7-10 days following the initial x-ray, MRI, or bone scan. The study and the report were reviewed by the staff radiologist. LEFT KNEE MR [**First Name (Titles) **] [**Last Name (Titles) 17596**] INDICATION HISTORY: A 32-year-old woman with end-stage renal disease, lupus, on hemodialysis, with severe knee pain and limited flexion. Evaluate for quadriceps tendon pathology or rupture. COMPARISON: Not available at the [**Hospital1 18**]. Note is made of MR of the pelvis dated [**2180-6-9**], and knee radiographs dated [**2180-6-30**]. TECHNIQUE: Sagittal PD, T2 fat sat, axial 3D fat sat, and coronal PD fat saturated sequences through the left knee were obtained without administration of [**Year (4 digits) **]. FINDINGS: The anterior and posterior cruciate ligaments are intact. The medial collateral ligament is intact. The lateral collateral ligament complex is intact. The popliteus muscle tendon is intact. The quadriceps tendon and patellar tendon are intact. The medial and lateral menisci are intact. There is a large joint effusion, with evidence of synovial proliferation, indicating presence of synovitis. The medial and lateral patellar retinacula are intact. The cartilage in patellofemoral compartment is preserved. There is irregularity of the cartilage of medial tibial plateau posteriorly, with subjacent bone marrow edema. There is trace bone marrow edema in the lateral femoral condyle (3:18), likely subchondral reactive change suggesting overlying cartilage abnormality versus small contusion. There is markedly abnormal signal in the bone marrow of the femur and tibia, which does not extend into the epiphyses, demonstrating high T2 and low T1 signal. Similar changes were seen on the MR of the pelvis on [**2180-6-29**]. There is marked soft tissue edema in keeping with anasarca. IMPRESSION: 1. Intact extensor mechanism. 2. Large joint effusion and synovitis. Diffuse soft tissue edema which is nonspecific, but consistent with anasarca. 3. Articular cartilage abnormalities, as above, with adjacent subchondral edema versus small contusion in the lateral tibial plateau. 4. Diffuse bone marrow signal abnormality. This is a nonspecific finding, of uncertain etiology. The differential is extensive, but given the multifocal nature of the abnormality, it may represent changes of renal osteodystrophy Discharge Labs: [**7-5**] WBC 7.7, Hct 34.3, Plt 157 [**7-4**]: 134/4.5/94/27/45/5.9<103 Ca 6.7, Mg 2.4, Phos 6.0 [**7-5**] CK 22 Brief Hospital Course: 32 y/o female with complicated past medical history with SLE with decubitus ulcers admitted for fever and pain control. Hypotension: She was initially admitted to the MICU for hypotension and potential sepsis. However, she was hemodynamically stable after fluid resuscitation and discharged to the floor. Her basline blood pressure typically is SBP ~ 90's. While her SBP has ranged from the 90-110's. Stage IV decubitus sacral ulcer: After exploration of her wound, there was fibrinous tissue and sacral bone. There was concern for osteomyelitis based upon an elevated ESR and MRI imaging. Wound cultures grew out E. coli and Enterococcus. Emperic antibiotics, Vancomyocin and Meropenem were started. Several surgical subspecialties were consulted for possible debridement and flap reconstruction. At this time, the patient is not a candidate for surgical reconstruction of the area. She had several low grade temperatures on the floor, but never developed hypotension. She was transitioned to tigicycline antibiotics to increase the antibiotic penetration in the skin. However, sensitivities from her wound cultures eventually demonstrated that the enterococcus was tigicycline resistent. She was restarted on Daptomycin and Meropenem. Per infectious disease, she will require 8 weeks of antibiotics with Daptomyocin and Meropenem. Day 1 is considered: [**2180-7-3**]. She will complete 8 weeks on [**2180-9-3**]. She will also need weekly CK levels for daptomycin treatment. She will need a wound vac for her ulcer, and a PICC line for her antibiotics to be placed at rehab. She has follow up with Infectious disease on [**7-19**]. She will follow-up with Dr. [**Last Name (STitle) 17597**] [**Name (STitle) 1007**] [**Doctor Last Name **] at [**Hospital1 100**] Outpatient clinic for wound care on [**7-13**]. . L Knee: MRI demonstarted a joint effusion with synovitis. Rheumatology removed fluid from the knee and administered a steroid injection [**7-6**]. Her fluid aspirate was sent to for culture, gram stain, and cell count. Her culture results will need to be followed. . L CT Elbow CT scan: Concern for non-displaced fracture at radial head. Ortho was consulted for possible brace, however they felt there was no need at this time for intervention or stabilization. Her pain continues to improve on her current regiment. Recently, her Vitamin D has been increased. . Pain Control: She was evaluated by the Acute Pain Service team. Her current regiment of Fentanyl Patch 75 mg q72h, Dilaudid 8 mg q4 PRN pain allows her to rest comfortably without oversedation, or hypotension. She was also kept on her Pregabaline, and Liderm patch (tendonitis of the shoulder). For wound changes in the hospital she received Dilaudid 1-2 mg IV. . Nutrition: Her calorie count was low (~300 calories). At this time we did not want to give her a g-tube or dobhoff tube. She is able to eat if food is placed in front of her. She needs to be fed at each meal in order to ensure adequate nutrition. . ESRD: She received [**Month/Year (2) 2286**] on Monday, Wednesday, and Friday. Her vitamin D-25 hydroxy level will need to be followed up. Recently her Calcitrol dose was changed from 0.25 to 0.5 mg, due to a PTH level of [**2176**] and CT findings consistent with osteopenia. She received her antibiotics after [**Year (4 digits) 2286**]. In order to ensure adequate fluid removal at [**Year (4 digits) 2286**], she should receive her midodrine prior to [**Year (4 digits) 2286**], at noon, and at 4 pm. Her calcium level has remained low so she was not restarted on her cinacalcet. . SLE: She was maintained on her home dose of Prednisone 5 mg daily. Due to her infected decubitis ulcer, we opted to treat her synovitis with local steroids. . Seizures: Per her old records she has tonic clonic seizures. She has not demonstrated any seizure activity while in the hospital. She was kept on her Keppra and Tomiramate. . Full Code . Contact Information: [**Name2 (NI) 4051**]: [**Telephone/Fax (1) 17598**] Husband: [**Telephone/Fax (1) 17599**] Medications on Admission: Keppra 1000mg daily MWF after HD and 500mg [**Hospital1 **] on non- HD days Prednisone 5mg daily Midodrine 10mg TID Bisacodyl 10mg daily PRN Miralax TID PRN Topiramate 100mg QHS Vancomycin 1gm Q hd protocol calcium acetate 667mg 2 caps TID w/ meals B complex-Vit C daily Docusate 100mg [**Hospital1 **] pantoprazole 40mg daily aspirin 81mg daily cymbalta 20mg daily pregabalin 25mg QHS lidoderm patch Q 24 calcium carbonate 500mg TID ensure TID cinacalcet 30mg daily prostat AWC 30cc [**Hospital1 **] dilaudid 4mg Q 4 prn fentanyl patch 50mcg Q 72 hrs TYlenol 650 PRN q 4 Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please take on non HD days. 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take after [**Hospital1 2286**] on M/W/F. 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**12-11**] Adhesive Patch, Medicateds Topical DAILY (Daily): to left elbow and left knee. 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 13. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*5 Patch 72 hr(s)* Refills:*0* 14. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain: hold for RR < 12. Disp:*30 Tablet(s)* Refills:*0* 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for Constipation. 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for elbow pain. 17. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 20. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 22. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 23. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection ASDIR (AS DIRECTED) as needed for pain. 24. Meropenem 500 mg IV Q7PM 25. Daptomycin 300 mg IV Q48H please give at 7PM 26. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 27. [**Month/Day (2) **] to Dr. [**First Name (STitle) **] [**Name (STitle) **] for wound care to Dr. [**Last Name (STitle) 17597**] [**Name (STitle) 1007**] [**Doctor Last Name **] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Stage Four Decubitus Ulcer Secondary Diagnosis: ESRD Oteopenia R Knee Synovitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Location (un) 17600**], Thank you for receiving your care at [**Hospital3 **] Hospital. You were admitted for low blood pressure and the ulcer on your back. You were evaluated by several surgical specialists as well as infectious disease physicinas who felt that your ulcer would heal with proper wound care and antibiotics. You also were evaluated for knee pain and L elbow pain. Your knee pain was due to inflammation surrounding the knee. Your elbow pain was due very weak bones. The following medications where changed during your hospital stay: Added: Lactulose Meropenem Daptomycin Stopped: Vancomyocin Cinacalcet Prostat AWC Tylenol Changed: Fentanyl Dilaudid Cymbalta Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2180-7-19**] at 11:30 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: [**2180-8-18**] at 11:30 AM With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Dr. [**Last Name (STitle) 17597**] [**Name (STitle) 1007**] [**Doctor Last Name **] for wound care [**7-13**], 1PM [**Hospital 100**] Rehab [**Telephone/Fax (1) 17601**] Completed by:[**2180-7-9**]

[ "707.23", "V49.75", "282.5", "719.06", "707.07", "276.7", "588.81", "733.90", "416.8", "041.4", "285.21", "518.89", "263.9", "730.08", "582.81", "727.00", "530.81", "403.91", "707.24", "585.6", "041.04", "707.03", "345.90", "V45.11", "511.9", "710.0" ]

icd9cm

[ [ [] ] ]

[ "81.91", "39.95", "99.23", "81.92" ]

icd9pcs

[ [ [] ] ]

17794, 17860

10333, 14400

411, 417

18004, 18004

4212, 10178

18879, 19695

3010, 3035

15022, 17771

17881, 17881

14426, 14999

18156, 18856

10194, 10310

3075, 4193

360, 373

445, 1728

17949, 17983

17900, 17928

18019, 18131

1750, 2554

2570, 2994

56,257

192,826

15355

Discharge summary

report

Admission Date: [**2198-6-26**] Discharge Date: [**2198-7-1**] Date of Birth: [**2118-4-11**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 80F with h/o parkinsons, who was found down after a fall down a flight of stairs. There was no clear precipitating event, and patient does not recall what happened. She was seen at [**Hospital3 **] and noted to have cervical tenderness and CT spine consistent with C4-C7 malalignment. The patient also has significant facial swelling on the left side with periorbital bruising and edema that is completely closing the L eye. The patient was transferred here from [**Location (un) 620**] for further management of her spine, facial trauma and possible syncope workup. Her other films from [**Location (un) 620**] appeared unremarkable. She currently cites pain over her c-spine, but otherwise is comfortable. She has no chest pain, SOB, nausea, vomiting, fevers, or chills. Past Medical History: HTN, gastroparesis, colitis, PD, depression, anxiety, glaucoma, vitamin D deficiency, osteoporosis Social History: Denies smoking, EToH, or drug use Family History: non-contributory Physical Exam: V/S: T 96.2 P 91 BP 150/89 RR 22 O2 98% RA GEN: AOx2, does not know location, preseverating, slight confusion HEENT: Significant periorbital edema/bruising around the L eye, unable to open L eye, abrasions to L face, small left forehead laceration, no facial tenderness, EOMI, PERRL Neck: Left sided abrasions, posterior C spine tenderness over C4-C7, c-collar in place CV: RRR, no m/g/r appreciated Lungs: Breath sounds bilaterally, lungs clear to ausculatation, no chest tenderness ABD: Soft, NT/ND EXT: able to move all extremties, +weakness in both lower extremities [**3-27**], but patient states this is baseline. palpable pulses bilaterally. Left arm with dorsal wrist bruise/hematoma, elbow abrasion. R palm bruising Pertinent Results: [**2198-6-26**] 03:15PM GLUCOSE-150* UREA N-15 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [**2198-6-26**] 03:15PM CALCIUM-8.7 PHOSPHATE-2.3* MAGNESIUM-1.7 [**2198-6-26**] 03:15PM WBC-12.4* RBC-4.91 HGB-14.3 HCT-42.1 MCV-86 MCH-29.0 MCHC-33.9 RDW-14.5 [**2198-6-26**] 07:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [**2198-6-28**] Chest X-ray: Cardiomegaly is mild to moderate. Left basal opacity and small amount of left pleural effusion are noted and potentially might represent infection. Upper lungs are clear. There is no pneumothorax. [**2198-6-28**] CT Head without contrast: IMPRESSION: 1. Decreased conspicuity of the previously described subarachnoid hemorrhage with redistribution to the occipital [**Doctor Last Name 534**] of the left lateral ventricle. 2. Improved appearance of left frontal subgaleal and peri-orbital hematoma without intra-orbital involvement. 3.Mild deformity of the left nasal bone may represent a smallf racture without sigf. dispalcement. ( se 2, im 1) [**2198-6-26**] CT Head: IMPRESSION: 1. Increased bilateral sulcal subarachnoid blood. 2. Increased left frontal subgaleal hematoma with extension to the preseptal periorbital soft tissues, but no evidence of intraorbital hematoma. Globe intact. No fracture. Brief Hospital Course: Ms. [**Known lastname 38472**] was admitted to the acute care surgery service after a fall down a flight of stairs. She was admitted to the TICU for monitoring and neuro checks. A CT head in the ED showed multiple SAH and neurosurgery was consulted. She was started on dilantin for 7 days. Her left periorbital swelling was monitored closely and remained able to be opened. Ortho spine also saw the patient and recommended c-collar initially, but that was subsequently cleared and removed. She was transferred to the floor on [**2198-6-28**] and did well. She tolerated a regular diet and her IV fluids were stopped on [**2198-6-30**]. She was started on her home medications on [**6-30**] as well. Medications on Admission: Sinemet 25-100 5x/day, metoprolol ER 25 QHS, Valsartan 80', Seroquel 25 Q1600/QHS, ondansetron 4''' prn, clonazepam 0.5'', venlafaxine ER 150', gabapentin 400'', brimonidine 0.15% Eye gtt'', timolol 0.5% Eye gtt'', MVI, Cosopt 2%-0.5% Eye gtt', ASA 81', Colace 100'', Vit D 1,000', calcium 1200', Prilosec OTC', Gas-X prn, Pepto-Bismol prn, cromolyn 4 % Eye Drops Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: [**12-24**] PO BID (2 times a day). 2. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO 5 TIMES/DAY (). 3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 6. phenytoin sodium extended 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily) for 2 days: Please take as directed for 2 days after discharge (7 day total). Disp:*6 Capsule(s)* Refills:*0* 7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for pain. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: small traumatic subarachnoid hemorrhage left periorbital swelling c4-c7 mal-alignment Discharge Condition: Mental Status: clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the acute care surgery service on [**2198-6-26**] for injuries sustained from a fall down a flight of stairs. Your CT scan showed C4-C7 malalignment. You also had facial swelling and bruising, as well as a small subarachnoid hemorrhage. You are improving daily and should continue to do so. You are being transferred to rehab for continuous support and therapy. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please get plenty of rest, continue to walk several times per day, Please also follow-up with your primary care physician. * If you develop any increased pain, numbness or tingling or any other symptoms that concern you please call your doctor or return to the Emergency Room. Followup Instructions: Please continue on dilantin for 2 days (7 days total). Follow up with Dr. [**Last Name (STitle) 44599**] in 4 weeks with a non-contrast CT head. Please call [**Telephone/Fax (1) 1669**] for this appointment or for any concerns. Please follow-up in the Acute Care Surgery clinic in [**2-23**] weeks: [**Telephone/Fax (1) 600**]. Completed by:[**2198-7-1**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5629, 5706

3485, 4186

307, 314

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150,486

36112

Discharge summary

report

Admission Date: [**2131-12-21**] Discharge Date: [**2132-1-10**] Date of Birth: [**2053-5-4**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: 78M s/p mechanical fall last night, went to ED for right orbital laceration but did not stay for head CT as one hour wait - this am was going back for CT but became very lethargic. Comes to ED with large acute SDH on CT with effacement of ventricle and midline shift Major Surgical or Invasive Procedure: Left Craniotomy for SDH History of Present Illness: 78M s/p mechanical fall the night before admission, went to ED for right orbital laceration but did not stay for head CT due to the one hour wait time. The morning of admission he was going to get his CT scan but became very lethargic. He came to ED with large acute SDH that was found on CT with effacement of ventricle and midline shift. Past Medical History: pericarditis dm 2 sleep apnea high chol left leg cellulitis Social History: lives in [**Hospital1 1562**] with wife, works real estate Family History: NC Physical Exam: Exam upon admission: Gen: obese, in hard collar, examined in ED HEENT: Pupils: [**3-25**] bilat Extrem: Warm and well-perfused. Neuro:lethargic, snoring, tries to open eyes to voice but could not, did follow commands with left upper and bilat lower extremeties, non-verbal Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Right upper ext appears weaker than left but was antigravity spontaneously. No pronator drift appreciated on left, unable to assess on right Sensation: Intact to light touch Pertinent Results: CT head [**12-21**]: There is a large approximately 21 mm left subdural hematoma. This is causing significant mass effect and midline shift of 13 mm. There is subfalcine herniation. There are periventricular ischemic changes along with small old lacunar infarct. There is no skull fracture. There is mild mucosal thickening in the ethmoid sinuses. CONCLUSION: Large left subdural hematoma with significant midline shift as described ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is abnormal septal motion/position. 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 appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Dilated ascending aorta. CT head [**12-24**]: FINDINGS: Again noted are post-operative changes, related to the evacuation of the left-sided subdural hematoma. There is no significant change in the size of the left temporal intraparenchymal hematoma as well as subdural hematoma noted along the left occipital region. There is no significant change in the surrounding edema and the mass effect on the left lateral ventricle and possible uncal herniation on the left side. Effacement of the left side of the perimesencephalic cistern, is again seen. There is no evidence of cerebellar tonsillar herniation. Mild shift of the midline structures to the right side, is unchanged. No new areas of hemorrhage are noted. IMPRESSION: No significant change in the post-operative changes, left temporal hematoma and left occipital subdural hematoma along with surrounding edema, mass effect on the left lateral ventricle and left-sided uncal herniation. Small amount of fluid in the sphenoid sinus and the left maxillary sinus and ethmoid air cells, are noted and new. Brief Hospital Course: Pt. was taken emergently to the OR on the date of admission for a left sided craniotomy for SDH evacuation. He was extubated post operatively. On POD#1 he had a mucus plug in the ICU leading to a respiratory arrest and subsequent asystolic event and re-intubation. Cardiology consult was obtained. There was no indication of a myocardial infarction. Rather, the arrest was due to his respiratory status. On [**12-26**] there was a family meeting in which they decided they would like to [**Hospital 81920**] rehab for the patient. He had a trach and peg on [**12-27**] and was screened for rehab. The patient's exam was slightly improved that day. He was opening his eyes and tracking the examiner. He moved spontaneously but did not follow commands. While in the ICU the patient removed PEG tube and required TPN for 7 days. After bowel rest, he was again fed by NGT/dophoff. He pulled several of these out. He was able to be transferred to the stepdown unit a few days prior to discharge. Speech and swallow evaluated him and recommended a modified diet. He therefore does not need a PEG at this time. He is currently on a trach mask and requiring infrequent suctioning. Secretions are pink-tinged at times however he is able to clear his airway effectively. The patient was evaluated by PT and OT who recommended rehab. He was discharged to rehab in the afternoon on [**2132-1-10**]. Medications on Admission: Lipitor 10' Metformin ER 500' Lasix 60' ASA 81' Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 9. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Insulin Regular Human Subcutaneous 17. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): End [**1-15**]. 18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): End Date [**1-15**]. 19. Furosemide 10 mg/mL Solution Sig: One (1) Injection DAILY (Daily). 20. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6 PRN () as needed for sytstolic over 160. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Acute SDH Resp. Failure Respiratory arrest Cardiac Arrest Coma Hemiparesis Anemia protein/calorie deficiency Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. . Please check with your physician to see when you can resume your Asprin. ??????If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion, lethargy or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. ??????New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2132-1-10**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "99.60", "99.15", "33.24", "96.04", "01.31", "31.1", "43.11", "33.21", "02.05", "96.72" ]

icd9pcs

[ [ [] ] ]

7408, 7478

4097, 5487

586, 611

7631, 7655

1717, 4074

9084, 9444

1157, 1161

5585, 7385

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34620

Discharge summary

report

Admission Date: [**2142-5-10**] Discharge Date: [**2142-5-16**] Date of Birth: [**2062-10-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1136**] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: None History of Present Illness: 79M with severe AS, metastatic prostate cancer with recent pseudomonal UTI, hydronephrosis s/p bilateral stent placement last month, presenting with hematuria and found to be hypotensive. He was recently admitted to [**Hospital1 18**] from [**Date range (1) 79432**] with ARF and new hydronephrosis/hydroureter requiring urologic stent placement. Pseudomonal UTI diagnosed at that admission and has been on cipro since. Also was sent to [**Hospital1 18**] given worsening AS to see if candidate for valvuloplasty, but appears to have been medically managed (full details/dc summary not available). His diuretics were changed from lasix to torsemide 30 mg daily. Since this admission he has been watching his fluid intake and has actually lost weight (7#) in addition to noting improvement in leg edema. He thinks his doctors [**Name5 (PTitle) **] have further decreased torsemide down to 20 mg daily but is unsure. No dyspnea/CP/PND. . He had mild but continued gross hematuria at time of discharge. This became sigificantly worse about 3 days ago and was associated with urinary frequency (voiding hourly) and feeling of distension and spasm. His hematocrit was also found to be low and he received 2 units of PRBCs - one yesterday and one the day prior. Per his family since the procedure he has had blood pressures in the 90's-100's. Given the hematuria and anemia, asked to come to [**Hospital1 18**]. . In the ED, initial vs were: T 97.9 67 115/48 18 100 on RA. He was evaluated by urology who placed a foley catheter and performed continuous bladder irrigation. He had some small clots. He was going to the floor, but developed intermittent episodes of hypotension to the high 80's. This was responsive to a fluid bolus. He received a total of 2 L of NS. His hematocrit decreased from 31.5 to 29.3 over 5 hours in the ED (received fluids). Vitals on transfer: 72 95/41 16 97 RA. He had one peripheral and was going to get another prior to transfer. . On the floor, patient reports feeling well, no complaints. . Review of sytems: (+) Per HPI (-) Denies fever, chills, headache, neck pain, sore throat, cough, shortness of breath since discharge. No change in orthopnea. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: - severe aortic stenosis: 0.8-1 valve area echo [**3-/2142**] - Prostate cancer s/p radiation therapy with metastatic disease to bone and lungs. on hydrocort/ketoconazole - Hydronephrosis/hydroureter s/p distal ureteral stent placement [**2142-4-5**] and replacement [**2142-4-16**]. - CAD: high coronary calcium though no flow limiting disease on cath [**3-/2141**]; no history of MI. - Atrial fibrillation, not on coumadin - chronic kidney disease: creatinine 1.4-1.7 - diastolic dysfunction - pericardial calcification with ?restrictive physiology on cath [**3-/2141**] - s/p appendectomy Social History: Lives with wife in [**Name (NI) 3844**]. no sick contacts. -[**Name2 (NI) 1139**] history: Quit 30 years ago. Smoked 25 years x3ppd. -ETOH: None -Illicit drugs: None Family History: There is no family history of premature coronary artery disease or sudden death. Mother passed away of CVA in her 40s. Father passed away of pneumonia in his 40s. Physical Exam: General: Alert, oriented, no distress. HEENT: Sclera anicteric, PERRL 3->2, MM slightly dry, oropharynx clear Neck: supple, JVD not able to be visualized, no LAD. Lungs: +bibasilar crackles. No wheezes/rhonchi. CV: irregular, loud systolic murmur best at RUSB with radiation to carotids. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place, fruit punch colored urine but most recent urine appears slightly less bloody Ext: slightly cool, 2+ pulses, no clubbing, cyanosis. 2+ bilateral pedal edema. Pertinent Results: ADMISSION LABS: [**2142-5-10**] WBC 9.6 / Hct 31.5 / Plt 275 INR 1.1 Na 146 / K 4.9 / Cl 107 / CO2 29 / BUN 24 / Cr 2.5 / BG 111 DISCHARGE LABS: [**2142-5-16**] Na 141 / K 3.8 / CL 106 / CO2 27 / BUN 18 / Cr 1 / BG 104 Ca 7.3 / Mg 1.9 / Phos 2.3 WBC 10.3 / Hct 27.8 / Plt 226 MICROBIOLOGY: [**2142-5-10**] Urine Cx negative [**2142-5-10**] Blood Cx x 2 negative STUDIES: [**2142-5-11**] CXR - 1. Low lung volumes, new retrocardiac opacity could be atelectasis. 2. Blunting of the left costophrenic angle. 3. Stable cardiomegaly, with pericardial calcification along the right heart. [**2142-5-11**] Renal US - 1. No evidence of hydronephrosis. 2. Probable cyst in the left upper pole. [**2142-5-15**] Echo EF > 65%; Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension; Compared with the prior study (images reviewed) of [**2142-4-3**], the findings are similar. Brief Hospital Course: 79M with metastatic prostate cancer, hydronephrosis s/p recent urologic stenting, recent pseudomonal UTI, and severe aortic stenosis was admtited with hematuria and hypotension. Due to his hypotension with systolic blood pressures in the 80s, he was initially admitted to the ICU and then transferred to the medical floor. 1. Hypotension. Upon arrival in the ICU, the differential diagnosis for his hypotension was broad, including infection, volume depletion, and adrenal insufficiency. He was started initially on broad spectrum antibiotics for coverage of urinary pathogens, fluid resuscitation, and stress dose steroids for adrenal insufficiency. His cultures were no growth to date x 72 hours and antibiotics were discontinued. His hypotension was ultimately thought most likely related to volume depletion in light of aggressive diuresis and hematuria. His hypotension resolved as his hematuria improved. Upon discharge, his systolic blood pressures ranged from 110-130. His flomax was held during this admission due to his hypotension. 2. Hematuria. Etiology was thought most likely related to radiation cystitis. Urine cultures were negative. He initially required continuous bladder irrigation. As his hematuria improved, continuous bladder irrigation was discontinued and the patient was able to void independently. He was discharged with urology follow-up with Dr. [**First Name (STitle) **] at [**Hospital1 18**]. His aspirin was held during this admission, and he was recommended to follow-up with his PCP regarding restarting this medication. 3. Acute Renal Failure. He had an acute elevation in his creatinine. This was thought to be mainly prerenal. A renal ultrasound did not show any evidence of obstruction. His creatinine steadily improved during his admission. 4. Metastatic prostate cancer. He was continued on ketoconazole and hydrocortisone. He was initially on stress dose steroids for treatment of adrenal insufficiency as a cause of his hypotension. Adrenal insufficiency appeared less likely and his steroids were rapidly tapered to his home regimen. 5. Recent pseudomonal UTI. After discussion with urology, his cipro was discontinued. Medications on Admission: According to [**3-/2142**] discharge summary and confirmed with patient - ciprofloxacin 500 mg [**Hospital1 **] (x1 month planned) - flomax 0.4 mg daily - torsemide 30 mg daily (?may have been decreased to 20 mg daily as outpatient) - Aspirin 81 mg DAILY - held x 1 day. - Metoprolol tartrate 25 mg [**Hospital1 **] - Hydrocortisone 20 mg Q8H - ketoconazole 200 mg [**Hospital1 **] - Pantoprazole 40 mg Q24H - Pravastatin 40 mg DAILY - oxycontin 10 mg - taking one tab QAM (not at PM) - Hydrocodone-Acetaminophen 5-500 mg Q6H as needed for pain. - Docusate Sodium 100 mg [**Hospital1 **] - senna [**Hospital1 **] prn - calcium/vitamin D - FeSo4 300 mg daily - mag hydroxide prn constipation - lupron Q3 months (due in [**Month (only) 205**]) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Ketoconazole 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QAM (once a day (in the morning)): This medication can make you drowsy. Do not drive or use heavy machinery until you know how this medication affects you. . 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: This medication can make you drowsy. Do not drive or use heavy machinery until you know how this medication affects you. . 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 14. Outpatient Lab Work Please have your chem 10 (sodium, potassium, chloride, bicarbonate, BUN, Creatinine, glucose, magnesium, calcium, and phosphorus) checked on Friday [**2142-5-18**] and have these results faxed to [**Telephone/Fax (1) 64799**]. Discharge Disposition: Home With Service Facility: Community Health & Hospice Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Hematuria 2. Radiation Cystitis 3. Metastatic Prostate cancer 4. Aortic Stenosis 5. Acute on Chronic Diastolic Congestive Heart Failure 6. Acute on Chronic Renal Failure SECONDARY DIAGNOSIS: 1. Benign Hypertension 2. Atrial Fibrillation 3. Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with hematuria (blood in the urine) and low blood pressures. This was most likely related to bladder problems related to your radiation. This gradually improved. You also developed significant swelling in your legs after receiving fluids and this gradually improved. We have made the following changes to your medications: - ciprofloxacin: We have discontinued this medication since you do not need this antibiotic any longer. - flomax: We have discontinued this medication due to your low blood pressure. You can consider restarting this medication when you see your urologist Dr. [**First Name (STitle) **] in [**Month (only) 205**]. - Aspirin: We have discontinued this medication due to your hematuria. You should restart this medication after talking with your cardiologist Dr. [**Last Name (STitle) 11250**]. - Metoprolol: We have decreased this dose due to your low blood pressures in the hospital. You can consider increasing this medication after you see Dr. [**Last Name (STitle) 11250**]. - Torsemide: We have decreased this dose to your low blood pressures. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: SURGICAL SPECIALTIES When: TUESDAY [**2142-6-19**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD [**Telephone/Fax (1) 4537**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **]-[**First Name7 (NamePattern1) 10588**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: Internal Medicine/Cardiology (Primary Care) Date: Thursday, [**2142-5-24**] @ 12:45pm Location:[**Location (un) **] CARDIOLOGY Address:[**Apartment Address(1) 64797**], GILFORD,[**Numeric Identifier 64798**] Phone: [**Telephone/Fax (1) 11254**]

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icd9cm

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icd9pcs

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26529

Discharge summary

report

Admission Date: [**2153-11-3**] Discharge Date: [**2153-11-12**] Date of Birth: [**2129-11-8**] Sex: F Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 3223**] Chief Complaint: 24 F s/p sledding accident w/ Grade 5 L renal rupture Major Surgical or Invasive Procedure: Left nephrectomy History of Present Illness: 23 F injured in sledding accident, airflighted to [**Hospital1 18**] trauma bay c/o diffuse abdominal pain radiating to the back. CT an of abdomen showed grade 5 left kidney laceration. Taken emergently to the operating room for left nephrectomy. Past Medical History: s/p CCY L wrist surgery Social History: Student at [**University/College 33918**], taking time off both parents deceased Family History: non-contributory Physical Exam: On Arrival to [**Hospital1 18**]: "98.8 88 100/palp 20 Alert, oriented, GCS=15 PERRLA EOMI non-tender neck chest breath sounds bilaterally LUQ tender>RUQ tender R side soft Pelvis stable Fast + fluid L gutter nl rectal tone guiac negative foley grossly bloody with urine back NT no deformities; no step-off cold, MAE spontaneously, sensation intact to light touch throughout" Pertinent Results: [**2153-11-3**] 05:35PM BLOOD WBC-8.4 RBC-3.27* Hgb-9.8* Hct-29.1* MCV-89 MCH-30.1 MCHC-33.8 RDW-13.5 Plt Ct-236 [**2153-11-3**] 07:59PM BLOOD WBC-14.8*# RBC-2.62* Hgb-7.7* Hct-22.1* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.2 Plt Ct-59*# [**2153-11-3**] 10:42PM BLOOD WBC-13.0* RBC-3.65*# Hgb-11.1*# Hct-30.4*# MCV-83 MCH-30.4 MCHC-36.5* RDW-14.9 Plt Ct-124*# [**2153-11-4**] 01:04AM BLOOD Hct-32.5* [**2153-11-4**] 04:15AM BLOOD WBC-9.2 RBC-3.37* Hgb-10.4* Hct-27.6* MCV-82 MCH-31.0 MCHC-37.8* RDW-15.5 Plt Ct-114* [**2153-11-4**] 10:22AM BLOOD Hct-26.1* [**2153-11-4**] 02:31PM BLOOD Hct-24.8* [**2153-11-4**] 06:56PM BLOOD Hct-24.0* [**2153-11-4**] 10:15PM BLOOD Hct-23.5* [**2153-11-5**] 05:12AM BLOOD WBC-10.8 RBC-2.92* Hgb-8.8* Hct-25.4* MCV-87 MCH-30.3 MCHC-34.8 RDW-16.0* Plt Ct-104* [**2153-11-5**] 09:35PM BLOOD WBC-10.5 RBC-2.39* Hgb-7.1* Hct-20.3* MCV-85 MCH-29.7 MCHC-34.9 RDW-15.3 Plt Ct-109* [**2153-11-6**] 12:20PM BLOOD Hct-22.2* [**2153-11-7**] 05:00AM BLOOD WBC-8.3 RBC-2.60* Hgb-8.0* Hct-22.2* MCV-85 MCH-30.8 MCHC-36.1* RDW-14.8 Plt Ct-144* [**2153-11-9**] 05:10AM BLOOD WBC-8.4 RBC-2.86* Hgb-8.7* Hct-24.7* MCV-86 MCH-30.3 MCHC-35.2* RDW-14.5 Plt Ct-270# [**2153-11-10**] 11:00AM BLOOD WBC-9.4 RBC-2.81* Hgb-8.6* Hct-24.5* MCV-87 MCH-30.4 MCHC-34.9 RDW-14.5 Plt Ct-350 [**2153-11-3**] 05:35PM BLOOD UreaN-22* Creat-1.3* [**2153-11-3**] 07:59PM BLOOD Glucose-255* UreaN-16 Creat-0.8 Na-143 K-4.9 Cl-117* HCO3-15* AnGap-16 [**2153-11-3**] 10:42PM BLOOD Glucose-231* UreaN-20 Creat-1.2* Na-144 K-3.7 Cl-112* HCO3-17* AnGap-19 [**2153-11-4**] 01:04AM BLOOD K-5.4* [**2153-11-4**] 04:15AM BLOOD Glucose-78 UreaN-19 Creat-1.3* Na-143 K-4.5 Cl-112* HCO3-23 AnGap-13 [**2153-11-5**] 05:12AM BLOOD Glucose-97 UreaN-18 Creat-1.5* Na-140 K-4.5 Cl-108 HCO3-19* AnGap-18 [**2153-11-6**] 04:51AM BLOOD Glucose-105 UreaN-12 Creat-1.1 Na-136 K-3.7 Cl-102 HCO3-29 AnGap-9 [**2153-11-7**] 05:00AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-141 K-3.6 Cl-103 HCO3-27 AnGap-15 [**2153-11-9**] 05:10AM BLOOD Glucose-93 UreaN-9 Creat-1.1 Na-138 K-3.4 Cl-100 HCO3-29 AnGap-12 [**2153-11-10**] 11:00AM BLOOD Glucose-100 UreaN-12 Creat-1.1 Na-138 K-3.8 Cl-103 HCO3-25 AnGap-14 Brief Hospital Course: Take emergently to OR for L nephrectomy by Dr. [**Last Name (STitle) 519**]. A very large retroperitoneal hematoma and shattered left kidney were seen intra-operatively. See operative report for full details. A JP drain was left overlying the left renovascular stump. Pt was in guarded condition, intubated to the TSICU postoperatively. On postoperative day #1 she remained intubated and sedated in the TSICU. Peri-operative kefzol was administered. On postoperative day #2 she was in stable condition on the floor. Her cervical spine was cleared and she was advanced to a clear liquid diet. Hematocrit remained stable 24.8-> 24.0->23.5->25.4. Creatinine at this time was 1.5. In the evening, repeat hematocrit was 20.5, she received 1 unit PRBC and made adequate urine. Her JP drain output tapered off and was discontinued. On [**2153-11-7**], she worked with the physical therapist, her abdomen was soft, non-distended, bowel sounds returned, and her incision remained clean, dry, and intact. She was advanced to a regular diet and her PCA pump was weaned. Incentive spirometry was encouraged. By Monday [**2153-11-12**], she was stable, ambulatory, AVSS, tolerating physical therapist. She was discharged to the care of her family and to follow-up in the trauma clinic with Dr. [**Last Name (STitle) 519**]. her staples were d/c'd in house on POD 9. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 3. Anzemet 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: grade 5 L kidney laceration s/p L nephrectomy Discharge Condition: Stable ambulatory tolerating regular diet Discharge Instructions: [**Name8 (MD) **] M.D. for increase in severity of symptoms, increase in pain, abdominal distension, nausea, vomitting, questions, or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 519**] in trauma clinic in [**6-3**] days. Please call clinic to schedule [**Telephone/Fax (1) 6439**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2153-11-12**]

[ "868.04", "866.03", "E884.9" ]

icd9cm

[ [ [] ] ]

[ "55.51", "99.04" ]

icd9pcs

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323, 341

5340, 5384

1208, 3370

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779, 797

4802, 5169

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4773, 4779

5408, 5554

812, 1189

230, 285

369, 617

639, 664

680, 763

70,078

146,279

4308

Discharge summary

report

Admission Date: [**2166-7-5**] Discharge Date: [**2166-7-24**] Date of Birth: [**2097-4-29**] Sex: M Service: MEDICINE Allergies: Ranitidine Attending:[**First Name3 (LF) 1973**] Chief Complaint: tachycardia, chest pain Major Surgical or Invasive Procedure: Right heart catheterization Temporary dialysis catheter x2 IR tunneled HD catheter PICC placement History of Present Illness: ICU HPI: 69yoM with h/o DM, CAD s/p CABG, admission from OSH for hyperkalemia and respiratory distress. He was admitted from his PCP's office to an OSH for evaluation of new pan-cytopenia 2.1>28%<83, acute renal failure and symptoms of fatigue and weakness. He developed worsening oliguric renal failure and new heart failure and was tranferred to [**Hospital1 18**] on [**7-5**] for further workup of renal dysfunction and new pancytopenia. Since transfer to [**Hospital1 18**] it was thought that he was suffering renal failure from ATN in setting of some combination of poor PO intake, hypotension on BP meds and contrast load at OSH. A temporary HD catheter was placed [**7-7**] and he began dialysis. . He has also been evaluated by the hematology service and bone marrow suppression thought likely due to suppression in setting of acute illness but also pending EBV, CMV, parvovirus, SPEP. UPEP negative for monoclonal spike. Hepatitis serologies negative. There was a plan for bone marrow bx. . Of note, his blood cultures have grown out Ampicillin sensitive enterococci, and he had a TTE just yesterday showing a large aortic valve vegetation. He was switched to Ampicillin yesterday. . He's also had a fair amount of anginal-type chest pain and was evaluated by cardiology. He's had anginal chest pain for quite a while, maybe x2 / month, worsened with exertion and relieved with rest. Denies palpitations. Tonight, his HR increased to the 140s, in sinus, with lateral ST depressions, which resolved with rate control using Metoprolol 5mg IV. This appears to have been going on nightly for several nights according to the floor night resident. He has been getting nitro paste and nebs. . VS on transfer to the floor were: 108/75, 88, 32, 95/4L. On exam on the floor, he has cardiac wheeze. ABG showed 7.4 / 35 / 77 on 4L. He looks well, but has some minor anterior chest pain. . ROS: As above, otherwise negative for SOB, n/v/abd pain/diarrhea, palpitations, dizziness. . Of note, pt was admitted [**1-/2166**] with enterococcal UTI, finished 7d course Ampicillin Past Medical History: PMH: Radiation cystitis s/p 60 hyperbaric oxygen treatments in [**2164**], clot irrigation [**10-20**], transfusions, silver nitrate irrigation, forumlin Prostate Cancer s/p RRP, XRT Colon cancer stage III s/p colectomy/postop FOLFOX CAD s/p CABG/ three stents Carotid stenosis Angina requiring nitroglycerin HTN DM II GERD PSH: CABG, [**2152**] Radical prostatectomy, [**2152**] Cholecystectomy, [**2159**] Appendectomy, [**2160**] Sigmoid colectomy, [**2162**] Cystoscopy, clot evacuation, [**10/2165**] Cystoscopy, formulin instillation [**2165-12-28**] PMH: Adenocarcinoma of the rectosigmoid Hypertension Coronary artery disease Prostate cancer Diabetes Mellitus Type 2 PSH: s/p CABG x4 [**2152**] s/p prostatectomy s/p appendectomy s/p cholecystectomy s/p ear, tonsil and adenoid surgery s/p femoral rodding s/p back surgery Social History: Retired estimator for an environmental company. Lives with wife. [**Name (NI) **] 4 healthy children and 4 grandchildren. Quit smoking in [**2165-12-11**], but previously smoked [**1-12**] ppd (~120 pack years). Previously drank ~ [**1-12**] case of beer daily, now sober for many years. Denies illicit drug use. Family History: - The patient does not know his biological parents Physical Exam: On admission: ICU physical: 97.4 p83 107/50 20 98% 2L NC Thin pleasant gentleman in no distress, appears stable, alert/conversant/attentive EOMI, no scleral icterus JV pulsations noted at the earlobe with +HJR Soft expiratory wheezes with R < L breath sounds, good air movement RRR with frequent ectopy and systolic murmur heard at BUSB, less at apex. Midline CABG scar noted. Soft NT ND abdomen, benign Notable pitting edema to mid shin, without chronic venous stasis changes noted, extremities are warm well perfused CN 2-12 intact, no focal neuro deficits noted Medicine floor physical: Vitals: T: 98.2 BP: 124/56 P: 81 R: 18 O2: 93% 2L General: Alert, oriented, tachypneic on moving in bed for exam, can speak in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, hard of hearing Neck: supple, JVP not elevated, no LAD Lungs: right lower lobe crackles, decreased breath sounds to mid back b/l, using accessory muscles to breathe (abdomen) CV: Distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, midline sternotomy scar Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, midline scar just below umbilicus Ext: Warm, well perfused, 1+ pulses, no clubbing Neuro: A+Ox3, difficulties with attention: saying the days of the week backwards, but can count backwards Pertinent Results: ADMISSION LABS: [**2166-7-5**] 07:00PM GLUCOSE-84 UREA N-122* CREAT-6.6*# SODIUM-131* POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-21* ANION GAP-16 [**2166-7-5**] 07:00PM ALT(SGPT)-17 AST(SGOT)-24 LD(LDH)-232 ALK PHOS-114 TOT BILI-0.6 [**2166-7-5**] 07:00PM ALBUMIN-2.3* CALCIUM-7.5* PHOSPHATE-7.9*# MAGNESIUM-2.2 [**2166-7-5**] 07:00PM HAPTOGLOB-121 [**2166-7-5**] 07:00PM WBC-2.8* RBC-3.27* HGB-9.3* HCT-27.9* MCV-86# MCH-28.5# MCHC-33.3 RDW-16.5* [**2166-7-5**] 07:00PM NEUTS-73* BANDS-7* LYMPHS-10* MONOS-6 EOS-2 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [**2166-7-5**] 07:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ BITE-OCCASIONAL [**2166-7-5**] 07:00PM PLT SMR-VERY LOW PLT COUNT-62*# [**2166-7-5**] 07:00PM PT-14.3* PTT-33.8 INR(PT)-1.2* [**2166-7-5**] 07:00PM RET AUT-2.5 DISCHARGE LABS: MICRO: [**2166-7-6**] 1:32 pm BLOOD CULTURE Source: Line-PICC. **FINAL REPORT [**2166-7-10**]** Blood Culture, Routine (Final [**2166-7-10**]): ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin = 1.5 MCG/ML, Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 4 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2166-7-7**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by DR. [**Last Name (STitle) **] ([**Numeric Identifier 18652**]) @ 8:43AM [**2166-7-7**]. Aerobic Bottle Gram Stain (Final [**2166-7-8**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Time Taken Not Noted Log-In Date/Time: [**2166-7-8**] 4:12 pm Blood (EBV) SPECIMEN TAKEN FROM CHEM# [**Serial Number 18653**]G. **FINAL REPORT [**2166-7-10**]** [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2166-7-10**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2166-7-10**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2166-7-10**]): POSITIVE >=1:10 BY IFA. INTERPRETATION: UNINTERPRETABLE EBV PATTERN. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. STUDIES: RENAL U/S [**2166-7-5**]: IMPRESSION: Normal sized kidneys, with mildly increased cortical echogenicity suggestive of renal disease. Interval resolution of previoulsy seen bilateral hydronephrosis. TTE [**2166-7-8**]: Conclusions The left atrium is dilated. The left ventricular cavity size is top normal/borderline dilated. There is mild to moderate regional left ventricular systolic dysfunction with anteroseptal/anterior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is a large vegetation on the aortic valve. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Eccentric mild to moderate ([**1-12**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. TTE [**2166-7-11**]: Conclusions The interventricular septum and apex of the left ventricle are hypokinetic. Right ventricular chamber size is normal with depressed free wall contractility. The aortic valve leaflets are moderately thickened. Mild to moderate ([**1-12**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Vegetations are present on all three aortic valve cusps. No obvious abscess seen but cannot be axcluded on the basis of this study. Compared with the findings of the prior study (images reviewed) of [**2166-7-8**], the findings are similar. CT CHEST [**2166-7-11**]: IMPRESSION: 1. Moderate bilateral pleural effusions. Adjacent consolidation is most likely atelectasis, but infection cannot be excluded. 2. Small right middle lobe consolidation is also most likely atelectasis, less likely infection. 3. Mild pulmonary edema. 4. Mild centrilobular emphysema. 5. Increased number and top normal size of mediastinal and retrotracheal lymph nodes are likely reactive. 6. Mild splenomegaly. CT HEAD W/O [**2166-7-11**]: IMPRESSION: No acute intracranial process. CT has poor sensitive for small embolic infarcts. An MR may be obtained for further evaluation if the clinical concern persists. TTE [**2166-7-16**]: Conclusions Focused views to assess size of known aortic valve vegetation and degree of aortic regurgitation. The aortic valve leaflets are moderately thickened. The larger of the aortic valve vegetations previously seen on complete studies dated [**2166-7-8**] and [**2166-7-11**] is now characterized by a wider base (more linear and mobile on the prior studies). The degree of aortic regurgitation is still in the mild-moderate range. An abscess was not visualized but cannot be excluded on the base of this study. TTE [**2166-7-23**]: Focused study. There is mild regional left ventricular systolic dysfunction with focal hypokinesis to akinesis of the mid to distal anterior septum, anterior wall, and apex. The right ventricular cavity is dilated and mildly hypokinetic. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is a moderate-sized vegetation on the aortic valve. Moderate (2+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**7-16**]/201, the vegetation size appears similar but the severity of aortic regurgitation is slightly increased. Brief Hospital Course: Mr. [**Known lastname 18654**] is a 69year old M with CAD s/p CABG, who presented with chest pain, tachycardia, found to have high grade enterococcal bacteremia with native aortic valve vegetation. He was transfered to the ICU for hypoxia and unstable angina. He was placed on ampicillin for enterococcal endocarditis. Cardiology followed the pt and felt that his chest pain was [**2-12**] heart failure and volume overload. His hospitalization was complicated by acute renal failure thought to be ATN, requiring dialysis. CT surgery was consulted, but given only mild-moderate AR, no surgery was recommended. # Enterococcal endocarditis: Pt has a history of enterococcal UTI in setting of past prostatectomy/radiation and radiation cystitis with a recent admission in [**2166-1-11**] for enterococcal UTI. He was started on Ampicillin with surveillance blood cultures, and ID following. TTE showed a large aortic valve vegetation, with EF 40-45%. His course was complicated by new heart failure. Cardiology followed the pt, and attributed his chest pain to heart failure and volume overload. He had a PA cathether placed which suggested more of a septic than cardiogenic picture of hypotension. As discussed below, he had dialsysis for fluid removal. Cardiothoracic surgery was consulted, and recommended no intervention. TEE was considered, but given pt was hypotensive, this was not pursued. Repeat TTE on [**7-11**] showed no change, with no severe AI. TTE was again repeated on [**7-16**], and showed mildly increased base of vegetation, but continued mild-moderate AR. Per CT surgery, no intervention given AR not severe. Per ID, gentamicin was added, dosed after dialysis. Followed troughs prior to each dialysis session, with goal =<1.0. Repeat echo done [**2166-7-23**] that showed a stable vegetation with slight increase in aortic regurgitation. Cardiology and cardiac surgery were notified, as patient was clinically improving there were no changes to the plan. Last positive blood culture was [**2166-7-10**]. All following cultures were negative at the time of discharge and the patient remained afebrile. He should be continued on ampicillin and gentamicin at least until [**2166-7-5**] when he follows up in [**Hospital **] clinic, with further course to be decided by them. He should continue to have a chem 7, CBC and LFT panel done weekly, with results faxed to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in the infectious disease department at [**Telephone/Fax (1) 11959**]. # Acute renal failure: Secondary to ATN with no evidence of abscess or septic emboli from imaging at OSH and no evidence of abscess on u/s here. ATN thought to be secondary to poor PO intake, volume contraction/hypotension. Renal was consulted, and given volume overload, pt had temporary line placed for HD. He was started on nephrocaps and sevelamer. He had a line holiday given bacteremia as discussed above, on [**2166-7-18**] a tunneled HD line was placed. He had dialyis with intervening hemofiltration to remove fluid as quickly as possible. # Acute Systolic CHF: Thought to be [**2-12**] new onset heart failure and volume overload as discussed above. ECG demonstrated ST depressions in precordial and lateral leads. Cardiac enzymes were trended and remained stable. Metoprolol was increased in the ICU for improved rate control. Cardiology followed the pt and did not feel anything other than supportive treatment was appropriate. He was started on Imdur 30mg daily, with SL nitroglycerin on a PRN basis. He should follow-up with his cardiologist as an outpatient to decide whether intervention for his angina would be beneficial once his symptoms have stabilized. Fluid overload, with components of acute pulmonary edema and chronic lung disease. The patient remains tachypneic with even small amounts of exertion. He improves with ipratropium and albuterol nebulizers. When he continues to be dypsneic, SL nitroglycerin can be used, especially in the setting of anginal symptoms. Other times, especially if he is anxious, 1mg of IV morphine can remove some of the work of breathing and make him more comfortable. As he continues to have fluid removed with dialysis, his breathing has been steadily improving. # Pancytopenia: Unclear etiology. Hematology was consulted, and workup was initiated on the medicine floors with HIV negative, UPEP negative. SPEP resulted as slightly abnormal, and repeat SPEP continued to show abnormalities. However, per Heme, this was of unclear significance. EBV serologies showed positive IgG and IgM, of unclear significance. Parvovirus showed positive IgG, negative IgM. They felt this was most likely [**2-12**] endocarditis/sepsis. # Delirium: Pt became confused as to the date, and appeared delirious during his MICU course. A CT head showed no acute process. Serial neurologic exams remained nonfocal. This was attributed to toxic metabolic encephalopathy given HD had been held, pain, and sepsis. He was started on Mirtazapine & Seroquel and moved from the ICU to the general medicine floor with drastic improvement in his symptoms. At the time of discharge, he was alert and oriented x3, able to do months of the year backwards, and able to remember historical details. #. Type 2 DM: At home, patient on Glargine 8 units QHS and a humalog sliding scale. Here, he was on a humalog sliding scale alone. As his health and appetite improve, he should be transferred back to his home regimen. Patient was transferred to an LTAC at [**Hospital1 1872**] Medications on Admission: HOME MEDICATIONS: - Imdur 90 mg 1XD - Humalog 8 units PRN - Docusate 100 mg [**Hospital1 **] PRN - Miralax PRN - Nitroglycerin SL PRN - Multivitamin 2 tabs 1XD - Ranexa 1000 mg [**Hospital1 **] - Crestor 10 mg 1XD - Lopressor 25 mg [**Hospital1 **] - Tylenol PRN - Calcium carbonate 500 mg [**Hospital1 **] - Percocet 5 1 tab Q4H PRN - Zofran 4 mg PO PRN . Meds on transfer to MICU ([**2166-7-5**]): Tylenol prn Ampicillin 2 G IV Q12H since [**7-8**] at 1450 Docusate [**Hospital1 **] Heparin 5000 SC TID Insulin sliding scale Ipratropium neb Isosorbide mononitrate ER 60mg daily Metoprolol tartrate 12.5mg [**Hospital1 **] Nitroglycerin SL 0.3 prn CP Nephrocaps 1 daily Nitroglycerin ointment 2% Senna [**Hospital1 **] prn Sevelamer carbonate 1600mg PO TID with meals . Meds on transfer from MICU to floor ([**2166-7-19**]): Acetaminophen 325-650mg PO Q6H:prn pain Ampicillin 2g IV Q12H Aspirin 325mg PO daily Atorvastatin 80mg PO daily Cepacol (Menthol) 1 loz prn sore throat Docusate Sodium 100mg PO BID Dextrose 50% 12.5g IV prn hypoglycemia Gentamicin 60mg IV QHD Glucagon 1mg IM Q15MIN: prn hypoglycemia Heparin 5000units SC TID Heparin Dwell (1000units/ml) [**2155**]-8000unit dwell prn HD line Ipratropium Bromide Neb Q6H Insulin SC sliding scale Isosorbide Mononitrate (ER) 30mg PO daily Maalox/Diphenhydramine/Lidocaine 15-30mL PO TID:prn pain Metoprolol Tartrate 25mg PO QID Morphine sulfate 1mg IV Q4H:prn chest pain Mirtazapine 7.5mg PO HS Nephrocaps 1 cap PO daily Nitroglycerin SL 0.3mg SL prn chest pain Quetiapine Fumarate 12.5mg PO HS 6pm Senna 1 Tab [**Hospital1 **]:prn constipation Xopenex Neb Sevelamer 1600mg PO TID with meals Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Repeat Q5 minutes x3 or until relief of symptoms. 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ampicillin 2 g IV Q12H 8. gentamicin sulfate (PF) 60 mg/6 mL Solution Sig: Sixty (60) mg Intravenous QHD: Measure trough prior to dialysis and give full dose if trough<1.0. 9. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2 hours) as needed for shortness of breath. 14. Humalog 100 unit/mL Solution Sig: As directed units Subcutaneous QACHS: Per sliding scale. 15. morphine 5 mg/mL Solution Sig: One (1) mg Injection Q4H (every 4 hours) as needed for dyspnea: To ease breathing for refractory dyspnea. Hold for sedation. 16. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): For appetite stimulation. 17. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): Give at 6pm. 18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): Continue until patient ambulatory. 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 21. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 22. heparin (porcine) 1,000 unit/mL Solution Sig: [**2155**]-8000 unit Injection PRN (as needed) as needed for dialysis: Dwell to catheter volume. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Enterococcal bacteremia Enterococcal native aortic valve endocarditis Acute renal failure Pancytopenia 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 for an infection in your blood causing injury to your heart, lungs, and bone marrow. This required you to stay in the intensive care unit for 2 weeks. Your aortic heart valve became infected from the infection in your blood and you need a long course of antibiotics (ampicillin and gentamicin) to clear the infection, which were started while you were in the intensive care unit. Pictures of your heart were taken to look at the infection of the valve. Also, your kidneys were damaged because of low blood flow during the infection. Your kidneys were no longer able to produce urine and you needed to have dialysis to remove fluid from your body. Since your bone marrow was also injured you needed blood transfusions. . You were having difficulty breathing, which was from the fluid in your lungs. Dialysis was used to remove the fluid and we gave you nebulizers, nitroglycerin, and morphine to help your breathing. You also had episodes of chest pain that were relieved with nitroglycerin and your ECG showed changes that were consistent with your known heart disease and the extra demand on your heart from the infection. . You are going to a long term acute care facility to help you regain strength and to continue to monitor your kidney function and heart valve infection. You will continue to get dialysis at the facility if your kidneys are still not working. . Medications started while in the hospital include: Ampicillin (antibiotic) Gentamicin (antibiotic) Morphine (breathing) Albuterol (breathing) Ipratropium (breathing) Mirtazipine (appetite stimulant) Quetiapine (to help with sleep - you should be able to stop when you leave the hospital) Sevelamer (kidney) Nephrocaps (kidney) . Medications we stopped in the hospital: Ranexa Calcium carbonate Percocet Zofran . Medication we changed while in the hospital: Imdur was decreased (for blood pressure and chest pain) Metoprolol was increased (for heartrate control) Take atorvastatin instead of rosuvastatin for cholesterol . Please go to your scheduled appointments. Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**] Phone: [**Telephone/Fax (1) 6699**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge** You have an appointment with infectious disease on [**2166-8-4**] at 11:30am because of the infection on your heart valve. The provider will be [**Name9 (PRE) 14621**] [**Last Name (NamePattern4) 14622**], MD, phone number [**Telephone/Fax (1) 457**]. Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2166-8-12**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern4) 4094**]: CARDIOLOGY Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**] Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**] Phone: [**Telephone/Fax (1) 8725**] Appointment: Wednesday [**8-14**] at 11AM Completed by:[**2166-7-24**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "37.21", "38.93" ]

icd9pcs

[ [ [] ] ]

21804, 21880

12269, 17786

294, 394

22027, 22027

5183, 5183

24278, 25801

3705, 3758

19486, 21781

21901, 22006

17812, 17812

22203, 24255

6039, 12246

3773, 3773

17830, 19463

231, 256

422, 2499

5199, 6022

3787, 5164

22042, 22179

2521, 3358

3374, 3689

773

170,261

6306

Discharge summary

report

Admission Date: [**2109-2-18**] Discharge Date: [**2109-3-17**] Date of Birth: [**2051-6-10**] Sex: M Service: MEDICINE Allergies: Vicodin / Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Right internal jugular central line placement Diagnostic paracentesis Right arterial line History of Present Illness: 57 y/o man w/ etoh cirrhosis presenting with abdominal pain. Pain began @ midnight last night and he came to the emergency department. . Paracentesis performed in ED showed hemorrhagic ascites with [**Numeric Identifier 890**] RBC and SBP with 6500 WBC, 83% polys. He was treated with Vanco/Levo/Clinda in the emergency department. EKG showed rapid atrial fibrillation vs. flutter but BP was low so he was bolused with 3L normal saline total. No rate controlling medications were given. . He reports that he took his morning medications including nadolol, digoxin, . Once in the ICU an arterial and central RIJ line were placed. He was volume resusitated with 1.5L bringing total to 4.5L. He also recevied 150grams of albumin. Liver was consulted and will be by to see the patient. A dIg level returned <.2 so he was dig loaded with .25 mg IV q6h x 24 hours. Past Medical History: 1. Hypertension - not an issue since liver failure 2. Atrial fibrillation on coumadin 3. Seasonal allergies 4. Shingles 5. Dental abscess 6. Peptic ulcer disease 7. CLL: in remission Social History: Significant for no tobacco usage, significant alcohol usage. He used to drink heavily in the past, with no history of any withdrawals or delirium tremens. He drinks about 14 glasses of wine a week Family History: diabetes, cancer and stroke. Physical Exam: Vitals: 97.6 130-150, irregular 83/50-100/50 17 98%2LNC General: Awake, alert, NAD. HEENT: + JVD, no LAD, moist oral mucose. Pulmonary: Lungs CTA bilaterally Cardiac: irregular rate and rhytm, [**3-13**] holosystolic murmur Abdomen: obese, soft, NT/ND, normoactive bowel sounds, liver ~ 2 cm below costal border; no asterixis. Minimal tenderness to palpation Back: no pain on palpation Extremities: 2+ edema LE Neuro: slightly flat affect Skin: mild scleral icterus, mild jaundice Pertinent Results: [**2109-2-18**] 05:00AM PT-15.9* PTT-35.0 INR(PT)-1.4* [**2109-2-18**] 05:00AM PLT SMR-NORMAL PLT COUNT-200 [**2109-2-18**] 05:00AM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ BURR-1+ ELLIPTOCY-1+ [**2109-2-18**] 05:00AM NEUTS-26* BANDS-1 LYMPHS-58* MONOS-3 EOS-2 BASOS-0 ATYPS-10* METAS-0 MYELOS-0 NUC RBCS-1* [**2109-2-18**] 05:00AM WBC-23.8* RBC-2.95* HGB-10.2* HCT-29.2* MCV-99* MCH-34.6* MCHC-34.9 RDW-25.2* [**2109-2-18**] 05:00AM TOT PROT-4.2* ALBUMIN-3.3* GLOBULIN-0.9* CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.2 [**2109-2-18**] 05:00AM CK-MB-NotDone [**2109-2-18**] 05:00AM cTropnT-<0.01 [**2109-2-18**] 05:00AM LIPASE-43 [**2109-2-18**] 05:00AM ALT(SGPT)-22 AST(SGOT)-64* LD(LDH)-484* CK(CPK)-40 ALK PHOS-100 TOT BILI-8.8* DIR BILI-2.1* INDIR BIL-6.7 [**2109-2-18**] 05:00AM estGFR-Using this [**2109-2-18**] 05:00AM GLUCOSE-112* UREA N-23* CREAT-1.0 SODIUM-136 POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-20* ANION GAP-15 [**2109-2-18**] 05:09AM LACTATE-2.7* [**2109-2-18**] 05:09AM COMMENTS-GREEN TOP [**2109-2-18**] 05:13AM AMMONIA-110* [**2109-2-18**] 05:30AM ASCITES WBC-6500* RBC-[**Numeric Identifier 24440**]* POLYS-83* LYMPHS-11* MONOS-5* EOS-1* [**2109-2-18**] 05:30AM ASCITES TOT PROT-1.8 GLUCOSE-56 LD(LDH)-142 ALBUMIN-1.5 [**2109-2-18**] 07:59AM PT-17.7* PTT-43.6* INR(PT)-1.6* [**2109-2-18**] 07:59AM PLT SMR-LOW PLT COUNT-151 [**2109-2-18**] 07:59AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-2+ SCHISTOCY-OCCASIONAL [**2109-2-18**] 07:59AM NEUTS-37* BANDS-14* LYMPHS-48* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2109-2-18**] 07:59AM WBC-13.5* RBC-2.55* HGB-8.5* HCT-25.6* MCV-100* MCH-33.5* MCHC-33.3 RDW-25.4* [**2109-2-18**] 07:59AM DIGOXIN-<0.2* [**2109-2-18**] 07:59AM ALBUMIN-2.8* CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.9 [**2109-2-18**] 07:59AM LIPASE-34 [**2109-2-18**] 07:59AM ALT(SGPT)-19 AST(SGOT)-32 LD(LDH)-190 ALK PHOS-83 AMYLASE-59 TOT BILI-7.2* [**2109-2-18**] 07:59AM GLUCOSE-124* UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-21* ANION GAP-11 [**2109-2-18**] 08:38AM LACTATE-1.6 [**2109-2-18**] 08:38AM TYPE-ART [**2109-2-18**] 02:21PM HCT-19.5* [**2109-2-18**] 02:21PM CORTISOL-27.3* [**2109-2-18**] 02:39PM TYPE-ART PO2-126* PCO2-32* PH-7.40 TOTAL CO2-21 BASE XS--3 [**2109-2-18**] 03:05PM CORTISOL-42.8* [**2109-2-18**] 03:26PM CORTISOL-45.4* [**2109-2-18**] 08:05PM HCT-21.6* . Microbiology (positive cxs): [**2109-2-18**] Peritoneal fluid - e. coli [**2109-2-28**] Sputum - Klebsiella pneumoniae [**2109-3-2**] Sputum - Klebsiella pneumoniae [**2109-3-4**] Sputum - Klebsiella pneumoniae [**2109-3-5**] Sputum - yeast [**2109-3-6**] BAL - yeast [**2109-3-8**] Sputum - yeast, Klebsiella pneumoniae . CXR [**2109-2-18**]: Compared to radiograph of seven hours prior. There is a new right IJ catheter with its tip at the atriocaval junction. There is no pneumothorax. Again seen are extensive calcified pleural plaques the sequela of prior asbestos exposure, emphysema, and a prominent basilar interstitial pattern which could relate to emphysema, asbestos related chronic lung disease, a component of volume overload, or a combination thereof. Persisting small left pleural effusion. Right CP angle excluded on this study. . CT Abd/Pelvis [**2109-2-18**]: 1. Hepatic cirrhosis with stigmata of portal hypotension including numerous varices, a recanalized umbilical vein and worsening splenomegaly at 18 cm. 2. Large amount of ascites overall similar in distribution and volume to [**2109-1-23**] CT. Thickening of the peritoneum is stable. No evidence of hemoperitoneum. 3. Small pericardial effusion incompletely evaluated on this abdominal CT. . ECHO [**2109-3-8**]: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild prolapse of the anterior mitral leaflet. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small circumferential pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mitral valve prolapse with mild regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2108-12-26**], pulmonary pressures are slightly lower (but still moderately elevated). The other findings are similar. . [**2109-3-8**] Abd/Pelvis ct: IMPRESSION: 1. No focal abscess identified. 2. Areas of consolidation in the dependent aspect of both lungs, likely representing a combination of atelectasis and infection. 3. Cirrhosis, with portal hypertension, varices, splenomegaly, and moderate ascites. 4. Enlarged right hilar, mediastinal lymph nodes, with pleural effusions, possibly reactive. Given some more nodular componenets also seen within the lungs, followup chest CT is recommended after resolution of current acute symptoms. Brief Hospital Course: Mr. [**Known lastname 10208**] was initially admitted to the hospital with recurrent SBP, after having recently completed a hospital coure for SBP having been dicharged on ciprofloxacin. On re-admission, paracentesis demonstrated e coli that was resistant to ciprofloxacin, and he was therefore switched to aztreonam and completed a 14 day course. However, his hospital course was further complicated by transfer to MICU due to hypercarbic hypoxic respiratory failure requiring intubation and hypotension with diagnosis of sepsis. Numerous cultures were sent from his blood, urine, stool, and sputum during his prolonged MICU course/infectious-sepsis work up, and positive culture data included sputum with growth of klebsiella pneumoniae and yeast. Patient was on numerous different antibiotics empirically during his hospital and MICU stay and eventually remained on meropenem and gentamicin for coverage of klebsiella, and vancomycin, caspofungin, and flagyl for empiric anti-microbial coverage. He also suffered from persisent hypotension causing his transfer to the MICU and throughout his MICU course for which he was on and off pressor support, including neosynephrine and vasopressin. Mr. [**Known lastname 10208**] also had ongoing hematological difficulties during his hospital course in part felt to be due to his underlying diagnosis of CLL along with his liver disease and his sepsis. These issues included persistent anemia requiring numerous blood transfusions to maintain his hematocrit, neutropenia for which he was treated with a 3 day course of IVIG and maintained on G-CSF, and thrombocytopenia requiring numerous platelet transfusions. His coagulopathy from his liver disease was also managed with numerous infusions of FFP to treat his elevated INRs. The patient also suffered from acute renal failure due presumably to sepsis which waxed and waned during his hospital course. He also developed severe anasarca with 32 liters positive during his MICU course, although he remained intravascularly dry with pressor requirement and renal failure. His anasarca was minimally responsive to lasix boluses, followed by starting on lasix drip, which was not tolerated by his blood pressure. He also had a history of atrial fibrillation, for which he was maintained on digoxin with poor heart rate control. Different measures were tried to control his heart rate, including nodal agents such as an esmolol gtt, but were not tolerated by his blood pressure. Given his prolonged MICU course, surgery was consulted for possible trach and PEG placement, but felt that Mr. [**Known lastname 24441**] peri-operative mortality risk was > 60%, and therefore was not a candidate for these procedures. Given his overall poor prognostic picture based on the above, his continued fever spikes and pressor requirement despite prolonged broad spectrum antibiotics coverage, along with his prolonged intubation without option of tracheostomy, discussions were had with the patient's sister and best friend, who were the [**Hospital 228**] health care proxy, including goals of care. Per discussion with the health care proxy's, they stated that the patient's goals would be quality, not quantity of life, and his goals of care were changed to comfort measures. The patient was extubated and pressor support discontinued and expired shortly after. Medications on Admission: coumadin 6 mg every other day; 5 mg other days Lasix 80 [**Hospital1 **] (increaased 10 days ago from 40 [**Hospital1 **]) lisinopril 2.5 daily Digoxin 0.25 daily PPI Nadolol 20 daily Pravastatin 10 daily aldactone 50 mg daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Alcoholic cirrhosis Spontaneous bacterial peritonitis sepsis Klebsiella pneumonia Respiratory failure Pancytopenia Chronic lymphocytic leukemia Atrial fibrillation Discharge Condition: Expired Discharge Instructions: NA - patient expired Followup Instructions: NA - patient expired

[ "567.23", "038.49", "401.9", "560.1", "789.59", "571.2", "427.32", "572.2", "285.9", "995.92", "785.52", "284.1", "578.9", "584.9", "204.11", "482.0", "518.81", "276.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "38.93", "45.13", "99.15", "54.91", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

11608, 11617

7951, 11303

296, 387

11825, 11835

2261, 7928

11904, 11928

1713, 1743

11581, 11585

11638, 11804

11329, 11558

11859, 11881

1758, 2242

242, 258

415, 1276

1298, 1483

1499, 1697

6,600

101,054

15237+15238

Discharge summary

report+report

Admission Date: [**2169-9-3**] Discharge Date: [**2169-9-15**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 82 year-old gentleman admitted on [**9-3**] with altered neurologic status. The patient and daughters were visiting in the [**Name (NI) 86**] area for a whale watch from [**State 531**]. The daughter noticed the change in speech and behavior and went to an outside hospital where a head CT showed bifrontal subdural hematoma. The patient was transferred to [**Hospital1 188**] for further management. The patient's subdural hematoma noted on head CT with some shift and mass effect with no invasive intervention required. Did not require intubation and no seizures were detected. The patient was placed on prophylactic Dilantin. The patient was on some intravenous nitroprusside to keep his blood pressure less then 150, but was successfully weaned off on [**9-6**]. He remained in the Neurological Intensive Care Unit until [**2169-9-5**]. He had an attempted arteriogram, which was not completed secondary to an incidental finding of a 4 by 5 cm AAA. Therefore vascular surgery was consulted. A CTA was done to measure the AAA. The patient also had an episode of acute renal failure most likely related to the dye from CT scan. Also post obstructive from inability to void. The patient's BUN and creatinine climbed to 60 and 3.6. Currently his creatinine is down to 2.5, BUN is 50. Vascular surgery will follow him as an outpatient for workup for this AAA and he will actually probably be referred to a doctor in [**State 531**] for further treatment of that. His renal failure is resolving at this time. He was seen by speech and swallow. The patient is able to tolerate a regular diet. He also developed a rash on [**2169-9-12**] on just his back. Dermatology was consulted and they felt it was heat rash, although Dilantin was discontinued and the patient also had complaints of fever. Fever workup to this point is negative. Chest x-ray is negative. Urine negative and blood cultures are pending. The patient was transferred to the regular floor on [**2169-9-6**] and was evaluated by physical therapy and occupational therapy and found to require rehab prior to discharge to home. He is being screened for a rehab in [**State 531**]. MEDICATIONS ON DISCHARGE: Azithromycin 250 mg po q 24 hours for nine days, which was started on [**2169-9-13**]. MOM 30 cc po q 6 hours prn, Simethicone 40 to 80 mg po q.i.d. prn. Miconazole powder 2% one application to the groin and the back of the neck b.i.d. Albuterol nebulizers one nebulizer inhaler q 6 hours prn. Protonix 40 mg po q 24 hours, Colace 100 mg po b.i.d., Hydrocortisone ointment one application q.i.d. to his back. Atenolol 50 mg po b.i.d. CONDITION ON DISCHARGE: Stable. He will follow up with his primary care physician and neurologist in [**State 531**] for further management. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-9-14**] 11:43 T: [**2169-9-14**] 12:29 JOB#: [**Job Number 44343**] Admission Date: [**2169-9-3**] Discharge Date: [**2169-9-18**] Service: Stat addendum His discharge was delayed secondary to lack of rehabilitation bed. He is being discharged on [**2169-9-18**] in stable condition and will be followed by a neurosurgeon and neurologist in [**State 16269**]. His condition was stable at the time of discharge. His vital signs were stable. He was afebrile. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2169-9-18**] 08:03 T: [**2169-9-18**] 08:06 JOB#: [**Job Number 40936**]

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Discharge summary

report

Admission Date: [**2202-9-19**] Discharge Date: [**2202-10-5**] Date of Birth: [**2159-5-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: [**Doctor First Name 3941**] firing. Major Surgical or Invasive Procedure: [**9-20**] - VT ablation, clinical VT non-inducible. Made substrate modification around apical scar region. At end induced non-clincal VT that was shocked and pt went into PEA. TTE showed no effusion although needle was stuck into pericardial/RV space and slow recovery of LV. ACLS with CPR started. . EEG . Evoking potential . Tracheostomy . PEG placement History of Present Illness: Mr. [**Known lastname **] is a 43 y/o M w/ DM, HTN, HPL, s/p STEMI with DES to prox LAD in 7/00, s/p [**Known lastname 3941**] placement in 12/00 for NSVT in setting of low EF, presenting after syncopal episode and [**Known lastname 3941**] firing. . The patient stated that he was in his usual state of health this afternoon when approx between 1-2pm he had an episode where he became dizzy and quickly fell to the floor. Patient states the he does not recall the events after he was on the floor, but regained consciousness after 2-3 mins (reportedly). Patient suffered a chipped left incisor as a result of the fall. Patient went about his usual day. Of note, patient had been drinking wine (one whole bottle on Saturday, unclear amount on day of admission). . Patient states three hours later, patient was lying on his bed and stated that he felt 'lightheaded' and then soon felt his [**Known lastname 3941**] fire. Pt had several more similar episodes, and EMS was called. During his transport by EMS, [**Known lastname 3941**] fired another 4-5 times. . On presentation to the ER, VS were 98.4, 110, 122/86, 24, 100 on NRB. Patient's [**Known lastname 3941**] fired another 4-5 times in ER. Pt was loaded Amio 150mg bolus and started on 1mg/hr gtt. Also administered 5mg IV and 50mg po metoprolol with 500cc bolus in ED. EKG in the ER, in NSR, did not show any ST-T changes concerning for ischemia. . On arrival to floor, VS were 92, 117/78, 18, 100% 2LNC . On assessment of patient's functional capacity, patient able to climb one flight of stairs, walk [**12-4**] city block, and sleep on 1 pillow before getting short of breath. Patient states that he is compliant with his medication regimen. . Cardiac review of systems is notable for absence of chest pain, ankle edema. All other ROS negative unless otherwise specified above. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: s/p STEMI [**6-/2193**], w/ large thrombus in the proximal LAD complicated by cardiogenic shock -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: [**6-/2193**] STEMI w/ DES to prox LAD -PACING/[**Month/Year (2) 3941**]: [**11/2193**]: [**Month/Year (2) 3941**] placement for Low EF, runs of NSVT. [**10-7**] - [**Month/Year (2) 3941**] Generator change- 3. OTHER PAST MEDICAL HISTORY: diabetes mellitus type 2 h/o alcohol and substance abuse h/o deep vein thrombosis partially treated with Coumadin positive hepatitis B serologies in the past, Social History: The patient lives with his female companion. He is currently unemployed. He smokes approximately one pack of cigarettes per week. He states he drinks wine only on the weekends and denies other recreational drug use. Per the chart, has a history of alcohol and substance abuse. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: Inferiorly displaced PMI, midclavicular line. RR, normal S1, loud S2. III/VI Holosystolic murmur at LLSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2202-9-19**] WBC-4.0 RBC-3.75* Hgb-11.9* Hct-37.4* MCV-100* MCH-31.7 MCHC-31.7 RDW-15.7* Plt Ct-260# [**2202-9-19**] PT-13.5* PTT-28.1 INR(PT)-1.2* [**2202-9-19**] Glucose-126* UreaN-31* Creat-1.8* Na-140 K-4.3 Cl-102 HCO3-23 AnGap-19 [**2202-9-19**] Lipase-137* GGT-527* [**2202-9-19**] Calcium-9.0 Phos-4.5 Mg-1.9 . LFT's dramatic increase from [**9-23**] to [**9-24**]: [**2202-9-23**] ALT-31 AST-43* LD(LDH)-364* AlkPhos-212* TotBili-1.9* [**2202-9-24**] ALT-1860* AST-5436* LD(LDH)-4536* AlkPhos-225* TotBili-2.8* . CBC: [**2202-9-24**] 04:44AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.9* Hct-35.0* MCV-100* MCH-31.0 MCHC-31.1 RDW-15.3 Plt Ct-174 [**2202-9-24**] 10:09PM BLOOD WBC-17.8*# RBC-3.48* Hgb-11.1* Hct-34.9* MCV-100* MCH-31.7 MCHC-31.7 RDW-15.4 Plt Ct-138* [**2202-9-25**] 02:47AM BLOOD WBC-18.5* RBC-3.32* Hgb-10.6* Hct-33.2* MCV-100* MCH-31.8 MCHC-31.8 RDW-15.4 Plt Ct-128* [**2202-9-28**] 04:30AM BLOOD WBC-10.9 RBC-3.15* Hgb-9.6* Hct-30.7* MCV-98 MCH-30.6 MCHC-31.4 RDW-15.8* Plt Ct-239 [**2202-10-4**] 04:51AM BLOOD WBC-15.0* RBC-3.23* Hgb-10.1* Hct-32.0* MCV-99* MCH-31.2 MCHC-31.5 RDW-16.5* Plt Ct-275 . Coagulation: [**2202-9-25**] 02:47AM BLOOD PT-35.0* PTT-91.3* INR(PT)-3.6* [**2202-9-27**] 06:40PM BLOOD PT-32.4* PTT-70.8* INR(PT)-3.3* [**2202-9-28**] 04:30AM BLOOD PT-31.2* PTT-65.8* INR(PT)-3.1* [**2202-9-30**] 04:19AM BLOOD PT-25.2* PTT-37.3* INR(PT)-2.4* [**2202-10-3**] 03:25AM BLOOD PT-16.6* PTT-31.6 INR(PT)-1.5* . Lytes: [**2202-9-25**] 02:47AM BLOOD Glucose-178* UreaN-59* Creat-4.6* Na-140 K-4.3 Cl-103 HCO3-15* AnGap-26* [**2202-9-25**] 04:55PM BLOOD Glucose-108* UreaN-65* Creat-5.0* Na-144 K-4.0 Cl-104 HCO3-19* AnGap-25* [**2202-9-26**] 06:16AM BLOOD Glucose-95 UreaN-73* Creat-5.8* Na-145 K-3.7 Cl-104 HCO3-20* AnGap-25* [**2202-9-30**] 04:19AM BLOOD Glucose-158* UreaN-50* Creat-2.6* Na-150* K-3.9 Cl-119* HCO3-21* AnGap-14 [**2202-10-4**] 04:51AM BLOOD Glucose-126* UreaN-29* Creat-1.4* Na-147* K-3.8 Cl-111* HCO3-26 AnGap-14 Liver Enzymes: [**2202-9-24**] 04:44AM BLOOD ALT-1860* AST-5436* LD(LDH)-4536* AlkPhos-225* TotBili-2.8* [**2202-9-25**] 02:47AM BLOOD ALT-3616* AST-9190* LD(LDH)-7895* AlkPhos-217* TotBili-3.7* [**2202-10-1**] 05:19AM BLOOD ALT-800* AST-278* AlkPhos-220* TotBili-4.9* [**2202-9-24**] 04:44AM BLOOD Lipase-74* [**2202-9-24**] 08:09AM BLOOD Lipase-98* [**2202-9-24**] 10:09PM BLOOD Lipase-126* [**2202-9-25**] 02:47AM BLOOD Lipase-183* [**2202-9-28**] 04:30AM BLOOD Lipase-850* . Cardiac Enzymes: [**2202-9-20**] 04:36AM BLOOD CK-MB-3 cTropnT-<0.01 [**2202-9-20**] 09:46PM BLOOD CK-MB-8 cTropnT-0.61* [**2202-9-21**] 01:23PM BLOOD CK-MB-NotDone cTropnT-0.75* [**2202-9-22**] 04:57AM BLOOD CK-MB-NotDone cTropnT-0.49* [**2202-9-24**] 10:09PM BLOOD Albumin-3.7 Calcium-8.2* Phos-6.9*# Mg-1.9 [**2202-9-26**] 06:16AM BLOOD Albumin-3.7 Calcium-8.7 Phos-5.3* Mg-2.6 [**2202-9-28**] 04:30AM BLOOD Albumin-3.4 Calcium-8.6 Phos-2.6* Mg-2.1 [**2202-10-4**] 04:51AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.5* . Others: [**2202-9-24**] 08:09AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2202-9-19**] 07:20PM BLOOD ASA-NEG Ethanol-244* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2202-9-29**] 03:22AM BLOOD Lactate-1.3 . RESPIRATORY CULTURE (Final [**2202-9-25**]): SPARSE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD #1. SPARSE GROWTH. GRAM NEGATIVE ROD #2. RARE GROWTH. NEISSERIA MENINGITIDIS. MODERATE GROWTH. BETA-LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO PENICILLIN. gram stain reviewed: 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI were observed ([**2202-9-24**]). . URINE CULTURE (Final [**2202-9-25**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S + + + + + + + + + + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Studies: EKG [**2202-9-30**] Sinus rhythm. Prolonged Q-T interval. Left anterior fascicular block. Reverse anterior R wave progression. Probable prior lateral myocardial infarction. Non-specific inferolateral T wave flattening. Compared to the previous tracing of [**2202-9-25**] Q-T interval is longer. UNILAT UP EXT VEINS US Study Date of [**2202-9-29**] IMPRESSION: 1. No evidence of DVT in left upper extremity. 2. Diminished phasicity of waveforms in the left subclavian vein compared to the right could be seen with a proximal venous stenosis; of note left sided pacemaker leads are present. CT HEAD W/O CONTRAST Study Date of [**2202-9-29**] IMPRESSION: Minimal change from the previous study; specifically, no evidence of herniation. Evoked Potential Study Date of [**2202-9-27**] MEDIAN NERVE SOMATOSENSORY EVOKED POTENTIAL (09-108): After stimulation of the right median nerve there were well-formed evoked potential peaks at the Erb's point and at the P/N13 waveform position. The peak at the N19 position was not well-formed but was legible and occurred within a normal latency. Thus, this is a normal median nerve somatosensory evoked potential after stimulation of the right median nerve. After stimulation of the left median nerve there were normal evoked potential peaks at Erb's point and at the P/N13 waveform positions, but there was no discernible peak at the N19 position. This study indicates normal large fiber somatosensory conducting system activity through the lower brain stem, but the absence of the N19 peak raises concern for dysfunction in the cortical thalamic areas after left median nerve stimulation. The normal-appearing AP after right median stimulation precludes use of this study for prognosis in coma. ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2202-9-24**] IMPRESSION: 1. Unremarkable hepatic architecture and no biliary dilatation. 2. Patent hepatic vasculature with markedly undulating bidirectional flow seen in the portal veins suggestive of right heart failure. CT HEAD W/ & W/O CONTRAST Study Date of [**2202-9-21**] IMPRESSION: 1. No acute intracranial process. 2. No pathologic focus of enhancement. 3. Paranasal sinus disease with fluid and secretions seen in the nasopharynx and sphenoid sinuses, presumably related to the presence of the endotracheal tube. NOTE ADDED IN ATTENDING REVIEW: There is no evidence of acute territorial infarction; there is a 10mm chronic lacune in the mid-left cerebellar hemisphere, in addition to the smaller one in the left thalamus, both likely unchanged since the remote [**12-4**] study. N.B. This study does not constitute formal CT angiography. Portable TTE (Complete) Done [**2202-9-21**] IMPRESSION: Left ventricular cavity enlargmenet with severe systolic dysfunction c/w multivessel CAD or other diffuse process. Probable apical left ventricular mural thrombus. Right ventricular cavity enlargement with free wall hypokinesis. Pulmonary artery systolic hypertension. Compared with the prior study (morning of [**2202-9-20**]; images reviewed), the right ventricular systolic function is now more depressed. Left ventricular cavity size and free wall motion are similar. A mural thrombus is also suggested on the prior study. CT ABDOMEN W/O CONTRAST Study Date of [**2202-9-20**] IMPRESSION: 1. No evidence of free gas in the abdomen or retroperitoneal hematoma. Small to moderate ascites of intermediate density that may reflect a small amount of hemorrhage within ascitic fluid, but not frank hemoperitoneum. 2. Small pleural effusions. 3. Intra-aortic balloon pump. Electrophysiology Study [**2202-9-20**] 1. The baseline rhythm was sinus, with SCL 867ms, AH 85ms, HV 69ms. 2. Electroanatomical mapping of the LV using CARTO was performed. There was an area of low voltage near the anterior septal and apical region consistent with scar. The EGMs recorded looked far field suggesting that there may have been a laminated clot at that region. 3. Double ventricular extra stimuli from the RV down to [**Telephone/Fax (3) 105113**] and 400-300-240 did not induce any sustained arrhythmias. Triple VES also did not induce any sustained arrhythmias. At most there were 2 VPC of similar morphology to his clinical VT, RBBB Right/Superior axis with V4 transition. 4. Dopamine up to 10mcg.kg/min was started. 5. Susbstrate modification involving encircling the border region of the suspected exit site and inside the scar was performed. 6. At the end of the substrate modification, we tried to induce VT again. 7. At [**Telephone/Fax (3) 105114**] from the LV ablation catheter, a sustained MMVT TCL 255, RBBB left/inf axis V2 transition was induced. It was different from the clinical VT and hemodynamically not tolerated. After 18 seconds he was externally cardioverted at 200J back into sinus rhythm. 8. After cardioversion, it was noticed he was back in sinus rhythm but had no blood pressure. This was confirmed with flushing of the arterial line and feeling no pulse. All catheters were removed from the heart and PEA code was called. 9. CPR was initiated immediately. Quick look under fluoroscopy showed that the heart borders were not moving but not enlarged. Stat TTE was ordered. Epinephrine was given IV. 10. Because of possible tamponade, and the stat TTE machine had not arrived, a pericardiocentesis needle was inserted into the pericardial space by the interventional cardiology attending. No pericardial blood was seen, but the needle did puncture the RV. The needle was withdrawn and pressure held. 11. Portable stat TTE showed that there was no pericardial effusion, RV was contracting, but the LV was minimally contracting. 12. Additional medications including epinephrine gtt, calcium gluconate, vasopressin, dopamine gtt was infused. With high pressor doses, the TTE showed some contraction of the LV infero-lateral wall with anterior akinesis similar to baseline. When the pressors were withdrawn, the LV function deteriorated. There was still no pericardial effusion seen. 13. The patient remained in sinus rhythm but with all the pressors was able to maintain a blood pressure with palpable pulses. At this time CPR was stopped. During CPR, the pressure in the arterial line was always in the low 100's. 14. An IABP was placed by the intervential cardiology attending. A TEE probe was placed and showed poor LV contraction with no pericardial effusion. 15. The patient was stabilized and then transferred to CT of the abdomen before going to the CCU. There was a question of distended abdomen and intra-abdominal bleeding. 16. 3 venous catheters and 1 IABP access in the R femoral groin was still present when sent to CCU. The [**Telephone/Fax (3) 3941**] therapies were re-activated. Brief Hospital Course: 43 y/o M w/ h/o Ischemic Dilated Cardiomyopathy (EF 20%) s/p [**Telephone/Fax (3) 3941**] placement who presents with VT Storm. # RHYTHM: Patient thought to have inferior focus of VT likely secondary to scar. Was taken for electrophysiology study for VT ablation, clinical VT non-inducible. Made substrate modification around apical scar region. At end induced non-clincal VT that was shocked and pt went into PEA. TTE showed no effusion although needle was stuck into pericardial/RV space and slow recovery of LV. ACLS with CPR started, pt was intubated. Returned to ICU on ballon pump. Balloon pump pulled [**9-20**], sedation continued as patient became very agitated on vent with propofol. Off propofol since 2pm on [**9-22**] with little improvement in MS. On [**9-23**], pt had multiple episodes of SVT ?????? [**Month/Year (2) 3941**] shocked him back into sinus tachycardia. These episodes improved with lidocane gtt (dc??????d [**9-25**]) and Amiodarone. Now transitioned to Dronedarone for rhythm control and out of concern for toxicity with Amiodarone. Digoxin also dc??????d given renal failure. Usually noted to have HR 68-82 SR with short periods of ventricular bigeminy. BP 89-123/60-70 on metoprolol and dronederone. On oral magnesium given daily need for magnesium repletion. # mental status: Concern for anoxic brain injury s/p hypoperfusion, (vs. etoh withdrawal, or excess sedation not being cleared by liver/kidneys.) Neuro does not believe this is sub-clinical seizures based on EEG. Off sedation since [**9-22**] at 2pm. Evoked potential noted to be intact, per neuro they feel that his neuro status may recover (1-10%) chance; if it does improve, would expect to happen in the next three weeks. Ongoing discussion with family re: goals of care, prognosis. The family has decided to pursue Trach/Peg for the patient. This was placed on [**10-4**]. - [**Month (only) 116**] use PEG for tube feeds starting noon on [**10-5**] (24 hrs after placement). - Family will have to reassess goals of care for patient if neurologic recovery cannot be seen within ~3 weeks, which is the time frame estimated by neurology in which improvement ought to be seen if it will happen at all. # Respiratory status: He is initiating spontaneous breathing. Questionable if patient is able to tolerate off the vent and likely will aspirate. Intubated: CPAP w/ PS @ FiO2 40%/5 PSV/ 5 peep. O2 sat 100%. RR 13-20. Lung sounds clear but diminished at bases. Very strong cough and frequently requires suctioning for clear, thick ETT secretions. # Fever/Leukocytosis: Fever improved but WBC remains elevated. UA growing enterococcus. Positive sputum cx, speciation pending, positive U/A growing Enterococcus,. Patient started on antibiotics on [**9-22**]. Foley draining amber colored urine. Completed course of IV ampicillin for treatment of enteroccoccal UTI (afebrile). - Ampicillin for vanc-sensitive enterococcus in urine (day 1=[**9-26**], to end [**10-5**]) - All recent cultures negative thus far. - Please follow up sputum and blood cultures on [**2202-10-5**]. # PUMP/Chronic Systolic Heart Failure: Euvolemic on examination without significant pedal edema. Antero-apical akinesis on TTE, had been off coumadin at home given non-compliance with INR checks as an outpatient. It was initially felt that patient had LV thrombus on TTE, but after further discussion it was felt that this was just fibrin and that anticoagulation was not warranted.. IABP removed [**9-21**]. Patient was intially volume overloaded with poor urine output but responded well to IV lasix and diuresed to euvolemia. - continue Metoprolol - lisinopril held due to renal failure - Lasix 40 mg daily, please follow up lytes # CORONARIES: Patient s/p large anterior myocardial infarction in [**2192**]. - Continue statin, aspirin, beta blocker. # ETOHism - Chronic issue. Patient likely minimizes his ETOH use. Not requiring CIWA currently given sedation. - CIWA Scale in place for when patient is extubated - MVI, folate, thiamine (NG) # Transaminitis: Improving transaminases, Likely shock liver from hypoperfusion Patient had unremarkable abdominal CT ([**9-20**]), negative RUQ US ([**9-24**]). Neg Hep serologies. LFTs now downtrending. - trend LFTs daily - check albumin, INR daily to follow liver function - keep tylenol level to less than 2gm / day - [**Hospital1 **] electrolytes # ARF: Patient presented with acute renal failure, likely [**1-4**] poor perfusion during arrest in the setting of poor forward flow [**1-4**] EF 20%. Improved over course of hospitalization with Cr 1.3 on discharge. # hypernatremia ?????? Patient had numerous episodes of hypernatremia during admission with Na as high as 150. Improved with correction of free water deficit (gentle D5W IV boluses +/- free water flushes with tube feeds). # ?LV mural thrombus ?????? Initially felt that thrombus/embolus seen on TTE [**9-21**], head CT negative for embolic CVA or other acute process. After discussion with EP, it was felt that this was likely just fibrin and no clear thrombus was present. - SQ heparin for DVT prophylaxis # cool L Lower Extremity: Hx of L foot slightly cooler than R but stable/improved clinically. # abd distension: Stable, +BS, CT negative. # macrocytic anemia: Likely secondary to alcohol. Continuing to trend daily. # COMMUNICATION: Fiance Quala [**Telephone/Fax (1) 105115**], Brother [**Name (NI) 13740**] [**Telephone/Fax (1) 105116**], [**Name2 (NI) **]r [**Name (NI) **] [**Telephone/Fax (1) 105117**] Medications on Admission: Lisinopril 10mg daily Lipitor 10mg daily Furosemide 10mg daily (recently reduced) Spironolactone 25mg daily Coreg 25mg daily Discharge Medications: 1. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 3. Therapeutic Multivitamin Liquid [**Telephone/Fax (1) **]: One (1) PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 6. Dronedarone 400 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution [**Telephone/Fax (1) **]: PER SLIDING SCALE Injection ASDIR (AS DIRECTED). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Telephone/Fax (1) **]: [**12-4**] Drops Ophthalmic PRN (as needed) as needed for dry eye. 10. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: [**12-4**] PO Q6H (every 6 hours) as needed for fever, comfort. 11. Magnesium Oxide 400 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 14. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: One (1) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 16. Lasix 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: titrate to evolemia. 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 18. Lab Work Please continue to check sodium, BUN, creatinine, potassium, and magnesium daily. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital - Radius [**Hospital 7755**] Hospital Discharge Diagnosis: anoxic brain injury Ventricular Tachycardia storm Pulseless electrical activity urinary tract infection Pancreatitis alcoholism Discharge Condition: hemodynamically stable on ventilator with trach in place. Neurologically is non-responsive but does spontaneously open eyes. His eyes are injected with blood bilaterally and he has thin blood secretions on suctioning. Discharge Instructions: You came to the hospital with [**Hospital 3941**] firing secondary to VT storm. During ablation procedure, you have gone into cardiac arrest with pulseless electrical activity to 30 minutes which resulted in neurological damage. You have been in a coma since, however, hemodynamically stable. You were also treated for a vancomycin-sensitive enterococcus urinary tract infection. You completed 10 days of treatment with ampicillin. Followup Instructions: Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2202-10-25**] 10:00 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**] 10:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2203-1-19**] 9:30 Completed by:[**2202-10-5**]

[ "997.01", "041.04", "997.1", "570", "V45.82", "V45.02", "V46.11", "599.0", "427.1", "348.1", "276.0", "250.00", "427.5", "428.22", "584.9", "285.9", "428.0", "414.01", "577.0", "303.90", "401.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "37.27", "37.61", "37.34", "96.6", "99.62", "43.11", "38.95", "31.1", "38.93", "99.60" ]

icd9pcs

[ [ [] ] ]

23174, 23267

15419, 16724

352, 710

23439, 23659

4480, 4480

24142, 24502

3581, 3696

21139, 23151

23288, 23418

20990, 21116

23683, 24119

3711, 4461

2721, 3077

6960, 15396

276, 314

738, 2590

4496, 6943

16739, 20964

3108, 3268

2634, 2700

3284, 3565

9,434

115,634

14755+56575+56577

Discharge summary

report+addendum+addendum

Admission Date: [**2124-7-11**] Discharge Date: [**2124-7-17**] Date of Birth: [**2052-8-6**] Sex: M Service: CHIEF COMPLAINT: Shortness of breath, now with chest tightness HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10220**] is a 71-year-old gentleman with a history of aortic stenosis, now with increasing shortness of breath and dyspnea on exertion and chest pain. Cardiac catheterization was performed which showed a 90?????? discrete lesion of the RCA, 80% discrete lesion of the proximal diagonal, 70% discrete lesion of the LAD proximally, 50% mid LAD discrete lesion as well as moderately severe aortic stenosis. Mr. [**Known lastname 10220**] was taken to the Operating Room on [**2124-7-11**] for coronary artery bypass graft and aortic valve replacement. PAST MEDICAL HISTORY: 1. Hypertension 2. Status post abdominal aortic aneurysm repair 3. Questionable heart block from abdominal aortic aneurysm surgery for which pacemaker was placed 4. Chronic renal insufficiency 5. Gastroesophageal reflux disease 6. Kyphosis 7. Aortic stenosis 8. Unstable angina SOCIAL HISTORY: Mr. [**Known lastname 10220**] lives with his wife. MEDICATION: 1. Lotrel 1 pill q day REVIEW OF SYSTEMS: Negative unless otherwise stated above. PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 68, blood pressure 130/80, respirations 20, weight 180 pounds. GENERAL: Well developed, well nourished male. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. NECK: Supple. CHEST: Clear with decreased breath sounds. HEART: Regular rate and rhythm with a 4/6 systolic ejection murmur. ABDOMEN: Soft, nontender. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGIC: Nonfocal. HOSPITAL COURSE: Mr. [**Known lastname 10220**] was taken to the Operating Room on [**2124-7-11**] where coronary artery bypass graft x3 and aortic valve replacement were performed. Coronary artery bypass graft included left internal mammary artery to LAD, saphenous vein graft to ramus, saphenous vein graft to PDA. Aortic valve replacement was performed with a #27 pericardial tissue valve. Mr. [**Known lastname 10220**] [**Last Name (Titles) 8337**] the operation without incident. He was transferred to the Cardiac Intensive Care Unit where he was weaned off drips and hemodynamically monitored. He was extubated and stabilized. After adequate fluid resuscitation was performed and hemodynamic stability was assured, Mr. [**Known lastname 10220**] was then transferred to the floor on the evening of postoperative day #1. On postoperative day #2, his chest tubes were discontinued and on postoperative day his pacing wires were discontinued. While on the floor, Mr. [**Known lastname 10220**] had a high level oxygen requirement for which he was aggressively diuresed. His pulmonary status was gradually improved and oxygen was weaned. On postoperative day #4, Mr. [**Known lastname 10220**] had a nonsustained beat run of V-tach. He was monitored over the next 72 hours without any further incidents. By postoperative day #7, Mr. [**Known lastname 10220**] was doing well. His pulmonary status continued to improve. He was tolerating a po diet and was ambulating with a level 5 therapy status. He is now ready for discharge on [**2124-7-17**]. DISCHARGE MEDICATIONS: 1. Metoprolol 75 mg po bid 2. Lasix 20 mg po qd 3. Potassium chloride 20 milliequivalents po qd 4. Aspirin 325 mg po qd 5. Percocet 1 to 2 tablets po q 4 to 6 hours prn 6. Docusate 100 mg po bid while taking Percocet FO[**Last Name (STitle) 996**]P: 1. Please follow up with Dr. [**Last Name (STitle) 43417**] in three to four weeks. 2. Follow up with Dr. [**Last Name (Prefixes) **] in four weeks DISCHARGE STATUS: Stable DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x3 2. AVR [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Doctor First Name 24423**] MEDQUIST36 D: [**2124-7-17**] 12:53 T: [**2124-7-17**] 13:02 JOB#: [**Job Number 43418**] Name: [**Known lastname 7531**], [**Known firstname **] Unit No: [**Numeric Identifier 7917**] Admission Date: [**2124-7-11**] Discharge Date: [**2124-7-17**] Date of Birth: [**2052-8-6**] Sex: M Service: ADDENDUM: Physical examination at discharge: Vitals 97.7, T max, T current 97.3, pulse 86, blood pressure 131/78, respirations 18, O2 saturation 95% on room air, PO intake 720, urine output 3,700. Head was normocephalic, atraumatic. Neck was supple. Heart was regular rate and rhythm. Lungs, mild wheezing bilaterally. Abdomen was soft, nontender, non distended, normoactive bowel sounds. Extremities, no clubbing, cyanosis or edema. Incision was clean, dry and intact. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 3027**] MEDQUIST36 D: [**2124-7-17**] 13:34 T: [**2124-7-26**] 15:53 JOB#: [**Job Number 7918**] Name: [**Known lastname 7531**], [**Known firstname **] Unit No: [**Numeric Identifier 7917**] Admission Date: [**2124-7-11**] Discharge Date: [**2124-7-17**] Date of Birth: [**2052-8-6**] Sex: M Service: ADDENDUM: Physical examination at discharge: Vitals 97.7, T max, T current 97.3, pulse 86, blood pressure 131/78, respirations 18, O2 saturation 95% on room air, PO intake 720, urine output 3,700. Head was normocephalic, atraumatic. Neck was supple. Heart was regular rate and rhythm. Lungs, mild wheezing bilaterally. Abdomen was soft, nontender, non distended, normoactive bowel sounds. Extremities, no clubbing, cyanosis or edema. Incision was clean, dry and intact. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 3027**] MEDQUIST36 D: [**2124-7-17**] 13:34 T: [**2124-7-26**] 15:53 JOB#: [**Job Number 7918**]

[ "411.1", "401.9", "440.1", "530.81", "593.9", "V45.01", "424.1", "427.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "35.21", "36.12", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

3764, 4357

3308, 3743

1738, 3285

1297, 1720

5337, 6011

1234, 1275

148, 195

224, 798

820, 1107

1124, 1214

11,426

180,238

46812

Discharge summary

report

Admission Date: [**2115-12-27**] Discharge Date: [**2115-12-31**] Date of Birth: [**2055-7-2**] Sex: F Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old woman with right ICA occlusion and a left recurrent stenosis. She is status post a Dacron graft of the left ICA and now has a delayed de [**Last Name (un) 11083**] stenosis at the distal anastomosis site of approximately 89%. PAST MEDICAL HISTORY: Depression, COPD, shortness of breath, paresthesias of the right hand, has had a left CEA x 3 in [**2105**] and [**2111**], and then 5/[**2114**]. ALLERGIES: Penicillin. PHYSICAL EXAM: Her BP was 161/74. She was an overweight well-healed. Positive carotid bruit on the left, 1+, and 2+ on the right. Neck supple. Chest clear to auscultation. Cardiac - S1 and S2, regular rate and rhythm. Abdomen was soft, nontender, nondistended, no bruits, positive bowel sounds. Extremities - no edema, 2+ PT pulses. The patient is being admitted for recurrent left ICA stenosis and a question of angioplasty and stent placement. HOSPITAL COURSE: On [**2115-12-25**], the patient underwent a left carotid stent angioplasty without complication. Postop, the patient was monitored in the recovery room where she remained neurologically stable. Vital signs stable. She was afebrile. Her pulses were intact. Her groin site was clean, dry and intact. She had no hematoma. Neurologically, she was awake, alert, oriented x 3, moving all extremities with good strength. She was started on heparin postprocedure, and continued on heparin until [**2115-12-29**] when she was discontinued off heparin. She remains on Plavix and aspirin. She will be discharged to home in stable condition with follow-up with Dr. [**Last Name (STitle) 1132**] in three to four week's time. DISCHARGE MEDICATIONS: Verapamil 120 mg po qd; Plavix 75 mg po qd; aspirin, enteric coated, 1-325 po qd; Zoloft 100 mg po qd; Lipitor 10 mg qd; Celexa 10 mg po qd. DISCHARGE CONDITION: Stable. FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in three to four week's time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2115-12-31**] 11:42 T: [**2115-12-31**] 10:44 JOB#: [**Job Number 99353**]

[ "496", "272.4", "433.10", "458.2" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50", "88.41" ]

icd9pcs

[ [ [] ] ]

2010, 2378

1846, 1988

1098, 1822

641, 1080

174, 429

452, 625

64,904

193,746

46922

Discharge summary

report

Admission Date: [**2132-1-9**] Discharge Date: [**2132-2-23**] Date of Birth: [**2066-7-17**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1384**] Chief Complaint: Perforated colon for a colostomy takedown. Major Surgical or Invasive Procedure: [**2132-1-9**]: Colostomy takedown with colorectal anstomosis [**2132-1-14**]: Ex-lap and resection of old anastomosis, Hartmenns procedure and colostomy [**2132-1-18**]: Resection of colostomy and ileostomy [**2132-1-21**]: Washout and drainage placement [**2132-2-8**]: Reopen old laparotomy with drain placement and Alloderm mesh placement History of Present Illness: The patient is a 65-year-old woman who has had a liver transplant. She presented with a perforated colon which was resected and a Hartmann pouch was made. She comes today for takedown of the colostomy. Past Medical History: - HTN - Liver transplant in [**2125**] for HCV acquired from blood transfusions following an abortion (acquired liver is hepatitis B positive) - Hep C (acquired Hep C after blood transfusion in setting of abortion. Her most recent HCV viral load is 5,000,000 copies per patient) - Hep B (per patient her transplanted liver came from a donor who had been exposed to hepatitis B) - Chronic kidney disease (peak Cr=3.2) Social History: Patient is from [**Location (un) 86**], but currently resides in [**State 108**]. She was spending time in [**Hospital3 **] with her husband visiting her children. She denies alcohol or tobacco use. She never smoked. Family History: Patient denies family history of malignancy or cardiac conditions. Physical Exam: VS: 96.9, 99, 110/56, 24, 100%, wt 50.3 kg General: NAD HEENT: PERRL, EOMI Card: RRR Resp: CTA bilaterally Abd: Soft, tender, wound VAC Extr: No edema, WWP, 2+ DPs Tubes: JP drains Neuro: MAE Discharge exam: Afebrile, VSS No distress RRR Lungs clear Abdomen soft, nontender, nondistended, central abdominal wound closing with wound vac, ostomy functioning, two JP drains Moves all extremities well Pertinent Results: On Admission: [**2132-1-9**] WBC-8.1# RBC-3.61* Hgb-10.0* Hct-31.5* MCV-87 MCH-27.8 MCHC-31.8 RDW-16.3* Plt Ct-159 PT-14.6* PTT-45.9* INR(PT)-1.3* Glucose-145* UreaN-23* Creat-2.1* Na-141 K-3.2* Cl-116* HCO3-16* AnGap-12 ALT-14 AST-17 AlkPhos-191* TotBili-0.4 Calcium-8.3* Phos-2.9 Mg-1.1* On Discharge: [**2132-2-21**] WBC-4.6 RBC-3.79*# Hgb-11.2*# Hct-34.1*# MCV-90 MCH-29.6 MCHC-32.8 RDW-17.2* Plt Ct-173 Glucose-167* UreaN-56* Creat-1.6* Na-139 K-5.1 Cl-108 HCO3-23 AnGap-13 ALT-20 AST-32 AlkPhos-237* TotBili-0.4 Calcium-8.4 Phos-4.7* Mg-2.1 calTIBC-183* Ferritn-1402* TRF-141* tacroFK-6.3 [**2132-2-23**] 05:57AM BLOOD WBC-4.7 RBC-3.87* Hgb-11.5* Hct-34.6* MCV-90 MCH-29.7 MCHC-33.1 RDW-16.9* Plt Ct-175 [**2132-2-23**] 05:57AM BLOOD Glucose-113* UreaN-74* Creat-1.9* Na-136 K-4.1 Cl-106 HCO3-22 AnGap-12 [**2132-2-23**] 05:57AM BLOOD ALT-33 AST-32 AlkPhos-299* TotBili-0.5 [**2132-2-23**] 05:57AM BLOOD Albumin-3.0* [**2132-2-20**] 04:53AM BLOOD calTIBC-183* Ferritn-1402* TRF-141* [**2132-2-22**] 05:00AM BLOOD tacroFK-9.4 Brief Hospital Course: 65 y/o female who presents for elective reversal of her Hartmanns procedure. She was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], she had the Hartmenns reversed and extensive lysis of adhesions. Post operatively the patient was mildly confused, which has happened in post op situations before. She received 2 units RBCs for Hct 24% On [**2132-1-14**] she was taken back emergently to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**MD Number(4) **] for resection of the old anastomosis, Hartmenns procedure and colostomy due to developed profuse drainage out of the wound. The new colostomy was very shallow and the area was difficult to maintain and keep dry. On [**2132-1-18**] she went again to the OR for resection of the colostomy as she had started to put out basically stool from her wound and there was concern for a bowel injury or dehiscence of the colon. Upon exploration, the old fascial closure at the top had separated. There was a separation of the colostomy from the site with leakage of stool into the peritoneum. As the entire right colon did not look normal Dr [**Last Name (STitle) 816**] elected to resect the entire right colon and bring out an ileostomy. The ileum was taken out through the skin and the ostomy matured. The midline incision was closed but required an AlloDerm fascial closure to close the defect. On [**2132-1-21**] she was noted to be having increased drainage out of her abdominal incision and due to concern for intra-abdominal abscess which was uncontrolled, she was taken back again for exploratory laparotomy and washout. Two new drains were placed, and the abdominal incision was attempted to be controlled with dressing changes. We also attempted VAC placement which was putting out the same stool appearing drainage that was coming out the drains. On [**2132-2-8**] she was taken back one more time for reopening of the old laparotomy with removal of the old drains and two new drains placed and also Alloderm mesh placement in the upper incisioal area. Gauze dressings were placed which were staying dry, and once the skin started to heal, a VAC was again placed to include the old ostomy site and the abdominal incision. The JP drains will remain in place to facilitate fistula formation. Neuro: Her mental status is clear. She is alert and oriented x 3. She is on her home dose of paroxetine and her affect is appropriate. Her pain is well controlled and she only requires small doses of intermittent IV morphine. . Cardiovascular: She is hemodynamically stable. Her blood pressure is the low side of normal and she is on midodrine [**Hospital1 **]. . Pulmonary: Oxygen saturations are 100% on room air. . Gastrointestinal: She does have an early fistula. Two JP drains are in place to help facilitate drainage and formation of this fistula. Her incisional was repaired with alloderm mesh which is exposed. A wound vac was placed over this mesh to help facilitate granulation and closure of the wound. The wound vac is also over the old ostomy wound. Her ileostomy is functioning. She is to remain NPO except for sips of tea and occasional ice chips. . Genitourinary: Her urine output is adequate with no issues. . Fluid/Electrolytes/Nutrition: She is maintained on continuous TPN for nutrition. She should have her electrolytes check twice a week. She was acidotic with a low bicarbonate requiring a bicarbonate drip. The drip was discontinued and the acetate increased in her TPN. Her bicarbonate is now normal. She should have her bicarbonate level monitored and the acetate in the TPN adjusted accordingly. . Hematological: Her hematocrit has remained stable at a range of 30-34. She is epoetin three times a week. . Endocrine: Her blood sugars have been well controlled. She is on sliding scale insulin while she is on TPN. . Infectious disease: She was maintained on adefovir throughout her hospital stay. . Immunosuppresion: She is on MMF 500mg [**Hospital1 **] and tacrolimus 1mg [**Hospital1 **]. She should have her CBC and her Tacro level monitored and the results faxed to the transplant office. Medications on Admission: adefovir 10mg daily, cellCept 500mg [**Hospital1 **],Protonix 40mg daily, paroxetine 40mg daily, Xifaxan 400mg tid, Prograf 2mg qam and 1mg qpm, calcium + vitamin D Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 2. Adefovir 10 mg Tablet Sig: One (1) Tablet PO q72 hours (). 3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Five Hundred (500) mg PO BID (2 times a day). 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection once a week. 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours): Please give sublingual. Open capsule and sprinkle powder under the tongue. 9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 10. Morphine Sulfate 0.5 mg IV Q6H:PRN pain 11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 13. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Hartmanns reversal for previous perforated colon Anastomotic breakdown peritonitis intra-abdominal abscess uncontrolled fistula s/p liver transplant [**2125**] for HCV Discharge Condition: Fair/Stable Alert and Oriented Orthostatic with ambulation and requires assist with walker when OOB Discharge Instructions: Please call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, increased abdominal pain, increased drainage from the VAC, skin breakdown in the area of the VAC, ostomy or drains. Measure and record the drain output twice daily and more often as needed. This drainage has been thick and tan/green in consistency and color. Continue labs once weekly on Mondays to include CBC, Chem 10, AST, ALT, T bili, Alk Phos, Trough Prograf level. Fax results to transplant clinic at [**Telephone/Fax (1) 697**] Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-2-28**] 8:00 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-3-6**] 8:00

[ "403.90", "E878.0", "041.4", "998.59", "V55.3", "E878.8", "E878.3", "070.54", "567.22", "E878.2", "585.4", "682.2", "568.0", "997.4", "558.9", "996.82", "E849.7", "569.61", "998.6" ]

icd9cm

[ [ [] ] ]

[ "86.89", "99.15", "54.91", "45.75", "50.12", "46.11", "54.12", "46.21", "46.52", "38.93", "54.59", "45.73", "96.6", "46.43" ]

icd9pcs

[ [ [] ] ]

8782, 8861

3142, 7313

314, 659

9073, 9175

2086, 2086

9779, 10067

1583, 1651

7528, 8759

8882, 9052

7339, 7505

9199, 9756

1666, 1859

1875, 2067

2390, 3119

231, 276

687, 891

2100, 2376

913, 1331

1347, 1567

904

109,069

6254

Discharge summary

report

Admission Date: [**2110-5-6**] Discharge Date: [**2110-5-9**] Date of Birth: [**2083-9-5**] Sex: M Service: MED D CHIEF COMPLAINT: Cough syrup overdose. HISTORY OF PRESENT ILLNESS: This is a 26-year-old man, with a past medical history notable for bipolar disorder, schizophrenia, lumbar fracture status post a 30' fall in [**2109-9-21**], who was brought in by EMS after admitting to taking 3-4 bottles of Robitussin. The patient was found to be agitated and delirious, and brought in voluntarily. Emergency Department temperature was 102, heart rate 148, blood pressure 128/78, respiration rate 20, O2 sat 92 percent on room air. The patient became gradually more agitated and required Ativan for a net dose of 50 mg over a course of 6 hours. Also required four-point leather restraints. Received IV fluid hydration for a total of 5 liters of normal saline, and was brought to the [**Hospital Ward Name 12573**] ICU for supportive care. PAST MEDICAL HISTORY: As above. A [**2104**] [**Hospital1 18**] for dextromethorphan overdose. Prior history of violence toward healthcare staff on prior admissions. Suicide attempt in early [**2104**] in which he took an overdose of Benadryl. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: 1. Abilify 50 mg qd. 2. Lexapro 10 mg qd. 3. Strattera 40 mg qd. 4. Provigil 100 mg qd. PHYSICAL EXAMINATION: VITALS ON PRESENTATION TO [**Hospital Ward Name **] ICU: 95.7 oral temperature, heart rate 84, blood pressure 124/65, respirations 15, satting 99 percent on 6 liter vent mask which was later tapered down to nasal cannula and then room air. GENERAL: He was a well-developed, disheveled man, in no apparent distress, normocephalic, atraumatic. HEENT: Pupils equally round and reactive to light, about 4-5 mm bilaterally. Mucous membranes were moist. NECK: Supple with no evidence of any nuchal rigidity or JVD. LUNGS: Notable for some upper airway noise, but otherwise clear with good air movement. CARDIOVASCULAR EXAM: Notable for a regular rate and rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, nontender with no palpable organomegaly. Normal bowel sounds were present. EXTREMITIES: Notable for purple painted fingernails, as well as evidence of blunt trauma on the shins, the heels, the superior aspect of the feet, the elbows, as well as the lateral aspects of the upper arms, but no evidence of any distal clubbing, cyanosis or edema. NEUROLOGIC: The patient mumbled to external stimuli, noxious stimuli, but was unable to follow commands. SOCIAL HISTORY: The patient reportedly has an apartment in [**Location (un) 86**]. ETOH and tobacco history unclear. LABS: White count 11.6, hematocrit 49.8, platelets 224. Electrolytes were within normal limits, but CK was noted to be 981. Urinalysis obtained through a Foley was notable for clear urine with a specific gravity of 1.017, large blood was noted, but no nitrites, no esterase, and no glucose, ketones, bilirubin 30, proteins not present. On microscopy there were 0-2 red blood cells, 0-2 whites, but no bacteria, no yeast, and no epithelial cells. ECG: Notable for axis deviation seen on prior ECG from [**2109-8-13**]. The patient's heart rate was tachy at 125, but QTC was 436. Serum tox was negative. Urine tox, however, was positive for amphetamines. HOSPITAL COURSE: The patient was maintained with a 1:1 sitter for purposes of agitation. The patient did not require further doses of Ativan while in the [**Hospital Ward Name 12573**] ICU, but was given aggressive IV fluid hydration for his likely rhabdomyolysis, given his elevated CK. CK's were trended q 8 h and noted to peak at over 22,000. Intravenous fluids which initially were normal saline were switched to D5W with 3 amps of bicarb/L running at 300 cc/h. The patient maintained excellent urine output of 200-300 cc/h during this episode. By day 2 of the patient's hospitalization he was fully awake, alert and oriented. It was somewhat unclear as to the circumstances of his overdose, whether they were intended to harm himself, or merely for the purposes of intoxication. The patient's restraints were removed, as he was deemed no further threat, though the 1:1 sitter was maintained. The addiction RN was consulted, as well as psychiatry, who felt that the etiology of the patient's overdose was unclear whether it was intentional or not, and felt that the patient was at risk and would need psychiatric hospitalization. Therefore, the patient was held for an additional with the plan for discharge now on [**2110-5-9**] to inpatient psychiatric facility. DISCHARGE MEDICATIONS: 1. Lexapro at 20 mg qd. 2. Abilify 50 mg qd. The patient has been medically cleared, the CK's have markedly dropped tenfold since the peak, and the patient is tolerating full PO's, and is ambulatory. [**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 24325**], [**MD Number(1) 24326**] Dictated By:[**Doctor Last Name 12733**] MEDQUIST36 D: [**2110-5-9**] 14:01:41 T: [**2110-5-9**] 15:05:25 Job#: [**Job Number 24327**]

[ "296.7", "305.90", "E980.4", "728.88", "E849.0", "295.90", "975.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4634, 5103

3351, 4611

1279, 1369

1392, 2551

154, 177

206, 968

991, 1255

2568, 3333

72,778

157,417

42214

Discharge summary

report

Admission Date: [**2136-8-8**] Discharge Date: [**2136-8-22**] Date of Birth: [**2093-8-25**] Sex: M Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 36263**] Chief Complaint: polytrauma/motor vehicle collision Major Surgical or Invasive Procedure: 1. [**2136-8-8**]: Right lower extremity washout/debridement 2. [**2136-8-10**]: Right lower extremity washout/debridement and vac dressing placement 3. [**2136-8-13**]: Incision and debridement of a crushing wound of the right lower extremity, 30 x 15 cm, with debridement of skin, subcutaneous tissue and fascia with application of the vac dressing. 4. [**2136-8-15**]: Irrigation and debridement of skin, subcutaneous tissue, muscle and fascia; Split-thickness skin graft reconstruction of left lower extremity. History of Present Illness: 42 year old male who was involved in a single car accident, was the driver of a truck which rolled over multiple times. Compartment was crushed. Patient recalls that he self extricated himself from the vehicle by kicking out the back window of the truck with his lower extremities. He recalls feeling a lot of pain at the time but does not know if his right lower extremity was injured during the initial crash or when he was kicking out the back window. He was found prone in the median near the rolled car. He was alert but disoriented. He has a large avulsion injury to his right lower extremity, intact pulses. He was intubated in the field with RSI when his pressure dropped after c-collar was placed in ambulance. At outside hospital he got vitamin K 10mg IV, tetanus shot, 1g Ancef. . INJURIES: RLE avulsion injury, Fractures of the bilateral first transverse process, right posterior first rib, bilateral second ribs, second right transverse process, fifth and sixth posterior left ribs, Fracture C7 left lateral mass, collapsed RUL. Past Medical History: venous insufficiency DVT RLE - [**2130**] (on coumadin) PE - [**2130**] (on coumadin) Social History: Patient his wife, [**Name (NI) 87054**], are separated and he stays with his mother in [**Name (NI) 8**] sometimes and helps care for her. He says he is presently trying to get 'on her lease'. Otherwise, he spends time at a homeless shelter. Pt reports he has a son he is estranged from, but is close to [**Female First Name (un) 91515**] child. He feels supported by family and his faith and says he has good support from his church community. Family History: No history of DVT/PE or hypercoagulable state to his knowledge. Physical Exam: Physical Exam: RLE with large full-thickness skin flap avulsion to lateral lower leg, exposed muscle bellies. Damage to peroneal muscles and tibialis anterior. DP/PT pulses dopplerable and symmetric. Pt was intubated in field so unable to so sensory motor exam, but does exhibit purposeful movements when examining flap. Flap is from medial to lateral with flap still attached entirely on the lateral side. Tissue is similar warmth to other exposed skin. No evidence of vascular damage on CTA of RLE. Pertinent Results: [**2136-8-8**] 09:52PM HCT-24.1* [**2136-8-8**] 05:53PM PT-19.1* INR(PT)-1.7* [**2136-8-8**] 03:12PM TYPE-ART PO2-188* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 [**2136-8-8**] 02:09PM HCT-26.6* [**2136-8-8**] 01:39PM TYPE-ART PO2-251* PCO2-54* PH-7.30* TOTAL CO2-28 BASE XS-0 [**2136-8-8**] 01:39PM LACTATE-1.0 [**2136-8-8**] 01:19PM GLUCOSE-147* UREA N-17 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-11 [**2136-8-8**] 01:19PM CALCIUM-7.7* PHOSPHATE-3.5 MAGNESIUM-1.8 [**2136-8-8**] 01:19PM WBC-15.0* RBC-3.45* HGB-9.6* HCT-25.9* MCV-75* MCH-27.8 MCHC-37.1* RDW-15.4 [**2136-8-8**] 01:19PM NEUTS-90.8* LYMPHS-5.5* MONOS-3.4 EOS-0.2 BASOS-0 [**2136-8-8**] 01:19PM PLT COUNT-182 [**2136-8-8**] 01:19PM PT-21.9* PTT-28.6 INR(PT)-2.0* [**2136-8-8**] 06:49AM TYPE-[**Last Name (un) **] [**2136-8-8**] 06:49AM GLUCOSE-201* LACTATE-4.1* NA+-148* K+-3.9 CL--115* TCO2-24 [**2136-8-8**] 06:49AM HGB-12.1* calcHCT-36 O2 SAT-74 CARBOXYHB-4 MET HGB-0 [**2136-8-8**] 06:40AM UREA N-20 CREAT-1.0 [**2136-8-8**] 06:40AM estGFR-Using this [**2136-8-8**] 06:40AM LIPASE-14 [**2136-8-8**] 06:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-8-8**] 06:40AM URINE HOURS-RANDOM [**2136-8-8**] 06:40AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2136-8-8**] 06:40AM WBC-28.5* RBC-4.54* HGB-12.2* HCT-34.2* MCV-75* MCH-26.9* MCHC-35.8* RDW-15.5 [**2136-8-8**] 06:40AM PLT COUNT-212 [**2136-8-8**] 06:40AM PT-29.5* PTT-28.8 INR(PT)-2.9* [**2136-8-8**] 06:40AM FIBRINOGE-344 [**2136-8-8**] 06:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2136-8-8**] 06:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-8-8**] 06:40AM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 [**2136-8-8**] 06:40AM URINE HYALINE-3* [**2136-8-8**] 06:40AM URINE MUCOUS-RARE [**2136-8-15**] 10:50AM BLOOD WBC-9.9 RBC-3.60* Hgb-10.3* Hct-27.5* MCV-76* MCH-28.5 MCHC-37.3* RDW-16.1* Plt Ct-284 [**2136-8-15**] 10:50AM BLOOD Plt Ct-284 [**2136-8-15**] 10:50AM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-135 K-4.2 Cl-99 HCO3-26 AnGap-14 [**2136-8-15**] 10:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8 [**2136-8-21**] 10:30AM BLOOD AT-PND ProtCFn-PND ProtSFn-PND [**2136-8-21**] 10:30AM BLOOD ACA IgG-PND ACA IgM-PND [**2136-8-22**] 04:40AM BLOOD AT-PND ProtCFn-PND ProtSFn-PND [**2136-8-22**] 04:40AM BLOOD ACA IgG-PND ACA IgM-PND [**2136-8-21**] 10:30AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [**2136-8-22**] 04:40AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND . RADIOLOGY: Radiology Report CT HEAD W/O CONTRAST Study Date of [**2136-8-8**] 6:44 AM IMPRESSION: No acute intracranial process. . Radiology Report -59 DISTINCT PROCEDURAL SERVICE Study Date of [**2136-8-8**] 6:45 AM IMPRESSION: 1. Focal dissection at the level of the diaphragmatic hiatus extending from T10 to L1. Better characterization could be obtained if desired with a dedicated CT angiographic study. No surrounding hematoma 2. Complete right upper lobe collapse likely from aspirated secretions 3. Endotracheal tube 5 cm above the carina. 4. Fractures of the bilateral first transverse processes, first posterior right rib, bilateral second posterior ribs,and fifth and sixth left posterior ribs. . Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2136-8-8**] 6:45 AM IMPRESSION: Fractures of the C7 lateral mass, the transverse processes of T1 bilaterally, the right posterior first rib and bilateral posterior second ribs though the second right rib fracture is better seen on the accompanying CT Torso. NOTE ADDED IN ATTENDING REVIEW: In addition to the above, there is an apparent significant disc herniation, possibly acute, at C4-5, which effaces the ventral thecal sac and may indent the underlying cord. This is poorly evaluated by this modality and would be better-assessed by MR, which would also be warranted (including axial T1-weighted sequences with fat-saturated sequences), if there is suspicion of left vertebral arterial injury in association with the C7 left posterior element fracture. . Radiology Report CTA LOWER EXT W/&W/O C & RECONS BILAT Study Date of [**2136-8-8**] 6:50 AM IMPRESSION: Extensive right lower extremity skin and subcutaneous tissue defects without evidence for active extravasation or definite signs of vessel injury. Please note the bolus timing was suboptimal, limiting the study. . Radiology Report CTA PELVIS W&W/O C & RECONS Study Date of [**2136-8-11**] 5:00 PM IMPRESSION: Technically limited study secondary to poor contrast bolus. Allowing for this limitation, there is an intimal flap again noted within the distal thoracic aorta starting near the diaphragmatic hiatus and terminating above the renal arteries, in a similar distribution as on the prior CT of [**8-8**]. . Radiology Report UNILAT UP EXT VEINS US LEFT Study Date of [**2136-8-12**] 2:49 PM IMPRESSION: No DVT of the left upper extremity. Please note that the left IJ was not interrogated due to the overlying cervical collar. . Radiology Report [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2136-8-20**] 3:04 PM IMPRESSION: 1. Left lower extremity demonstrating acute popliteal and peroneal and one of two paired tibial veins with thrombus. 2. Findings compatible with old thrombus and thrombophlebitis involving the right popliteal vein. The right common femoral vein appears unremarkable, the right superficial femoral vein and tibial veins could not be interrogated due to a skin graft and surgical drainage and dressing respectively. . Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2136-8-20**] 3:58 PM IMPRESSION: 1. Left lower lobe subsegmental filling defect with peripheral flow suggests chronic rather than acute pulmonary embolism. 2. Left subclavian PICC line with distal portion coiled in the subclavian and tip terminating in the brachiocephalic junction. 3. Stable focal descending thoracic aortic dissection. 4. Redemonstration of multiple fractures as described above. . MICROBIOLOGY: [**2136-8-21**] 8:45 am SWAB Source: right lateral leg exudate. GRAM STAIN (Final [**2136-8-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Brief Hospital Course: The patient was transferred from an OSH to the [**Hospital1 18**] for trauma evaluation and subsequently admitted to the acute care surgery service on [**2136-8-8**]. . Patient intubated in field, transferred to [**Hospital1 **] with large RLE degloving injury, CTA of RLE revealed no evidence of extravasation, poor visualization of vessels distal to ankle likely secondary to edema. Patient was taken to the OR for several washout and debridements and wound vac placements to the RLE by the Acute Care Service (ACS). The Plastic and Reconstructive Surgery service was consulted for help with RLE wound closure. A skin graft was recommended post adequate debridement. . The Vascular service was consulted for intimal flap noted at level of T10 on initial scans. This was a traumatic aortic dissection not involving any major branches off of the aorta. THe patient remained hemodynamically stable with the exception of hypotension with propofol. Vascular recommended tight blood pressure control with goal systolics 100-140 and a repeat CT in a few days. A repeat CT performed on [**2136-8-11**] showed an intimal flap again noted within the distal thoracic aorta starting near the diaphragmatic hiatus and terminating above the renal arteries, in a similar distribution as on the prior CT of [**8-8**]. Vascular recommended a repeat CT in 6 months with Vascular follow up appointment. . Neurosurgery was also consulted given CT spine findings of fractures seen through the left lateral mass of C7 as well as the first transverse processes bilaterally. Neurosurgery recommended that C-Collar should continue at all times and that the patient should follow up with a repeat CT scan of the cervical spine in 8 weeks post the original trauma. C-collar was maintained in hospital and patient compliance was reinforced several times. . On [**2136-8-15**] the patient went to the OR with Plastics service and had a split thickness skin graft to RLE wound from right thigh donor site. He was then transferred to the care of the Plastics service. A wound vac was applied to graft site and removed on [**2136-8-21**] to reveal a skin graft site with approximately 90% take. The graft site did have an odor when the wound vac appliance was removed. There was no evidence of purulent drainage but a swab culture was obtained and sent and patient was placed on Augmentin PO. . The Heme-Onc service was consulted for patient's history of DVT/PE and to help determine whether patient needed to resume coumadin therapy. Patient was maintained on heparin subcutaneous injections during his initial admission. Recommendations included obtaining doppler studies of BLEs as well as a chest CT to rule out PE. Lower extremity dopplers revealed 3 blood clots to the left lower extremity and evidence of an old clot to the right lower extremity. The chest CT revealed evidence of an old pulmonary embolus. Patient's heparin subcutaneous injections wer discontinued and patient was initiated on Lovenox injections. Patient was commenced back on coumadin on [**2136-8-21**] while maintaining a lovenox bridge. Heme-Onc recommended maintaining this bridge until INR became therapeutic between [**1-5**]. Hypercoagulation labs were also obtained and sent with exception of Factor V Leiden and Prothrombin Mutation Analysis which will need to be obtained as an outpatient. The lab values were still pending at the time of this discharge. Patient's PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91516**] (office) [**Telephone/Fax (1) 5139**], will follow up with the Plastics service regarding any outstanding data that she requires. . Pain: Patient's pain was controlled utilizing Dilaudid PCA, injections, and IV during periods of severe pain. Once patient's pain had decreased he reported good pain control with Oxycodone. ID: Patient had a PICC inserted to left upper extremity for IV antibiotics and blood draws. Patient was initially given cefazolin and unasyn IV upon admission. Unasyn IV was maintained and then patient was changed to PO Augmentin upon discharge to rehab facility. The left upper extremity PICC line was discontinued. Directly after discharge from floor, micro swab from RLE wound cultures grew Pseudomonas. [**Hospital3 **] facility was called immediately and updated on this new information and it was agreed that Ciprofloxacin 500mg po BID x 14 days would be added to medication regimen. GI/GU: Patient initially had foley catheter upon admission but this was discontinued when indicated and patient was able to void without issue. Patient was maitained on a bowel regimen to encourage bowel movements. At the time of discharge on hospital day #15, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating with , voiding without assistance, and pain was well controlled. Medications on Admission: Coumadin Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<[**Age over 90 **]m hr<60 . 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily) as needed for constipation. 7. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for road rash: apply to road rash/abrasions as needed . 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day: Discontinue 24 hours after INR is between [**1-5**]. 11. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. 12. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 13. warfarin 5 mg Tablet Sig: Two (2) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 14. warfarin 5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Right lower extremity degloving injury 2. Multiple rib fractures 3. Type B aortic dissection 4. Lateral C7 mass fracture 5. acute left lower extremity DVTs 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 acute care surgery service on [**2136-8-8**] for injuries related to a motor vehicle collision. You were then transferred to the Plastic and Reconstructive surgery service on [**2136-8-15**] for reconstructive surgery of your RLE wound. Please follow these discharge instructions: . General Discharge Instructions: -Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. -Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. [**Name10 (NameIs) **] have a C7 spinal fracture and must wear your cervical collar (neck brace) for 6 more weeks. -Always wear your right lower extremity multipodus boot when in and out of bed. -Your right lower extremity dressing should be changed once a day and as needed. Apply xeroform dressing to skin graft site, cover with abdominal pads, wrap in Kerlix gauze and then wrap with Ace wrap. -Elevate your right lower extremity as much as possible. -you may leave your right lower extremity wound open in the shower and let the water run over it. Pat it dry and apply new dressing. -cover your right thigh 'donor site' with plastic wrap dressing to protect it from moisture. Followup Instructions: NEUROSURGERY FOLLOW UP: Regarding your C7 fracture (cervical spine): Please call/or have the patient call ([**Telephone/Fax (1) 88**] to schedule a follow-up appointment in 6 weeks, with a Non-contrast CT scan of the cervical spine. The Neurosurgery office is located in the [**Hospital **] Medical Building, [**Hospital Unit Name 12193**]. . PCP [**Name9 (PRE) **] should follow up with PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91516**] (office) [**Telephone/Fax (1) 5139**]. Dr. [**Last Name (STitle) 91516**] will be helping to manage coumadin dosing and coags via the [**Hospital1 2177**] coumadin clinic. . VASCULAR SURGERY Regarding your aortic dissection: You will need a repeat CT scan in 6 months and a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please call the office to schedule a 6 month follow up visit and mention that you need a CT scan scheduled prior to the visit: ([**Telephone/Fax (1) 2867**] . PLASTIC AND RECONSTRUCTIVE SURGERY: Regarding your right lower extremity skin graft: You will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] 1 week after discharge. Please call his office to schedule an appointment> ([**Telephone/Fax (1) 36264**] Dr.[**Name (NI) 2989**] clinic is located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 470**], Surgical Specialties. Completed by:[**2136-8-22**]

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icd9cm

[ [ [] ] ]

[ "86.28", "38.91", "38.97", "83.39", "86.59", "83.65", "96.71", "86.69", "83.45", "38.89" ]

icd9pcs

[ [ [] ] ]

16026, 16096

9609, 14503

338, 855

16299, 16299

3123, 9507

18119, 18132

2520, 2586

14562, 16003

16117, 16278

14529, 14539

16790, 16792

2616, 3104

18143, 19640

16824, 18096

264, 300

9542, 9586

883, 1929

16314, 16458

1951, 2039

2055, 2504

19,310

130,172

53129

Discharge summary

report

Admission Date: [**2181-8-12**] Discharge Date: [**2181-8-16**] Date of Birth: [**2101-5-1**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Quinolones Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: non-functional PICC line Major Surgical or Invasive Procedure: peripherally inserted central venous catheter History of Present Illness: 80F PMH Multiple hemorrhagic CVAs [**12-21**] amyloid angiopathy, non-vocal and unable to follow commands at baseline, s/p recent admission for aspiration PNA (multiple admissions with last 3 months for pulmonary complications),hiatal hernia and discharged on TPN and no PO meds, p/w fevers. The patient lives at home where her husband is her primary care giver. She was brought by husband on [**8-12**] because PICC not working well. Unable to draw blood thru it. But had TPN last night. . The husband also noticed increased cough, mainly at night for 4 days No fever/chill/ redness at PICc site or any other new symptoms. Past Medical History: - Multiple intraparenchymal hemorrhages due to amyloid angiopathy. The first hemorrhage was in [**2160**] (presented with R hemiparesis). Later had a large L fronto-parietal bleed (became aphasic). - Focal motor facial seizures. Previously treated with Dilantin, now on Neurontin. - Myoclonic jerks - High cholesterol - Hypertension - Hx of Hospital Admission for Pneumonia vs. Bronchitis instigated by patient inability to clear secretions from Upper Respiratory Tract. Was Intubated. Social History: Lives at home with her husband who is her primary caregiver. Also has a home health aide. They take 24 hour care of her. She is unable to do any of her ADLs and requires a Foley at baseline. She is fairly nonresponsive at baseline, but occ says [**11-20**] words or laughs at the TV according to her family. No tobacco, EtOH, or illicit drug use. Family History: h/o cad and stroke in the family Physical Exam: Upon presentation to [**Hospital Unit Name 153**]: T BP 130/80 P 93 O2 93 on RA initially _> 85 on RA-> 99% on 100%NRB GEn: respiratory distress, thin frail female HEENT: Pupil equal and reactive, NC/AT, mucus membrane moist NEck: Supple, no LAD CV: RRR, no murmur/rubs/gallops Resp: ant exam w/ good inspiratory throughout, no wheezing or focally decreased BP Abd: Soft, non-tended, non-distended, + bowel sounds Ext: warm, no edema, no erythema, +2 distal pulses Neuro: open eyes, does not follow command, moves hand and leg spontaneously (non-verbal at baseline) Pertinent Results: [**2181-8-12**] 09:35AM GLUCOSE-110* UREA N-20 CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 [**2181-8-12**] 09:49AM LACTATE-1.5 [**2181-8-12**] 09:35AM CALCIUM-9.8 PHOSPHATE-4.0 MAGNESIUM-2.0 [**2181-8-12**] 09:35AM WBC-7.6 RBC-3.60* HGB-11.5* HCT-32.6* MCV-90 MCH-31.9 MCHC-35.3* RDW-15.6* [**2181-8-12**] 09:35AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-MOD [**2181-8-12**] 09:35AM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-MOD EPI-0-2 Brief Hospital Course: 80 year old female h/o CVA, baseline mental status non-communicative, on TPN, aspiration precaution, h/o UTI (klebseilla and pseudomonas), h/o mucus plugging, admitted for PICC malfunction, now w/ acute respiratory distress of unclear etiology. . # hypoxic repiratory distress-This was thought to be most likely due to mucus plugging vs aspiration. Her EKG was not suggestive of ischemic causes. Initial ABG 7.48/31/53 on 100% NRB was suggestive of significant hypoxemia. She received respiratory suctioning which produced significant amt of thick secretion. Her O2 sats improved from 85 on room air initially to high 90s on 100 NRB to 99-100 on shovel mask on [**8-15**]. She was briefly given vancomycin/flagyl along with ceftazdiime (already given for empiric UTI treatment). This was stopped on days 2 ([**8-15**]) of her ICU stay as her oxygenation improved and her hypoxic episode thought to be related to mucus plugging. By time of discharge she was breathing well with normal oxygenation on room air. . #UTI - She was initially started on ceftazdime given recent hospitalization/ pseudomonas UTI/ chronic foley cath. Her urine on followup revealed poly-flora oganism thought to be chronic colonization given her chronic in-dwelling foley. THe foley was changed on admission. Ceftaz was d/c on day 2 as she was not thought to have UTI. . #Anemia-Her hct remained stable while she was in the hospital. . # FEN: The patient is TPN dependent at baseline secondary to her her neurologic defecits. After changing her PICC line, she received daily TPN in consultation with the nutritionists. . #Access- She initially came in for malfunction of PICC. A new R PICC was place in her antecubital area . # Code status- Extensive discussion was healed with the husband and he agreeed that she can be intubated if needed, but do not resucitate - this plan was made effective on [**2181-8-14**]. . # Dispo: the patient was discharged to home with services. Medications on Admission: tylenol prn Alb q6 nebs prn atrovent nebs q6 CLonidine patch 0.1mg/24hr q Sun Vancomycin 500 mg Q 12H x 7 days (finish on [**8-6**]) . Meds on admission: alb q6 combivent TPN clonidine patch Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain or fever. 3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday): apply [**11-20**] patch if sbp < 95. Disp:*5 Patch Weekly(s)* Refills:*2* 4. TPN TPN per nutrition protocol include Famotidine 40 mg IV per TPN bag 5. Line Care PICC line care per protocol 6. Atrovent 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Wound Care wound care to coccyx per included instructions Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Aspiration . Secondary: Bronchiectasis Hiatal Hernia Multiple strokes Discharge Condition: stable. afebrile. normal oxygenation on room air. PICC line functioning appropriately. Discharge Instructions: You have been evaluated and treated for a malfunctioning PICC line and for aspiration. Your PICC line was changed. Your breathing status improved with regular suctioning. . You will resume your home services of VNA and TPN. . If you develop any new concerning symptoms please contact your doctor. Followup Instructions: Please call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment within the next 1-2 weeks. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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10978

Discharge summary

report

Admission Date: [**2161-1-13**] Discharge Date: [**2161-2-6**] Date of Birth: [**2102-11-16**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1491**] Chief Complaint: here for TIPs eval Major Surgical or Invasive Procedure: s/p failed TIPs on [**2161-1-20**] History of Present Illness: Briefly, the patient is a 58 y/o F with cirrhosis likely, secondary to sarcoidosis, c/b esophageal varices who presents for direct admission for TIPS evaluation. The pt was recently admitted from [**Date range (1) 35603**] for TIPS eval s/p episode of hematemesis with banding at an OSH. She became febrile during that admission and there was concern that she had endocarditis so she was started on vancomycin and was to complete at least a 6 week course. Additionally developed R swollen leg and was found to have abscesses along the muscle of the R thigh. Several of these were drained by IR and a pigtail catheter was placed in her leg. TIPS procedure was not done at that admission because of concern for endocarditis. She was discharged with instructions to continue vancomycin for at least 6 weeks until she was either re-admitted to the hospital for TIPs or was seen by ID. She stopped her vancomycin on [**2161-1-12**] and was directly admitted to the hospital on [**2161-1-13**]. She states that in the interval between her hospitalizations she has been doing well and thinks her right thigh is improving. The pigtail catheter was removed as an outpatient. She is able to walk around more than she was able to before, but still feels very tired. She also notes she was seen by Dr. [**Last Name (STitle) **] and had additional banding of her varices. She denies N/V, fevers, chills, diarrhea, urinary symptoms or confusion. She did have some abdominal pain yesterday but thinks it was [**1-22**] to having to sit up during her 5 hour car ride from [**State 1727**]. The pain has since resolved. Past Medical History: 1) Hepatic sarcoid (dx [**2134**]) -> cirrhosis s/p liver biopsy X 3; significant portal hypertension with massive splenomegaly and esophageal varices 2) Sarcoidosis - pulm involvement, s/p mediastinsocopy and biopsy [**2124**] 3) Esophageal varices s/p bleeds in [**3-25**] and another one in [**11-24**] in spite of band ligation therapy (most recent [**2161-1-1**]) 4) ? Endocarditis ([**Date range (1) 35604**]) 5) Thigh abscesses (?rel to septic emboli, [**Date range (1) 35604**]) 6) Hypersplenism - splen 19 cm -> thrombocytopenia 7) History of dysphagia 8) GERD 9) Hypertension 10) OSA 11) Bipolar disorder, type II 12) Spastic bladder with incontinence 13) Constipation Social History: Denies smoking, etOh, no illicits. married has 2 daughters. Family History: Denies h/o CVA, heart attack. Mother lung cancer (smoker) Physical Exam: VS: 98.6 93/58 73 20 98% RA GEN: pleasant woman, NAD, resting comfortably HEENT: NC, AT, no scleral icterus, OP clear, MM sl dry Heart: regular, nl S1S2, 2/6 systolic murmur at LSB, non-radiating Lungs: scattered crackles Abdomen: + BS, soft, distended, NT, + fluid wave Ext: bilateral LE pitting edema (RLE greater than left). R thigh wtih erythema and slighly warm. No fluctuance. Neuro: CN II-XII intact, non focal, no asterixis. Pertinent Results: Labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2161-2-6**] 06:00AM 7.4# 3.00* 10.2* 28.2* 94 33.9* 36.1* 19.6* 78* BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2161-2-6**] 06:00AM 78* [**2161-2-6**] 06:00AM 17.0*1 39.6* 1.6* 1 NOTE NEW NORMAL RANGE AS OF 12:00AM [**2161-1-14**].;ABNORMAL PROTHROMBIN TIME (PT) INCREASED DUE TO;LABORATORY CHANGE TO A MORE SENSITIVE PT [**Name (NI) 25013**].;INR VALUES REMAIN THE SAME. MONITOR WARFARIN BASED ON INR ONLY! MISCELLANEOUS HEMATOLOGY Gran Ct [**2161-1-24**] 04:22AM [**2104**]* ADD ON HEMOLYTIC WORKUP Ret Aut [**2161-2-6**] 06:00AM 2.2 VOIDED SPECIMEN VoidSpe [**2161-1-20**] 04:34PM SPECIMEN R1 INCOMPLETELY LABELED SPECIMEN 1 SPECIMEN RECEVIED UNLABELED Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2161-2-6**] 06:00AM 97 28* 1.4* 133 4.1 94* 291 14 1 NOTE UPDATED REFERENCE RANGE AS OF [**2160-6-20**] ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2161-2-6**] 06:00AM 135 4.8* 2.1* 2.7 [**2161-2-5**] 05:40AM 121 4.5* 1.8* 2.7 ADDED DBIL,HAP,LD [**2161-2-5**] 12:42PM [**2161-2-4**] 05:30AM 5.3* [**2161-2-3**] 10:23AM 11 36 156* 6.3* 2.0* 4.3 ADDED CHEM [**2161-2-3**] 11:08AM [**2161-2-2**] 05:15AM 10 30 109 120* 5.3* ADDED CHEM [**2161-2-2**] 10:35AM [**2161-1-31**] 06:44AM 4.5* [**2161-1-30**] 06:30AM 4.7* [**2161-1-27**] 07:20AM 10 23 92* 75 2.5* LFT ADDED [**1-27**] @ 11:02 [**2161-1-24**] 04:22AM 29 69* 126* 1.3 [**2161-1-22**] 11:41AM 26 [**2161-1-22**] 04:47AM 30 96* 153 24* 184* 1.7* [**2161-1-21**] 11:15PM 24* [**2161-1-21**] 04:15AM 17 59* 175 204* 2.1* ADDED CHEM [**2161-1-21**] 12:12PM [**2161-1-20**] 08:15AM 14 39 1.1 [**2161-1-15**] 05:56AM 144 ADDED ALB,LD [**2161-1-15**] 12:07AM [**2161-1-14**] 06:10AM 15 53* 342* 1.2 OTHER ENZYMES & BILIRUBINS Lipase [**2161-1-22**] 04:47AM 20 CPK ISOENZYMES CK-MB cTropnT [**2161-1-22**] 11:41AM NotDone1 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 [**2161-1-22**] 04:47AM NotDone1 0.03*2 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2161-2-6**] 06:00AM 9.2 1.9* 2.0 HEMATOLOGIC Hapto [**2161-2-5**] 05:40AM 31 ADDED DBIL,HAP,LD [**2161-2-5**] 12:42PM [**2161-1-16**] 05:46AM 79 HAPTO ADDED [**1-16**] @ 15:14 OTHER ENDOCRINE Cortsol [**2161-1-21**] 09:06AM 24.8*1 Source: Line-tlcl 1 NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9 [**2161-1-21**] 08:35AM 21.3*1 Source: Line-tlcl 1 NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9 [**2161-1-21**] 08:05AM 13.91 1 NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9 HEPATITIS HBsAg HBsAb HBcAb HAV Ab IgM HAV [**2161-1-28**] 12:00PM NEGATIVE [**2161-1-19**] 05:06AM NEGATIVE NEGATIVE NEGATIVE POSITIVE IMMUNOLOGY RheuFac CEA AFP [**2161-1-29**] 05:55AM 2.21 <1.02 1 MEASURED BY [**Doctor Last Name 8721**] ELECSYS (ECLIA) 2 <1.0 MEASURED BY [**Doctor Last Name 8721**] ELECSYS (ECLIA) [**2161-1-24**] 04:22AM 15*1 1 60 IU/ML CORRESPONDS TO 1:80 TITER, 120 IU/ML TO 1:160 TITER, ETC HIV SEROLOGY HIV Ab [**2161-1-29**] 06:39AM NEGATIVE CONSENT RECEIVED [**2161-1-19**] 05:06AM NEGATIVE CONSENT FORM RECEIVED ANTIBIOTICS Vanco [**2161-2-6**] 06:00AM 19.6* LAB USE ONLY Prblm RedHold [**2161-2-6**] 06:00AM HOLD VOIDED SPECIMEN VoidSpe [**2161-1-20**] 04:34PM INCOMPLETE1 INCOMPLETELY LABELED SPECIMEN 1 INCOMPLETELY LABELED SPECIMEN HEPATITIS C SEROLOGY HCV Ab [**2161-1-19**] 05:06AM NEGATIVE . Micro: all cultures negative . Right lower ext venous doppler:IMPRESSION: No DVT. . [**1-14**] Abdominal ultrasound:IMPRESSION: 1. Patent IVC and hepatic veins. 2. Patent main and right portal veins with hepatopetal flow. 3. Cirrhotic liver. 4. Large quantity of ascites. . R thigh MRI: IMPRESSION: Persistent yet decreased volume of fluid within multilobulated tubular collections within the soft tissues and muscles of the right thigh. No new fluid collection identified. . MRI abdomen: IMPRESSION: 1. Nodular, atrophic cirrhotic liver consistent with patient's history of sarcoidosis. Liver volume equals 1160 cc. 2. Portal vein thrombosis, as described above. 3. Evaluation of hepatic arterial supply is limited due to non-breath-hold technique. However, prior abdominal CT scans demonstrate conventional hepatic arterial anatomy. 4. Right-sided effusion, ascites and evidence of portal hypertension. Evaluation of the reformatted images on a separate workstation were valuable in delineating the anatomy. . Echo: INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver. Left pleural effusion. Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Agitated saline contrast study demonstrated no significant intracardiac shunt at rest or with cough and Valsalva release (cannot definitively exclude). . MIBI: SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 milligram/kilogram/min. Two minutes after the cessation of infusion, Tc-[**Age over 90 **]m sestamibi was administered IV. No anginal symptoms or ischemic changes noted. INTERPRETATION: Image Protocol: Gated SPECT Resting perfusion images were obtained with thallium. Tracer was injected 15 minutes prior to obtaining the resting images. This study was interpreted using the 17-segment myocardial perfusion model. The image quality is adequate. Ascitis, splenomegaly and small liver are noted. Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 78%. IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and function. 3. LVEF of 78%. 4. Ascitis, splenomegaly and small liver are noted. Brief Hospital Course: 58F with sarcoidosis, with pulmonary involvement and liver cirrhosis, HTN, R atrophic kidney, esophageal varices, who presented for re-eval for TIPS as well as initial work-up for liver transplant. . # TIPS evaluation - Patient was initially admitted on [**2160-12-2**] to [**2160-12-26**] for potential TIPs eval due to recurrent variceal bleeding in [**11-24**] requiring banding. Patient subsequently was found R thigh abscesses (drained by IR, Cx grew Strep Miliri) and bacteremia ([**12-2**] - 2/2 bottles MSSA). TIPS was deferred while she completed 6 week treatment with Vancomycin. Patient was readmitted and had subsequent reimaging of her thigh. The results showed persistent but smaller fluid collections in the right thigh. The location of the persistent collections were deemed not to be amenable to percutaneous drainage by IR. Patient subsequently underwent TIPS on [**1-20**]. It failed due to clots in the intrahepatic and extrahepatic portal vein with short segment of portal vein occlusion and cavernous transformation. The course was complicated by hypotension and hypoxia and subsequent transfer to the ICU as described below. . # Liver transplant eval: Upon return to the floor patient underwent liver transplant evaluation. Transplant surgery was consulted and patient is to be followed by Dr. [**Last Name (STitle) 816**] in outpatient while she completes her course of antibiotics. Patient also underwent pre-operative evaluation by the pulmonary service while in house. An MRI was also obtained outlining the liver size. Patient also underwent cardiac MIBI that showed preserved EF with no reversible defects and no suggestion of CAD. Patient was also given 1st Hepatitis B shot as she has never been exposed or immunized according to her serologies. Patient was also found to be HepC Ab negative. Her [**Last Name (un) **] IgM negative but IgG positive showing previous exposure/immunization. Patient also had a negative HIV test. Patient was also positive for HSV 1 Ab, negative for HSV 2 Ab. His Ca [**73**]-9 was wnl @ 7. Pt also had RF of 15 (high nl). Negative AFP @ <1.0. Negative CEA @ 2.2. Negative rubella, non-reactive RPR. Negative AMA. Patient has a positive Ab for VZV (IgG), EBV (IgG not IgM), positive CMV IgG and IgM but undetectable CMV viral load. Negative Toxoplasma Ab. Nl Angiotensin converting enzyme. Social work were involved as well as Dr. [**Last Name (STitle) **] (transplant psychiatry) notified. - patient will need completion of her Hepatitis B shot series - f/u with Dr. [**Last Name (STitle) 816**] . # Cirrhosis: Patient has a long standing cirrhosis due to her sarcoid. She has US performed that showed patent main and right portal veins with hepatopetal flow. Unfortunately TIPS were not able to be performed as described above. Patient was continued on ursodiol 300 mg [**Hospital1 **]. She was continued on Levofloxacin 500 mg QD for SBP prophylaxis. Her lactulose was intermittently held as she experience profuse diarrhea. Patient never showed any signs of encephalopathy or asterixis. Patient was subsequently restarted on Lasix 40 mg QD and her spironolactone which was subsequently increased to 50 mg po QD. Patient was also restarted on low dose nadolol and to be continued on 20 mg QD. She is to continue her medications and follow up with Dr. [**Last Name (STitle) **]. . # Hypotension: Patient with a transient episodes of hypotension after failed tips on [**1-20**]. Differential diagnosis at the time included blood loss (although minimal EBL during TIPS), sepsis (patient with negative culture, to date, afebrile, no WBC, but is currently being treated for bacteremia), volume depletion given recent paracentesis and large fluid shifts or post-anesthesia induced hypotension. Patient required neosynephrine for 24 hours. Patient was also started on hydrocortisone/fludrocortisone for 3 days despite nl stim test (13.9-> 21.3-> 24.8). Upon return to the floor patient tolerated repeat paracentesis (3L) well and she tolerating her diuretics and nadolol well. . # Hypoxia - Patient has underlying restrictive pulmonary disease due to her underlying sarcoidosis. Patient was diagnosed in the 70s. Her CXR during this admission was also c/w mod pulmonary edema, probably due to aggressive volume resuscitation. Patient was + 10 L during her unit stay. Hepatopulmonary/ARDS was also in the differential. Patient was given albumin with intermittent paracentesis to mobilize fluid from lungs (50 IV BID albumin x 7 days). She continued to use CPAP at night and was gradually weaned off O2 with excellent sats as she was diuresed with 40 IV lasix. Patient is to continue on Lasix 40 PO and Spironolactone 50 PO QD. Patient also underwent pulmonary evaluation while in house. She is cleared for her transplant surgery. ABG on room gas did reveal hypoxia of paO2 of 57, after long discussion it was decided that this close to her baseline due to her underlying restrictive lung disease. Patient is to follow up with pulmonary clinic as outpatient. . # R thigh abscess/myositis - Patient was found to have R thigh abscesses (drained by IR, Cx grew Strep Miliri) and bacteremia ([**12-2**] - 2/2 bottles MSSA). This admission she presented after finishing 6 week course of vancomycin. ID service was re consulted and advised continuing Vancomycin for a total of [**7-30**] weeks. R thigh was reimaged and showed persistent but some reduction in the size of collection. They were deemed not to be amenable to drainage. Patient is to follow up with Dr. [**Last Name (STitle) 2716**] in the [**Hospital **] clinic. Patient is to have her Vanco trough check in [**2-21**] weeks 1/2 hour before her dose. She is to continue Vancomycin IV 750 QD until she sees Dr. [**Last Name (STitle) 2716**] in the clinic. VNA will provide PICC line care. # Endocarditis: Patient has been on Vancomycin since [**2160-12-3**] for presumed endocarditis given MSSA bacteremia, [**Last Name (un) 1003**] lesions, and R thigh abscesses. She did not have any evidence of vegetations on repeat Echo's. No TEE is done as patient is a high risk due to esophageal varices. Patient is to continue vancomycin for myositis. . # CRI. Baseline 1.2-1.3. Patient is at her baseline. She has a congenital atrophic right kidney. Long standing sarcoidosis and liver failure are also probably contributing to her renal insufficiency. Patient is to have her Cr checked weekly. . # Impaired glucose tolerate - patient with early AM sugars of 120-140. Her postprandial sugars are 110-140, with occasional values of 170. Patient was subsequently d/c off insulin. She may require introduction of oral agents in the future if her BS remains elevated now that she is titrated off prednisone. She has never required home glucose control before. . # Thrush. Continue nystatin swish and swallow as needed. . # Bipolar disorder. Continue Lamotrigine and Fluoxetine. . # Code - full code . # Communication - w/pt and husband [**Name (NI) **] [**Telephone/Fax (1) 35605**] . # Access - right PICC . # Dispo - patient will follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 816**]. Patient will have weekly lab draws done and followed by her [**Last Name (STitle) 3390**]/Dr. [**Last Name (STitle) **]. Medications on Admission: -1. Lamotrigine 50 mg qd -2. Fluoxetine 20 mg qd -3. Oxybutynin Chloride 10 mg [**Hospital1 **] -4. Nexium 40 mg qd -5. Nadolol 40 mg qd -6. Ursodiol 300 mg [**Hospital1 **] -7. Sucralfate 1 g [**Hospital1 **] -8. Levofloxacin 500 mg Tablet qd until TIPS -9. Lactulose 15 cc TID -10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). -11. Spironolactone 100 mg qd -12. Furosemide 40 mg qd Discharge Medications: 1. Outpatient Lab Work Hepatitis B - 2nd shot; 1st shot [**2161-1-28**] 2. Supplies Hospital bed, due to persistance of ascites, frequent paracentesis, evaluation for liver transplant and sarcoid restrictive lung disease 3. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 24H (Every 24 Hours): for a total of 750 mg per each dose. Disp:*45 Recon Soln(s)* Refills:*3* 4. Supplies Please do PICC line care per protocol 5. Outpatient Lab Work CBC, Chem 10, PT, PTT, INR, total Bilirubin, albumin qweekly 6. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*3* 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*3* 8. Oxybutynin Chloride 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*3* 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for dry skin, itching. Disp:*1 tube* Refills:*5* 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 tube* Refills:*5* 11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 mdi* Refills:*5* 12. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*3* 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day): 1 tablespoon; as needed for thrush. Disp:*450 ML(s)* Refills:*2* 14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*3* 15. 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:*3* 16. Sucralfate 1 g Tablet Sig: One (1) Tablet PO twice a day: please take 2 hour apart from Levoquin. Disp:*120 Tablet(s)* Refills:*2* 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 18. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*3* 19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 20. Outpatient Lab Work Please check Vancomycin trough level 1/2 hour before daily vancomycin dose in [**3-26**] weeks. Please fax results to Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 2716**] Fax [**Telephone/Fax (1) 1419**] in [**3-26**] weeks. Discharge Disposition: Home With Service Facility: [**Doctor Last Name 35606**]Community Services Discharge Diagnosis: Cirrhosis Hypotension R thigh myositis with abscess Sarcoidosis with pulmonary and liver involvement Restrictive pulmonary disease due to sarcoidosis Chronic renal insufficiency with atrophic R kidney Discharge Condition: stable. Assymptomatic on room air. CPAP at night. Ambulating, tolerating PO. Discharge Instructions: Please take all your medications as prescribed. You will need weekly and then maybe [**Hospital1 **]-weekly lab check: for CBC, Chem 10, liver function tests. You will also need weekly paracentesis taps to remove your ascites fluid. These will be arranged by your [**Hospital1 3390**] in [**Name9 (PRE) 1727**]. Please follow up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) 2716**]. Please remind your [**Last Name (STitle) 3390**] to send Vancomycin level in [**3-26**] weeks to Dr. [**Last Name (STitle) 2716**]. You will also need to complete the Hepatitis B immunization series. Followup Instructions: You have the following prescheduled appointments: You will follow up with Dr. [**Last Name (STitle) 2716**] for your abscess/antibiotic issues: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2161-3-2**] 10:30 Please have your [**Month/Day/Year 3390**] office check vanco level in AM, 1/2 hour before your dose and have it forwarded to Dr. [**Last Name (STitle) 2716**] - Fax [**Telephone/Fax (1) 1419**] in [**3-26**] weeks. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2161-4-15**] 1:00 Transplant surgeon: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-3-19**] 10:00 Please arrange weekly taps and lab monitoring by your [**Month/Day/Year 3390**]: [**Name Initial (NameIs) 3390**]: [**Last Name (LF) **],[**First Name8 (NamePattern2) 177**] [**Doctor Last Name **] [**Telephone/Fax (1) 35602**] Completed by:[**2161-2-6**]

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icd9cm

[ [ [] ] ]

[ "88.64", "54.91", "00.17", "42.33" ]

icd9pcs

[ [ [] ] ]

21123, 21200

10774, 18065

291, 328

21445, 21525

3291, 10751

22216, 23308

2763, 2822

18532, 21100

21221, 21424

18091, 18509

21549, 22193

2837, 3272

233, 253

356, 1967

1989, 2670

2686, 2747

24,443

103,546

9474

Discharge summary

report

Admission Date: [**2128-1-25**] Discharge Date: [**2128-2-3**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: slow responses, right sided weakness Major Surgical or Invasive Procedure: thoracentesis nasogastric tube placement History of Present Illness: 86yo right handed man with PMH significant for uncontrolled HTN and hyperlipidemia who was in his USOH the night of presentation when he walked to the restroom at 8:30pm. He then sat on the couch but when his wife called to him to come to dinner, he was slow to respond, stood but could not walk due to right-sided weakness and his speech was slurred. She gave him a series of commands which he performed but his response time was significantly slowed and she had difficulty understanding his speech. At this point, she called EMS. He is now transferred here after CT of the head at OSH showed a 2.5cm x 2.4cm left thalamic ICH with slight rupture into the ventricle. On presentation to [**Location (un) 620**], he was hypertensive to 231/88 and he was given lopressor, to lower his pressure to the current level of 204/64. Past Medical History: anemia, w/u pending - referred by PCP to hematologist. Wife brought in letter stating the belief that he has a problem with "red cell production" HTN x [**3-18**] yrs, often uncontrolled to 200's hyperlipidemia GERD ankylosing spondylitis L ICA carotid stenosis (complete occlusion) h/o tuberculosis "in his neck", s/p multidrug treatment x 6mos no MI, CAD, or stroke Social History: Lives with his wife, retired SBO. Quit smoking 8yrs ago after 20ppyr history. No other drug use. Family History: brother died of MI at age 70 Physical Exam: Exam on discharge: VS 98.5 204/64 16 98% 97 Gen Lying in bed in NAD CV rrr Pulm ctab Abd soft Ext L foot erythematous and swollen, warm to touch NEURO MS Lying in bed with eyes closed. Opens them to voice. Oriented to hospital and city, states it is [**2128**]. Speech is very dysarthric (from normal baseline) and slow but fluent and without apparent errors. Follows simple commands. Slow response time. CN Pupils anisocoric (b/l cataracts) - L 1.5mm and R 2mm; neither reacts. VFF to confrontation. EOMI including upgaze. Facial sensation intact. R NLF flat. Smile full. Hearing intact. Palate rises symmetrically. Shrug [**4-17**]. Tongue midline Motor normal bulk/tone. +R pronator drift D B T WE FE FF IP Q H DF PF TE Coord Decreased FFM/RAMs on right side, esp compared to non-dominant left side Reflexes 2+ throughout, except for 1+ at ankles. Toe up on R, down on L Sensory intact to all primary modalities throughout, no extinction to LT Gait deferred Pertinent Results: Admission labs: CBC: WBC-3.5* RBC-3.28* Hgb-10.0* Hct-28.9* MCV-88 MCH-30.4 MCHC-34.5 RDW-19.0* Plt Ct-124* Coags: PT-12.1 PTT-31.6 INR(PT)-1.0 Chem10: Glucose-130* UreaN-27* Creat-1.4* Na-133 K-3.9 Cl-102 HCO3-26 Calcium-7.8* Phos-3.8 Mg-2.0 LFTs: ALT-33 AST-38 CK(CPK)-44 AlkPhos-473* TotBili-0.5 Albumin-3.3* Lipase-54 GGT-321* Cardiac enzymes negative x 3 Other labs: proBNP-7299* ABG: Type-ART pO2-100 pCO2-53* pH-7.34* calTCO2-30 Base XS-0 Repeat: Type-ART pO2-103 pCO2-49* pH-7.33* calTCO2-27 Base XS-0 Pleural fluid: WBC-550* RBC-482* Polys-9* Lymphs-72* Monos-0 Meso-1* Macro-18* TotProt-1.9 Glucose-127 LD(LDH)-89 Albumin-1.3 Cholest-37 GRAM STAIN-FINAL; FLUID CULTURE-PENDING; ANAEROBIC CULTURE-PENDING; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PENDING CXR: Right-sided volume loss and right apical pleural thickening, unchanged. Increased opacity involving the right lung may represent scarring versus atelectasis. Comparison with previous radiographs would help to better assess for long-term interval change. Loculated left-sided pleural effusion. Increased air space opacity involving the left mid and lower lung is less conspicuous than seen previously. Diagnostic considerations include asymmetric pulmonary edema and pneumonia. Chest CT: Small right and moderate left pleural effusions, probably not transudate, greater and maybe loculated in the left side. Peripheral consolidation in the right upper lobe, largely scarring, but peribronchial thickening in the lower lobes, could be chronic or subacute infection. Fusiform aneurysmal dilatation of the suprarrenal abdominal aorta. Head CT [**1-25**]: The left thalamic hemorrhage is similar in size, measuring 2.6 x 2.4 cm. There is interval increase in a small amount of intraventricular hemorrhage. There is no new mass effect, hydrocephalus, or major vascular territorial infarction. Slight bulge of normally midline structures to the right is noted. Surrounding osseous and soft tissue structures are again noted. Mucosal thickening is seen in the sphenoid sinus. Repeat [**1-27**]: The left thalamic hemorrhage has decreased in size. There has been an increase in the amount of intraventricular blood. Otherwise, no change. L LENI: No evidence of intraluminal thrombus. Abd u/s: 1. Normal gallbladder and no biliary ductal dilatation. 2. No hydronephrosis. ECHO: The left atrium is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: Impression: 86yo man with PMH significant for HTN presents with dysarthria and subtle right-sided weakness, along with delayed response time cognitively, and was found to have left thalamic bleed with slight extension into the ventricle, likely secondary to hypertension. His hospital course was complicated by multiple medical problems as detailed below. He was eventually transferred to the MICU for hypercarbic respiratory failure, made DNR/DNI and expired. Hospital course: 1. hemorrhage - He was initially admitted to the stroke service for management. His blood pressure was difficult to control (see below). His exam remained unchanged with severe dysarthria, slight right hemiparesis, and waxing and [**Doctor Last Name 688**] mental status most likely secondary to metabolic encephalopathy (see medical problems listed below). 2. hypertension - His blood pressure remained poorly controlled initially: metoprolol was initiated but was ineffective. Hydralazine was added and was initially successful at controlling the blood pressure, but his blood pressure increased again when the metoprolol was weaned. ACE inhibitor was not started due to mild acute renal failure. His HCTZ was continued. 3. respiratory difficulties - Due to his bulbar weakness, the patient was unable to clear his secretions. He was treated with aggressive chest PT and deep suction (which was difficult due to deviated trachea). A CXR on admission showed a loculated pleural effusion on the left, which was not seen on previous x-rays. The pulmonary service was consulted, and performed a diagnostic thoracentesis, which was consistent with a transudative effusion. ECHO was performed, which showed... Diuresis was started. For wheezing, he was treated with albuterol and atrovent. A chest CT showed emphysematous changes. He continued to decline and developed hypercarbic respiratory failure requiring transfer to the MICU. He was made comfort care and expired. 4. elevated alkaline phos - His alk phos remained elevated during his hospitalization. This may be secondary to his ankylosing spondylitis, but was rather high for this explanation. GGT was elevated, but abdominal ultrasound was negative. 5. ?cellulitis - He was initially treated for concern for L foot cellulitis with cefazolin. However, suspicion remained low and the antibiotics were discontinued without effect. LENI was negative. 6. renal failure - He was noted to have rising creatinine and BUN during the beginning of his hospital stay, with low UOP at times. FeNa was 0.22% and urine eosinophils were negative, no hydronephrosis on abdominal ultrasound. He was initially treated with IVF, and when UOP picked up and renal function stabilized, diuresis was started. 7. FEN - He failed his speech and swallow. An NGT was placed by IR on [**1-26**], and tube feeds started [**1-28**]. 8. Code Status - Pt was made DNR/DNI by his family after worsening neurologic deficits manifested in the setting of respiratory failure. He expired at 11:45 pm on [**2128-2-3**]. Medications on Admission: toprol lipitor protonix iron sulfate isosorbide Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure. Stroke. Renal failure. Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A

[ "518.81", "682.7", "272.0", "401.9", "530.81", "584.9", "431", "511.9", "285.9", "515" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

8917, 8926

5792, 6254

297, 339

9014, 9024

2748, 2748

9076, 9082

1713, 1743

8947, 8993

8844, 8894

6272, 8818

9048, 9053

1758, 1758

221, 259

367, 1192

1777, 2729

2764, 3109

1214, 1583

1599, 1697

3121, 5769

27,550

160,966

16879

Discharge summary

report

Admission Date: [**2123-3-24**] Discharge Date: [**2123-3-28**] Date of Birth: [**2046-7-2**] Sex: M Service: [**Doctor Last Name 1181**]/MEDICINE CHIEF COMPLAINT: Drowsiness and altered mental status. HISTORY OF PRESENT ILLNESS: The patient was transferred from the Medical Intensive Care Unit. For the [**Hospital 228**] hospital course in the Medical Intensive Care Unit, please refer to Medical Intensive Care Unit discharge summary. This is a 76 year old male who presented with drowsiness and altered mental status as well as hyperkalemia and hyponatremia. The patient is an 76 year old male with a history of renal cell carcinoma, transitional cell bladder carcinoma admitted to the Emergency Department from home and brought by family for altered mental status where the patient was confused and dizzy in the setting of recent urinary tract infection, diarrhea and decreased p.o. intake. Similar episodes have occurred multiple times over the last year, all requiring hospitalizations with altered mental status that improved with hydration and treatment of underlying infection. This recent episode began two weeks ago. The patient had diarrhea times one week which had abated spontaneously by the time of admission. The patient was also being treated for Stenotrophomonas urinary tract infection on [**2123-3-12**], and then had a ten day course of Bactrim. During this time, the patient had decreased p.o. intake. The patient fell at home and was noted to have slurred speech. There were no other medication changes. The patient continued on his intrathecal Clonidine, Dilaudid and Bupivacaine over this time with increased creatinine also noted from [**2123-2-4**], when his creatinine was 1.3 to 2.3 on [**2123-3-10**]. The patient was to come to the [**Hospital1 346**] on the day of admission to the hospital for a routine magnetic resonance scan to rule out brain metastasis and then was to be admitted to the oncology service. However, the patient was noted to be quite somnolent in the Emergency Department and arterial blood gas was performed that revealed a pH of 7.12, CO2 47 and oxygen 123, bicarbonate 19, felt to be consistent with metabolic acidosis without respiratory compensation and primary respiratory acidosis, felt likely secondary to altered mental status. Medical Intensive Care Unit evaluation was called and the patient was tried on BiPAP. Arterial blood gas post BiPAP was 7.24/44/155. The patient was noted to be more alert and appropriate. He was also given Kayexalate, calcium carbonate, insulin, D50 for elevated potassium. Urine electrolytes were sent. PAST MEDICAL HISTORY: 1. Renal cell carcinoma, noted to be clear cell type, diagnosed in [**2119-11-1**], status post treatment with Gemzar which was completed in [**2122-11-30**]. Otherwise, the patient had metastases to the lungs, lower sacrum, right femur, status post radiation therapy. The patient is also status post a left partial nephrectomy in [**2121-2-28**], and a right partial nephrectomy in [**2120-5-31**]. 2. Transitional cell carcinoma of the bladder with metastasis to the penis, status post radiation therapy. The patient was diagnosed in [**2099**]. Status post treatment with BCG times twelve. 3. Chronic pain, on intrathecal pain pump placed at [**Hospital6 4193**] in [**2122-10-31**], for severe penile pain and internal spasms. 4. Urosepsis in [**2122-11-30**], found to be consistent with Klebsiella. Otherwise, the patient on prior admissions has had Methicillin resistant Staphylococcus aureus urinary tract infection as well. 5. Coronary artery disease, status post coronary artery bypass graft in [**2120-10-31**]. Four vessel disease. Echocardiogram in [**2122-12-31**], revealed left ventricular ejection fraction 60% with 2+ mitral regurgitation and no other abnormalities. 6. Biliary stent placed in [**2120**]. 7. Deep vein thrombosis in the distal right femoral vein external to the right proximal superficial femoral vein, status post inferior vena cava filter. 8. Status post transurethral resection of prostate. 9. History of nephrolithiasis. 10. Suprapubic catheter placement for chronic urinary retention. ALLERGIES: Codeine which causes facial swelling. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg one p.o. once daily. 2. Atenolol 12.5 mg one p.o. once daily. 3. Fluoxetine 30 mg one p.o. once daily. 4. Neurontin 300 mg one p.o. three times a day. 5. Prevacid 30 mg one p.o. once daily. 6. Magnesium Oxide 400 mg one p.o. once daily. 7. Daily multivitamin. 8. Colace 100 mg one p.o. once daily. 9. Cranberry capsules 405 mg one p.o. twice a day. 10. Xylocaine 5% jelly to penis p.r.n. 11, Bupivacaine, Dilaudid and Clonidine pump which is a [**Company 1543**] pump. FAMILY HISTORY: Significant for mother who expired secondary to cervical cancer, father who had malaria and died from ETOH related complications. No other malignancy in the family. SOCIAL HISTORY: The patient has no history of tobacco, no ETOH. He lives with wife and daughter who is nearby. The patient is married, has four children in total. The patient did smoke tobacco in the past, however, but no current use. he is the ex-vice president for a company . LABORATORY DATA: On admission, white blood cell count was 6.3, 57 neutrophils, 26 lymphocytes, 8 eosinophils, hematocrit 34.7, platelet count 199,000. Coagulation studies revealed prothrombin time 13.6, partial thromboplastin time 34.2, INR 1.2. Sodium 123 and his baseline is 129 to 139, potassium 7.0, highest potassium prior to this date was 5.5, chloride 97, bicarbonate 19, blood urea nitrogen 47, creatinine 2.3, anion gap 7.0, glucose 115, calcium 9.6. ANC 4650. Cortisol at 5:00 p.m. is 12.3. AST 26, ALT 32, alkaline phosphatase 90, LDH 175, total bilirubin 0.4 and direct is 0.1, albumin 3.4. Also, please note that the patient's baseline creatinine is 1.3 to 1.5. Subsequent sodium checks in the Emergency Department were as follows: at 5:00 p.m. on date of admission 125 with a potassium of 6.8, at 10:00 p.m. sodium 126 and potassium 6.2, at 12:00 a.m. sodium 128 and potassium 5.7. Arterial blood gases at 9:00 p.m. 7.21/47/123/20, at 10:00 p.m. 7.21/46/130/19 and then BiPAP was initiated and at 12:00 a.m. 7.24/44/150/20. Chest x-ray is significant for bilateral nodular densities consistent with prior metastases, no evidence of congestive heart failure, no infiltrates and possible cardiomegaly. Electrocardiogram was significant for sinus bradycardia at 56 beats per minute which the patient has a history, left atrial abnormality, right bundle branch block, left anterior fascicular block and no evidence of ST-T wave changes. Urine showed [**3-5**] red blood cells, 0-2 white blood cells, few bacteria and no leukocytes and no nitrites. Urine electrolytes are as follows: sodium 125, urine osoms 287. Otherwise, TSH was within normal limits at 0.57. Serum osoms were 281. PHYSICAL EXAMINATION: Temperature was 97.7, blood pressure 140/45, pulse 35 to 47 which is the patient's baseline, respiratory rate 16, oxygen saturation 100% on 100% nonrebreather. Generally, the patient is somnolent but arousable, alert and oriented to person and time but not place. Head, eyes, ears, nose and throat is normocephalic and atraumatic. Extraocular movements are intact. The pupils are equal, round, and reactive to light and accommodation. Sclera anicteric. Mucous membranes are dry. Otherwise, no lesions, exudates or petechiae are noted in the oropharynx. The neck is supple with no jugular venous distention and no lymphadenopathy or evidence of thyromegaly. The heart is regular rate and rhythm, normal S1 and normal S2 with a II/VI systolic murmur. The lungs are clear with bibasilar crackles noted bilaterally. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. Suprapubic catheter is noted and is clean, dry and intact. No surrounding erythema is noted. Extremities are free of any cyanosis, clubbing or edema and are warm to touch. Dorsalis pedis pulses 2+ are palpated. HOSPITAL COURSE: 1. Acidemia - Again felt consistent to metabolic and respiratory acidosis combined. The patient was initially maintained on BiPAP and his mental status improved considerably. He was also hydrated with initially normal saline and later changed to bicarbonate with good response. His acidosis largely corrected by the time of discharge when his bicarbonate was 24. 2. Hyponatremia - The patient's hyponatremia was initially felt likely to prerenal state given that it was improving with intravenous hydration and his urine electrolytes were not consistent with syndrome of inappropriate diuretic hormone picture. Other things that were considered were hypocortisol state with hyponatremia and hyperkalemia, however, the patient had no evidence of hypotension or other findings of hypocortisol state. Then hypoaldosteronism was considered. The patient's cortisol levels were sent off and his cortisol levels random and after Cortrosyn stimulation test were all above 20 and felt not to be consistent with a hypocortisol state. Hypoaldosteronism was entertained and aldosterone level was sent and was pending at the time of this dictation. The endocrinology service was consulted and their differential diagnosis was wide but included hypocortisol state including hypoaldosteronism state. The patient did have a random cortisol checked and Cortrosyn stimulation test. Again, his Cortrosyn stimulation test revealed that his cortisol levels were above 20. The endocrinology service felt that this effectively ruled out hypocortisol state and attention should be turned to hypoaldosteronism state, possible type four RTA. The patient did undergo a magnetic resonance scan of his abdomen with particular attention paid to his adrenals which was done prior to discharge but was pending by the time of this dictation. The reason for obtaining this magnetic resonance scan was that the patient did have a history of bladder cancer as well as renal cell carcinoma and it is conceivable that he could have sustained metastatic disease to his adrenal gland. 3. Hyperkalemia - Again, this is felt secondary to a combination of acute renal failure acidosis. His potassium improved considerably with hydration and p.r.n. Kayexalate and insulin and D50. Electrocardiogram was checked and revealed no evidence of hyperkalemia associated electrocardiographic changes. Acute renal failure was nonoliguric. The patient's creatinine improved with intravenous hydration. Urine eosinophils were checked and were negative. Again, it was felt likely secondary to prerenal state. The patient's renal function improved considerably with intravenous hydration and by the date of discharge, the patient's creatinine had reduced to 1.7. 4. Acute renal failure - The renal service was consulted and felt that hypoaldosteronism state was definitely on the differential diagnosis and aldosterone was sent off but again was pending at the time of discharge. The patient's acute renal failure, however, did respond to intravenous fluids and had almost normalized by the time of discharge. 5. Altered mental status - Again, somnolence was felt to be secondary to acute renal failure, elevated blood urea nitrogen, acidemia, narcotics. The patient's blood cultures were sent and were no growth to date by the time of discharge. The patient had a magnetic resonance scan of his brain which was performed by the time of discharge but not read. Otherwise, the patient's mental status improved considerably and he was at his baseline by the time of discharge. 6. Code Status - The patient was a full code. Communication was with the patient's wife and daughter. The patient's other medical problems remained stable during this hospitalization. DISCHARGE DIAGNOSES: 1. Renal failure. 2. Transitional cell carcinoma. 3. Renal cell carcinoma. 4. Hyponatremia. 5. Hyperkalemia. 6. Metabolic and respiratory acidosis. 7. Altered mental status. FOLLOW-UP PLANS: The patient had an appointment with Dr. [**Last Name (STitle) **] from the Department of Hematology/Oncology on [**2123-4-7**], at 1:30 p.m. He had an appointment with Myrielle [**Doctor Last Name **], R.N. at the [**Hospital Ward Name 23**] Hematology/Oncology Center on [**2123-4-7**], at 2:00 p.m. The patient was also to have a potassium and sodium drawn on Monday, [**2123-3-29**], or Tuesday, [**2123-3-30**], and the results were to be faxed to Dr.[**Name (NI) 47540**] office for interpretation. Tests pending at the time of discharge include aldosterone and magnetic resonance scan of head and abdomen. CONDITION ON DISCHARGE: Stable. He was ambulating and tolerating p.o., urinating and having bowel movements without difficulty. His altered mental status, metabolic and respiratory acidosis, hyperkalemia, hyponatremia had resolved. The patient's renal function with creatinine was nearly at baseline by the time of discharge. DISCHARGE STATUS: The patient will be discharged to home with VNA services and close follow-up. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg one p.o. once daily. 2. Lansoprazole 30 mg one p.o. once daily. 3. Fluoxetine 10 mg three tablets p.o. once daily. 4. Docusate 100 mg one p.o. twice a day. 5. Lidocaine HCl 5% ointment apply to mucous membranes twice a day p.r.n. 6. Kayexalate 10 mg one p.o. q.o.d. 7. Nifedipine 30 mg tablet sustained release one tablet p.o. once daily. 8. Magnesium Oxide 400 mg one p.o. once daily. 9. Acetaminophen 325 mg one to two tablets q4-6hours as needed for pain. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2123-4-16**] 10:06 T: [**2123-4-18**] 13:15 JOB#: [**Job Number 47541**]

[ "414.00", "276.5", "276.1", "V45.81", "584.8", "V10.51", "276.4", "V10.53", "276.7" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

4787, 4954

11853, 12035

13123, 13876

4273, 4770

8097, 11832

6970, 8080

12053, 12668

182, 221

250, 2633

2655, 4247

4971, 6947

12693, 13097

77,037

147,717

34978

Discharge summary

report

Admission Date: [**2185-8-7**] Discharge Date: [**2185-8-12**] Date of Birth: [**2164-11-10**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Vancomycin Attending:[**First Name3 (LF) 5569**] Chief Complaint: N/V, poor PO intake Major Surgical or Invasive Procedure: Kidney Biopsy Received 2 units RBCs History of Present Illness: 20F with ESRD [**1-24**] atrophic kidneys now s/p recent cadaveric renal tx on [**2185-7-27**]. Post-op course c/b HTN and N/V. Patient was hypertensive in the 180-190's and experienced signficant nausea and emesis while in the SICU. After her BP was better controlled, her N/V stopped. The rest of her post-operative course was uncomplicated. She is now coming to the ED after experiencing N/V. The nausea started 8 AM today, followed by emesis (breakfast the light green yellowish fluid). Still passing gas, normal bowel movements. No f/c. No dysuria. Urine output is brisk and clear, not concentrated per patient. Because of the emesis, she has not been able to keep any of her medications down except for the Tacrolimus. She has been nauseated all day and continues to be even with Zofran. She currently denies CP or SOB. No HAs or difficulties with vision. Her BP in the ED is 200/110. Past Medical History: - hypertension - ovarian cyst (s/p dermoid ovarian cystectomy) - AVF creation - congenitally small kidneys, right smaller than left Social History: Lives at home with parents, single, currently not working. Denies smoking, ETOH, or illicits. No herbal medications. Family History: Her father had a CABG, diabetes, hypertension, hypercholesterolemia. Mother died of breast cancer. Physical Exam: 99.2 79 200/103 16 100 Anxious, A+OX3 RRR, [**12-28**] soft systolic murmur at LLSB CTAB Soft, NT/ND, incision is c/d/i, some eechymosis around the incision, previous JP site is c/d/i no c/c/e noted Labs: WBC: 10.8 Hct: 30.5 Plt: 362 Chem 10: 137/5.1/107/18/41/3.1 (4.9)/101 Lactate: 0.9 EKG: NSR @ 82, no significant ST or Q waves seen (compared to pre-op). Pertinent Results: [**2185-8-12**] 06:15AM BLOOD WBC-9.2 RBC-2.51* Hgb-7.8* Hct-23.5* MCV-94 MCH-30.9 MCHC-32.9 RDW-13.1 Plt Ct-244 [**2185-8-11**] 05:40PM BLOOD PT-14.0* PTT-25.8 INR(PT)-1.2* [**2185-8-12**] 06:15AM BLOOD tacroFK-7.3 [**2185-8-7**] 05:55PM BLOOD Glucose-101 UreaN-41* Creat-3.1*# Na-137 K-5.1 Cl-107 HCO3-18* AnGap-17 [**2185-8-12**] 06:15AM BLOOD Glucose-92 UreaN-21* Creat-3.0* Na-137 K-5.0 Cl-110* HCO3-18* AnGap-14 Brief Hospital Course: 20F s/p cadaveric renal transplant [**2185-7-27**] readmitted with persistent N/V likely secoondary to HTN. She was admitted to SICU where she was started on a Labetolol drip with some improvemet of her BP. A Clonidine patch was started to achieve better BP control. She was also bolused with IV fluids. Her home meds were resumed including her immunosuppressive meds. A renal transplant duplex good resistive index, and evidence of good venous flow in the transplant renal vein. Good flow was identified in the transplant renal artery without focal abnormality. She was transferred out of the SICU afer 3 days. SBP was down to the 130-140 range. A renal transplant biopsy was performed on [**8-11**] for creatinine that was stable at 3.1-3.2. Biopsy was reported to be negative for rejection. Hematocrit decreased to 23.5 on [**8-12**] from 25.6 on [**8-11**]. 2 units of PRBC were administered on [**8-12**]. Prograf dose was adjusted while in hospital based on trough levels. She was discharged to home on [**8-12**] in stable condition with creatinine of 3.0 voiding 2600cc/day of urine. The biopsy site was without bleeding. Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 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. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*1* 11. 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* 12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 13. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). Disp:*4 Patch Weekly(s)* Refills:*2* 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a day: Starting AM [**8-13**]. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO once for 1 doses: PM dose 8/21. Discharge Disposition: Home Discharge Diagnosis: s/p kidney transplant readmitted with hypertension, nausea/vomiting Prograf toxicity Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding, the clips are out, the steri strips will fall off on their own Labwork every Monday and Thursday per transplant clinic guidelines Drink enough fluids to keep your urine light yellow in color No driving if taking narcotic pain medication You may shower, pat incision dry Monitor Blood pressures and call if consistently greater than 140 No heavy lifting You do not need to restart Coumadin. Aspirin on hold until clinic appointment Followup Instructions: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-8-18**] 8:40 [**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2185-8-18**] 10:00 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-8-25**] 10:40 Completed by:[**2185-8-15**]

[ "401.9", "995.29", "E933.1", "787.01", "V42.0" ]

icd9cm

[ [ [] ] ]

[ "55.23" ]

icd9pcs

[ [ [] ] ]

6147, 6153

2546, 3681

325, 363

6282, 6289

2104, 2523

7016, 7375

1605, 1707

4906, 6124

6174, 6261

3707, 4883

6313, 6993

1722, 2085

265, 287

392, 1298

1320, 1454

1470, 1589

12,836

161,639

15658

Discharge summary

report

Admission Date: [**2144-10-26**] Discharge Date: [**2144-11-30**] Date of Birth: [**2144-10-26**] Sex: M Service: NEONATOLOGY This is a discharge summary covering the period of [**10-26**] to [**2144-11-30**] HISTORY: This is the 980 gram product of a 28 [**1-23**] week twin gestation, born to a 27-year-old GI P0-II mother. Maternal RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B strep unknown. This was a spontaneous monochorionic diamniotic twin gestation. Ultrasound at 22 weeks showed a size discordance, attributed to twin-twin transfusion. Subsequent ultrasound showed increasing oligohydramnios, but biophysical profiles were acceptable. The mother received steroid treatment. The children were Apgars of 7 at one minute and 8 at five minutes. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The child was intubated initially and received surfactant, rapidly weaned to CPAP and then nasal cannula. After an episode of sepsis, the child was reintubated, but then rapidly weaned back to nasal cannula. He is currently on approximately 50-75cc of 100% low flow, on caffeine. 2. Fluids, electrolytes and nutrition: The child was initially started on intravenous fluids. The feedings were advanced. He is currently tolerating full feeds of 150 cc/kg of 28 calorie formula with ProMod. 3. Cardiovascular: The patient initially required some blood pressure support on dopamine. He was rapidly weaned off the dopamine. He did receive one course of indomethacin for a patent ductus. He has subsequently not required any blood pressure support. 4. Infectious Disease: Several days into his hospital course, he was noted to have increased spells. CBC and blood culture were obtained. The culture grew staphylococcus epidermidis after 24 hours. At that time, he had a PICC in place for less than 24 hours, and had been on ampicillin and gentamicin. He was changed over to vancomycin and gentamicin, and immediately improved clinically, however, his blood cultures continued to grow staphylococcus epidermidis on subsequent days despite the PICC removal. He completed his course of antibiotics on DOL#24, cultures remained completely negative. 5. Neurology: He had a head ultrasound which was normal on day of life 3, 10 and 31. He did receive some blood transfusions for anemia. FOLLOW-UP He will require a ROP screen on [**2144-12-2**] MEDICATIONS Ferrinsol 0.15cc po/pg qd Vitamin E 5 IU po/pg qd Caffeine citrate 12.5mg po/po qd CONDITION AT THE TIME OF DICTATION: Stable DISPOSITION: [**Hospital6 33**], Level III NICU. DIAGNOSIS: 1. Prematurity 2. Apnea of prematurity 3. Staphylococcus epidermidis sepsis 4. Normal HUS DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477 Dictated By:[**Name8 (MD) 45197**] MEDQUIST36 D: [**2144-11-13**] 19:11 T: [**2144-11-14**] 00:12 U: [**2144-11-30**] 09.30 JOB#: [**Job Number 26935**]

[ "765.13", "038.10", "771.81", "V31.01", "774.2", "770.89", "770.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "03.31", "96.6", "96.04", "99.83" ]

icd9pcs

[ [ [] ] ]

839, 2965

65,862

172,640

36485

Discharge summary

report

Admission Date: [**2122-12-30**] Discharge Date: [**2123-1-4**] Date of Birth: [**2044-4-1**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Metronidazole / Tetracycline Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional dyspnea Major Surgical or Invasive Procedure: [**2122-12-30**] - Aortic Valve Replacement History of Present Illness: This is a 78 year old male with known aortic stenosis. Prior to knee replacement surgery, he underwent cardiology evaluationand an echocardiogram demonstrated significant progression of his aortic stenosis. Given the above finding, he was referred for aortic valve replacement. His current symptoms include exertional dyspnea. Past Medical History: - Dyslipidemia - Severe COPD on chronic oxygen therapy at home - Obesity - Sleep Apnea - History of Stroke, Cerebella infarct - Carotid Disease - Osteoarthritis - Memory Disorder - Chronic Venous Insufficiency - Macular Degeneration - History of Kidney Stones - History of Ulcerative Colitis - Basal Cell Carcinoma s/p multiple lesion removal Social History: Last Dental Exam: partial dentures, last seen 4 yrs ago Lives with: Wife, in [**Name2 (NI) 3915**] Occupation: Retired Military Tobacco: Quit 15 years ago. [**3-9**] PPD for 50 years ETOH: Quit 15 years ago Family History: Denies premature coronary artery disease Physical Exam: admission: Pulse: 91 Resp: 20 O2 sat: 93% B/P Right: 158/58 Height: 69 inches Weight: 244lbs General: Well-developed obese male in no acute distress who uses motorized wheelchair for transportation Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] 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 2+ with severe venous insufficiency changes bilateral lower legs Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 1+ Left: 1+ DP Right: np Left: np PT [**Name (NI) 167**]: np Left: np Radial Right: 2+ Left: 2+ Carotid Bruit Right: trans m Left: trans m Pertinent Results: [**2122-12-30**] ECHO PRE BYPASS The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 1.0cm2). Trace to mild aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**12-6**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being atrially paced. There is normal right ventricular systolic function. The left ventricle displays borderlinenormal systolic function with an ejection fraction of 50%. There is a bioprosthesis in the aortic position. It appears well seated. No aortic regurgitation is definitively seen but can not completely rule out a small paravalvular leak. The leaflets can not be seen. The peak gradient through the aortic valve was 22 mmHg with a mean gradient of 17 mmHg at a cardiac output of about 5.5 liters/minute. The effective valve orifice area was 1.7 cm2. The mitral regurgitation is improved - now mild. The tricuspid regurgitation is also improved - now mild to moderate. An echodensity consistent with a hematoma is seen in the aortic root adjacent to the left atrium. Now blood flow can be demonstrated within it. The thoracic aorta appears intact after decannulation. [**2123-1-3**] 05:05AM BLOOD WBC-8.6 RBC-2.35* Hgb-7.9* Hct-24.0* MCV-102* MCH-33.7* MCHC-33.0 RDW-15.7* Plt Ct-155 [**2123-1-2**] 04:03AM BLOOD WBC-11.2* RBC-2.55* Hgb-8.7* Hct-26.4* MCV-104* MCH-34.0* MCHC-32.8 RDW-16.0* Plt Ct-143* [**2123-1-3**] 05:05AM BLOOD UreaN-32* Creat-1.0 Na-139 K-4.5 Cl-104 [**2122-12-30**] 01:57PM BLOOD UreaN-14 Creat-0.6 Na-139 K-4.2 Cl-111* HCO3-25 AnGap-7* [**2122-12-31**] 02:30AM BLOOD Type-ART Temp-36.1 Rates-/22 FiO2-50 pO2-65* pCO2-34* pH-7.37 calTCO2-20* Base XS--4 Intubat-NOT INTUBA Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2122-12-30**] for surgical management of his aortic valve disease. He was taken to the Operating Room where he underwent replacement of his aortic valve with a tissue prosthesis. Please see operative note for details. Postoperatively he was taken to the intensive care unit in stable condition for invasive monitoring. Within several hours he was weaned from sedation, awoke neurologically intact and was extubated. On postoperative day one, aspirin, beta blockade and diuretics were resumed. Later on postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. Chest tubes and epicardial pacing wires were removed per protocol. His preoperative steroid doses and Methadone for chronic myalgias were resumed. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The remainder of his post-op course was uneventful and he was discharged to rehab on post-operative day 5 with the appropriate medications and follow-up appointments. He was discharged to [**Location (un) 14468**] Nursing and Rehabilitation in [**Location (un) 1456**] for further recovery prior to going home. Medications on Admission: Prednisone 5mg daily, Simvastatin 20mg daily, Protonix 40mg daily, Advair 250/50 one inhalation twice daily, Singulair 10mg daily, Albuterol MDI prn, Lidoderm patchm, Mercaptopurin 50mg twice daily, Methadone 10mg twice daily, Folic acid 1mg daily, Ammonium lactat cream, Asparin 81mg daily, Acetaminophen prn, Calcium carbonate 500mg daily, Vitamin B-12 500mg daily Discharge Medications: 1. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. folic acid 1 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): to affected areas. 9. methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**5-14**] Puffs Inhalation Q6H (every 6 hours). 13. pneumococcal 23-valps vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection NOW X1 (Now Times One Dose). 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 16. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 18. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: Aortic Valve Stenosis s/p Aortic Valve replacement dyslipidemia chronic obstructive pulmonary disease on oxygen therapy at home Obesity obstructive Sleep Apnea s/p Stroke- Carotid Disease Osteoarthritis Chronic Venous Insufficiency Macular Degeneration History of Kidney Stones History of Ulcerative Colitis s/p multiple lesion removalof basal cell carcinomas Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema -trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**2123-1-28**] at1:15pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] on [**2-1**] at 1:30pm Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 82651**] ([**Telephone/Fax (1) 79695**]in [**3-9**] 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:[**2123-1-4**]

[ "V58.65", "496", "V46.2", "272.4", "459.81", "V12.54", "V15.82", "278.01", "327.23", "362.50", "715.96", "285.9", "433.10", "V85.36", "396.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8280, 8391

4717, 5997

327, 372

8795, 8973

2231, 4694

9861, 10454

1335, 1377

6414, 8257

8412, 8774

6023, 6391

8997, 9838

1392, 2212

269, 289

400, 728

750, 1095

1111, 1319

81,068

189,813

36843

Discharge summary

report

Admission Date: [**2180-2-18**] Discharge Date: [**2180-2-18**] Service: NEUROSURGERY Allergies: Percocet / Codeine Attending:[**First Name3 (LF) 1271**] Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 87 yo RHM with hx of HTN, CAD, COPD requiring home O2 and recently diagnosed Afib on Coumadin who was found down at home around 9pm. Per son who is at bedside, patient was seen normal 5~10 minutes prior to being found down in his room next to his bed on his back. He went up to his room close to 9 pm and when his son went to [**Hospital1 **] him good night, he found his father on the floor with eyes semi-opened but no responding and snorting loudly. EMS was called and upon their arrival, patient was found to have poor respiratory effort hence he was intubated at the scene then taken to [**Hospital3 **]where he was noted to have bilateral SDH with L>R and INR of 3.7 hence transferred him after 10mg of IV Vit K. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: - AAA s/p repair with Aortoiliac stent graft repair of abdominal aortic aneurysm. -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none until day of admission -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - COPD - Peripheral Vascular Disease, s/p aortoiliac graft Social History: -Tobacco history: 1 ppd x 40 years -ETOH: 3 cocktails per week, no history of more -Illicit drugs: none -Lives at home alone, although he has recently been staying with his son. His wife is in a nursing home for dementia. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: O: T: 97 BP: 144/83 HR: 73 R 16 O2Sats 100% intubated Gen: Sedated and intubated. HEENT: Pupils: R>L and non-reactive Neck: in [**Location (un) 2848**]-J collar Lungs: Clear Cardiac: Irregularly irregular - very faint. Abd: Soft, NT, BS+ Extrem: 1+ dorsalis pedis. Neuro: Mental status: Intubated and sedated. No response to verbal or noxious stim. Cranial Nerves: Pupils are asymmetric with R > L and both unreactive. Unable to test OCR due to hard cervical collar. No blinking to visual threat. +Gag with suction. Face appears symmetric. Motor: Normal bulk and tone bilaterally. No movements even to noxious stim. Sensation: No response to noxious stim. Reflexes: B T Br Pa Ac Right 1 0 1 0 0 Left 1 0 1 0 0 Toes downgoing bilaterally Pertinent Results: [**2180-2-18**] 12:30AM BLOOD WBC-8.0 RBC-4.03* Hgb-11.2* Hct-34.5* MCV-86 MCH-27.8 MCHC-32.4 RDW-15.2 Plt Ct-171 [**2180-2-18**] 12:30AM BLOOD PT-22.5* PTT-25.8 INR(PT)-2.1* [**2180-2-18**] 12:30AM BLOOD Glucose-192* UreaN-33* Creat-1.2 Na-148* K-3.4 Cl-106 HCO3-32 AnGap-13 [**2180-2-18**] 12:30AM BLOOD ALT-19 AST-34 CK(CPK)-53 AlkPhos-57 TotBili-0.3 [**2180-2-18**] 12:30AM BLOOD Lipase-84* [**2180-2-18**] 12:30AM BLOOD cTropnT-0.03* Brief Hospital Course: The patient was not responsive to verbal or noxious stimuli. There is no spontaneous movements. His pupils are asymmetric and unreactive bilaterally. He does have gag but no other brainstem function found. There is no movement even to noxious stim. There is biceps and [**Last Name (un) **] reflexes with down going toes. Patient had repeat head CT that shows worsened SDH with subfalcine herniation,transtentorial and uncal herniation. Given the hemorrhage, most likely traumatic exacerbated by anticoagulation. Given the severity of the hemorrhage with his mass effect/herniation and poor exam, prognosis grim and surgical and medical intervention appear futile at this point. Outcomes was discussed with the family and given patient's wishes, goal of care is to maximize comfort. Patient also cleared per trauma while in ED. He was admitted to the neurosurgery service, he was extubated and quickly passed away. Medications on Admission: . Coumadin 2. Simvastatin 40mg daily 3. Toprol XL 50mg daily 4. Lisinopril 5mg daily 5. Lasix 40mg daily 6. Advair 100/50 [**Hospital1 **] 7. Spiriva 18mcg daily 8. MVI 9. Alprazolam 0.25mg [**Hospital1 **] 10. Albuterol PRN Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Subdural Hematoma Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: n/A [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2180-2-18**]

[ "427.31", "348.4", "428.0", "414.01", "428.32", "348.5", "401.9", "496", "E888.9", "V46.2", "432.1", "272.4", "V45.82", "790.92", "E934.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4229, 4238

3006, 3925

248, 254

4299, 4308

2543, 2983

4360, 4489

1650, 1765

4201, 4206

4259, 4278

3951, 4178

4332, 4337

1780, 2053

1120, 1300

191, 210

282, 1018

2147, 2524

2068, 2131

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Discharge summary

report

Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-20**] Date of Birth: [**2057-9-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5755**] Chief Complaint: confusion and left sided weakness Major Surgical or Invasive Procedure: central line History of Present Illness: 81 yo female with history of CAD, DM, severe PVD sent from NH with MS changes and new left sided weakness. She was discharged to the NH after a recent stay at [**Hospital1 18**] for pneumonia, on [**Doctor First Name **] service. On Levo/Flagyl for UTI from NH. Slightly unclear if still on these from [**Name (NI) **]. According to notes at baseline she is slightly confused, but was non-verbal on EMS arrival. She was found by EMS lying down unable to ambulate. . She was recently admitted [**Date range (1) 55077**] for L fem endarterectomy and patch angioplasty with L fem-[**Name (NI) 55075**] PTFE jump graft([**6-22**]) then Left [**Name (NI) 55076**] PTFE graft, removal of fem-veingraft PTFE graft, ligation of fem-AT vein graft [**6-23**]. She was started on levo/flagyl [**6-24**] for pneumonia and was discharged to complete 2 week course of levofloxacin/flagyl. She was recommended to go to rehab but her family preferred to take her home. She returned [**7-2**] as her family was unable to care for her at home and was discharged to rehab [**7-3**]. . In the ED her vitals were Temp 99.8, HR 60, BP 103/47, RR 20, 100% RA. She was found to smell of ketones. While in the ED her BP dropped to 74/27 but responded to IV fluids. She was found to have a glucose of "critically high". Her NA 128 K 6.8, BUN/creat 86/2.5, A right IJ was placed. She was treated with Vancomycin, Ceftriaxone. She was started in an insulin drip, IV fluids (2L recorded). Given Calcium Gluconate, and Bicarb and written for kayaxlate which was never given. In the ED she had minimal urine output. A head CT showed no evidence of bleed. CXR was unremarkable. She was tranfered to the [**Hospital Unit Name 153**] for further care. Past Medical History: # Diabetes Mellitus # Hypercholesterolemia # Coronary artery disease # Hypertension # Chronic renal insufficiency, baseline Creat 0.9-1.0 # Peripheral vascular disease s/p Left common femoral and profunda femoralendarterectomies with Dacron patch angioplasty and left PTFE jump graft from common femoral artery to pre-existing fem-AT bypass [**2139-6-22**] and then Thrombectomy of left profunda femoral artery and common femoral artery and bypass graft to the anterior tibial artery, transposition of proximal PTFE graft off of the common femoral artery over to the profunda femoral artery on the left side, removal of distal PTFE graft, ligation of vein graft to the left anterior tibial artery [**2139-6-23**] Social History: was admitted from [**Hospital **] Health Center NH. Living at home previously. Cantonese speaking only. Family History: Noncontributory Physical Exam: Gen: female in NAD HEENT: MM dry, OP clear, right and left pupils surgical Neck: No LAD, no JVD, right IJ in place Lungs: limited exam, scattered crackles CV: RRR, nl S1S2, no murmers Abd: obese, soft, non-tender, non-distended, positive BS Ext: no edema, left extremity with surgical scar exuding old blood, no erythema or pus, left sided groin surgical scar with no erythema or exudate, left extremity cold with non-doplerable pulses, doplerable pulses on the right, left buttock stage 2 decub doesn't appear infected. Skin tenting, erythema over perineum. Neuro: pupils surgical, muscle twitching, unable to get good DTRs, minimal [**Name2 (NI) **] to pain, no grimace Pertinent Results: [**2139-7-14**] 02:40PM WBC-12.2* RBC-4.39# HGB-13.5# HCT-44.2# MCV-101*# MCH-30.7 MCHC-30.5* RDW-16.3* [**2139-7-14**] 02:40PM NEUTS-94.2* BANDS-0 LYMPHS-3.0* MONOS-2.2 EOS-0.3 BASOS-0.3 [**2139-7-14**] 02:40PM PLT SMR-HIGH PLT COUNT-468* . [**2139-7-14**] 03:20PM PT-11.8 PTT-40.6* INR(PT)-1.0 . [**2139-7-14**] 03:20PM GLUCOSE-872* UREA N-82* CREAT-2.5*# SODIUM-129* POTASSIUM-6.8* CHLORIDE-88* TOTAL CO2-6* ANION GAP-42* [**2139-7-14**] 03:20PM ALBUMIN-3.3* CALCIUM-9.0 PHOSPHATE-7.6*# MAGNESIUM-3.5* . [**2139-7-14**] 03:20PM ALT(SGPT)-12 AST(SGOT)-8 CK(CPK)-51 ALK PHOS-80 AMYLASE-73 TOT BILI-0.4 [**2139-7-14**] 03:20PM LIPASE-56 . [**2139-7-14**] 03:20PM CK-MB-NotDone cTropnT-0.01 [**2139-7-14**] 09:44PM CK-MB-7 cTropnT-0.07* [**2139-7-15**] 09:00AM CK-MB-7 cTropnT-0.21 [**2139-7-15**] 04:00PM CK-MB-7 cTropnT-0.15 . [**2139-7-14**] 04:08PM LACTATE-2.4* . [**2139-7-14**] 06:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2139-7-14**] 06:30PM URINE RBC->50 WBC-21-50* BACTERIA-MANY YEAST-MANY EPI-0-2 . BLOOD CX [**2139-7-14**]: NO GROWTH URINE CX [**2139-7-19**]: PENDING C DIFF: NEGATIVE X 1 . [**2139-7-14**] 6:30 pm URINE Site: CATHETER **FINAL REPORT [**2139-7-15**]** URINE CULTURE (Final [**2139-7-15**]): YEAST. >100,000 ORGANISMS/ML.. . ekg [**2139-7-15**]: Sinus rhythm Consider prior inferior myocardial infarction Nonspecific low amplitude anterolateral T wave changes Since previous tracing of [**2139-6-28**], further T waves changes present . NON-CONTRAST HEAD CT [**2139-7-14**]: There is no evidence of intracranial hemorrhage, shift of normally midline structures, or major vascular territorial infarct. There is mild asymmetry to the ventricles with slight prominence of the left ventricle. Moderate-to-severe periventricular hypoattenuation is consistent with chronic microvascular ischemic changes. There is no evidence of major vascular territorial infarct. Faint lacunar infarcts are seen in the left caudate and internal capsule. Osseous structures and soft tissues are unremarkable. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial hemorrhage or major vascular territorial infarct. If there is strong suspicion for a CVA, MRI with DWI is more sensitive for acute ischemia. . BRAIN MRI [**2139-7-17**]: Diffusion images demonstrate subtle areas of increased signal in both external capsules as well as in the left periventricular region which demonstrate increased signal on ADC map indicative of chronic changes and T2 shine through. There is no evidence of a slow diffusion identified to indicate acute infarct. There is no mass effect, midline shift or hydrocephalus. Moderate brain atrophy is seen. There are diffuse periventricular and subcortical white matter hyperintensities predominantly in the frontal lobe indicative of severe changes of small vessel disease. IMPRESSION: Severe changes of small vessel disease. Subtle areas of increased signal on diffusion images appear to be due to T2 shine through. Moderate brain atrophy. MRA OF THE HEAD: The head MRA demonstrates atherosclerotic disease affecting the distal vertebral arteries, proximal basilar artery and left middle cerebral artery with irregularity of the flow signal. There is an area of narrowing at the distal right vertebral artery which appears to be due to greater than 50% narrowing of the vertebral artery. No evidence of occlusion seen in the arteries of anterior and posterior circulation. IMPRESSION: Atherosclerotic disease affecting both cavernous carotids, left middle cerebral artery and vertebral and proximal basilar arteries as described above. Probable stenosis of distal right vertebral artery near its junction with the vertebrobasilar artery. . CHEST, ONE VIEW [**2139-7-14**]: Comparison with multiple previous examinations, including [**2136-5-23**] and [**2139-6-27**]. New right IJ central venous line with the tip at the cavoatrial junction. Thickening in the right lung apex, unchanged since the last exam. Linear atelectasis at the left lung base. Lungs otherwise appear clear. Cardiac, mediastinal, and hilar contours are unchanged. Midline sternotomy wires and evidence of previous CABG. No pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality. Successful right IJ line placement. . US EXTREMITY NONVASCULAR LEFT [**2139-7-15**] Focused ultrasound scanning was performed in the left lower extremity over the patient's known fluid collections in the left thigh and left groin. Between the patient's two suture sites in the left lateral thigh is an ovoid fluid collection measuring 3.7 x 1.1 x 1.5 cm, which contains some heterogeneous internal echogenicity most consistent with hematoma. Color Doppler evaluation demonstrates no internal flow within this collection. Left inguinal collection is similar in appearance, measuring 4.0 x 1.6 x 3.1 cm, with heterogeneous internal echogenicity, also most consistent with hematoma. Note is also made of several prominent lymph nodes in the left groin. IMPRESSION: Two fluid collections in the left lower extremity, one overlying the left thigh laterally, and second in the left groin, with son[**Name (NI) 493**] features most consistent with hematoma. . Brief Hospital Course: # Diabetic ketoacidosis: Likely precipitant = lack of insulin administration. No underlying infection (urine cx, cxr, wound site evaluation/ultrasound without evidence of infection) so antibiotics d/c after 48 hours, no MI, and no other precipitant identified. Gap closed on an insulin gtt in the ICU and volume restored with aggressive IVF. Patient was restarted on a [**Hospital1 **] insulin 70/30 regimen, similar to her home doses. On the day of discharge, her afternoon blood sugar was still in the 200's so her AM 70/30 dose was increased to her home dose. Her home PM dose has not yet been reached (25 units qpm) but her AM blood sugars have been well controlled. Continue to check fingerstick blood sugars [**Hospital1 **] and cover with sliding scale humalog prn. . # Delirium: Patient confused on admission. Likely toxic metabolic related to hyperglycemia + uremia. She is now alert and oriented x 3. Head CT and MRI were done given reports of left sided weakness. These show definite vascular disease but no evidence for acute stroke. She does have chronic microvascular disease. Again, no evidence found for an underlying infection, as a possible contributor. . # Acute renal failure: Likely prerenal due to hyperglyceia/DKA. Resolved with IVF. . # CAD: Troponin leak but in the setting of acute renal failure and MB flat. EKG unremarkable. No complaints of chest pain. Stress [**3-18**] without inducible ischemia. Patient continued on her ASA, plavix, statin (dose doubled this admission for LDL 79), BB, and [**Last Name (un) **]. She has evidence of diastolic CHF on ECHO from [**3-18**] but is euvolemic. Recommend increasing valsartan and metoprolol to her home doses, as needed for goal sbp < 130 and dbp < 80. . # PVD: No acute issues. Wounds clean/dry/intact. Vascular saw patient in house and recommend continuing dry dressing to left groin and packing left thigh wound with wet to dry [**Hospital1 **] with overlying dry dressing. She can weight bear on her left lower extremity, as tolerated. Ultrasound only showed stable hematoma at the wound sites. Dr. [**Last Name (STitle) **] from vascular aware patient has only intermittent dorsalis pedis pulses in the left foot but is deferring any further intervention for the time being. He will see her in follow-up outpatient to discuss continued managment. . # PPx: Heparin SC, PPI, bowel regimen, wound care (see nursing notes and page 1) . # FEN - monitor lytes as above. . # Contact: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13260**] Cell [**Telephone/Fax (1) 55078**] . # DNR/DNI (changed in ED) . # [**Hospital 3671**] Rehab, [**Location (un) 1514**], Ma Medications on Admission: Aspirin 81 mg PO DAILY Metoprolol 50 mg PO BID Atorvastatin 20 mg PO DAILY Pantoprazole 40 mg PO Q24H Bisacodyl 10 mg PO/PR DAILY:PRN Clopidogrel Bisulfate 75 mg PO DAILY Docusate Sodium (Liquid) 100 mg PO BID Senna 1 TAB PO BID:PRN Percocet prn Valsartan 320 mg PO DAILY Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): until ambulating regularly. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp < 110. 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp < 110 or hr < 60. 11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: max 3 grams per day. 12. insulin 70/30 38 units sq qam 13. insulin 70/30 22 units sq qpm 14. humalog insulin sliding scale 1 injection sq [**Last Name (LF) **], [**First Name3 (LF) **] insulin sliding scale Discharge Disposition: Extended Care Facility: [**Hospital 3671**] Rehabilitation & Nursing Center - [**Location (un) 1514**] Discharge Diagnosis: primary: diabetic ketoacidosis delirium stage 2 sacral decubitus ulcer secondary: peripheral vascular disease coronary artery disease hypertension hypercholesterolemia Discharge Condition: good: hemodynamically stable, afebrile off antibiotics, blood sugars in 200s Discharge Instructions: Please monitor for temperature > 101, redness/pain/drainage at surgical wounds, change in mental status, or other concerning symptoms. Followup Instructions: Please schedule follow-up with patient's primary care doctor within 1 week of discharge from rehab. Phone: [**Telephone/Fax (1) 8236**]

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36143

Discharge summary

report

Admission Date: [**2141-1-28**] Discharge Date: [**2141-2-17**] Date of Birth: [**2063-8-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: The patient is an outside hospital transfer for mixed respiratory failure, neurology work-up. He was initially admitted to OSH for lethargy. Major Surgical or Invasive Procedure: Intubation Tracheostomy Percutaneous Gastrostomy tube History of Present Illness: Mr. [**Known lastname 81970**] is a 77yoM with recent h/o hypercarbic respiratory failure [**2-27**] asp PNA who presented on [**2141-1-27**] to [**Hospital1 5109**] for lethargy ([**Hospital1 2436**] ICU [**Telephone/Fax (1) 81971**]). He was transferred for further management and work-up of his respiratory status. Most recently on [**2141-1-27**], he became lethargic at home with sats in the 80's on home dose 3L NC. He reportedly had difficulty answering questions, but denied F/C/cough. Per the notes, he was not wearing his home BiPAP or NC as he was supposed to after d/c from rehab. CXR at the OSH showed ? new right effusion and PNA, but he was not started on antibiotics. ABG at the time was 7.18/104/106/41 on 2LNC; he was started on BiPAP but later intubated for poor MS [**First Name (Titles) **] [**Last Name (Titles) **] developed hypoxemia. Per notes, secretions were minimal. Chest CTA was negative for PE. Head CT was negative; Mirapex was held due to the lethargy. BP meds were held on [**2141-1-28**]. He recieved D5W-1/2NS at 75 cc/hr. Prior to transfer on [**2141-1-28**], he was noted to have O2 sats ~92% with PaO2's around 50 on FI02 of 80% with a PEEP of 7.5; tidal volume was set to 450 with a RR 16. Past Medical History: #) Recent hypercarbic resp failure since [**2140-12-20**] -- admitted in [**12-3**] with aspiration PNA; c/b parapneumonic effusion -- was discharged to rehab after hospitalization on BiPAP at night with 2LNC during the day #) Parksinson's Disease -- diagnosed 3-4 months ago based on rigidity and withdrawal from ADL's, as well as 30 lb weight loss -- did not tolerate Sinemet (started in late [**Month (only) 359**] or early [**Month (only) **]; had hallucinations) or Requip (somnolence); was recently started on Mirapex. -- Neurologist is Dr. [**Last Name (STitle) 81972**] #) H/O papillary cell transitional cell bladder CA, [**2134**] #) s/p TURP, ? BPH #) HTN #) Hyperlipidemia #) IgA gammopathy-- per OSH H&P, first "noticed" in [**9-/2140**] #) Pancytopenia-- per OSH H&P, first "noticed" in [**9-/2140**] #) ? h/o chronic dysphagia-- supposedly prior to PD dx -- had S&S eval prior to d/c on [**2140-12-30**]; no evidence of aspiration on the study #) ? iron overload #) Erosive gastritis [**9-/2140**] #) ? Asbestiosis-- calcifications c/w per recent chest CT's Social History: -- girlfriend [**Name (NI) 81973**] has been with him for 25+ years -- originally from [**Country 4754**], moved here in the [**2082**]'s -- used to play professional soccer for [**Country 4754**] -- an ex-smoker; unclear how much and when he quit -- denied EtOH Family History: Unknown. Physical Exam: VS on arrival to the ICU: T 99.0; 121/46 (cuff), 141/46 (left alin), HR 57; vent settings AC, 450/14, 100/PEEP 8 General: intubated, sedated; elderly; had OG tube HEENT: OP clear but dry Lungs: decreased BS on left base; crackles half-way up throughout; no wheezes Cardio: RRR, no m.r.g. appreciated Abd: +BS, soft, ND Extremities: no edema, WWP Skin: no rashes, no petechiae Neuro: sedated; 2+ reflexes throughout On discharge: VS: T 97.0, BP 102/40, HR 97, RR 22, 94% on [**Last Name (un) **] air. Tm 97.6, 102-138/40-58, 97-117, 18-22 General: NAD HEENT: OP clear Lungs: decreased BS on bilateral bases; no wheezes, poor air movement in bilateral upper fields, but improved from yesterday. Cardio: regular, S1/S2, no murmurs, rubs or gallops appreciated. Abd: +BS, soft, ND Extremities: no edema, WWP Skin: no rashes, no petechiae Neuro: A&Ox3, normal strength, no tremor. +ve for right foot drop. Pertinent Results: ADMISSION LABS: [**2141-1-29**] 12:08AM BLOOD WBC-8.0 RBC-3.19* Hgb-10.7* Hct-29.0* MCV-91 MCH-33.6* MCHC-36.9* RDW-16.5* Plt Ct-160 [**2141-1-29**] 12:08AM BLOOD Neuts-73.8* Lymphs-16.1* Monos-9.4 Eos-0.3 Baso-0.4 [**2141-1-29**] 12:08AM BLOOD PT-13.7* PTT-35.2* INR(PT)-1.2* [**2141-1-29**] 12:08AM BLOOD Glucose-92 UreaN-28* Creat-1.3* Na-129* K-4.3 Cl-89* HCO3-38* AnGap-6* [**2141-1-29**] 12:08AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.7 MICROBIOLOGY: [**2141-1-29**] Urine culture: negative [**2141-1-29**] Blood culture, two sets: NGTD [**2141-1-29**] Sputum culture: GRAM STAIN: >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | ENTEROBACTER CLOACAE | | CEFEPIME-------------- 8 S <=1 S CEFTAZIDIME----------- 4 S 16 I CEFTRIAXONE----------- 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 4 S <=1 S MEROPENEM------------- 8 I <=0.25 S PIPERACILLIN---------- 8 S 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S RADIOLOGY: OSH Radiology Reports: [**2141-1-28**] Admission CXR: ? loculated effusions b/l L > R, decreased lung volumes on left [**2141-1-27**] CXR report from OSH: interval decrease in LLL consolidation compared to [**Date range (1) 81974**]; reportedly new right pleural effusion [**2141-1-27**] Head CT: negative for IC bleed and mass effect [**2141-1-28**] [**Hospital1 18**] AMDISSION CXR: Flattening of both diaphragms is present consistent with COPD. Blunting of the right costophrenic angle is present. In the absence of prior films, it is not known whether this is chronic or acute. If acute the degree of failure should be suspected. Old rib fractures are noted. IMPRESSION: COPD, right effusion. [**2141-1-31**] FOLLOW-UP CXR: In comparison with the study of [**1-30**], there is more sharp appearance of the left hemidiaphragm, though there is still residual left basilar atelectasis. No evidence of shift of the mediastinum to the left at this time. The degree of right effusion has apparently decreased, though some of this could relate to the more upright position of the patient on this image. No evidence of acute focal pneumonia. Video swallow [**2141-2-1**]: Trace penetration was noted to occur during the swallow nectar thick liquids and cleared independently. The penetration was noted to occur consistently during the swallow on thin liquids and did not clear, increasing the risk of trace aspiration after the swallow. One episode of overt aspiration was noted to occur during the swallow on thin liquids. Cough was ineffective in clearing aspirated material. [**2141-2-7**]: Torso CT: IMPRESSION: 1. Trace pleural effusions, right lung atelectasis and left lower lobe collapse. Although no mass is identified, given the calcified pleural plaques (implying asbestos exposure), differential consideration for the etiology of collapse must include a bronchogenic carcinoma. Further evaluation with bronchoscopy is recommended. 2. Scattered, sub-5-mm pulmonary nodules as detailed above, recommend follow- up in 6-12months with cross-sectional imaging. 3. Subcentimeter hypoattenuating pancreatic tail lesion, differential includes side- branch IPMN and recommend attention to this area on subsequent imaging. [**2141-2-7**]: MRI Head: IMPRESSION: Normal brain MRI. [**2141-2-8**]: TTE: IMPRESSION: Bicuspid aortic valve with minimal aortic stenosis. Normal regional and globa biventricular systolic function. Dilated aortic root. Biatrial enlargement. [**2-8**]: Carotid U/S: IMPRESSION: There is less than 40% stenosis within the right internal carotid artery. There is 60 to 69% stenosis within the left internal carotid artery. [**2141-2-9**]: EMG: IMPRESSION: Abnormal study. The electrophysiologic findings are highly suggestive of a disorder of motor neurons or their axons; however, multilevel radicular abnormalities or meningeal infiltrative/inflammatory process might produce a similar electrophysiologic picture. Clinical correlation is required. Spine MRI [**2-11**]: CONCLUSION: Degenerative disc disease as discussed above. No evidence of spinal cord or cauda equina compression. CXR [**2-16**] Tracheostomy tube is in standard position. Improving bibasilar atelectasis and persistent pleural effusions. Otherwise, no change from recent study. Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-2-17**] 03:26AM 7.0 2.64* 8.7* 24.8* 94 32.8* 35.0 17.3* 166 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-2-17**] 03:26AM 145* 17 0.9 138 3.8 99 37* 6* Calcium Phos Mg 8.8 2.6* 1.8 Brief Hospital Course: MIXED RESPIRATORY FAILURE: Mr. [**Known lastname 81970**] was admitted with respiratory failure, worse ventillatory than hypoxic, thought to be due to an aspiration/hospital-acquired pneumonia. His hypoxia rapidly corrected with significant improvement in lung volumes (recruitment) on CXR. His ventillatory failure was gradually improved with bronchodilators and antibiotics, and he was extubated without complication on [**2141-1-31**]. He was initially started on vancomycin and zosyn on admission on [**2141-1-28**]; vancomycin was discontinued on [**2141-1-31**] when sputum cultures returned pseudomonas. Speciation return Enterococcus and Pseudomonas on [**2141-2-1**] and the patient was started on Cefepime to finish on [**2141-2-7**]. There was concern that neuromuscular weakness may be contributing to his poor respiratory status, though it was unclear whether this was a primary problem or secondary to deconditioning from being on the ventillatory (he was also on a vent for two weeks earlier in [**1-2**] at [**Hospital3 2783**] with aspiration PNA; he had difficulty weaning at the time). At [**Hospital1 18**], negative inspiratory forces were recorded at -11, -20 and -23 on [**11-22**] prior to extubation. Of note, the patient has a history of pancytopenia and was noted to have a relative leukocytosis of 8.0 on admission. WBC had decreased to 2.8 upon discharge. After discussion with the family, the patient underwent a trach/PEG placement without complications. On the second day post operatively, the patient developed repeated desaturations while on the vent to the mid 80s, but was asymptomatic. A bronchoscopy revealed multiple mucus plugs which were extracted. However, overnight the patient spiked a fever to 101. The patient's cultures became positive for pseudomonas, which was sensitive to ceftazidime which was started on [**2-16**] to be continued until [**2141-3-2**]. (Of note, the patient's previous pneumonia was pseudomonas treated with cefepime). Please call [**Telephone/Fax (1) 2756**] to follow up microbiology sensitivites on the sputum cultures. HYPERTENSION: Mr. [**Name14 (STitle) 81975**] has baseline hypertension on home doses of amlodipine and lisinopril. Blood pressures were initially in the 140's systolic on admission, but climbed after he was extubated. Prior to speech and swallow evaluation, he was maintained on IV metoprolol and hydralazine. He was later changed to his prior medciation amlodipine when he was cleared to take PO's. His Linisopril was not resumed as his blood pressure was well controlled on Amlodipine. LETHARGY: Mr. [**Known lastname 81970**] initially presented to [**Hospital3 **] for lethargy. His pramipexole for Parkinson's Disease had been held by the OSH for concern that medication side effects could be contributing; head CT and EtOH level were negative. It is likely his ventillatory resp failure upon admission to the OSH was also contributing to his somnolence. While at [**Hospital1 18**], he did not have problems with somnolence once off sedation for the ventillator. Pramipexole remained held. WEAKNESS: Mr. [**Known lastname 81970**] was recently diagnosed 3-4 months ago with Parkinson's Disease. Neurology evaluation here showed dementia and right foot drop. He was felt to likely have what have arteriosclerotic disease which is chronic small vessel changes in the brain with white matter abnormalities and lacunes. While the patient was on the floor, he had acute respiratory distress and hypercapnia in the CT scanner while evaluating for possible stroke. The patient was intubated and transferred to the ICU, and doing well when he was weaned from the vent. He tolerated approximately 6 hours extubated before needing to be reintubated for work of breathing. Of note, the patient's NIFs were ranging from -8 to -13 on minimal vent settings. Patient was further evaluated by the Neuromuscular service where an EMG was performed, indicating the patient has the diagnosis of ALS. A spinal MRI was obtained revealing no evidence of cord compression or cauda equina that could be causing his weakness. WEIGHT LOSS: He has had a 30 pound weight loss in the last 3-4 months. It is unclear whether this has been secondary to behavioral/PD-related problems or malignancy, a more likely possibility is ALS as discussed above. HISTORY OF BPH: He had as foley on admission and was continued on his home tamsulosin dose once he was taking PO's, restarted on discharge PENDING ISSUES FOR FOLLOW-UP: Follow up Pseudomonas cultures/sensitivities Medications on Admission: MEDICATIONS on transfer: Combivent inhalers Omeprazole Pramipexole-- on list, though reportedly held due to delta MS [**First Name (Titles) 61368**] [**Last Name (Titles) **] Terazosin 10 mg QHS Lisinopril 20 mg QD Amlodipine 5 mg QD Enoxaparin 40 mg SQD Acetaminophen 650 mg PO Q4 hours PRN MEDICATIONS at home (doses not listed): Flomax Lisiopril Amlodipine Omeprazole Mirapex Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 3. Saline Flush 0.9 % Syringe Sig: One (1) Injection Q8H:PRN: Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. . 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 14 days: Until [**2141-3-2**]. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary Diagnoses: - Amylotrophic Lateral Sclerosis - Ventilator Associated Pneumonia-pseudomonas Secondary: -Hypertension Discharge Condition: Stable, afebrile, A&Ox3 (baseline). Patient with known right foot drop and dementia NOS (at baseline), tracheostomy & percutaneous gastric tube in place. Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of shortness of breath. You were found to have an infection in your airways which required IV antibiotics. A breathing tube was placed because you were unable to breath on your own. Because you were having such difficulty coming off the breathing tube, a Neurological evaluation was completed. The Neurologists determined that you most likely have Amylotrophic Lateral Sclerosis, or ALS. It was necessary to undergo a procedure to place a permanent breathing tube in your neck, a tracheostomy, to help you breath. You also had a feeding tube placed to undergo tube feeds. You have been given a PICC line (central IV line) for continuation of IV antibiotics. While you were here, you were seen by Neurology who felt that you did not display signs of Parkinson's and more likely carry the diagnosis of ALS. This diagnosis was made by MRI's of your spine and head, and an EMG of the muscles of your chest. Thus, your Parkinson's medication Mirapex was discontinued. You were started on the medication Aggrenox which can help to prevent strokes. You will follow up with the Neuromuscular specialist, Dr. [**Last Name (STitle) **], in approximately one month. Her office will contact you to set up the appointment. If you do not hear from them, the phone number is ([**Telephone/Fax (1) 81976**]. Your Mirapex was discontinued. Your Lisinopril was discontinued. You were started on Aggrenox (1 capsule twice a day). You are also being given Ceftazidime IV (2g every 8hours) for an additional 14 days. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Please see your PCP, [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) 1313**], as needed. Please follow up with Dr. [**Last Name (STitle) **] in the next month. You will be contact[**Name (NI) **] for the appointment date. Please follow up in neuromuscular clinic in 1 month by calling [**Telephone/Fax (1) 81977**] to schedule an appointment

[ "518.81", "276.3", "507.0", "041.7", "335.20", "584.9", "401.9", "997.31" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11", "33.24", "96.71", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

15824, 15924

9197, 13766

454, 510

16092, 16248

4124, 4124

18103, 18471

3172, 3183

14197, 15801

15945, 16071

13792, 13792

16272, 18080

8897, 9174

3198, 3614

3628, 4105

274, 416

538, 1779

5895, 8881

4140, 5886

13817, 14174

1801, 2875

2891, 3156

19,117

182,495

30336

Discharge summary

report

Admission Date: [**2112-3-3**] Discharge Date: [**2112-3-9**] Date of Birth: [**2034-5-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2698**] Chief Complaint: hypoxia, cardiogenic shock Major Surgical or Invasive Procedure: bronchoscopy ([**2112-3-4**]) cardiac catheterization and IABP placement ([**2112-3-4**]) History of Present Illness: Patient is a 77 year old male with PMHx significant for recurrent espohageal adeno carcinoma who appeared to go into cardiogenic shock after having L main bronchus stent placed. Patient with known esophageal CA s/p resection in [**4-/2108**] with recurrence in [**2110**] s/p chemotherapy (last [**2112-2-4**]) who has been having increased shortness of breath for the past 2 months. Patient intially felt to have bronchitis and treated with antibiotics without improvement of symptoms. He underwent biopsy of L main bronchus which showed espohageal adenocarcinoma along the wall. One day PTA patient CXR showed opacification of L chest and had bronch on [**2112-3-3**] which showed LMS obstruction. Past Medical History: Prostate Ca s/p XRT (dx 10 years ago) Esophageal Adenocarcinoma s/p Ivor-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72182**] [**4-12**] with recurrence [**2110**] s/p chemo ([**2112-2-4**]) GERD Social History: Lives with family; vacuum system mechanic, + etoh use (4 cans/day); + tobacco history quit in [**2096**]; 25 pack/year history; Family History: unable to obtain (intubated/sedated) Physical Exam: T 98.6 BP 88/44 (on 0.10 levophed) HR 78 O2Sat 90% Vent AC Tv 430 FiO2 100% PEEP 15 RR 28 7.38/42/181 Gen: Patient intubated and sedated Heent: ETT tube in place with OG tube Neck: no bruit; +2 carotid Lungs: Bronchial Breath sounds ant/lat Cardiac: RRR S1/S2 no murmurs Abd: soft, midline scar Ext: no edema Neuro: sedated Pertinent Results: Bedside TTE ([**2112-3-4**]): There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed with septal, anterior and apical akinesis and hypokinesis elsewhere. The right ventricular cavity is unusually small. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. . Cardiac cath ([**2112-3-4**]): Bronchoscopy w/ biopsy ([**2112-3-4**]): [**2112-3-8**]: ECHO: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and apex (EF 40-45%). The ascending aorta is mildly dilated. There are three moderately thickened aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion, without echocardiographic signs of tamponade. Brief Hospital Course: On [**2112-3-4**] pt was taken to the OR for rigid bronchoscopy, flexible bronchoscopy, micro-debridement, metallic-covered stent placement 14 x 40. Patient tolerated procedure well and was sent to PACU. In the PACU patient became hypertensive and tachycardic to 120s with LBBB pattern. Pt O2Sat dropped to 70-80s and he was intubated. A CXR was obtained which was consistent with b/l pulmonary edema. Patient was given 40 IV lasix with minimal response. An emergent TTE was done which showed severe LV systolic dysfunction with LVEF < 20%, no tamponade, perserved RV systolic function. Swan was placed and hemodynamics showed PAP 45/30 Ci 1.1 CO 1.5-2.0 and SVO2 55-60. Patient given ASA and started on epinephrine infusion. He was sent to the cath lab where it was revealed that he had clean coronaries. A IABP was placed and pt sent to CCU team. The patient was admitted to the CCU team post-cath and a femoral a-line was placed by the fellow. He was maintained on norepinephrine and dobutamine drips overnight to maintain his BP in the setting of his cardiogenic shock. The FiO2 on his vent was initially weaned down slightly, though he was intially unable to tolerate anything lower than an FiO2 of 70%. Overnight between hospital days 1 and 2, he became acutely tachycardic to the 140s with a stable BP and a moderate drop in his cardiac index. ECGs were suggestive of atrial tachycardia and he was electricallu cardioverted on the morning of hospital day #2 under the supervision of the cardiology attending. On HD#3 he was bronched and found to have malignant airway obstruction s/p stent placement for post-obstructive PNA. He was maintained on broad spectrum IVAB. Hemodynamics stabilized , pressors and IABP were weaned, he was diuresed and then extubated successfully. repaet echo was done which showed improved EF 40-45%. On HD#4 pt was transfferred from the ICU to the floor. He continued to do well was to complete a 14 day course of broad spectrum po antibiotics and was d/c'd to home w/ VNA services on HD#6. Medications on Admission: Casodex 40mg qd Zoladex SQ q3mo Tylenol #3 prn Lorazepam prn MVI Discharge Medications: 1. Metronidazole 500 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 2. Levofloxacin 500 mg Tablet [**Date Range **]: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:*9 Tablet(s)* Refills:*0* 3. Linezolid 600 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day for 9 days. Disp:*18 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Captopril 25 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day) as needed. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day) as needed. 10. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 11. Combivent 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: One (1) Inhalation every six (6) hours. Disp:*1 MDI* Refills:*2* 12. oxygen 2 liters /min continuous portability for pulse dose system Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: esophageal adenoca s/p Ivor-[**Doctor Last Name **], prostate ca, GERD, anxiety Discharge Condition: good-requires home oxygen for saturation of 83% on roomair Discharge Instructions: Call Dr[**Doctor Last Name **] office [**Telephone/Fax (1) 10084**] if you develop chest pain, shortness of breath, fever, chills. Followup Instructions: You have a follow up appointment on [**2112-3-18**] at 12:30pm with Dr. [**Last Name (STitle) **] call your cardiologist for a follow up appointment regarding your medications Completed by:[**2112-4-21**]

[ "150.8", "197.0", "518.5", "300.00", "998.0", "530.81", "486", "785.51", "428.0", "426.3" ]

icd9cm

[ [ [] ] ]

[ "88.56", "38.93", "37.61", "33.22", "38.91", "96.05", "96.04", "33.91", "32.01", "96.71" ]

icd9pcs

[ [ [] ] ]

6974, 7045

3353, 5384

297, 388

7169, 7230

1914, 3330

7409, 7616

1517, 1555

5499, 6951

7066, 7148

5410, 5476

7254, 7386

1570, 1895

231, 259

416, 1119

1141, 1356

1372, 1501

46,588

179,696

10534

Discharge summary

report

Admission Date: [**2112-8-16**] Discharge Date: [**2112-9-10**] Date of Birth: [**2045-12-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Bronchoscopy PICC placement History of Present Illness: Mr. [**Known lastname 34698**] is a 66 year old man with PMH notable for POEMS s/p autoSCT [**12-15**], therapy-related MDS (no MDS therapy), recently hospitalized for F/N and diagnosed with recurrence of POEMS syndrome, CKD on HD presenting with 2 day h/o worsening BUE motor fasciculations and depressed level of consciousness. Patient recently admitted with neutropenic fever and hypotension initially requiring intubation. Work-up notable for B+glucan and regimen tailored to voriconazole and cipro at time of discharge. Pt admitted yesterday [**3-10**] fasciculations and altered mental status. Had been doing well on the floors except for complaints of penile/bladder pain that was challenging to control with methadone, morphine, percocet and dilaudid. Foley catheter was placed to help with symptom relief (helped in previous admissions). This evening pt was noted to be febrile to 101.3 with SBP 60s-70s. Pt was transferred to [**Hospital Unit Name 153**] for further management. On arrival to the MICU, patient's VS were T101.2, HR106, BP73/53, R20, 88%RA -> 96%2LNC. Pt was moaning in pain. Past Medical History: ONCOLOGIC HISTORY: POEMS syndrome manifested by polycythemia, polyneuropathy, organomegaly, endocrinopathies including hypocalcemia, hypothyroidism, hypogonadism and elevated PTH (diagnosed in [**2099**]). In [**2101**] anasarca that eventually progressed to respiratory failure, treated with plasmapheresis and prednisone followed by 18 months of cyclophosphamide. [**4-/2108**]/[**2108**]: Bortezomib (1.3 mg/m2 days 1,4,8,11 and dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three cycles discontinued due to painful lower extremity neuropathy. [**11/2108**] high dose cytoxan for stem cell mobilization ([**11/2108**]) [**12/2108**] high dose melphalan with stem cell rescue ([**2108-12-9**]) In remission since than. [**4-/2112**]: bone marrow aspirate and biopsy showed dysplastic basophilic and polychromatophilic erythroblasts, a marked left shift and dysplastic myelopoiesis and abundant hyperchromic megakaryocytes, which initially were felt to be consistent with colchicine toxicity; however, chromosome studies performed on that bone marrow material revealed an abnormal karyotype 15/16 studied cells showed a complex clone with the following anomalies. He had deletion in the long arm of chromosome 5 between band 5q13 and 5q33, otherwise known as 5q minus. He had monosomy 13, monosomy 17, monosomy 20, and addition of an unidentified marker chromosome and [**2-12**] double minute chromosomes. These were all consistent with a myeloid abnormality since there were not an increased number of blasts much more consistent with MDS. OTHER PAST MEDICAL HISTORY: 1. POEMS syndrome: First diagnosed in [**2099**] with treatment described above. His manifestations have been as follows: A. Polyneuropathy - CIDP in [**2099-6-6**]; Painful lower extremity sensory neuropathy and proprioception defects. B. Organomegaly - Splenomegaly C. Endocrinopathy - Hypothyroidism, hypogonadism, hypocalcemia related to hypoparathyroidism D. Monoclonal gammopathy E. Skin and nail changes - now resolving. F. Pulmonary hypertension and restrictive lung disease. G. Chronic renal insufficiency (which has now resolved with therapy) H. Anasarca, now resolved. I. Hyperuricemia and gout - now resolved J. Polycythemia and thrombocythemia - now resolved 2. Vitamin B12 deficiency 3. S/p compound fracture, [**2103-8-7**] 4. S/p tracheostomy [**2101**] 5. prostate cancer s/p brachytherapy 6. gout 7. pulmonary HTN and restrictive lung disease 8. chronic kidney disease 9. C Dif ([**5-/2112**]) 10. Acute angle glaucoma ([**2112-4-27**]) Social History: Pt is a Ukrainian refugee who immigrated to the US in [**2049**]. He lives with his wife and they have two sons. [**Name (NI) **] cigarettes, very occasional alcohol. He works as a paint salesman for [**Last Name (un) 34699**]-[**Location (un) 805**]. He is also a [**Country 3992**] veteran. Exposed to [**Doctor Last Name **] [**Location (un) **], which he believes is the etiology of his POEMS. Family History: Mother is alive and has SLE, fibromyalgia. His father's medical history is unknown. Half-sister with ovarian cancer. Physical Exam: ADMISSION EXAM General: Awake, groaning in pain. Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, mild tenderness to palpation, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Not responding to questions or commands DISCHARGE EXAM Genl: Awake, lethargic but arousable Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, mild tenderness to palpation, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: responds to yes/no questions Pertinent Results: [**2112-8-16**] 02:10PM WBC-3.2* RBC-2.66* HGB-8.0* HCT-24.4* MCV-92 MCH-29.9 MCHC-32.7 RDW-14.8 [**2112-8-16**] 02:10PM NEUTS-15* BANDS-0 LYMPHS-15* MONOS-61* EOS-1 BASOS-0 ATYPS-6* METAS-2* MYELOS-0 NUC RBCS-1* [**2112-8-16**] 02:10PM BLOOD UreaN-38* Creat-0.6 Na-136 K-4.3 Cl-99 HCO3-28 AnGap-13 [**2112-8-16**] 02:10PM BLOOD ALT-109* AST-64* LD(LDH)-350* AlkPhos-343* TotBili-0.4 [**2112-9-9**] 04:06AM BLOOD WBC-2.8* RBC-2.96* Hgb-8.8* Hct-25.8* MCV-87 MCH-29.9 MCHC-34.2 RDW-14.7 Plt Ct-40* [**2112-9-9**] 04:06AM BLOOD Glucose-107* UreaN-32* Creat-0.5 Na-138 K-3.6 Cl-98 HCO3-31 AnGap-13 [**2112-9-2**] 03:49AM BLOOD Neuts-60 Bands-3 Lymphs-25 Monos-8 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-2* MICRO: [**2112-8-21**] 3:36 am BLOOD CULTURE: NO GROWTH. [**2112-8-21**] 12:23 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2112-8-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2112-8-23**]): NO GROWTH, <1000 CFU/ml. POTASSIUM HYDROXIDE PREPARATION (Final [**2112-8-22**]): NO FUNGAL ELEMENTS SEEN. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2112-8-21**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2112-9-5**]): YEAST. Respiratory Viral Antigen Screen (Final [**2112-8-22**]): negative [**2112-8-23**] 4:34 am URINE: NO GROWTH. [**2112-8-27**] 3:23 pm BLOOD CULTURE: NO GROWTH. [**2112-8-29**] 4:46 am STOOL: C. difficile DNA amplification assay Negative for toxigenic C. difficile [**2112-8-29**] 3:46 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2112-8-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2112-9-1**]): ~1000/ML Commensal Respiratory Flora. NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [**2112-9-5**]): Negative for Cytomegalovirus early antigen by immunofluorescence. IMAGING: [**8-21**] Chest Ct IMPRESSION: 1. Compared with prior exam, there has been interval resolution of scattered bilateral consolidations, with interval appearance of new areas of discrete consolidation and ground-glass opacities in the left upper, right lower and right middle lobes suggesting multifocal pneumonia. 2. Interval worsening of bibasilar atelectasis, right worse than left, with nearly total collapse of the right lower lobe. . 3. No radiologic signs to explain pelvic pain. 4. Significant interval improvement of anasarca, with almost complete resolution of pleural effusion and ascites. 5. Mild perinephric stranding and cardiomegaly not significantly changed compared with prior exam. 6. Supporting devices are in expected positions. CT HEAD W/O CONTRAST Study Date of [**2112-8-22**] FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass effect, or infarction. There is swelling and a small scalp hematoma overlying the left forehead. Prominent ventricles and sulci suggest age-related involutional changes. The basal cisterns appear patent, and there is preservation of [**Doctor Last Name 352**]-white differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The globes are intact bilaterally. IMPRESSION: No evidence of hemorrhage, mass effect, edema, or infarction. Small left frontal scalp hematoma. Chronic changes as described above. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2112-8-26**] IMPRESSION: Normal right upper quadrant ultrasound. Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages and rare bronchial cells. CHEST (PORTABLE AP) Study Date of [**2112-9-6**] Transient improvement in the diffuse severe consolidative pulmonary abnormality which recurred between [**9-2**] and [**9-4**] have reversed slightly, although to some extent the greater opacification in both lungs could be due to lower lung volumes. Nevertheless, this raises possibility of superimposition of a component of hydrostatic edema or a developing diffuse alveolar damage. The global nature of the abnormality argues against worsening of concurrent pneumonia or pulmonary hemorrhage. Small bilateral pleural effusions are unchanged. Heart size is indeterminate. Feeding tube passes into the stomach and out of view. Right subclavian line ends close if not beyond the superior cavoatrial junction. No pneumothorax. Right PIC line can be traced as far as the lower margin of the clavicle. No pneumothorax. Brief Hospital Course: 66 yo M w/POEMS syndrome and MDS a/w worsening motor fasciculations and decreased level of consciousness at rehab facility admitted for febrile neutropenia and hypotension with multifocal pneumonia. During the course of his admisssion, he had multiple issues, as detailed below. However, he and his family made a decision to change goals of care to focus on comfort measures only, and he expressed a desire to return home with hospice care. Hospital issues prior to patient changing goals of care to comfort measures: # Hypotension / Septic shock: On admission, Pt met SIRS criteria with enterococcus from urine culture, coag-neg staphlococcus in [**2-8**] blood cx from [**8-18**], and radiologic evidence for multifocal pneumonia. He was treated with vancomycin, cefepime for pneumonia. Given his h/o aspergillus pneumonia and that he was neutropenic upon admission, ambisome was added to cover for fungal etiologies. He intermittently required IV fluids and Levophed to maintain his MAP > 65. He required stress dose hydrocortisone. CXR and chest CT revealed multifocal lobar pneumonia. Blood Cx was positive for coagulase negative staphlococcus. Bronchoalveolar lavage on [**8-29**] and [**8-31**] showed no organisms on culture. # Respiratory failure: The patient was intubated on [**8-20**] for hypoxic respiratory failure and airway protection secondary to pneumonia complicated by diffuse alveolar hemorrhage. CT chest showed new focal opacities in the left upper, and right lower and right middle lung lobes consistent with pneumonia. The infectious disease team followed the patient and provided recommendations. He was initially treated with vancomycin, cefepime, and ambisome. BAL showed no organisms on culture. The patient was extubated on [**2112-9-1**]. Ambisome was later switched to voriconazole due to persistent low potassium while on ambisome and an 8 day course of vancomycin and meropenem was completed for gram positive cocci in blood cultures. The patient was actively diursed with IV lasix and electrolytes were repleated as needed for component of fluid overload. He remained on a face tent to maintain oxygen saturation. On the final days of hospitalization, family family refused nasal cannula. His O2 sats remained in the mid to low 90s on room air. # POEMS/MDS: Patient has a history of myelodysplastic syndrome and POEMS. He was followed by the hematology service during his admission. His Hct was in the low 20s throughout this admission. He received transfusions of packed red blood cells as need to maintain hematocrit about 21. He also received platelet transfusions as need with a goal platelet of 40 given diffuse alveolar hemorrohage. He was further treated with neupogen and prednisone; lenolidomide was held due to concern for neurotoxicity. # Pain management: He has chronic pain throughout, including bladder spasms, and was treated with oxybutynin, dilaudid PRN, and fentanyl patches. Fentanyl patches were intermittently discontinued when he had fevers. Pain management was difficult with higher doses causing altered mental status. The pain was most responsive to the IV steroids. Dilaudid was discontinued toward the end of hospitalization. Once the decision was made to start hospice, patient's pain needs were met with IV hydrocortisone and morphine. He was discharged with presciptions for hydrocortisone and oral morphine solution. # Urine with enterococcus - A urine cx growing vancomycin-resistant enterococcus. The patient was treated with antibiotics as described above. # Muscle fasciculations- Per neurology, this represents multifocal myoclonus and asterixis, which are fairly non-specific and likely [**3-10**] cortical irritation. Etiology unclear, but most likely toxic/metabolic effect or underlying infection. #Dysphagia: Patient had trouble swallowing medications and failed his speech and swallow evaluation [**3-10**] regurgitation/aspiration. Patient was receiving tube feeds through an NG tube, which became clogged. Upon removal of the NG tube, patient began having nosebleeds and a discussion of replacing the tube vs. TPN vs. PEG was had with the family. At this point, the family decided that conservative management with comfort goals would be best. Hospice was consulted and made the necessary arrangements for the patient to go home with hospice care. TRANSITIONAL ISSUES Patient will be going home with hospice services. The company is Hospice of Greater [**Location (un) 86**] and Greater [**Hospital1 1474**] ([**Telephone/Fax (1) 34701**]). The appropriate prescriptions were provided. Patient's family was provided with official DNR/DNI form to present on encounters with EMS. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[**Name (NI) 581**]. 1. Levothyroxine Sodium 112 mcg PO DAILY 2. Acyclovir 400 mg PO Q8H 3. Cyanocobalamin [**2100**] mcg PO DAILY 4. Thiamine 100 mg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Citalopram 20 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Gabapentin 600 mg PO BID 9. Midodrine 2.5 mg PO TID 10. Dexamethasone 3 mg PO Q12H 11. Methadone 2.5 mg PO QAM 12. Methadone 5 mg PO QHS 13. OxycoDONE (Immediate Release) 5 mg PO Q2H:PRN severe pain 14. Phenazopyridine 100 mg PO TID Duration: 3 Days 15. Oxybutynin 5 mg PO TID 16. Lidocaine Jelly 2% 1 Appl TP TID:PRN penile pain 17. Terazosin 1 mg PO HS 18. Lenalidomide 10 mg PO DAILY 19. Voriconazole 200 mg PO Q12H 20. Docusate Sodium 100 mg PO BID 21. Senna 1 TAB PO BID:PRN constipation 22. Pantoprazole 40 mg PO Q24H 23. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR DAILY 24. Ondansetron 8 mg PO Q4-6HRS:PRN nausea 25. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Morphine Sulfate (Concentrated Oral Soln) 5-15 mg PO Q2H:PRN pain RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5-15 mg by mouth every 2 hour Disp #*30 Milliliter Refills:*0 2. Hydrocortisone Na Succ. 50 mg IV Q8H RX *Solu-Cortef (PF) 100 mg/2 mL 50 mg hydrocortisone every 8 hours Disp #*21 Unit Refills:*0 Discharge Disposition: Home With Service Facility: Hospice of Greater [**Location (un) 86**] Discharge Diagnosis: Primary: POEMS Syndrome Secondary: Fungal pneumonia Respiratory failure Diffuse Alveolar Hemorrhage VRE UTI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 34698**], You were admitted to the hospital because of worsening of your POEMS syndrome. During your hospitalization, you and your family decided to focus primarily on your comfort, and you are being discharged home with hospice care. We have stopped all medications except those to help treat your pain and discomfort. The medications that we recommend you continue are morphine solution and intravenous hydrocortisone. Please contact Hospice of Greater [**Location (un) 86**] and Greater [**Hospital1 1474**] with any new concerns at [**Telephone/Fax (1) 34701**]. Followup Instructions: None Completed by:[**2112-9-12**]

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icd9cm

[ [ [] ] ]

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36186

Discharge summary

report

Admission Date: [**2141-10-26**] Discharge Date: [**2141-10-30**] Date of Birth: [**2092-6-19**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 7651**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Trans esophageal echocardiogram Cardioversion History of Present Illness: Pt is a 49 yo M with PMH of HTN, ETOH abuse, asthma who presented to OSH with 1 month history of DOE and palpitations. Formerly active person but reports recently exercise limited to SOB. Noted last night unable to walk upstairs due to SOB. Patient was seen by PCP who noted him to be in rapid a-fib. He was sent to OSH ED. At the OSH, initial vitals were T97.4 hR 120-130s BP 120/79 RR 18-20 99% RA. There, patient had CTA that was negative for PE but did reveal an enlarged heart. He received ceftriaxone and azithromycin for concern of PNA. Pt was in afib with RVR (HR 120-130s). He received lopressor IV 5mg x 2, Digoxin 0.25mg x 1, ASA 325mg, 1L NS. Given persistent rapid A fib, he was started on diltiazem gtt which brought heart rate down to 110's prior to transfer. His first set of cardiac enzymes was negative. He then received lasix 40mg IV x 1 for presumed volume overload. Patient admits to excessive drinking, approximately [**11-30**] drinks per day with recent increase secondary to job stress. Taken from admission note Past Medical History: HTN Asthma OSA on CPAP ETOH abuse Social History: -Tobacco history: Former smoker, quit 20 yrs ago -ETOH: 6-12 beers 3-4x per week, no history of withdrawal seizures -Illicit drugs: No marijuana, cocaine, IVDU (prior history of amphetamines) Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: T= BP=97/78 HR= 104-115 in atrial fibrillation RR= 16 O2 sat= 96 4L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. atrial fibrillation, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at bases bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2141-10-30**] 07:30AM BLOOD WBC-8.5 RBC-4.89 Hgb-16.4 Hct-45.1 MCV-92 MCH-33.6* MCHC-36.5* RDW-13.4 Plt Ct-265 [**2141-10-30**] 07:30AM BLOOD PT-15.2* PTT-97.5* INR(PT)-1.3* [**2141-10-30**] 07:30AM BLOOD Glucose-95 UreaN-24* Creat-1.1 Na-137 K-4.3 Cl-104 HCO3-23 AnGap-14 [**2141-10-28**] 04:15AM BLOOD ALT-94* AST-73* AlkPhos-46 TotBili-0.3 [**2141-10-30**] 07:30AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.7 [**2141-10-28**] 04:15AM BLOOD calTIBC-296 Ferritn-1298* TRF-228 [**2141-10-26**] 11:46PM BLOOD TSH-1.8 [**2141-10-26**] 11:46PM BLOOD T4-7.0 [**2141-10-27**] 12:32PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2141-10-27**] 12:32PM BLOOD HIV Ab-NEGATIVE [**2141-10-27**] 12:32PM BLOOD HCV Ab-NEGATIVE [**10-27**] TEE: No intracardiac thrombus seen. Moderate mitral regurgitation. [**10-27**] TTE: Dilated left ventricle with severe global systolic dysfunction. Mild right ventricular systolic dysfunction. Moderate secondary mitral regurgitation. Pleural effusion. [**10-27**] CXR: Borderline cardiomegaly. Bilateral pleural effusions, left greater than right. Retrocardiac opacity. Brief Hospital Course: 49 yo M with PMH of HTN presents with DOE and new onset atrial fibrillation # CAD: Pt had a normal ECHO in [**2139**]. EKG showed T wave inversion and pt ruled out for MI with negative cardiac enzymes. # PUMP: Per OSH report and confirmed on [**Hospital1 18**] CXR, pt had cardiomegaly. This was though to be due to either tachycardia induced cardiomyopathy, idiopathic cardiomyopathy, viral cardiomyopathy or alcohol induced cardiomyopathy. Other etiology were ruled out including hemochromatosis (normal Iron and TIBC, although Ferritin elevated), thyroid disease (normal TSH), HIV and viral hepatitis. Pt responded well to IV lasix with improved shortness of breath and oxygen requirement. # RHYTHM: Atrial fibrillation with RVR. Unclear if dilated cardiomyopathy was the primary etiology with secondary afib, or if chronic paroxysmal afib is the cause of the dilation. ECHO did not reveal any structural abnormalities other than a reduced ejection fraction, there was no evidence of pulmonary causes and thyroid disease was ruled out. Pt was initially rate controlled with a diltiazem drip, later transitioned to rate control with beta blocker. Pt was initially anticoagulated with heparin. After TTE and TEE to rule out thrombus, pt underwent cardioversion which was only transiently successful before the rhythm reverted to atrial fibrillation. He was then started on Amiodarone load and anticoagulation with Coumadin and Lovenox drip. # HTN: Pt was titrated up on lisinopril and metoprolol. # Elevated LFTs: Unclear etiology as pattern is neither obstructive nor consistent with etoh, viral or ischemia. Pt denied abdominal/RUQ tenderness. Hepatotoxic meds were avoided and LFTs remained stably elevated. # OSA: Pt evaluated by respiratory but did not tolerate CPAP. He was counseled to follow up evaluation for OSA and CPAP as an outpt. He was noted to have confirmed periods of apnea and desats to 80s on monitor with following episodes of tachypnea and resolving sats. # ETOH ABUSE: Pt did not show signs of withdrawl but was maintained on a CIWA scale and prn Diazepam or Ativan. # ANXIETY: Pt had multiple episodes of anxiety, intially thought to be alcohol withdrawl but timeframe not consistent. He was treated with low dose ativan with good effect. Medications on Admission: ASA 81mg daily Lisinopril 10mg daily Singulair 10mg daily Albuterol PRN Nicorette Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Warfarin 2 mg Tablet Sig: 3.5 Tablets PO once a day. Disp:*150 Tablet(s)* Refills:*2* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days: Take until [**2141-11-1**]. Disp:*8 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Please check INR on [**2141-10-31**] when you see Dr. [**Last Name (STitle) **]. 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day). Disp:*4 syringe* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start taking on [**2141-11-2**]. Disp:*30 Tablet(s)* Refills:*2* 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:*180 Tablet Sustained Release 24 hr(s)* Refills:*3* 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Dilated Cardiomyopathy Acute Systolic Congestive Heart Failure: EF 28% Atrial Fibrillation Discharge Condition: stable. INR 1.3 BUN 24 Creat: 1.1 K 4.3 HIV and Hepatitis neg Discharge Instructions: You had trouble breathing before you were admitted and was found to have a a weak heart. Your ejection fraction (a measure of heart strength) is 28%. A normal ejection fraction is 55%. This means that you have been diagnosed with Acute Systolic Congestive Heart Failure. We started you on Toprol XL to slow your heart rate and continued you on Lisinopril to decrease the workload of the heart. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Please also call Dr. [**Last Name (STitle) **] if you have trouble breating, lying flat or notice any swelling. Adhere to 2 gm sodium diet . Please refrain from drinking caffeinated coffee and using nicorette gum. There can interfere with your medicines. . You also have atrial fibrillation, a common heart arrhythmia. This rhythm, along with the weak heart, puts you at risk for a stroke. You have been started on a blood thinner, coumadin (warfarin) to prevent blood clots that can lead to a stroke. The goal INR (coumadin level) is [**1-15**]. Today your INR is 1.3. Until your INR is therapeutic, you will need to inject Lovonox, a long acting blood thinner. You will be seen by Dr. [**Last Name (STitle) **] tomorrow. He will tell you what dose of coumadin to take from now on. You have been started on amiodarone for control of the atrial fibrillation. This medicine can sometimes affect your lungs and your thyroid. Your thyroid function is normal now, you will need to check this again in a few months. You will also need pulmonay function tests soon, this will be set up by Dr. [**Last Name (STitle) **]. . Please call Dr. [**Last Name (STitle) **] if you have any nosebleeds, dark or bloody stools, increasing bruising, dizziness, swelling in your hands or feet, chest pain, trouble breathing at night, or any other unusual symptoms. Followup Instructions: Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 3858**] Date/Time: Tuesday [**10-31**] at 1:15pm. Cardiology: [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Tuesday [**11-14**] at 9am Completed by:[**2141-10-31**]

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icd9cm

[ [ [] ] ]

[ "99.61", "88.72" ]

icd9pcs

[ [ [] ] ]

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7748, 9593

1789, 2675

255, 276

390, 1432

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1505, 1698

61,667

108,518

27129

Discharge summary

report

Admission Date: [**2160-3-12**] Discharge Date: [**2160-3-15**] Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 2297**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]M h/o autoimmune hemolytic anemia, recurrent GIB, mechanical aortic valve on coumadin and multiple similar admissions, most recently [**2160-1-2**], presenting from [**Hospital 100**] Rehab with anemia, HCT 19.4 from recent baseline 28 in setting of therpaeutic INR. Patient is a relatively poor historian but reports onset of fatigue and feeling weak and pale today with DOE. He denies BRBPR, melena, hematemesis, N/V/D, abdominal pain. Denies lightheadedness, dizziness, SOB, palpitations. He denies CP currently but states he had chest pressure several days ago on his way to breakfast in a wheelchair. Has never had pressure like this before. . In ED, initial VS: 97.5 88 95/64 16 97% 2L NC. Exam was significant for guaiac positive dark stool. Labs significant for HCT 19.4 (28.5 [**2160-2-25**]) and INR 2.9. SBP remained in the 90s but did not drop <90. GI was consulted. He was typed and crossed and transfused 1 units PRBCs via PICC. He was initially going to be admitted OMED but due to low HCT and borderline low BPs, he was admitted to MICU. VS prior to transfer: 98.5 89 95/72 18 100%2L. . ROS: + dysuria, unclear duration. Denies cough, fever, chills, SOB, diaphoresis, joint pains, headache, visual changes, rash. Past Medical History: # Anemia, multifactorial as below, baseline HCT 28 # Autoimmune hemolytic anemia (Coomb's +, warm autoantibody), on prednisone 10mg Po daily # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia # Aortic mechanical valve, recently Coumadin resistant so intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **] # hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon with melanotic stool in terminal ileum # GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on the wall opposite the ampulla. Small hiatal hernia. Otherwise normal EGD to third part of the duodenum. # H/o presyncope # CKD Cr 1.6-2.0 Stage III # CAD s/p NSTEMI [**7-10**] # Chronic CHF, likely diastolic, ([**9-9**] EF=50%) # Hyperlipidemia # Hypertension # Depression vs adjustment disorder after death of brother # Prostate cancer- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer # Dementia Social History: Never smoked, no EtOH or other drugs. Currently living at [**Hospital 100**] Rehab. Uses wheelchair typically. Requires a significant degree of assistance in all his ADLs and IADLs. Has 2 sons and 4 grandchildren. Family History: No bleeding diatheses. Father had stomach cancer. No other cancers including colon. Physical Exam: VS: Afeb 115/55 76 100%2L GEN: pleasant, pale appearing, comfortable, NAD HEENT: PERRL, EOMI, + conjuctival pallor, anicteric, MM slightly dry, OP without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: Faint crackles L base. Otherwise CTA with good air movement throughout. CV: RRR, S1 and S2 wnl, mechanical click. No rubs or [**Last Name (un) 549**]. CABG scar well healed. ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. Slight mottling. 1+ DP/PT SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3 (month, date, ICU at [**Hospital1 18**]). Cn II-XII intact with R ptosis (old per pt). RECTAL: Dark brown guaiac positive stool Pertinent Results: Admission Labs [**2160-3-12**] 04:00PM WBC-10.0# RBC-1.89*# HGB-6.6*# HCT-19.0*# MCV-101* MCH-35.1* MCHC-34.8 RDW-22.4* NEUTS-79* BANDS-5 LYMPHS-6* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-1* ALT(SGPT)-12 AST(SGOT)-19 LD(LDH)-192 ALK PHOS-42 TOT BILI-0.3 GLUCOSE-130* UREA N-48* CREAT-1.6* SODIUM-139 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 [**Hospital3 **] [**2160-3-12**] 04:00PM BLOOD Hapto-33 [**2160-3-13**] 02:19AM BLOOD WBC-6.3 RBC-2.65*# Hgb-8.8*# Hct-25.2*# MCV-95 MCH-33.1* MCHC-34.8 RDW-22.0* Plt Ct-147* [**2160-3-14**] 04:16AM BLOOD WBC-4.3 RBC-2.87* Hgb-9.4* Hct-25.9* MCV-90 MCH-32.6* MCHC-36.1* RDW-21.7* Plt Ct-131* [**2160-3-14**] 03:09PM BLOOD Hct-27.4* [**2160-3-14**] 04:16AM BLOOD PT-25.2* PTT-30.2 INR(PT)-2.4* [**2160-3-13**] 02:19AM BLOOD Glucose-109* UreaN-46* Creat-1.5* Na-138 K-4.3 Cl-105 HCO3-22 AnGap-15 [**2160-3-13**] 02:19AM BLOOD CK-MB-8 cTropnT-0.20* [**2160-3-13**] 10:19AM BLOOD CK-MB-6 cTropnT-0.19* [**2160-3-13**] 07:55PM BLOOD cTropnT-0.13* Discharge Labs [**2160-3-15**] 04:37AM BLOOD WBC-4.5 RBC-2.78* Hgb-9.2* Hct-26.5* MCV-95 MCH-33.2* MCHC-34.9 RDW-21.4* Plt Ct-143* [**2160-3-15**] 04:37AM BLOOD PT-22.0* PTT-29.4 INR(PT)-2.1* [**2160-3-15**] 04:37AM BLOOD Glucose-101* UreaN-38* Creat-1.5* Na-141 K-4.0 Cl-108 HCO3-24 AnGap-13 [**2160-3-15**] 04:37AM BLOOD ALT-11 AST-19 LD(LDH)-208 AlkPhos-39* TotBili-0.5 [**2160-3-15**] 04:37AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.3 Brief Hospital Course: [**Age over 90 **]M with autoimmune hemolytic anemia, mechanical aortic valve on coumadin and recurrent GIB and admissions for anemia presenting from rehab with anemia, HCT 19 and guaiac positive stool. . #. Anemia: Most likely related to recurrent ongoing GIB given dark guaiac positive stool and negative hemolysis labs. Continued prednisone for AIHA. He has had work up in past including colonoscopy and capsule endoscopy without finding source of bleed. Guaiac positive although remained hemodynamically stable. Received 4 units of pRBC. The patient declined any further work up such as endoscopy. Discussed with Dr. [**Last Name (STitle) **] (outpatient hematologist) and will plan to monitor and transfuse as needed as an outpatient. He was discharged to his nursing home with instructions to monitor HCTs and INR q2-3 days. He will continue on PO PPI [**Hospital1 **]. His carvedilol was held due to BPs in 100s/60s and HR 70s. . #. Mechanical Aortic valve: The patient has a goal INR of [**3-5**].5 per Dr. [**Last Name (STitle) **]. He wishes to be closer to 2. Currently on coumadin 4mg dailiy. This will need to be followed as an outpatient adn adjusted for INR goal of 2. . #. Chest pressure/Elevated trop: Resolved. Also has slight ST depressions on ECG. Likely demand ischemia in setting of anemia and GIB. Patient ruled out for acute myocardial infarction and troponins trended down. He had no further episodes of chest pressure during hospital stay. . #. Dysuria: Patient had reports of dysuria but denied UA or foley at this time. He remained afebrile and without leukocytosis. . #. GERD: PO PPI. . #. CAD/Hyperlipidemia/HTN: Continued statin. Held carvedilol in setting of GIB and stable blood pressures. Can restart as outpatient as necessary. . Medications on Admission: Carvedilol 3.125 mg Tablet 1 (One) Tablet(s) by mouth twice a day Folic acid 1 mg Tablet 4 (Four) Tablet(s) by mouth daily Levothyroxine 75 mcg Tablet 1 Tablet(s) by mouth once a day Omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth twice a day Prednisone 10 mg Tablet 1 (One) Tablet(s) by mouth daily. Simvastatin 40 mg Tablet 1 Tablet(s) by mouth every evening Bactrim 400 mg-80 mg Tablet 1 Tablet(s) by mouth once a day Warfarin 4.5 mg by mouth daily Acetaminophen 650 mg Tablet 1 Tablet(s) by mouth every 6 hours as needed for pain Bisacodyl [Dulcolax] 5 mg Tablet, Delayed Release (E.C.) 2 Tablet(s) by mouth every two days Cyanocobalamin (vitamin B-12) [Vitamin B-12] 1,000 mcg Tablet 2 (Two) Tablet(s) by mouth daily [**2159-6-4**] Docusate sodium [Colace] 100 mg Capsule 1 Capsule(s) by mouth twice a day (Prescribed by Other Provider) Senna 8.6 mg Tablet 2 Tablet(s) by mouth at bedtime nr zinc oxide 40 % Ointment topical as needed for prn . Discharge Medications: 1. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA). 7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: GI bleed; Anemia Secondary Diagnosis: Autoimmune hemolytic anemia, Mechanical aortic valve on coumadin, recurrent GI bleeds, GERD Discharge Condition: Mental Status: Confused - sometimes. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with anemia and low blood counts related to GI bleeding. You were seen by the GI doctors who discussed [**Name5 (PTitle) 19824**] and benefits of different options with you and you and yoru family decided not to pursue further invasive prcedures to look for the source of the bleeding. You were transfused 4 units of blood with improvement in your blood counts. We made the following changes to your medications 1. We held your carvedilol. This can be restarted if your blood pressure remains stable. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You should have your blood counts and coumadin level checked as detailed. Followup Instructions: Please follow up with your physicians at [**Hospital 100**] rehab as well as with your hematologist, Dr. [**Last Name (STitle) **]. Call ([**Telephone/Fax (1) 6179**] for an appointment with Dr. [**Last Name (STitle) **] next week.

[ "V43.3", "428.32", "412", "285.1", "272.4", "578.9", "294.8", "428.0", "403.90", "V10.46", "V58.61", "283.0", "585.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8531, 8597

5051, 6820

228, 234

8790, 8790

3588, 5028

9734, 9970

2766, 2854

7843, 8508

8618, 8618

6846, 7820

9010, 9711

2869, 3569

180, 190

262, 1512

8675, 8769

8637, 8654

8842, 8986

1534, 2515

2531, 2750

21,611

124,518

7678

Discharge summary

report

Admission Date: [**2173-3-25**] Discharge Date: [**2173-4-3**] Date of Birth: [**2106-2-26**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 465**] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: Tunnelled catheter placement History of Present Illness: 67 y/o female with h/o uterine cancer s/p chemo and XRT 4 with mets to small bowel s/p small bowel resection, who presented from [**Hospital3 **] with ARF. She initially presented to [**Hospital3 7571**]with generalized weakness, fatigue, increased SOB, and general sense of malaise. There, vitals were T 97.3, HR 97, BP 132/69, RR 18, sat 100% RA and was noted to be slightly disheveled and confused, but oriented, and slow to respond. ABG 7.11/11/113; WBC 20, Hct 22, BUN 101, creatinine 14.8 (baseline [**5-5**] 1.1, [**4-6**] 2.5; [**8-6**] 2.8; [**12-7**] 3.3). Per report, Pt made no urine even after foley placement. Given 500 cc NS bolus. Given Vanc 1gm IV/Levo 500 IV/Flagyl 500 IV, transfused 2UPRBCs, 1amp bicarb. Patient refused CTA, CT head and admission at [**Location (un) **] and was then transferred to [**Hospital1 18**] for further care and urgent dialysis. . In the [**Hospital1 18**] ED, T 97.0; BP 97/50; HR 87; RR 20; 98%RA. Pt seen by renal, recommmended 2gm calcium gluconate X2, 2 amps bicarb in D5W at 125cc/hr. Femoral line placed. Head CT negative. Past Medical History: # Uterine cancer: diagnosed 7-8 years ago s/p total hysterectomy. Then subsequently found to have mets to small bowel s/p resection then chemo, XRT. Since then, she has had multiple surgeries for bowel adhesions. Social History: No tobacco, rare alcohol, no Illicits. Family History: No fam hx of kidney disease. Sisiter had cysts on kidneys. Father died of lung cancer. Mother died of ?colon/stomach cancer. Her brother and sister are both obese and have HTN. Physical Exam: Well appearing thin white female. T 98.8 BP 117/66 HR 75 RR 20 Sat 97% RA SKIN: thin, papery HEENT: PEERL, EOMI, mucous membranes moist, sclera anicteric. NECK: No LAD or bruits. CHEST: Lungs clear. HEART: Regular rhythm. Pericardial rub. ABD: NABS. Soft, NT, ND. No ingunal LAD. EXT: No edema. Good pulses. NEURO: Alert and oriented to person place and time. CN II-XII intact. Full 5/5 strength throughout. Pertinent Results: [**2173-3-25**] 09:05PM BLOOD WBC-17.9* RBC-2.20* Hgb-6.4* Hct-20.2* MCV-92 MCH-29.3 MCHC-31.9 RDW-15.4 Plt Ct-216 [**2173-3-26**] 01:16AM BLOOD WBC-14.7* RBC-1.91* Hgb-5.7* Hct-17.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-15.2 Plt Ct-198 [**2173-3-26**] 11:44AM BLOOD Hct-20.4* [**2173-3-26**] 05:45PM BLOOD Hct-23.5* [**2173-3-26**] 10:10PM BLOOD WBC-10.0 RBC-2.63*# Hgb-8.1*# Hct-22.5* MCV-86 MCH-31.0 MCHC-36.2* RDW-14.6 Plt Ct-141* [**2173-3-27**] 04:29AM BLOOD WBC-7.8 RBC-2.93* Hgb-8.9* Hct-25.3* MCV-86 MCH-30.6 MCHC-35.4* RDW-14.7 Plt Ct-149* [**2173-3-28**] 06:10AM BLOOD WBC-7.2 RBC-3.11* Hgb-9.2* Hct-27.3* MCV-88 MCH-29.6 MCHC-33.8 RDW-14.9 Plt Ct-161 [**2173-3-29**] 04:50AM BLOOD WBC-8.8 RBC-3.21* Hgb-9.7* Hct-28.6* MCV-89 MCH-30.2 MCHC-33.8 RDW-15.0 Plt Ct-199 [**2173-3-30**] 04:50AM BLOOD WBC-8.8 RBC-3.13* Hgb-9.3* Hct-28.3* MCV-90 MCH-29.7 MCHC-32.9 RDW-15.2 Plt Ct-215 [**2173-3-31**] 04:45AM BLOOD WBC-7.6 RBC-3.09* Hgb-9.3* Hct-28.0* MCV-91 MCH-30.1 MCHC-33.3 RDW-15.5 Plt Ct-191 [**2173-4-1**] 04:35AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.9* Hct-29.7* MCV-91 MCH-30.2 MCHC-33.3 RDW-15.3 Plt Ct-210 [**2173-4-2**] 04:40AM BLOOD WBC-8.3 RBC-3.18* Hgb-9.4* Hct-28.7* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.2 Plt Ct-158 [**2173-3-25**] 09:05PM BLOOD Glucose-92 UreaN-100* Creat-15.7* Na-141 K-3.8 Cl-112* HCO3-LESS THAN [**2173-3-26**] 01:16AM BLOOD Glucose-109* UreaN-101* Creat-15.8* Na-145 K-3.0* Cl-111* HCO3-8* AnGap-29* [**2173-3-26**] 10:10PM BLOOD Glucose-95 UreaN-57* Creat-9.7*# Na-144 K-2.6* Cl-106 HCO3-19* AnGap-22* [**2173-3-27**] 04:29AM BLOOD Glucose-91 UreaN-60* Creat-10.2* Na-144 K-3.1* Cl-108 HCO3-19* AnGap-20 [**2173-3-28**] 06:10AM BLOOD Glucose-93 UreaN-43* Creat-7.9*# Na-143 K-3.5 Cl-107 HCO3-23 AnGap-17 [**2173-3-29**] 04:50AM BLOOD Glucose-94 UreaN-49* Creat-9.1*# Na-142 K-3.9 Cl-104 HCO3-23 AnGap-19 [**2173-3-30**] 04:50AM BLOOD Glucose-93 UreaN-54* Creat-9.6* Na-141 K-3.8 Cl-104 HCO3-23 AnGap-18 [**2173-3-31**] 04:45AM BLOOD Glucose-88 UreaN-31* Creat-6.6*# Na-144 K-3.8 Cl-104 HCO3-27 AnGap-17 [**2173-4-1**] 04:35AM BLOOD Glucose-86 UreaN-39* Creat-8.4*# Na-144 K-3.6 Cl-104 HCO3-27 AnGap-17 [**2173-4-2**] 04:40AM BLOOD Glucose-95 UreaN-26* Creat-6.3*# Na-143 K-3.5 Cl-104 HCO3-29 AnGap-14 [**2173-4-3**] 06:00AM BLOOD Glucose-85 UreaN-34* Creat-8.0*# Na-140 K-3.8 Cl-101 HCO3-26 AnGap-17 [**2173-3-26**] 01:16AM BLOOD ALT-13 AST-18 LD(LDH)-194 CK(CPK)-273* AlkPhos-61 Amylase-278* TotBili-0.2 [**2173-3-26**] 01:16AM BLOOD CK-MB-20* MB Indx-7.3 cTropnT-0.08* proBNP-[**Numeric Identifier 27934**]* [**2173-3-30**] 04:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2173-3-30**] 04:50AM BLOOD HCV Ab-NEGATIVE Head CT: No evidence of masses or hemorrhage CXR: Left lower lobe opacity either representing atelectasis or consolidation. Continued followup is suggested given clinical history. Echocardiogram: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion (< 1.0 cm in diastole). The effusion appears circumferential. Renal U/S: 1. No hydronephrosis. 2. Echogenic kidneys suggesting medical renal disease. Brief Hospital Course: 67 y/o female with hx metastatic uterine cancer presenting with acute on chronic renal failure. Tunnelled catheter placed. Initiated dialysis. # Acute renal failure: Unclear etiology as to whether obstructive (retroperitoneal fibrosis, ureteral obstruction from adhesions) versus intrarenal (ATN vs AIN from NSAID use). No evidence of hydro, so not c/w complete obstruction. Appears to be chronic based on small kidney size by U/S and rising Cr over last several years. Had pericardial friction rub during most of stay that was gone at the time of discharge. No clinical or echocardiographic evidence of tamponade, and no other evidence of uremia. A tunnelled dialysis catheter was placed, and dialysis was initiated. # Metabolic Acidosis: Corrected with bicarb and dialysis. Likely [**3-5**] uremia. # Anemia: Unclear what is baseline. Likely [**3-5**] to decreased erythropoietin production from renal failure. No overt signs of blood loss, guaiac neg in ED. RDW nl. MCV nl. Received a total of 3 units pRBCs and was initiated on erythropoietin replacement with dialysis. Medications on Admission: Advil- per daughter, patient has been taking at least 2 advil QHS for past few months, stopped a week ago Benedryl PRN Clams Forte Twin Lab B12 Ensure Prilosec OTC (just started) Rilazapam half pill [**Hospital1 **] Discharge Medications: 1. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: End-stage renal disease Secondary: Uterine cancer s/p multiple lysis of adhesions Discharge Condition: Stable, ambulatory Discharge Instructions: You were admitted because of kidney failure and have started dialysis. Please call your primary care doctor or return to the hospital if you experience bleeding, chest pain, shortness of breath or anything else concerning. Please take all of your medications as prescribed. Please attend dialysis in [**Location (un) 1514**], MA, Tuesdays, Thursdays and Saturdays. Please make a follow-up appointment with your primary care doctor as soon as possible. Followup Instructions: Please make a follow-up appointment with your primary care doctor as soon as possible. Please make a follow-up appointment with your nephrologist. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "584.9", "782.3", "423.9", "518.0", "585.6", "424.0", "288.60", "585.9", "276.2", "285.9", "787.91", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "38.95", "88.72" ]

icd9pcs

[ [ [] ] ]

7877, 7883

6288, 7367

290, 321

8019, 8040

2359, 5017

8543, 8815

1737, 1915

7634, 7854

7904, 7998

7393, 7611

8064, 8520

1930, 2340

231, 252

349, 1429

5026, 6265

1451, 1665

1681, 1721

64,520

128,347

21097

Discharge summary

report

Admission Date: [**2197-8-22**] Discharge Date: [**2197-8-25**] Date of Birth: [**2141-10-24**] Sex: F Service: [**Doctor First Name 147**] Allergies: Codeine Attending:[**First Name3 (LF) 301**] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: 1. Laparoscopic attempted Roux-en-Y gastric bypass. 2. Open Roux-en-Y gastric bypass. 3. Repair of incisional hernia, primary closure. History of Present Illness: The patient is a 55-year-old nurse who had been evaluated by [**Hospital1 **] Bariatric Program and deemed a good candidate for surgical weight loss. She has a weight of 261 pounds and has demonstrated a good understanding of the risks, benefits, and alternatives of gastric bypass. She has a hx/o multiple supervised diets. Past Medical History: Past medical history includes hypertension, osteoarthritis, and status post cholecystectomy and hysterectomy. Social History: She socially drinks and smokes 4-8 per week. Family History: A brother with a [**Name (NI) 33554**] gastric bypass 1-1/2 years ago and in-law underwent a gastric bypass in North [**Doctor First Name **]. Physical Exam: On physical exam, her weight is 261 pounds and a height of 4 feet 10 inches. She is awake and alert. Neck is supple. Breathing comfortably. Lungs are clear to auscultation. Heart is regular with no murmurs. Her abdomen is soft and nontender with no rebound. Extremities have full range of motion with some edema, but good strength. Skin with no rashes. Pertinent Results: [**2197-8-22**] 01:56PM HCT-40.9 Brief Hospital Course: In the OR, Ms [**Known lastname 55989**] planned lap GBP was converted to open. Post-op she remained intubated and was closely monitored in the PACU and T-SICU. Her O2 sats were 92%. She was weaned and extubated on POD1 with sats of 94% and transferred to the floor. She passed the methylene blue test without problem. [**Name (NI) **] NGT was dc'ed. Pain was well-controlled with PCA. On POD2, she was started on Stage 1 and later transitioned to Stage II. She was transitioned to po pain meds as well without any problems. She ambulated well three-times a day post-op. On POD3, she was transitioned to Stage III, which she tolerated well. She was later deemed stable and suitable for discharge the same day. Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) cc PO BID (2 times a day) as needed for indigestion. Disp:*600 cc* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*250 ML(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**1-6**] teaspoons PO every 4-6 hours as needed for pain. Disp:*250 mL* Refills:*0* 4. Flinstones multivitamins with Iron Sig: One (1) chewable tab PO once a day. Disp:*120 chewables* Refills:*2* 5. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day for 6 months. Disp:*360 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Morbid obesity. 2. Hypertension. 3. Osteoarthritis. 4. Incisional hernia/small. Discharge Condition: Good Discharge Instructions: Please stay on stage 3 diet until follow-up. Do not self-advance diet, drink from a straw, or chew gum. No heavy lifting (>10lbs) for 6 weeks. You may shower (no tub bathing or swimming for 6 weeks) as long as no drainage from wound sites. If there is clear drainage, cover wound and stop showering. Please [**Name8 (MD) 138**] MD for temp >101.5, persistent nausea/vomiting or pain, or drainage from wound. Please crush all pills. Followup Instructions: In 3 weeks at [**Hospital 1560**] clinic. Please call [**Telephone/Fax (1) 305**] for appointment. Completed by:[**2197-8-28**]

[ "568.0", "560.1", "V64.41", "278.01", "997.4", "553.21", "715.36" ]

icd9cm

[ [ [] ] ]

[ "53.51", "44.31", "54.59" ]

icd9pcs

[ [ [] ] ]

2992, 2998

1600, 2311

302, 439

3125, 3131

1541, 1577

3616, 3747

1007, 1152

2334, 2969

3019, 3104

3155, 3593

1167, 1522

248, 264

467, 795

817, 929

945, 991

28,256

125,197

34435

Discharge summary

report

Admission Date: [**2128-9-4**] Discharge Date: [**2128-9-12**] Date of Birth: [**2101-4-16**] Sex: F Service: MEDICINE Allergies: Azithromycin Attending:[**First Name3 (LF) 552**] Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: Pheresis catheter placement History of Present Illness: Ms. [**Known lastname 79158**] is a 27yo F otherwise healthy p/w nausea, blood-tinged emesis, and nonbloody diarrhea x 2 days and found to be thrombocytopenic and anemic at an OSH, thus transferred to [**Hospital1 18**] for further eval/mgmt. 2 days prior to admission ([**9-2**]), pt began to develop severe, intermittent HA starting at the back of her head radiating forward around 10:30AM at work and felt extremely "sick", eventually decided to go home at around 1PM. Once reaching home, pt became nauseous w/ frequent emesis and watery/yellow diarrhea, up to BM x 10/day. Emesis was at times slightly bloody, but no blood in stool. Pt denies dysuria, hematuria, or back pain, but did notice that her urine output has decreased w/ poor PO intake in the past 2 days. Pt tried to rest and increase PO fluid intake, but symptoms persisted the next day so her family decided to bring her to the OSH ED. ROS: Reports shakes/chills, night sweats, malaise, and poor appetite. No recent sick contact or travel. No recent fatigue, or other illness except a URI for 2 days around [**8-20**]. No easy bruising, rashes, hemoptysis, abdominal pain, CP, SOB, myalgias/arthralgias, weight loss. Of note, pt did develop a "cold sore" on her lower lip a few days ago just prior to her symptoms. Denies any problems with bleeding or clotting in the past. Currently she denies HA, and is mainly bothered by her persistent and frequent nausea and vomiting. She has not had any episodes of diarrhea since arrival to the ED. At the OSH, VS were T98.7 BP142/72 HR86 RR16 100%RA. Pt underwent a head CT which was reportedly negative. Labs were --138/3.6/108/23/45/1.6/126, 8.1>10.9/29.9<12, MCV85.8, estimated GFR 38.7 (nml>60), abnormal RBC morphology w/ ?UTI on U/A (+bacteria, brown, 100 mg/dl glucose, 40 mg/dl ketones, +leukocytes, ++nitrites, ++blood, >300mg/dl protein, 25-50RBC, 5-10WBC). Pt was given ciprofloxacin 400 mg IV x 1 for UTI, Morphine 2 mg IV x 2 for pain, ondansetron 2 mg IV x 2 for severe nausea. Once stabilized, pt was ransferred to [**Hospital1 18**] for eval/mgmt. In the ED, T 98.6 BP 131/62 P 90 R 16 O2 sats 99% on RA. She was given ceftriaxone 2 g IV, doxycycline 100 mg IV, Zofran 4 mg IV, and 1 liter NS. Peripheral blood smear revealed about [**2-18**] schistocytes per hpf, tear drops and a few myelocytes, very few spherocytes. Heme/onc was consulted and suspected TTP-HUS, thus contact[**Name (NI) **] the blood bank to facilitate plasmapheresis and as well as IR to place a pheresis catheter. Blood culture, lactate level were sent. Past Medical History: GERD Renal stones Obesity Social History: Smokes 10 cigarettes per day. Denies EtOH or drug use. Not sexually active. Works at an office. Lives with family (parents, 2 siblings). Family supportive and involved. Went to Castle Island last weekend, but no other travel. Denies tick or other bug bites. Family History: Mother: DM type 2, HTN, thyroid condition Father: DM type 2, HTN, 2 stents placed for CAD 1 brother who is healthy 1 sister with asthma M Grandmother: CHF M Grandfather: CVA No family history of malignancies, bleeding or clotting problems. Physical Exam: Vitals: T 98.6 BP 131/62 P 90 R 16 99% on RA GENERAL: Obese, young female ill-appearing but in NAD, belching frequently HEENT: PERRL, EOMI. Anicteric sclerae. Oral mucosa is moist, no thrush, no petechia on the palate. Few small petechiae periorbitally. NECK: Supple. no cervical LAD. No nuchal rigidity, thyromegaly, or JVP appreciated. NODES: No supraclavicular, axillary lymphadenopathy. LUNGS: Clear to auscultation bilaterally. No rales/rhonchi/wheezes. HEART: Regular rate, normal rhythm, nl S1 S2, no M/G/R. ABDOMEN: Obese, soft, NT/ND, no hepatosplenomegaly appreciated EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Few ecchymoses on L nasal ridge as well as on RUE in area of tourniquet or blood draw and BP cuff. Quarter-sized ecchymosis on RUE. Few scattered petechiae on upper and lower extremities but very few and only evident on close inspection. No rashes on palms or soles. NEURO: CN II-XII intact, AOx3, strength in upper and lower extremities [**6-21**] and equal and sensation to light touch grossly intact. 2+ b/l patellar reflexes. Downgoing toes. Coordination/Gait not assessed. Pertinent Results: ADAMTS13 Activity and Inhibitor Results Units Reference Interval ------- ----- ------------------ ADAMTS13 Inhibitor 3.6 <=0.4 ADAMTS13 Activity <5 % L >=67 INTERPRETIVE COMMENTS: Severe deficiencies of ADAMTS13 (activity <5-10%) appear to be a relatively specific finding in patients with a clinical diagnosis of idiopathic thrombotic thrombocytopenic pupura TTP will show severe ADAMTS13 deficiency , and a functional inhibitor can be demonstrated in 40-90% of these individuals. Plasma exchange therapy may induce remission of clinical symptoms of TTP despite persistance of severe ADAMTS13 deficiency. A persistently abnormal ADAMTS13 assay during remission is associated with increased risk for recurrent clinical episodes of TTP. Severe congenital ADAMTS13 deficiency ([**First Name9 (NamePattern2) 79159**] [**Doctor Last Name 1147**] syndrome) is an autosomal recessive condition which may present as thrombotic microangiopathy in either children or adults; inhibitors are generally not observed in these patients. Other where severe ADAMTS13 deficiency has been reported include disseminated intravascular coagulation, netastatuc nakugbabct, advanced cirrhosis and severe sepsis. Severe ADAMTS13 deficiency is rarely observed in secondary thrombotic microangiopathies (e.g. diarrhea-associated hemolytic uremic syndrome or after hematopoietic stem cell transplantation). Mild moderate deficiency of ADAMT13 activity has been observed in multiple medical conditions. Hemolysis with plasma free hemoglobin greater than 2gm/L or an elevated bilirubin level in the sample can cause artifactually low ADAMTS13 activity and false positive inhibitor results. EFFICTIVE [**2128-9-3**] Brief Hospital Course: Ms. [**Known lastname 79158**] is a 27yo female admitted with diarrhea, HA, N/V and found to be thrombocytopenic and anemic, findings consistent with HUS-TTP. 1)TTP-HUS: Patient presented with hemolytic anemia, thrombocytopenia, and renal failure. Upon transfer to [**Hospital1 18**], microangiopathic hemolytic anemia was evident by lab data including elevated LDH, undetectable haptoglobin, elevated bilirubin and >2 schistocytes/100x field on peripheral smear. Given clinical presentation of nausea, vomiting, and diarrhea, it is likely that she has HUS-TTP [**3-20**] to an infectious process likely E.coli O157:H7 (although no bloody diarrhea) or other infectious diarrheal illness. Other possible though less likely causes of her presentation and findings would include an acquired or congenital ADAMTS13 deficiency or unidentified toxin or medication. Given the negative direct Coombs test it is less likely a warm hemolytic anemia, and normal PT and PTT in the setting of anemia and severe thrombocytopenia would argue against DIC. With elevated creatinine and lack of MS changes such as seizures and coma, patient probably has HUS more than TTP; however, it is clinically difficult to distinguish between the two at the moment. Hematology-oncology and the blood bank was consulted and recommended starting plasmapheresis. Pheresis catheter was placed by IR. She was transferred to the MICU during her hospital stay given increased nursing needs. Her hematocrit was monitored closely and she was transfused for goal hct>21. Daily hemolysis labs were obtained as per hematology. An ADAMTS 13 level was also sent which showed very low activity, and the presence of an inhibitor. She was also started on Prednisone 90mg daily (1mg/kg) per hematology oncology. Pt was given daily plasmapheresis treatments for 8 days, last on [**9-11**]. Pt's Platelet count remained stable over the last 2-3 days. Ideally, hematology would have liked to keep patient until monday to ensure plt stability but patient was strongly insistent on being discharged asap. After discussion with the hematology team, it was decided that patient would be discharged on Sunday w/ outpt CBC check on monday, which will be reviewed by the hematology fellow. IR was contact[**Name (NI) **] to have the pheresis catheter removed. Pt also has follow up appt w Dr. [**Last Name (STitle) **] on [**9-16**] and Prednisone 90mg QD is to be continued until then per Heme. 2)Acute Renal Failure: Patient presented with creatinine of 1.7 on admission but normalized with IVFs and plasmapheresis. 3)N/V/Diarrhea: Patient presented with this constellation of symptoms. She likely had a GI illness in the setting of HUS-TTP. She was treated with Ceftriaxone for 2 days and then Ciprofloxacin for 1 day to complete a 3 day course. Stool cultures were ordered but not sent since her diarrhea had quickly resolved. 4)Anxiety. She did have anxiety regarding the diagnosis, but as her clinical health improved, her anxiety resolved. Pt was initially placed on ativan but that was quickly tapered down to 0.25mg QD prn and pt was given a limited supply without refills at discharged Medications on Admission: Ibuprofen PRN Prevacid PRN No new medications or supplements Discharge Medications: 1. Prednisone 20 mg Tablet Sig: 4.5 Tablets PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 2. Lorazepam 0.5 mg Tablet Sig: [**2-18**] Tablet PO once a day as needed for anxiety for 5 days. Disp:*3 Tablet(s)* Refills:*0* 3. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Thrombotic-thrombocytopenic purpura/hemolytic uremic syndrome. Acute renal failure, resolved Anxiety Hx GERD Discharge Condition: GOOD Discharge Instructions: You were admitted with thrombotic-thrombocytopenic purpura/hemolytic uremic syndrome. Return to the ED if you develop recurrent abdominal pain, bruising, other rashes, confusion or headache, similar to this episode. Followup Instructions: Hematology appointment: Thursday [**2128-9-16**] at 1pm, location [**Hospital Ward Name **] 9B with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You need to have a CBC drawn tomorrow [**2128-9-13**] on [**Location (un) 436**] of the building you were hospitalized in, Felberg 7, early in AM.

[ "787.91", "300.00", "283.11", "278.00", "305.1", "584.9", "446.6", "530.81", "V13.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.71", "99.04" ]

icd9pcs

[ [ [] ] ]

10370, 10376

6482, 9629

298, 327

10529, 10536

4635, 6459

10801, 11241

3249, 3490

9741, 10347

10397, 10508

9655, 9718

10560, 10778

3505, 4616

232, 260

355, 2908

2930, 2958

2974, 3233

31,045

172,113

9495

Discharge summary

report

Admission Date: [**2189-5-27**] Discharge Date: [**2189-6-4**] Date of Birth: [**2114-3-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Left lower lobe mass. Major Surgical or Invasive Procedure: [**2189-5-27**] Bronchoscopy, Left Thoracotomy, left lower lobectomy [**2189-5-31**] Ultrasound-guided diagnostic and therapeutic right-sided thoracentesis. History of Present Illness: Mr. [**Known lastname 32304**] is a 75 year-old male with a history of CAD/AS s/p CABG/AVR (pericardial) [**10/2181**], Afib, CRI, Multiple mylemoa who was found to have a left lower lobe nodule on chest x-ray, a followup CT revealed a lung cancer. He is being admitted for left lower lobectomy and medialstinal lymph node biopsy. Past Medical History: Atrial fibrillation s/p SJ PPM [**3-/2187**] for bradycardia Hypertension, Hyperlipidemia Diet control diabetes IgG Kappa Multiple Myleoma Chronic Renal Insuffiencency baseline cre (3.0-3.5) Coronary Artery Disease & Aortic Stenosis s/p CABG/AVR (pericardial) [**10/2181**] Social History: Mr. [**Known lastname 32304**] [**Last Name (Titles) 18038**] cigar for a few years, but quit about 20 years ago. Nondrinker. He worked in a chemical company, but is retired. Lives with the family, has two kids, both of them are healthy. Family History: Mother: diabetes mellitus Physical Exam: General: 75 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: decreased breath sounds left lower lobe otherwise clear GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm Incision: left thoracotomy, clean dry intact with steri-strips Neuro: non-focal Pertinent Results: [**2189-6-3**] 07:25AM BLOOD WBC-5.5 RBC-3.12* Hgb-9.8 Plt Ct-343 [**2189-6-1**] WBC-6.5 RBC-3.03* Hgb-9.8* Hct-28.4 Plt Ct-254 [**2189-5-26**] WBC-4.3 RBC-3.62* Hgb-11.4* Hct-33.4 Plt Ct-292 [**2189-6-3**] Glucose-140* UreaN-69* Creat-3.1* Na-131* K-5.2* Cl-100 HCO3-22 [**2189-6-1**] Glucose-105 UreaN-74* Creat-3.3* Na-130* K-4.9 Cl-99 HCO3-23 [**2189-5-27**] Glucose-138* UreaN-62* Creat-3.2* Na-138 K-4.2 Cl-105 HCO3-23 [**2189-6-4**] PT-12.0 INR(PT)-1.0 [**2189-6-3**] PT-12.0 PTT-25.4 INR(PT)-1.0 [**2189-5-28**] URINE CULTURE (Final [**2189-5-29**]): NO GROWTH. [**2189-5-28**] A-Line Blood Culture, Routine (Final [**2189-6-3**]): NO GROWTH. [**2189-5-28**] Venipuncture. Blood Culture, Routine (Final [**2189-6-3**]):NO GROWTH. [**2189-5-31**] 10:24 am PLEURAL FLUID GRAM STAIN (Final [**2189-5-31**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2189-6-3**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. CHEST (PA & LAT) [**2189-6-4**] FINDINGS: In comparison with study of [**6-3**], there is little change. Postoperative findings are again seen in the left hemithorax with substantial volume loss. The right lung is essentially clear. Pacemaker device remains in place. Brief Hospital Course: Mr. [**Known lastname 32304**] was admitted on [**2189-5-27**] and underwent successful Flexible bronchoscopy; cervical mediastinoscopy left thoracotomy with left lower lobe lobectomy; mediastinal lymph node sampling. He was extubated in the operating room and transferred to the SICU. He pain was well controlled via an Epidural managed by the acute pain service. He had 1 [**Doctor Last Name 406**] drain, 1 chest tube to suction and a Foley in place. On POD #1 EP interrogated his pacer, he was started on a clear liquid diet and was seen by physical therapy. He was pan cultured for fevers of 101 which had no growth. Aggressive pulmonary toileting was continued. On POD #2 he transferred to the floor and overnight had an episode of atrial fibrillation and responded to IV beta-blockers. His amiodarone and PO beta-blockers were restarted. On POD #3 the chest-tube was removed and the [**Doctor Last Name 406**] drain was placed to bulb which drain moderate amount of serosanguinous fluid. On POD #4 on chest x-ray a right lower lobe effusion was noted and underwent Ultrasound-guided diagnostic and therapeutic right-sided thoracentesis for removal of 600 mL of serosanguineous. On POD #5 the epidural was removed and he was converted to PO pain medication with good control. On POD #6 he continued to have episodes of paroxysmal atrial fibulation and was V-paced. Electrophysiology was consulted to interrogate pacer. Since he had multiple episodes of asymptomatic atrial fibrillation they recommended anticoagulation which Coumadin was started. His Foley was removed and he voided without difficulty. He tolerated a regular diet, physical therapy continued to follow. On POD #8 the [**Doctor Last Name 406**] drain was removed and he was discharged to home with VNA. He will follow-up with his PCP for further Coumadin dosing and with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Amiodarone 200mg daily, Norvasc 10 mg [**Hospital1 **], Lasix 40 mg [**Hospital1 **] minoxidil 10mg daily, Lipitor 20 mg daily, aspirin 81 mg daily, terazosin 5 mg daily, Imdur 60 mg daily, allopurinol 100 mg daily, Nexium 40 mg daily, Catapres 1 patch qwk, Toprol-XL 25 mg daily, nitro tabs, Flonase, Procrit 40,000 units when HGB < 12 and Ambien prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Norvasc 10 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO as directed: to maintain INR Goal 2.0-2.5. Disp:*30 Tablet(s)* Refills:*2* 19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 32305**] Home Health and Hospice Care Discharge Diagnosis: Atrial fibrillation s/p DDD [**3-/2187**] Chronic renal insuffiency baseline Cre (3.0-3.5) IgG Kappa Multiple myeloma Diet-Controll Diabetes Hypertension/Hyperlipidemia Coronary Artery Disease & Aortic Stenosis, s/p CABG/AVR (pericardial) [**10/2181**] Discharge Condition: stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Incision develops drainage or increased pain or redness Steri-strips remove in 10 days or soon if start to come off Chest-tube site remove dressing on Saturday, cover with a bandaid Should site begin to drain cover with a clean dressing and change as needed to keep site clean and dry Warfrin 2 mg with dinner. Please call Dr. [**Last Name (STitle) 32306**] your PCP for further coumadin dosing. INR Goal 2.0-2.5 for atrial fibrillation. INR on Monday [**6-8**] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on [**6-16**] at 1:00pm in the Chest Disease Center, [**Location (un) 453**] [**Hospital1 **] Building Report to the Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with your cardiologist for pacer interrogation in 1 month. Call Dr.[**Name (NI) 32307**] office for a follow-up appointment. Completed by:[**2189-6-4**]

[ "511.9", "162.5", "203.00", "414.00", "250.00", "427.31", "272.4", "698.9", "V42.2", "403.90", "585.9", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "32.49", "38.93", "33.23", "40.11", "89.64", "34.22", "34.91" ]

icd9pcs

[ [ [] ] ]

7451, 7531

3223, 5129

342, 502

7828, 7837

1888, 2881

8519, 8958

1434, 1461

5534, 7428

7552, 7807

5155, 5511

7861, 8496

1476, 1869

280, 304

530, 862

2917, 3200

884, 1159

1175, 1418

18,739

121,377

7668

Discharge summary

report

Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-21**] Service: MEDICINE Allergies: Codeine / Morphine Attending:[**First Name3 (LF) 5893**] Chief Complaint: dysphagia Major Surgical or Invasive Procedure: EGD History of Present Illness: 85M with CAD, CHF EF 20%, VT s/p [**First Name3 (LF) 3941**], ESRD on HD, p/w dysphagia. He ate a meal on [**11-16**] that included [**Last Name (un) 27891**]. Following that meal he felt the sensation of food stuck in throat. He has been unable to take down and keep down any food or fluid since that meal. Everything that he has eaten gets regurgitated up slowly. He lives with his daughter. The family initially watched the symptoms hoping that they would resolve, however the symptoms continued and he was brought to the ED. He denies f/c. No nausea. No coughing or SOB. In the ED, GI was contact[**Name (NI) **]. CXR showed no PNA, metoclopramide was given x1. He was admitted to hospitalist service for further management. Past Medical History: CAD s/p multiple PCIs h/o recurrent polymorphic VT s/p pacemaker [**Name (NI) 3941**] implantation Systolic dysfunction (LVEF 20-25%) HTN Hypercholesterolemia h/o TIA ESRD on HD Factor V Leiden heterozygote Hypothyroidism Depression h/o melanoma Prostate cancer s/p B subcapsular orchiectomy Social History: Patient has a 20-30 PY smoking hx, rare EtOH, lives with daughter. Family History: M, d 80: Heart failure F, d 76: Died in sleep Siblings (1 sister, 3 brothers): MI, dementia, heart disease Physical Exam: VS: Temp: 98.1 BP: 108/60 HR: 76 RR: 18 O2sat: 99 2L . Gen: In NAD. HEENT: No food or object is able to be noted on gross exam. PERRL, EOMI. Mucous membranes moist. No oral ulcers. Neck: Supple, no LAD, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, continuous AVF thrill Abdomen: soft, NT, ND, NABS, no HSM. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Neurological: alert and oriented X 3 Skin: No rashes or ulcers. Psychiatric: Appropriate. Pertinent Results: [**2141-11-18**] 08:21PM GLUCOSE-97 UREA N-21* CREAT-3.2* SODIUM-142 POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-41* ANION GAP-12 [**2141-11-18**] 08:21PM estGFR-Using this [**2141-11-18**] 08:21PM WBC-5.8 RBC-4.12* HGB-12.3* HCT-34.7* MCV-84 MCH-29.8 MCHC-35.3* RDW-17.1* [**2141-11-18**] 08:21PM NEUTS-72.5* LYMPHS-16.2* MONOS-6.8 EOS-3.6 BASOS-0.9 [**2141-11-18**] 08:21PM PLT COUNT-190 [**2141-11-18**] 08:21PM PT-43.4* PTT-45.5* INR(PT)-4.8* Brief Hospital Course: 1. Food impaction: the patient did not respond to IV reglan given at admission. He underwent EGD on [**11-19**] which demonstrated a large food particle in the esophagus that was pushed into the stomach. He required intubation for the procedure, but was easily extubated. He tolerated a clear liquid diet and was advanced to a mechanical soft/dysphagia diet. There was a possible ring identified on EGD. He will continue on his outpatient PPI and will follow up with GI in [**11-23**] weeks for repeat evaluation. He had a cough following the procedure. CXR was ordered and preliminary read did not demonstrate evidence of an infiltrate--final read (available after discharge)indicates atelectasis and possible aspiration/early infectious process. 2. ESRD: underwent HD on [**2141-11-20**], seen by renal HD/consult team. 3. CAD/CHF: not currently active. Given low BP on this admission, BP medications were held with the instruction to discuss restarting with his outpatient providers--follow up scheduled for next week. 4. Anticoagulation: supratherapeutic at admission and coumadin held. Goal as outpatient 1.8-2.5. INR 3.1 on day of discharge. Will have repeat INR drawn at HD to determine timing of restarting coumadin. 5. h/o VT: outpatient mexiletine 6. Hypothyroidism: continued levothyroxine 8. Disposition: discharged home following EGD and toleration of a mechanical/soft diet. Full code. GI/Cardiology/PCP follow up in the next 1-2 weeks. Medications on Admission: 1. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 2. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO TID (3 times a day). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 14. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day. 18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO every other day: Will take alternating 2mg, 1 mg every other day. Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Levoxyl 200 mcg Tablet Sig: One (1) Tablet PO daily (). 6. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 13. Colace 50 mg/5 mL Liquid Sig: One (1) PO twice a day. 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Food Impaction in Esophagus Duodenitis Secondary: Coronary artery disease Recurrent polymorphic VT Hypertension Ischemic cardiomyopathy Elevated cholesterol End stage Renal disaee Hypothyroidism Depression Discharge Condition: Stable, tolerating po Discharge Instructions: You were admitted with food impaction in your esophagus and underwent an upper endoscopy. You tolerated the procedure well and were extubated without complication. You were tolerating a soft diet and your medications at discharge. Because your blood pressures were low, we held your blood pressure medications (Metoprolol and Lisinopril, both on dialysis and non-dialysis days) while in the hospital and on discharge. Please re-address restarting these medications with your primary care physician or your cardiologist (you are scheduled to see Dr. [**Last Name (STitle) **] on [**2141-12-1**] and Dr. [**Last Name (STitle) 1968**] on [**2141-12-6**]). You will need an outpatient GI evaluation in [**11-23**] weeks following discharge and likely a repeat EGD. We recommend you continue with a diet of soft food until you see GI as an outpatient. Please take your medication as you were prior to admission, there were no changes. Please resume your prior anticoagulation with INR checks. Please seek medical attention for chest pain, shortness of breath, abdominal pain, inability to tolerate your medication or food or any other concerning symptom. Followup Instructions: GI follow up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2141-12-5**] 2:00. [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Unit Name 1825**] [**Location (un) 859**] Gi Suite Other upcoming appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-12-1**] 1:20 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-12-1**] 2:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-12-6**] 10:30

[ "585.6", "414.8", "V10.46", "V45.11", "V45.82", "V58.61", "403.91", "V45.02", "244.9", "414.01", "272.0", "535.60", "V12.54", "E915", "285.9", "428.22", "428.0", "787.20", "289.81", "935.1" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95", "96.71", "98.02" ]

icd9pcs

[ [ [] ] ]

6791, 6862

2571, 4036

238, 244

7122, 7146

2095, 2548

8350, 8353

1422, 1531

5564, 6768

6883, 7101

4062, 5541

7170, 8327

1546, 2076

8365, 9096

189, 200

272, 1006

1028, 1321

1337, 1406

43,107

146,413

37087

Discharge summary

report

Admission Date: [**2144-11-27**] Discharge Date: [**2144-12-2**] Date of Birth: [**2082-10-2**] Sex: F Service: MEDICINE Allergies: Tetracycline / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2181**] Chief Complaint: Alcohol withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 62 year old female with a history of alcohol abuse who is transferred from [**Hospital3 2783**] for management of possible subarachnoid hemorrhage. The patient reports that she has been in the emergency room at [**Hospital1 2436**] on four occassions in the past week for falls and pain. One on occassion there was head trauma and she required staples. She presented today for pain associated with an earlier fall as well as for medical clearance for detoxification. She notes that she has had a headache for over the past few days. On arrival she is visibly intoxicated and no further history is able to be obtained. Per her husband she has been drinking more frequently over the few months, now on a daily basis. She typically drinks nips of vodka (5-10 per day). He does not endorse any inciting factors to her increased alcohol intake. She has been using eye openers and he is concerned about her drinking. He denies a history of alcohol withdrawal. He denies a recent history of other illicit substances. He does recall that two weeks ago she was admitted to [**Hospital3 2783**] and required a blood transfusion but he is unclear why she needed this. On arrival to [**Hospital3 2783**] her initial vitals were T: 97.2 HR: 109 BP: 151/97 RR: 16 O2: 95% on RA. She received 1 liter normal saline, thiamine 100 mg IV x 1, ativan 1 mg IV x 2 and was section 12. Per notes her husband brought her in for alcohol detoxification. She admitted to drinking two shots of vodka today. On arrival she was slurring her words and was unsteady on her feet. She had previously been seen at [**Hospital1 2436**] twice this week for falls and claimed to have lost the bottle of vidocin she had received earlier in the week. CT head was concerning for possible small subarachnoid hemorrhage. She was transfered to this hospital for neurosurgical evaluation. In the ED, initial vs were: T: 97.4 P: 99 BP: 150/80 R: 16 O2 sat 99% on RA. She received two liters of normal saline. Heart rate was initially in the low 100s and increased to the 130s. She received ativan 1 mg IV x 4 and valium 10 mg IV x 1. EKG showed sinus tachycardia at 133, normal axis, normal intervals, no acute ST segment changes, no priors for comparison. She was admitted to the MICU for management of alcohol withdrawal. On arrival to the MICU she endorses headache and ankle pain. She says that she is hungry. She denies fevers, chills, night sweats, weight loss, rhinorrhea, congestions, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, hematuria, leg pain or swelling. All other review of systems is negative in detail. Past Medical History: Alcohol abuse - history of hospitalization for withdrawal. Denies a history of seizures of delerium tremens. Social History: Social History: Drinks 5-10 nips of vodka daily. Smokes 1 ppd for many years. Denies illicit drug use. Last alcohol use today. History of hospitalization for withdrawal but denies seizures or DTS. Family History: Non-contributory Physical Exam: Vitals: T: 95.2 BP: 123/66 P: 109 R: 14 O2: 99% on RA General: Lethargic, oriented to person, date, note place, intermittently falls asleep during interview, no distress HEENT: PERRL, EOMI, bruise over right eye, sclera anicteric, MM dry, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: CN II-XII tested and intact, strength 5/5 in upper and lower extremities, sensation intact to light touch throughout, gait not tested, right ankle with strong pulses, good capillary refill, no gross deformity Skin: Multiple 1 cm shallow ulcers on sacral region and bilateral lower extremities with mild erythema, no warmth, no pus Pertinent Results: Admission Labs: Na 148, K 3.4, Cl 109, CO2 16, BUN 10, Cr 0.5, Glu 99 AST 62, ALT 22, AP 325, TB 0.4, Albumin 3.2, Amylase 67, Lipase 97 WBC 6.7, Hct 39, Plts 209 INR 0.9 UA Leuk small, nitrate positive, protein trace Alcohol 531 Toxicology screen - opiates positive Micro: [**2144-11-27**] 3:00 pm URINE ADDED ON TO CHEM #69131M. **FINAL REPORT [**2144-11-30**]** URINE CULTURE (Final [**2144-11-30**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Images: CT C-spine: Straightening of the cervical lordosis is noted which may be due to patient position or muscle spasm. There is no evidence of fracture. There is no prevertebral soft tissue swelling. There are mild degenerative changes in the cervical spine. CT Head: Suboptimal study due to patient motion in the scanner. No definite acute subarachnoid hemorrhage is seen. Posterior fossa is limited for evaluation, due to motion. There is no evidence of large acute infarction, or large mass. There is prominence of ventricles and sulci, likely age-related atrophy. There is no shift of midline structures. There is no evidence of hydrocephalus. There is no evidence of fracture. Small hematoma seen in the subcutaneous soft tissues in the right supraorbital area is noted. Globes are intact. EKG: sinus tachycardia at 133, normal axis, normal intervals, no acute ST segment changes, no priors for comparison. Brief Hospital Course: 62 year old female with a history of alcohol abuse transferred to this hospital for management of a possible subarachnoid hemorrhage, admitted to the MICU for management of alcohol withdrawal. Hospital course by problem: Alcohol withdrawal: The morning of admission the patient was tachycardic, tremulous and agitated, [**Doctor Last Name **] above 10 on a CIWA scale. She was given PO valium for withdrawal symptoms. Soon afterwards she was demanding to go home though there was still significant concern for severe withdrawal. She could not clearly articulate the risks involved with her going home while actively withdrawing. She was seen by psychiatry who felt that she did not have the capacity to make the decision to leave against medical advice. She was started on thiamine, folate and a multivitamin. Her withdrawal symptoms improved and by the second day she was no longer requiring valium. At the time of discharge, she was not actively withdrawing, but she did continue to be agitated. SW saw the patient and recommended outpatient ETOH programs, though at this time the patient doesn't seem interested. She was advised to stop drinking alcohol, and to voluntarily give up her driver's license as she has been known to drink alcohol and drive previously Possible Subarachnoid Hemorrhage: Patient with report of subarachnoid hemorrhage at OSH for which she was transferred. Re-read of her head CT on arrival here was felt to be more consistent with motion artifact. She was seen by both the trauma surgery service and neurosurgery service who felt that no acute surgical management was required. A CT c-spine was negative and she was clinically cleared for fracture. Home situation/possible dementia: Through the patient's stay in the ICU, it became increasingly clear that she was not completely cognitively intact. She had extensive deficits on a mini mental status exam by psychiatry. Initially it was felt that she was nonetheless safe at home, but after more extensive discussion it became clear that her husband had elements of dementia as well and that she was likely caring for him. She was seen by social work. Psych felt that her mental status had somewhat improved at the time of discharge, but she still has significant deficits. SW believed the patient would benefit from elder services at home, who will see her at discharge and evaluate their home situations and put in services in place that would be beneficial to both her and her husband. She was felt safe to discharge home with services, and she understood the risks of drinking alcohol as well. She also realized that she needed help at home to assist both her and her husband. s/p fall: Patient gave a history of multiple falls at home. Her gait on exam was unsteady and physical therapy felt that she should be in a monitored setting. She is at significant risk of falling again, and agreed to a home safety evaluation by a elder protective services UTI: patient was found to have positive UA and urine culture for klebsiella. She was treated with cephalexin and will complete a 7 day course for both UTI and cellulitis (below) Skin Lesions: Patient with multiple small superficial lesions on her back and lower extremities with mild erythema, consistent with chronic excoriations. She has no leukocytosis or fevers and there were no signs of superinfection. A wound culture showed skin flora. She will complete a 7 day course of cephalexin Medications on Admission: Duloxetine 30mg daily Ibuprofen PRN Folic Acid Discharge Medications: 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days: last day [**2144-12-4**]. Disp:*7 Capsule(s)* Refills:*0* 2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Cellulitis Urinary Tract Infection Status post fall Skin abrasions Alcohol abuse Discharge Condition: No signs of withdrawal, tachycardic to 110s, oriented to place and time but with underlying signs of dementia. Discharge Instructions: You were admitted to the hospital to evaluate you after a fall and with concerns that you were withdrawing from alcohol. At the time of discharge, you are not showing signs of withdrawal, but we would like to monitor you further. However, you and your husband have agreed to bear the risk of going home, and have been cautioned about the warning signs of high heart rate, irritability/agitation, shaking & tremor. Our physical therapists think that you should be in a 24 hour supervised environment to prevent falls, whether at home or at a facility. Based on conversations with you and your husband, we are sending you home with an evaluation by Elder Protective Services. We recommend that you voluntarily give up your drivers license and not drive at this time. Please return to the hospital or call your physician if you develop shakiness or anxiety, feel depressed, fall again at home, or have any new symptoms that you are concerned about. Please also call your physician or the numbers provided by our Social worker if would like assistance with quitting drinking. We think that this is an important step for you and would like to help you stop drinking. Since you were admitted, we have made the following changes to your medication regimen: 1) Cephalexin, and antibiotic to be taken as directed 2) Thiamine 100 mg daily 3) Folic acid 1 mg daily 4) multivitamin 1 tablet daily Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 15916**] appointment on [**2144-12-8**] at 10:45 AM (Fax [**Telephone/Fax (1) 83587**])

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10523, 10529

6496, 6690

327, 333

10674, 10787

4471, 4471

12229, 12453

3402, 3420

10053, 10500

10550, 10653

9982, 10030

10811, 12206

3435, 4452

269, 289

6719, 9956

361, 3036

5827, 6473

4487, 5818

3058, 3168

3200, 3386

8,114

139,741

22774

Discharge summary

report

Admission Date: [**2198-11-21**] Discharge Date: [**2198-12-4**] Date of Birth: [**2138-6-21**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CAD s/p CABG x 4 LIMA->LAD, SVG->RCA, SVG->D1, SVG->D2 Carotid artery stenosis s/p Carotid stenting History of Present Illness: 60 yr old female with hx of high cholesterol, HTN, DM who is transferred here from OSH for revascularization of left craotid stenosis. Pt was found to have bilateral carotid stenosis (moderate on right, severe on left) by her PCP and was scheduled to have an elective CEA on the left. She denies chest pain but it was recommended that she have a cardiac work-up prior to her CEA. On [**2198-10-30**], pt underwent an excercise test with nuclear imaging which produced chest pain at a low work load. The imaging showed evidence of inferolateral and posterolateral ischemia and infero-apical infarction. A cardiac catheterization was scheduled for the middle of [**Month (only) 404**]. However, two days prior to this admission, pt was shopping and experienced a sharp substernal chest pain that radiated across her chest and into her left arm associated with diaphoresis, no SOB, no nausea. She sat down to rest and it resolved within 15 minutes. Later that day, she experienced that same chest pain, associated with diaphoresis but this time, she was at rest. She called her cardiologist and he suggested that she come to the hospital given that these sx were suggestive of unstable angina. At that time, she ruled out for MI with enzymes and EKG and cardiac catheterization was done. On [**2198-11-20**], cardiac cath showed severe multivessel CAD with high grade stenosis of the proximal and mid-LAD, large D1 and D2 branches, ostial LCx and ostial RCA. Pt was transferred to [**Hospital1 18**] for carotid artery stenting followed by CABG. Past Medical History: 1. CAD 2. Carotid artery stenosis 3. Hypertension 4. High cholesterol 5. DM, type II 6. Depression 7. Anxiety 8. Arthritis 9. s/p cholecystectomy [**03**]. s/p hysterectomy and tubal ligation Social History: married with four children lifelong non-smoker no alcohol no IVDA Family History: mother died of melanoma at age 81 but had CAD Father with CAD and died of CVA at 65 4 children are healthy Physical Exam: temp 96.5, BP 108/74, HR 85, RR 18, O2 100% on RA, FS 133 Gen: NAD, comfortable HEENT: PERRL, EOMI, MMM, OP clear, anicteric sclera Neck: no bruits, no JVD at 45 degrees CV: RRR, no c/r/m/g Chest: clear, good insp effort Abd: +BS, soft, obese, NTND, no renal bruits heard Groin: right cath site with ecchymoses, no active bleeding or oozing, no thrill or bruit; no femoral bruit on left Ext: no edema, warm, 2+ pulses, no varicosities Neuro: AO x 3, CN 2-12 intact Psych: flattened affect; slightly tangential Pertinent Results: Pre-op EKG [**11-21**]: Sinus rhythm, rate 70. Normal tracing. Pre-op CXR [**11-26**]: No active lung disease identified [**2198-11-21**] 10:10PM BLOOD WBC-9.1 RBC-4.02* Hgb-12.5 Hct-36.2 MCV-90 MCH-31.0 MCHC-34.4 RDW-13.3 Plt Ct-323 [**2198-11-29**] 06:50AM BLOOD WBC-14.9* RBC-3.11* Hgb-9.2* Hct-27.2* MCV-87 MCH-29.5 MCHC-33.7 RDW-15.5 Plt Ct-238 [**2198-12-3**] 04:32PM BLOOD Hct-27.5* [**2198-11-21**] 10:10PM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2 [**2198-11-21**] 10:10PM BLOOD Plt Ct-323 [**2198-11-28**] 02:00AM BLOOD PT-14.2* PTT-31.7 INR(PT)-1.3 [**2198-11-29**] 06:50AM BLOOD Plt Ct-238 [**2198-11-21**] 10:10PM BLOOD Glucose-208* UreaN-16 Creat-0.6 Na-140 K-3.7 Cl-104 HCO3-26 AnGap-14 [**2198-12-3**] 04:32PM BLOOD Glucose-107* UreaN-16 Creat-0.6 Na-140 K-3.7 Cl-100 HCO3-28 AnGap-16 [**2198-11-21**] 10:10PM BLOOD ALT-26 AST-19 CK(CPK)-74 AlkPhos-58 TotBili-0.7 [**2198-11-21**] 10:10PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2198-11-21**] 10:10PM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8 [**2198-11-22**] 07:25AM BLOOD Triglyc-322* HDL-37 CHOL/HD-5.4 LDLcalc-97 [**2198-11-26**] 12:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026 [**2198-11-26**] 12:15PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2198-11-26**] 12:15PM URINE RBC-21-50* WBC-[**1-19**] Bacteri-OCC Yeast-NONE Epi-0-2 Brief Hospital Course: As mentioned in the HPI, pt is a 60 yr old female with hx of DM, high cholesterol, DM recently found to have bilateral carotid stenoses and multi-vessel coronary artery disease on cath transferred to [**Hospital1 18**] for carotid revascularization before CABG. Pt. first had neurology consult before proceeding with carotid stenting (see note). On [**2198-11-23**], pt had successful PTA and stenting of the [**Doctor First Name 3098**] (please see procedure report for details). Over the next several days following her left carotid stenting, pt. was medically managed without incident and received appropriate anticoagulation meds while awaiting CABG. On [**2198-11-27**] pt was brought to the operating room and underwent coronary artery bypass graft surgery x 4 and left femoral artery repair(pleae see surgical note for full details). Pt tolerated the procedure well with a CPB time of 119 minutes and XCT of 100 minutes. Pt was transferred to CSRU in stable condition with a Phenylephrine drip for BP support, Insulin drip, and being titrated on Propofol. Later that day, propofol was weaned and NMB reversed. Pt became awake and was extubated without incidence. Pt. was moving all extremeties, awake, alert, and neurologically intact. POD #1 - Pt. was stable. Weaned off of all drips. Swan Ganz catheter removed. Pt. was transferred to telemetry floor. POD #2 - Pt. was somewhat dyspneic in AM. Pt. had decrease BS at bases. Lasix was increased to 40 mg IV bid and CXR was ordered. CXR revealed a small left apical pneumothorax. Two left-sided chest tubes are in unchanged position with stable cardiomegaly. Atelectasis within both lower lobes. POD #3 - Repeat CXR revealed there has been slight decrease in the size of the patient's left apical pneumothorax. Chest tubes off suction,now wter seal. Pt. hemodynamically stable. Epcardial pacing wires and foley removed POD #4 - Another repeat CXR revealed no changes in the size of the left apical pneumothorax. Chest tubes were then removed. Post chest tube removal CXR showed there is a small left apical pneumothorax. Pt. cont. to encouraged to ambulate and get OOB with PT. POD # [**3-23**] - Over the next three days pt slowly improved and was finally at level 5 on POD #7. Throughout post-op course pt was seen by PT and medically managed with stable glucose control. Pt. was discharged home with VNA services. D/C PE: T 98 P 93 BP 124/72 RR 18 Neuro: Alert, oriented, non-focal Pulm: CTAB -w/r/r Cardiac: RRR -c/r/m/g Sternum: Stable, inc. with steri strips c/d/i, -drainage/erythema Abd: Soft, NT/ND, +BS Ext: Warm, 2+ edema, leg inc. C/D/I with steri strips. Medications on Admission: fish oil ranitidine 50mg [**Hospital1 **] lipitor 80mg qd lopid 600mg qd zestril 20mg qd risperdal 1mg qd ativan 1mg po q8 prn albuterol/atrovent asa 325mg qd metoprolol 25mg [**Hospital1 **] glucophage? Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*90 Tablet(s)* Refills:*0* 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 2 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. 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* 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: CAD s/p CABG x 4 LIMA->LAD, SVG->RCA, SVG->D1, SVG->D2 Carotid artery stenosis s/p Carotid stenting HTN ^chol DM2 depression anxiety OA s/p Cholecystectomy s/p hysterectomy and tubal ligation Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: wound clinc in 2 weeks Dr [**Last Name (STitle) 51717**] in [**12-20**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2199-2-26**]

[ "250.00", "300.00", "411.1", "433.10", "998.12", "414.01", "401.9", "493.90", "512.1" ]

icd9cm

[ [ [] ] ]

[ "00.61", "39.61", "39.31", "00.63", "36.13", "88.42", "36.15", "88.72", "88.41" ]

icd9pcs

[ [ [] ] ]

8856, 8918

4376, 7002

333, 434

9153, 9159

2984, 4353

9360, 9508

2331, 2439

7256, 8833

8939, 9132

7028, 7233

9183, 9337

2454, 2965

283, 295

462, 2017

2039, 2232

2248, 2315

27,745

121,267

25804+57467

Discharge summary

report+addendum

Admission Date: [**2157-1-19**] Discharge Date: [**2157-1-29**] Date of Birth: [**2094-3-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain and shortness of breath Major Surgical or Invasive Procedure: picc line placement [**2157-1-21**] picc line placement [**2157-1-25**] History of Present Illness: The patient is a 62 year0old male well-known to the transplant surgery service recently discharged home on [**2157-1-15**]. His most recent admission for management of his anticoagulation with a supratherapeutic INR to 6.3. He had an orthotopic liver transplant [**2156-12-8**] complicated post-operatively by a NSTEMI where he underwent a failed cardiac catheterization on [**2156-12-27**]. He was discharged [**2156-12-29**] and returned on [**2157-1-1**] with continued chest pain. During that hospitalization was emergently taken to the operating room with peritonitis and where he underwent a exploratory laparotomy, drainage intra-abdominal abscess, resection necrotic distal common bile duct and hepaticocholedochojejunostomy on [**2157-1-3**]. His postoperative course was complicated by an episode of atiral fibrillation with spontaneous cardioversion on a diltiazem drip. On [**2157-1-7**] he underwent a cholangiogram which demonstrated mild stenosis at the hepaticojejunostomy anastamosis with mild left greater than right intrahepatic biliary ductal dilatation and mild delay of contrast passage into jejunal loops with no evidence of biliary leak. He was discharged home on [**2157-1-10**] on anticoagulation for atrial fibrillation. . Today, he presents with diffuse abdominal pain that progressed tonight approximately 11PM associated with shortness of breath and chest pain. The chest pain was similar to what he has previously experienced, however, the diffuse abdominal pain is new onset, not localized, associated with increased abdominal girth, and difficulty with urination. He reports he has had intermittent shortness-of-breath since yesterday afternoon but has significantly worsened tonight. Past Medical History: 1. Alcohol-related cirrhosis status post TIPS placement [**2154-10-8**] requiring dilatation [**2154-10-15**] now s/p orthotopic liver transplant [**2156-12-8**] 2. Upper GI bleeding in [**2152**]. Patient was treated at an outside hospital and it is unclear whether his upper GI bleed was secondary to esophageal varices or peptic ulcer disease. 3. Coronary artery disease status post angioplasty in the [**2129**]. 4. Diabetes mellitus type 2 diagnosed in [**2152**]. Hemoglobin A1c [**2154-10-4**] was 6.3 5. Umbilical hernia status post repair [**2154-11-3**] 6. Right knee surgery 7. Depression 8. HCC, growth [**Last Name (un) 64259**] 2.5x2.5cm confirmed on [**2156-9-8**] at the dome of the liver 9. Recurrent recent paracentesis due to refractory ascites Social History: Married with two adult sons. Formerly worked as a vice president of a trucking company. Drank from the age of 20 until [**2154-9-19**]. He never smoked. Denies IV drug use. Family History: Father and brother died of MI at the age of 52. His mother and sister have diabetes. Physical Exam: Vitals: 99.9 74 173/82 20 92% 3LNC RRR Coarse breath sounds throughout, difficulty with deep breaths Tense abdomen, distended, mildly TTP diffusely, hypoactive bowel sounds, incision are clean, dry, intact except for left lateral portion with wet-to-dry dressing, staples present. Extremities warm and dry, palpable pulses distally Pertinent Results: On Admission: [**2157-1-19**] WBC-10.2 RBC-3.27* Hgb-10.3* Hct-29.0* MCV-89 MCH-31.5 MCHC-35.6* RDW-15.9* Plt Ct-251 PT-18.1* PTT-36.1* INR(PT)-1.7* Glucose-85 UreaN-31* Creat-2.2* Na-137 K-5.6* Cl-106 HCO3-18* AnGap-19 ALT-26 AST-42* CK(CPK)-46 AlkPhos-307* Amylase-43 TotBili-0.9 cTropnT-0.07* Calcium-8.4 Phos-3.1 Mg-1.4* Brief Hospital Course: 62 y/o male s/p liver transplant and cardiac history who presented with shortness of breath and diffuse abdominal pain. He had an episode of rapid AFib in the ER and was given IV Lopressor. He was transferred to the SICU and was placed on an Esmolol drip. Tube cholangiogram was performed: which demonstrated mild stasis of contrast through the hepaticojejunostomy anastomosis site and mild dilatation of the intrahepatic biliary ducts. There was no evidence of biliary leak. He also underwent U/S guided paracentesis for small to moderate ascites found on U/S. Fluid drained was found to have WBC: 1750 RBC: [**Numeric Identifier 2249**] Diff P:66 L:13 Macrophage:21 Culture showed 4+ PMNs without any bacteria noted. Cultures were negative. A repeat diagnostic tap was negative. Blood and urine cultures were negative. Vanco and Zosyn were started empirically. Cardiac consultation occurred throughout the remainder of his hospital stay as he was transferred in and out of the SICU several times for recurring afib necessitating an Esmolol drip. Lopressor was increased to 100 tid and amiodarone was increased to 400mg [**Hospital1 **] with an extra loading dose of 400mg on [**1-27**]. Recommendations included decreasing the amiodarone to qd after a week. Rhythm converted to sinus with HRs in the 50-52 range with a SBP range of 94-107. He denied lightheadedness, CP, SOB and nausea. PT declared him safe for discharge home. A PICC line was inserted on [**1-21**] in anticipation of the necessity of continuing IV antibiotics. The patient had self d/c'd this line. This was replaced oon [**1-26**]. A portable cxr demonstrated placement in the SVC. There was some improvement in the pulmonary edema noted on previous CXRs and there was a L pleural effusion. Coumadin 0.5mg qd was resumed. INR was 2.3 on [**1-27**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor was arranged for him for discharge. His prior PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] ([**Telephone/Fax (1) 5315**];[**Telephone/Fax (1) 64261**]who is a cardiologist was contact[**Name (NI) **] and is willing to follow [**Name (NI) 5699**] upon discharge. Medications on Admission: Mycophenolate Mofetil 1000 mg [**Hospital1 **] Prednisone 12.5 mg DAILY Valganciclovir 450 mg DAILY Trimethoprim-Sulfamethoxazole 80-400 mg DAILY Fluconazole 200 mg DAILY Pantoprazole 40 mg DAILY Docusate Sodium 100 mg [**Hospital1 **] Metoprolol Tartrate 50 mg [**Hospital1 **] Oxycodone 5-10 mg Tablet PO Q4-6H Disp:*20 Tablet(s)* Refills:*0* Citalopram 20 mg DAILY Tamsulosin 0.4 mg QHS Senna 8.6 mg [**Hospital1 **] Aspirin 325 mg DAILY Simvastatin 10 mg DAILY Isosorbide Mononitrate 30 mg DAILY Insulin Glargine 12 units SC Insulin Regular Human sliding scale Coumadin 0.5 mg DAILY Tacrolimus 1 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): decrease to 7.5mg once daily on [**2-6**]. 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*12 * Refills:*2* 14. syringes Sig: One (1) syringe 3x/week for Epogen: supply 1 cc syringe with 25 gauge fine needle. Disp:*1 box* Refills:*1* 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): decrease to 400mg once daily on [**2-3**]. Disp:*35 Tablet(s)* Refills:*0* 16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 18. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 19. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 20. Warfarin 1 mg Tablet Sig: .5 Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*1* 21. Outpatient Lab Work Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, PT/INR and trough prograf level. fax to [**Telephone/Fax (1) 697**] [**Hospital1 18**] Transplant Office Attn: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**], RN coordinator 22. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO 2 tablets TID until [**1-31**], then take 2 tablets [**Hospital1 **]: Take two tablets three times daily until [**1-31**], then take two tablets twice daily. Disp:*124 Tablet(s)* Refills:*2* 23. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Afib s/p liver transplant [**11-25**] DM II Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take any of your medications, dizziness, chest pain,palpitations, shortness of breath, redness/bleeding/drainage [**Company 5249**] tube site, malaise or any concerns. Labs twice weekly. "[**Doctor Last Name **] of Hearts Monitor" x1 week Please call 1-[**Telephone/Fax (1) 64262**] on Sun [**1-30**] to have the holter lab technician assist you in setting up your [**Doctor Last Name **] of Hearts Monitor. Try to call between 11AM and 12PM. You will have your weight monitored by the transplant clinic after discharge. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2157-2-2**] 1:40 Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] [**Telephone/Fax (1) 5315**] to schedule a follow up in 1 week. Name: [**Known lastname 11379**],[**Known firstname **] Unit No: [**Numeric Identifier 11380**] Admission Date: [**2157-1-19**] Discharge Date: [**2157-1-29**] Date of Birth: [**2094-3-28**] Sex: M Service: SURGERY Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 2800**] Addendum: abdominal pain probably secondary to bacterial peritonitis Discharge Disposition: Home With Service Facility: [**Location (un) 9684**] Home Care Services [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2157-3-18**]

[ "585.9", "V45.82", "250.00", "789.09", "789.59", "V42.7", "403.90", "V58.61", "428.0", "V45.89", "567.23", "414.01", "427.31", "272.0", "338.29", "410.72", "311" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "87.54", "54.91" ]

icd9pcs

[ [ [] ] ]

11079, 11312

3988, 6221

352, 426

9634, 9641

3639, 3639

10331, 11056

3179, 3267

6897, 9449

9567, 9613

6247, 6874

9665, 10308

3282, 3620

274, 314

454, 2180

3653, 3965

2202, 2968

2984, 3163

19,303

146,139

52603

Discharge summary

report

Admission Date: [**2122-11-6**] Discharge Date: [**2122-11-26**] Date of Birth: [**2043-10-18**] Sex: M Service: CSU DEATH SUMMARY: ADMISSION DIAGNOSIS: Syncope with unstable angina, status post cardiac catheterization and stent placement, complicated by coronary artery dissection followed by emergent coronary artery bypass grafting. BRIEF HISTORY: This is a 79-year-old male with a history of chronic renal insufficiency, diabetes, hypertension, who has been worked up for falling down over the past few days prior to admission, as well as a history of spinal stenosis in his lumbar region. He was admitted to the medicine service and was worked up. Due to his history of chronic renal insufficiency, it was felt that he was going to require dialysis therapy and underwent a left upper extremity brachial cephalic arteriovenous [**Doctor Last Name 4726**]-Tex graft placement on [**2122-11-12**]. He was evaluated by occupational therapy and physical therapy, etc., during that time as well as the renal service. Because of relative hypotension with a pressure of 80 systolic, antihypertensive therapy was held. On [**2122-11-14**] the patient developed angina at rest which transiently responded to nitroglycerin with new ST depressions noted laterally. He was started on heparin and aspirin and cardiology was consulted. Chest x-ray seemed to be consistent with what appeared to have been congestive heart failure. The patient was felt that, given his EKG changes, that it would be appropriate to take him for cardiac catheterization which was done. The patients was DNR and had initially refused cardiac cath. However, he then agreed to the procedure. The patient was taken to the cardiac catheterization laboratory on [**2122-11-16**]. He was found to have LAD and RCA coronary disease. Angioplasty of the left anterior descending artery was attempted, but this complicated by percutaneous interventional dissection of the left anterior descending artery and thus was taken for emergent coronary artery bypass grafting by Dr. [**Last Name (STitle) **], in which he underwent a left internal mammary anastomosis to the left anterior descending artery as well as a saphenous vein graft to the right coronary artery. The LAD was very diseased and required endarterectomy inorder to be bypassed. He tolerated this relatively uneventfully in the operating room and was transferred immediately postoperatively to the cardiac surgery recovery unit. He was then extubated by postoperative day #3 and was placed on a Lasix drip to facilitate urine output as he had chronic renal insufficiency. He was being followed by renal and because of his excellent response to intravenous Lasix, any dialysis episodes were held off at that time. However, on postoperative day #3, in the evening, he developed an episode of upper sternal discomfort and was evaluated by the cardiology service. The patient was in the presence of the health care proxy and discussion of possibly taking him to cardiac catheterization was decided against this. The patient, during this episode, had elevated troponin but given the patient's anatomy and the cardiology service input, it was decided that the patient would not benefit from any further procedures. The patient, as well as the health care proxy, also refused any further procedures. The patient was maintained on a Lasix drip in the postoperative course, supplemented with some low-dose Neo- Synephrine to maintain accessible blood pressure. Echocardiogram was also obtained the night of the event, postoperative day #3, and this showed heart function consistent with the preoperative state. The renal service decided that the patient would undergo dialysis on postoperative day #10 and as the patient was transferring from chair to bed, he became unresponsive and underwent a cardiac arrest. Following a very brief episode of CPR, the pulse was regained and, as well, a transient neurologic recovery was seen. However, the [**Hospital 228**] health care proxy at that point in time pointed out that the patient was to be DNR and the documentation was provided for this. It should be noted that the DNR order was reversed in the immediate preoperative period as the patient was taken to the operating room. However, the DNR decision, per the health care proxy, was upheld as Dr. [**Last Name (STitle) 911**] from cardiology was present during this time. He pronounced the patient at 2:20 p.m. on [**2122-11-26**]. A coroner's case was refused as was a postmortem examination. DISCHARGE DIAGNOSIS: Fall, syncope, unstable angina, coronary artery disease, status post percutaneous intervention and coronary artery bypass grafting. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern4) 95954**] MEDQUIST36 D: [**2122-11-26**] 22:12:25 T: [**2122-11-27**] 11:48:46 Job#: [**Job Number 108594**]

[ "585.9", "707.15", "414.01", "250.60", "997.1", "998.11", "E879.0", "584.9", "403.91", "286.9", "722.10", "250.40", "411.1" ]

icd9cm

[ [ [] ] ]

[ "37.22", "00.66", "00.40", "36.11", "39.27", "39.61", "38.93", "88.56", "36.15", "36.07", "00.47" ]

icd9pcs

[ [ [] ] ]

4560, 4968

176, 4538

11,446

165,408

45880

Discharge summary

report

Admission Date: [**2203-8-7**] Discharge Date: [**2203-8-13**] Date of Birth: [**2146-4-3**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Aspirin / Codeine / Lipitor / Lisinopril Attending:[**First Name3 (LF) 3151**] Chief Complaint: Hypotension, dizziness Major Surgical or Invasive Procedure: Intubation. History of Present Illness: Patient is a 57 year old female with past medical history of aortic valve replacement, hypertension, and hypothyroidism who presented to the emergency department with dizziness and fall after taking all of her daily medications at one time on the evening of [**2203-8-7**]. . Patient relates that she usually takes her medications for the day all at once (except a few evening medications) in the morning, including plavix, levoxyl, klonipin, lisinopril, triampterene/HCTZ, diovan, lopressor, imdur, lamictal, and possibly others. She reports she became dizzy and fell after taking her medications. Otherwise she has felt well recently. She does relate some episodes of chest pain several weeks ago and had seen cardiology for them. Otherwise she has felt in her usual state of health, however some increasing fatigue. In the ED she denied chest pain, palpitations, shortness of breath, fever, or chills. . Hospital Course: . In the ED, her vitals were: T 98.7, BP 62/30, RR 20s, Oxygen saturation 98% on RA, HR 68. She was given 2L IVF without improvement in her BPs, so dopamine was started. She also received narcan w/out effect, glucagon, and charcoal, with emesis. She was intubated for airway protection and a tiple lumen was placed. A head CT was completed and negative for any acute process. . She was transferred to the MICU where she ws kept on dopamine and propofol while intubated, for a day, and successfully extubated on [**8-8**] without difficulty. She was given 4L IVF. To work up her hypotension, a TSH was checked. An echo was completed and cultures were sent. Her creatinine was elevated up to 2.0, but urine output remained good. Her BP meds were held, as were a number of her psychiatric medications, some of which were restarted prior to transfer to the floors. SW and psychiatry followed patient, who is adamant that the overdose was unintentional. . Tonight upon reviewing the HPI and hospital events, patient states she is feeling tired, and not quite at her baseline, but otherwise well. She has no specific complaints, aside from concerns about the stress that her hospitalization has created on her and her family. Currently she is concerned about money that she had with her and was signed out to her daughter, who claims she never got it. She denies CP, SOB, abdominal pain, nausea, vomiting, headache, or dizziness. Past Medical History: -CAD with LVEF > 50%, s/p CABG in [**2195**] (LIMA>>LAD, SVG>>PDA and OMI), stent placement in [**2199**], cath demonstrated 2 VD -NonQ wave MI -Aortic Valve Replacement [**2195**], Mitral Valve ring-annuloplasty -Hypertension -Hyperlipidemia -Hypothyroidism secondary to RAI for [**Doctor Last Name 933**] Disease -Depression with psychosis -Discoid Lupus -PTSD -Carcinoid s/p resection in [**2173**] -COPD -s/p TAH and b/l BOS -Hemolytic Anemia -Migraine -T9/T10 Disc Herniation Social History: Lives at home with her son, daughter, granddaughters, nephew, [**Name2 (NI) 802**], and granddaughter's close friend. Denies alcohol use, smokes about 1 PPD. Denies drug use. Family History: Father, healthy, in his 80s. Mother, 73, deceased, had DM HTN. Sister died at age 47 from MI. Brother died from liver cirrhosis. Physical Exam: At MICU admission . Physical Exam: VS: Tm 96.0 BP 125/70 HR 64 O2: on AC Gen: sedated, intubated HEENT: PERRL. JVD not elevated. Hrt: RRR. 2/6 SEM with S2 click. Lungs: CTAB no RRW. Abd: S/NT/ND +BS. Ext: WWP. No edema. 2+pulses. Neuro: not able to assess. . Upon admission to floor from MICU: Tm 98.4 Tc 98.2 BP 130/62, range 126-130/60-62 HR 74 RR 16, 97% on RA FSBG 125 @ 1700 Weight 89.1 kg -General: Pleasant female appearing younger than stated age, in NAD, resting in bed comfortably, appearing slightly tired. -HEENT: NC/AT. MMM, PERRL, no scleral icterus, no conjunctival pallor, no LAD or thyromegaly/thyroid nodules. Supple neck, flat JVP. -Cardiac: RRR, II/VII SEM with mechanical-sounding click. No gallops, rubs. -Lungs: CTAB, no w/r/r, good air movement. -Abdomen: soft, NT, ND, +BS, no HSM -Extr: Warm, well perfused, trace edema, no lesions, DP 2+ bilaterally, PT 2+ bilaterally. -Neuro: CNs grossly intact, motor/sensation intact, A&Ox3. -Psych: Slightly flat affect, reserved, appears slightly depressed, down. . Pertinent Results: DATA: EKG:NSR @ 67. Norm Axis and intervals. RBBB pattern unchanged from prior. No ST-T wave changes. . CXR: [**2203-8-7**]: FINDINGS: Bedside AP examination labeled "supine at 19:40H" is compared with the similar study obtained approximately one hour earlier. There has een interval repositioning of the ET tube, with tip now approximately 3.8 cm proximal to the carina. An NG tube extends below the diaphragm and beyond the film, with its side-hole in the region of the gastric body and the gaseous distention of the stomach has resolved. A new right internal jugular central venous catheter terminates in the region of the cavo-atrial junction with no supine evidence of pneumothorax. There is patchy, streaky opacity involving the left lung mid-zone and base which may represent subsegmental atelectasis. The patient is status post median sternotomy with CABG and probable AVR, as before. . CT Head: [**2203-8-7**]: FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, shift of normally midline structures, or hydrocephalus. There are no fractures. There is extensive opacification within the nasopharynx and nasal cavity which is new. There is mild mucosal thickening within the ethmoid air cells. The visualized maxillary sinuses, mastoid air cells, and the middle ear cavities are clear. Soft tissues appear unremarkable. IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. New nasopharyngeal and nasal cavity opacification. Direct visualization is recommended. . ECHO [**2203-8-8**]: Conclusions: The left atrium is normal in size. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A well-seated annuloplasty ring is present. There is a minimally increased gradient consistent with trivial mitral stenosis. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2201-2-17**], the estimated pulmonary artery systolic pressure is now lower. Biventircular systolic function and valvular function are similar. Brief Hospital Course: Assessment and Plan: 57 year old female with HTN, AVR, depression, and hypothyroidism presents with hypotension after taking all medications at one time, presents to floors after stay in MICU with intubation and pressors, now hemodynamically stable. . # Hypotension/Medication Ingestion: Given the acute onset of symptoms shortly after the patient reports she took "all of her pills," it is highly likely, as thought by the MICU and ED teams, that the patient suffered adverse consequences of taking too many blood pressure and sedating medications at once. It appears that she took her klonopin, lisinopril, triampterene/HCTZ, diovan, lopressor, and imdur, all at one time. Psychiatry and social work followed closely with the medical team, and did not feel that it was a suicide attempt, although clearly there was a need to review patient's medication list with her and try simplify her regimen. - TSH was checked while in the MICU, was found to be decreased (see discussion below). - Her blood cultures were all negative, with the [**2203-8-9**] culture still pending at time of discharge--it was felt that sepsis was very unlikely. - BP has slowly rose while off BP medications, and a few of her medications were re-introduced. Given her cardiac history, it was desirable to get her beta-[**Month/Day/Year 7005**] and [**Last Name (un) **] restarted, so she was titrated back up to 100mg of metoprolol [**Hospital1 **], and 40 of valsartan, with blood pressures remaining in the 100-120 systolic range--she was switched to Toprol XL for easier dosing at discharge. - A VNA was arranaged to assist with medication management and administration at home. - Food preparation alternatives and low-salt diet was discussed at length with patient, as it was recognized that she ate a lot of salty food and her pressures would likely rise upon return to her home. . # Depression- There was concern over whether medication overdose was intended, however, as noted above psych evaluated patient and felts it was a mistake. Psychiatry and social work followed closely and assisted with evaluating patient and setting up services for post-discharge. It was felt she was safe to return home, as she denied and continued to deny any suicidal or homicidal ideations. - Klonopin 1mg TID and Seroquel 150mg QHS were re-introduced and well tolerated. - In coordination with her outpatient psychiatrist, Celexa 10mg was started in place of prozac, and her lamictal was held. - Social work and psychiatry set up a social work appointment for shortly after discharge, as well as arranged for patient to enter partial hospitalization program at [**Hospital1 882**] hosptial on [**Hospital1 766**] the 24th. - A psychiatric VNA was arranged to assist with transition back home. . # ARF: Resolved, was likely secondary to volume depletion, as well as decreased renal perfusion secondary to low BP. Baseline creatinine is about 1.3 and her peak was 2.0. - Encouraged patient to keep drinking a lot of fluids. . # Hypothyroidism- Per OMR notes, her dose was recently increased in [**Month (only) 205**], although patient states she never changed her dose and has continued to take 112mcg, and now her TSH is low at 0.041. - We decreased her Levothyroxine dose to 100 mcg, and this will need to be followed up as an outpatient. Patient did not appear hyperthyroid on exam and it was felt that an overdose of levothyroxine was unlikely to account for the low TSH. . # Nasopharyngeal opacification: Was most likely secondary to congestion or some sinusitis--patient had no symptoms during this stay. This may be further followed up, if desired, as an outpatient. . . # AVR: On coumadin for aortic valve replacement, INR Goal 2.5-3.5. Coumadin restarted at home dosing. . # CAD: Restarted [**Month (only) **], plavix, as well as beta [**Month (only) 7005**] and [**Last Name (un) **]. . # Hyperlipidemia: Restarted atorvastatin. . # Safety/Discharge planning: - Physical therapy evaluated patient and felt she was safe to return home. - Social work, case management, and psychiatry arranged for close follow up, home services. A follow up appointment with her [**Name8 (MD) 6435**] NP was also arranged for the near future. Medications on Admission: . Meds: Per OMR -albuterol PRN -aspirin 325mg daily -atorvastatin 10mg daily -clonazepam 1mg QAM, 2mg [**Hospital1 **] -clopidogrel 75mg daily -folic acid 5mg daily -imdur SR 60mg daily -lamictal 50mg QAM for now (CHECK OMR FOR EXACT DOSING) -levothyroxine 112mcg daily -metoprolol tartrate 100mg [**Hospital1 **] -ntg PRN -percocet 2.5/325 1mg Q6:PRN -protonix 40mg daily -prozac 10mg QAM -seroquel 300mg QHS -triampterene/hydrochlorthiazide 37.5/25 1tab daily -valsartan 80mg daily -warfarin 3mg as directed . ??? taking lisinopril 5mg - patient still with this medication in her cabinet . Allergies: Iodine; Iodine Containing Aspirin Codeine Lipitor (Oral) (Atorvastatin Calcium) Lisinopril Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*0* 3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Toprol XL 200 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* 10. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Quetiapine 100 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). Disp:*45 Tablet(s)* Refills:*0* 12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Folic Acid Oral 14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: -Hypotension Secondary Diagnoses: -Coronary Artery Disease -Hypothyroidism -s/p Aortic Valve replacement -Hypertension -Hyperlipidemia -Depression -Discoid lupus -PTDS -COPD -s/p TAH and b/l BOS -Hemolytic Anemia -Migraine -T9/T10 Disc Herniation Discharge Condition: Stable. Discharge Instructions: You were admitted due to a fall and very low blood pressure. You spent time in the intensive care unit where a ventilator helped your breathing and medications helped support your blood pressure. It was thought that the very low blood pressure was a result of taking too many medications at one time. You were monitored carefully, and a number of test were completed to ensure there were no other causes for your illness. A few of your blood pressure medications were re-started, at lower doses. You should take your medications exactly as prescribed, and follow up closely with Dr. [**Last Name (STitle) 665**] to monitor your blood pressure and medications. . As discussed during your admission, you should avoid eating a lot of salt. This includes adding salt to your meals, as well as pre-packaged, canned, or frozen meals, as they also contain a lot of salt. You may wish to set aside a portion of food for yourself prior to adding salt, as you are preparing food for others. . Please contact Dr. [**Last Name (STitle) 665**], or go to the emergency room, if you experience fever, chills, chest pain, shortness of breath, headache, dizziness, thoughts of harming yourself or others, or other concerning symptoms. . Please follow up with Dr. [**Last Name (STitle) **] in psychiatry on [**2203-8-17**] at 3:30pm. . Please follow up at Dr.[**Name (NI) 666**] office at [**Hospital **], with his nurse [**Last Name (Titles) 6793**], [**First Name3 (LF) **] Fren, on Thursday, [**8-18**], at 9:40 am. . You also have a social worker appointment at [**Hospital **] on [**Last Name (LF) 2974**], [**8-19**], at 1:00 pm with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**]. The number is ([**Telephone/Fax (1) 97716**]. . A visiting nurse will also assist with your medications and ensure you are doing well once you are discharged. The visiting nurse will be from [**Hospital 119**] Homecare ([**Telephone/Fax (1) 97717**]. . Arrangements have been made for you to start the partial hospitalization program at [**Hospital 882**] Hospital, and you have been accepted to start there on [**Last Name (LF) 766**], [**8-22**] at 10:00am. [**Doctor Last Name **] Huppuch, psychiatry nurse [**Last Name (Titles) 3525**], [**First Name3 (LF) **] follow up with on via telephone next week. Followup Instructions: . Please follow up with Dr. [**Last Name (STitle) **] in psychiatry on [**2203-8-17**] at 3:30pm. . Please follow up at Dr.[**Name (NI) 666**] office at [**Hospital **], with his nurse [**Last Name (Titles) 6793**], [**First Name3 (LF) **] Fren, on Thursday, [**8-18**], at 9:40 am. You will need to have your thyroid function studies repeated in a few weeks, and your coumadin level checked, in addition to your blood pressure. . You also have a social worker appointment at [**Hospital **] on [**Last Name (LF) 2974**], [**8-19**], at 1:00 pm with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**]. The number is ([**Telephone/Fax (1) 97716**]. . A visiting nurse will also assist with your medications and ensure you are doing well once you are discharged. The visiting nurse will be from [**Hospital 119**] Homecare ([**Telephone/Fax (1) 97717**]. . Arrangements have been made for you to start the partial hospitalization program at [**Hospital 882**] Hospital, and you have been accepted to start there on [**Last Name (LF) 766**], [**8-22**] at 10:00am. [**Doctor Last Name **] Huppuch, psychiatry nurse [**Last Name (Titles) 3525**], [**First Name3 (LF) **] follow up with on via telephone next week.

[ "401.9", "584.9", "V58.61", "V45.82", "496", "309.81", "311", "V45.81", "V43.3", "296.30", "518.81", "414.00", "593.9", "244.9", "285.9", "695.4", "272.4", "458.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

13545, 13603

7224, 11423

350, 363

13913, 13923

4653, 5554

16273, 17506

3456, 3586

12170, 13522

13624, 13624

11449, 12147

1315, 2741

13947, 16250

3636, 4634

13677, 13892

288, 312

391, 1298

5563, 7201

13643, 13656

2763, 3245

3261, 3440

54,850

122,020

38142

Discharge summary

report

Admission Date: [**2105-5-29**] Discharge Date: [**2105-6-5**] Date of Birth: [**2039-12-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 922**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the second diagonal coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; as well as reverse saphenous vein single graft from aorta to the posterior descending coronary artery. History of Present Illness: This 65 year old patient has had approximately five years of intermittent exertional chest discomfort. He has a history of hypertension and hyperlipidemia.He reports that several stress tests through the years have been normal. More recently these episodes have been occurring with increased frequency and with less and less exertion. Last Tuesday he had an episode of substernal chest pain that occurred after climbing one flight of stairs. His symptoms did not resolve for at least a half hour. He denies any resting discomfort, shortness of breath or increased fatigue. He underwent cardiac cath at [**Hospital1 18**] which revealed 3 vessel disease. He is now admitted for CABG. Past Medical History: HTN, hyperlipidemia, renal calculi-s/p laser therapy and surgery gout,arthritis,diverticulitis, eczema, hemmorhoids s/p appy, s/p vasectomy,s/p renal stone surgery Social History: Lives with: wife Occupation: [**Name2 (NI) 85101**] engineer Tobacco: never ETOH: 3 drinks per year Family History: + CAD sister had an MI in her 50s Physical Exam: On Admission Pulse:57 Resp:14 O2 sat: 98% on 2 liters NC B/P Right: 160/82 Left: Height: 68" Weight: 99.5 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2105-6-4**] 04:40AM BLOOD WBC-11.6* RBC-3.70* Hgb-10.8* Hct-33.0* MCV-89 MCH-29.2 MCHC-32.7 RDW-14.0 Plt Ct-148* [**2105-5-30**] 05:00AM BLOOD WBC-9.0 RBC-4.71 Hgb-14.0 Hct-42.2 MCV-90 MCH-29.8 MCHC-33.2 RDW-14.2 Plt Ct-194 [**2105-6-1**] 02:01PM BLOOD PT-14.4* PTT-31.3 INR(PT)-1.2* [**2105-5-30**] 05:00AM BLOOD PT-13.6* PTT-27.0 INR(PT)-1.2* [**2105-6-4**] 04:40AM BLOOD UreaN-20 Creat-1.2 Na-134 K-4.2 Cl-99 [**2105-5-30**] 05:00AM BLOOD Glucose-94 Creat-1.2 Na-138 K-4.2 Cl-102 HCO3-28 AnGap-12 [**2105-6-3**] 04:05AM BLOOD ALT-16 AST-21 LD(LDH)-169 AlkPhos-40 Amylase-30 TotBili-0.4 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 85102**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 85103**] (Complete) Done [**2105-6-1**] at 9:18:57 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**Known firstname 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-12-18**] Age (years): 65 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG ICD-9 Codes: 424.1, 424.0, 424.3 Test Information Date/Time: [**2105-6-1**] at 09:18 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: AW2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.2 cm Findings LEFT ATRIUM: Normal LA size. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Thoracic aorta intact. No significant change from pre-bypass study I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2105-6-1**] 12:59 ?????? [**2097**] CareGroup IS. All rights reserved. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2105-6-1**] where the patient underwent CABG X4 (LIMA-LAD, SVG to OM, SVG to diag, SVG to RCA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis duue to in hospital prior to surgery. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. 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 #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was cleared by DR. [**Last Name (STitle) 914**] and discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Norvasc 10 mg PO daily, Atenolol 100 mg PO daily,Diprolene cream 0.05% PRN eczema, Fluocinolone cream 0.025% cream PRN eczema, Zocor 40 mg PO daily Prednisone PRN for gout,ASA 81 mg PO daily,Diovan 160 mg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 doses. Disp:*10 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: coronary artery disease s/p HTN hyperlipidemia renal calculi -s/p laser therapy and surgery -gout -arthritis -diverticulitis and homorrhoids -eczema Past Surgical History: s/p appy s/p vasectomy s/p renal stone surgery Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage right and Leg Left - healing well, no erythema or drainage. Edema: minimal Discharge Instructions: 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. 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**]). **Please call cardiac surgery office with any questions or concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call person during off hours.** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] on [**2105-7-14**] 1:15pm [**Telephone/Fax (1) 170**] Please call to schedule appointments with your Primary Care: Dr. [**Last Name (STitle) 85104**] [**Telephone/Fax (1) 17663**] in [**12-27**] weeks Cardiologist: Dr. [**Last Name (STitle) 23705**] in [**12-27**] 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:[**2105-6-5**]

[ "414.2", "411.1", "V13.01", "716.90", "414.01", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.13", "39.61", "36.15", "88.56", "88.49", "37.22" ]

icd9pcs

[ [ [] ] ]

9827, 9886

7377, 8618

332, 739

10194, 10434

2490, 7354

11193, 11759

1774, 1810

8884, 9804

9907, 10056

8644, 8861

10458, 11170

10079, 10173

1825, 2471

280, 294

767, 1453

1475, 1640

1656, 1758

301

160,332

51158

Discharge summary

report

Admission Date: [**2189-11-10**] Discharge Date: [**2189-11-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3151**] Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: transfusion 3Units PRBCs History of Present Illness: Pt is a 85 yo man with metastatic gall bladder cancer presents w/ weakness, disorientation and dehydration. Pt was diagnosed with cancer 1 year ago and underwent surgery 5 months ago secondary to increasing RUQ abdominal pain. He remained stable until about 1 month ago when he began to feel progressively weaker and have less of an appetite. Pt usually slept 18-20 hours per day and when awake would like in a chair in front of the television and only sip broth when forced. For the past 3 days pt has had almost no intake po. This morning grandson describes pt as somnolent and not arousable to voice. He states that pt would stare at him but not respond and was unable to answer his name or where he was. he called pts pcp who advised him to come to the ED. . Per pts grandson, during the past month patient has complained of increasing abdominal pain, mid to low back pain, weakness, fatigue and decreased appetite. Pt would only take in sips on broth when forced. Pts grandson estimates that he has lost about 40lbs in the last month. Per Pts grandson, he has not complained of nausea, vomiting, fever or chills. He has had minimal urine output. ON ROS, pt is moderately responsive and denies any pain. Past Medical History: -gallbladder carcinoma, small cell type. dx [**2188-12-14**], surgical resection [**2189-5-14**] with positive margins. Pt was not a candidate for systemic chemotherapy. -hypertension -hypercholesterolemia -sick sinus syndrome s/p pacemaker placement [**2180**] -PUD -Abdominal Aortic Aneurysm -BPH -chronic back pain, bone scan 3wks ago show no evidence of metastatic disease. Social History: cimetidine 400mg [**Hospital1 **] metoprolol 25mg daily percocet 5-325mg TID prn for pain Family History: NC Physical Exam: VS: Tc: 95.6 P: 72 BP: 108/62 RR: 16 O2 sat: 98% weight: 50.4k Gen- appears fatigued, responds to commands HEENT-anicteric, no injections, OP clear, MM dry Cor- RRR, S1, S2, 2/6 SEM LUSB Lungs- CTA b/l Abd-palpable epigastric mass, NT, ND, positive bs Extrem- no CCE Pertinent Results: CBC: [**2189-11-10**] 12:13PM BLOOD WBC-13.6* RBC-2.34* Hgb-7.6* Hct-23.1* MCV-99* MCH-32.7* MCHC-33.1 RDW-21.1* Plt Ct-353 [**2189-11-11**] 09:00AM BLOOD WBC-12.4* RBC-2.85* Hgb-9.1* Hct-26.7* MCV-94 MCH-31.7 MCHC-33.9 RDW-21.8* Plt Ct-245 [**2189-11-12**] 03:23AM BLOOD WBC-14.7* RBC-3.15* Hgb-10.3* Hct-29.4* MCV-93 MCH-32.5* MCHC-34.8 RDW-20.7* Plt Ct-222 [**2189-11-13**] 05:58AM BLOOD WBC-16.5* RBC-2.99* Hgb-9.8* Hct-27.8* MCV-93 MCH-32.8* MCHC-35.3* RDW-21.2* Plt Ct-241 [**2189-11-14**] 10:36AM BLOOD WBC-17.4* RBC-3.03* Hgb-9.7* Hct-28.9* MCV-96 MCH-32.1* MCHC-33.6 RDW-21.4* Plt Ct-223 [**2189-11-15**] 06:15AM BLOOD WBC-16.0* RBC-3.04* Hgb-9.9* Hct-29.2* MCV-96 MCH-32.5* MCHC-33.9 RDW-21.6* Plt Ct-228 [**2189-11-16**] 06:50AM BLOOD WBC-12.1* RBC-2.87* Hgb-9.4* Hct-27.3* MCV-95 MCH-32.7* MCHC-34.4 RDW-22.1* Plt Ct-172 . COAGS: [**2189-11-10**] 12:13PM BLOOD PT-15.2* PTT-25.2 INR(PT)-1.4* [**2189-11-11**] 09:00AM BLOOD PT-15.6* PTT-25.9 INR(PT)-1.4* [**2189-11-12**] 03:23AM BLOOD PT-16.5* PTT-27.1 INR(PT)-1.5* [**2189-11-13**] 05:58AM BLOOD PT-16.6* PTT-27.2 INR(PT)-1.5* [**2189-11-14**] 10:36AM BLOOD PT-17.1* PTT-30.2 INR(PT)-1.6* . LYTES: [**2189-11-10**] 12:13PM BLOOD Glucose-122* UreaN-69* Creat-1.8* Na-143 K-4.6 Cl-109* HCO3-19* AnGap-20 [**2189-11-11**] 09:00AM BLOOD Glucose-106* UreaN-55* Creat-1.4* Na-144 K-3.9 Cl-114* HCO3-16* AnGap-18 [**2189-11-12**] 03:23AM BLOOD Glucose-78 UreaN-48* Creat-1.4* Na-145 K-4.0 Cl-119* HCO3-14* AnGap-16 [**2189-11-13**] 05:58AM BLOOD Glucose-103 UreaN-46* Creat-1.3* Na-147* K-3.8 Cl-122* HCO3-14* AnGap-15 [**2189-11-14**] 10:36AM BLOOD Glucose-97 UreaN-40* Creat-1.4* Na-145 K-3.6 Cl-117* HCO3-15* AnGap-17 [**2189-11-15**] 06:15AM BLOOD Glucose-92 UreaN-38* Creat-1.3* Na-142 K-3.7 Cl-116* HCO3-15* AnGap-15 [**2189-11-16**] 06:50AM BLOOD Glucose-103 UreaN-41* Creat-1.0 Na-141 K-3.3 Cl-113* HCO3-16* AnGap-15 . LFTs: [**2189-11-10**] 12:13PM BLOOD ALT-81* AST-171* AlkPhos-3306* Amylase-82 TotBili-4.1* [**2189-11-11**] 09:00AM BLOOD ALT-74* AST-170* LD(LDH)-898* AlkPhos-2799* Amylase-57 TotBili-5.7* [**2189-11-12**] 03:23AM BLOOD ALT-79* AST-169* LD(LDH)-789* AlkPhos-2798* TotBili-7.4* DirBili-6.0* IndBili-1.4 [**2189-11-13**] 05:58AM BLOOD ALT-74* AST-146* AlkPhos-2740* TotBili-8.2* [**2189-11-15**] 06:15AM BLOOD ALT-65* AST-129* TotBili-13.7* [**2189-11-16**] 06:50AM BLOOD ALT-57* AST-110* AlkPhos-2444* TotBili-14.5* Brief Hospital Course: #) metastatic gall bladder cancer: Pt presented with common bile duct obstruction [**1-15**] tumor effect from gallbladder mass. There was a palpable abdominal mass on PE and progressively increasing transaminases, bilirubin, alk phos. Pt also developed an upper GI bleed with hematemesis at presentation. GI, GI [**Doctor First Name **], ERCP and IR were consulted re: possible interventions. Stenting was not an option given pts anatomy/obstruction during past surgery and pt was not thought to be stable enough for IR intervention for the bleeding. Pt was transfused and stabilized in the MICU. He has been hemodynamically stable with no continued hematemesis. Hct has been stable between 27-29. After discussion with patients family the decision was made for care measure only. Pt has been pain controlled with morphine IV and SL. He is very stoic and often denies pain to the medical team but has complained to his family. He has been tolerating clear fluids w/o problem. His family visits him every day. Medications on Admission: percocet 5-325mg TID prn for pain patient has not been taking: cimetidine 400mg [**Hospital1 **] and metoprolol 25mg daily Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: [**12-15**] PO Q1-2H () as needed for pain. 2. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea, emesis. Suppository(s) Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Upper GI Bleed, Common Bile Duct obstruction secondary to tumor from metastatic gallbladder cancer. Discharge Condition: stable, poor Discharge Instructions: You were evaluated for bleeding in your gastrointestinal tract. Gastroenterology and Interventional Radiology were consulted and there was no intervention that would stop the bleeding. You were transfused with blood and have been stable. . It is important that you are comfortable and not in pain. Please continue to take all medications for pain as prescribed. Please tell your family or other caretakers if you are in pain, uncomfortable, or there is anything else you need. Followup Instructions: na

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6250, 6327

4805, 5822

282, 309

6471, 6486

2381, 4782

7012, 7018

2074, 2078

5996, 6227

6348, 6450

5848, 5973

6510, 6989

2093, 2362

225, 244

337, 1548

1570, 1950

1966, 2058

1,474

107,116

54017+54018

Discharge summary

report+report

Admission Date: [**2106-10-12**] Discharge Date: Service: Medicine, [**Hospital1 **] Firm HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 110736**] is an 85-year-old female with coronary artery disease, aortic stenosis, congestive heart failure, and asthma who is status post recent hospitalization for pulmonary edema and pneumonia who presented one day after discharge with a chief complaint of increased shortness of breath. She was found to have desaturation to the 60s on room air at her nursing home. On admission, a chest x-ray showed a new right upper lobe infiltrate as well as progression of her old right lower lobe pneumonia. She presented to the Emergency Department and was transferred to the floor and started on ciprofloxacin and vancomycin. She was intubated on hospital day four for respiratory distress with desaturation to the 70s on 3 liters nasal cannula. Her arterial blood gas at that time was 7.17, PCO2 86, PO2 65 on 100% nonrebreather. She was continued on ciprofloxacin and vancomycin on the unit and was successfully extubated on [**10-17**]. On transfer to the floor the patient had a chief complaint of sore throat which she blamed on intubation. She denied shortness of breath. PAST MEDICAL HISTORY: 1. Coronary artery disease, 3-vessel disease. Cardiac catheterization in [**2106-9-20**] revealed 80% left main, 100% middle left anterior descending artery, 80% proximal circumflex. She is not an intervenable or operable candidate. 2. History of congestive heart failure, diastolic ejection fraction equals 50%. 3. Aortic stenosis, valve area of 0.9 cm2. 4. Paroxysmal atrial fibrillation. 5. Pacemaker. 6. Right cerebrovascular accident. 7. Breast cancer, status post left mastectomy. 8. Hypercholesterolemia. 9. Hypertension. 10. Asthma. MEDICATIONS ON TRANSFER: Procainamide 500 mg p.o. four times a day, Colace 100 mg p.o. b.i.d., K-Dur 20 mEq p.o. q.d., lactulose 30 cc p.o. t.i.d., Coumadin 1 mg p.o. q.d., Protonix 40 mg p.o. q.d., iron sulfate 325 mg p.o. q.d., Lopressor 37.5 mg p.o. b.i.d., Neurontin 200 mg p.o. b.i.d., Atrovent nebulizers q.4h. p.r.n., aspirin 325 mg p.o. q.d., Alphagan eyedrops b.i.d., Trusopt eyedrops b.i.d., Synthroid 50 mcg p.o. q.d., Diflucan 100 mg p.o. q.d., levofloxacin 250 mg intravenously q.d., vancomycin 1 g intravenously q.12h. ALLERGIES: EPINEPHRINE, PENICILLIN, and BACTRIM. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.6, blood pressure 112/60, heart rate 68, respirations 18, saturation 98% on 4 liters. In general, she was in no apparent distress. Pupils were equally round and reactive to light. Extraocular movements were intact. The oropharynx was clear. Neck had no jugular venous distention, lymphadenopathy, or carotid bruits. Cardiac revealed a regular rate and rhythm, a 2/6 systolic murmur maximal at the base and apex without radiation to the neck. No gallops. Lungs had bilateral wheezes and crackles. The abdomen was soft, nontender, and nondistended. No organomegaly or masses. Normal active bowel sounds. Extremities had no edema, 1+ distal pulses. LABORATORY DATA ON PRESENTATION: White blood cell count 7, hematocrit 30.5. INR 2.8. Sodium 139, potassium 3.3, bicarbonate 32, BUN 9, creatinine 0.7. Last arterial blood gas on [**10-16**] was 7.4/48/111. Sputum Gram stain had greater than 25 polys, 2+ gram-positive cocci in pairs and clusters, 1+ gram-negative rods. Sputum culture had sparse oropharyngeal flora. Urinalysis had 3 to 5 white blood cells, few bacteria. Urine cultures were negative. RADIOLOGY/IMAGING: Chest x-ray on [**10-16**] revealed no acute congestive heart failure of pneumonia. Chest x-ray on [**10-19**] revealed interval development of bilateral patchy alveolar infiltrates most prominent in the left lower lobe and lingula. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: Pneumonia. The patient's admission chest x-ray showed new right upper lobe pneumonia and progression of old right lower lobe pneumonia. She was started on ciprofloxacin and vancomycin. The ciprofloxacin was discontinued and substituted with levofloxacin on [**10-15**]. The vancomycin was continued for seven days and then discontinued after sputum cultures revealed that the gram-positive cocci were oropharyngeal flora. Flagyl was added on [**10-18**] for concern for aspiration pneumonia. At the time of this dictation, which is [**10-20**], she is on day five of levofloxacin, day three of Flagyl, and status post seven days of vancomycin which has been discontinued. The patient also has [**Female First Name (un) **] esophagitis and has been on Diflucan for this. 2. PULMONARY: A respiratory care was consulted, and the patient has been receiving Atrovent nebulizers. She does not tolerate some pathomimetics and has not been receiving albuterol. 3. CARDIOVASCULAR: The patient has severe coronary artery disease but is not a candidate for intervention or coronary artery bypass graft. She is also very preload dependent because of her aortic stenosis. She continues on aspirin and Lopressor for her coronary artery disease. She has a history of not tolerating nitrates in the past, and we have been holding these. She has recurrent episodes of chest pain which may be angina or related to her pneumonia. Her creatine kinases have remained flat during this hospitalization. She has been given low doses of morphine for her chest pain p.r.n. She also has a history of paroxysmal atrial fibrillation and has been on procainamide for this. She is currently rate controlled. Given her current tenuous respiratory status and history of asthma, if she were to need more rate control would recommend trying diltiazem instead of increasing her Lopressor. She has also been receiving Lasix for her history of congestive heart failure. 4. ANTICOAGULATION: The patient is on Coumadin. 5. GASTROINTESTINAL: The patient has a history of severe constipation and is on a very aggressive bowel regimen. 6. FLUIDS/ELECTROLYTES/NUTRITION: The patient is not tolerating p.o. at this time and is an aspiration risk. She is currently receiving tube feeds via nasogastric tube. 7. CURRENT CLINICAL ISSUES: On [**10-20**], the patient had acute shortness of breath and desaturations to the 80s on 3 liters nasal cannula. She required 100% nonrebreather for a period of time. Her arterial blood gas while on the nonrebreather mask was pH of 7.3, PCO2 63, PO2 78. She was given intravenous Lasix 20 mg with good urine output and morphine intravenously. Her chest x-ray during this episode showed bilateral diffuse infiltrates which were read as asymmetric pulmonary edema and underlying emphysema. Her electrocardiogram at this time showed atrial fibrillation with a rate of 100. After treatment, she showed clinical improvement and was weaned to oxygen by nasal cannula. Her second gas was pH of 7.41, PCO2 of 52, PO2 of 56; which was taken when she was on 4 liters oxygen by nasal cannula with a saturation in the low 90s. The patient's respiratory distress is due to congestive heart failure superimposed on pneumonia, asthma, and possibly emphysema. She has severe cardiac disease as well. Her clinical course is deteriorating, and her prognosis is very poor. She remains full code, per her son, who wants aggressive measures. There have been multiple lengthy discussions with her son regarding the futility of further aggressive measures, but he is not yet ready to change her code status at this time. He has consented to speak with the palliative care consultation, however, to discuss future options. At this point in time, however, she does remain full code and may need to be transferred to the unit if her respiratory status declines. This is an interval Discharge Summary. Please see addendum for further clinical course. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**] Dictated By:[**Name8 (MD) 4925**] MEDQUIST36 D: [**2106-10-20**] 14:35 T: [**2106-10-22**] 07:28 JOB#: [**Job Number **] (cclist) Admission Date: [**2106-10-12**] Discharge Date: [**2106-11-4**] Date of Birth: Sex: Service:Medicine HISTORY OF PRESENT ILLNESS: The patient is an 85 year old female with coronary artery disease, aortic stenosis, congestive heart failure, asthma, status post recent hospitalization for pulmonary edema and pneumonia, presenting one day after discharge with the chief complaint of increased nursing home. A chest x-ray was done showing a new right upper lobe infiltrate and progression of an old right lower lobe infiltrate. The patient was intubated on [**2106-10-15**], for respiratory distress, with oxygen saturation in the 70% range on three liters nasal cannula, with an arterial blood gas showing pH 7.17, pCO2 86, pO2 65 on 100% nonrebreather. The patient was extubated on [**2106-10-17**], without complications and arterial blood gases prior to transfer to the medical floor was on [**2106-10-16**], showing a pH of 7.40, pCO2 48, pO2 111. On the general medical floor, the patient had a chief complaint of sore throat which she blamed on intubation. Otherwise, the patient did not report any shortness of breath. PAST MEDICAL HISTORY: 1. Coronary artery disease. Three vessels disease, nonoperable. Cardiac catheterization on [**9-20**], showed 80% left main, 100% mid left anterior descending, 80% proximal circumflex. 2. Moderate aortic stenosis with a valve area of 0.9 cm2. 3. Paroxysmal atrial fibrillation. 4. Pacemaker. 5. Right cerebrovascular accident. 6. Breast cancer, status post left mastectomy. 7. Hypercholesterolemia. 8. Hypertension. 9. Congestive heart failure with an ejection fraction of 50%. 10. Asthma. MEDICATIONS ON TRANSFER FROM INTENSIVE CARE UNIT: [**Unit Number **]. Procainamide 500 mg p.o. q.i.d. 2. Colace 100 mg p.o. b.i.d. 3. K-Dur 20 meq p.o. q.d. 4. Lactulose 3 mg p.o. t.i.d. 5. Coumadin 1 mg p.o. q.h.s. 6. Protonix 40 mg p.o. q.d. 7. Iron Sulfate 325 mg p.o. q.d. 8. Lopressor 37.5 mg p.o. b.i.d. 9. Neurontin 200 mg p.o. b.i.d. 10. Atrovent nebulizer q4hours. 11. Aspirin 325 mg p.o. q.d. 12. Alphagan eye drops b.i.d. 13. Trusopt eye drops b.i.d. 14. Synthroid 50 mcg p.o. q.d. 15. Diflucan 100 mg p.o. q.d. 16. Levofloxacin 250 mg p.o. q.d. 17. Tube feeds. 18. Vancomycin one gram intravenous b.i.d. ALLERGIES: Epinephrine, Penicillin, Bactrim. SOCIAL HISTORY: The son was very involved in the patient's care. Code status full. PHYSICAL EXAMINATION: On admission, temperature 98.6, blood pressure 112/60, heart rate 68, respiratory rate 18, oxygen saturation 98% on four liters nasal cannula. In general, the patient was an elderly Russian female in no acute distress. Head and neck examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The oropharynx is clear. There is no jugular venous distention, lymphadenopathy or carotid bruits. Cardiac - regular rate and rhythm, II/VI systolic ejection murmur which was heard loudest at the base and apex, without radiation to the neck. No gallops. Lungs - Bilateral wheezes and crackles. Abdomen is soft, nontender, nondistended, no hepatosplenomegaly or masses. Normal bowel sounds. Extremities - No cyanosis, clubbing or edema, 1+ dorsalis pedis pulses bilaterally. LABORATORY DATA ON TRANSFER: White blood cell count 7.0, hematocrit 30.5, platelets 353,000. Prothrombin time 20.2, partial thromboplastin time 39.7, INR 3.8. Sodium 139, potassium 3.3, chloride 100, bicarbonate 32, blood urea nitrogen 9, creatinine 0.7, glucose 118. Last arterial blood gases on [**2106-10-16**], revealed pH 7.4, pCO2 48, pO2 111. Sputum gram stain and culture done on [**2106-10-16**], showing more than 25 polymorphonuclear leukocytes, less than 10 epithelial cells, 3+ gram positive cocci in pairs and clusters, 1+ gram negative rods. Urinalysis showed [**2-22**] white blood cells, few bacteria, 0-2 epithelial cells. Urine culture showed less than 10,000 organisms. HOSPITAL COURSE: This was an 85 year old female with coronary artery disease, severe aortic stenosis, congestive heart failure, asthma, status post recent hospitalization for pulmonary edema, pneumonia, presenting one day after discharge from recent hospitalization with shortness of breath and desaturations. The patient was found to have progressive infiltrates on chest x-ray consistent with a persistent pneumonia, probably an aspiration pneumonia. 1. Infectious disease - The patient was continued on a two week course of Levofloxacin and Flagyl, and a seven day course of Vancomycin. As the patient had worsening pulmonary status during her hospital stay, the Levofloxacin and Flagyl were continued beyond a two week course and Cefepime was added for broad coverage. As the patient's clinical status deteriorated and the patient was made DNR/DNI and then comfort measures only, her antibiotics were discontinued on [**2106-11-2**], as the patient only had a single lumen PICC line and was on intravenous Morphine for pain control and comfort. 2. Pulmonary - The patient had a history of pulmonary edema and was admitted with a multilobar pneumonia, presumed secondary to aspiration. The patient was continued on antibiotics with triple therapy (Levofloxacin, Flagyl and Cefepime which was added later on for broadening coverage). The patient had multiple episodes of desaturation when transferred to the general medical floor which initially were relieved by administering Lasix intravenous in addition to small doses of Morphine Sulfate for treating episodes of pulmonary edema which were presumed to be causing these frequent episodes of shortness of breath. On [**2106-10-29**], the patient experienced an episode of desaturation to 88% on five liters after which an oxygen face tent was placed, with mild improvement in oxygen saturation to 93%. A chest x-ray was obtained which revealed right lung collapse. The patient was subsequently placed on a 100% face mask and was saturating 88 to 92%. The patient was then placed on BiPAP with reinflation of the right lung. However, the patient persisted to remain on 100% face mask. As the patient refused subsequent BiPAP, the patient was continued on conservative measures for the remainder of her hospital course to manage her respiratory condition. The patient was continued on oxygen, nebulizers p.r.n., and was positioned on her left side to promote blood flow to the good lung. 3. Cardiovascular - Coronary artery disease - The patient had left main disease which was inoperable. As the patient had in the past experienced severe hypotension with nitrates, nitrates were avoided. The patient was continued on beta blockade. The patient was given Morphine Sulfate intermittently for relief of ischemic pain. Paroxysmal atrial fibrillation - The patient was initially on Lopressor, Procainamide and low dose Diltiazem with good control of her heart rate. However, the patient's subsequently started experiencing intermittent episodes of atrial fibrillation to a heart rate of 120s, which were initially well controlled with intermittent boluses of intravenous Lopressor. During the hospital course, the patient developed a wide complex tachycardia, and the electrophysiology service was consulted to see whether the patient could have her pacer adjusted so that the ventricles would not be paced at the same rate as her atria during episodes of atrial fibrillation. The electrophysiology service simply suggested continuing Procainamide and Lopressor at their current doses, with adjustment of Procainamide to keep the Q-Tc interval less than 500. With further difficulty controlling the patient's heart rate, the patient was placed on a Diltiazem drip. This was later changed to the oral form in interest of intravenous access. Congestive heart failure - The patient was given Lasix intravenous standing dose and Lasix intravenous p.r.n. for episodes of interval pulmonary edema during hospital stay. 4. Gastrointestinal - The patient was placed on aggressive bowel regimen. The patient was initially on tube feeds through nasogastric tube. However, at one point during the hospital course, tube feeds were suctioned through the patient's mouth, and were subsequently discontinued in light of the presumed risk of aspiration. 5. Code Status - The patient was initially a full code on transfer from Intensive Care Unit to the general medical floor. As the patient's clinical status deteriorated, the primary medical team had numerous discussions with the patient and her son re; code status. There was much resistance of the son to making his mother DNR/[**Name2 (NI) 835**], as he seemed to think the best thing to do for her as well as for himself would be to prolong her life as much as possible. There was a period during the [**Hospital 228**] hospital stay where her son went out of state, and she expressed to us her desire to be made DNR/DNI. Holding true to the patient's wishes, the patient was subsequently made DNR/DNI. As the patient's clinical status deteriorated, she was requiring persistent oxygen requirement, was becoming more visibly short of breath, was becoming hypotensive, and was having frequent bouts of atrial fibrillation which were very difficult to control. The son finally agreed that the patient should be made comfort measures only, in light of the futility of her medical condition. The patient was subsequently taken off all intravenous medications except for a Morphine drip, which was titrated to comfort. The patient was taken off all monitors including telemetry monitoring, oxygen saturation monitoring and monitoring of vital signs. The patient expired on [**2106-11-4**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**] Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2107-4-13**] 18:30 T: [**2107-4-13**] 19:49 JOB#: [**Job Number 6769**]

[ "414.01", "507.0", "493.20", "428.0", "707.0", "424.1", "413.9", "427.31", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

12128, 18090

10578, 12110

8274, 9273

1842, 3829

9295, 10469

10486, 10555

17,054

184,701

17560

Discharge summary

report

Admission Date: [**2115-4-20**] Discharge Date: [**2115-4-25**] Date of Birth: [**2042-2-16**] Sex: F Service: [**Hospital1 **] CHIEF COMPLAINT: One week abdominal distention, weakness and shortness of breath. Of note, the patient was initially admitted to the Coronary Care Unit and then transferred to the Medical Floor. HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old woman with a history of type B aortic dissection, abdominal aortic aneurysm, RCIA and [**Female First Name (un) **], aneurysm, renal artery stenosis and hepatitis B, cirrhosis who presents to [**Hospital1 1444**] from an Emergency Room in [**Hospital1 1474**]. The patient initially presented with a history of increasing shortness of breath, abdominal distention and fatigue at [**Hospital1 1474**]. The patient had a CT angio and her systolic blood pressure was in the 200s. The patient was transferred to [**Hospital1 69**] whose CT was read as not being appreciably different from the last CT performed on [**2115-4-10**]. The patient was seen by Dr. [**Last Name (STitle) 48972**] last year. The patient was placed on nitroprusside drip, po Labetalol 200 mg a day and was seen by the liver service who performed an esophagogastroduodenoscopy to evaluate for guaiac positive stools and hematocrit of 22.8 on presentation. The esophagogastroduodenoscopy showed varices in the lower third of the esophagus with the middle grade one. The esophagogastroduodenoscopy also showed erosions consistent with portal hypertension. A sigmoidoscopy was performed, which showed spotting from the hemorrhoids. The patient status post esophagogastroduodenoscopy required 2.5 mcg per minute of nitroprusside and Norvasc 5 mg po q.d. was started with a goal blood pressure of decreased blood pressure given the dissection. PAST MEDICAL HISTORY: 1. Type B aortic dissection. 2. Cirrhosis. 3. Hepatitis B. 4. Abdominal aortic aneurysm 5.5 cm. 5. History of varices. 6. History of ascites. 7. RC one aneurysm, [**Female First Name (un) **] aneurysm. 8. Severe left renal stenosis. 10. Question CRI. ALLERGIES: No known drug allergies. MEDICATIONS: Triamterene/HCTZ 37.5/25. SOCIAL HISTORY: The patient has no current alcohol or tobacco use. She is Cambodian and does not speak English. PHYSICAL EXAMINATION ON PRESENTATION: Her vital signs were temperature 97. Heart rate of 56 to 60. Blood pressure 139/60. Is and Os 840 in and 280 out. She was 100% on nasal cannula. In general, no acute distress, lying in bed. HEENT pupils are equal, round and reactive to light. Lungs clear to auscultation anteriorly. Cardiovascular no JVD, regular rate and rhythm. S1 and S2. +S4 2 out of 6 systolic ejection murmur at the right upper sternal border. Abdomen shifting dullness, small liver, guaiac positive, positive bowel sounds, positive distention. Extremities 1+ pedal edema, 2+ sacral edema. IMAGING: Chest x-ray showed no infiltrate or congestive heart failure. Right upper lobe opacity. CT of the pelvis from [**4-10**] showed dissection of lower thoracic abdominal aorta and right common iliac, infrarenal abdominal aortic aneurysm maximum diameter 5.5 by 5 cm. Right common iliac aneurysm, left internal iliac aneurysm, severe left renal artery cirrhosis, cirrhosis of the liver, portal hypertension, varices. LABORATORIES AT [**Hospital1 **]: White blood cell count 5.2, hematocrit 22.8, platelets 63. Diff 72.6, lymphocytes 11.1, 106, 2.8. Electrolytes sodium 135, K 3.3, chloride 103, bicarb 25, BUN 40, creatinine 1.5, glucose 143, INR 1.3, albumin 2.1. White blood cell [**Pager number **], red blood cell [**Pager number **], polys 6, lymphocytes 28, monocytes 46, eosinophils 1, mesothelial cells 14, macro 15. Chest x-ray of [**2115-4-20**] showed a 1.1 cm pulmonary nodule right upper lobe, prominent tortuous aorta. Medications from transfer from CCC included Tylenol, Trazodone, Docusate sodium, Pantoprazole, Lactulose, ferrous, Amlodipine 10 mg po q.d., Labetalol500 mg po b.i.d., Albuterol nebulizers. HOSPITAL COURSE: 1. Patient with a history of aortic dissection initially placed on nitroprusside drip for blood pressure control. The patient's blood pressure medications were weaned during the course of her hospitalization. It was necessary to maintain a blood pressure so that her aortic dissection would not progress. Vascular Surgery was consulted and no intervention was considered an option during the hospitalization. 2. Shortness of breath: Patient with no pneumonia on x-ray. It was possible that her shortness of breath might be consistent to volume overload. On [**2115-4-22**] a repeat chest x-ray was performed. The impression was a right upper lobe lung nodule. Further evaluation with a CT was suggested. There was also an increase in patchy opacity at the right lung base. The differential included atelectasis versus an evolving pneumonia. There was also a small persistent, small right pleural effusion. As a result the patient was discharged on Levofloxacin for possible pneumonia, which attributed to her hypoxia. 3. Hematology: Patient with iron deficiency anemia, decreased iron. Patient was transfused 2 units of packed red blood cells. The patient's hematocrit was felt to require an outpatient colonoscopy. Of note, the patient was status post an esophagogastroduodenoscopy with bleeding varices, status post sigmoidoscopy with bleeding source hemorrhoids. 4. Gastrointestinal: Patient with a history of hepatitis B cirrhosis and increasing abdominal girth. The patient had an ultrasound guided abdominal paracentesis to evaluate for SBP. These showed transudative. The etiology of cirrhosis with VNA/IGGA were sent. On [**2115-4-21**] an abdominal ultrasound and diagnostic paracentesis was performed, which showed a small 3 cm pocket of ascites located within the right lower quadrant the patient in the sitting position. An abdominal ultrasound on [**4-22**] was performed. The impression was a nodular liver consistent with the patient's known cirrhosis, patent flow to the liver, borderline enlarged spleen, mild ascites and abdominal portion of the aortic dissection seen in the dissection consistent with both CT and MR recently with correlation of the studies was suggested. 5. Kidney: The patient developed acute renal dysfunction during her hospitalization. The differential included drug induced ATN versus hypotension versus secondary to aortic dissection. It was felt that it was likely due to hypotension. The patient was rehydrated in house. A renal ultrasound was performed on [**5-23**]. The ultrasound showed color flow seen to both kidneys, but the wave form is parvus sitarist suggesting more proximal stenosis in both renal arteries. There was no evidence of echogenic kidney seen with medical renal disease. The patient's creatinine on presentation was 1.5. The patient, however, was not felt to be a hemodialysis candidate at this time. 6. Prophylaxis: The patient was placed on pneumoboots. 7. Nutrition: Nutrition was provided with Boost and a cardiac healthy low protein diet. FINAL DIAGNOSES: 1. Liver cirrhosis 2. Renal failure. 3. Aortic aneurysm. The patient was recommended to follow up with her primary care physician within one week. Major surgical invasive procedures were none. DISCHARGE CONDITION: Fair. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg po q.d. 2. Amlodipine 5 mg tablets two tabs po q.d. 3. Levofloxacin 250 mg po q.d. 4. Labetalol HCL 100 mg po b.i.d. 5. Lactulose 15 ml oral t.i.d. [**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. [**MD Number(1) 9632**] Dictated By:[**Last Name (NamePattern1) 201**] MEDQUIST36 D: [**2115-5-22**] 09:37 T: [**2115-5-22**] 13:10 JOB#: [**Job Number 48973**]

[ "280.9", "599.0", "789.5", "441.01", "276.1", "070.22", "403.91", "571.5", "511.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.24", "54.91" ]

icd9pcs

[ [ [] ] ]

7363, 7370

7393, 7869

4068, 7125

7142, 7341

163, 343

372, 1818

1840, 2180

2197, 4050

1,533

174,474

48159

Discharge summary

report

Admission Date: [**2179-3-29**] Discharge Date: [**2179-4-2**] Date of Birth: [**2119-11-3**] Sex: F Service: MEDICINE Allergies: Theophylline / Flagyl / Clindamycin / Antihistamines Attending:[**First Name3 (LF) 9240**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 59 yo F w/PMHx sx for substance abuse, COPD, and asthma who presented after being discharged today from a rehab facility. Pt had c.diff colitis, requiring emergency ex-lap with partial colectomy and ileostomy. Patient's post-operative course was c/b pneumonia, COPD flare. Patient states that she was admitted to [**Hospital1 756**] for a reversal of her ileostomy one month ago, and was sent to rehab from there. She did well there, and was discharged to home today on multiple medications, including oxycodone and ativan. She states that she took 3 ativan and 2 oxycodone at home due to worsening pain. She states that she usually takes 1-2 tablets at a time. Four hours after discharge, patient was found by her sister to be minimally responsive at home, responsive only to painful stimuli. Upon arrival by EMS, patient was given Narcan, and woke up completely. Pt denies any other substance use. She does note dizziness on standing and diarrhea, which is chronic for her. . In the ED, patient had a CXR which showed a right infrahilar aspiration. Her EKG was unremarkable. She received 1L NS. . ROS: She denies any chest pain, palpitations, SOB, headache, dizziness, abdominal pain, fevers, chills, rash. She notes constant diarrhea as well as associated nausea. She notes some dizziness on standing. Past Medical History: 1) COPD: intubated previously, she uses O2 only when not feeling well. FEV1 0.64L. Her functional status is poor--she is not able to do much besides ADLs due to dyspnea. 2) Asthma 3) Parotid CA, tonsillar CA s/p surgery and XRT c/b mandibular osteonecrosis. 4) Intermittent RLE edema: took lasix for a few days 2-3 weeks ago. Etiology is not known. 5) Mitral valve prolapse. NO h/o of CAD. Social History: Lives at home, just discharged from rehab on day of presentation. Single. On disability. Hx substance abuse, including alcohol, tobacco, cocaine, opiates. Family History: Father with h/o laryngeal CA, PE Physical Exam: VS: T98.2/99.4 BP 125/75 HR 115 O2sat 93% 2L NC. Gen: cachectic appearing female in NAD. Speaking in a whisper. HEENT: MM dry. No oral ulcers or lesions. Radiation changes on right jaw. Hrt: Distant heart sounds. No MRG. Lungs: Poor air movement. Minimal expiratory wheezing. No rales or rhonchi. Abd: Soft, nontender. Normoactive BS. Ileostomy revision site with full thickness wound, with no drainage. Good granulation tissue. Ext: Warm. Neuro: PERRL. Pinpoint pupils. Able to move all extremities. Pertinent Results: Na:139 K:5.2 Cl:95 TCO2:30 Creat 1.0 Glu:170 . 9.8 \ 11.4 / 577 D ------ 33.8 N:92.1 Band:0 L:5.2 M:1.8 E:0.5 Bas:0.4 UA: Neg leuks, neg nitrites, trace protein, occ bacteria, [**4-12**] WBC. CXR: 1. Upper zone redistribution, without other evidence of CHF. Probable underlying COPD with pulmonary hypertension. 2. Right infrahilar patchy air -- this could be due to aspiration or pneumonic infiltrate. 3. Probable scarring at the left lung base. Recommend comparison with previous films when they become available, to confirm this. 4. Asymmetry of breast shadows as described. . EKG: Sinus rhythm. PRWP. No acute ST-T changes. Intervals fine. No significant change from prior. . Serum tox: negative Urine tox: positive for cocaine, opiates Brief Hospital Course: Ms. [**Known lastname **] is a 59 yo F w/hx polysubstance abuse who presents after being found unresponsive at home, likely [**3-12**] substance abuse, now improved after Narcan administration. Hospital course by problem: . #. Unresponsiveness. Most likely etiology for episode of unresponsiveness is narcotics overdose, with reversal with Narcan. Pt has a significant substance abuse history, and tox screen is positive for both cocaine and opiates on admission. We monitored her in the ICU and she returned to her baseline. We obtained a social work consult and screened her for placement. This event occurred within four hours of your discharge from rehab so feel it is safest for you to return to a rehab. . #. Aspiration pneumonitis. Patient with evidence of aspiration pneumonitis on CXR, likely from episode of being down on at home. Patient also on pureed diets at discharge from rehab, possibly due to hx of esophageal dysmotility. We monitored her oxygen requirement. She remained at her normal requirement of 2L NC so did not start antibiotics. . #. COPD/asthma. Patient with FEV1 0.64L, with history of intubations in the past. She was breathing well on 2L NC. -Albuterol/ipratropium nebulizers q6h -Advair inhaler 500/50 1 puff [**Hospital1 **] -Continue home prednisone dose of 10 mg qd with PPI and insulin SC . #. S/P colostomy revision. -we monitored site. It did not appear to be superinfected -Tylenol for pain relief . #. Substance abuse. Patient with evidence of cocaine/opiates on tox screen, and has a significant substance abuse history. Pt denies any current use of cocaine. -We placed a social work consult . #. Hx alcohol abuse. -MVI, folate, thiamine. -No need for CIWA scale as serum alcohol negative, and just discharged from rehab on day of admission . #. Hx depression. Patient denied SI, although has a hx of depression and episode of overdose today. She denied that it was intentional and had no thoughts of hurting herself. -Continued Zyprexa and Remeron . #. Anemia. Patient with microcytic anemia, of unclear duration. -iron studies did not indicate chronic inflammation or iron deficiency -we guaiac'd stools . #. FEN. Pureed diet. Ensure 1 can three times a day. Aspiration precautions. 1L LR overnight. . #. PPx. Heparin SC. Senna/colace. Simethicone. PPI. Acetaminophen for pain relief. . #. Code. DNR/DNI. . #. Communcation. With patient. Medications on Admission: Remeron 45 mg qhs Zyprexa 5 mg qam Prilosec 20 mg qd Advair 500/50 1 puff [**Hospital1 **] FOlic acid 1 tab qd Magnesium oxide 400 mg qd SImethicone 80 mg tid PRednisone 10 mg qd Duoneb 1 treatment qid Oxycodone 5 mg 1-2 tabs q4h prn Ativan 0.5 mg q6h prn . Allergies: Theophylline, flagyl, clindamycin, antihistamines Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation four times a day. 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 15. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed: Please take according to taper: half tab 4 times daily for one day, then 3 times daily for one day, then two times daily for one day, then once daily for one day, then stop. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - cocaine abuse - opiate intake - altered mental status - COPD Secondary: - asthma - HCV - colostomy reversal - esophageal dysmotility - hx of substance abuse: cocaine, tobacco, alcohol - parotid cancer s/p surgery and xrt c/b mandibular osteonecrosis - MVP - depression and anxiety Discharge Condition: fair Discharge Instructions: You were admitted with altered mental status. This was thought secondary to inappropriate use of your medications. You had cocaine and opiates in your system. We treated you with Narcan and you awoke. Given your altered mental status, we monitored you in the intensive care unit. You improved back to your baseline. . Please take your medications as instructed. Please followup with your PCP. [**Name10 (NameIs) 357**] contact your physician or return to the emergency department if you experience shortness of breath, chest pain, abdominal pain, or worsening confusion. We have decided to have your sister administer your medications. Please follow up with your PCP as scheduled. Followup Instructions: 1. Please followup with Dr. [**First Name (STitle) **] on [**4-7**] at 10:15am. You can call [**Telephone/Fax (1) 101516**] if you have questions. 2. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 101517**] of Addiction Consultation and Evaluation Services. Call [**Telephone/Fax (1) 79298**] for an appointment in the next week.

[ "285.9", "305.1", "E879.2", "526.4", "304.91", "311", "V10.02", "070.70", "780.09", "238.71", "300.00", "305.03", "965.8", "E850.8", "507.0", "V10.89", "424.0", "530.81", "530.5", "305.60", "493.20" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7885, 7891

3641, 6030

326, 332

8227, 8234

2875, 3618

8970, 9345

2304, 2338

6400, 7862

7912, 8206

6056, 6377

8258, 8947

2353, 2856

273, 288

360, 1698

1720, 2116

2132, 2288

63,103

189,920

438+439

Discharge summary

report+report

Admission Date: [**2187-10-29**] Discharge Date: Date of Birth: [**2135-10-28**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 3761**] is a 52-year-old female who was transferred to the [**Hospital1 190**] in hyperacute fulminant liver failure thought to be secondary to either Bactrim reaction versus acetaminophen toxicity. She was admitted to the medical intensive care unit initially and became progressively obtunded, with significant encephalopathy requiring intubation and ventilatory support. Her liver function was notable for transaminases with an ALT and AST of 9500 and 17,500 respectively and worsening hyperbilirubinemia. She became progressively more coagulopathic, and it was thought that she was most likely going to need orthotopic liver transplantation for survival. Given the critical nature of her illness, she was transferred to the transplant surgical service and to the surgical intensive care unit for further management. This management initially entailed aggressive control and monitoring of intracranial pressures in conjunction with the neurosurgical service. This required placement of an intracranial bolt and aggressive volume management with the use of hypertonic saline and mannitol. She continued to receive aggressive cardiopulmonary support with again, as noted, full ventilatory support and vasopressor support for hypotension. COURSE BY SYSTEMS: Neurologically, as noted above the patient required placement of an intracranial bolt for ICP monitoring. Her ICPs had climbed into the high 30s. This was managed with hyperventilation and usage of mannitol and hypertonic saline. Over the course of the next 4-5 days as her liver function improved, her intracranial pressures decreased. Her sedation and paralytics were weaned. She had removal of her intracranial bolt on [**2187-11-6**], and it was noted on subsequent imaging that she had approximately a 4-cm, right frontal, intracranial hemorrhage. This was followed serially with CT scans and there was no progression of the bleeding. The bleeding was thought to be secondary to her severe coagulopathy and thrombocytopenia in the setting of her instrumentation. She was started on Keppra for seizure prophylaxis to finish a 10-day course. On [**2187-11-12**], the patient was extubated and her neurologic exam was notable for response to voice and opening of her eyes. She was moving her left upper extremity and her right lower extremity with 2/5 strength and had minimal movement in her right upper extremity and left lower extremity, not following the predicted neurologic pattern if this was a deficit associated with her intracranial bleeding. In terms of her respiratory status, it is noted that the patient required full ventilatory support and was extubated on [**2187-11-12**]. She initially did well, but, secondary to what was thought to be pulmonary edema, required reintubation on [**2187-11-13**] after failure of noninvasive positive pressure ventilation. She had some degree of what appeared to be an ARDS-type reaction or transfusion- associated lung injury requiring high amounts of PEEP and oxygenation during the initial days of her intensive care unit stay. This resolved over the course of the next several days with diuresis and supportive therapy. In terms of her cardiovascular status, the patient initially had blood pressure support with the use of vasopressors in order to minimize her intravascular volume which was thought to exacerbate her cerebral edema. The vasopressors were weaned by ICU day 6, and there was no further requirement for this. There were no significant dysrhythmias. The patient, initially thought to most certainly require liver transplantation, spontaneously improved in terms of her liver function over the course of her 2 weeks in the intensive care unit. This was evidenced by progressive ability to metabolize her lactate, stabilization of her blood sugars, and autocorrection of her coagulopathy. By the time of her transfer, while she continued to have a hyperbilirubinemia, her transaminases had completely normalized. A Dobbhoff feeding tube was in place for post- pyloric tube feedings. The patient's transaminases were elevated; this was thought to be secondary to a possible mild ischemic pancreatitis which might have developed during her requirement for vasopressors. She otherwise did not seem to be symptomatic for this and was tolerating tube feeds. Therefore, this was not aggressively pursued. In terms of her overall fluid status, her baseline weight is 37 kg. On the day of transfer, she weighed about 44 kg. This volume overload was being managed with hemodialysis daily on an as-needed basis. The patient's renal function, which had been quite labile throughout her hospitalization, stabilized, with creatinine in the 2.9-3.4 range. She makes approximately 500-700 mL of urine per day, but is dialysis-dependent. She currently receives hemodialysis through a left femoral hemodialysis catheter. In terms of her ID issues, the patient was initially started on vancomycin for prophylaxis against intracranial infection with the bolt in place. She developed a leukocytosis, and the thought was that she may have been developing pneumonia given the persistent difficulty oxygenating her. She was started empirically on Zosyn. Sputum cultures failed to evidence any pneumonic process, and these antibiotics were discontinued. In terms of hematologic issues, the patient developed what appeared to be a DIC versus TTP picture, for which the hematology service was following. She evidenced a consumptive coagulopathy with significant destruction of platelets. Her thrombocytopenia likely contributed to her intracranial bleeding. The patient required special HLA-typed platelet transfusions in order to maintain a platelet count above 100,000. She also developed a significant anemia without any evidence of bleeding. This was thought to be secondary to hemolysis in the face of an elevated indirect bilirubin and a depressed haptoglobin. Her thrombocytopenia and anemia resolved by [**11-11**], and she no longer required any transfusion of any blood products. At the present time, the patient is requiring intensive care for management of respiratory failure and renal failure. She is no longer in need of liver transplantation, and therefore, given her primary medical issues, she will be transferred to the medical intensive care unit. At the time of transfer, the patient is receiving the following medications: Protonix 40 mg p.o. once daily; insulin sliding scale; fentanyl as needed; heparin 5000 units subcu t.i.d.; Keppra 500 mg IV q.12 hours. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 3762**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2187-11-13**] 18:23:57 T: [**2187-11-13**] 19:19:38 Job#: [**Job Number 3764**] Admission Date: [**2187-10-29**] Discharge Date: [**2187-11-23**] Date of Birth: [**2135-10-28**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 1936**] Chief Complaint: Acute liver failure Major Surgical or Invasive Procedure: Intubation with extubation on [**2187-11-16**] Hemodialysis Intracranial bolt placement [**10-31**] and removal [**2187-11-5**] History of Present Illness: Pt is a 52F with OCD (stable recently, but h/o OD, anorexia and alcohol use in past), ileostomy, GERD with delayed gastric emptying, who presented to [**Hospital3 3765**] on [**10-28**] with nausea and dizziness. There she was initially dx'd with dehydration, ARF and UTI but then found to have ALT of 25,370 and of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was transferred to [**Hospital1 18**]. . She had been having fevers for ~10 days. On [**10-23**] she went to her PCP who diagnosed [**Name Initial (PRE) **] UTI (grew klebsiella) and was taking Bactrim. She continued to have general malaise and fevers despite bactrim and asa. On [**10-28**] she called her PCP who recommended some tylenol. Per husbands report she took 650mg x2 before coming in to the ED on [**10-28**]. There she was initially dx'd with dehydration, ARF and UTI. She was given home doses of simvastatin and SSRIs, but then found to have ALT of 25,370 and of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was transferred to [**Hospital1 18**]. On presentation initial vs were: 97.5 P89, 112/37 19 99%RA 37kg. . (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Anorexia Nervosa with multiple psychiatric and medical admissions PTSD OCD hypercholesterolemia osteoporosis Colostomy [**3-3**] constipation likely related to anorexia GERD with delayed gastric emptying persistent microhematuria s/p cystourethrography on [**10-6**] Social History: -Tob: denies -EtOH: denies -Illicits: None -Living situation: Lives with husband -Occupation: retired Family History: Non-contributory Physical Exam: From MICU: VS: 101/4 136/76 120 29 98%RA Gen: lightly jaundiced, feeling generally unwell HEENT: mild scleral icterus, OP clear, EOMI, Pupils 4 to 3mm Neck: No JVD, no thyromegaly, no LAD Cor: RRR no m/r/g, exagerated heart sounds Pulm: diffuse rhonchi Abd: ileostomy, +BS, NT Extrem: 2+ edema, Skin: some petchiae seen most prominently in distal extremities, no rash Neuro: intubated and sedated, tracking with her eyes but not responding to commands, + asterixis, upgoing toes bilaterally, 5/5 strength Pertinent Results: [**2187-11-23**] 04:58AM BLOOD WBC-11.1* RBC-2.58* Hgb-7.8* Hct-22.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-15.7* Plt Ct-906* [**2187-11-23**] 04:58AM BLOOD Neuts-70.3* Lymphs-14.2* Monos-3.8 Eos-11.0* Baso-0.7 [**2187-11-23**] 04:58AM BLOOD PT-12.9 PTT-26.7 INR(PT)-1.1 [**2187-11-23**] 04:58AM BLOOD Glucose-108* UreaN-49* Creat-1.5* Na-131* K-3.2* Cl-107 HCO3-12* AnGap-15 [**2187-11-23**] 04:58AM BLOOD ALT-384* AST-243* LD(LDH)-290* AlkPhos-439* TotBili-1.5 [**2187-11-23**] 04:58AM BLOOD Lipase-473* [**2187-11-23**] 04:58AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.7 [**2187-11-13**] 03:14AM BLOOD calTIBC-244* Ferritn-894* TRF-188* [**2187-10-31**] 07:43AM BLOOD TSH-1.8 [**2187-10-31**] 07:43AM BLOOD Free T4-1.5 [**2187-10-30**] 12:01AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE . [**2187-11-14**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular function. Mild mitral regurgitation. . [**2187-11-14**] CT head: IMPRESSION: 1. Widespread ground-glass attenuation likely represents pulmonary edema as reported on serial chest radiographs, but superimposed asymmetrical foci of consolidation in the lower lobes and 2 small nodules raises the concern for coexisting pulmonary infection. 2. Moderate bilateral pleural effusions and anasarca. 3. Over distention of endotracheal tube cuff. . [**2187-11-15**] Liver/Gallbladder US: No evidence of a distended gallbladder to suggest cholecystitis. However, gallbladder is not well visualized; likely contracted. No history of cholecystectomy could be elicited from CareWeb. Dr. [**Last Name (STitle) 3766**] was paged to discuss these findings at 1:45 p.m. . [**2187-11-18**] MRI Head:IMPRESSION: 1. No significant change in the large right frontal intraparenchymal hematoma, 3.8x3.4cm subacute in stage with surrounding edema, peripheral nodular hyperintense areas and mild mass effect on the frontal [**Doctor Last Name 534**] of the right lateral ventricle. 2. No new hemorrhage or acute infarction. 3. Patent major intracranial arteries without focal flow-limiting stenosis, occlusion, or aneurysm more than 3 mm within the resolution of MR angiogram. 4. Diminutive right distal vertebral artery, likely related to hypoplasia or normal variant (effective PICA termination); left fetal PCA. 5. Moderate amount of fluid in the mastoid air cells on both sides and small amount in the left side of the sphenoid sinus. Brief Hospital Course: Pt is a 52F with OCD (stable recently, but h/o OD, anorexia and alcohol use in past), ileostomy, GERD with delayed gastric emptying, who presented to [**Hospital3 3765**] on [**10-28**] with nausea and dizziness. There she was initially dx'd with dehydration, ARF and UTI but then found to have ALT of 25,370 and of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was transferred to [**Hospital1 18**]. . She had been having fevers for ~10 days. On [**10-23**] she went to her PCP who diagnosed [**Name Initial (PRE) **] UTI (grew klebsiella) and was taking Bactrim. She continued to have general malaise and fevers despite bactrim and asa. On [**10-28**] she called her PCP who recommended some tylenol. Per husbands report she took 650mg x2 before coming in to the ED on [**10-28**]. There she was initially dx'd with dehydration, ARF and UTI. She was given home doses of simvastatin and SSRIs, but then found to have ALT of 25,370 and of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was transferred to [**Hospital1 18**]. On presentation initial vs were: 97.5 P89, 112/37 19 99%RA 37kg. . Initially the patient was treated in the MICU. She was thought to be in hyperacute fulminant liver failure either secondary to Bactrim reaction versus acetaminophen toxicity - tylenol level peaked at 10.0 >24 hrs after last ingestion. She became progressively obtunded, with significant encephalopathy requiring intubation and ventilatory support. Her liver function was notable for transaminases with an ALT and AST of 9500 and 17,500 respectively and worsening hyperbilirubinemia. She became progressively more coagulopathic, and it was thought that she was most likely going to need orthotopic liver transplantation for survival. She was transfered to the SICU and transplant team. Her liver function spontaneously improved over the course of 2 weeks. This was evidenced by progressive ability to metabolize her lactate, stabilization of her blood sugars, and autocorrection of her coagulopathy. . During her stay in the SICU, she required respiratory ventilation, vasopressors for hypotension and intracranial pressure monitoring. The patient initially had blood pressure support with the use of vasopressors in order to minimize her intravascular volume which was thought to exacerbate her cerebral edema. The vasopressors were weaned by ICU day 6, and there was no further requirement for this. . Given the concern for hepatic encephalopathy and cerebral edema, ICP was initiated. Hypertonic saline and mannitol were used for aggressive volme managment. Her ICPs had climbed into the high 30s, which improved with treatment. Her sedation and paralytics were weaned. She had removal of her intracranial bolt on [**11-6**], [**2187**], and it was noted on subsequent imaging that she had approximately a 4-cm, right frontal, intracranial hemorrhage. This was followed serially with CT scans and there was no progression of the bleeding. The bleeding was thought to be secondary to her severe coagulopathy and thrombocytopenia in the setting of her instrumentation. She was started on Keppra for seizureprophylaxis to finish a 10-day course. . In terms of her respiratory status, it is noted that the patient required full ventilatory support with hypoxic respiratory failure. She was found to have ARDS. She was extubated on [**2187-11-12**]. She initially did well, but, secondary to what was thought to be pulmonary edema, required reintubation on [**2187-11-13**] after failure of noninvasive positive pressure ventilation. She had some degree of what appeared to be an ARDS-type reaction or transfusion-associated lung injury. . The patient also spiked fevers intermittenly starting [**11-7**]. She was on Vancomycin fom [**2187-10-31**] for ppx with bold placement. Zosyn was added for the concern for PNA when she spiked fevers and had a leukocytosis. Pan cultures were negative. She then developed a drug rash leading to the discontinuation of Vanc and Zosyn on [**11-10**]. Cipro was started in lieu of Zosyn but was discontinued on [**11-13**] . The patient was transferred to the floor on [**2187-11-18**] and did well. Cr is gradually trending down. Keppra was stopped on [**11-21**] [**3-3**] rise in LFT's. Since that time, LFT's continue to trend down. The patient's outstanding issues include: . 1 Intraparenchymal hemorrhage: s/p bolt removal with thrombocytopenia and coagulopathy [**3-3**] liver failure. Stable on MRI [**2187-11-18**]. Pt's aphasia likely [**3-3**] bleed. EEG from [**11-19**] without epileptiform activity, consistent with encephalitis and focal findings consistent with intraparenchymal bleed. Keppra d/c'd [**11-21**] with rise in LFT's thought to possibly be [**3-3**] drug rxn. She has had no evidence of seizure activity and is currently off seizure prophylaxis. Pt's ability to communicate and respond to commands seems to be improving daily. Pt failed video swallow [**11-20**]. However, she was re-evaluated on [**11-23**] prior to transfer and she was found to be safe to take teaspoon trials of nectar thick liquids and pureed food. Will plan to continue tube feeds for nutrition at this time. She has been working with PT and OT at time of transfer. She will have neuro follow up as below after discharge. . # ARF- Possibly [**3-3**] AIN from Bactrim/ tylenol possibly with ATN component. Cr today continues to trend down at 1.5 prior to transfer. Of note, nephrology thinks that her ongoing acidosis is likely related to her liver pathology and does not think bicarbonate should be used to correct this. At transfer, her bicarb is 12. Renal team thinks that this should correct itself as her kidneys recover. Her lytes should be monitored daily. We recommend she continue on NS at 75 cc/hr for now. - Continue IVF with NS at 75cc/hour . # Respiratory failure- stable since extubation [**11-16**]. . # Hepatic failure- LFT's leveling off. Amylase and Lipase are trending down so continuing TF. With pt's Eosinophilia, it seems that drug allergy to keppra could very well have been causing rise in LFTs seen on [**11-19**]. Lactulose is being continued [**Hospital1 **] PRN to help clear her sensorium and assist with constipation. We recommend the facility to which she is being discharged continue to trend LFTs daily for now. She will have outpatient hepatology follow up as below. - Trend LFTs Daily . # Fevers- currently resolved, afebrile since transfer to the floor. S/p tx with zosyn. No infectious source found on bronch or LP in MICU. Pt now without foley but incontinence also a risk factor for UTI. However, pt currently afebrile with WBC 11.1. . # Thrombocytosis: Plt very slowly trending down at 906 at time of transfer. Likely due to reactive physiology. . # Drug Rash: Drug rash per derm thought to be most likely [**3-3**] Zosyn but Vanc or fluconazole also possible. Now pt with exfoliation of whole body. Skin underneath intact. . # Anemia: Stable at 22.9 on day of discharge. iron/ TIBC ratio 17% indicating mild iron deficiency. Will continue iron supplementation. . # Sacral decub: Pt with sacral decub developed in house. She was seen on the day of discharge by wound care. Please see attached note from wound care about recommended dressing. Pt should be followed by wound care specialists as an outpatient. . FEN- TF at 30 cc/hr. We would recommend that pt continue IVF, NS at 75cc/hour until she is better able to take in PO volume. Also, she is currently cleared to take nectar thick liquids and pureed foods in teaspoon trials. Access- right PICC PPX- lansoprazole, no anticoagulation with h/o intraparenchymal bleed. Code- Full Medications on Admission: Medications prior to hospitalization are unable to be confirmed by pt during this hospitalization. The pt's records indicate she was on high doses of SSRI. Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2 times a day) as needed. 3. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Hyperacute fulminant hepatic failure Secondary diagnoses: Acute Renal failure Increased intracranial pressure s/p Bolt procedure Intraparenchymal bleed Aphasia Dysphagia OCD Anemia Drug rash Discharge Condition: Stable Discharge Instructions: You were admitted with liver failure. We are unsure of the exact cause of your liver failure at this time but we think it was a reaction to the tylenol and bactrim you had been taking. While you were here you also had kidney failure. You recieved dialysis for this but you no longer need this and your kidney function is returning to normal. In addition, you had increased pressure in your brain from your liver failure while you were here. This required a bolt placement in your head to monitor your pressure. After this was removed, it was noticed that you had a bleed into your brain. This bleed has been stable for 2 weeks. You will need extensive physical and occupational therapy at rehab. . Please keep all your follow up appointments as below. . If you have any chest pain, shortness of breath, fever, chills, nausea, vomitting, yellowing of your skin or eyes, blood in your urine or any other concerning symptoms, please call your doctor or return to the ED. Followup Instructions: Please follow up with neurology, Dr. [**Last Name (STitle) **] on Tues [**12-25**] at 2:30pm. Please call [**Telephone/Fax (1) 3767**] to make sure they have all of your information at least 1 week before your appointment. . Please follow up in the liver center with Dr. [**Last Name (STitle) 696**] on [**11-28**] at 2:50pm. If you need to reschedule, please call [**Telephone/Fax (1) 2422**]. . Please follow up with nephrology, Dr. [**Last Name (STitle) **], on Tuesday [**11-27**] at 8am. If you need to reschedule, call [**Telephone/Fax (1) 3768**]. . Please call your previous outpatient psychiatrist to arrange follow up withing 2 weeks. Completed by:[**2187-11-23**]

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icd9cm

[ [ [] ] ]

[ "38.95", "99.07", "96.04", "03.31", "38.93", "39.95", "99.05", "33.24", "38.91", "01.10", "99.04", "99.15", "96.71", "96.72" ]

icd9pcs

[ [ [] ] ]

21075, 21090

12855, 20480

7241, 7371

21344, 21353

9868, 11374

22370, 23047

9309, 9327

20687, 21052

21111, 21111

20506, 20664

21377, 22347

9342, 9849

21188, 21323

7182, 7203

7399, 8882

11383, 12832

21130, 21167

8904, 9173

9189, 9293

77,565

189,804

46056

Discharge summary

report

Admission Date: [**2139-12-3**] Discharge Date: [**2139-12-7**] Date of Birth: [**2077-10-7**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 1711**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac catheterization with POBA(PCA without stenting) of Prox/mid LAD History of Present Illness: Mr [**Known lastname 1557**] is a 62 year old man with history of CAD status post MI in 99 with LAD disease and stenting who presented with chest pain and was transferred to [**Hospital1 18**] after found to have anterior ST elevation. Patient is a poor historian and history is obtained from records. He first noted chest pain this afternoon at around 1400. He has a history of seizure disorder and initially thought he was having a seizure but later developed chest pain promting him to the [**Hospital3 3383**] ED. He describes the pain as left sided chest pain, [**10-24**] in severity, radiating to arm. This was associated with nausea and vomiting. He denies any lightheadedness, palpitations or SOB. He also discoses involuntary muscle movements in left upper extermity prior to chest pain. He could not describe whether this was typical of his seizure disorder. He was found to have anterior ST elevations with reportedly elevated CE and was given aspirin, clopidrogel, heparin ggt and eptifibatide. He was taken to cath lab where he was found to have diffuse LAD disease. This was ballooned and the patient is transfered to the CCU post procedure. He currently still has chest pain that is [**5-24**] in severity. Of note he has had a history of similar chest pain throughout the years since his MI in 99. In 03 he had a nuclear stress test that is reported as negative for ischemic changes. In [**9-23**] he had a TTE with preserved EF and no WMA. On review of systems, s/he denies any dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope, prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. Past Medical History: 1. Coronary artery disease status post myocardial infarction with severe stenosis in his apical LAD as well as occluded obtuse marginal. S/P LAD stent in 99. 2. History of seizure disorder, on medications. Last seizure was four weeks back. 3. History of psoriasis. 4. History of glaucoma. 5. History of chronic sinusitis. 6. History of nephrotic syndrome with baseline [**Date Range **] 1.0. Social History: Mr. [**Known lastname 1557**] lives alone and gets occasional help from his nieces and nephews. [**Name (NI) **] used to smoke pipe for about 50 years, but quit two years back. He quit alcohol about 11 years back. There is no history of illicit drug use. He is retired for about eight years and worked for [**Company 2676**] for 34 years prior to that. Family History: Significant for end-stage renal disease in father and mother. History of hypertension, diabetes and coronary artery disease in father. History of seizure disorder in mother. Father had some cancer and Mr [**Known lastname 1557**] is unsure of the type of cancer. Physical Exam: Admission PE: GENERAL: WDWN NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. 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: [**2139-12-3**] 06:33PM HCT-35.1* [**2139-12-3**] 06:33PM PTT-39.6* [**2139-12-3**] 10:19AM GLUCOSE-124* UREA N-20 CREAT-1.5* SODIUM-140 POTASSIUM-4.9 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13 [**2139-12-3**] 10:19AM ALT(SGPT)-116* AST(SGOT)-607* LD(LDH)-[**2160**]* CK(CPK)-6011* ALK PHOS-82 TOT BILI-0.3 [**2139-12-3**] 10:19AM CK-MB-GREATER TH cTropnT-21.94* [**2139-12-3**] 10:19AM ALBUMIN-2.0* CALCIUM-7.6* PHOSPHATE-5.2* MAGNESIUM-2.0 [**2139-12-3**] 10:19AM HCT-35.5* [**2139-12-3**] 10:19AM PLT COUNT-312 [**2139-12-3**] 01:04AM GLUCOSE-144* UREA N-14 CREAT-1.2 SODIUM-138 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-25 ANION GAP-9 [**2139-12-3**] 01:04AM CK(CPK)-[**Numeric Identifier 98013**]* [**2139-12-3**] 01:04AM CK-MB-GREATER TH cTropnT-GREATER TH [**2139-12-3**] 01:04AM CALCIUM-7.9* PHOSPHATE-4.2 MAGNESIUM-2.0 CHOLEST-576* [**2139-12-3**] 01:04AM %HbA1c-5.3 [**2139-12-3**] 01:04AM WBC-16.4* RBC-4.23* HGB-13.2* HCT-39.0* MCV-92 MCH-31.3 MCHC-33.9 RDW-13.6 [**2139-12-3**] 01:04AM TRIGLYCER-94 HDL CHOL-76 CHOL/HDL-7.6 LDL(CALC)-481* [**2139-12-3**] 01:04AM PLT COUNT-354 [**2139-12-2**] 11:25AM GLUCOSE-155* UREA N-13 CREAT-1.0 SODIUM-138 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13 [**2139-12-2**] 11:25AM estGFR-Using this [**2139-12-2**] 11:25AM CK(CPK)-2396* [**2139-12-2**] 11:25AM CK-MB-413* MB INDX-17.2* cTropnT-2.33* [**2139-12-2**] 11:25AM WBC-15.6* RBC-4.49* HGB-13.7* HCT-41.7 MCV-93 MCH-30.5 MCHC-32.8 RDW-13.5 [**2139-12-2**] 11:25AM PLT COUNT-313 [**2139-12-2**] 11:25AM PT-12.0 PTT-58.0* INR(PT)-1.0 C. Cath: **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN DISCRETE 40-50 6) PROXIMAL LAD DIFFUSELY DISEASED 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 100 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX DIFFUSELY DISEASED 13) MID CX DIFFUSELY DISEASED 13A) DISTAL CX DIFFUSELY DISEASED 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 80-90 15) OBTUSE MARGINAL-2 NORMAL COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA had a distal 40-50% lesion. The LAD had a proximal stent that was patent, and was totally occluded in the mid vessel. The LCx had diffuse disease. The OM1 was 80-90% stenosed. The RCA was a large vessel with mild, diffuse disease. 2. Resting hemodynamics revealed mildly elevated right sided filling pressure with RVEDP 13mmHg. There was Mild pulmonary arterial systolic hypertension with PASP of 41mmHg. The cardiac index was preserved at 2.8 l/min/m2. There was moderate stetemic arterial systoli cand diastolic hypertension with SBP of 190mmHg and DBP 115mmHg. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Moderate systemic arterial hypertension. ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal anteroseptal and anterior akinesis and apical akinesis. No apical thrombus identified. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trace mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a very small pericardial effusion. Compared with the prior study (images reviewed) of [**2139-7-24**], left ventricular systolic function is now moderately impaired with regional wall motion abnormality consistent with anterior myocardial infarction. There is a very small pericardial effusion in the current study. This study was compared to the prior study of [**2139-7-24**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg). LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate regional LV systolic dysfunction. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV chamber size. Normal RV systolic function. AORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Physiologic MR (within normal limits). TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Small pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Brief Hospital Course: # ST elevation myocardial infarction - Mr [**Known lastname 1557**] was taken to the cardiac cath lab where he was noted to have a mid-proximal LAD occlusion which was opened by balloon angioplasty without stenting. He was started on integrelin, aspirin, plavix, BB, ACE-I, statin for his STEMI. After 18 hours of integrillin he was started on heparin and bridged to coumadin for his apical akinesis with low EF (35%). Plavix will be held at this time because of coumadin. He will likely require coumadin for 3 months post STEMI for apical akinesis and then can be changed to Plavix. His Cardiac enzymes were trended to peak and downtrended. Myoglobinuria may be playing a role in setting of significantly elevated CK. - Continue ASA, BB, ACEI, statin, warfarin on d/c. . # elevated blood pressure - Resolved with beta blockade and ACE inhibitor. Lisinopril was [**Month (only) **] by 50% at discharge because of rising creatinine, please increase as needed when Creatinine improves. . # dyslipidemia - Started on statin therapy. . # leukocytosis - Resolved with resolution of his STEMI. No evidence of infection. . # Reported involuntary mm movements, h/o seizure - Seen by neuro, who requested that we continue his home tegretol. . # ARF - Mr [**Known lastname 51552**] [**Last Name (Titles) **] peaked at 2.0 most likely [**2-16**] poor forward flow. Cr improved with fluids over course of hospitalization 1.3. ACEi was initially held and then restarted at lower dose as noted above. . # Membranous GN - Stable. Outpatient renal physician aware, may have played a role in dyslipidemia if it progressed to nephrotic syndrome. Pt was ordered for lasix 20 mg [**Hospital1 **], not taking at home. Started again at 20 mg daily. . # Seizure disorder: Continued CBZ. Note that this medication can also contribute to derangement of lipid profile. Medications on Admission: Tegretol XR 200mg QID ASA 81mg QD Atenolol 100mg QD Naprosyn 500mg q6h PRN Xalatan drops QHS furosemide 20 mg [**Hospital1 **] (not taking) Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). Disp:*60 Tablet(s)* Refills:*2* 2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO QID (4 times a day). Disp:*120 Tablet Sustained Release 12 hr(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 100 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* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. 8. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day: Start taking 2 [**Hospital1 **] aspirin (160mg) daily on [**1-6**] instead of 325 mg. . 9. Xalatan 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime. 10. Outpatient Lab Work Please check PT/INR on Wednesday [**2139-12-9**], call results to Dr. [**Last Name (STitle) **] office at [**Telephone/Fax (1) 7477**] fax:[**Telephone/Fax (1) 12227**] 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: ST Elevation Myocardial Infarction Acute on Chronic Renal Failure Acute on Chronic systolic congestive Heart Failure. Hypertension Seizure Disorder Discharge Condition: Stable [**Last Name (un) 1425**], easily distracted Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were transferred to [**Hospital3 **] Deaconness when it was determined that you were having a heart attack. You were taken for cardiac catheterization and a large artery suppying your heart was opened. You were observed, your medications were adjusted and cleared to go home. Your kidneys were not working well, they are improving now. You will see Dr. [**Last Name (STitle) **] in 2 weeks. The following changes were made to your medications: 1. You were started on Warfarin 2mg which you should take for 3 months. This is to prevent blood clots. You should start plavix 75mg at the end of this 3 month period, Dr. [**Last Name (STitle) **] will do this. 2. Your aspirin was increased to 325 daily which you should take for 1 month then take 160mg (2 baby aspirin) daily ongoing after that 3. Your Lisinopril was decreased to 5 mg daily 4. Your Atenolol was discontinued 5. You were started on Metoprolol XL to take the place of the Atenolol. 6. Do not take Naproxen until after you see Dr. [**Last Name (STitle) **] on [**12-15**]. . Weight yourself every day before breakfast. Please call Dr. [**Last Name (STitle) **] if you have a weight gain of more than 3 pounds in 1 day or 6 pounds in 3 days. Please also call if you notice trouble breathing during the day or at night, swelling in your hands or feet. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 7477**] Date/Time: [**12-14**] at 11:30am. . Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**1-5**] at 9am. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**]. . Nephrology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2139-12-15**] 2:00 Dermatology: Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB) Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2140-3-8**] 11:30 Opthamology: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2140-3-22**] 9:45 Completed by:[**2139-12-7**]

[ "585.9", "403.90", "272.4", "428.0", "414.01", "584.9", "410.11", "428.23", "412", "345.90" ]

icd9cm

[ [ [] ] ]

[ "88.52", "00.40", "99.20", "00.66", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

12739, 12796

9309, 11158

275, 349

12988, 13114

4184, 6920

14483, 15421

3072, 3338

11348, 12716

12817, 12967

11184, 11325

6937, 9177

13138, 14460

9226, 9286

3353, 4165

230, 237

377, 2259

2281, 2683

2699, 3056

31,260

187,708

2722

Discharge summary

report

Admission Date: [**2111-3-4**] Discharge Date: [**2111-3-16**] Date of Birth: [**2045-4-2**] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[**First Name3 (LF) 1899**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: pulmonary intubation CVVH History of Present Illness: This is a 65 year old woman with severe LV diastolic dysfunction, severe TR, and RV failure often refractory to diuretics and has previously required CVVH/UF, CRI (baseline Cr 2.5), HTN, DM, and Afib, and ulcerative colitis who is transfered to [**Hospital1 18**] from [**Hospital3 **] with acute appendicitis and congestive heart failure. Please see the CCU fellows note for details. In brief, the patient presented with right-sided abdominal pain x 3-4 days when she presented to [**Hospital3 **] on [**2111-3-2**]. She denied any nausea of vomiting or change in bowel movements at initial presentation. She underwent an abdominal CT which demonstrated a 10m enlarged appendix with phlegmon and fat stranding. She was not taken to the OR because of her comorbiditis and there was no obvious pocket to drain. She was medically managed with Cipro/Flagyl. It is not clear how much IVF she received- but per OSH records, she was given 'discretionary use' of IVF. She was also started on diuretic (unclear the dose)and and her response to diuretics is not clear. The patient was transfered to [**Hospital1 18**] for further surgerical evaluation of her phlegmon. She was transferred on neosynephrine. . Initial labs revealed a severe metabolic acidosis with a ABG of 7.19/42/101, a HCO3 of 15, an anion gap of 23, and a Lactate of 1.2. She was 15kg over her dry weight (81.4kg on arrival with a dry weight off 66). The patient is drowsy with providing limited additional details or history. She denies CP but feels somewhat short of breath and unable to lie flat. She denies abdominal pain. . Limit review of systems, given patient mental status. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -severe diastolic dysfunction of left ventricle -severe pulmonary hypertension -right ventricular contractile dysfunction and dilatation with recurrent right heart failure, requiring ultrafiltration in past -severe tricuspid regurgitation -atrial fibrillation not on coumadin [**1-22**] GI bleed -Patent foramen ovale (closed [**3-/2109**]) prior to closure, was allowing right to left shunting at the atrial level during periods of aggressive pressure and volume unloading 3. OTHER PAST MEDICAL HISTORY: - ulcerative colitis - angioectasia of entire colon (last colonoscopy [**2108**]) - chronic renal insufficiency (baseline 1.5) - history of ETOH abuse with current ETOH use - Chronic massive leg edema with recurrent leg cellulitis - Ventral hernia status post repair Social History: - separated from husband - lives alone, ambulates unassisted, drives - four children, son [**Name (NI) **] is health care proxy - [**Name (NI) 1139**] history: denies - ETOH: [**1-23**] drinks daily, denies history of withdrawal symptoms. Prior heavy EtOH use. - Illicit drugs: denies Family History: -Father with MI at age 68 -Mother breast cancer at age 52 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: 65 yo F in no acute distress HEENT: mucous membs moist, no lymphadenopathy, JVD 1/2 up sitting in chair. CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity, irreg irreg, [**1-26**] systolic murmur at LUSB ABD: soft, mildly TTP, non-distended, BS normoactive. no rebound/guarding, neg [**Doctor Last Name 515**] sign. EXT: 1+ edema to calfs. NEURO: CNs II-XII intact. 3/5 strength in U/L extremities. SKIN: no rash PSYCH: A/O, appears comfortable. Pertinent Results: Labs on admission: [**2111-3-4**] 09:12PM BLOOD WBC-12.9*# RBC-3.34* Hgb-10.7* Hct-33.7* MCV-101* MCH-32.1* MCHC-31.8 RDW-15.5 Plt Ct-187 [**2111-3-4**] 09:12PM BLOOD Neuts-87* Bands-0 Lymphs-3* Monos-8 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2111-3-4**] 09:12PM BLOOD Glucose-72 UreaN-86* Creat-3.9*# Na-134 K-4.4 Cl-100 HCO3-15* AnGap-23* [**2111-3-4**] 09:12PM BLOOD Albumin-4.0 Calcium-9.4 Phos-6.3*# Mg-1.9 [**2111-3-4**] 09:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs on Discharge: [**2111-3-16**] 06:00AM BLOOD Hct-28.2* [**2111-3-15**] 09:45AM BLOOD WBC-4.6 RBC-3.24* Hgb-10.0* Hct-31.7* MCV-98 MCH-30.7 MCHC-31.5 RDW-15.0 Plt Ct-360 [**2111-3-16**] 06:00AM BLOOD Glucose-97 UreaN-38* Creat-3.0* Na-131* K-3.4 Cl-85* HCO3-39* AnGap-10 [**2111-3-16**] 06:00AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7 . ECHO [**2111-3-5**]: IMPRESSION: Suboptimal image quality. Small left ventricular cavity size with low normal systolic function. Dilated right ventricle with global systolic dysfunction and signs of pressure and volume overload. Moderate to severe tricuspid regurgitation. Mild mitral regurgitation. At least mild pulmonary hypertension (likely underestimated due to high right atrial pressures in setting of 3+ tricuspid regurgitation). Compared with the findings of the prior study (images reviewed) of [**2110-12-16**], left ventricular function is mildly reduced, predominantly due to abnormal septal motion. There may be less mitral regurgitation . CXR [**2111-3-9**]: FINDINGS: As compared to the previous radiograph, the nasogastric tube is now visible. It is coiled in the stomach but the tip is located in the middle parts of the stomach. No evidence of complications, notably no pneumothorax. Otherwise unchanged chest radiograph. Unchanged cardiac silhouette. . CT ABdominal: [**2111-3-6**] IMPRESSION: 1. Distended and fluid filled appendix, compatible with known acute appendicitis. No abscess or perforation. 2. Volume overloaded state with cardiomegaly, diffuse soft tissue edema, small pleural effusions, and small ascites. 3. Pleural effusions are associated with adjacent compressive atelectasis. 4. T10, L3, and L4 wedge compression deformities. Brief Hospital Course: #. Acute on Chronic Diastolic CHF: She is presented 15 kg over her dry weight. Required intubation and lasix IV gtt and metolazone boluses. Now at dry weight of 66 kg with minimal peripheral edema, clear lungs and no O2 requirement. Back on home dose of torsemide. No ACE/[**Last Name (un) **] at home and no indication as pt has diastolic dysfunction. Was on spironolactone at home but this has not been restarted because of rising creatinine. Consider restarting once creatinine is decreasing. Pt will need daily weights and chem-7 checked on Wednesday [**3-18**]. She will f/u with Dr. [**First Name (STitle) 437**]. . #. Acute appendicitis: Noted at [**Hospital 1774**] Hospital with right sided abdominal pain and evidence on CT, medically managed and symptoms have resolved. The surgical service followed her here and will see her after discharge. Initially on cipro/flagyl, then changed to vanco/Zosyn, now back to cipro flagyl and will need 3 more days of these antibiotics to complete a 14 day course. Will need another 3 days for total of 2 week course. She is eating and drinking normally despite mild nausea this am. No fevers or leukocytosis. . #.Combined metabolic and respiratory acidosis: Now resolved after intubation and CVVH. Thought to be related to acute kidney failure and decompensated CHF. Required pressors while in CCU to maintain BP. . #. Acute on chronic kidney injury: Thought to be related to CHF exacerbation requiring CVVH. Creatinine is now rising in the setting of aggressive diuresis, 3.0 at discharge with baseline about 2.0. Expect creatinine to decrease with lower torsemide dose. Please recheck creatinine on [**3-18**] and avoid nephrotoxic meds. . # Atrial fibrillation- CHADS of 3. not on coumadin [**1-22**] GI bleeding. Remains on aspirin 81 g daily . # Diabetes mellitus- not on home meds, does not seem to have been on them in the past. Last A1C 4.9 - carbohydrate consistant diet . # Nutrition: Pt required dietary modification after intubation, now has been cleared by speech therapy and is eating normally. Encourage high calorie/protein shakes> Fluid restriction of 1.5-2.0 liters per day depending on creatinine and fluid status. . # Goal of Care: Pt was seen by palliative care and social worker during this hospital stay. She admits that she is getting sicker but states that she does not have conversations with her family about dying or planning for her death as this is not discussed in the family. She remains a full code and would want to be intubated but not "kept alive by machines". She has some bruising on her back that is unusual and was asked about this by social worker here. She denies any abuse at home and states she is not concerned about any of her family members. Medications on Admission: HOME MEDICATIONS: Albuterol PRN Buproprion XL 150 mg daily Neurontin 100 mg daily Mesalamine 0.375 gram daily metoprolol 25 mg [**Hospital1 **] omeprazole 20 mg daily Oxycodone 5 mg 4x/day KCl 20 mEq daily Aldactone 25 mg daily Torsemide 40 mg [**Hospital1 **] ASA 81 mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 9. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 11. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work Please check Chem-7 and magnesium on Wendesday [**2111-3-18**] Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center - [**Location (un) **] Discharge Diagnosis: Acute Appendicitis Acute on Chronic Diastolic CHF Acute on Chronic Kidney injury Hypertension Atrial Fibrillation 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 had acute appendicitis and needed to be transferred to [**Hospital1 18**] for treatment. Your appendicitis was treated with 2 weeks of antibiotics and you will see a surgeon in another 2 weeks to make sure that the problem is resolved. You needed to be aggressively diuresed to get rid of extra fluid. As a result, your kidney function worsened and you will need to have this followed carefully after you leave to make sure it is improving. . We made the following changes to your medicines: 1. STOP taking neurontin, mesalamine, and aldactone 2. START taking ciprofloxacin and flagyl for your appendacitis 3. Change metoprolol to a long acting version 4. START tylenol as needed for pain. . Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: . Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Location: [**Hospital1 **] [**Hospital **] MEDICAL CARE CTR [**Location (un) 2788**] Address: [**Location (un) **], [**Location (un) 2788**],[**Numeric Identifier 13479**] Phone: [**Telephone/Fax (1) 2789**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.** Department: TRANSPLANT CENTER When: MONDAY [**2111-3-30**] at 10:45 AM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: MONDAY [**2111-3-23**] at 1:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]

[ "403.91", "038.9", "428.33", "785.52", "427.31", "995.92", "416.8", "397.0", "276.4", "250.00", "305.01", "540.1", "518.81", "272.4", "585.6", "428.0", "584.5" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "96.6", "96.72", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

10418, 10502

6185, 8923

347, 375

10660, 10660

3946, 3951

11692, 12929

3244, 3417

9251, 10395

10523, 10639

8949, 8949

10836, 11669

3432, 3927

2143, 2618

8967, 9228

293, 309

4478, 6162

403, 2049

3966, 4458

10675, 10812

2649, 2924

2071, 2123

2940, 3228

31,336

148,804

53103

Discharge summary

report

Admission Date: [**2172-9-24**] Discharge Date: [**2172-10-3**] Date of Birth: [**2096-8-10**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Cephalexin / Allopurinol Attending:[**First Name3 (LF) 898**] Chief Complaint: upper abdominal pain Major Surgical or Invasive Procedure: cardiac catherization History of Present Illness: Ms. [**Known lastname **] is a 76 yo female with a h/o HTN remote h/o breast cancer, who presented with a chief complaint of abdominal pain for 1 day duration. She reports that she has been feeling "weak" and with increasing fatigue over several weeks. She saw her PCP with these symptoms and was found to have a UTI and she was treated with cipro. However, her weakness persisted. Approximately 3 days ago, she noted feeling nauseus and vomitting. 1 day prior to admission, she reports a continuous across her upper abdomen, but most predominantly in her epigastrium. Denies diarrhea. She also reports that she has been having progressively worsening SOB x 1 month. On the day of admisison she reports having even worsening shortness of breath, to the point where she had to be carried to the ED by her son. She denies chest pain, palpitations, lower extremity edema. She denies fever, chills, cough. +hematuria. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1) DMII 2) Diverticulosis 3) Depression/Anxiety 4) Hypertension 5) h/o gastric ulcer +herpes 6) osteoarthrits s/p bilateral TKR 7) chronic cystitis, on nitrofurantoin suppression 8) CRI, baseline cr 1.5 9) Gout Social History: Social history is significant for the absence of current or former tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 94.8, BP 145/75, HR 95, RR 16, O2 100% on 4L NC Gen: elderly, pale and ill-appearing WF, supine in bed, in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, diffusely tender, No abdominal bruit. No masses or organomegaly. No rebound/guarding. Ext: No c/c/e. Right groin with hematoma and large ecchymoses. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP MEDICAL DECISION MAKING Pertinent Results: LABORATORY DATA: Na 135, K 5.1, Cl 106, HCO3 10, BUN/Cr 64/2.4, Glu 222, Ca [**74**] WBC 25.4 (88%N, 7%L, 4%M, 0%B), Hct 46.8, Plt 319 16.6/36.1/1.5 Amylase 695, Lipase 2979 [**2172-9-24**] 08:25PM BLOOD WBC-25.4*# RBC-5.19 Hgb-15.9 Hct-46.8 MCV-90 MCH-30.7 MCHC-34.0 RDW-15.8* Plt Ct-319 [**2172-9-25**] 12:03AM BLOOD WBC-21.0* RBC-3.88*# Hgb-11.6*# Hct-34.3*# MCV-88 MCH-29.8 MCHC-33.8 RDW-15.8* Plt Ct-251 [**2172-10-2**] 06:03AM BLOOD WBC-5.3 RBC-2.80* Hgb-8.5* Hct-25.2* MCV-90 MCH-30.4 MCHC-33.7 RDW-15.8* Plt Ct-119* [**2172-10-3**] Hct: 33.0 [**2172-9-24**] 08:25PM BLOOD Neuts-88.0* Bands-0 Lymphs-7.1* Monos-4.6 Eos-0.1 Baso-0.2 [**2172-9-28**] 05:26AM BLOOD Neuts-75.3* Bands-0 Lymphs-17.3* Monos-6.5 Eos-0.7 Baso-0.2 [**2172-9-27**] 09:51AM BLOOD Ret Aut-3.8* [**2172-9-25**] 03:15PM BLOOD Fibrino-94*# [**2172-9-28**] 05:26AM BLOOD Fibrino-140*# [**2172-9-25**] 03:15PM BLOOD FDP-320-640* [**2172-9-24**] 08:25PM BLOOD Glucose-222* UreaN-64* Creat-2.4* Na-135 K-5.1 Cl-106 HCO3-10* AnGap-24* [**2172-10-2**] 06:03AM BLOOD Glucose-104 UreaN-19 Creat-1.0 Na-137 K-4.0 Cl-109* HCO3-22 AnGap-10 [**2172-9-24**] 08:25PM BLOOD ALT-41* AST-33 CK(CPK)-43 AlkPhos-169* Amylase-695* TotBili-0.7 [**2172-10-1**] 05:43AM BLOOD ALT-20 AST-28 LD(LDH)-228 AlkPhos-153* Amylase-186* TotBili-0.7 [**2172-9-24**] 08:25PM BLOOD Lipase-2979* [**2172-10-1**] 05:43AM BLOOD Lipase-366* [**2172-9-24**] 08:25PM BLOOD CK-MB-4 cTropnT-<0.01 [**2172-9-25**] 12:03AM BLOOD CK-MB-NotDone cTropnT-0.12* [**2172-9-25**] 06:11AM BLOOD CK-MB-19* MB Indx-14.0* cTropnT-0.29* [**2172-9-24**] 08:25PM BLOOD Albumin-4.2 Calcium-10.0 Phos-4.9*# Mg-1.7 [**2172-10-2**] 06:03AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.6 Iron-PND [**2172-9-25**] 12:03AM BLOOD Triglyc-50 [**2172-9-27**] 06:28AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE [**2172-9-27**] 06:28AM BLOOD AMA-NEGATIVE [**2172-9-27**] 06:28AM BLOOD [**Doctor First Name **]-NEGATIVE [**2172-9-27**] 06:28AM BLOOD IgG-691* IgA-157 IgM-80 [**2172-9-27**] 06:28AM BLOOD HCV Ab-NEGATIVE . EKG demonstrated sinus tachycardia, rate 120's, with new ST elevations in II, III and aVF. ST depressions in I, aVL. . TELEMETRY demonstrated: sinus tachycardia . CARDIAC CATH performed on [**9-24**] demonstrated: Left system with minor disease throughout. Right coronary with diffuse disease and thrombus but patent with flow, BMS 2.5 x 18 placed distally and proximally. . HEMODYNAMICS: RV end diastolic 14. PCW mean 20. CO 11.4. CI 6.4. FEMORAL VASCULAR US RIGHT [**2172-9-25**] 10:49 AM FEMORAL VASCULAR US RIGHT Reason: r/o pseudoaneurysm, AV fistula, pulsatile flow within hemato [**Hospital 93**] MEDICAL CONDITION: 76 year old woman with REASON FOR THIS EXAMINATION: r/o pseudoaneurysm, AV fistula, pulsatile flow within hematoma INDICATION: 76-year-old female with pulsatile flow within groin hematoma, rule out pseudoaneurysm or AV fistula. FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of the right groin were performed. Just anterior to the common femoral artery, there is a 0.5 x 0.5 x 0.4 cm rounded structure with vascular flow consistent with a small pseudoaneurysm. Appropriate vascular flow is identified in the right common femoral artery and the right common femoral vein. No fluid collections were identified. IMPRESSION: 0.5 cm pseudoaneurysm in the right groin. No AV fistula or fluid collection identified. . [**2172-9-25**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. The inferior wall is hypokinetic. All other segments of the left ventricle are hyperdynamic (EF 70-80%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. . [**2172-9-25**] CT Abdomen IMPRESSION: 1. Mild stranding about the pancreas as noted above, which may be related to fluid elsewhere or possibly secondary to the patient's known pancreatitis. 2. Hyperdense fluid identified predominantly within the peritoneal cavity but also within the retroperitoneum as noted. Not c/w hemmorhage 3. Cirrhotic-appearing liver with a focal contour abnormality, which also may be further evaluated by ultrasound. 4. Small bilateral pleural effusions as noted above. 5. Findings consistent with acute tubular necrosis of the kidneys. Findings are discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name 1022**] at the time of dictation. . [**2172-9-29**] MRI/MRA Liver: FINDINGS: Study is slightly limited by motion artifact. Again seen is a nodular contour to the liver, consistent with cirrhosis. The signal intensity of the liver appears relatively uniform throughout. No signal abnormality is seen in the region of concern, within the right lobe of the liver, as seen on previous CT. Normal vessels seen coursing through this area. Small amount of perihepatic ascites again noted. There is no evidence of splenomegaly. The adrenal glands and kidneys appear grossly unremarkable. Slightly increased T2 signal is seen within the body of the pancreas, relative to the head and tail, which could be consistent with patient's known pancreatitis. Small bilateral pleural effusions, right greater than left, also noted. IMPRESSION: 1. Nodular-contour to the liver consisent with cirrhosis, without evidence of focal signal abnormality to suggest a focal lesion. Normal-appearing parenchyma seen in the area of concern as described by CT. 2. Perihepatic ascites. 3. Increased T2 signal within the body of the pancreas, which could be consistent with known pancreatitis. 4. Bilateral pleural effusions. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] at 3 p.m. on [**2172-9-29**]. [**2172-10-2**] Femoral US FINDINGS: Previously identified 5 mm right common femoral artery pseudoaneurysm is no longer identified. However, now seen is a rather robust and tortuous vessel originating off the common femoral artery which courses superficially into the subcutaneous tissues, possibly representing a recruited vessel in the setting of patient's extensive skin bruising. Focused scanning around the right groin demonstrates no definite hematoma. IMPRESSION: Small pseudoaneurysm no longer identified. While a robust tortuous vessel is seen coursing superficially as described, no hematoma is identified to explain a drop in hematocrit requiring transfusion. Consider repeat CT imaging of the abdomen/pelvis to evaluate further for hematoma as clinically indicated. [**2172-10-2**] CT Abdomen CT OF THE ABDOMEN WITHOUT IV CONTRAST: Assessment is limited by streak artifact from the patient's arms. There has been slight interval increase in size of bilateral small- to- moderate pleural effusions, right greater than left. There is associated subsegmental atelectasis. The liver contour again appears nodular, consistent with cirrhosis. High- density material again seen surrounding the liver, possibly representing hemoperitoneum, not significantly changed in appearance from prior study. Patient is status post cholecystectomy. Again seen is stranding surrounding the pancreas, possibly secondary to fluid seen elsewhere versus related to patient's known pancreatitis. The spleen, adrenal glands, and kidneys appear relatively stable. Punctate calcification noted within the left kidney, without evidence of hydronephrosis. There has been interval decrease in the amount of free intraperitoneal fluid. No evidence of free air within the abdomen. Fat- containing umbilical hernia again noted. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid, bladder, and uterus appear unremarkable. Moderate amount of free fluid seen within the pelvis as well. Compared to prior study, increased soft tissue stranding is seen within the subcutaneous tissues bilaterally. Assessment is limited by streak artifact from the patient's arms. Minimal stranding in the right groin region again seen, consistent with recent catheterization. BONE WINDOWS: No suspicious lytic or blastic lesion seen. IMPRESSION: 1. New increased nonspecific soft tissue stranding seen within the subcutaneous tissues bilaterally, suggesting third-spacing of fluid. 2. Interval decrease in amount of hyperdense fluid seen within the peritoneal cavity and retroperitoneum. 3. Cirrhotic-appearing liver again seen. 4. Slight increase in size of small-to-moderate bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 76 y/o woman presenting with STEMI who got BMS x 2 to RCA and pacreatitis, found here to have cirrhosis. 1) Cardiac: Patient presented to hospital with abdominal pain, and was found on EKG and enyzmes to have a STEMI. She was emergently cardiac cathed and got 2 bare metal stents to the RCA. Integrillin discontinued in cath lab secondary to hematoma. she was started on ASA, plavix and bblocker. She had an echo that showed preserved EF of 70% and no akinesis. . 2) Pancreatitis: No evidence of gallstones, no ETOH abuse. Normal Calcium and triglycerides, no risk factors for HIV. Recent medications include cephalexin and doxycycline, neither of which has been implicated in pancreatitis. POssible ischemia as, rare cases of pancreatic ischemia have been reported. Infection remains possible in the setting of leukocytosis. However no associated symptoms suugesting a specific pathogen. Of note, patient has a remote h/o pancreatitis x 2 previous episodes > 15 years prior. Abdominal pain resolved within 1 day of admission. Patient NPO on admission, foley catheter. With distributive shock, and maintained on aggressive fluid diuresis until maintained BP. CT scan done emergently which showed stranding around the pancreas and fluid in the retroperotoneal space, as well as a cirrhotic liver. Amylase and Lipase have continued to trend down throughout admission. . 3. Cirrhosis: New found cirrhosis on CT scan, confirmed with MRI/MRA liver. Liver panel sent out and no etiology of cirrhosis has been found. Patient has history of + [**Doctor First Name **] in the past. Patient will be followed in liver clinic for possible biopsy. . 3) Acute renal failure: Acute on chronic, likely secondary to hypoperfusion in the setting of MI and distributive shock seconary to pancreatitis. Creatinine of 2.4 on presentation; hydrated agressively. Creatinine returned to 1.0 on discharge. . 4) Metabolic acidosis: Ph 7.17 with gap of 19 at presentation. Differential for a gap acidosis includes lactic acidosis vs. DKA vs. toxic ingestions (acetominophen/ASA/ethanol/methanol) vs. uremia vs. non-ketotic hyperglycemia. Lactate 2.0. Possible related to pancreatitis and uremia. Resolved by discharge. . 5) Leukocytosis: Patient met SIRS criteria with WBC 25, T<96, and HR>90. Consider possible sources of infection as pancreatitis vs. cystitis vs. other intraabdominal process vs. PNA. started on meropenim, but no source of infection found, and this was discontinued. Leukocytosis resolved by discharge. . 6) Anemia: Patient with 12 point hematocrit drop following PCI, with right groin hematoma and frank hematuria. Guaic negative. likely dilutional secondary to aggressive fluid recuscitation. Transfused 1 unit PRBC for Hct fallig below 30. Retroperotneal fluid unchanged. Groin stable. Patient received two units of prbc's the day before discharge with adequate increase in her hematocrit from 25.0 to 33.0. CT Abdomen/pelvis did not show hematoma or source of bleeding. . 8)Femoral artery aneurysm: .5x.5x.5 aneurysm. very small, no bruit. Patient had repeat ultrasound on [**2172-10-2**] which showed resolution of pseudoaneurysm. Her follow-up ultrasound scheduled for [**10-16**] can be cancelled. The number is in the discharge instructions paperwork. . 9) DM2: Tight glucose control with HISS in the setting of critical illness. Metformin held in the setting of ARF (of note, patient's baseline Cr is above accepted cutoff for this medication). Metformin will be restarted at discharge with return of creatinine to 1.0. The insulin sliding scale will be discontinued. . 10)Psuedogout: Patient's colchicine was held in the setting of renal failure. The patient's creatinine has returned to [**Location 213**], and the patient should discuss with her PCP whether she should restart this medication. . 11)Hypertension: Patient's hypertensive medications, Lisinopril, atenolol, nifedipine, and ethacryinic acid were held and replaced with metoprolol. Patient's blood pressure has been maintained 130-160 with just metoprolol 75mg PO three times daily. The ethacrynic acid was added before discharge. The ethacrynic acid can be titrated up as needed to increase diuresis. The patient's former hypertensive medications can be re-administered at the discretion of her PCP. . 12)Urinary frequency: Patient had a foley for the majority of her hospitalization. The foley was discontinued the day before discharge and she continued to produce adequate urine, urinating each hour. UA confirmed no infection was present. An antispasmodic [**Doctor Last Name 360**] was considered but not added. She has follow-up with her outpatient urologist on [**2172-10-12**]. Medications on Admission: 1) Metformin 850 mg TID 2) Atenolol 100 mg daily 3) Lisinopril 40 mg [**Hospital1 **] 4) Ethacrynic acid 50 mg daily 5) Prilosec 40 mg daily 6) Nifedipine 60 mg daily 7) Macrodantin 100 mg qHS 8) Nortriptyline 10 mg daily 9) Colchicine 0.6 mg [**Hospital1 **] 10) Timolol 1 drop OU qHS 11) Oxybutynin 2.5-5 mg daily PRN dysuria 12) Albuterol PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation q4h: PRN as needed for cough and wheezing. 9. Triamcinolone Acetonide 0.1 % Lotion Sig: One (1) application Topical twice a day: Apply to feet twice a day. 10. Ethacrynic Acid 25 mg Tablet Sig: Two (2) Tablet PO once a day. 11. Lamisil 1 % Cream Sig: One (1) application Topical once a day: apply to feet once a day. 12. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital 3145**] Nursing Home - [**Location (un) 3146**] Discharge Diagnosis: ST-elevation myocardial infarction pancreatitis Acute Renal Failure Femoral artery pseudoaneurysm Anemia Discharge Condition: good 97.7 140/78 68 18 100%RA Discharge Instructions: You were admitted to the hospital with abdominal pain and fatigue. While hospitalized, you were found to have had a heart attack, pancreatitis, and acute renal failure. You were treated for your heart attack with two bare metal stents, and your pancreatitis and renal failure resolved with aggressive fluid resuscitation. While in the hospital, your ethacrynic acid, colchicine, and metformin were discontinued secondary to your renal failure and low blood pressure. The ethacrynic acid was re-administered the day of discharge because your renal function and blood pressure returned to [**Location 213**]. Your lisinopril, atenolol, and nifedipine were also held while being hospitalized. You were instead started on metoprolol with adequate control of your blood pressure. Please discuss with your PCP before restarting any of these medications. Follow up as outlined below. Call your physician immediately or else return to the hospital if you experience any chest pain, shortness of breath, fevers, palpitations, sweating, nausea, vomiting, abd pain, or any other concerning symptoms. You have a vascular study scheduled for Date/Time:[**2172-10-16**] 10:00. You will need to call and cancel this appointment because you already received this study in the hospital. The telephone number is: [**Telephone/Fax (1) 327**]. . Your new PCP is [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. You can call her at [**Telephone/Fax (1) 1144**] to schedule an appointment. Followup Instructions: Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2172-10-12**] 4:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2172-10-20**] 9:30 Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB) Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2172-11-16**] 8:50 Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name Initial (NameIs) **].D. [**Telephone/Fax (1) 1144**]. You will need to call to schedule an appointment. Provider: [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**] [**Name Initial (NameIs) **].D., Gastroenterology, [**2173-2-17**] 10:45am at the Liver Center. Number [**Telephone/Fax (1) 109391**]. His office will call you to try to schedule an earlier appointment.

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14244+56519

Discharge summary

report+addendum

Admission Date: [**2129-1-24**] Discharge Date: [**2129-2-2**] Date of Birth: [**2046-10-11**] Sex: M Service: SURGERY Allergies: Percocet / Magnesium Citrate Attending:[**First Name3 (LF) 1234**] Chief Complaint: Left lower extremity claudication, thoracic aneurysm. Major Surgical or Invasive Procedure: PROCEDURES: 1. Endovascular repair of descending thoracic aortic aneurysm with extension .46-46/ 46-42- Talent thoracic 2. Right-to-left femoral-femoral crossover graft with 8-mm PTFE, right superficial femoral artery embolectomy with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] catheter. History of Present Illness: The patient is an 82-year-old male who has a complicated vascular history which started with a ruptured infrarenal abdominal aortic aneurysm. This was repaired initially with a Zenith Endograft. This graft then later required explantation and aortobi-iliac graft operative repair. He recovered well from this but suffered a left graft limb occlusion which did not cause limb threat but has created lifestyle-limiting left lower extremity claudication. He presents at this time for endovascular repair of his remaining thoracic aneurysm and femoral-femoral bypass graft. Past Medical History: 1. CAD, s/p CABG ([**2117**]) with an LIMA to LAD and vein graft to the first diagonal, obtuse marginal, and right coronary arteries. 2. AAA, s/p repair as follows: [**2127-10-8**] - Endovascular aneurysm repair. Bilateral femoral artery exposures. [**2127-10-16**] - Exposure of left common femoral artery and primary repair; Balloon angioplasty of proximal extension cuff of endograft(aorta) and left CIA and EIA [**2127-10-30**] - Contained rupture of aortic aneurysm, status post endovascular stent graft including suprarenal fixation, Palmaz stent and cuff followed by conversion of endovascular aneurysm repair to open aneurysm repair with infrarenal tube bifurcated graft. 3. PVD, s/p bilateral carotid endarterectomies ([**2123**], [**2127**]). 4. COPD 5. Hyperlipidemia 6. Hypertension 7. ?Mild Congestive heart failure, per OMR, but pt denies pedal edema or ever being told he had HF, EF > 55% 10/08 8. Anxiety 9. Left rotator cuff tear, s/p repair 10. Obstructive sleep apnea, on CPAP 11. Atrophic right kidney 12. s/p right knee replacement Social History: Smoker x 40 years (~2 ppd), quit 21 years ago. Drinks 2 glasses of wine [**2-23**] nights per week. Drinks egg nog with rum during the holiday season. Family History: Mother died of breast cancer. One sister had a "liver condition". Patient is unsure whether there is any family history of CAD. Physical Exam: PHYSICAL EXAMINATION Vitals: T: 99.4 degrees Fahrenheit, BP: 94/49 mmHg supine, HR 102 bpm(100-110), RR 18, O2: 95 % on 3L. Gen: Pleasant, well appearing... Eyes: No conjunctival pallor. No icterus. ENT: MMM. OP clear. CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th intercostal space, mid clavicular line. Irregular. nl S1, S2. No murmurs, rubs, clicks, or gallops. Full distal pulses bilaterally. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, mild tenderness in the scar area, ND. No HSM. Abdominal aorta was not enlarged by palpation. No abdominal bruits. Heme/Lypmh/Immune: No CCE, no cervical lymphadenopathy. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-22**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Mood and affect were appropriate Pertinent Results: [**2129-2-1**] 05:45AM BLOOD WBC-7.9 RBC-3.49* Hgb-10.7* Hct-33.3* MCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 Plt Ct-278 [**2129-2-1**] 05:45AM BLOOD PT-25.3* PTT-34.8 INR(PT)-2.4* [**2129-2-1**] 05:45AM BLOOD Glucose-99 UreaN-12 Creat-1.1 Na-140 K-4.0 Cl-104 HCO3-26 AnGap-14 [**2129-2-1**] 05:45AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.7 [**2129-1-24**] 4:06 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2129-1-27**]): No MRSA isolated. CTA: INDICATION: 81-year-old male status post PTFE/EVAR with hematocrit drop. Evaluate for hemorrhage. CT CHEST WITHOUT CONTRAST: There are no pathologically enlarged axillary lymph nodes. Scattered mediastinal lymph nodes measure up to 7 mm in short axis, not meeting CT criteria for pathologic enlargement and unchanged. Atherosclerotic calcifications involve the thoracic aorta and coronary arteries. The patient is status post endovascular stent repair of a descending thoracic aorta aneurysm, however evaluation of the stent itself is limited without contrast. There is no pericardial or pleural effusion. Lung windows reveal diffuse centrilobular and paraseptal emphysema. Multiple bilateral pulmonary nodules are not significantly changed compared to [**1-10**], including a 7-mm nodule at the left lung base (2:51). Left greater than right bibasilar atelectasis is present. A small amount of secretions are present in the right mainstem bronchus. Otherwise, the airways are patent to the subsegmental level bilaterally. CT ABDOMEN WITH CONTRAST: Non-contrast evaluation of the liver, spleen, pancreas, adrenal glands and kidneys are unremarkable. Intra-abdominal loops of large and small bowel are of normal caliber and there is no pneumoperitoneum or free fluid. Scattered small mesenteric and retroperitoneal lymph nodes do not meet CT criteria for pathologic enlargement. The patent is status post stenting of an abdominal aortic aneurysm, however, evaluation of both it and the known chronic occlusion of the left common iliac and internal and external iliac arteries is limited without contrast. Atherosclerotic calcifications again involve the abdominal aorta and its branches. CT PELVIS WITHOUT CONTRAST: The rectum, sigmoid and prostate are unremarkable. Scattered diverticula of the descending colon are not associated with acute inflammation. The bladder contains a Foley and non- dependent air. There is no free pelvic fluid or pathologically enlarged pelvic or inguinal lymph nodes. Post-surgical changes are noted in the inguinal regions bilaterally with small hyperdense collections along the anterior aspect of the common femoral vessels, left greater than right, likely representing small hematomas, not large enough to cause a hematocrit drop. A fem-fem bypass is new since [**1-10**]. Bone windows reveal no worrisome lytic or sclerotic lesions. IMPRESSION: 1. No significant hemorrhage noted in the chest, abdomen or pelvis. Small foci of hemorrhage along the anterior aspects of the common femoral vessels bilaterally secondary to recent procedure are not enough to explain hematocrit drop. 2. Extensive atherosclerotic disease status post stenting of descending thoracic and abdominal aortic aneurysms, though evaluation is limited without contrast. 3. Scattered descending colonic diverticula without evidence of acute diverticulitis. 4. Emphysema with unchanged bilateral small pulmonary nodules. Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname 1730**] M was admitted on [**1-24**] with Thoracic aortic aneurysm and left leg ischemia with left iliac occlusion. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a: Right to left femoral-femoral bypass graft done after endovascular repair of descending thoracic aneurysm. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. Had intra-op TTE. Preserved EF of 55%, diagnosis of Diastolic, chronic CHF. He was then transferred to the CVICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. While in the CVICU he did have atrial fibrillation. Cardiology consulted. Started on Amio. Remained in Afib. Po diltiazem started, other medications adjusted. Pt sill in afib, but with rate control. Started on Coumadin with INR goal. of [**2-23**]. During his bouts of afib, he did have low BP, resusitated with PRBC. HCT stable on DC. When he was stabalized from the acute setting of post operative care, he was transfered to floor status. On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. Pt did fail voiding trial. Replaced foley. Started on flomax. Pt to have foley removed by Rehab in [**2-23**] days. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO HS (at bedtime) as needed for indigestion. 3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: INR goal is [**2-23**]. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 7 days, then 200 [**Hospital1 **] x 7 days, Then 200 mg po qd. Then have patient f/u with PCP to DC. 9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain . 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Please swith to long acting at time of DC at rehab. 15. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Thoracic aortic aneurysm and left leg ischemia with left iliac occlusion. AFIB Urinary Retention PVD COPD Hyperlipidemia Hypertension Mild Congestive heart failure, per OMR, but pt denies pedal edema or ever being told he had HF, EF > 55% 10/08 Anxiety Obstructive sleep apnea, on CPAP Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Aortic Aneurysm Discharge Instructions Medications: ?????? If instructed, take Aspirin 325mg (enteric coated) once daily ?????? If taking Aspirin, Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and [**Month/Day (3) **] dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-26**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-5-3**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-5-3**] 2:00 Completed by:[**2129-2-2**] Name: [**Known lastname 1474**],[**Known firstname **] M Unit No: [**Numeric Identifier 7650**] Admission Date: [**2129-1-24**] Discharge Date: [**2129-2-2**] Date of Birth: [**2046-10-11**] Sex: M Service: SURGERY Allergies: Percocet / Magnesium Citrate Attending:[**First Name3 (LF) 270**] Addendum: Pt with hematuria. On coumadin with failure to void. Has foley. Pt set up with urology as outpt, for possible cystoscopy. Discharge Disposition: Extended Care Facility: [**Hospital3 1620**] - [**Location (un) 1621**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**] Completed by:[**2129-2-2**]

[ "997.1", "401.9", "428.0", "427.31", "V45.81", "272.4", "788.20", "496", "428.32", "458.9", "444.22", "599.71", "440.21", "441.2" ]

icd9cm

[ [ [] ] ]

[ "39.73", "38.08", "88.44", "39.29" ]

icd9pcs

[ [ [] ] ]

14463, 14691

7011, 8918

343, 665

10914, 10914

3590, 6988

13678, 14440

2529, 2659

8941, 10489

10604, 10893

11059, 13098

13124, 13655

2674, 3571

249, 305

693, 1265

10928, 11035

1287, 2342

2359, 2512

29,578

133,340

1656

Discharge summary

report

Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-25**] Date of Birth: [**2091-7-1**] Sex: M Service: MEDICINE Allergies: Betadine Attending:[**First Name3 (LF) 1711**] Chief Complaint: DOE Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 33M with pmh of borderline htn presenting with complaint of new PND and DOE. Pt was in his USOH until 2 weeks prior when he began to have difficulty sleeping due to waking up after sleeping for ~30 minute with shortness of breath and coughing. He attempted to sleep propped up with pillows, but he continued to wake up with dyspnea. During this time he also noted DOE, finding himself dyspneic after walking up only 1 flight of stairs (was able to walk [**3-11**] flights before). He denies palpitations, chest pain, lower extremity edema. He notes that he had influenza 6 weeks prior which he recovered from without comlpications. He denies fevers, night sweats, weight loss, joint pains, n/v/d, dysuria. He reports that he lives in a wooded area with ticks, and 1 month earlier found a tick on his right shoulder which he removed at that time. He has noted a perstant 1 cm erythematous rash that is blanching and non-pruritic, but no other rash. . Because of these symptoms of dyspnea pt went to his PCP. [**Name10 (NameIs) **] his PCP's office he was found to be tachy to 112 and EKG reportedly showed flipped T in I, aVL, V6, and possible Q wave in II and aVR. Because of this he was sent to the ED. . ED Course: T:97.7, BP:133/87, HR:123, RR:22, O2:99% on RA. Labs were drawn, and D-Dimer was elevated. Chest Xray and CTA were performed (see below). CXR was clear, and CTA was without PE, but did show pulmonary edema. BNP was checked, and was found to be elevated. 1 set of CE were sent, and were negative. . ROS: negative, except as noted above Past Medical History: MEDICAL: History of borderline HTN. Mild psoriasis. . SURGICAL 1. Status post tonsillectomy in [**2101**]. 2. Status post surgery for undescended right testicle in [**2113**]. 3. Status post arthroscopy in [**2106**]. 4. Status post Bankart repair of his right shoulder in [**2108**]. 5. Surgical debridement of foot infection in [**2119**]. Social History: He is married and living with his wife and 2 children. He currently works in an IT job. Cigarettes, none. Alcohol, none. Caffeine, none. He is sexually active in a mutually monogamous relationship. He has no concerns about STDs. Family History: Family history significant for diabetes and heart disease in a maternal grandfather, breast cancer in an aunt, lung cancer in a paternal grandfather, and depression in an aunt. In addition, his paternal grandfather had a stroke. Physical Exam: VS: T:98.7, BP:110/80, HR:109, RR:18, O2:96RA GEN:mid aged man in NAD with wife at bedside [**Name (NI) 4459**]:NCAT, EOMI, [**Name (NI) 5674**], OP clear NECK:supple, no lad, JVP not elevated CHEST: Crackles at bil bases, no wheeze CV: nml s1 s2, tachy regular, no m/r/g ABD:soft, nt nd, no hsm EXT: no edema. No clubing or cyanosis NEURO: A+Ox3, grossly intact Skin: 1 cm erythematous blanching macule on the posterior right shoulder. Pertinent Results: [**2125-6-19**] 07:40PM CK-MB-NotDone cTropnT-<0.01 [**2125-6-19**] 07:40PM CK(CPK)-97 [**2125-6-19**] 03:58PM URINE HOURS-RANDOM [**2125-6-19**] 03:58PM URINE GR HOLD-HOLD [**2125-6-19**] 03:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]- [**2125-6-19**] 03:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2125-6-19**] 11:08AM CK(CPK)-112 [**2125-6-19**] 11:08AM cTropnT-<0.01 [**2125-6-19**] 11:08AM CK-MB-3 proBNP-1717* [**2125-6-19**] 11:08AM TSH-1.9 [**2125-6-19**] 11:08AM WBC-11.8*# RBC-5.18 HGB-14.7 HCT-43.1 MCV-83 MCH-28.4 MCHC-34.1 RDW-13.9 [**2125-6-19**] 11:08AM NEUTS-78.7* LYMPHS-16.4* MONOS-3.3 EOS-1.3 BASOS-0.4 [**2125-6-19**] 11:08AM PLT COUNT-286 [**2125-6-19**] 11:08AM PT-12.7 PTT-30.1 INR(PT)-1.1 [**2125-6-19**] 11:08AM D-DIMER-675* . . ECG: sinus tach @ 109, slightly low voltage, nml intervals, Suggestion of "P-mitral" p-wave in I and II, Q in III and aVF, J point elevation in V2 and V3, TWI in aVL. No comparison available. . Studies: CHEST (PA & LAT) Study Date of [**2125-6-19**] 10:52 AM The lungs are clear. There is no pleural effusion or pneumothorax. Cardiomediastinal silhouette and pulmonary vasculature are within normal limits. The osseous structures are grossly unremarkable. IMPRESSION: No acute cardiopulmonary process. . CTA Chest [**2125-6-19**] Prelim read: No PE, Bilateral ground glass opacities and fluffly alveolar opacities, incorrelation with clinical features most consistent with pulomnary edema. Brief Hospital Course: #Dilated Cardiomyopathy: Patient was admitted with new onset PND and DOE. He was found to have a dilated cardiomyopathy on TTE with an ejection fraction of 20%. SPEP and UPEP were negative. No evidence of thyroid dysfunction or hemochromatosis. The etiology was thought to be post viral. He symptomatically improved while in the hospital and he was discharged on a low dose of beta-blocker and ACEI. He may need a cardiac MRI as an outpatient and should be followed with serial echos. . #Rhythm - While in the hospital, the patient was noted to have a wide complex tachycardia. During the episode, he was given IV metoprolol which cause his blood pressure to drop. He was transferred to the CCU because of a concern for unstable VT. Further review of the EKGs with the EP service determined the most likely etiology of his rhythm was actually a sinus tachycardia with abarrancy. His heart rate was controlled at the time of discharge. He will be followed by the EP service as an outpatient. Medications on Admission: Ibuprofen 800 mg by mouth TID-QID PRN Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Dilated Cardiomyopathy Discharge Condition: Stable Discharge Instructions: You were seen in the hospital for shortness of breath. You were found to have a dilated cardiomyopathy, likely from a viral illness. You were started on medications to help prevent worsening of you heart function. You will need to be followed closely by the cardiology service, with repeat Echocardiograms and possible a cardiac MRI. . Please take all of your medication as prescribed . Please make all of the appointments suggested below. . Either call your primary care physician or return to the emergency room if you have any chest pain, shortness of breath, palpiations, lightheadedness, or other symptoms of concern to you. Followup Instructions: Cardiology: Please call Dr.[**Name (NI) 9578**] office at [**Telephone/Fax (1) 5003**] and make a follow up appointment in [**3-11**] weeks. . Electrophysiology: Please call Dr.[**Name (NI) 1565**] office at [**Telephone/Fax (1) 285**] and make a follow up appointment in 9 months. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Date/Time:[**2125-6-28**] 9:40 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2125-7-16**] 8:00 Completed by:[**2125-7-1**]

[ "724.5", "V18.0", "458.9", "427.89", "216.6", "V17.3", "401.9", "428.21", "428.1", "425.4", "424.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6214, 6220

4807, 5811

272, 278

6287, 6296

3220, 4784

6977, 7564

2515, 2746

5899, 6191

6241, 6266

5837, 5876

6320, 6954

2761, 3201

229, 234

306, 1876

1898, 2247

2263, 2499

21,722

111,549

48283

Discharge summary

report

Admission Date: [**2182-10-25**] Discharge Date: [**2182-10-27**] Service: MEDICINE Allergies: Mevacor / Iodine; Iodine Containing / Nizoral A-D Attending:[**First Name3 (LF) 2704**] Chief Complaint: Reason for admit: left ICA stent . Major Surgical or Invasive Procedure: left internal carotid artery stenting History of Present Illness: HPI: 85 year-old male with PMH of CVA, AS s/p bovine AVR, CAD s/p SVG to PDAin [**4-/2176**], trans-venous pacemaker for third degree HB who presents for placement of left internal carotid artery stent. Patient has had two recent possible TIAs, manifested as aphasia, that resulted in a carotid ultrasound. The ultrasound on [**2182-10-23**] revealed progression of the left ICA stenosis from 40-59% stenosis to now greater than 90% stenosis. The known occluded right ICA was again documented. He was thus referred for left ICA stenting. On the night of admission he was premedicated with Prednisone, Zantac, and Benadryl given a history of dye allergy. Past Medical History: PMH: CVA [**93**] years ago ? TIA Known right ICA occlusion Depression Anxiety, panic attacks AS, s/p AVR and CABG x1 [**2176**] s/p PM implant [**2176**] Glaucoma Previous falls Progressive supranuclear palsy (PSP) HTN Hyperlipidemia . Social History: Social History: Married Retired family care physician [**Name9 (PRE) **] tobacco . . Family History: noncontributory Physical Exam: EXAM: Temp 97.4 BP 124/60 Pulse 66 Resp 18 O2 sat 95% RA Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy, no carotid bruits Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, 2/6 SEM at LUSB radiating to the L carotid Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - pt slightly confused, conversant with no dysphasia, though circumferential in conversation; during hx he often repeated elements of the hx; pt with left facial droop Skin - No rash Pertinent Results: [**2182-10-25**] 07:26PM GLUCOSE-138* UREA N-29* CREAT-1.6* SODIUM-141 POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-25 ANION GAP-19 [**2182-10-25**] 07:26PM CALCIUM-9.8 PHOSPHATE-2.5* MAGNESIUM-2.3 [**2182-10-25**] 07:26PM WBC-9.2 RBC-4.53*# HGB-14.2# HCT-42.9 MCV-95 MCH-31.2 MCHC-33.0 RDW-13.2 [**2182-10-25**] 07:26PM PLT COUNT-250 MODERATELY HEMOLYZED 141 103 29 138 AGap=19 5.5 25 1.6 Ca: 9.8 Mg: 2.3 P: 2.5 14.2 9.2 250 42.9 . DATA: Carotid US ([**2182-10-22**]): 1. Progression of left ICA stenosis from 40-59% stenosis, now greater than 90% stenosis. 2. Occluded right ICA again documented. 3. Antegrade flow in both vertebral arteries. . NCHCT ([**2181-3-16**]): Chronic right superior division middle cerebral artery infarct. [**2182-10-22**] CArotid series IMPRESSION: Compared to the study of [**2179**]: 1. Progression of left ICA stenosis from 40-59% stenosis, now greater than 90% stenosis. The referring physician was notified of this result. 2. Occluded right ICA again documented. 3. Antegrade flow in both vertebral arteries. [**2182-10-25**] CTA head/neck No acute intracranial hemorrhage. Stable encephalomalacia in right MCA distribution from [**2181-3-16**]. NO CT evidence of acute minor or major vascular territorial infarct. Occlusion of right internal carotid artery from level of bifurcation to cavernous portion, where there is reconstitution of contrast opacification. Brief Hospital Course: A/P: 85 yo male with h/o CVA, AS s/p bovine AVR, CAD s/p SVG to PDA, pacemaker placement and known complete right carotid artery stenosis here for elective L carotid stenting following recent carotid dopplers. 1) Left carotid stenosis-- On [**10-22**] an out-pt carotid series, prompted by two episodes of aphasia demonstrated progression of left ICA stenosis. The pt was admitted on [**10-25**]/o5 for elective left ICA stenting. CTA head and neck were performed the night of admission for further elucidation of carotid anatomy. On [**10-26**] the pt received successful stenting of his left ICA. The pt was medcically stable post-procedure. He was kept overnight for observation post-op. He will f/u with Dr. [**First Name (STitle) **] in 2 weeks 2) CV: CAD: The pt is s/p CABG in '[**76**]. Throughout his admission he was contined on asa, plavix, and lipitor. [**Name (NI) 101711**] pt was paced with a transvenous pacer. pump: The pt's last ECHO in '[**76**] showed nml LV function. He demonstrated no signs of failure clinically 3) [**Name (NI) 42398**] pt was placed back on his home dose of norvasc post-op. His BP was well-controlled throughout the admission. 4) hyperlipidemia--The pt was placed on his home lipitor throughout his admission. 5) depression/anxiety--The pt remained on his home lexapro and alprazolam prn anxiety. 6) glauma--The pt continued on his home dose of trusopt, latanoprost, betoptic S 7) [**Name (NI) 48980**] pt was NPO past midnight for procedure, and resumed a low Na/cardiac healthy diet post procedure. 8) ppx: The pt was eating post-procedure, and kept on hep sc throughout admit. 9) FULL CODE Medications on Admission: Allergies: Parabin Nizoral contrast -> hives . Medications: Plavix 75mg daily Lexapro 10mg daily Norvasc 10mg daily Zocor 20mg daily Xanax 0.25mg 1-3x/day p.r.n. ASA 325mg daily Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO ONE TO THREE TIMES PER DAY PRN () as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: left internal carotid artery stenosis Discharge Condition: Stable Discharge Instructions: Pt or pt's family should contact PCP or go to ED if pt has: [**Name (NI) **] headaches Changes in vision Changes in mental status Changes in speech Changes in motor functioning Chest pain Changes in breathing SBP >140, per VNA Followup Instructions: Pt should follow-up with Dr. [**First Name (STitle) **] in approximately 2 weeks. Pt's family should contact Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 40086**] to set-up appointment.

[ "V45.81", "433.10", "414.00", "401.9", "V42.2" ]

icd9cm

[ [ [] ] ]

[ "00.63", "00.61", "00.40", "00.45", "88.41" ]

icd9pcs

[ [ [] ] ]

6104, 6153

3577, 5223

294, 334

6235, 6244

2112, 3554

6520, 6762

1403, 1420

5452, 6081

6174, 6214

5249, 5429

6268, 6497

1435, 2093

220, 256

362, 1023

1045, 1283

1315, 1387

43,224

183,763

45039

Discharge summary

report

Admission Date: [**2137-11-24**] Discharge Date: [**2137-11-30**] Date of Birth: [**2069-3-16**] Sex: M Service: MEDICINE Allergies: Penicillins / Flecainide / Quinidine/Quinine Attending:[**First Name3 (LF) 106**] Chief Complaint: cath Major Surgical or Invasive Procedure: cardiac catheterization x 2 History of Present Illness: This is a 68 year old male with history of type II DM, HTN, atrial fibrillation on coumadin , s/p CABG and s/p nephrectomy who presents for pre-hydration prior to elective cardiac catheterization. . The patient states that about 6 months ago he started to have chest pain. The pain is midline at about the level of the sternal angle. He describes it as sometimes a heaviness and sometimes "almost sharp." The pain is associated with shortness of breath but he denies nausea, vomiting and diaphoresis. At first the pain was present when doing activities that he described as "small exertion," such as brushing teeth, getting out of bed and shaving; however, he did not feel the pain with activities requiring "great exertion," such as walking or lifting 5-lb weights. Over the last several weeks, he began to have the pain occaisionally when he was at rest. It lasted [**6-13**] minutes and was not releived by nitroglycerin. He has not had any pain this past week, but he attributes this to the fact that he has not been moving around much as advised by his cardiologist. The patient's last catheterization was at this hospital when he was admitted for NSTEMI in [**2127**]. At that time he had severe shortness of breath at rest. He says that the symptoms he is having now are not reminiscent of his prior heart attack. Recent past medical history is notable for a 5-day hospitalization for pneumonia. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, increased ankle edema, palpitations, syncope or presyncope. Past Medical History: -HTN -DMII, (AIC [**2137-9-19**] 7.9) c/b neuropathy, retinipathy, nephropathy -h/o vertigo -atrial fibrillation, treated with amiodarone [**2125**] -atrial flutter in 08/98 treated with cardioversion and pacemaker revision -Hypercholesterolemia -s/p CABG [**2117**] (LIMA-->LAD, SVG-->DIAG) -Supraventricular tachycardia in [**4-/2114**], with a question of pre-excitation with a bypass tract -SSS, s/p pacemaker [**7-/2120**], requiring repositioning of an atrial lead in 9/92 -s/p LAD PCA x 3 in [**2108**]'s, s/p RCA stenting [**11/2127**] -s/p bilateral arthroscopic knee surgeries in [**2104**] -s/p left nephrectomy [**3-11**] renal cell carcinoma Social History: -Tobacco history: smoked for 30+ years but not since [**2130**] -ETOH: denies -Illicit drugs: denies Family History: Father with CAD and cancer. Mother had cancer. Brother had stroke and sz. Physical Exam: VS: T 98.3, BP 122/67, HR 74, R 20, 97% RA, weight 151.7kg GENERAL: obese man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Stenotomy scar, well-healed. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi but with decreased breath sounds in the right base. ABDOMEN: Soft, NT, obese. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: stasis dermatitis bilateral LE, 1+ pitting edema BLE, no ulcers, DPs 2+ bilaterally Pertinent Results: Hematology WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**11-29**].4 3.53* 11.5* 33.3* 94 32.6* 34.6 14.7 192 [**11-28**].2 3.48* 11.1* 32.5* 93 31.8 34.1 14.5 183 [**11-27**].7 3.43* 11.0* 32.1* 94 32.0 34.2 14.6 169 [**11-26**].4 3.59* 11.3* 33.8* 94 31.4 33.3 14.9 196 [**11-25**].2 3.69* 11.5* 34.8* 94 31.0 32.9 15.1 198 [**11-24**].3 3.74* 12.0* 35.2* 94 32.0 34.0 14.7 214# Chemistry Glu UreaN Creat Na K Cl HCO3 AnGap [**339-11-29**]* 37* 2.3* 140 4.3 97 33* 14 [**263-11-28**]* 41* 2.2* 140 3.9 99 32 13 [**277-11-27**]* 37* 2.2* 137 4.0 96 33* 12 [**283-11-26**]* 34* 2.1* 140 4.4 98 33* 13 [**359-11-25**]* 35* 1.9* 138 4.9 101 25 17 [**2091-11-23**]* 37* 2.0* 142 4.1 103 30 13 [**2137-11-24**] %HbA1c 7.2*1 LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [**2137-11-25**] 06:00AM 166 376*1 29 5.7 62 ECHO [**11-25**] The left atrium is dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with akinesis of the anterior septum, anterior wall and apex. Overall left ventricular systolic function is mildly depressed (LVEF= 35-40 %). A left ventricular mass/thrombus cannot be excluded. 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricular cavity with akinesis of the anterior septum, anterior wall and apex. The mid inferior wall is probably mildly hypokinetic. Overall image quality is poor and the lateral wall is not well seen. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Biatrial dilatation. CATH [**11-28**]: PTCA COMMENTS: Initial angiography revealed a long 70% proximal lesion in the SVG-OM and a 95% stenosis in the mid-graft. There was also a 80% mid RCA lesion. We planned to treat these lesions with PTCA and stenting. Bivalirudin was given prophylactically. Starting with the SVG, as 6F Hockey Stick guide provided good support. A Choice PT ES wire was advanced without difficulty. The anastomosis of the SVG-OM was predilated with a 1.5mm and then 2.5mm balloon at low pressure. A 4.0 Spider protection device was then placed in the distal graft and the mid-vessel stenosis was predilated with the 2.5mm balloon. A 4.0x15mm Promus DES was deployed at 18atm. A 4.0x28mm Promus DES was then delivered to the proximal lesion and deployed at 20atm. At this point, IVUS was performed and demonstrated good stent strut apposition. We then turned our attention to the RCA stenosis. A 6F JR4 guide provided good support. A Prowater wire was advanced without difficulty. The lesion was direct stented with 3.5x33mm Cypher DES at 10atm. IVUS was again performed and demonstrated good strut apposition. Final angiography revealed no residual stenosis, TIMI 3 flow, and no apparent dissection. COMMENTS: 1. Successful PCI of the SVG-OM with a 4.0x15mm Promus DES in the mid-graft and 4.0x28mm Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55492**]. 2. Successful PCI of the mid-RCA with a 3.5x33mm Cypher DES. 3. IVUS of both vessels revealed good stent strut apposition. Brief Hospital Course: 68 year old man with CAD s/p CABG in [**2117**] (LIMA->LAD, SVG->Diag) and stent to RCA in [**2127**], poorly controlled diabetes, and morbid obesity presenting with substernal chest pain and found to have RCA with diffuse disease and high grade stenosis of SVG to Diag but no intervention as had flash pulmonary edema now s/p another cath with PCI with DESx2 to SVG-OM and RCA. # CAD s/p CABG in [**2117**] and s/p cath on this admission with DESx2 to SVG-OM and DES to RCA --aspirin --statin --beta blocker --[**Last Name (un) **] --imdur --fish oil #CHF, acute on chronic systolic and diastolic, EF 35-40% Exacerbation in setting of prolonged pre-cath hydration. Responded well to lasix. --[**Last Name (un) **], beta blocker, fish oil as above --continue lasix 80mg qam and 40mg qnoon # DM II: Blood sugars controlled with NPH 80mg [**Hospital1 **] andsliding scale. Hgb A1C 7.2 # CKD [**3-11**] diabetic nephropathy and also s/p nephrectomy for RCC. Creatinine 2.3 on discharge. Baseline is 2.0-2.3. # Urinary retention. The patient had urinary retention after first cath and required foley. He was started on tamsulosin. He was voiding on his own on day of discharge. # h/o atrial fibrillation, aflutter, SVT Remained in AV paced rhythm. Continued home regimen of amiodarone, digoxin, dysopyramide, beta blocker. Continued coumadin on discharge. # Hypertension Held amlodipine as only taking 2.5mg and BPs well controlled. Continued all other antihypertensives. # Hyperlipidemia --continued zetia, statin (atorvastatin substituted for fluvastatin while in house) # COPD: Currently stable. Continued spiriva # h/o vertigo: Stable. Continued home regimen of meclizine and valium Medications on Admission: 1. Zetia 10mg daily 2. Fish oil 1g [**Hospital1 **] 3. Lasix 40mg TID 4. Aspirin 81mg daily 5. Fluvastatin 80mg daily 6. Gabapentin 600mg TID 7. Dysopyramide 150mg [**Hospital1 **] 8. Amiodarone 100mg QAM and 100mg Q every other PM 9. Verapamil 120mg [**Hospital1 **] 10. Meclizine 50mg [**Hospital1 **] 11. Imdur 90mg [**Hospital1 **] 12. Ranitidine 150mg [**Hospital1 **] 13. Diazepam 2.5mg [**Hospital1 **] 14. Metoprolol 50mg [**Hospital1 **] 15. Digoxin 0.125 daily 16. Losartan 50mg TID 17. Warfarin 5mg daily 18. Amlodipine 2.5mg daily 19. Humalog 40QAM and 20QPM 20. NPH (Humilin) 80QAM and 80-100QPM 21. Darvocet one tablet Q6hours prn 22. Potassium 23. Vitamin C 24. Glucosamine 25. Metamucil Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO every morning and every other evening. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Verapamil 120 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Losartan 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Meclizine 50 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Disopyramide 150 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours). 10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 16. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 19. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 21. Fluvastatin 80 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 22. Humulin N 100 unit/mL Suspension Sig: Eighty (80) units Subcutaneous twice a day. 23. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*2* 24. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*3* 25. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once). Discharge Disposition: Home Discharge Diagnosis: Primary: Coronary artery disease, congetive heart failure Secondary: diabetes mellitus type 2, paroxysmal atrial fibrillation Discharge Condition: stable Discharge Instructions: Dear Mr. [**Known lastname 9779**], It was a pleasrue taking care of you. You were admitted to the hospital because you were having chest pain and your cardiologist wished to perform a diagnostic cardiac catheterization. During your first catheterization you became short of breath and required a brief admission to the cardiac care unit. You went for a second catheterization that showed stenosis of one of the vein grafts and also the right coronary artery. Stents were placed in both vessels. We stopped your amlodipine because you were taking only a very small dose and your blood pressure is well controlled. NEW MEDICATIONS: START clopidogrel (Plavix) **It is extremely important to take this every day to prevent a clot from forming in the stent. START: tamsulosin: to prevent urinary retention STOP amlodipine Continue all medications as prescribed and keep all outpatient appointments. If you experience chest pain, shortness of breath, fevers, or any other concerning symptoms please contact your cardiologist or come to the emergency department for evaluation. For your heart failure, weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 Followup Instructions: Dr. [**Last Name (STitle) **], Tuesday [**12-3**] at 2pm Phone: [**Telephone/Fax (1) 8725**] [**Name8 (MD) 7986**], NP in [**Hospital 159**] Clinic, [**12-5**] at 2:30pm at [**Hospital Ward Name 23**] Bldg [**Location (un) 470**]

[ "250.40", "411.1", "428.43", "V58.67", "272.0", "427.81", "788.20", "414.02", "V10.52", "V45.01", "997.1", "357.2", "V45.73", "250.60", "362.01", "585.9", "414.01", "584.9", "428.0", "V45.82", "E879.0", "427.31", "278.01", "250.50", "412", "496", "403.90", "997.5" ]

icd9cm

[ [ [] ] ]

[ "00.24", "00.47", "36.07", "00.41", "88.57", "37.22", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

12428, 12434

7792, 9487

311, 341

12604, 12613

4010, 7769

13898, 14132

3094, 3170

10241, 12405

12455, 12583

9513, 10218

12637, 13875

3185, 3991

267, 273

369, 2280

2302, 2959

2975, 3078

2,100

140,146

21538

Discharge summary

report

Admission Date: [**2142-4-28**] Discharge Date: [**2142-5-3**] Date of Birth: [**2071-7-2**] Sex: M Service: MEDICINE Allergies: Aspirin / Heparin Agents / Nadolol Attending:[**First Name3 (LF) 12174**] Chief Complaint: Dark Stool, Low Hct from Baseline Major Surgical or Invasive Procedure: Endoscopy Venogram Revision of TIPS Blood Transfusion History of Present Illness: 70 yom with PMH of alcoholic cirrhosis with gastric and esophageal varices sent in by PCP after having [**Name Initial (PRE) **] Hct that dropped from 40 to 28 in the setting of guaiac positive black stool. He was recently admitted for a UTI at [**Hospital3 **] and received 2 doses of heparin SC, although per patient he is not supposed to have heparin. He was treated at [**Hospital1 34**] from [**Date range (1) 56769**] for a urinary tract infection with associated hematuria. About 1 week ago he had one episode of BRBPR. Since then his stools have been very dark, almost black. Has 2-3BMs per day on the lactulose. He had one brief episode of lightheadedness ealrier this week, but has otherwise felt at his baseline. He has had a good urine output, no dysuria or hematuria. . In the ED, initial vs were: T99.7 P 104 BP138/72 R 18 O2 sat 98% 2L NC. Patient was given pantoprazole, ciprofloxacin, and an octreotide drip was started. NG lavage was done which just showed pink fluid, onbloody after pt. had consumed raspberry soda. Last set VS HR 88 BP 170/91 98 2L NC prior to transfer. . On presentation to the MICU, the patient appeared stable, in NAD without any complaints of pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ETOH abuse- stopped heavy drinking in [**2136**]- prior to that [**2-17**] pint a day, now drinks 2-3 beers/day Hypertension Cirrhosis Diabetes Mellitus Type 2 - recently insulin dependent [**2142-4-16**] Afib- was on coumadin in past COPD s/p TIPS [**2136-12-20**] s/p hernia repair s/p repair of deviated septum Social History: Lives with wife. Wife currently undergoing treatment for lung cancer. Retired meat cutter. Previous strong alcohol history of 1 qt./day for several years. Had stopped drinking, recently restarted 2-3 beers daily. Family History: Brother w/ ETOH abuse. Father died at 63 secondary to ETOH, Cancer. Physical Exam: Vitals: T: BP: 145/58 P: 86 R: 18 O2: 95% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, moderately distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Had rectal exam in the ED notable for dark/black stool, heme+ GU: no foley Ext: warm, well perfused, 2+ pulses, 2+ pitting edema of BLE (per patient at baseline, somewhat improved) Pertinent Results: Imaging [**2142-4-28**] Liver Ultrasound IMPRESSION: 1. Patent TIPS shunt with appropriate velocities. Flow in the portal system directed towards the TIPS. 2. Cirrhotic liver without focal liver lesions . [**2142-4-28**] CXR IMPRESSION: No acute cardiopulmonary disease; no PTX. . [**2142-5-1**] TIPS Revision Preliminary Report !! PFI !! TIPS revision performed including dilatation of TIPS shunt and embolization of portal vein varix. . [**2142-4-27**] 10:27PM BLOOD WBC-5.9 RBC-3.17* Hgb-10.2* Hct-31.3* MCV-99* MCH-32.2* MCHC-32.6 RDW-16.6* Plt Ct-221# [**2142-4-28**] 05:01AM BLOOD WBC-5.2 RBC-2.77* Hgb-8.8* Hct-26.9* MCV-97 MCH-31.7 MCHC-32.7 RDW-16.1* Plt Ct-148* [**2142-4-29**] 03:04AM BLOOD WBC-5.8 RBC-3.09* Hgb-9.9* Hct-30.1* MCV-97 MCH-31.9 MCHC-32.8 RDW-17.1* Plt Ct-183 [**2142-4-29**] 07:00PM BLOOD Hct-31.3* [**2142-4-30**] 06:55AM BLOOD WBC-6.3 RBC-4.01*# Hgb-12.2* Hct-38.1* MCV-95 MCH-30.4 MCHC-32.0 RDW-16.7* Plt Ct-182 [**2142-4-30**] 05:05PM BLOOD Hct-34.8* [**2142-5-1**] 06:50AM BLOOD WBC-6.9 RBC-4.04* Hgb-12.6* Hct-38.3* MCV-95 MCH-31.2 MCHC-32.9 RDW-16.6* Plt Ct-214 [**2142-5-1**] 05:15PM BLOOD Hct-34.3* [**2142-5-2**] 07:10AM BLOOD WBC-5.1 RBC-3.57* Hgb-11.5* Hct-34.2* MCV-96 MCH-32.3* MCHC-33.7 RDW-16.5* Plt Ct-153 [**2142-4-27**] 10:27PM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-141 K-4.5 Cl-110* HCO3-23 AnGap-13 [**2142-5-2**] 07:10AM BLOOD Glucose-115* UreaN-13 Creat-0.8 Na-139 K-3.9 Cl- 105 HCO3-29 AnGap-9 [**2142-4-27**] 10:27PM BLOOD ALT-37 AST-71* AlkPhos-83 TotBili-0.9 [**2142-4-28**] 05:01AM BLOOD ALT-31 AST-62* LD(LDH)-264* AlkPhos-71 TotBili-0.8 [**2142-4-30**] 06:55AM BLOOD ALT-75* AST-163* LD(LDH)-236 AlkPhos-93 TotBili-1.5 [**2142-5-1**] 06:50AM BLOOD ALT-73* AST-114* LD(LDH)-231 AlkPhos-96 TotBili-1.3 [**2142-4-28**] 05:01AM BLOOD Calcium-7.4* Phos-3.6 Mg-1.8 [**2142-5-2**] 07:10AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.7 [**2142-4-28**] 01:22AM BLOOD Lactate-1.5 [**2142-4-28**] Blood cultures pending . Endoscopy [**2142-4-28**] Impression: Varices at the gastroesophageal junction Erosion in the gastroesophageal junction compatible with NG tube induced trauma Friability, granularity, erythema, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Gastric bezoar Polyps in the antrum Blood in the duodenal bulb, second part of the duodenum and third part of the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: erythromycin 250mg IV now. Cipro 400mg IV bid Continue PPI IV bid and octreotide Drip Follow Hct and transfusion (Hct around 27-30%) Pt needs repeat EGD either tomorrow or the day after tomorrow. . [**2142-4-30**] Impression: Friability, erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with severe portal hypertensive gastropathy Polyp in the stomach Abnormal mucosa in the duodenum Varices at the fundus Otherwise normal EGD to second part of the duodenum Recommendations: Potential bleeding from severe gastropathy and polyps vs antral varices. Fundal varices present but without stigmata of recent bleeding. Please continue with evaluation of TIPS with hepatic venogram. Continue nadolol. Please return to [**Hospital1 **] Brief Hospital Course: Mr. [**Known lastname 7931**] is 70 year old man with a history of alcoholic cirrhosis, s/p TIPS who presented with an upper GI bleed and 12 point hematocrit drop. . # GI Bleed: He underwent an EGD upon arrival to the MICU. There were no active areas of bleeding visualized. An ultrasound showed a patent TIPS. He received one unit of pRBC's. He was placed on octretide, pantoprazole, and ciprofloxacin. His hematocrit remained stable overnight. He was transferred to the floor and underwent a repeat EGD. This demonstrated severe portal hypertensive gastropathy and some antral varices. He underwent a TIPS revision. His hematocrit continued to remain stable. His pantoprazole was increased to twice daily. . # Liver Disease: He originally had a TIPS placed in [**2136**] following a variceal bleed. He underwent a venogram which showed elevated pressures. His TIPS was revised. He was encouraged to stop drinking alcohol. He was continued on lactulose. He was not started on a beta-blocker because of a reported history of bronchospasm noted in his [**2136**] hospital course. . # COPD: Continued home medications. No acute issues. . # Atrial fibrillation: His digoxin was continued. His diltiazem was held in the setting of a GI bleed. He went into atrial fibrillation with RVR prior to restarting diltiazem. This responded well to oral diltiazem. He was discharged on his home dose. . # Diabetes: He continued to receive glargine. . # Alcohol Use: There were no signs of alcohol withdrawal. He was counseled extensively to abstain from all alcohol. . # Tobacco Use: He was placed on a nicotine patch. Smoking cessation was encouraged. He declined a presciption for the patch. . Code: He was a full code during this admission. Medications on Admission: Lactulose 10 gram/15 mL Oral Soln Oral, five times a day Amoxicillin 500 mg Tab Oral, 1 Tablet(s) Twice Daily Protonix 40 mg Tab Oral, 1 Tablet, Delayed Release (E.C.)(s) QDay Diltiazem SR 180 mg 24 hr Tab Oral 1 Tablet SR 24 hr(s) Once Daily Digoxin 125 mcg Tab Oral, 1 Tablet(s) Once Daily Lantus 100 unit/mL Sub-Q Subcutaneous, 22 Once Daily, at bedtime Flomax 0.4 mg 24 hr Cap Oral 1 Capsule, SR 24 hr(s) QHS Advair Diskus -- Unknown Strength 1 Disk with Device(s) Twice Daily Albuterol Sulfate HFA 90 mcg/Actuation Aerosol Inhaler Inhalation 1 HFA Aerosol Inhaler(s) Every 4-6 hrs, as needed Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: 10-15 MLs PO 5X/DAY (5 Times a Day). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 5. 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* 6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 8. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper GI Bleed Portal Hypertension Alcoholic Cirrhosis Secondary Diagnosis: Diabetes Mellitus type II Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital with bleeding from your gastrointestional tract. While you were in the hospital, we did several studies to find out where the bleeding was coming from. You also required a blood transfusion. While you were in the hospital, we revised your TIPS. It is very important to stop drinking alcohol. Alcohol will continue to damage your liver. We made the following changes to your medications: We increased your pantoprazole to twice daily. Followup Instructions: We have scheduled an appointment for you with Dr. [**Last Name (STitle) 29117**]. Please go to his office on Monday at 10 AM. Please call [**Telephone/Fax (1) 17465**] if you have any questions. You will have your blood counts checked at this appointment. We also scheduled an appointment for you with the Liver Center. Your appointment is scheduled on [**5-8**] at 10:15 with Dr. [**Last Name (STitle) **] at [**Last Name (NamePattern1) 439**]. It is on the [**Location (un) **] in the [**Hospital Unit Name **]. Please call [**Telephone/Fax (1) 2422**] with any questions. Please let Dr. [**Last Name (STitle) 29117**] know that you are going to this appointment.

[ "496", "456.21", "211.1", "305.1", "572.3", "456.8", "E879.8", "285.1", "401.9", "427.31", "571.2", "V58.67", "303.91", "996.74", "250.00", "537.89", "535.41" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.79", "39.50", "00.40", "88.64" ]

icd9pcs

[ [ [] ] ]

9920, 9926

6628, 8359

328, 383

10112, 10112

3379, 6605

10808, 11478

2654, 2723

9008, 9897

9947, 9947

8385, 8985

10260, 10707

2738, 3360

10737, 10785

1622, 2070

255, 290

411, 1603

10043, 10091

9966, 10022

10127, 10236

2092, 2408

2424, 2638

29,164

194,535

44994

Discharge summary

report

Admission Date: [**2153-3-13**] Discharge Date: [**2153-3-21**] Date of Birth: [**2072-1-21**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2712**] Chief Complaint: Hypotension, Afib with RVR Major Surgical or Invasive Procedure: CVL History of Present Illness: Ms. [**Known lastname **] is a very pleasant 81 year old woman with a PMH significant DM, COPD, CAD, and recent abdominal surgeries for necrotic bowl who prsents from [**Hospital 100**] Rehab with Afib with RVR and hypotension. . She was sent to the ER from [**Hospital 100**] Rehab due to hypotension and afib with RVR with rates in the 150s. Rehab noted her to be congested on a stat CXR, and so gave her 40 mg IV Lasix x 2, as well as Dilt 30mg PO x 2, with improvement of HR to 80's. However, she then dropped her blood pressure, so they gave her 500 mg IVF prior to her transfer. She was also potentially given Zosyn and Vancomycin. . Initial VS in the ED were were 97.2 87 90/45 18 92% 4L. Labs were notable for BUN 50, HCT 30.5, Plts 148, Lactate 1.6, dirty U/A. CXR per report showed new bibasilar opacities with possible L sided effusion. Surgery was consulted secondary to her history of operative resection of necrotic bowel and primary anastamosis [**2153-2-9**] and re-operation for anastomotic leak and re-anastomosis [**2153-2-18**]. They DC'ed her retention sutures, and debrieded her abdominal wound. . Per note from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], has a court appt gaurdian still pending. For now, patient agreed to be full code, and continue all medical care. Afib with felt to be [**2-15**] volume overload on a STAT CXR, with fluid collection L>R. She got 30 mg PO Dilt x 2, and 40 mg IV lasix x 2. Anticoagulation was recently discontineud given apparent recent GI bleed with a HCT 24 last week, needing 2 U over two days, at which point Lovenox and coumadin were DC'ed. Her labs at [**Hospital 100**] Rehab were recently notable for WBC 9.5, HCT 30.3, Plt 152, Bicarb 28. A wound cultures from [**3-6**] showed MRSA. Per team there, she had been continued on Metronidazole and Cipro past the 14 day course outlined by surgery [**2-15**] continued WBC count elevation. . On her most recent discharge from [**2153-3-2**], she was admitted with diffuse lower abdominal pain and abdominal distention, with a CT showing small bowel thickening c/w gastroenteritis versus ischemia from a low flow state. GI was consulted and recommended NG decompression in addition to initiation of cipro and flagyl. However, repeat CT scan showed worsened small bowel thickening and interloop fluid, and on [**2153-2-18**] she underwent ex-lap with small bowel resection and lysis of adhesions. Her prior admission was also complicated with hypotension and afib with RVR, Patient has a known history of post operative atrial fibrillation, and initally post op she was intubated and required pressors. Her RVR required her to be loaded with digoxin, and she was placed on heparin gtt. She also had difficult to diurese pleureal effusions, so underwent bilateral CT placements, which drained transudates. During her hospitalization, she was on Vancomyin for a wound infection (surgical) and Cipro/Flagyl for her anastaomic leak. . On arrival to the MICU, she is AAOx3, pleasant, conversant, but hypotensive. Past Medical History: - Diabetes - Schizoaffective disorder - COPD - HTN - CAD - Hypercholesterolemia - GERD - h/o head injury @ age 11 - Perforated duodenal ulcer in [**2148**] s/p cholecystectomy, anterior parietal cell vagotomy, and [**Location (un) **] patch closure by Dr. [**Last Name (STitle) **]. - Ex lap, resection small bowel, primary anastomosis & re-operation for anastomotic leak [**2153**] Social History: She denies alcohol and tobacco use. Never married. Family History: She says her parents are still alive. She thinks her siblings are healthy . Physical Exam: A&O x 3, somewhat confused. Uncomfortable d/t Right hip pain HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Irreg irreg Lungs: Coarse ronchi bilateral bases Abdomen: Midline incision w/ mixed granulation tissue and minimal fibrinous tissue. No purulence or drainage. Skin surrounding retention suture bridge w/ peeling, non-blanching erythema. GU: Foley present Ext: Right foot w/ mottling and dusky, black distal 2nd toe. Dopplerable DP pulses bilaterally per surgery. Pertinent Results: [**2153-3-21**] 04:26AM BLOOD WBC-6.8 RBC-2.45* Hgb-7.5* Hct-24.4* MCV-100* MCH-30.6 MCHC-30.7* RDW-17.1* Plt Ct-160 [**2153-3-20**] 04:15AM BLOOD WBC-5.6 RBC-2.57* Hgb-7.9* Hct-24.8* MCV-96 MCH-30.6 MCHC-31.7 RDW-16.7* Plt Ct-164 [**2153-3-19**] 02:59AM BLOOD WBC-5.8 RBC-2.50* Hgb-7.8* Hct-23.8* MCV-95 MCH-31.0 MCHC-32.6 RDW-16.1* Plt Ct-164 [**2153-3-18**] 03:48AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.3* Hct-26.0* MCV-95 MCH-30.5 MCHC-32.0 RDW-15.6* Plt Ct-171 [**2153-3-17**] 03:45AM BLOOD WBC-6.0 RBC-2.58* Hgb-7.8* Hct-23.9* MCV-93 MCH-30.3 MCHC-32.6 RDW-15.4 Plt Ct-149* [**2153-3-16**] 04:56AM BLOOD WBC-7.8 RBC-2.79* Hgb-8.5* Hct-27.2* MCV-97 MCH-30.5 MCHC-31.3 RDW-15.6* Plt Ct-167 [**2153-3-15**] 04:31AM BLOOD WBC-8.3 RBC-2.91* Hgb-9.0* Hct-28.2* MCV-97 MCH-31.0 MCHC-32.1 RDW-15.6* Plt Ct-187 [**2153-3-14**] 05:44PM BLOOD WBC-7.6 RBC-2.79* Hgb-8.5* Hct-27.0* MCV-97 MCH-30.5 MCHC-31.4 RDW-15.3 Plt Ct-185 [**2153-3-14**] 03:24AM BLOOD WBC-8.3 RBC-2.86* Hgb-9.0* Hct-27.3* MCV-96 MCH-31.3 MCHC-32.7 RDW-15.8* Plt Ct-154 [**2153-3-13**] 03:12PM BLOOD WBC-8.5 RBC-3.17*# Hgb-9.6* Hct-30.5* MCV-96 MCH-30.3 MCHC-31.4 RDW-15.6* Plt Ct-148* [**2153-3-19**] 02:59AM BLOOD Neuts-70 Bands-0 Lymphs-14* Monos-13* Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2153-3-17**] 03:45AM BLOOD Neuts-77.8* Lymphs-14.6* Monos-5.0 Eos-2.1 Baso-0.5 [**2153-3-16**] 04:56AM BLOOD Neuts-76.5* Lymphs-15.4* Monos-4.6 Eos-2.7 Baso-0.8 [**2153-3-14**] 03:24AM BLOOD Neuts-85.0* Lymphs-9.4* Monos-4.3 Eos-0.9 Baso-0.3 [**2153-3-13**] 03:12PM BLOOD Neuts-83.9* Lymphs-9.4* Monos-4.5 Eos-1.9 Baso-0.4 [**2153-3-21**] 04:26AM BLOOD PT-14.4* PTT-28.4 INR(PT)-1.3* [**2153-3-19**] 05:04PM BLOOD PT-20.0* PTT-69.8* INR(PT)-1.9* [**2153-3-19**] 09:29AM BLOOD PT-18.5* PTT-86.3* INR(PT)-1.7* [**2153-3-19**] 02:59AM BLOOD PT-17.4* PTT-63.8* INR(PT)-1.6* [**2153-3-18**] 03:48AM BLOOD PT-16.3* PTT-70.9* INR(PT)-1.5* [**2153-3-15**] 04:31AM BLOOD PT-15.5* PTT-83.5* INR(PT)-1.5* [**2153-3-13**] 05:34PM BLOOD PT-13.4* PTT-28.8 INR(PT)-1.2* [**2153-3-21**] 04:26AM BLOOD Glucose-391* UreaN-45* Creat-2.3* Na-130* K-4.4 Cl-100 HCO3-20* AnGap-14 [**2153-3-20**] 04:15AM BLOOD Glucose-140* UreaN-43* Creat-2.1* Na-139 K-4.4 Cl-108 HCO3-23 AnGap-12 [**2153-3-19**] 02:59AM BLOOD Glucose-79 UreaN-39* Creat-1.6* Na-141 K-4.2 Cl-109* HCO3-21* AnGap-15 [**2153-3-14**] 03:24AM BLOOD Glucose-137* UreaN-46* Creat-1.1 Na-138 K-3.9 Cl-106 HCO3-23 AnGap-13 [**2153-3-13**] 11:51PM BLOOD Glucose-195* UreaN-47* Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-23 AnGap-13 [**2153-3-13**] 03:12PM BLOOD Glucose-160* UreaN-50* Creat-1.1 Na-137 K-3.6 Cl-104 HCO3-24 AnGap-13 [**2153-3-14**] 03:24AM BLOOD ALT-9 AST-22 LD(LDH)-209 CK(CPK)-177 AlkPhos-58 TotBili-0.2 [**2153-3-13**] 09:48PM BLOOD ALT-7 AST-22 LD(LDH)-161 AlkPhos-59 TotBili-0.2 [**2153-3-16**] 04:56AM BLOOD proBNP-3042* [**2153-3-15**] 04:31AM BLOOD cTropnT-0.12* [**2153-3-14**] 03:24AM BLOOD CK-MB-6 cTropnT-0.10* [**2153-3-13**] 09:48PM BLOOD CK-MB-6 cTropnT-0.10* [**2153-3-13**] 03:12PM BLOOD cTropnT-0.10* [**2153-3-13**] 03:12PM BLOOD CK-MB-6 proBNP-[**2046**]* [**2153-3-21**] 04:26AM BLOOD Calcium-8.2* Phos-5.2* Mg-2.1 [**2153-3-20**] 04:15AM BLOOD Calcium-8.4 Phos-5.1* Mg-2.2 [**2153-3-14**] 03:24AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9 Cholest-77 [**2153-3-13**] 11:51PM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0 [**2153-3-13**] 09:48PM BLOOD calTIBC-133* Ferritn-295* TRF-102* [**2153-3-14**] 03:24AM BLOOD Triglyc-129 HDL-20 CHOL/HD-3.9 LDLcalc-31 [**2153-3-13**] 03:12PM BLOOD TSH-3.3 [**2153-3-13**] 03:12PM BLOOD Free T4-1.1 [**2153-3-13**] 03:12PM BLOOD Cortsol-24.4* [**2153-3-16**] 04:56AM BLOOD Vanco-21.7* [**2153-3-19**] 03:13AM BLOOD Type-[**Last Name (un) **] pO2-36* pCO2-60* pH-7.22* calTCO2-26 Base XS--5 [**2153-3-18**] 12:26PM BLOOD Type-[**Last Name (un) **] pO2-58* pCO2-58* pH-7.22* calTCO2-25 Base XS--4 [**2153-3-14**] 12:04AM BLOOD Type-ART Temp-36.7 O2 Flow-3 pO2-68* pCO2-49* pH-7.32* calTCO2-26 Base XS--1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2153-3-13**] 10:13PM BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-61* pH-7.25* calTCO2-28 Base XS--2 [**2153-3-13**] 10:13PM BLOOD Lactate-2.4* [**2153-3-13**] 03:11PM BLOOD Lactate-1.6 [**2153-3-18**] 12:26PM BLOOD Lactate-0.8 [**2153-3-18**] 08:08AM BLOOD Lactate-0.8 [**2153-3-15**] 07:06PM BLOOD O2 Sat-73 [**2153-3-14**] 12:04AM BLOOD freeCa-1.28 Micro: [**2153-3-19**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2153-3-16**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2153-3-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2153-3-14**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2153-3-14**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [**2153-3-13**] URINE URINE CULTURE-FINAL {YEAST} EMERGENCY [**Hospital1 **] [**2153-3-13**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] Imaging: CT HEAD W/O CONTRAST Study Date of [**2153-3-21**] 8:00 AM Wet Read: EHAb WED [**2153-3-21**] 9:27 AM No CT evidence for acute intracranial process. However, MR is more sensitive for acute infarct. BILAT LOWER EXT VEINS Study Date of [**2153-3-15**] 9:14 AM IMPRESSION: No evidence of deep vein thrombosis in either leg; however, note is made that this study is somewhat technically limited. The left calf veins and the right peroneal veins could not be visualized. Portable TTE (Complete) Done [**2153-3-14**] at 11:30:00 AM FINAL Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with normal free wall contractility. 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 to moderate ([**1-15**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. Mild symmetric LVH. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. Mild to moderate mitral regurgitation. Borderline dilatation of the right ventricle with normal function, moderate tricuspid regurgitation and mild to moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2153-2-13**], the degree of mitral regurgitation has increased. The right ventricle was probably borderline dilated on the prior echo. CHEST (PORTABLE AP) Study Date of [**2153-3-19**] 3:04 AM IMPRESSION: AP chest compared to [**3-16**] through 4: Moderate bilateral pleural effusion right greater than left may have increased in between [**3-16**] and 4, currently unchanged. Persistent mediastinal and pulmonary vascular engorgement, and mild cardiomegaly. Pulmonary edema is probably mild, though substantially obscured by pleural effusion. Left jugular line ends above the thoracic inlet. No pneumothorax. Brief Hospital Course: Ms. [**Known lastname **] is a very pleasant 81 year old woman with a PMH significant DM, COPD, CAD, and recent abdominal surgeries for necrotic bowl who presents from [**Hospital 100**] Rehab with Afib with RVR and hypotension. . # Goals of care: Spoke with attorney and newly appointed guardian during hospitalization, patient is to be made DNR/DNI as well as CMO given worsening respiratory status, possible stroke this AM, and worsening pain. She was started on a morphine gtt, and ativan PRN, and passed away shortly after her status was changed. # Unilateral weakness: Concern fvor stroke this AM; prelim read on CT does not show any evidence of obvious stroke, but MRI would be more sensitive. . # Respiratory distress: Intubated during admission midway through hosptialization secondary to increased respiratory effort. Efforts were made to diurese her, without great effect, and bilateral pleural effusiosn were not thought amentable to tap. Extubated on [**3-17**]. Initially did well, but then became progressively more tachypneic and ultimately developed AMS. Efforts at suctioning have yielded limited success despite use of saline nebs to loosen secretions and cough assist machine. Tolerates NP suctioning poorly. Some component of respiratory failure may be due to effusions, which have re-accumulated since her prior admission (not tapped given no optimal fluid pocket on U/S). Trialed on BiPap overnight on [**3-17**] which resulted in improved pH, mental status and clinical appearance, but there is concern for further drying out already thick secretions leading to mucous plugging and/or aspiration. Weaned off bipap on [**3-18**]. This morning has increased O2 requirement, likely due to increasing volume/pleural effusions. She was treated for several days with vancomycin/Cefepime for a presumed PNA, but never grew any cultures, and did not spike any fevers during her hosptialization. Acute renal failure: Likely secondary to previous episodes of hypotension previously. Giving more colloid threatens her respiratory status. Her renal failure developed 2-3 days prior to her death, likely secodnary to poor intravascular volume. # Mottled lower extremites: Likely in the setting of some vasculopathy in addition to poor perfusion state. Causing significant pain. Was on heparin gtt, but DC'ed heparin gtt 2 days prior to passing. Her R toes were evaluated by vascular surgery, who did not have any acute interventions for her. Her RLE gave her a great deal of pain during her hosptialization # Atrial Fibrillation with RVR: Repeat ECHO showed an LVEF that was probably normal, with some mitral regurgitation, and dilated RV. Troponins have essentially been stable. She has been started on amiodarone for rhythm control. Has completed amiodarone load w/ IV gtt, but developed tachycardia when transitioned to PO amiodarone. She was trialed on IV amiodraone, as well as IV digoxin, with some effect; amiodraone gtt was DC'ed after patient made CMO. # Hypotension: Infectious etiologies have been excluded w/ negative cultures. It seems like her hypotension is most directly related to her heart rate- pressures drop when heart rate exceeds 100. Of note, Doppler pressures have been about 10 mmHg above regular cuff pressure [**Location (un) 1131**]. We are tolerating MAPs of 50-55 given tough cuff readings and severe PVD. We had difficulties obtaining MAPs given that she had a diffiulct A-line placement. # S/P Laparatomy: Secondary to necrotic bowel as well as anastomotic leak. Both of these continue to remain concerns given the patient's current presentation and lactate, surgery following. Wound appears clean, no e/o infection. # Persistent ileus: Secondary to bowel surgery as above. High residuals with attempt at TF; TF now held. She was started on TPN while in house. Medications on Admission: Albuterol 2.5 mg Q2H Aspirin 325 mg Daily Diltiazem 30 mg TID Fluticasone Proprionate 2 puff [**Hospital1 **] Guaifenesin 600 mg [**Hospital1 **] Insulin SS Miconazole Nitrate Daily Nystatin 50,0000 U TID swish and swallow omeprazole 40 mg Daily Quetiapine 25 mg [**Hospital1 **] Hydromorphone 1 mg IV Q6H PNR Ipratropium Bromide 0.5 mg Q4H PNR Zofran 4 mg Q8H PRN Ocean Spary Camph/meth/phenol 1 appl [**Hospital1 **] Discharge Disposition: Expired Discharge Diagnosis: Afib with RVR< deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

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Discharge summary

report

Admission Date: [**2134-7-2**] Discharge Date: [**2134-7-20**] Date of Birth: [**2104-6-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3127**] Chief Complaint: End Stage Liver Disease secondary to HBV/HCV Major Surgical or Invasive Procedure: liver transplant [**2134-7-2**] History of Present Illness: Pt is a 30M with hemophilia A, HIV, HCV, HBV, and cirrhosis with portal hypertension, varices, and recurrent ascites who was admitted on [**2134-7-2**] for a liver transplant. For the past 6 months he has required therapeutic paracentesis q1-2 weeks. Last tap on [**2134-6-30**] for 5 liters. Past Medical History: 1. HIV: since age 7, secondary to transfusions. CD4 nadir 163 in [**1-11**] as noncompliant w/ HAART, developed resistance. Last CD4 was 222 in [**4-15**] on HAART. 2. Hemophilia: c/b hemarthrosis, bone cysts, joint destruction, narcotic dependence, s/p left knee synovectomy 3. Cirrhosis, pursuing liver transplant - Hepatitis B - Hepatitis C - known to have portal hypertension with esophageal varices and gastropathy noted in [**2134-2-10**]. - worsening liver function thought secondary to exacerbation of HIV resistant to lamivudine, with change in meds to atazanavir, ritonavir, and truvada - admission for hepatic encephalopathy at the end of [**1-15**] 4. HBV/HCV as above 5. Pseudotumor with a bone graft and tendon shortening in L arm 6. Chronic Pain, narcotic dependence 7. Nephrolithiasis 8. status post MVA [**12-12**] 9. Splenic hematoma 10. LLE cellulitis- s/p surgery [**5-13**] at [**Hospital1 2025**] 11. history of narcotic dependence 12. Depression Social History: h/o ETOH abuse in distant past, no h/o DTs or withdrawal, several drinks only in last 7 years. Also hx of IVDU (heroin) several yrs ago - has not used in a few years. Patient born and raised in [**Hospital1 1474**]. Parents divorced when he was a child. Infected with HIV at age 7. Not working - has worked in the past doing AIDS education at schools. Lives at the Embassy health rehab. Family History: mother - premenopausal breast cancer, mild hypertension father - hypertension, lymphedema (?) maternal uncle - has Hemophilia A several cousins - hemophilia A four half-siblings in good health Physical Exam: Temp - 100.1F, Pulse - 98, BP - 118/68, 98% RA, 94.3kg General - NAD HEENT - EOMI B/L, PERRLA B/L, scleral icterus present, no thrush Neck - no LAD, no bruits Lungs - coarse LLL CV - RRR, 3/6 systolic murmur Abd - ascites present, NT, ND, +BS Ext - 3+ B/L edema Skin - jaundice Neuro - AA&O x 3 Pertinent Results: On admission: Na - 127, K - 4.6, Cl - 100, CO3 - 21, BUN - 18, Cr - 0.7, Gluc - 119 WBC - 5.1, Hct - 26.7, Plat - 95 PT - 29, PTT - 88.3 INR - 3.0 AST - 126, ALT - 48, AP - 216, TBil - 3.6, Alb - 2.3 CXR - L base haziness, possible atelectasis EKG - SR, no ectopy Brief Hospital Course: Pt is a 29M admitted on [**7-2**] for liver transplant. Pt was give 50 units/kg Factor VIII prior to procedure and 20 units/kg q12hours postoperatively. In addition HBIG was given intraop as well as postop. Procedure went without incidence and pt was transfered to the SICU, intubated in stable condition. Please see OP note for details. Post-operatively factor VIII level was 92. Duplex ultrasound of the liver on POD 0 showed normal hepatic artery and portal vein flow. On POD 1 pt began having significantly increased bloody output from the JP and his hematocrit decreased from 30 to 25. However, the decision was made not to reexplore the pt. and to continue the factor VIII replacement. Over the next two days the JP output decreased with continued factor VIII replacement and his hematocrit stablized after transfusion with 2units pRBCs. On POD 2 pt was extubated without difficulty and on POD 3 pt was restarted on his home HIV meds of Kaletra, Tenofovir, and Emtricitabine. On POD 4 pt was transfered to the floor and his diet was advanced. While on the floor pt was noted to become bradycardic to a HR in the low 40s, with the lowest being 28. Pt. remained asymptomatic through the bradycardic events. He was seen by cardiology who felt that the episodes were physiologic sinus bradycardia and were not concerned given the lack of symptoms. Cardiology recommended pt wear [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts montior as an outpatient and would follow up with him in the clinic. On POD 6, [**7-9**], the pt recieved his second dose of tacrolimus 0.5mg which were being dosed based on levels secondary to interaction with his HIV medications. After recieving the tacrolimus the pt. was noted to have a seizure episode resoliving after [**2-12**] minutes. Stat CT was negative for a bleed and the patient was transferred to the ICU. At that time it was noted that his Mg was slightly low (1.6) and this was repleted. At this time his Remeron was stopped because of its ability to lower seizure threshold. He was started on Keppra which was later stopped as the patient had no further seizure episodes, a negative MRI, and a negative EEG. At that time it was felt that the seizure was most likely due to tacrolimus toxicity. On [**7-14**] pt was noted to complain of significantly increased pain and had elevated liver enzymes. A CT was done which showed only a small hematoma and significantly dilated loops of bowel. At that time it was felt that the pain was secondary to constipation and the elevated liver enzymes were a result of dehydration. With an aggressive bowel regimen the pt. had a bowel movement and reported significant improvement in pain. Pt had no further acute episodes and was discharged back to his [**Hospital1 1501**] facility on [**7-20**], POD 17. Medications on Admission: Spironolactone 50mg qDay Lasix 40mg qDay Atazanavir 300mg qDay Mirtazapine 12 qHS Tenofovir 300 qDay Emtricitabine 200 qDay Ritonavir 100 qDay Reglan 10 QID Clotrimazole 10 QID ranitidine 150 qDay hydromorphone 16 q3-4 hours oxycontine 140mg q8 hours lactulose 30mL [**Hospital1 **] ferrous sulfat 325 qDay quinine Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) ML PO DAILY (Daily). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Prograf 0.5 mg Capsule Sig: dose to be adjusted by Transplant Office based on levels Capsule PO per transplant office: check with [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN at [**Hospital1 18**] Transplant Office for dose [**Telephone/Fax (1) 10575**]. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 14. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Dulcolax 10 mg Suppository Sig: One (1) Rectal qday prn as needed for constipation. 17. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. 18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Oxycodone 160 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). 22. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO every eight (8) hours. 23. Tacrolimus - pt is to follow up with the transplant clinic for FK levels and dosing per levels. Discharge Disposition: Extended Care Facility: [**Hospital6 2542**] - [**Hospital1 1474**] Discharge Diagnosis: S/P Liver Transplant HCV HBV HIV Hemophilia Bradycardia,resolved Discharge Condition: stable Discharge Instructions: Call Transplant office [**Telephone/Fax (1) 673**] for: * fevers/chills * nausea/vomiting * inability to take medication * increased abdominal pain * decreased urine output * any bleeding * redness/swelling/drainage from wound . Take all your medications as instructed. Do not restart home medications unless instructed. . Labs every Monday and Thursday for cbc, chem 10, Calcium, phos, AST, Tbili, amylase, lipase, U/A, prograf trough. Fax results to [**Telephone/Fax (1) 673**]. attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2134-7-29**] 10:40 Call Dr.[**Last Name (STitle) 22830**] (Cardiologist)([**Telephone/Fax (1) 12468**] to schedule follow up in 1 month otherwise [**9-21**], at 1020 located [**Hospital Ward Name 23**] 7 on the [**Location 29083**]: ECHO LAB TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2134-7-22**] 11:00 Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2134-7-29**] 10:00 Call Dr. [**Last Name (STitle) 2148**] to schedule a follow-up appt to discuss pain medications ([**Telephone/Fax (1) 4170**] Completed by:[**2134-7-20**]

[ "070.70", "275.2", "572.3", "427.89", "564.00", "276.51", "285.1", "070.30", "719.49", "E933.1", "286.0", "304.01", "042", "780.39", "570" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.06", "96.6", "99.04", "00.93", "38.93", "50.59" ]

icd9pcs

[ [ [] ] ]

8324, 8394

2942, 5783

357, 391

8503, 8512

2654, 2654

9118, 9840

2130, 2324

6148, 8301

8415, 8482

5809, 6125

8536, 9095

2339, 2635

273, 319

419, 714

2668, 2919

736, 1710

1726, 2114

5,109

103,323

21861

Discharge summary

report

Admission Date: [**2146-1-17**] Discharge Date: [**2146-1-24**] Date of Birth: [**2106-1-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Hyperglycemia, hypernatremia Major Surgical or Invasive Procedure: none History of Present Illness: 40 yo M with presumptive diagnosis of UC (dx by colonoscopy at OSH), hospitalized [**Date range (3) 57353**] with BRBPR attributed to UC flare c/b RF (Cr as high as 3.9, with baseline creatinine now 1.5), liver U/S findings of nodularity and heterogenous echotexture suggestive of cirrhosis, anemia w/findings suggestive of chronic disease, and thrombocytopenia in the setting of not having taken his chronic prednisone for two months. . Four days prior to the current admission his prednisone had been tapered from 60 to 30 mg daily. At the same time he developed lighheadedness, polyuria, polydypsea, and blurred vision. He denied fevers, chills, chest pain, cough, SOB, abdominal pain, nausea, vomiting, diarrhea, or dysuria, or any recurrent BRBPR. . In the ED, vital signs were stable. Initial labs showed Na+ 162 (corrected for hyperglycemia 171.4), K+ 4.5, Glucose 928, pH 7.38, Ca 10.5, Phos 7.7, creatinine 3.1. WBC elevated to 14.8 with 86%N. He was given 4L NS, 10units iv insulin, started on an insulin gtt and transferred to the [**Hospital Unit Name 153**]. . Previous work-up: 1) Abdominal CT and ultrasound: demonstrating echogenic liver c/w cirrhosis without any masses or lesions, sigmoid bowel wall thickening. 2) Renal biopsy: suggestive of ATN, no evidence of immune-complex glomerulonephritis. 3) HIV negative 4) [**Doctor First Name **] positive 1:40 speckled 5) Anti-SM negative 6) antimitochondrial antibody negative 7) hepatitis serologies negative 8) AFP negative 9) SPEP without significant monoclonal elevation 10) ceruloplasmin wnl 11) low positive ASO titer. Past Medical History: 1. Ulcerative colitis: diagnosed 1.5 years ago by colonoscopy in NJ after a relatively acute presentation over a 2 week time span, hospitalized [**3-2**] prior, treated with steroids and Pentasa as an outpatient 2. CRI (baseline creatinine 1.5) 3. Cirrhosis 4. Anemia of chronic disease 5. Thrombocytopenia Social History: Married Nigerian immigrant. Works as instructor for autistic children. Lived in NJ for five years. Educated in [**Country 532**] with medical degree. No known HIV exposure, no history of blood transfusions, no known exposures to active TB, no recent travel. Denies tobacco, alcohol or drug use. Family History: Denies any family history of diabetes, autoimmune disease, renal disease, thyroid disease, gastrointestinal diseases Physical Exam: BP123/90, T96.9, HR70-90, RR15, O2sat100%RA Gen: thin male, NAD HEENT: EOMI, PERRL, MMdry, cracked lips, no lad CV: RRR, no mrg, nl s1s2, PMI slightly laterally placed Lungs: CTAB Abd: thin, soft, NT, ND, +BS, no masses, no HSM Back: no CVAT, no spinal tenderness Ext: no C/C/E, 2+ radial/DP/PT Skin: no rashes, multiple oval shaped scars on both shins and one on abdomen Neuro: A&O x3, strength 5/5 throughout, sensation intact grossly to fine touch + pain, nl tone, reflexes 2+ throughout B biceps/patellar Pertinent Results: LABS ON ADMISSION: [**2146-1-17**] 07:05PM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE EPI-0 [**2146-1-17**] 07:05PM URINE BLOOD-NEG NIT-NEG PROT-NEG GLUC-1000 KET-TR BILI-NEG UROBIL-NEG PH-5.0 LEUK-NEG [**2146-1-17**] 07:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.031 [**2146-1-17**] 07:40PM PT-14.3* PTT-23.3 INR(PT)-1.3 [**2146-1-17**] 07:40PM PLT COUNT-174# [**2146-1-17**] 07:40PM NEUTS-86.2* LYMPHS-12.4* MONOS-1.3* EOS-0 BASOS-0.1 [**2146-1-17**] 07:40PM WBC-14.8*# RBC-4.74# HGB-14.0# HCT-44.3# MCV-94 MCH-29.5 MCHC-31.6 RDW-17.9* [**2146-1-17**] 07:40PM ALBUMIN-4.7 CALCIUM-10.5* PHOSPHATE-7.7*# MAGNESIUM-3.6* [**2146-1-17**] 07:40PM LIPASE-61* [**2146-1-17**] 07:40PM AST(SGOT)-28 ALK PHOS-335* AMYLASE-266* TOT BILI-0.9 [**2146-1-17**] 07:40PM GLUCOSE-978* UREA N-77* CREAT-3.1*# SODIUM-162* POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-26 ANION GAP-28* [**2146-1-17**] 09:30PM GLUCOSE-814* UREA N-74* CREAT-2.9* SODIUM-162* POTASSIUM-7.7* CHLORIDE-120* TOTAL CO2-20* ANION GAP-30* ########################################### LABS ON DISCHARGE: [**2146-1-23**] 06:50AM BLOOD WBC-6.6 RBC-3.44* Hgb-10.0* Hct-29.7* MCV-87 MCH-29.2 MCHC-33.8 RDW-17.7* Plt Ct-69* [**2146-1-23**] 06:50AM BLOOD Glucose-86 UreaN-26* Creat-1.4* Na-139 K-3.1* Cl-108 HCO3-24 AnGap-10 [**2146-1-23**] 06:50AM BLOOD ALT-142* AST-139* LD(LDH)-247 AlkPhos-285* Amylase-142* TotBili-0.8 [**2146-1-23**] 06:50AM BLOOD Lipase-73* [**2146-1-23**] 06:50AM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.1* Mg-1.6 ########################################### Head CT: no hemorrhage or mass effect ########################################### CXR: no acute cardiopulmonary disease ########################################### MRCP: 1. Cirrhotic liver with confluent fibrosis. There are no arteriorly enhancing lesions or dominant masses. 2. There is no biliary ductal dilatation or imaging features to suggest cholangitis. 3. Small amount of ascites. ########################################### PENDING LABS: --C-PEPTIDE CA [**60**]-9 --HEPARIN DEPENDENT ANTIBODIES --INSULIN ANTIBODIES --ISLET CELL ANTIBODY --PARVOVIRUS B19 ANTIBODIES (IGG & IGM) Brief Hospital Course: 40 yo M with presumptive history of UC, hospitalized in [**11-7**] with BRBPR attributed to UC flare c/b ARF, cryptogenic cirrhosis, anemia, and thrombocytopenia, presenting [**2146-1-17**] with nonketotic hyperosmolar hyperglycemia and hypernatremia. . 1. HYPERGLYCEMIA: patient presented with nonketotic hyperosmolar hyperglycemia, which may be due to his recent steroid course. He had been treated in house with iv steroids for his presumed UC flare and was discharged to home on a slow prednisone taper. In the setting of lasix use, steroids can cause nonketotic hyperosmolar hyperglycemia. However, given his hepatic and renal issues, an autoimmune or infectious process was also considered. The patient's previous work-up to this end was negative. He was initially started on an aggressive fluid rehydration with 1/2NS for free water deficit + insulin gtt and eventually switched to glargine, and a sliding scale humaloginsulin regimen on the second day of admission. [**Last Name (un) **] was consulted and recommended the above regimen and a panel of autoantibody studies to determine if the pt has type I or II DM. His humalog sliding scale was optimized while on the medicine floor. He was discharged on glargine 10 units at bedtime and humalog sliding scale for breakfast, lunch and dinner. . 2. HYPERNATREMIA: most likely due to osmotic diuresis in hyperglycemic patient. Sodium corrected for elevated serum glucose was 171.4mEq/dl. Free water deficit was 7.4L + insensible losses. 1/2 NS was used for intravascular fluid repletion. Na is 146 on day of transfer. . 3. HYPERCALCEMIA: likely due to acute renal failure vs. dehydration. No signs of GI, cardiac, psychiatric, or muscular affects. corrected with IVFs . 4. HYPERPHOSPHATEMIA: as above, likely due to dehydration and corrected with IVFs. . 5. ARF on CRI: baseline creatinine 1.6. ARF likely prerenal in setting of hypovolemia secondary to osmotic diuresis, improved from 3.1 to 1.4 with IVFs. . 6. ELEVATED WBC: WBC 14.6 with left shift. Most likely due to steroid use vs stress response. Pt remained afebrile with no evidence of infection on UA or CXR, and his WBC returned to [**Location 213**]. . 7. THROMBOCYTOPENIA: ranged from 49 to 91 after a decrease from 174 with IVF at admission. Thought possibly secondary to unintentional heparin exposure, but continued to be in "double digits" despite no heparin. A HIT antibody test was performed and was pending at the time of discharge. Steroids and liver disease may both be affecting thrombocyte generation. . 8. UC: questionable diagnosis based on colonoscopy reports. Patient is now follwed by Dr. [**First Name (STitle) 572**] who was notified of his admission. UC stable for now. On 30 mg prednisone QD w/o symptoms. To be reassessed as outpt by Dr. [**First Name (STitle) 572**] in one week from discharge. . 9. Cirrhosis: Etiology unknown but U/S on previous study suggestive of cirrhosis. Pt declined liver biopsy at that time. His LFTs, alkphos, amylase and lipase remained mildly elevated. A MRCP was performed the day before discharge, and a preliminary report showed: 1. Cirrhotic liver with confluent fibrosis. There are no arterially enhancing lesions or dominant masses. 2. There is no biliary ductal dilatation or imaging features to suggest cholangitis. 3. Small amount of ascites. The Pt refused a liver biopsy. No clear etiology for his cirrhosis was elucidated. . 10. FEN: renal, diabetic/carbohydrate controlled diet . 11. Communication: with the patient and his cousin [**Name (NI) 57354**] Aru [**Telephone/Fax (1) 57355**]) . 12. Code: Full Medications on Admission: Prednisone (60mg changes to 30mg daily) Folate Vit B complex Lasix 40mg daily (discontinued recently) Discharge Medications: 1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. glargine take 10 units at bedtime every day, two months supply, 3 refills 3. humalog take as directed by sliding scale; breakfast, lunch and dinner; roughly two month supply (assuming 5-10 units per ml); 3 refills 4. insulin syringes two month supply; 3 refills 5. blood test lancets two month supply; 3 refills 6. blood glucose test strips two months supply, 3 refills Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Diabetes Mellitis c/b Hyperosmalar Non-ketotic Syndrome. 2. Acute Renal Failure. 3. Hypernatremia. 4. Acute on chronic thrombocytopenia. Secondary: 1. Chronic Renal insufficiency - biopsy with probable ATN. 2. Cryptogenic Cirrhosis. 3. Ulcerative Colitis. 4. Anemia - chronic disease. Discharge Condition: stable Discharge Instructions: 1) Seek immediate medical attention if experiencing blurred vision, increased thirst, increased urination, fever, chills, abdominal pain, vomiting, diarrhea. 2) Take all medications as prescribed 3) Follow-up all appointments Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP) [**2145-1-30**] 2:00 pm, phone [**Telephone/Fax (1) 250**] . Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (un) **] Diabetes Center, [**2145-2-7**] 1:00 pm, phone [**Telephone/Fax (1) 2378**] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2146-1-31**] 4:15 pm

[ "276.1", "555.9", "584.5", "285.29", "E932.0", "250.20", "287.5", "571.5", "593.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9793, 9799

5498, 9138

342, 348

10140, 10148

3316, 3321

10425, 11011

2646, 2764

9290, 9770

9820, 10119

9164, 9267

10172, 10402

2779, 3297

274, 304

4408, 4879

376, 1983

4889, 5475

3335, 4389

2005, 2318

2334, 2630

25,212

162,663

43261

Discharge summary

report

Admission Date: [**2152-2-14**] Discharge Date: [**2152-2-19**] Date of Birth: [**2078-9-27**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Shellfish Derived / Feldene / Bee Pollen Attending:[**First Name3 (LF) 1234**] Chief Complaint: Severe, lifestyle-limiting claudication Major Surgical or Invasive Procedure: 1. Aortobifemoral bypass graft with 14 x 7-mm bifurcated Dacron graft. 2. End-to-side proximal aortic anastomosis, end-to-side bilateral femoral anastomosis. History of Present Illness: 73 y/o female with severe atherosclerotic disease who has had multiple prior surgeries for significant claudication and initally had relief of symptoms, however, she now presents with new disease in her left femoral artery and a very small distal infrarenal abdominal aorta with very limited flow through the iliacs. These were not stentable lesions. The patient has life limiting claudication due to her disease and after extensive discussions with Dr. [**Last Name (STitle) **] about the risks and benefits of surgery now presents for elective aorto-bifemoral bypass. Past Medical History: 1.CAD:CABG x3 [**2131**] ..... PTCA/ stent [**2137**] ..... NSTEMI [**5-/2146**] 2.Atrial fibrillation in setting of pneumonia @OSH post-op [**5-/2146**] 3.Carotid stenosis 4.HTN 5.Legionella pneumonia 6.Aspiration pneumonia post-op [**5-/2146**] 7.Pseudomonas UTI post-op [**5-/2146**] 8.GI bleed 9.Normocytic anemia 10.Depression PSH: 1.Appendectomy 2.Cholecysectomy 3.TAH 4.Removal of parathyroid tumor 5.CABG x3 [**2131**] Dr. [**Last Name (STitle) 14714**] 6.Breast biopsies '[**38**] Dr. [**Last Name (STitle) **] 7.Left CEA [**2146-5-9**] Dr.[**Last Name (STitle) **] 8.Right CEA [**2146-5-22**] Dr.[**Last Name (STitle) **] 9.B/L lower extremity angiogram 10.Redo right common femoral, redo right iliofemoral endarterectomy and bovine pericardial patch angioplasty. Profunda femoral endarterectomy [**12-25**] 11.Angioplasty of right common femoral artery [**8-24**] 12.LLE arteriogram [**12-26**] Social History: Retired former interior designer. Married and lives with her husband. She denies tobacco. She drinks about 4oz alcohol per day. Family History: Family members with diabetes Physical Exam: Exam on discharge A&O, NAD Regular rate and rhythm Chest clear to auscultation Abdomen soft, nondistended, appropriately tender at incisions, incisions midline and groins clean, dry, and intact with staples, no drainage. Lower extremities without edema. Warm and well perfused with brisk cap refill. Palpable DP pulses bilaterally. Pertinent Results: [**2152-2-18**] 06:13AM BLOOD WBC-7.9 RBC-3.55* Hgb-10.1* Hct-29.9* MCV-84 MCH-28.3 MCHC-33.6 RDW-16.6* Plt Ct-191 [**2152-2-18**] 06:13AM BLOOD PT-11.2 PTT-23.1 INR(PT)-0.9 [**2152-2-19**] 07:30AM BLOOD Glucose-99 UreaN-14 Creat-1.1 Na-140 K-3.6 Cl-103 HCO3-27 AnGap-14 Brief Hospital Course: The patient was admitted postoperatively after undergoing an aortobifemoral bypass. Please see the operative report for full details of the surgery. She remained intubated and was admitted to the Cardiovascular ICU postoperatively. She was extubated the following morning. Her hemodynamics remained stable postop and she remained euvolemic. She was noted to have a fever POD1 overnight and she was empirically started on IV antibiotics for a possible pneumonia as she had copious sputum production. Her epidural was removed on POD2 and she remained pain controlled on an IV then PO pain regimen. She was started on plavix and gently diuresed on POD2. On POD3 she was transfered to the VICU in good condition. She was started on sips of clear liquids on POD3 and advanced to regular on POD4. Her home medications were all resumed. Her antibiotics were discontinued POD4 as she no longer had sputum production and CXR was negative for infiltrates and she remained without a leukocytosis. She initially was on bedrest with venodynes for DVT prophylaxis and her activity was liberalized POD3 and she was out of bed ambulating with minor nursing assistance on POD4 & 5. She was seen by physical therapy and cleared for discharge home. She was discharged to home on POD 5 in good condition, ambulating independently, tolerating a regular diet, and with adequate pain control. Medications on Admission: amlodipine 10', atorva 80', clopidogrel 75', esomeprazole 40', ezetimibe 10', lorazepam 0.5qhs, losartan 50', metoprolol xl 25', sertraline 50', triamterene-HCTZ 37.5/25', ASA 325', caco3/mvi/vitd' 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. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*0* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*35 Tablet(s)* Refills:*0* 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1) Tablet PO once a day. 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Peripheral Arterial Disease Aortoiliac Occlusion Coronary Artery Disease Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: ACTIVITIES: - [**Month (only) 116**] shower, pat dry your incision, no tub baths - No driving while taking narcotic pain medications - No lifting heavy objects - Resume activities as tolerated, slowly increase activity as tolerated - Expect your activity level to return to normal slowly DIET: - Diet as tolerated, eat a well balanced meal - Your appetite may take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications WOUND: - You may have some swelling and feel a firm ridge along the incision, slightly red and raised - Keep your incision open to air - Keep wound dry and clean, call if noted to have redness, draining, or swelling, or if temp is greater than 101.5 - Follow-up for staple removal in 2 weeks OTHERS: - You may have a sore throat and/or mild hoarseness - Try warm tea, throat lozenges or cool/cold beverages MEDICATIONS: - Continue all of your prior medications except for your esomeprazole which has been changed to ranitidine. You should avoid esomeprazole and all proton pump inhibitors (PPIs) since you are taking plavix. You may take ranitidine or another H2 blocker medication for reflux symptoms. - Your metoprolol (lopressor/Toprol) dose has been changed to better control your blood pressure. Please take the new dose instead of your prior dose. A prescription is being sent home with you. - You should inform your PCP of all medication changes and have your blood pressure checked by your PCP [**Name Initial (PRE) **]. - You are being sent home with a prescription for pain medicine should you need it. You may take tylenol alone (as a substitute) +/- ibuprofen if your pain is mild. - You should take colace (a stool softener) and eat a high fiber diet while you are taking narcotic pain medication to prevent constipation Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-3-3**] 11:00 Completed by:[**2152-2-19**]

[ "E878.2", "401.9", "338.18", "311", "427.31", "V88.01", "440.0", "997.39", "V45.79", "V45.82", "285.9", "V45.81", "V13.02", "440.21", "486", "998.11", "518.5", "440.8", "412" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.25" ]

icd9pcs

[ [ [] ] ]

5637, 5693

2922, 4307

368, 536

5823, 5823

2627, 2899

7870, 8053

2230, 2260

4555, 5614

5714, 5802

4333, 4532

5971, 7847

2275, 2608

289, 330

564, 1136

5838, 5947

1158, 2067

2083, 2214

54,589

131,896

530

Discharge summary

report

Admission Date: [**2165-10-10**] Discharge Date: [**2165-10-16**] Date of Birth: [**2107-12-18**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 4393**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 57 year old male with history of EtOH and HCV cirrhosis (genotype 1, treatment-naive) complicated by ascites, hepatic encephalopathy, with most recent EGD in [**2163**] showing no varices, as well as seizure disorder, polysubstance abuse on methadone, with recent admission for hepatic encephalopathy, now referred from his PCP's office for hyperkalemia and acute renal failure. He admits that he is often noncompliant with her medications, and is almost completely reliant on his sister [**Name (NI) **] to administer them (he can't even say which meds he's on). His last admission ([**9-13**] - [**2165-9-19**]) was notable for hyponatremia, hyperkalemia, acute kidney injury, and encephalopathy. He underwent large volume paracentesis (4.7L), from which the peritoneal fluid grew GPCs and he was treated with vancomycin for 48 hours until cultures returned showing one bottle growing peptostreptococcus (believed to be a contaminant). Antibiotics were discontinued at that time and he had no further signs of infection for the remainder of his hospital stay. His acute kidney injury was thought to be related to hypovolemia from overdiuresis, improved with IV albumin. His hyperkalemia was treated with kayexylate and the hyponatremia improved with fluid restriction (132 on discharge). His hepatic encephalopathy resolved with lactlose. He was given ciprofloxacin 250mg daily for SBP prohpylaxis (given low peritoneal fluid protein) and spironolactone was decreased from 200 to 100mg + furosemide decreased from 80 to 40mg. Since discharge, patient has had 3 weekly, large volume paracenteses ([**9-24**] - 5L, [**10-3**] - 4.75L, [**10-7**] - 3L). He was seen by his PCP today who checked routine labs, which showed K+ of 6.8 along with acute kidney injury (creatinine of he was referred to the ED for further management. In the ED, triage vitals were 96.7 73 109/65 20 97%. He was AAox3 and without complaints. Labs showed K 6.8, Na 121 (ranging 121-132 in past 20 days) Cr 1.9 (baseline ranging 0.9- 1.8 in past 20 days) INR 1.7, AST 47 ALT 89 tbili 1.4, Lactate 2.1. EKG reportedly had no peaked T waves, He was given calcium gluconate, dextrose + insulin, kayexelate, and 1L IV NS. His blood glucose dropped and he started having terrible muscle cramps, requiring morphine and lorazepam to calm him down. He is being admitted to the ICU after he received too much insulin and concern for hypoglycemia. On arrival to the MICU, he is awake, oriented, but sleepy. His muscle cramps are much improved and he is having lots of diarrhea. His electrolytes have started to normalize. Past Medical History: - Cirrhosis [**2-21**] EtOH and HCV (genotype 1, treatment naive) --- Decompensations: hepatic encephalopathy, ascites requiring weekly paracenteses, --- IV drug abuse (quit in [**2151**]) --- Alcohol abuse (quit in [**2151**]) --- Confirmed by biopsy in [**2159**] --- Being actively considered by transplant - Seizure disorder, not on any AEDs - Polysubstance abuse, on methadone Social History: Tobacco history: [**3-24**] ppd currently. 40 years total. -ETOH: None since [**2151**] -Illicit drugs: Previous Heroin, none since [**2151**] -Home: Lives with brother and sister. Does hobbies around the house. Family History: Father - unknown Mother - deceased age 71, ?cancer, hypercholesterolemia Siblings - AIDS, hypercholesterolemia Physical Exam: On admission: Vitals: T: 97.7, BP:121/62, P: 113, R 20, O2:97% RA General: alert, oriented, no acute distress, but requires re-directing to keep his attention; temporal wasting HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous; EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; chest remarkable for gynecomastia Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: markedly distended and tympanitic, non-tender, bowel sounds present, significant splenomegaly palpated with some ascites leaking from umbilicus and prior paracentesis sites GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CNII-XII intact, 5/5 strength upper/lower extremities (able to sit himself up for lung exam), grossly normal sensation, gait deferred Discharge PE: Physical Exam: VS: 98.7, 109/54, 79, 18, 94% RA I/O 300 alb, 960 PO, 825 urine, 2BM General: A&Ox3; in NAD HEENT: Sclera anicteric CV: RRR, no murmurs Chest: gynecomastia Skin: scattered angiomata Lungs: CTAB with decreased BS at the bases bilaterally, no wheezes, rales, rhonchi Abdomen: distended but soft, non-tender, bowel sounds present Ext: warm, well perfused, 2+ DP pulses, trace LE edema with overlying increased skin pigmentation Neuro: minimal asterixis Pertinent Results: Labs on admission [**2165-10-10**] 06:05PM BLOOD WBC-9.4 RBC-3.68* Hgb-13.1* Hct-40.0 MCV-109* MCH-35.6* MCHC-32.7 RDW-13.2 Plt Ct-106* [**2165-10-10**] 06:05PM BLOOD Neuts-73.8* Lymphs-12.8* Monos-12.3* Eos-0.7 Baso-0.3 [**2165-10-10**] 06:05PM BLOOD PT-17.6* PTT-41.9* INR(PT)-1.7* [**2165-10-9**] 01:07PM BLOOD UreaN-41* Creat-1.8* Na-121* K-5.9* Cl-89* HCO3-27 AnGap-11 [**2165-10-10**] 06:05PM BLOOD ALT-47* AST-78* CK(CPK)-50 AlkPhos-95 TotBili-1.4 [**2165-10-10**] 06:05PM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.7*# Mg-2.4 [**2165-10-10**] 06:21PM BLOOD Lactate-2.1* MICRO: Blood cx [**10-10**]: pending (NGTD) Urine cx [**10-11**]: neg Ascites cx [**10-11**]: pending (NGTD) IMAGING: RUQ U/S [**10-11**]: 1. Cirrhosis with large volume ascites. 2. Patent hepatic vasculature. 3. Unchanged dilatation of the common bile duct to 10 mm without intrahepatic biliary duct dilatation. CXR [**10-11**]: Heart size is normal. Mediastinum is normal. Mild interstitial prominence is demonstrated, unchanged since the prior study. Bilateral pleural effusions are moderate, slightly decreased since prior examination but minimally. Upper lungs are essentially clear. There is no pneumothorax. [**2165-10-15**] 05:50AM BLOOD WBC-4.4 RBC-2.85* Hgb-10.1* Hct-30.9* MCV-108* MCH-35.5* MCHC-32.8 RDW-13.2 Plt Ct-64* [**2165-10-13**] 06:35AM BLOOD Neuts-54.9 Lymphs-26.9 Monos-14.7* Eos-2.7 Baso-0.8 [**2165-10-15**] 05:50AM BLOOD Plt Ct-64* [**2165-10-15**] 05:50AM BLOOD UreaN-44* Creat-1.3* Na-134 K-4.9 Cl-102 HCO3-27 AnGap-10 [**2165-10-12**] 04:10PM BLOOD FDP-10-40* [**2165-10-15**] 05:50AM BLOOD ALT-39 AST-74* AlkPhos-50 TotBili-2.5* [**2165-10-15**] 05:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.5 Brief Hospital Course: 57 year old male with history of EtOH and HCV cirrhosis with multiple prior hospitalizations for encephalopathy and ascites requiring weekly paracenteses, initially admitted to the ICU for stabilization of blood sugars after treatment for hyperkalemia, transferred to the Liver service for management of his ascites and encephalopathy. He was started on lactulose and rifaximin and his encephalopathy cleared. On [**10-14**] he underwent paracenteses with removal of 3L fluid. On this admission his creatinine peaked at 1.9 on [**10-10**]. Home Lasix and Aldactone were held. On the floor he was given three units of albumin and creatinine eventually trended down to 1.3. With improvement in [**Last Name (un) **], potassium also trended down. On the day of discharge ([**10-16**]) it was noted to again be elevated at 5.6, confirmed with a value of 5.3 later in the day. He was given a dose of Kayexylate with instructions for outpatient lab draw (LFTs and basic chemistry) on [**10-18**] and to follow up with Dr. [**Last Name (STitle) **] on [**2165-10-24**]. . >> Active Issues: # Hepatic encephalopathy: Presented with asterixis change in mental status relative to baseline. MS improved with lactulose. Infectious workup negative to date with neg Ucx; tap neg for SBP [**10-11**]. Bl cx NGTD. CXR without evidence of PNA. RUQ U/S with dopplers unremarkable. . # [**Last Name (un) **]: Cr of 1.9 on adm. Cr improved with albumin but plateaued at 1.5. Baseline approx 0.9. Most likely from diuretics causing prerenal azotemia, especially since improvement after albumin but DDx also included HRS. Ulytes c/w prerenal etiology with low Una which may also suggest HRS. Pt given 2 day albumin challenge without significant improvement in Cr. Diuretics held and pt will discharged off diuretics and plan for weekly taps for ascites mgmt. After third albumin dose Creatinine trended down to 1.5 and remained stable at that level until discharge. . # Hyperkalemia: On adm, K 6.8 without EKG changes. Pt given insulin/glucose in ED as well as kayexalate and hyperK resolved. Pt initially with muscle cramping on adm, which resolved with treatment of hyperkalemia. Etiology likely from [**Last Name (un) **] in combination with spironolactone and questionable compliance. On day of discharge [**10-16**] it was noted to be high at 5.6 and then confirmed with repeat chemistries in the afternoon. Pt was given one dose of kayexylate with instructions to go for lab draw on [**10-18**]. Pt is to follow up with Dr. [**Last Name (STitle) **] in [**Hospital 1326**] clinic on [**2165-10-24**]. . # Leukocytosis: WBC bump to 12.8 [**10-11**], and quickly normalized. No clear infectious source. . # Hyponatremia: likely from decompensated cirrhosis. Na as low as 120 and improved with holding diuretics and fluid restriction. . # Thrombocytopenia: plts to 28 on [**10-12**], improved to 68. DIC/hemolysis labs suggestive that this is most likely related to cirrhosis vs low grade chronic DIC. . # Hypoglycemia: From insulin given in ED for hyperkalemia. Resolved. Likely has nothing to do with the degree of his liver failure, as he does not appear to be in these late stages yet. Fingersticks stable in ICU. . >> Chronic issues: # HCV and EtOH cirrhosis c/b diuretic-refractory ascites requiring weekly therapeutic taps, as well as HE: Asterixis and significant ascites on exam. Receiving transplant work-up as outpt. Continued cipro 250mg daily for now for SBP ppx. HE mgmt per above. Consider TIPS for diuretic refractory ascites. Discontinue diuretics on discharge and proceed with weekly therapeutic taps for ascites mgmt. . # Polysubstance abuse: continue methadone 100 TRANSITIONAL ISSUES # Communication: [**Name (NI) 420**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 4408**] # Code: Full code # Consider TIPS for diuretic-refractory ascites. # Basic chemistries and LFTs to be drawn on Friday [**10-18**]. Please follow up at appointment with Dr. [**Last Name (STitle) **] on [**2165-10-24**]. # F/u: Dr. [**Last Name (STitle) **] in Liver transplant clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Methadone 100 mg PO DAILY Hold for sedation 2. Lactulose 30 mL PO TID 3. Rifaximin 550 mg PO BID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Furosemide 40 mg PO DAILY hold for SBP<90 6. Spironolactone 100 mg PO DAILY Hold for K>5.5 7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q24H 2. Lactulose 30 mL PO TID 3. Methadone 100 mg PO DAILY Hold for sedation 4. Rifaximin 550 mg PO BID 5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) 6. Outpatient Lab Work Please draw LFTs and a basic chemistry panel on [**10-18**] and fax the results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 4409**] ICD-9: 571.5. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute kidney injury Hyperkalemia Hepatic encephalopathy Secondary diagnosis: Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 4401**], It was a pleasure taking care of you in the hospital. You were admitted because of high potassium levels in your blood and labs suggestive of decreased kidney function. Your blood sugar dropped low after you were given insulin to treat the high potassium levels. You had to be observed overnight in the ICU. You developed a bit of confusion. We did not find any infections to explain this. We gave you lactulose and you improved. Please follow-up at the appointments listed below. Please see the attached list for updates and changes to your home medications. Please make sure to take lactulose so that you have [**3-24**] bowel movements daily. We have stopped the two diuretics below. Please stop taking them at home: STOP: Furosemide 40 mg by mouth DAILY STOP: Spironolactone 100 mg by mouth DAILY Please have your labs drawn this Friday ([**2165-11-17**]) and then follow up with our liver center in 2 weeks as below. Followup Instructions: Department: TRANSPLANT When: THURSDAY [**2165-10-24**] at 11:00 AM With: TRANSPLANT FELLOW & [**Doctor Last Name **] [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: LIVER CENTER When: THURSDAY [**2165-11-7**] at 12:40 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: THURSDAY [**2166-2-27**] at 1:30 PM With: ULTRASOUND [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2165-10-16**]

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icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

11708, 11714

6811, 7879

283, 297

11877, 11877

5084, 6788

13014, 14007

3575, 3688

11294, 11685

11735, 11735

10902, 11271

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231, 245

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11754, 11811

3717, 4584

11892, 12004

10031, 10876

2944, 3328

3344, 3559

77,382

196,744

11022

Discharge summary

report

Admission Date: [**2109-3-20**] Discharge Date: [**2109-3-20**] Service: MEDICINE Allergies: Patanol Attending:[**First Name3 (LF) 3556**] Chief Complaint: Delerium Major Surgical or Invasive Procedure: Femoral Line Placement Intubation History of Present Illness: This is a [**Age over 90 **] year old male with a history of dementia, hypertension, and depression who was brought in by his daughters for confusion. The patient was in his usual state of health one week ago. On Saturday he developed acute onset nausea, vomiting and diarrhea. his daughter had similar symptoms at that time. He was not experiencing any fevers or chills at that time. He was not having melena or hematochezia. His symptoms actually improved over Saturday to Sunday. He was seen by his primary care physician on [**Name9 (PRE) 766**] who felt that he was recovering from a viral gastroenteritis at that time and encouraged increased PO intake and prescribed compazine. He actually ate well on Tuesday and appeared somewhat better. Tuesday night he was noted by his family to be actutely confused. The patient's mental status waxes and wanes but this was significatnly worse than previous episodes that they have witnessed. He also was noted to vomit dark material with food. His family brought him to the emergency room. When EMS was called he was noted to have be found lying in bed with dark emesis surrounding him. Finger stick in the field was 164. Oxygen saturation was low 90s on room air. In the ED, initial vs were: T: 97.6 P: 47 BP: 104/56 R: 18 O2 sat: 98% on NRB. Initial HR recorded in nursing notes is 150. He had an EKG which showed sinus tachycardia with PACs, [**Street Address(2) 4793**] depressions in II, V3-V5. Portable CXR showed a new right sided infiltrate with concern for pneumobilia. A PA and lateral CXR and upright KUB were recommended. Initial labs were notable for a WBC count of 14.5 with 78% neutrophils. Lactate was 3.8. Creatinine was elevated at 1.8 from baseline of 1.3. He received levofloxacin 750 mg IV x 1. He also received diltiazem 20 mg IV x 1 and zofran 4 mg IV x 1. He received one liter of normal saline prior to floor transfer. On the floor he appears comfortable and is able to speak in short sentences. He reports that he is at the doctor's office. He does not know the date. He denies pain. He does endorse mild difficulty breathing. He denies fevers, chills, chest pain, nausea, abdominal pain, diarrhea, constipation, dysuria, hematuria, legp [**Doctor First Name **] or swelling. Past Medical History: Dementia (Alzheimer's, Vascular) Hypertension Gait disturbance Vitamin B12 deficiency Constipation Depression Anxiety Hyperlipidemia Chronic low back pain Cataract Colon cancer, status post partial colectomy [**2082**]. Prostate cancer status post TURP and Lupron Urinary Incontinence Thyroid Nodule Social History: The patient is a retired minister. He lives with his two daughters in a two-family home. He has formal supports that help him at home. He attends a day program at the [**Last Name (un) 35689**] House. He has a five year smoking history but quit many years ago. No history of alcohol use. No illicit drug use. Family History: Brother with myocardial infarction at age 57. Physical Exam: Admission Physical Exam: Vitals: T: 97.0 BP: 140/60 P: 96 R: 28 O2: 97% on 2L General: Easily arouses to voice, oriented to person, "doctor's office," not hospital or time, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Mild course breath sounds throughout, worse at the right base, decreased breath sounds at the right base, unable to appreicate egophony, no rales or ronchi CV: Mild tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: firm, non-tender, mild distention, tympanitic to percussion, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Hematology: [**2109-3-20**] 11:58AM WBC-8.0 RBC-3.93*# HGB-10.8*# HCT-34.2*# MCV-87 MCH-27.5 MCHC-31.7 RDW-14.4 [**2109-3-20**] 11:58AM PLT COUNT-147* [**2109-3-20**] 11:58AM PT-16.4* PTT-43.7* INR(PT)-1.5* [**2109-3-20**] 05:15AM WBC-14.5*# RBC-5.43 HGB-15.2 HCT-45.1 MCV-83 MCH-28.0 MCHC-33.8 RDW-14.3 [**2109-3-20**] 05:15AM NEUTS-78* BANDS-0 LYMPHS-6* MONOS-16* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2109-3-20**] 05:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2109-3-20**] 05:15AM PLT SMR-NORMAL PLT COUNT-216 [**2109-3-20**] 05:15AM PT-12.4 PTT-21.6* INR(PT)-1.0 Chemistries: [**2109-3-20**] 11:58AM GLUCOSE-305* UREA N-55* CREAT-1.9* SODIUM-145 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-22* [**2109-3-20**] 11:58AM ALT(SGPT)-386* AST(SGOT)-351* CK(CPK)-210 ALK PHOS-27* TOT BILI-0.6 [**2109-3-20**] 11:58AM CK-MB-7 cTropnT-0.02* [**2109-3-20**] 11:58AM CALCIUM-7.5* PHOSPHATE-5.4*# MAGNESIUM-1.7 [**2109-3-20**] 06:02AM LACTATE-3.8* [**2109-3-20**] 05:15AM GLUCOSE-169* UREA N-56* CREAT-1.8* SODIUM-137 POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-29 ANION GAP-17 [**2109-3-20**] 05:15AM CK(CPK)-166 [**2109-3-20**] 05:15AM cTropnT-0.03* [**2109-3-20**] 05:15AM CK-MB-7 [**2109-3-20**] 05:15AM CALCIUM-9.1 PHOSPHATE-2.1* MAGNESIUM-2.0 CXR Portable [**2109-3-20**]: There is new increased volume loss on the right side. There is a small right pleural effusion and opacity the right lung base concerning for infection or aspiration. The cardiac silhouette is mildly enlarged, unchanged. There is no large pneumothorax. The mediastinal and hilar contours are unremarkable. Tubular lucency in the right upper quadrant may represent air within the biliary tree. EKG: EKG which showed sinus tachycardia at 122 with PACs, [**Street Address(2) 11342**] depressions in II, V3-V5. Microbiology: Blood cultures x 2 pending Brief Hospital Course: Assessment and Plan: [**Age over 90 **] year old male with a history of dementia, hypertension, and depression who was brought in by his daughters for confusion found to have tachycardia, leukocytosis, elevated lactate and right sided pneumonia in the emergency room. Shortly after arrival the patient experienced a code blue while in the department of radiology. On initial exam he appeared comfortable but was tachypneic to the mid 20s. His abdomen was firm and there was question of pneumobilia on initial portable CXR in addition to right sided volume loss likely representing pneumonia. A repeat PA and lateral CXR and KUB were recommended for further evaluation of this potential finding. Prior to transfer to radiology the patient was noted to vomit a small amount of coffee ground material. I was unable to guaiac this but it had classic appearance. All oral medications were discontinued, the patient was made NPO and was started on IV protonix 40 mg [**Hospital1 **]. NG lavage was not performed secondary to compromised respiratory status in the setting of pneumonia. He had received a second 1 liter fluid bolus immediately on arrival to the floor given initial concern for evolving sepsis (leukocytosis, tachycardia, elevated lactate and pneumonia) and his heart rate had improved to the high 90s. He was transported to radiology for the above studies. While in radiology the patient was not continued on telemetry. He was noted by staff in radiology to have vomited and to be in respiratory distress. The patient was noted to be unresponsive and there was difficulty with mask ventilation secondary to aspirated coffee ground material. A wide complex tachycardia was noted on the monitor and he received electric shocks, epinephrine, vasopressin, bicarbonate among other therapies. He subsequently developed pulseless electrical activity. He was intubated by anesthesia. A femoral line was placed by surgery and he received blood products for presumed gastrointestinal bleeding and aspiration leading to hypoxia and hypovolemia induced PEA arrest. Ultimately the code team was able to regain a pulse and he was transferred to the MICU service. On arrival to the MICU the patient was in critical condition. This was discussed with his two daughters who decided to change his goals of care to focus on comfort. His breathing tube was removed. He was started on a morphine drip and expired at approximately 3:30 PM. Medications on Admission: Atorvastatin 5 mg daily Benazepril 5 mg daily Citalopram 10 mg daily Cyanocobalamin 1000 mcg IM qmonth Donepazil 10 mg daily Lupron Pancrease 250 mg TID with meals Namenda 10 mg [**Hospital1 **] Tolterodine 2 mg daily Trazodone 25 to 50 mg QHS:PRN Aspirin 81 mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Aspiration pneumonia Gastrointestinal bleeding Dementia Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.60", "96.04", "38.93", "99.62" ]

icd9pcs

[ [ [] ] ]

8818, 8827

6018, 8467

224, 260

8927, 8936

4067, 5995

8992, 9131

3240, 3287

8786, 8795

8848, 8906

8493, 8763

8960, 8969

3327, 4048

176, 186

288, 2567

2589, 2891

2907, 3224

25,148

144,481

29479

Discharge summary

report

Admission Date: [**2106-10-24**] Discharge Date: [**2106-10-26**] Date of Birth: [**2033-5-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain and nausea. Major Surgical or Invasive Procedure: CTA with MMS reconstructions. History of Present Illness: This 73 [**Male First Name (un) 4746**] presented to [**Hospital3 **] ER with chest pain and nausea. He was hypertensive and had a CTA which revealed a Type B aortic dissection. He was transferred to [**Hospital1 18**] for further management. Past Medical History: HTN CAD, s/p CABG [**09**] yrs. ago ^chol. Rheumatoid arthritis Melanoma Social History: Lives with wife. Cigs: none ETOH: none Family History: DM Physical Exam: Elderly [**Male First Name (un) 4746**] in NAD HEENT: NC/AT, PERLA, EOMI, poor dentition Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. Lungs: Clear to A+P CV: RRR without R/G/M, nl s1, s2 Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bialt. throughout. Neuro: nonfocal Pertinent Results: [**2106-10-26**] 07:20AM BLOOD WBC-11.2* RBC-4.34* Hgb-13.3* Hct-37.5* MCV-86 MCH-30.5 MCHC-35.4* RDW-13.9 Plt Ct-160 [**2106-10-26**] 07:20AM BLOOD Glucose-124* UreaN-16 Creat-1.1 Na-139 K-4.5 Cl-100 HCO3-30 AnGap-14 RADIOLOGY Preliminary Report CTA CHEST W&W/O C &RECONS [**2106-10-25**] 6:09 PM CTA CHEST W&W/O C &RECONS; CT ABD W&W/O C Reason: eval Type B dissection Field of view: 40 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 73 year old man with type B disseciton at OSH REASON FOR THIS EXAMINATION: eval Type B dissection CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 73-year-old man with type B dissection at outside hospital. Evaluate. COMPARISON: None. TECHNIQUE: MDCT imaging of the chest, abdomen, and pelvis was performed following the administration of 100 cc of intravenous Optiray. Nonionic contrast was administered per protocol. Coronal and sagittal reformatted images were obtained. CT ANGIOGRAM CHEST: Dissection of the intrathoracic aorta begins distal to the arch and terminates just proximal to the diaphragm. Both lumens opacify symmetrically. The ascending aorta enhances normally without evidence of penetrating ulcer or hematoma. There is mild atherosclerosis, however, the remaining great vessels enhance normally. No filling defects within the pulmonary artery, or proximal branches. The heart, pericardium are unremarkable. There is no pericardial effusion. There is a small left pleural effusion with compressive atelectasis. Lung windows reveal centrilobular emphysema. Tiny 1-2 mm mainly subpleural nodules are seen bilaterally. CT ABDOMEN WITHOUT ORAL, WITH IV CONTRAST: Intra-abdominal aorta is aneurysmal, measuring up to 4.7 cm at the level of the diaphragm. Distal to this, the diameter decreased slightly and then in the infrarenal portion, it measures up to 3.7 cm. There is dense atherosclerosis, with intramural thrombus along its course. There is no evidence of dissection. All intra- abdominal arteries enhance appropriately. Imaging of the organs is somewhat limited by the phase of contrast injection. Allowing for this, the liver, pancreas, spleen, bilateral adrenal glands, and both kidneys are unremarkable. Small gallstones are seen within and otherwise normal-appearing gallbladder. The abdominal loops of large and small bowel are normal in caliber and contour. The appendix is seen in the right lower quadrant and appears normal. There is no mesenteric or retroperitoneal lymphadenopathy. There is no free air and no free fluid. CT PELVIS WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: The bladder, sigmoid, rectum, and prostate are unremarkable. There is no inguinal or pelvic lymphadenopathy. There is no free air and no free fluid. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous abnormalities. IMPRESSION: 1. Type B aortic dissection extending from the aortic arch just proximal to the level of the diaphragm. 2. Aneurysmal dilatation of the intra-abdominal aorta at the level of the diaphragm, with ectasia more distally. 3. Centrilobular emphysema. 4. Atherosclerosis. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] Brief Hospital Course: This 73 [**Male First Name (un) 4746**] was admitted to the CSRU for blood pressure control and was started on IV NTG. He was weaned off NTG and Lopressor and Lisinopril were increased. He was transferred to the floor on HD#2 and had a CTA with MMS reconstruction which revealed a Type B dissection of the aorta from the distal arch to the diaphragm. He also has an abdominal aortic aneurysm. He was discharged to home with a BP of 130/70 in 40 mg of Lisinopril and Lopressor 100 mg [**Hospital1 **]. He will be seen in 3 weeks in the aorta clinic with Dr. [**Last Name (STitle) 1290**]. Medications on Admission: Lopressor 100 mg PO BID Lisinopril 20 mg PO daily ASA 325 mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Type B aortic dissection. s/p CABG [**09**] yrs. ago HTN CAD ^chol. Rheumatoid arthritis Melanoma Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 1290**] for 3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 1 week. Completed by:[**2106-10-26**]

[ "714.0", "V45.81", "V10.82", "272.0", "441.01", "492.8", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5551, 5557

4411, 5005

346, 378

5699, 5706

1205, 1619

5800, 5971

820, 824

5125, 5528

1656, 1702

5578, 5678

5031, 5102

5730, 5777

839, 1186

284, 308

1731, 4388

406, 652

674, 748

764, 804

42,501

147,324

9087

Discharge summary

report

Admission Date: [**2165-11-13**] Discharge Date: [**2165-11-22**] Date of Birth: [**2093-2-10**] Sex: F Service: CARDIOTHORACIC Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 1406**] Chief Complaint: Dyspnea on exertion, recent abnormal ETT Major Surgical or Invasive Procedure: [**2165-11-13**] Cardiac Catherization [**2165-11-14**] Coronary artery bypass graft x 3 with: left internal mammary artery (LIMA) to left anterior descending artery, reverse greater saphenous vein to mid right coronary, and reversed saphenous vein to an OM-2 as well as endovascular harvest of the vein. History of Present Illness: 72 year old [**Location 7972**] female who was recently referred for cardiac consultation after complaining of dyspnea on exertion, increasing pillow orthopnea and a cough. Recent stress testing revealed marked ischemic EKG changes with exercise of only 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (2.8 METS) and echo evidence of ischemia involving the basal inferior septum, basal inferior and posterior wall. She was referred for left heart catheterization. She was found to have coronary artery disease upon cardiac catheterization and is now being referred to cardiac surgery for revascularization. Past Medical History: Coronary artery disease s/p coronary artery bypass graft x 3 Past medical history: Hypertension Hyperlipidemia Diabetes mellitus Mild Renal insufficiency/Microalbuminuria Hypercalcemia, recent. Calcium and vitamin D discontinued. Anemia Multinodular goiter/Hyperthyroidism Osteopenia Lower back pain Hirsutism Anxiety Social History: Widowed. She has three children, two living in RI, and one living in [**Country 3587**]. She alternates living with her niece [**Name (NI) **] and her daughter. [**Name (NI) **] is her primary care provider and dispenses her medications, brings her to office visits. Previously worked as a seamstress. Home Care Services: Denies Tobacco: Denies ETOH: Denies Recreational drug use: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: Pulse:59 Resp:18 O2 sat:100/RA B/P Right:173/65 Left:169/66 Height:5'3" Weight:142 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs faint crackles at the bases bilaterally Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [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**]: +1 Left:+1 Radial Right:cath site Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: Cardiac Cath: [**2165-11-13**]: 1. Selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a severe diffuse 80% mid lesion that tapered to 90% focally. Small diagonal branches noted. The LCx was a large system giving rise to a larg bifucating OM. The upper pole of the OM had a 60-70% stenosis. The RCA was totally occluded at the level of the ostium with limited ascending aortography showing no evidence of ostium. Left to right collaterals from LCX and LAD were noted to fill retrogradely to the level of the acute marginal branch. 2. Limited resting hemodynamics demonstrated an LVEDP of 14mm Hg and a central aortic pressure of 146/63mm Hg. . Chest CT [**2165-11-13**]: 1. No evidence of aortic calcifications in this patient scheduled for CABG. 2. Extensive enlargement of the thyroid gland with potential infarction of the trachea, correlation with ultrasound might be considered on a non-emergency basis. Intrathoracic component of the thyroid enlargement is noted. 3. Several pulmonary nodules as described. Reassessment in one year is recommended. 4. Small hiatal hernia. 5. Cortical cyst. . Echo [**2165-11-14**]: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic fxn. Trace - 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. Radiology Report CHEST (PA & LAT) Study Date of [**2165-11-17**] 1:47 PM Final Report FINDINGS: Comparison is made to previous study from [**2165-11-15**]. There is again seen atelectasis at both lung bases which is plate like. The cardiac silhouette is enlarged but stable. Median sternotomy wires are present. There are small bilateral pleural effusions. No pneumothoraces or signs for overt pulmonary edema is present. Right-sided central venous catheter has been removed. [**2165-11-21**] 06:02AM BLOOD WBC-6.8 RBC-3.13* Hgb-8.6* Hct-26.5* MCV-85 MCH-27.3 MCHC-32.3 RDW-13.1 Plt Ct-284 [**2165-11-21**] 06:02AM BLOOD Glucose-130* UreaN-18 Creat-1.1 Na-142 K-4.4 Cl-106 HCO3-27 AnGap-13 [**2165-11-20**] 06:05AM BLOOD ALT-21 AST-31 LD(LDH)-215 AlkPhos-66 Amylase-43 TotBili-0.2 [**2165-11-20**] 06:05AM BLOOD Lipase-47 [**2165-11-21**] 06:02AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.9 [**2165-11-14**] 06:05AM BLOOD %HbA1c-7.1* eAG-157* Brief Hospital Course: 72 yo F with HTN, HLD, DMII insulin dependent who was transferred to cardiac catherization for a positive stress test, found to have multi-vessel CAD warranting CT surgery evaluation for CABG. # CAD: Positive stress test and left heart catherization show three vessel CAD: Totally occluded RCA, 90% prox LAD and 70% LCx. She was transferred for CABG. The patient was brought to the operating room on [**11-14**] by Dr [**Last Name (STitle) **], where the patient underwent: Median sternotomy with a coronary artery bypass x3 with left internal mammary artery (LIMA) to left anterior descending artery, reverse greater saphenous vein to mid right coronary, and reversed saphenous vein to an OM-2 as well as endovascular harvest of the vein. Her BYPASS TIME was 79 minutes with a CROSS-CLAMP TIME of 68 minutes. She tolerated the operation well and post-operatively was transferred to the CVICU in stable condition. She remained hemodynamically stable in the immediate post-op period and was extubated. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She was ready for transfer to stepdown floor on POD1 but there were no beds available and she remainded in the ICU until POD2, when the patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued per cardiac suregry protocol. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The remainder of her post-operative course was uneventful.She was gently diuresed toward her preop weight. By the time of discharge on POD #8 the patient was ambulating with asistance, the wound was healing and pain well controlled with Percocet. The patient was discharged home with limited services in good condition with appropriate follow up instructions. Medications on Admission: - ASPIRIN 81 mg Daily - LISINOPRIL-HYDROCHLOROTHIAZIDE 20 mg/25 mg- 2 Tablets daily - PRAVASTATIN 80 mg daily - PROPRANOLOL 80 mg twice a day - DILTIAZEM HCL 120 mg daily - NITROGLYCERIN 0.3 mg/hour Patch 24 hr - NITROGLYCERIN 0.3 mg, SL prn CP - INSULIN GLARGINE 100 unit/mL Solution - 38 U sc qd - METFORMIN 850 mg three times a day - LORATADINE- 10 mg daily - OMEPRAZOLE 20 mg daily - CITALOPRAM 20 mg daily - FLUNISOLIDE 0.025 % - 2 sprays [**Hospital1 **] - ACETAMINOPHEN 500 mg Tablet - 1-2 tablets PRN - CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400 unit Tablet [**Hospital1 **] - ARTIFICIAL TEARS - one drop qid ou Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 9. insulin glargine 100 unit/mL Solution Sig: resume pre-op schedule Subcutaneous once a day. 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 12. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. Disp:*7 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 3 Past medical history: Hypertension Hyperlipidemia Diabetes mellitus Mild Renal insufficiency/Microalbuminuria Hypercalcemia, recent. Calcium and vitamin D discontinued. Anemia Multinodular goiter/Hyperthyroidism Osteopenia Lower back pain Hirsutism Anxiety Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg: Left- healing well, no erythema or drainage. Edema: trace bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for 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**] 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 Wound check: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2165-12-3**] 10:00am in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] Surgeon: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2165-12-19**] 1:30pm in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD :[**Telephone/Fax (1) 62**] Date/Time:[**2165-12-4**] 1:20 Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 31364**] [**Last Name (NamePattern1) 31365**] in [**4-9**] 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:[**2165-11-22**]

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icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "36.15", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

9940, 9998

5787, 7813

386, 693

10359, 10585

2929, 5764

11473, 12446

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10019, 10080

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306, 348

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10102, 10338

1728, 2117

30,450

102,382

24691

Discharge summary

report

Admission Date: [**2109-10-27**] Discharge Date: [**2109-11-1**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2518**] Chief Complaint: Fall/Stroke. Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a [**Age over 90 **] year-old right handed woman with alzheimers and a left bundle branch block was admitted to the trauma service after a fall. The history is entirely obtained from the record as the patient is a very poor historian. When asked why she was in the hospital, she said "I don't know." The patient lives by herself in [**Hospital3 4634**]. She fell on the morning prior to consultation when she was reaching from her walker from the bedside. The walker slipped away and she fell forward onto her face. She denied LOC, dizzyness, CP, SOB, or Palpitions prior to the fall per the Neurosurg [**MD Number(3) 7057**] ED. Of note the patient fell two weeks ago and was seen here. At that time there was no blood on her head ct. A new head CT performed [**2109-10-27**] revealed an acute left parieto-occipital hemorrhage. ROS: This was attempted but the patient is not felt to be an adequate historian. Past Medical History: Mild Dementia, Alzheimers Hearing Impariment -requires left ear hearing aid. R-frozen shoulder Osteoporosis Depression Has Left bundle branch block on EKG. Social History: Lives at "[**Doctor Last Name 62292**] House" [**Hospital3 **]. Goes to day care twice weekly. Daughter [**Name2 (NI) 17486**] supportive and invloved. Uses walker at home. Non-smoker, no ETOH. Family History: NC Physical Exam: Vitals: T:99.7 P:60 R:15 BP:143/71 SaO2:99%RA General: Awake, at times cooperative and times inattentive, NAD. HEENT: She has ecchymoses over face under eyes and over upper lip, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs with rare crackles at the bases bilaterally. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Intermittently Alert and intermittently cooperative with the exam. She will close her eyes and drift off in the middle of being examined. She is unable to tell a linear history. She was able to tell the days of the week forward but not backwards. Language is quite sparse. Prosody was normal, no dysarthria. patient able to name neck tie and fingers, but was unable or unwilling to name knot of neck tie, knuckles, thumb or finger nails. She is able to read, though she read a sentence other than the one she was instructed to. Registration and recall were not tested as patient was too inattentive. -Cranial Nerves: Olfaction not tested. PERRL 2 to 1mm and brisk. Possible right homonymous hemianopsia - patient difficult to assess. There is bilateral ptosis. Funduscopic exam impossible with intattentive and increasingly uncooperative patient. Normal saccades. Facial sensation intact to light touch. No facial droop, facial musculature symmetric. Hearing diminished and shouting required. Tongue protrudes in the midline. Palate not visualized. -Motor: Normal bulk, tone increased in the lower extremities. Patient doesn't comply with pronator drift testing. No adventitious movements noted. No asterixis noted. . Unable to perform formal motor exam due to inatentiveness. Patient has anti-gravity movement of all four extremities. Her right shoulder is apparently quite painful to her. -Sensory: Patient's response to could, pin, and joint position were not correct despite testing in the upper and lower extremity. Responses for vibration were correct in the upper extremity. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Pertinent Results: [**2109-10-27**] 03:30PM BLOOD WBC-10.4# RBC-3.62* Hgb-11.9* Hct-35.0* MCV-97 MCH-33.0* MCHC-34.2 RDW-13.4 Plt Ct-298 [**2109-10-30**] 06:10AM BLOOD WBC-7.8 RBC-3.51* Hgb-11.5* Hct-34.4* MCV-98 MCH-32.7* MCHC-33.4 RDW-12.8 Plt Ct-311 [**2109-10-27**] 03:30PM BLOOD PT-13.1 PTT-29.3 INR(PT)-1.1 [**2109-10-27**] 03:30PM BLOOD Glucose-92 UreaN-29* Creat-0.8 Na-138 K-4.1 Cl-104 HCO3-25 AnGap-13 [**2109-10-30**] 06:10AM BLOOD Glucose-101 UreaN-15 Creat-0.8 Na-136 K-4.1 Cl-102 HCO3-25 AnGap-13 [**2109-10-29**] 03:55AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2109-10-29**] 06:55AM BLOOD CK-MB-3 cTropnT-<0.01 [**2109-10-29**] 03:55AM BLOOD CK(CPK)-87 [**2109-10-29**] 11:10AM BLOOD CK(CPK)-72 [**2109-10-28**] 03:52AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.2 [**2109-10-30**] 06:10AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.3 [**2109-10-29**] 06:55AM BLOOD calTIBC-274 VitB12-347 Ferritn-52 TRF-211 [**2109-10-29**] 03:55AM BLOOD %HbA1c-5.1 [**2109-10-29**] 03:55AM BLOOD Triglyc-73 HDL-61 CHOL/HD-2.3 LDLcalc-62 [**2109-10-30**] 06:10AM BLOOD TSH-1.6 [**2109-10-28**] 03:52AM BLOOD Phenyto-10.8 X-Ray: Shoulder: No evidence of acute fracture or dislocation. Unchanged from [**2109-10-14**] CT Head: Acute left parieto-occipital intraparenchymal hemorrhage with subarachnoid component. Mild adjacent edema, but no significant mass effect or midline shift. CT Chest: Benign 1cm calcified granuloma in the right lower lobe. Carotids: Duplex and color Doppler demonstrate no appreciable plaque or wall thickening involving either carotid system. The peak systolic velocities bilaterally are normal as are the ICA/CCA ratios. There is also normal antegrade flow involving both vertebral arteries. MRI: 1. Extremely motion limited examination. 2. Subacute left parietooccipital intraparenchymal hemorrhage with no demonstrable features of amyloidosis or infarction. Possible etiologies include traumatic hemorrhage, hypertension, and cannot exclude a very occult underlying mass or vascular malformation. MRA Brain: There are no major areas of stenosis identified. Extremely motion limited examination. Brief Hospital Course: Ms. [**Known lastname 62291**] was initially admitted to the Trauma service as her ICH was felt to be secondary to the trauma of her fall. However after further history was obtained, it appeared that her fall was forward onto her face, not towards the back, therefore it was felt that the bleed was not secondary to the fall. Her daughter raised the fact that the walker was actually placed to the right of her bed and as she developed a R sided neglect she may have fallen trying to reach the walker. Her work-up included an MRI of the brain to evaluate for amyloid. This did not show old microbleeds. Carotid dopplers were also ordered to evaluate for possible embolic etiologies however these vessels appeared clear. A TTE was not repeated, as she had a one very recently. Another possibility for her ICH may have been from an embolic metastasis. Her initial CXR showed a RLL coin lesion. This was evaluated further with CT which showed an old calcified granuloma and not malignancy. Her management included a FLP which was excellent (LDL 62/ HDL 61) and an A1c of 5.1. She was therefore not treated for either DM or HLD. She was also not treated with aspirin or heparin given her recent bleeding. She was treated with dilantin to prevent seizures. She was sub therapeutic initially and was reloaded. She will complete a 10 day course with a 3 day taper. For her dementia, she had a work-up including a TSH and B12 which were both normal. She was continued on Aricept. Her anemia was evaluated with iron studies which were consistent with chronic disease. Her Hct remained stable. She was diagnosed with a UTI and was treated with Bactrim DS, renally dosed and will complete a 7 day course. After discharge, she has follow-up scheduled with Dr. [**First Name (STitle) **] Medications on Admission: Aricept 10 daily Namenda 10 [**Hospital1 **] Celexa 10 daily Enablex 7.5 [**Hospital1 **] Omeprazole 20mg Daily Ultram 50mg 0.5-1 daily Alleve 220mg Ca/VitD 500-125 three times daily. Estring (Changed every three months) Fosamax 70mg once weekly. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO daily (). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Taper on [**11-6**]: [**11-6**]-TID [**11-7**]-[**Hospital1 **] [**11-8**]-QD then stop. 7. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Intracranial hemorrhage Dementia UTI Discharge Condition: Stable Discharge Instructions: Please follow-up with Dr. [**First Name (STitle) **] as scheduled Please continue with your dilantin as prescribed Please complete your course of antibiotics for your UTI Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2109-12-20**] 10:00, needs registration update & referral from PCP Follow-up MRI of brain in [**1-13**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

[ "733.00", "294.10", "599.0", "426.3", "331.0", "431", "285.29", "E884.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8992, 9062

6100, 7882

278, 285

9142, 9150

3989, 5164

9369, 9695

1645, 1649

8179, 8969

9083, 9121

7908, 8156

9174, 9346

2901, 3970

1664, 2269

225, 240

313, 1239

5173, 6077

2284, 2884

1261, 1418

1434, 1629

69,289

179,175

35686+58022

Discharge summary

report+addendum

Admission Date: [**2163-3-11**] Discharge Date: [**2163-3-21**] Service: CARDIOTHORACIC Allergies: Procainamide / Flomax / Uroxatral Attending:[**First Name3 (LF) 165**] Chief Complaint: fatigue, dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization Coronary artery bypass graft times two and aortic valve replacement with a 27mm [**Company 1543**] Mosaic Porcine valve [**2163-3-16**] History of Present Illness: This 87 year old gentleman has a history significant for aortic stenosis, tachy-brady syndrome s/p pacemaker and paroxysmal atrial fibrillation. Recently, he has been experiencing shortness of breath with minimal exertion and also reports intermittent chest pressure that occurs unrelated to activity. He had a fall in his basement last week. He denies having syncope and states he tripped. He denies LOC. He denies any dizziness or lightheadedness at all. He has chronic right foot edema after knee replacement surgery. He denies any PND or orthopnea andstates he sleeps very well. He sleeps in a recliner due tochronic back pain. He denies any claudication symptoms. Hereports frequent skin tears and currently has one on his right lower leg and left forearm. Due to concern about these symptoms, the patient was seen by his PCP and an echo was done on [**2163-3-8**]. This report is not presently available, however it reportedly revealed worsening aortic stenosis. The patient was referred for catheterization to further evaluate need for AVR and possbly CABG. On [**2163-3-11**] patient [**Date Range 1834**] cardiac cath which revealed a tight stenosis in LCx and RCA. It was therefore decided that he would undergo both CABG for his CAD as well as AVR for his severe AS complicated by CHF. Past Medical History: Prostate cancer diagnosed 7 months ago, treated conservatively TURP 21 years ago for BPH Aortic stenosis Atrial fibrillation Pacemaker [**2162-4-29**] Chronic back pain s/p remote spinal fusion surgery [**2118**] Breast tumor removed at age 15 Bilateral hernia repairs Rectal surgery x 4 for fissures and hemorrhoids Total knee replacement- right Appendectomy age 13 Elbow surgery s/p cardiac catheterization approx 13 years ago with clean coronaries essential tremor of unknown origin hypothyroid Cardiac Risk Factors: Diabetes(-), Dyslipidemia(+), Hypertension(+) Pacemaker/ICD for AF/tachy-brady syndrome Social History: Social history is significant for the 3ppd X 20yrs quit 47 years ago. There is no history of alcohol abuse. Married, patient??????s wife and daughter will accompany pt to procedure and then return home. They would like to be called post procedure and can be reached at [**Telephone/Fax (1) 81183**] or cell # [**Telephone/Fax (1) 81184**] [**Doctor First Name 717**]. Family History: both parents died at age 76-mother died from a stroke, father died following a stroke from complications from carotid artery surgery. Father had an MI at age 60. Brother died from suicide. Another brother died from pancreatic cancer. Physical Exam: VS - T 96.6 HR 60s BPs 130s-160s/40s-60s RR18 O2sat 98RA Gen: WDWN elderly male in NAD. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink. MMM Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-4**] soft systolic murmur at RUSB radiating to carotids No thrills, lifts. No S3 or S4. Chest: CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Groin site without hematoma, dressing c/d/i. No bruit. Ext: Edema to ankles bilaterally R>L. Neg homans signs Skin: stasis dermatitis bilaterally, no ulcers. Pulses: Right: Femoral 2+ DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2163-3-11**] 09:15AM GLUCOSE-150* UREA N-27* CREAT-1.4* SODIUM-137 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [**2163-3-11**] 09:15AM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-119* AMYLASE-54 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4 [**2163-3-11**] 09:15AM ALBUMIN-3.8 [**2163-3-11**] 09:15AM %HbA1c-5.4 [**2163-3-11**] 09:15AM WBC-5.1 RBC-3.07* HGB-9.8* HCT-29.0* MCV-94 MCH-31.9 MCHC-33.8 RDW-14.6 [**2163-3-11**] 09:15AM NEUTS-78.5* LYMPHS-14.1* MONOS-4.4 EOS-2.7 BASOS-0.2 [**2163-3-11**] 09:15AM PLT COUNT-144* [**2163-3-11**] 08:56AM TYPE-ART PO2-114* PCO2-44 PH-7.44 TOTAL CO2-31* BASE XS-5 INTUBATED-NOT INTUBA [**2163-3-11**] 08:56AM HGB-12.2* calcHCT-37 O2 SAT-98 [**2163-3-11**] 08:00AM INR(PT)-0.9 [**2163-3-20**] 05:16AM BLOOD WBC-8.8 RBC-3.07* Hgb-9.8* Hct-27.8* MCV-91 MCH-32.0 MCHC-35.4* RDW-16.6* Plt Ct-91* [**2163-3-20**] 05:16AM BLOOD PT-15.5* INR(PT)-1.4* [**2163-3-20**] 05:16AM BLOOD Glucose-106* UreaN-26* Creat-1.0 Na-139 K-3.3 Cl-104 HCO3-28 AnGap-10 Brief Hospital Course: A cardiac catheterization was performed on [**2163-3-11**] which demonstrated two vessel coronary artery disease. On [**2163-3-11**] carotids were performed and revealed less than 40% stenosis on the right and 70-79% on the left. Dental clearance was obtained. He was seen by podiatry for right 2nd digit pain and an abscess was drained at bedside. He was seen by speech and swallow and found to have mild dysphagia. He was seen by wound care for a right lower leg ulcer which has been healing poorly. Adaptic was recommended to be placed on the wound. He was placed on Kefzol for thrombophlebitis on his right upper extremity. On [**2163-3-16**] Mr. [**Known lastname 43400**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times two and an aortic valve replacement with a 27mm [**Company 1543**] Mosaic Porcine valve. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. Mr. [**Known lastname 43400**] was weaned from the ventilator and extubated without difficulty. His pacing wires were removed on POD#2 since he has his own internal pacer. He was transferred from the ICU to the floor on POD#2. He was started on coumadin for baseline atrial fibrillation which he was in prior to surgery and betablocker and diuretics. His platelet count was noted to be steadily declining. His medications were reviewed and zantac d/c'd. A HIT panel was negative. His chest tubes were removed on POD#3. Hematocrit and platelets are recovering. Mr. [**Known lastname 43400**] was evaluated by physical therapy and rehab was recomended. The patient was found stable for discharge to rehab on POD 5. Medications on Admission: Slow K 600mg 1 capsule [**Hospital1 **] Warfarin 5mg/7.5mg MWF, last dose Monday Amiodarone 200mg daily Amlodipine 5mg daily Primidone 50mg daily Lasix 20mg, 3 tablets daily Docusate sodium 100mg [**Hospital1 **] Erythromycin Ophthalmic ointment daily for dry eye Synthroid 0.125mg daily konsyl OTC for fiber 6 grams daily with juice aspirin 81mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. Primidone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR [**2-1**], Dx: A-fib. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for 2 days: through [**2163-3-22**]. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Furosemide 40 mg IV Q12H 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: two vessel coronary artery disease severe aortic stenosis hypertension hypercholesterolemia prostate cancer tachy-brady syndrome atrial fibrillation chronic back pain essential tremor of unknown origin hypothyroidism s/p fall last week (no syncope) s/p rectal surgery for fissures s/p appendectomy s/p permanent pacemaker s/p right total knee replacement s/p transurethral resection of prostate s/p bilateral elbow surgery s/p spinal fusion in [**2118**] s/p breast tumor removed age 15 s/p hernia repairs s/p bilateral cataract surgery Discharge Condition: good Discharge Instructions: You were admitted to the hospital with fatigue and an abnormal valve in your heart. You had a catheterization to evaluate the valve and this showed some coronary artery disease as well. You were having trouble swallowing. You had some tests that show that the muscles that help you swallow are very tight which is causing your trouble swallowing. You were given instructions for how to swallow and should follow them at home. You should crush your medications to take them. You may at some point want to have surgery for this and your primary care doctor can help you arrange this. Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 81185**] please call for appointment Dr [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**] in [**2-1**] weeks ([**Telephone/Fax (1) 81186**] please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2163-3-21**] Name: [**Known lastname 13010**],[**Known firstname 33**] T Unit No: [**Numeric Identifier 13011**] Admission Date: [**2163-3-11**] Discharge Date: [**2163-3-21**] Date of Birth: [**2075-6-2**] Sex: M Service: CARDIOTHORACIC Allergies: Procainamide / Flomax / Uroxatral Attending:[**First Name3 (LF) 265**] Addendum: Clarification on medication Lasix to be 40 mg twice a day oral - spoke with rehab [**3-21**] at 1535 Discharge Disposition: Extended Care Facility: [**Location (un) 1353**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2163-3-21**]

[ "414.01", "244.9", "V45.79", "272.0", "V43.65", "427.81", "V58.61", "458.29", "V45.4", "584.9", "428.0", "110.1", "333.1", "V10.46", "427.31", "338.29", "V15.88", "V45.01", "424.1" ]

icd9cm

[ [ [] ] ]

[ "89.45", "36.12", "37.21", "35.21", "38.93", "86.27", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

11290, 11461

4740, 6424

263, 425

9070, 9077

3714, 4717

10171, 11267

2793, 3029

6828, 8436

8510, 9049

6450, 6805

9101, 10148

3044, 3695

207, 225

453, 1756

1778, 2391

2407, 2777

17,125

105,639

4496

Discharge summary

report

Admission Date: [**2102-2-13**] Discharge Date: [**2102-2-17**] Service: [**Hospital1 139**] Firm HISTORY OF PRESENT ILLNESS: This is an 87-year-old woman with history of COPD who presents with decreased mental status, mumbling, anorexia, and dyspnea for the last 2-3 days. In [**2101-10-8**] the patient was admitted to the [**Hospital1 69**] MICU for COPD exacerbation and pneumonia, intubated for respiratory failure times 24 hours, given Levaquin and steroids and then discharged on [**2101-11-1**]. She was recently readmitted to the MICU on [**2102-1-29**] with an ABG of 7.18, PCO2 122, PO2 217 on non invasive ventilation with improvement in mental status and ABG to 7.4/63/56. Her hypercarbia was thought to be secondary to Opioids and Benzos. She was not given steroids during that admission. Now patient presents with decreasing mental status, mumbling, anorexia and dyspnea times 2-3 days. No fevers, chills, nausea, vomiting, chest pain, palpitations, abdominal pain or cough. The patient arrived by ambulance from home, was somnolent but arousable to verbal stimuli. Her vital signs on admission, temperature 98.8, blood pressure 126/34, pulse 91, respiratory rate 30 and O2 sats of 75% on room air, with increasing to 93% on four liters of oxygen. Her ABG at that time was PH 7.22, PCO2 95, PO2 85 on four liters of oxygen. Bi-pap ventilation was initiated with increase in sats to 93 to 97%. She was more awake with the bi-pap ventilation. Her next gas showed improvement with PH 7.24, PCO2 87 and PO2 of 62. Upon initial presentation to the MICU her white blood cell count was 20.4 and subsequently she was given one dose of Levaquin. She was hydrated with D5 normal saline. Upon stabilization of her respiratory status, she was transferred to the [**Hospital1 139**] service on [**2102-2-14**]. PAST MEDICAL HISTORY: COPD, on home O2 2-3 liters for last four years. Adenocarcinoma of the rectum, status post resection, LAR [**4-/2098**]. Lower back pain. Osteoarthritis. Anxiety. Migraine headaches. SIADH. Osteoporosis. Old lacunar infarct in the right coronary radiata. ALLERGIES: Doxycycline. MEDICATIONS: On admission, Albuterol 2 puffs [**Hospital1 **], Atrovent 2 puffs tid, Ritalin 5 mg q day, Colace 100 mg po bid, Zantac 150 mg po bid, Klonopin 0.5 mg [**Hospital1 **], Darvon 65 mg po q 6 hours prn, Megace 40 mg/ml 1 tsp qid, Serevent 2 puffs [**Hospital1 **]. SOCIAL HISTORY: The patient is divorced, lives with her two sons at home. History of tobacco use, quit 20 years ago, prior to that 40 pack year history. No ethanol, no IV drug use, no exercise. PHYSICAL EXAMINATION: On transfer to [**Hospital1 139**] service, temperature 97.4, pulse 82, blood pressure 138/60, respiratory rate 18, O2 saturation 97% on 35% venti mask. General, alert and oriented times two, no apparent distress. Pulmonary, decreased breath sounds bilaterally, no wheezes or crackles. Cardiovascular, regular rate and rhythm, S1 and S2. Abdomen, nontender, non distended, positive bowel sounds, soft. Extremities, no cyanosis, erythema or edema. LABORATORY DATA: White blood cell count 12.6, hematocrit 33.6, platelet count 291,000, sodium 132, potassium 4.8, chloride 31, CO2 36, BUN 27, creatinine 0.6, glucose 141, calcium 8.4, phosphorus 2.6, magnesium 1.9. HOSPITAL COURSE: 1. Pulmonary: Through the rest of her course on the [**Hospital1 139**] firm the patient's pulmonary status remained stable. She did not require any bi-pap at night and her O2 requirements slowly decreased to baseline level of [**3-12**] liters. Her O2 saturation at time of discharge was 93% on two liters of oxygen. The patient's respiratory decompensation was thought to be secondary to excessive Benzodiazepines, narcotics on top of her underlying COPD. The patient's white blood cell count decreased over the course of her stay in the hospital. Since there was no radiographic evidence of pneumonia, the patient was not continued on antibiotics. No steroids were initiated. 2. Infectious Disease: The patient's white blood cell count decreased over the course of her stay in the hospital. The patient remained afebrile throughout the course of her stay in the hospital. The patient had femoral line placed in her femoral vein. Initial sets of blood cultures drawn through the femoral line grew coagulase negative staphylococcus and corynebacterium. Subsequently the femoral line was removed and the tip was sent for culture. The tip culture also grew coagulase negative staphylococcus and corynebacterium. Prior to starting Vancomycin, two surveillance cultures were drawn peripherally. The patient was started on Vancomycin for empiric treatment. The surveillance cultures remained negative at time of discharge and subsequently the Vancomycin was stopped. The patient remained afebrile throughout the course of her stay in the hospital. The patient's white blood cell count trended down through her course in the hospital. 3. GI: The patient's hematocrit remained stable throughout her course of stay in the hospital. Her stool was guaiac positive. Given her history of rectal carcinoma, she will need a follow-up colonoscopy as an outpatient. She remained hemodynamically stable throughout the course of her stay in the hospital. 4. Neuro: The patient's mental status improved with improvement in her respiratory status. The change in mental status that brought her to the hospital was likely secondary to her hypercarbic respiratory distress. DISCHARGE DIAGNOSIS: 1. Hypercarbic respiratory failure secondary to Benzodiazepine and narcotic use. DISCHARGE MEDICATIONS: Atrovent MDI 2 puffs tid, Serevent MDI 2 puffs [**Hospital1 **], Albuterol MDI 2 puffs q 4-6 hours prn, Tylenol prn, Zantac 150 mg po bid, Colace 100 mg po bid, Ritalin 5 mg po q day, Megace 40 mg/ml, 1 tsp qid. DISCHARGE CONDITION: Fair. Discharged to home with skilled nursing and VNA, home PT. Patient to follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**]. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 5753**] MEDQUIST36 D: [**2102-2-17**] 17:19 T: [**2102-2-21**] 10:08 JOB#: [**Job Number 19214**]

[ "496", "518.81", "300.00", "276.5", "E853.2", "E850.2", "965.00", "969.4", "584.9" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

5881, 6339

5646, 5859

5539, 5622

3335, 5518

2649, 3318

137, 1838

1861, 2428

2445, 2626

11,317

164,777

6401

Discharge summary

report

Admission Date: [**2133-7-9**] Discharge Date: [**2133-7-13**] Date of Birth: [**2053-8-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Disabling claudication Major Surgical or Invasive Procedure: B/L fem endarectomy History of Present Illness: Elderly male with worsening claudication b/l Past Medical History: DM, CAD, s/p MI and CABG [**2109**], ^chol, HTN, GERD, PVD w/ occ. [**Last Name (un) **], S/P bil. CEA's, S/P multiple colonoscopies with polyp removal, Multiple ortho procedures on back and knees, Essential tremor, Cardiac: cath [**9-22**] -Native three vessel CAD, Patent SVG->D1/LAD and SVG->OM, Severe SVG->dRCA disease in proximal graft and distal to graft, Mod. diastolic LV dysfunction, Successful PTCA of the PDA ostium and drug-eluting stenting of the distal RCA into the PLB, Successful drug-eluting stenting of the proximal SVG-RCA. Social History: remote smoker rare alcohol Family History: non contributary Physical Exam: elderly male, nad supple / farom neg lymphandopathy, supraclavicular nodes neg lesions nare / oral pharnyx / auditoru cta b/l rrr without murmers benign inc: c/d/i Pulses: palp fem b/l, absent [**Doctor Last Name **] b/l, right palpable pt / dp, left monophasic pt /dp Pertinent Results: [**2133-7-13**] WBC-6.7 RBC-3.35*# Hgb-10.9*# Hct-29.9* MCV-89 MCH-32.5* MCHC-36.3* RDW-15.1 Plt Ct-126* [**2133-7-13**] Plt Ct-126* [**2133-7-13**] Glucose-116* UreaN-25* Creat-1.3* Na-137 K-4.5 Cl-105 HCO3-25 AnGap-12 [**2133-7-13**] Calcium-8.3* Phos-3.4 Mg-1.9 [**2133-7-9**] Glucose-117* Lactate-1.8 Na-135 K-4.0 Cl-110 [**2133-7-10**] Creat-27 Albumin-0.6 Alb/Cre-22.2 [**2133-7-9**] 9 CHEST PORT. LINE PLACEMENT Reason: check line FINDINGS: The tip of the right IJ central venous catheter is in the superior vena cava. The heart size, mediastinal and hilar contours are stable and normal. Median sternotomy sutures are noted. There is bilateral diffuse emphysema. No areas of consolidations, pneumothorax or pleural effusion are seen. There is some bilateral apical scarring. Noted left costophrenic angle is not included in the film. IMPRESSION: 1. Tip of the right IJ venous catheter is in the superior vena cava. 2. Bilateral diffuse emphysema. Brief Hospital Course: pt admitted [**2133-6-9**] Pt underwent a B/L femoral endarectomy. Pt tolerated the procedure well, there were no complications. Pt extubated in the [**Hospital 24680**] to the PACU in stable condition. Once pt recovered from anesthesia. Pt transfered to the VICU inn stable condition. [**2133-7-10**] [**Last Name (un) **] clinc see pt. HLIV, A-line DC'd, allowed OOB, Diet was advanced. [**2133-7-11**] Pt had post op illeus Central line was DC'd. Ptr transfused 2 units of blood for low hct. Pt had low PLT, heparin was DC'd. HIT panel sent off. [**2133-7-12**] Foley DC'd On discharge, pt is ambulating, taking PO, pos BM, pt urinating without problems. Medications on Admission: flomax 0.4, felodipine 10, lasix 80' qam, asa 325', plavix 75', omeprazole 20, metoprolol 100'', fisinopril 60', isosorbide 60'', mvi, ferrous sulfate 325'', quinine sulfate 650, atorvastatin 80', ezetimibe 10', insulin 14/13/21, spiriva inhaler Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 4. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Quinine Sulfate 325 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Insulin Take as directed Discharge Disposition: Home Discharge Diagnosis: b/l fem stenosis / pvd Discharge Condition: Stable Discharge Instructions: This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are no specific restrictions on activity. You should be as active as is comfortable. Resume driving when you are comfortable without the need for pain medication. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid heavy lifting (over 10 pounds) for 4-6 weeks after surgery. No strenuous activity for 4-6 weeks after surgery. BATHING/SHOWERING: You may bathe or shower immediately upon coming home. Dissolving sutures, which do not have to be removed were probably used. Your wounds are covered with a clear, plastic dressing which should be left in place for three (3) days. Remove it after this time and wash your incisions gently with soap and water. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude.. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. MEDICATIONS: Unless told otherwise, you should continue taking all of the medications that you were on before surgery. You will be given a new prescription for pain medication, which should be taken every three (3) to four (4) hours if necessary. WOUND CARE: Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. Unless the doctor instructs otherwise, you may resume showering with the staples in place on the third day after surgery (if the incision is dry). When the staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Unless the doctor instructs otherwise, you may resume showering on the third day after surgery (if the incision is dry) Avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! You should be seen in the office approximately ten (10) days to two (2) weeks following discharge from the hospital. A CT scan of the abdomen will have to be preformed just prior to that visit and this will be scheduled with your visit when you call the office. Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit.. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your incisions New pain, numbness or discoloration of your feet or toes Fevers and or chills PLEASE CALL THE OFFICE WITH ANY QUESTIONS OR CONCERNS THAT MIGHT DEVELOP. Followup Instructions: Please call Dr [**Last Name (STitle) 1391**] at [**Telephone/Fax (1) 2625**]. Schedulae an appointment for two weeks. Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2133-7-20**] 1:40 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2133-9-3**] 10:15 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2133-9-3**] 10:30 Completed by:[**2133-7-13**]

[ "492.8", "997.4", "287.4", "560.1", "333.1", "530.81", "E878.8", "250.00", "V45.81", "401.9", "440.21" ]

icd9cm

[ [ [] ] ]

[ "38.18", "99.04" ]

icd9pcs

[ [ [] ] ]

4447, 4453

2379, 3049

336, 358

4519, 4527

1382, 2356

9184, 9932

1060, 1078

3345, 4424

4474, 4498

3075, 3322

4551, 7363

1093, 1363

273, 298

7376, 8140

8164, 9161

386, 432

454, 1000

1016, 1044

26,949

174,602

32100

Discharge summary

report

Admission Date: [**2183-9-1**] Discharge Date: [**2183-9-10**] Date of Birth: [**2137-3-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p trauma - fall from mountain bike Major Surgical or Invasive Procedure: Closed reduction, percutaneous pinning of right metacarpal body, placement of right arm cast History of Present Illness: Mr. [**Known lastname 66947**] is a 43 y.o. male who fell forward over his handlebars while riding his mountain bike. After his fall he experienced +LOC despite having a helmet on. Pt now complains of right hand pain, lower back pain, and left shoulder numbness and weakness. Past Medical History: depression Social History: Pt is married and has 2 children Family History: noncontributory Physical Exam: T: 97.4 HR: 74 BP: 138/82 RR: 17 93% RA Gen: no apparent distress HEENT: normocephalic, atraumatic, anicteric, neck supple, no masses Card: regular rate and rhythm, without murmurs, rubs, or gallops Lungs: clear to auscultation bilaterally, no wheezes, rales, or rhonchi Abd: soft, nontender, nondistended Ext: no clubbing, cyanosis, or edema, bivalved short arm cast intact on right upper extremity, pt unable to abduct or elevate left shoulder greater than 30 degrees Neuro: CNII-XII grossly intact, pt reports tingling and burning over left shoulder Pertinent Results: TRAUMA #2 (AP CXR & PELVIS PORT) [**2183-9-1**] 5:46 PM IMPRESSION: Unremarkable trauma series. . CT torso [**2183-9-1**] 6:01 PM IMPRESSION: 1. No evidence of soft tissue injury within the chest, abdomen, and pelvis. 2. Mild anterior wedge compression fractures involving T10 through T12. 3. Nondisplaced spinous process fractures of T9 and T10. 4. Minimally displaced right posterior rib fractures of T9 through T11. . CT HEAD W/O CONTRAST [**2183-9-1**] 5:58 PM IMPRESSION: No evidence of intracranial hemorrhage or edema. . CT C-SPINE W/O CONTRAST [**2183-9-1**] 5:59 PM IMPRESSION: Nondisplaced, oblique fracture of the right-sided transverse process of the C1 vertebral body which traverses the transverse foramen. . CTA NECK W&W/OC & RECONS [**2183-9-1**] 6:21 PM CONCLUSION: No radiographic evidence to suggest that there is a vascular injury or other area of hemodynamically significant stenosis present. . CT T-SPINE W/O CONTRAST [**2183-9-2**] 12:17 PM IMPRESSION: 1. Fractures involving the posterior elements of T9 and T10, without evidence of epidural hematoma. 2. Mild compression fractures involving T10 through T12. 3. Multiple right-sided posterior rib fractures. . MRA NECK W&W/O CONTRAST [**2183-9-2**] 4:18 AM CONCLUSION: No definite sign for luminal compromise of the right vertebral artery at the level of the C1 fracture. . MR CERVICAL SPINE W/O CONTRAST [**2183-9-2**] 4:18 AM CONCLUSION: Findings suggest the possibility of multiple sites of soft tissue injury, but without clearly identifiable focal ligamentous disruption or alignment abnormality of the spine identified. . SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT [**2183-9-2**] 6:46 PM IMPRESSION: There is no evidence of an acute bony injury. . HAND (AP, LAT & OBLIQUE) RIGHT PORT [**2183-9-3**] 5:42 PM IMPRESSION: There is no evidence of an acute bony injury. Soft tissue swelling is seen dorsally, at the level of the metacarpals. Comparison is made to a study from two days previously. . MR BRACHIAL PLEXUS W/O CONTRAST [**2183-9-7**] 9:03 AM IMPRESSION: Traumatic injury of the left anterior scalene muscle with edema surrounding the muscle and the brachial plexus posteriorly, just superior to the thoracic outlet. The brachial plexus fibers are grossly intact, however, evaluation is slightly limited by patient motion. . MR SHOULDER W/O CONTRAST LEFT [**2183-9-7**] 9:03 AM IMPRESSION: 1. Edema within the teres minor and deltoid muscle without muscle atrophy. Per discussion with the trauma physician caring for the patient, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17296**], this patient sustained trauma to his neck, shoulder, and back during a mountain biking accident. These findings could be consistent with trauma. If the absence of trauma, this constellation of findings would be unusual and can be seen in post-viral brachial neuritis (Parsonage-[**Doctor Last Name **] syndrome). 2. Susceptibility artifact in the superior glenoid extends into the spinoglenoid notch. Most likely this represents blooming of artifact from surgical clips. If clinically indicated, a non-contrast CT of the left shoulder may be helpful in evaluating the placement and extension of these clips. Brief Hospital Course: Pt was admitted to the trauma SICU. Neurosurgery was consulted. Per neurosurgery's recommendations, the patient was treated with a hard c-collar at all times (for 6 weeks), log-roll precautions, and an MRI/MRA of the pt's neck was performed to rule out carotid & vertebral artery injury. The pt was fitted for a TLS orthotic. Plastic surgery was consulted for ulnar-sided right hand pain. It was found that the patient had a 5th metacarpal dislocation. This injury was managed with closed reduction and percutaneous pinning and short arm cast on HD8. Orthopaedic surgery was consulted for the pt's left shoulder numbness and weakness. MR of the brachial plexus and shoulder demonstrated an injury to the left anterior scalene muscle. This injury was managed conservatively, and the pt was instructed to follow up with orthopaedic surgery as an outpatient. Also during this hospitalization the patient was started on metoprolol for control of his hypertension. He was instructed to follow up with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of his hypertension. The patient was discharged home with services in stable condition on HD10. Medications on Admission: celexa Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): As needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): Do not take other medications containing Acetaminophen (tylenol) as this may cause serious liver damage. Disp:*80 Tablet(s)* Refills:*0* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs * Refills:*0* 7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: 1 [**12-31**] Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain: Do not drive while taking this medication. Do not take other sedatives or drink alcohol while taking this medication. Disp:*120 Tablet(s)* Refills:*0* 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*qs ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: s/p [**Location 75131**]biking crash Right C1 transverse process fracture Right posterior rib fracture T9-T12 Anterior wedge compression fractures T10-T12 Nondisplaced spinous process fractures T9-T10 Right 5th metacarpal dislocation Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital after your mountain biking accident and were found to have fractures in your cervical and thoracic spine as well in your 9th-11th right ribs. You were seen by neurosurgery who recommended a neck (cervical) collar at all times as well as a (TLSO) back brace. You should follow-up with Dr. [**Last Name (STitle) 548**] off neurosurgery in 6 weeks. Because of persistent dislocation of your right fifth finger, you had a pinning of your right fifth finger and a cast was placed. You should follow-up with plastic surgery in 3 weeks to have the cast removed. Because of left shoulder numbness & weakness you had an MRI which showed traumatic injury of your scalene muscle but no obvious injury to the nerves (brachial plexus). You should see Dr. [**Last Name (STitle) 1005**] in [**2-2**] weeks for your shoulder pain and weakness. You may require an additional test known as an EMG if your weakness persists. Followup Instructions: Please follow up in Plastic surgery clinic in 3 weeks for [**Date Range **] of your right hand surgery. You should call ([**Telephone/Fax (1) 75132**] to set up an appointment. Please follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks for further [**Last Name (STitle) **] of your left shoulder weakness; call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic in 2 weeks, call [**Telephone/Fax (1) 6439**] for an apppointment. Please follow up with your primary care doctor in the next week regarding your blood pressure and overall physical.

[ "833.05", "807.03", "805.01", "805.2", "E826.1", "E849.9", "796.2", "780.09" ]

icd9cm

[ [ [] ] ]

[ "79.74", "78.54" ]

icd9pcs

[ [ [] ] ]

7504, 7563

4698, 5868

350, 444

7841, 7850

1458, 4675

8844, 9464

849, 866

5925, 7481

7584, 7820

5894, 5902

7874, 8821

881, 1439

274, 312

472, 749

771, 783

799, 833

4,676

105,401

49263

Discharge summary

report

Admission Date: [**2159-5-14**] Discharge Date: [**2159-5-17**] Date of Birth: [**2087-12-13**] Sex: M Service: OTOLARYNGOLOGY Allergies: Nsaids Attending:[**First Name3 (LF) 7729**] Chief Complaint: Obstructive sleep apnea Major Surgical or Invasive Procedure: septoplasty with outfracture and cautery of inferior nasal turbinates History of Present Illness: 71 yo M with h/o obstructive sleep apnea was taking CPAP at home. He had elective septoplasty procedure and outfracture and cautery of nasal turbinates. Past Medical History: OSA, Gout, GERD, HTN, Hypercholestrolemia Family History: Married Physical Exam: Patient has both packs removed from his nose. He doesnt have blood in his throat.No difficulty in breathing. Pertinent Results: [**2159-5-14**] 10:45AM PTT-58.8* [**2159-5-14**] 10:45AM PLT COUNT-223 [**2159-5-14**] 10:45AM WBC-8.1 RBC-5.17 HGB-14.8 HCT-42.4 MCV-82 MCH-28.5 MCHC-34.8 RDW-14.2 [**2159-5-14**] 12:15PM PT-13.3 PTT-23.2 INR(PT)-1.2 [**2159-5-14**] 12:28PM PLT COUNT-235 [**2159-5-14**] 12:28PM WBC-9.2 RBC-5.02 HGB-14.1 HCT-39.6* MCV-79* MCH-28.1 MCHC-35.6* RDW-13.2 [**2159-5-14**] 12:28PM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2159-5-16**] 03:16AM BLOOD PT-13.3 PTT-23.7 INR(PT)-1.2 Brief Hospital Course: Patient had bleeding from his nose postop in PACU. He had an epistat placed in his left nose and a meracell packing in right nose. [**Name (NI) **] PTT was 58. He mentioned that couple of years ago he had to get Vitamin K before a surgical procedure. Patient was transfered to ICU for observation. Hematology was consulted and they recommeneded that patient doesnt need any treatment. They wanted coags to be normalized. Patient didn't have any bleeding in ICU. His left epistat was removed on POD#1 and he didn't bleed. His Right meracell packing was taken out on POD#2. Patient was transfered to regular floor. He has been tolerating soft solid diet. He has been afebrile and ambulating. He will be discharged to home on [**2159-5-17**] Medications on Admission: Aspirin Discharge Medications: Aspirin Percocet Keflex Discharge Disposition: Home Discharge Diagnosis: Septoplasty, nasal turbinate outfracture/cautery, and postop bleed Discharge Condition: Stable Discharge Instructions: Please do not do any heavy excercise, blowing of nose or excessive sniffing for 1 month. If there is bleeding again, please contact us [**Name (NI) 2678**]. Followup Instructions: Please make an appointment with Dr. [**Last Name (STitle) 1837**] in one week Completed by:[**2159-5-16**]

[ "E878.8", "998.11", "780.57", "401.9", "530.81", "478.0", "272.0", "470", "274.9" ]

icd9cm

[ [ [] ] ]

[ "21.62", "21.88", "21.03" ]

icd9pcs

[ [ [] ] ]

2148, 2154

1300, 2042

298, 369

2264, 2272

785, 1277

2477, 2585

632, 641

2100, 2125

2175, 2243

2068, 2077

2296, 2454

656, 766

235, 260

397, 551

573, 616

14,710

181,548

24929

Discharge summary

report

Admission Date: [**2197-8-1**] Discharge Date: [**2197-8-4**] Date of Birth: [**2145-7-31**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 11495**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None Brief Hospital Course: Patient was admitted to the CCU for treatment of right ventricular thrombosis. The risks of TPA were discussed with the patient and he decided to pursue lysis. Prior to treatment his oxygen saturation was in the low 90's on non-rebreather. After lysis his oxygen requirement decreased and he was able to breath comfortable on 5 L NC. He had no evidence of bleeding or any other complications of TPA. He was continued on heparin drip after TPA and was sent to the floor as he was hemodynamically stable and had decreasing O2 requirements. He was transitioned to Lovenox and was stable and the plan was to continue Lovenox as an outpatient. However, on the day he was transferred to the floor he became increasingly SOB. The house staff was called and while examining him he went into respiratory failure and eventually respiratory arrest. A code was called and the patient was found to be in PEA. High on the differential was new clot burden and lytics were attempted. However, despite attempts of resuscitation for 45 minutes but was refractory to resuscitation. His family was notified and offered an autopsy which they declined. Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired

[ "276.7", "401.9", "415.19", "157.8", "584.9", "276.2", "197.8", "197.7", "397.0", "429.89", "197.0" ]

icd9cm

[ [ [] ] ]

[ "99.10", "99.60" ]

icd9pcs

[ [ [] ] ]

1507, 1516

344, 1484

315, 321

1567, 1577

1537, 1546

256, 277

510

129,136

24454

Discharge summary

report

Admission Date: [**2150-4-30**] Discharge Date: [**2150-5-6**] Date of Birth: [**2099-3-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: Altered MS Major Surgical or Invasive Procedure: R subclavian central line placement Intubation- no complications. History of Present Illness: Pt is a 51 year old African American woman with PMH sig for HTN and hyperlipid with a remote hx of depression who was admitted on [**2150-5-1**] after she was found unresponsive by her husband at their home [**Name (NI) 2974**] evening. She reportedly went to her room that evening to take a nap, which was not unusual, at around 5pm per her children. Her husband checked on her at 8:15 pm and found her unresponsive and (per medical chart)"foaming at the mouth." She reportedly had multiple pill bottles out, but it was unclear at that point how much she had taken. Pt psych who went through the pills with the patient's husband, there were approx 70 Klonipin tabs missing, in addition to Nifedipine and Amytriptiline tabs missing. . In the ED, VS HR 60s SBP 110-130s (No temp taken at that time). Noted to be very lethargic and vomiting, and subsequently intubated for airway protection. No ABG taken prior to intubation. Pt given propofol for intubation. Pt had NG tube placed, and charcoal was given. Labs were notable for a urine tox (+) for benzodiazepines and TCAs. ABG taken after intubation 7.24/67/304 (Vent AC 550 x 15/PEEP 5/FiO2 100%). Pt then transferred to the MICU. In the MICU she remained intubated for obtundation. She was extubated on [**5-2**]. She then had a witnessed aspiration and was started on Levo and Flagyl. . The patient is still unable to give a consistent story of why she is in the hospital. She reports that she fell off of a step stool and hit her head. She also reports that she is in th hospital for her pneumonia. She ademently denies any overdose on her medications as the reason she was admitted. She denies taking too many of her pills. Per patient's nurse in the ICU, who has been working with her for several days, after she was extubated 2 days ago, she did say that she took too many pills, but since then has also stated that she took too many pills because she was having pain in her foot which she broke one year ago. Past Medical History: HTN Hyperchol ? depression/ anxiety s/p surgical repaier for foot ankle fx. C/b staph infection. Social History: Lives with husband and 3 kids. Occ ETOH. 3 cig/d x 4 months. No IVDU/no illicit drug use. Does not work. Family History: DM Physical Exam: VITALS: General: awake and alert. Pleasant and talkative. Obese. HEENT: pupils 3mm b/l and reactive. anicteric, pink conjunctivae. No LAD. Heart: RRR s1 s2; no m/g/r Lungs: Audible exp wheeze. Bronchial BS. No rales or rhonchi on exam. Abd: obese, soft, NT, ND, slightly hypoactive BS Ext: warm, 1(+) radial/DP pulses B. R foot with well healed scars and 1+ edema. L foot with trace edema. Neuro: Awake and alert. - Oriented x3 - CN II-12 intact - Able to recall [**2-26**] objects - Unable to spell world or perform serial 7 or 3's. - Able to count backwards from 10. - Aware of [**Country 2451**] war and current President. States former President was [**Last Name (un) 38492**]. Pertinent Results: [**2150-4-30**] 10:00PM GLUCOSE-128* UREA N-11 CREAT-1.1 SODIUM-139 POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [**2150-4-30**] 10:00PM ALT(SGPT)-47* AST(SGOT)-60* CK(CPK)-276* ALK PHOS-68 AMYLASE-116* TOT BILI-0.3 [**2150-4-30**] 10:00PM LIPASE-26 [**2150-4-30**] 10:00PM CK-MB-4 cTropnT-<0.01 [**2150-4-30**] 10:00PM ALBUMIN-4.0 CALCIUM-7.9* PHOSPHATE-5.3* MAGNESIUM-2.0 [**2150-4-30**] 10:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.0 bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2150-4-30**] 10:00PM URINE HOURS-RANDOM [**2150-4-30**] 10:00PM URINE UCG-NEGATIVE [**2150-4-30**] 10:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2150-4-30**] 10:00PM WBC-10.2 RBC-3.94* HGB-11.2* HCT-34.3* MCV-87.1 MCH-28.3 MCHC-32.5 RDW-15.2 [**2150-4-30**] 10:00PM NEUTS-82* BANDS-0 LYMPHS-14* MONOS-2 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2150-4-30**] 10:00PM PLT SMR-NORMAL PLT COUNT-331 [**2150-4-30**] 10:00PM PT-13.6* PTT-23.2 INR(PT)-1.2 [**2150-4-30**] 10:00PM D-DIMER-288 [**2150-4-30**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2150-4-30**] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016 . . CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: No acute intracranial hemorrhage is identified. There is no mass effect or shift of normally midline structures. The lateral ventricles are symmetric and nondilated. The [**Doctor Last Name 352**]-white differentiation is preserved. There are tiny basal ganglia lacunes. Bone windows demonstrate no evidence of fracture within the surrounding osseous structures. The mastoid air cells are normally pneumatized. There is a small amount of fluid within the ethmoid air cells, and minimal mucosal thickening within the right maxillary sinus. There appears to be proptosis. IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. Minimal mucosal thickening within the maxillary sinus and fluid in the ethmoid sinuses, findings that could possibly relate to mild sinusitis. . . Post extubation CXR: The endotracheal tube and NG tube have both been removed. A right subclavian central venous catheter remains in place. There is an unusual sharp turn and a kink seen within the mid portion of the line in the brachiocephalic vein. There is mild cardiomegaly. Mediastinal contours are normal. The aorta is slightly unfolded and tortuous. The lungs are clear. Pulmonary vasculature is normal. There is no pneumothorax. The osseous structures are unremarkable. IMPRESSION: Mild cardiomegaly with no radiographic evidence of acute cardiopulmonary process. Interval extubation. . . Brief Hospital Course: ASSESSMENT: A 51-year-old female admitted after found down with respiratory failure, question benzo overdose, now stable with a question of delirium. 1. Respiratory failure: The patient was intubated for airway protection on admission secondary to question of an overdose. AVG on admission was consistent with respiratory acidosis from hyperventilation. The patient had a questionable history of asthma versus COPD. She had an audible wheeze, but no wheeze on exam. The patient was continued on her albuterol and Atrovent inhalers during her admission. She was extubated after approximately 48 hours. After this, she had a witnessed aspiration for which she was treated with levofloxacin and Flagyl for 5 days. Her respiratory status markedly improved by the time of discharge and she was requiring no further medications. The patient states that she does not take inhalers at home and therefore these were discontinued on discharge. 2. Mental status changes/overdose: On admission, the patient had a positive tox screen for benzodiazepines, which were most concerning for mental status changes. The patient also had positive tox screens for tricyclic acids, which she was known to be taking for sleep. An EKG was done in the ICU, which showed mild QT prolongation, which resolved by the time of transfer to a medicine floor. All narcotics were held in both the ICU and after the patient was transferred to the medicine floor. Mental status improved, however, the patient continued to deny the fact that she overdosed. The patient states after she awoke in the ICU, that she had tripped on a stool in her bedroom and that is why she was found down. However, per reports from EMS, there were pills all over the patient's bed. The patient states that these pills spilled when husband dragged her across the bed. The patient's story persisted with multiple different interviews by different physicians. The patient was seen by psychiatry, who felt that initially the patient was delirious; however, by the time of discharge, she was no longer delirious and maintained her story that she did not accidentally or intentionally overdose on pills. She states that occasionally she will take extra Klonopin when she gets anxious. She was recently given the Klonopin for her anxiety by a psychiatrist that she sees in the outpatient. The patient was monitored by psychiatry service throughout her admission, and felt that she did not require an inpatient admission after she was medically stable. Her mental status did improve and per her family she was at her baseline at the time of discharge. The patient was not discharged on any narcotics or benzodiazepines and was asked to follow up with her outpatient psychiatrist for further evaluation of the need for antianxiety medications. The patient denied any psych history and states that she was only taking the Klonopin on rare occasion. 3. LFTs abnormality: Patient had elevated LFTs on admission, but they trended down to normal on transfer from the ICU. It was felt that this may have been due to an element of shock liver, and hypoperfusion while the patient was down. Her acetaminophen level was 6. 4. Hypertension. Patient has an extensive list of blood pressure medications including clonidine 0.2 mg p.o. b.i.d., Lopressor 50 mg p.o. b.i.d., nifedipine 30 mg sustained release p.o. once daily., and hydrochlorothiazide 20 mg p.o. once daily. The patient was maintained on this regimen and her blood pressure was well controlled throughout her admission. 5. Hyperlipidemia: After her LFTs normalized, the patient was restarted on her home dose of Lipitor. 6. Status post foot surgery: Upon further investigation of this, the patient reports that she broke her foot approximately 1 year ago and the incision of the repair became infected. She was on a course of antibiotics and had severe pain. She was receiving pain medication for a while after this procedure, however, she does report that she no longer takes pain medications for it, however, still has pain in her foot. All pain medications were held during this admission due to her mental status changes. The patient also did not request further pain medications during this admission. 7. FEN. The patient was maintained on a cardiac diet and her electrolytes were repeated as needed. The patient was a full code during this admission. Medications on Admission: Amitriptyline Clonidine Lipitor ASA Nifedipine CR Ambien Toprol Nitro tab HCTZ Tramadol Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Benzodiazepine overdose Delirium Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you experience shortness of breath, chest pain, severe nausea/vomiting/diarrhea or any other severe symptoms. Please return to the hospital or call your doctor if you are feeling any symptoms of depression. Please call your doctor is you have any questions about your symptoms. - Please go to your follow-up appointment with Dr. [**First Name (STitle) 4135**] on [**2150-5-7**] at 11am. Followup Instructions: Please follow-up with your Psychiatrist on [**2150-5-7**] at 11am. Please follow-up with your PCP [**Last Name (NamePattern4) **] [**12-28**] weeks.

[ "285.9", "518.81", "E853.2", "969.4", "272.4", "780.09", "507.0", "401.9", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

11064, 11070

6099, 10495

326, 394

11147, 11155

3376, 6076

11623, 11775

2654, 2658

10634, 11041

11091, 11126

10521, 10611

11179, 11600

2673, 3357

275, 287

422, 2395

2417, 2515

2531, 2638

83,435

153,523

39077

Discharge summary

report

Admission Date: [**2143-3-14**] Discharge Date: [**2143-3-19**] Date of Birth: [**2092-6-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p construction accident, blunt trauma to spine Major Surgical or Invasive Procedure: [**2143-3-14**]: PROCEDURES: 1. Open reduction of thoracic fracture/dislocation. 2. T10 laminotomy, bilateral. 3. T11 laminectomy, T12 laminectomy. 4. Posterolateral fusion T9 through L2. 5. Posterior pedicle instrumentation T9 through L2. 6. Application of local autograft for fusion augmentation. 7. Application of allograft for fusion augmentation. History of Present Illness: 50yM working construction when a ceiling collapsed and the debris fell onto his back, he was transported in with severe back pain Past Medical History: denies Social History: NC Family History: Noncontributory Pertinent Results: CT Head [**2143-3-14**] IMPRESSION: No acute intracranial process. Brief Hospital Course: Admitted to the TSICU after undergoing trauma scans. CT head and c-spine were negative. CT torso revealed a T12 chance fracture,left sided rib fractures and a right sided apical pneumothorax. A right sided pigtail catheter was placed with good result, however the CXR following morning revealed worsening pneumothorax. A larger thoracostomy tube was then placed and the pigtail removed. Post thoracosotmy chest film showed his lung re-expanded adequately. The chest tube was eventually removed on [**3-18**] and post-oull chest imaging revealed no evidence of pneumothorax. He was taken to the OR on [**3-14**] by Orthopedic Spine Surgery for fusion/laminectomy of his vertbral fracture. He tolerated this well and was extubated successfully the following morning. The pain service was consulted for recommedations pertaining to pain control. His diet was advanced for which he was able to tolerate and his pain was controlled on oral narcotics. Physical therapy was consulted and he was recommended for home. Follow up instructions were provided at time of discharge. Medications on Admission: Denies Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical ASDIR (AS DIRECTED) as needed for pain: apply topically to affected area, one patch on each shin. Disp:*60 Adhesive Patch, Medicated(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Hydromorphone 4 mg Tablet Sig: 11/2 Tablets PO Q4H (every 4 hours) as needed for PAIN: please take as needed for pain every 4 hours. Disp:*90 Tablet(s)* Refills:*0* 7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain.* Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Blunt trauma to spine Injuries: 1-T1 transverse proess fracture 2-T12 chance fracture 3-Left posterior [**8-12**] rib fractures 4-Left pulmonary contusions 5-Small right apical pneumothorax Discharge Condition: Activity Status: Ambulatory - Independent Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Discharge Instructions: You suffered an injury as a result of a reported work related trauma. This injury resulted severe back and leg pain. You have sustained fractures to your spine and ribs as well as a significant bruise in your left lung, and fluid in your right lung. Continue to walk as physical therapy has instructed you. The spine surgeons would like to you wear the TLSO brace when walking and apply dry sterile gauze dressings to your spine insicion daily for 2 weeks until you are seen by Dr. [**Last Name (STitle) 1007**] in the spine clinic. Your lung injuries required you to have a chest tube and you now have a dressing where this tube was, you may keep a gauze dressing on this area for the next 5 days. You may shower, however let the warm water run over the surigical incisions and pat them dry, apply new dressing after the shower. Followup Instructions: Follow up in trauma surgery clinic with Dr. [**Last Name (STitle) **] in 2 weeks. You will need a chest xray prior to this appointment. Please call ([**Telephone/Fax (1) 2300**] to schedule this appointment and x-ray. Please followup with Dr. [**Last Name (STitle) 1007**] for your Spine surgery in [**3-7**] weeks. The spine clinic number is [**Telephone/Fax (1) 3736**] Completed by:[**2143-3-28**]

[ "861.21", "860.0", "E884.9", "805.2", "807.02" ]

icd9cm

[ [ [] ] ]

[ "81.05", "81.63", "03.53" ]

icd9pcs

[ [ [] ] ]

3190, 3196

1067, 2141

361, 714

3433, 3475

975, 1044

4438, 4842

939, 956

2198, 3167

3217, 3412

2167, 2175

3581, 4415

273, 323

742, 873

3490, 3557

895, 903

919, 923

67,796

155,851

28054

Discharge summary

report

Admission Date: [**2132-6-6**] Discharge Date: [**2132-6-14**] Date of Birth: [**2059-9-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: multifocal pneumonia Reason for MICU transfer: hypotension Major Surgical or Invasive Procedure: Tunneled dialysis catheter placement History of Present Illness: This is a 72 year old female with h/o COPD, CKD, HTN, DM, gout now transferred here with pneumonia. The patient presented to [**Hospital1 **] [**Location (un) 620**] with shortness of breath and cough since Tues . Patient feels generally fatigued. Patient saw her PCP on [**Name9 (PRE) 5929**] who gave her a Z-Pak. Patient denies any chest pain. She also notes URI symptoms. She felt worse and felt dizzy so she went to [**Hospital1 **] [**Location (un) 620**]. In [**Location (un) 620**] ED, initial VS were HR: 108 BP: 77/51. Labs were notable for WBC 13.7 (88% neut and no bands), Hct 27.6 (baseline in low 30s), lactate 0.8. Cr was elev at 6.9 (baseline 3.1). TnT was 0.057. Hypotension was thought to be due to sepsis as well as dehydration. Pt was given Ceftriaxone/Levoquin. Patient was not responding after 5 L of fluid. A right subclavian was placed. Pt then suddenly had an episode of atrial tachycardia that was wide complex. Central line was backed up from its original marking at 20 to 16. Neo was given, however, the patient still hypotensive. Levophed was subsequently added. Pt rec'd a total of 9L IVF there. Pt was then transferred to [**Hospital1 18**] as there are no ICU beds at [**Location (un) 620**]. . In the ED here, initial VS were: 98.2 108 105/62 18 97% 3L. Vanc was added to her abx regimen. Pt was then admitted to ICU for further management. On transfer, VS were Temp: 97.9 ??????F (36.6 ??????C), Pulse: 104, RR: 20, BP: 132/70, O2Sat: 94%, O2Flow: 2L. . On arrival to the MICU, pt is lying comfortably in bed. States she feels fatigued. States breathing is comfortable. Endorses productive cough. Denies chest pain. Review of systems: (+) Per HPI (-) Endorses intentional weight loss (50 lb in 2 yrs). Endorses headhaches since being sick. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. Endorses constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Endorses bruising on bilat arms from her dog. Past Medical History: Hyperlipidemia. Atrial ectopy/atrial tachycardia. Mild ascending aortic dilatation. Obesity. Diabetes mellitus. (not on any meds now) Gout. COPD. Lumbar stenosis L4-L5, low back pain Esophageal dysphagia. HTN. CKD. Social History: Lives at home with husband. quit smoking in [**2100**]. denies EtOH, drugs. Family History: NC Physical Exam: Physical Exam on Admission: Vitals: T:97.7, HR:107, BP:96/54, RR:29, O2sat: 91%4LNC General: obese, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachy, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, with occ wheezes, decr breath sounds on R base, no use of accesory muscles Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, +varicose veins. R first toe ttp, but no warmth/erythema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation On discharge: VS: 98.3, 110-138/58-80, 71-78, 18-20, 92-95% on RA General: NAD, conversant AOx3, HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, Quinton dialysis catheter in R neck CV: regular rate & rhythm, normal S1 + S2, no murmurs appreciated today, no rubs or gallops Lungs: No respiratory distress, distant breath sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, +varicose veins, 2+ LE pitting edema R first toe ttp, but no warmth/erythema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: Lab Results on Admission: [**2132-6-6**] 04:23AM BLOOD WBC-18.4* RBC-3.21* Hgb-8.8* Hct-30.2* MCV-94 MCH-27.6 MCHC-29.3* RDW-15.2 Plt Ct-206 [**2132-6-6**] 04:23AM BLOOD Neuts-87* Bands-0 Lymphs-2* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2132-6-6**] 04:23AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+ Tear Dr[**Last Name (STitle) **]1+ [**2132-6-6**] 04:23AM BLOOD PT-12.4 PTT-24.2* INR(PT)-1.1 [**2132-6-6**] 04:23AM BLOOD Glucose-180* UreaN-80* Creat-5.7* Na-137 K-4.7 Cl-107 HCO3-13* AnGap-22* [**2132-6-6**] 04:23AM BLOOD ALT-71* AST-138* CK(CPK)-161 AlkPhos-235* TotBili-0.3 [**2132-6-6**] 04:23AM BLOOD CK-MB-4 cTropnT-0.11* [**2132-6-6**] 12:09PM BLOOD CK-MB-6 cTropnT-0.19* [**2132-6-8**] 05:00PM BLOOD cTropnT-0.17* [**2132-6-6**] 04:23AM BLOOD Calcium-6.7* Phos-5.7* Mg-1.8 [**2132-6-6**] 04:23AM BLOOD Cortsol-46.2* [**2132-6-7**] 03:35PM BLOOD Type-MIX Temp-36.3 pO2-51* pCO2-56* pH-7.04* calTCO2-16* Base XS--16 [**2132-6-6**] 05:36AM BLOOD Lactate-0.5 [**2132-6-7**] 07:56PM BLOOD freeCa-1.10* Urine: [**2132-6-6**] 04:24AM URINE Color-Red Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2132-6-6**] 04:24AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2132-6-6**] 04:24AM URINE RBC->182* WBC-36* Bacteri-FEW Yeast-NONE Epi-0 [**2132-6-6**] 04:24AM URINE CastHy-5* [**2132-6-7**] 10:45AM URINE Hours-RANDOM UreaN-300 Creat-44 Na-40 K-15 Cl-34 Discharge: [**2132-6-14**] 07:35AM BLOOD WBC-9.7 RBC-2.71* Hgb-7.6* Hct-25.0* MCV-92 MCH-28.1 MCHC-30.4* RDW-15.0 Plt Ct-143* [**2132-6-14**] 07:35AM BLOOD Glucose-100 UreaN-38* Creat-3.8*# Na-144 K-3.6 Cl-107 HCO3-30 AnGap-11 [**2132-6-14**] 07:35AM BLOOD Calcium-8.1* Phos-3.8# Mg-1.9 Microbiology: [**2132-6-6**] 4:24 am URINE Source: Catheter. **FINAL REPORT [**2132-6-7**]** URINE CULTURE (Final [**2132-6-7**]): NO GROWTH. Time Taken Not Noted Log-In Date/Time: [**2132-6-6**] 5:22 am URINE TAKEN FROM URINE HEM #0180P. **FINAL REPORT [**2132-6-6**]** Legionella Urinary Antigen (Final [**2132-6-6**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. Imaging: Radiology Report CHEST (PORTABLE AP) Study Date of [**2132-6-7**] 10:36 AM FINDINGS: Comparison is made to the prior study from [**2132-6-7**]. There is a right-sided central venous catheter whose distal lead tip is at the cavoatrial junction, appropriately sited. There is mild cardiomegaly. There is some prominence of pulmonary interstitial markings suggestive of mild fluid overload. Small bilateral pleural effusions are present. Radiology Report ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2132-6-7**] 12:52 PM IMPRESSION: 1. No evidence of hydronephrosis. 2. Gallbladder is surgically absent. CBD measures 10 mm, which may reflect post-surgical changes. No obstructing CBD stone is seen. Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2132-6-7**] 7:07 PM FINDINGS: Comparison is made to prior study from [**2132-6-7**], 10:47 a.m. There is a right IJ central venous line which has been placed and the distal tip is in the superior SVC. There is a right subclavian catheter with the distal lead tip in the distal SVC. Heart size is upper limits of normal but stable. There is persistent moderate pulmonary edema, bilateral pleural effusions and left retrocardiac opacity. Vein Mapping: Final Report INDICATION: 72-year-old female with chronic kidney disease, being evaluated for possible dialysis fistula placement. TECHNIQUE AND FINDINGS: The upper extremity venous system was evaluated with B mode, color and spectral Doppler ultrasound. The subclavian veins present with normal phasicity bilaterally. On the right side, the right cephalic vein is patent with diameters ranging between 0.11 and 0.58 cm. The right basilic vein is patent with diameters ranging between 0.1 and 0.37 cm. On the left side, the left cephalic vein is patent with diameters ranging between 0.14 and 0.41 cm. The left basilic vein is patent proximally with diameters ranging between 0.11 and 0.31. The distal segment of the left basilic vein was not visualized. The brachial and radial arteries are patent bilaterally with normal Doppler waveforms. IMPRESSION: Patent cephalic and basilic veins bilaterally with diameters as described above. Brief Hospital Course: Ms. [**Known lastname 68279**] is a 72 year old with COPD, CKD, HTN, gout now transferred here with pneumonia and septic shock complicated by [**Last Name (un) **] with metabolic acidosis requiring initiation of CVVH in unit which has since been discontinued. Ms. [**Known lastname 68280**] renal function has continued to decline and will require long term dialysis. . . # Hypotension/Septic Shock/Pneumonia: Patient presented with hypotension, fever, and leukocytosis likely due to sepsis secondary to pneumonia. AM cortisol was 46.2, making adrenal insufficiency unlikely. On admission patient required pressor support with levophed which was weaned off by hospital day 2. Her home ACE and lasix were held in setting of hypotension. Patient was initially started on ceftriaxone, levofloxacin and vancomycin for severe CAP. Vancomycin was discontinued on [**6-9**] given clinical improvement. She was also started on a 5 day course of low dose dexamethasone with two day taper which has been completed. #Acute kidney injury superimposed on chronic renal disease: Cr peaked at 6.9 up from baseline of 3. Likely from ATN [**2-14**] to hypotension. Due to worsening acid/base status CVVH was initiated. However, given improvement in acidosis, urine output and electrolytes, CVVH was discontinued [**6-9**]. Creatinine follwing cessation of CVVH continued to rise ~1 point/day, and a tunneled line was placed for long-term dialysis. Vein mapping was performed in preparation for future fistula placement. Ms. [**Known lastname 68279**] recieved dialysis on [**6-13**]. . #Mixed metabolic and respiratory acidosis: Patient had mixed anion gap and non-anion gap metabolic and respiratory acidosis. Metabolic portion was likely from [**Last Name (un) **] and fluid administration, which improved with initiation of CVVH . # Transaminitis: Was found on admission with ALT 73, AST 138. Likely related to poor hepatic perfusion and cholestasis from sepsis. RUQ U/S negative for hepatic pathology. Statin was held. LFTs trended down. . # Elevated troponin: Elevated at 0.11 on admission likely [**2-14**] ARF, ruled out with decreasing serial trops. Low susp for ACS, given lack of CP and reassuring EKG. . # COPD: Continued home albuterol, advair, spiriva, breathing has been stable. Initially, Ms. [**Known lastname 68279**] was maintained on 2L NC, but was able to be weaned to room air with SpO2 ranging from 92 to 95%. . # Gout: On day of discharge, Ms. [**Known lastname 68279**] noted pain in her right major toe with pain consistent with prior gout flares. She was given colchicine 0.3mg (in light of her renal failure). She will require re-evaluation for her right toe pain over the coming days. She cannot recieve colchicine for another 14 days given her end stage renal disease and the fact that colchicine is not removed by dialysis. . # Bone health: Continue home calcitriol, Vit D . # DMII: Managed with ISS while in house . # Hypothyroidism: Continued home levothyroxine . # HTN/HL: Continued ASA. Statin held given transaminitis and ACE held in the setting of [**Last Name (un) **]. . # Depression: Continued home sertraline . # Low back pain: Continued gabapentin Transitional Issues: -Ms. [**Known lastname 68280**] Right toe pain will require re-evaluation after the one time dose of colchisine. She cannot recieve colchicine for another 14 days given her end stage renal disease and the fact that colchicine is not removed by dialysis. -Ms. [**Known lastname 68280**] long-term dialysis needs will need to be readdressed as it is possible, albeit unlikely, that she will recover renal function. Medications on Admission: albuterol sulfate 90 mcg HFA 2 puffs day as needed calcitriol 0.25 mcg daily febuxostat [Uloric] 40 mg daily fluticasone-salmeterol [Advair] 500 mcg-50 mcg/Dose 1 puff daily furosemide 40mg and 80 mg alternating every other day gabapentin 100 mg daily levothyroxine 112 mcg daily moexipril 15 mg daily omeprazole 20 mg twice a day sertraline 100 mg daily simvastatin 80 mg daily tiotropium bromide [Spiriva] 18 mcg 1 spray orally daily aspirin 325 mg daily cyanocobalamin (vitamin B-12) 2,000 mcg day lactobac cmb #3-fos-pantethine [Probiotic & Acidophilus] daily multivitamin daily vitamin D 1000U daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-14**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. febuxostat 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation once a day. 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lactobacillus acidophilus Capsule Sig: One (1) Capsule PO once a day. 16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 20. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 21. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Acute on Chronic Renal Failure Community Acquired Pneumonia complicated by septic shock Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 68279**], You were admitted with a serious infections of your lungs. This infection caused your blood pressure to drop to very unsafe levels which subsequently caused your kidneys to fail. Your lung infection appears to be improving well, and you have a few more days of antibiotics. Unfortunately your kidneys have not improved. It is still possible that over the next few weeks to months, that your kidneys will recover, but for now at least you will need dialysis. The following medication changes have been made: START nephrocaps (a multivitamin) for your kidney health daily START Miralax, senna, colace, lactulose and bisacodyl for constipation. Colace you should use daily, the others you should use as needed. Discontinue meoxipril for the time being as this can harm kidney function Decrease the dose of simvastatin from 80mg daily to 40mg daily as elevated doses of this medication can be toxic Decrease aspirin from 325mg to 81mg Followup Instructions: Following discharge from rehab, you will follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13075**]. You will see your nephrologist at dialysis once discharged. Department: TRANSPLANT CENTER When: TUESDAY [**2132-7-1**] at 2:30 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "486", "038.9", "250.00", "403.91", "496", "244.9", "276.2", "785.52", "584.9", "V45.11", "995.92", "585.6", "274.9", "311" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

15279, 15362

9072, 12250

364, 403

15532, 15532

4330, 4342

16716, 17275

2854, 2858

13343, 15256

15383, 15511

12711, 13320

15715, 16693

2873, 2887

3621, 4311

12271, 12685

2114, 2504

263, 326

431, 2095

4357, 9049

15547, 15691

2526, 2743

2759, 2838

66,818

120,213

51081

Discharge summary

report

Admission Date: [**2113-12-11**] Discharge Date: [**2113-12-13**] Date of Birth: [**2046-9-28**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1185**] Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: The patient is a 67 yo French-creole speaking female with ESRD [**2-15**] diabetic nephropathy on HD and hypertension p/w nausea and dizziness for one day. The patient endorses two episodes of non-bilious, non-blood vomiting over last 24 hours as well. Denies any chest pain, but has had intermittent shortness of breath throoughout the day. The patient's most recent dialysis session was two days prior to admission (Saturday), and proceeded without complication according to the patient. The patient endorses taking all of her daily medications today, including all cardiac meds, but is unable to provide further details about timing. . In the ED inital vitals were, 96.8 32 162/53 18 97%RA. Labs were significant for initial K 6.8. EKG was significant for bradycardia to 31 and prolonged QTc. No peaked T waves, QRS widening, or PR prolongation. The patient was given insulin/D50/Ca gluconate, and her K trended to 5.8. Patient was also given kayexelate 30 g. Lactate was 2.4. Troponin was 0.02. The patient was admitted to the MICU for bradycardia. VS on transfer: 150/70 34 18 100%RA. . On arrival to the ICU, the patient endorses no current symptoms. She denies any N/V, dizziness, lightheadedness, CP or SOB. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: ESRD on HD M/W/F Type 2 diabetes Hypertension GERD Osteomyelitis Glaucoma Hepatitis B Hepatitis C Hemorrhoids C. diff colitis HIT antibody positive Social History: -Home lives with [**Doctor First Name **], her husband -Cigarettes none -Alcohol none -Caffeine light Family History: Noncontributory Physical Exam: Vitals: T: BP: 175/51 P: 66 R: 16 O2: 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: tunneled dialysis catheter in place in L subclavian, c/d/i . DISCHARGE VITALS 98.9, 136/50, 60, 18, 96RA Exam unchanged from admission exam as documented above. Pertinent Results: CXR: [**2113-12-11**] FINDINGS: AP portable view of the chest demonstrates the hilar and mediastinal silhouettes are unremarkable. Aortic arch calcifications are present. Moderate cardiomegaly and mild pulmonary edema are new. Minor fissure thickening reflects edema. There is no pneumoperitoneum Dialysis catheter tip projects over cavoatrial junction, unchanged. Nasogastric tube has been removed. IMPRESSION: New mild cardiac decompensation. . Blood cultures pending at the time of discharge. . ECGs initially demonstrating sinus arrest with junctional escape rhythm at rate in 30s and retrograde P wave, subsequently in a bradycardic ectopic atrial rhythm, eventually in sinus bradycardia (rate 60) with STT changes c/w known LVH and prior ECGs. . [**2113-12-11**] 09:05PM BLOOD WBC-4.8 RBC-3.59* Hgb-10.2* Hct-30.1* MCV-84 MCH-28.4 MCHC-34.0 RDW-17.0* Plt Ct-166 [**2113-12-12**] 09:38AM BLOOD WBC-7.0 RBC-3.58* Hgb-10.7* Hct-30.3* MCV-85 MCH-29.8 MCHC-35.2* RDW-17.3* Plt Ct-121* [**2113-12-13**] 07:15AM BLOOD WBC-9.3 RBC-3.69* Hgb-10.8* Hct-30.8* MCV-83 MCH-29.2 MCHC-35.0 RDW-17.7* Plt Ct-91* [**2113-12-11**] 09:05PM BLOOD Plt Ct-166 [**2113-12-12**] 09:38AM BLOOD Plt Ct-121* [**2113-12-13**] 07:15AM BLOOD Plt Smr-LOW Plt Ct-91* [**2113-12-11**] 09:05PM BLOOD Neuts-52.8 Lymphs-33.5 Monos-5.0 Eos-8.3* Baso-0.4 [**2113-12-12**] 02:26AM BLOOD Glucose-325* UreaN-58* Creat-7.4* Na-135 K-7.2* Cl-98 HCO3-27 AnGap-17 [**2113-12-12**] 09:38AM BLOOD Glucose-112* UreaN-20 Creat-3.9*# Na-140 K-3.4 Cl-101 HCO3-28 AnGap-14 [**2113-12-13**] 07:15AM BLOOD Glucose-56* UreaN-18 Creat-4.0* Na-142 K-3.0* Cl-99 HCO3-33* AnGap-13 [**2113-12-12**] 02:26AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.6 [**2113-12-12**] 09:38AM BLOOD Calcium-8.8 Phos-3.1# Mg-2.0 [**2113-12-13**] 07:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9 . Brief Hospital Course: The patient is a 67 yo French-creole speaking female with ESRD secondary to diabetic nephropathy on HD and poorly-controlled hypertension who presented on [**12-11**] with nausea and dizziness and was found to be hyperkalemic to 6.8, and bradycardic to 31 with prolonged QTc. She hadn't missed any HD (last session was 2 days prior to admission). The patient endorsed taking all of her medications. ROS was positive for two episodes of non-bilious, non-bloody vomiting over the preceding 24 hours as well. In the ER the patient was given insulin/D50/Ca gluconate, and her K trended to 5.8. Patient was also given kayexelate 30 g. The patient was admitted to the MICU for persistent assymptomatic bradycardia. ECGs initially demonstrating sinus arrest with junctional escape rhythm at rate in 30s and retrograde P wave, she was subsequently in a bradycardic ectopic atrial rhythm, eventually she converted spontaneously to sinus bradycardia with STT changes c/w known LVH and prior ECGs. During her ICU stay she was noted to be hypertensive in the setting of holding of all of her antihypertensives, so amlodipine, nifedipine, hydralazine, lisinopril, and lasix were restarted. She also had a fever to 100.0 and blood cultures were drawn which are pending with no growth to date at the time of discharge. HD was performed on [**12-12**] and she was seen by her outpatient nephrologist Dr. [**Last Name (STitle) 118**]. After transfer to the medical floor she remained normotensive and relatively bradycardic (resting HR 60) off of labetalol. She was discharged on all of her home anti-HTNs except labetalol given sinus bradycardia and lasix as she is anuric. We advised her to discuss the combination of amlodipine and nifedipine with her outpatient providers as both of these medications belong to the same class. We also advised her to discuss simvastatin given the possiblity of increased adverse events when combined with amlodipine. An appointment was made for her to follow-up with her PCP. Medications on Admission: Active Medication list as of [**2113-11-20**]: AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day APRACLONIDINE - (Prescribed by Other Provider) - 0.5 % Drops - three times a day ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth once a week FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day HYDRALAZINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 10 mg Tablet - 50 four times a day INSULIN GLARGINE [[**Date Range **]] - (Prescribed by Other Provider) - 100 unit/mL Solution - 10 hs LABETALOL - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth twice a day LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 % Drops - hs LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day NIFEDIPINE - (Prescribed by Other Provider) - 60 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day TIMOLOL [BETIMOL] - (Prescribed by Other Provider) - 0.5 % Drops - once a day FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth three times a day INSULIN REGULAR HUMAN [HUMULIN R] - (Prescribed by Other Provider) - 100 unit/mL Solution - as dir as Discharge Medications: 1. amlodipine 10 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 2. apraclonidine 0.5 % Drops [**Date Range **]: One (1) Drop Ophthalmic TID (3 times a day). 3. hydralazine 50 mg Tablet [**Date Range **]: One (1) Tablet PO Q6H (every 6 hours). 4. insulin glargine 100 unit/mL Solution [**Date Range **]: Ten (10) units Subcutaneous at bedtime: CONTINUE TO TAKE THE SAME DOSES OF INSULIN AT HOME AS YOU DID PREVIOUSLY. 5. latanoprost 0.005 % Drops [**Date Range **]: One (1) Drop Ophthalmic HS (at bedtime). 6. lisinopril 10 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. nifedipine 60 mg Tablet Extended Release [**Date Range **]: One (1) Tablet Extended Release PO DAILY (Daily). 8. simvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 9. timolol maleate 0.5 % Drops [**Date Range **]: One (1) Drop Ophthalmic DAILY (Daily). 10. ferrous sulfate 300 mg (60 mg iron) Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 11. Humulin R 100 unit/mL Solution [**Date Range **]: AS DIRECTED Injection four times a day: CONTINUE TO USE THE SAME SLIDING SCALE AS YOU DID PREVIOUSLY. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hyperkalemia complicated by sinus arrest with junctional escape. ESRD on hemodialysis. DMII complicated, poorly controlled Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 106087**], You came to the Emergency Department with nausea and were admitted to the Medical ICU with hyperkalemia (high potassium in the blood) and EKG changes which resolved with medication and dialysis. We have stopped labetalol and have continued all of your other home medications. Please follow-up with your nephrologist at dialysis regarding when to re-start labetalol. We have also stopped lasix, as you do not make urine, this medication has no effect on you. Please adhere to a low-potassium diet. You were provided with information regarding this. You should discuss the combination of amlodipine and nifedipine with your PCP as these two medications are very similar--we did not change this as you have been on this combination for at least over 6 months. Also, please discuss switching simvastatin to an alternative cholesterol medication with your PCP given the small risk of an interaction with amlodipine. Please also discuss with your PCP and nephrologist whether you should be taking aspirin daily. ================== MEDICATION CHANGES: STOP lasix HOLD labetalol and discuss with your nephrologist at dialysis Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] B. Location: [**Location (un) 2274**]-[**Hospital1 **] Address: [**Hospital1 34796**], [**Hospital1 **],[**Numeric Identifier 4293**] Phone: [**Telephone/Fax (1) 2573**] When: Friday, [**12-22**], 2:30 PM --Previously scheduled appointments: Department: CARDIAC SERVICES When: THURSDAY [**2113-12-14**] at 3:00 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2113-12-15**] at 3:40 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMODIALYSIS When: THURSDAY [**2113-12-14**] at 12:00 PM [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2113-12-14**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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164,271

13981

Discharge summary

report

Admission Date: [**2135-6-22**] Discharge Date: [**2135-7-3**] Date of Birth: [**2093-4-27**] Sex: M Service: O-MED/BMT HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 41769**] is a 42-year-old male with a past medical history significant for lupus diagnosed one year prior to admission, Raynaud's syndrome diagnosed one year prior to admission, positive antinuclear antibody titer of 1:1280 in a speckled pattern, and a history of an elevated prostate-specific antigen who initially presented to an outside hospital with severe anemia and thrombocytopenia. Approximately seven months prior to admission, the patient developed malaise, episodic subjective tactile fevers, drenching night sweats, shaking chills, and a 2-pound weight loss over a 4-month period. He took six to eight ibuprofen per day for symptomatic relief. He experienced approximately two week cycles of feeling poorly associated with feeling better. His primary care physician administered empiric azithromycin without relief of symptoms. He denied any headaches; however, he described a shooting "heat and pain" radiating up his posterior neck to his occiput; left greater than right. He denies any photophobia or visual changes. He reports mild dry eyes, mild peripheral edema, and increased burping. He saw a rheumatologist in [**2135-3-11**] who, according to the patient, felt lupus was reasonably well controlled at that time. In the middle of [**Month (only) 956**] through [**Month (only) 958**] he felt better, and he took a cruise to the Caribbean. Over the past four weeks prior to admission he developed the onset of progressive fatigue, malaise, and dyspnea in the absence of cough, more frequent fevers, dry mouth, and worsening dysphagia with dry foods. He denied any odynophagia. He developed a pruritic rash over his thighs, abdomen, and arms which was worse at night and lasted approximately one week. His fatigue was so severe that he had to rest after inserting his contact lenses. [**Name2 (NI) **] reports dry heaves approximately five days prior to admission. He denies any nausea, abdominal pain, chest pain, diarrhea, or constipation. He denies any light or [**Male First Name (un) 1658**]-colored stools, blood per rectum, and dysuria. He does note some [**Location (un) 2452**] urine. His symptoms progressed to the point which, on the day prior to admission, he sought medical attention at [**Hospital3 15174**]. A [**Hospital3 15174**], he was febrile to 104 degrees Fahrenheit. He was started on ampicillin, and sulbactam, and empirically. He was found to have elevated liver function tests with a total bilirubin of 7.5, ALT of 105, AST of 106, and alkaline phosphatase of 325. His direct Coombs test was positive. His hematocrit was 24%. His platelet count was less than 10. His sodium was 127. He received a platelet transfusion at [**Hospital3 15174**]. He was transferred to the [**Hospital1 69**] for further workup. PAST MEDICAL HISTORY: 1. Lupus; diagnosed one year prior to admission. 2. Raynaud's syndrome, diagnosed one year prior to admission. 3. Hypertension. 4. Meningitis 12 years prior to admission. He was in a coma for 36 hours. Positive antinuclear antibody with titer of 1:1380 in a speckled pattern. 5. Elevated prostate-specific antigen of approximately 5.4 in [**2134-10-9**] and [**2135-2-8**]. A biopsy in [**2134-9-8**] demonstrated high-grade prostatic intraepithelial neoplasia. A subsequent biopsy in [**2135-2-8**] demonstrated chronic inflammation only. 6. Erectile dysfunction. MEDICATIONS ON ADMISSION: Procardia-XL 90 mg p.o. q.d., Viagra as needed, Advil as needed, multivitamin, vitamin E. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He denies any tobacco, alcohol, or illicit drug use. He works as a teacher at a college. He owns a book store. He lives with his wife and son. [**Name (NI) **] has two parrots at home. One of the parrots died of an unknown causes three weeks prior to admission. FAMILY HISTORY: There is no family history of blood dyscrasias. His father has prostate cancer. His mother has osteoporosis but is otherwise in good health. His sister has lupus. Another brother and sister are in good health. PHYSICAL EXAMINATION ON PRESENTATION: He was a pale nontoxic-appearing male in no apparent distress. Temperature was 98.4, blood pressure was 108/70, heart rate was 108, respiratory rate was 20, oxygen saturation was 99% on 2.5 liters of oxygen. Pupils were equal, round, and reactive to light. Extraocular movements were intact. Scleral were icteric. The oropharynx was benign with moist mucous membranes. The neck was supple. There was a 1.5-cm lymph node in the cervical chain on the right side and small posterior cervical lymph node on the right side. There was some small cervical chain lymph nodes on the left side. The heart was regular with normal first heart sound and second heart sound. No murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. The abdomen was soft. The right upper quadrant was tenderness to palpation. There was no rebound or guarding. The liver edge was palpable as was the spleen tip. There were normal active bowel sounds. There were bilateral tender lymph nodes on the right axilla. The groin had a 1.5-cm lymph node in the right inguinal area. The extremities were without clubbing, cyanosis or edema. There was diffuse macular rash on the chest, arms, and abdomen. The reflexes were 1+ throughout. PERTINENT LABORATORY DATA ON PRESENTATION: Data revealed white blood cell count was 12.2 (with 15% neutrophils, 7% bands, 64% lymphocytes, 2% monocytes, 1% eosinophils, 10% atypical lymphocytes, 1% metamyelocytes), hematocrit was 18%, platelet count was 9. PT was 13.5, PTT was 31.8, D-dimer was 1000 to [**2133**]. Sodium was 132, potassium was 4, chloride was 99, bicarbonate was 22, blood urea nitrogen was 16, creatinine was 0.8, blood glucose was 175. ALT was 85, AST was 89, LDH was 885, alkaline phosphatase was 306, total bilirubin was 6, direct bilirubin was 3.9, indirect bilirubin was 2.1. Calcium was 7, magnesium was 2, phosphate was 3.7. uric acid was 5.7. A blood smear demonstrated microspherocytes, larger basophilic stippled cells, anisocytosis with minimal poikilocytosis. There were numerous plasmacytoid cells and large atypical cells as well. There was a paucity of platelets with giant formed platelets seen. HOSPITAL COURSE: He was initially admitted to the Medicine Service for further management and workup for possible leukemia or lymphoma. Given the extent of hemodynamic monitoring that would have been required initially, he was transferred to the Medical Intensive Care Unit for further management. He was in the Medical Intensive Care Unit for one day and then was subsequently transferred to the Bone Marrow Transplant Service as a diagnosis of leukemia was lymphoma was continued to be worked up. 1. HEMATOLOGY: He underwent a bone marrow biopsy at the time of admission. The bone marrow biopsy demonstrated a markedly hypercellular marrow for his age group with lymphoplasmacytic hyperplasia with scattered large immunoblasts. Diagnostic features of a lymphoproliferative disorder were not seen. The immunopotentiating demonstrated no phenotypic evidence of leukemia or lymphoma. Mr. [**Known lastname 41769**] was a difficult cross match in the blood bank and had evidence of regular antibodies. He underwent a thorough workup by the blood bank. His blood demonstrated evidence of both cold and warm autoantibodies. He received a total of 5 units of packed red blood cell blood transfusion and 4 units of platelets blood transfusion. Due to the likelihood of autoimmune warm hemolytic anemia, autoimmune cold hemolytic anemia, and autoimmune thrombocytopenia he was started on stress-dose steroids. He also received 150 of IVIG in four doses of 40 each. His platelet counts were initially unresponsive to the platelet transfusion, corticosteroids, and IVIG. However, several days after he revealed his last dose of IVIG, his platelet count began to rise. After reaching a nadir of 6000, the platelet count was 92,000 at the time of discharge. His hematocrit did show some response to blood cell transfusions and corticosteroids. It rose from 18% on admission to 30% at the time of discharge. He underwent radiologic screening to evaluate for evidence of leukemia or lymphoma. A liver and gallbladder ultrasound demonstrated evidence of a simple hepatic cyst with no intrahepatic ductal dilatation. The gallbladder was normal. There was splenomegaly present. A CT of the torso demonstrated bilateral extensive cervical, axillary, anterior mediastinal, and precordial lymphadenopathy of which the largest lymph nodes were in the left axilla. The spleen was markedly enlarged and contained numerous wedge-shaped regions of hypoattenuation and calcific fossae. There were multiple small lymph nodes in the abdomen around the pancreatic tail, superior mesenteric artery, and in the retroperitoneum. The largest abdominal lymph node was at the level of the aortic bifurcation and measured 1.6 cm in diameter. There was no evidence of bony destruction. A CT of the neck to evaluate his cervical lymph nodes demonstrated abnormal parotid glands which were slightly enlarged within an irregular cystic pattern, question representative of Mikulicz syndrome. It should be noted that he had been started on intravenous corticosteroids prior to the CT scan of the neck and torso and that his palpable lymph nodes had shrunk dramatically by the time that the radiographic studies had been done. He underwent an excisional biopsy of a right axillary lymph node. No definitive morphologic immuno definitive features of the lymph node or proliferative disorder were seen. At the time of discharge, the etiology of his autoimmune warm hemolytic anemia, autoimmune cold hemolytic anemia, and autoimmune thrombocytopenia had not been elucidated. 2. RHEUMATOLOGY: He had a Rheumatology evaluation for the possibility that these symptoms were all related to a rheumatologic disorder. The differential diagnosis included lupus, [**Doctor Last Name 3501**] syndrome, a viral infection, lymphoproliferate disorder, and thrombotic thrombocytopenic purpura. A rheumatologic series of tests were ordered to further determine the possible nature of his symptoms. Erythrocyte sedimentation rate was initially 100 but had decreased to 17 by the week after discharge. His absolute CD4 count was greater than 2500. His serum viscosity was 1.8 which was at the upper limit of normal. His lupus anticoagulant was negative. There was no evidence of glomerulonephritis in sever urinalyses. Antinuclear antibody was positive as a titer of 1:320 in a speckled pattern. Anti-double-stranded DNA antibodies were negative. Rheumatoid factor was negative. A SPEP demonstrated evidence of a polyclonal hypogammaglobinemia with no evidence of a monoclonal immunoglobulin. A C3 was 30 (normal range 65 to 163). C4 was 2 (normal range 12 to 36). Human immunodeficiency virus antibody test was negative. Hepatitis C antibody was negative. A UPEP demonstrated some albumin, but no evidence of a Bence-[**Doctor Last Name **] protein. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus immunoglobulin G antibodies were positive. [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus immunoglobulin M antibodies were positive. These results were evidence of an infection with [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus at an indeterminate time in the past. A Monospot test for acute [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus infection was negative. A rapid plasma reagin test for syphilis was nonreactive. A test for cytomegalovirus immunoglobulin G antibody was negative. Cultures of the right axillary lymph node were negative for evidence of aerobic bacterial infection, anaerobic bacterial infection, or mycobacterial, or fungal infection. A further test for [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus early antigen was positive at 1.47 (negative is less than 0.9 with equivocal being 0.91 to 1.09). A test for [**Doctor Last Name 3271**]-[**Doctor Last Name **] viral capsid antigen immunoglobulin M antibody was negative. A test for Brucella immunoglobulin G antibody was negative. A test for Brucella immunoglobulin M antibody was negative. A test for anticardiolipin immunoglobulin M antibody and immunoglobulin G antibody were both positive. A test for mycoplasma pneumoniae immunoglobulin G antibody was positive. A test for Parvovirus B19 immunoglobulin G antibody was positive. A test for Parvovirus B19 immunoglobulin M antibody was negative. A test for anti-Ro antibody was negative. A test for anti-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 41770**] was negative. A test for anti-[**Doctor Last Name 1968**] antibody was negative. A test for anti-RNP antibody was positive. A test for beta-2 microglobulin was abnormal at 5.7 (normal 0.7 to 1.8). The Rheumatology Service was unable to come up with a unifying diagnoses for all of these findings at the time of discharge. 3. INFECTIOUS DISEASE: An Infectious Disease consultation was also sought. They recommended many of the viral and bacterial tests detailed in the section entitled Rheumatology. At the time of discharge, there was no obvious infectious etiology for his presenting signs and symptoms. 4. DERMATOLOGY: Due to his rash and the possibility that this represented a cutaneous manifestation of his systemic disease, he had a Dermatology consultation. Their impression was that although he had evidence of a background-benign livedo reticularis on his inner thighs, it was not to a degree suggestive of vasculopathy. Their impression was that his cutaneous findings were most consistent with a viral exanthem. Despite workup as an inpatient, at the time of discharge, no unifying diagnosis could be found for the constellation of symptoms, signs, and laboratory abnormalities in Mr. [**Known lastname 41769**]. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: He was to follow up as an outpatient two days after discharge for repeat hematocrit and platelet count. He was to further follow up in the outpatient [**Hospital **] Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7818**]. DISCHARGE DIAGNOSES: 1. Autoimmune warm hemolytic anemia. 2. Autoimmune cold hemolytic anemia. 3. Autoimmune thrombocytopenia. 4. Hypertension. 5. Question systemic lupus erythematosus. MEDICATIONS ON DISCHARGE: 1. Prednisone 120 mg p.o. q.d. 2. Nystatin swish-and-swallow q.i.d. 3. Protonix 40 mg p.o. q.d. 4. Procardia-XL 90 mg p.o. q.d. 5. Folic acid 1 mg p.o. q.d. 6. Calcium carbonate 500 mg p.o. t.i.d. with meals. 7. Multivitamin one tablet p.o. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**] Dictated By:[**Last Name (NamePattern1) 7787**] MEDQUIST36 D: [**2135-10-7**] 09:45 T: [**2135-10-13**] 11:33 JOB#: [**Job Number 41771**]

[ "710.0", "288.0", "401.9", "283.0", "287.5" ]

icd9cm

[ [ [] ] ]

[ "41.31", "40.11" ]

icd9pcs

[ [ [] ] ]

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166, 2970

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118,105

51421+59346

Discharge summary

report+addendum

Admission Date: [**2103-6-14**] Discharge Date: [**2103-6-20**] Date of Birth: [**2026-4-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: SOB Major Surgical or Invasive Procedure: s/p CABGx4(LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **], PDA) [**2103-6-14**] History of Present Illness: SOB X 1 month, + stress test, cath revealed 3vCAD, referred for CABG Past Medical History: CAD, s/p MI HTN angina glaucoma spinal fusion L5-S1 [**6-/2093**] appendectomy knee replacement Social History: retired, quit smoking 20 years ago, lives alone, drinks Scotch daily ? amount Family History: father + MI age 44 Physical Exam: unremarkable pre-op Pertinent Results: [**2103-6-19**] 06:20AM BLOOD WBC-10.3 RBC-3.69* Hgb-12.3* Hct-35.3* MCV-96 MCH-33.2* MCHC-34.8 RDW-14.3 Plt Ct-227 [**2103-6-19**] 06:20AM BLOOD Glucose-103 UreaN-11 Creat-0.7 Na-138 K-4.5 Cl-103 HCO3-26 AnGap-14 [**2103-6-19**] 06:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.6 [**2103-6-16**] 11:31AM BLOOD Type-ART pO2-75* pCO2-37 pH-7.50* calTCO2-30 Base XS-4 [**2103-6-16**] 11:31AM BLOOD Glucose-109* Na-132* K-3.8 PATIENT/TEST INFORMATION: Indication: Intra-op TEE for CABG BP (mm Hg): 105/44 HR (bpm): 62 Status: Inpatient Date/Time: [**2103-6-14**] at 08:52 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW215-5:5 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aorta - Arch: 2.3 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions: PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving phenylephrine by infusion. 1. Global left ventricular systolic function is normal. Right ventricular systolic function is normal. 2. Aorta is intact post decannulation 3. Other findings are unchanged Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2103-6-14**] 17:44. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted day of surgery. Taken to the OR for CABG X 4 and left lung biopsy. Please see OR report for details of operation. Pt. extubated on POD # 1, due to some hypoxia. He transferred to the telemetry floor on POD # 2, was started on Beta blockers and diuresis. He had a brief episode of AFib post-op, but htis was not sustained. He has had some confusion, mostly in the evenings, and has been given small doses of Haldol as needed with good effect. He has remained hemodynamically stable, and continues to progress slowly from a mobility standpoint, and is ready to be transferred to a rehab facility. Medications on Admission: Aciphex 40' Celebrex 200' Norvasc 5' Enalapril 5' Atenolol 50' ASA 81' Lipitor 40' MVI Amitriptylline 10' Lutein 5' Folic Acid Xalatan eye gtts Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed. Disp:*30 Packet(s)* Refills:*0* 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 vial* Refills:*2* 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day. 12. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lutein 6 mg Capsule Sig: One (1) Capsule PO once a day. 16. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: CAD s/p MI ^chol. HTN PVD arthritis esophageal strictures s/p R CEA Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Call our office with sternal drainage, temp>101.5 Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2103-7-11**] 1:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2103-9-7**] 10:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 31979**] Follow-up appointment should be in 2 weeks Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Completed by:[**2103-6-20**] Name: [**Known lastname 497**],[**Known firstname **] Unit No: [**Numeric Identifier 17401**] Admission Date: [**2103-6-14**] Discharge Date: [**2103-6-20**] Date of Birth: [**2026-4-29**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1543**] Addendum: Atenolol increased to 100 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed. Disp:*30 Packet(s)* Refills:*0* 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 vial* Refills:*2* 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day. 12. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. Lutein 6 mg Capsule Sig: One (1) Capsule PO once a day. 15. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 16. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2103-6-20**]

[ "443.9", "515", "272.0", "414.01", "427.31", "412", "365.9", "413.9", "492.8" ]

icd9cm

[ [ [] ] ]

[ "36.13", "36.15", "39.61", "33.28", "88.72" ]

icd9pcs

[ [ [] ] ]

10344, 10575

4829, 5439

324, 422

7391, 7399

825, 1240

7727, 8745

750, 770

8768, 10321

7300, 7370

5465, 5610

7423, 7704

1266, 4769

785, 806

281, 286

450, 520

4806, 4806

542, 639

655, 734

68,702

177,868

37728

Discharge summary

report

Admission Date: [**2122-9-22**] Discharge Date: [**2122-9-30**] Date of Birth: [**2039-8-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: fell out of bed Major Surgical or Invasive Procedure: none History of Present Illness: 83 y/o female transferred from outside facility after a CT of the head revealed a SDH/SAH and punctate contusion. Per transfer notes patient fell from standing this morning at [**Hospital3 **] while in the bathroom, it is unclear per the patient and per transfer notes whether this was a syncopal episode or a traumatic fall. Upon questioning the patient was alert and oriented but completely amnestic to the event. She states that she fell out of bed while sleeping. Past Medical History: Hypothyroidism Breast CA, s/p right mastectomy Social History: Lives in [**Hospital3 **] with her husband Remote history of smoking Family History: non contributory Physical Exam: T:97 BP:119 /72 HR:98 R 13 O2Sats: 98% 2L Gen: WD/WN, comfortable, NAD. HEENT: Pupils:4-2mm b EOMs: intact Neck: Hard cervical collar Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: poor recall Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-21**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2122-9-22**] 12:20PM WBC-10.7 RBC-4.46 HGB-13.7 HCT-41.0 MCV-92 MCH-30.7 MCHC-33.4 RDW-14.1 [**2122-9-22**] 12:20PM NEUTS-86.5* LYMPHS-9.0* MONOS-4.2 EOS-0.2 BASOS-0.1 [**2122-9-22**] 12:20PM PLT COUNT-140* [**2122-9-22**] 12:20PM PT-12.8 PTT-25.2 INR(PT)-1.1 [**2122-9-22**] 12:20PM GLUCOSE-129* UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12 [**2122-9-22**] 12:20PM CK-MB-9 cTropnT-0.30* [**2122-9-22**] 08:23PM LACTATE-1.9 [**2122-9-22**] Head CT : 1. Small right frontoparietal subdural hematoma and subarachnoid hemorrhage with foci of subarachnoid bleed in the left parietal and left occipital suggesting contrecoup injury. No significant change since the prior study done at outside hospital. 2. No fractures identified. [**2122-9-22**] C Spine CT : 1. No acute C-spine fractures or abnormal alignment detected. Please note that MRI is more sensitive for ligamentous /cord injury. 2. Mild degenerative changes of the C-spine, without significant spinal canal stenosis. 3. Bilateral apical lung opacities. Correlate with dedicated chest imaging, either x-ray or CT. [**2122-9-22**] Chest/Abd ST : 1. Consolidation in the dependent portion of the lungs bilaterally, possibly due aspiration, atelectasis or infection. Small bilateral pleural effusions. 2. No evidence of traumatic injury to the remainder of the torso. 3. Moderate diverticulosis without diverticulitis. 4. Over-distention of the endotracheal tube balloon. 5. 6 mm enhancing lesion within the periphery of the left lobe of the liver is non-specific and may represent a flash-filling hemangioma, adenoma, or area of FNH. [**2122-9-23**] Cardiac echo : The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the distal 40 percent of the left ventricle. Estimated left ventricular ejection fraction is 30 percent. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 3 mmHg) due to mitral annular calcification. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2122-9-24**] Cardiac Echo : The left atrium is moderately dilated. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of mid left ventricular walls and akineisis of apical walls and apex. Overall left ventricular systolic function is severely depressed. Estimated ejection fraction is 25-30%. There is evidence of diastolic dysfunction. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is moderate pulmonary artery systolic hypertension. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2122-9-23**], there is worsening of the of pulmonary artery systolic hypertension, which is now moderate. IMPRESSION: Severly depressed left ventricular systolic function, evidence of diastolic dysfunction with elevated PAWP (> 18 mmHg). Moderate [2+] tricuspid regurgitation, moderate pulmonary artery systolic hypertension. [**2122-9-27**] CXR : There are small bilateral pleural effusions, mildly decreased on the right since prior study. Clips are present in the right axilla. Heart and mediastinum are within normal limits. Lungs are otherwise grossly clear. Carotid duplex [**9-29**]: no stenosis Brief Hospital Course: Mrs. [**Known lastname **] was transferred to [**Hospital1 18**] for further evaluation and management of her SDH. During her stay in the ER she desaturated to the mid 80's and was urgently intubated. A repeat Head CT was done which showed no change and she was subsequently transferred to the Trauma ICU. Her vital signs were stable and her neurologic status was evaluated off sedation. She was able to move all four extremities and responded appropriately to commands. She was extubated 24 hours later successfully and again her neuro exam was unchanged. She was then transferred to the Trauma floor for further management Unfortunately on [**2122-9-24**] she desaturated again and was transferred back to the ICU. She was in CHF and required vigorous diuresis and BIPAP. A cardiac echo was done which revealed diastolic heart failure, pulmonary hypertension and an EF of 25%. She subsequently developed atrial fibrillation and was placed on a diltiazem drip. She eventually converted to NSR and the cardiology service was consulted. Their recommendations included further diuresis then [**Hospital1 **] Lasix, beta blockers for afib with discontinuation of diltiazem and starting an ACEI. A follow up echo is recommended in [**5-25**] weeks with her cardiologist and if her diastolic dysfunction improves then her ACEI may be able to be stopped. Their thought is that she may have Takotsubo's stress cardiomyopathy which may resolve in time. Carotid studies were normal. She was transferred back to the Trauma floor and was seen on multiple occasions by PT and OT. She was slowly making progress with ambulation. Her neurologic exam was unchanged and she will need to have a repeat non contrast head CT in 8 weeks followed by an appointment with Dr. [**Last Name (STitle) **]. She received a 10 day course of phenytoin prophylactically and had no seizures. Mrs. [**Known lastname **] was transferred to rehab on [**2122-9-30**] to increase her mobility and get her back to her baseline. Medications on Admission: Levoxyl 50 mcg Po daily ASA 81 mg PO Daily Calcium supplement Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: hold SBP < 100 HR < 60. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Levolyl 50 mcg PO Daily Discharge Disposition: Extended Care Facility: [**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**] Discharge Diagnosis: Right frontal/parietal subdural hematoma Small SAH CHF Atrial fibrillation Cardiomyopathy Discharge Condition: stable Discharge Instructions: ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up appointment in [**1-20**] weeks Call Dr. [**Last Name (STitle) 41243**] for a follow up appointment in [**12-19**] weeks Call Dr. [**Last Name (STitle) **] ( Neurosurgery) at [**Telephone/Fax (1) 1669**] for a follow up appointment in 8 weeks. You will need a non contrast head CT before the visit. This can be booked when you call to make the appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2122-9-30**]

[ "293.0", "285.9", "E888.9", "V45.89", "424.2", "412", "719.41", "424.0", "428.0", "427.31", "790.29", "410.71", "401.9", "426.3", "416.8", "414.01", "V10.3", "428.31", "851.41", "244.9", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "38.93", "96.71", "96.04", "93.90" ]

icd9pcs

[ [ [] ] ]

9396, 9498

6508, 8517

328, 335

9632, 9641

2297, 6485

10327, 10916

1007, 1025

8629, 9373

9519, 9611

8543, 8606

9665, 10304

1040, 1258

273, 290

363, 833

1530, 2278

1273, 1514

855, 904

920, 991

7,030

147,098

7527

Discharge summary

report

Admission Date: [**2168-4-12**] Discharge Date: [**2168-4-18**] Date of Birth: [**2087-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Prednisone / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2168-4-12**] - CABGx3 (Mammary artery to left anterior descending artery, vein to ramus and vein graft to obtsue marginal artery); Mitral valve Repair (26mm Annuloplasty Band) [**2168-4-12**] - Flexible cystoscopy with wire placement and Foley catheter introduction to bladder. History of Present Illness: This is an 81-year-old male who had increasing shortness of breath. His workup revealed that he had a positive exercise stress test. He underwent a cardiac catheterization, and this demonstrated 3-vessel coronary artery disease. It was recommended that he undergo coronary bypass grafting and, after risks and benefits were explained to him, he agreed to proceed. Past Medical History: PVD COPD Hyperlipidemia HTN MRSA Pneumonia Emphysema Prostate Cancer Prostatectomy Social History: Retired. Quit smoking [**2143**] 45 pk/yrs. Does not drink. Lives with fiance. Edentulous. Family History: Father died of ? MI at age 54. Physical Exam: 64 sr 129/76 (R) 153/81 (L) GEN: Elderly man in NAD but mildly SOB with talking HEENT: Unremarkable NECK: Supple, FROM LUNGS: Diminished BS throughout with mild exp wheeze HEART: RRR, Nl S1-S2 ABD: Ventral hernia noted, S/NT/ND/NABS EXT: Pulses [**1-12**]+ throughout. Warm, well perfused. NO varicosities noted NEURO: No carotid bruits. Nonfocal Discharge Vitals 99, 80 SR, 121/63, 20 Sat 2l NC 98% RA 84% wt 71.4kg Neuro A/O x3 nonfocal Cardiac RRR no m/r/g Pulm CTA bilat Abd soft, NT, ND, +BS Ext warm pulses palpable +1 LE edema Sternal inc CDI no erythema no drainage sternum stable Left EVH thigh ecchymotic, no erythema Pertinent Results: [**2168-4-17**] 04:15AM BLOOD WBC-7.7 RBC-3.37* Hgb-10.7* Hct-30.4* MCV-90 MCH-31.7 MCHC-35.2* RDW-13.7 Plt Ct-174 [**2168-4-12**] 01:38PM BLOOD WBC-8.1 RBC-3.05*# Hgb-9.9*# Hct-28.6*# MCV-94 MCH-32.5* MCHC-34.7 RDW-13.0 Plt Ct-128* [**2168-4-17**] 04:15AM BLOOD Plt Ct-174 [**2168-4-13**] 03:10AM BLOOD PT-13.5* PTT-32.3 INR(PT)-1.2* [**2168-4-12**] 01:38PM BLOOD PT-16.3* PTT-44.3* INR(PT)-1.5* [**2168-4-12**] 01:38PM BLOOD Plt Ct-128* [**2168-4-18**] 05:45AM BLOOD K-4.2 [**2168-4-17**] 04:15AM BLOOD Glucose-106* UreaN-29* Creat-1.0 Na-135 K-3.4 Cl-94* HCO3-37* AnGap-7* [**2168-4-12**] 02:42PM BLOOD UreaN-15 Creat-0.8 Cl-111* HCO3-25 [**2168-4-17**] 04:15AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 CXR RADIOLOGY Final Report CHEST (PA & LAT) [**2168-4-17**] 3:56 PM CHEST (PA & LAT) Reason: Eval. for interval change [**Hospital 93**] MEDICAL CONDITION: 81 year old man with CAD, pre-op for CABGpt currently in cath lab HA, [**Hospital Ward Name **] 4. plse do after 3:45 pm REASON FOR THIS EXAMINATION: Eval. for interval change CHEST, TWO VIEWS, ON [**4-17**] HISTORY: Preop CABG. REFERENCE EXAM: [**4-16**]. FINDINGS: There are bilateral pleural effusions that are slightly larger than on the prior study. There is bilateral lower lobe volume loss. The cardiac and mediastinal silhouettes are unchanged. DR. [**First Name (STitle) **] [**Doctor Last Name **] Approved: MON [**2168-4-18**] 8:37 AM TEE PATIENT/TEST INFORMATION: Indication: Intraop CABG. Evaluate valves, ventricular function, aortic atheroma/contours. Height: (in) 66 Weight (lb): 144 BSA (m2): 1.74 m2 BP (mm Hg): 165/65 HR (bpm): 63 Status: Inpatient Date/Time: [**2168-4-12**] at 11:36 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.2 cm (nl <= 5.2 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.3 cm Left Ventricle - Fractional Shortening: *0.16 (nl >= 0.29) Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aorta - Arch: 2.3 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 7 mm Hg Aortic Valve - Mean Gradient: 4 mm Hg Aortic Valve - Valve Area: *2.0 cm2 (nl >= 3.0 cm2) Mitral Valve - Peak Velocity: 0.8 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 0.75 INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Minimally increased gradient c/w minimal AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Pericardial calcifications. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. Conclusions: Pre Bypass: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild to moderate mid inferior hypokinesis. LVEF 45-50%. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the arch and descending thoracic aorta. There are three aortic valve leaflets.The left coronary cusp may have decreased mobility. There is minimal aortic valve stenosis. Aortic valve area 1.94 cm2 averaged on continuity, 2.24 cm2 averaged on plainemetry. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. The jet is posteriorly directed with a vena contracta from 4-6 mm in diameter. There is partial restrictioin of the postierior leaflet, most likely involving P2. There is a trivial/physiologic pericardial effusion. There are pericardial calcifications. Post Bypass: Patient is AV paced on epinepherine and phenylepherine gtt. LV function is improved with LVEF >55%. Septal wall motion is consistent with av pacing. Inferior wall motion is improved. There is a partial mitral ring prosthesis insitu. Peak and mean gradients are 3 mm Hg. There is no residual mitral regurgitation. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2168-4-12**] 13:48. [**Location (un) **] PHYSICIAN: EKG Sinus rhythm. No significant change compared to the previous tracing of [**2168-4-12**]. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] B. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 186 134 [**Telephone/Fax (2) 27518**] 79 37 Brief Hospital Course: Mr. [**Known lastname 27519**] was admitted to the [**Hospital1 18**] on [**2168-4-12**] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and a mitral valve repair. Please see operative note for details. Of note, he was a difficult foley placement due to a stricture. The urology service was consulted who performed a cystoscopy and foley placement. Gentamicin, ciprofloxacin and ancef were given for prophylactic coverage. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 27519**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, aspirin and statins were resumed. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was ready for discharge to rehab on POD 6. Medications on Admission: Albuterol/Atrovent Nebs Spiriva Inhaler daily Mucinex 600mg twice daily Diltiazem 120mg daily Aspirin 81mg daily Zocor 10mg daily Atrovent nasal spray Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: Greenbriar Terrace Discharge Diagnosis: CAD Hyperlipidemia HTN COPD Pneumonia Prostate Cancer Prostatectomy Emphysema PVD Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. [**Telephone/Fax (1) 170**] Please follow-up with Dr. [**Last Name (STitle) 11493**] in 2 weeks. [**Telephone/Fax (1) 11650**] Please follow-up with Dr. [**Last Name (STitle) **] after discharge from rehab Completed by:[**2168-4-18**]

[ "414.01", "443.9", "596.0", "V15.82", "496", "424.0", "V10.46", "272.4", "486" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "57.94", "36.12", "35.12", "88.72" ]

icd9pcs

[ [ [] ] ]

10545, 10590

8071, 9150

319, 602

10716, 10724

1926, 2752

11235, 11540

1227, 1259

9351, 10522

2789, 2910

10611, 10695

9176, 9328

10748, 11212

3370, 7762

1274, 1907

260, 281

2939, 3344

630, 996

7796, 8048

1018, 1103

1119, 1211

50,415

139,744

35981

Discharge summary

report

Admission Date: [**2156-3-30**] Discharge Date: [**2156-4-9**] Date of Birth: [**2083-8-11**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7729**] Chief Complaint: Metastatic melanoma, left neck, with thyroid carcinoma. Left cerebellar infarct. Major Surgical or Invasive Procedure: 1. Left partial parotidectomy with facial nerve dissection. 2. Left modified radical neck dissection. 3. Total thyroidectomy . 4. Reconstruction of left neck defect with pectoralis major myocutaneous flap. History of Present Illness: The patient is a 72-year-old male who presented with an enlarging mass in the left upper neck. The tumor involved the skin. Prior to his presentation at the cutaneous oncology clinic, an incisional biopsy had been done into the mass, revealing metastatic melanoma. The primary site remains unknown. During the course of his evaluation which included a CT-PET scan, he was found to have an upper mediastinal mass in addition to his large left neck mass. A chest CT was obtained, and this was felt to probably be of thyroid origin. A fine needle aspiration was then completed and this demonstrated cells suggestive of papillary thyroid carcinoma. Past Medical History: HTN, DM, BPH, left leg electrocution injury s/p RFFF, multiple right and left neck and face skin cancers (both squamous cell and melanoma), s/p left post neck melanoma WLE and SLNBx [**2152**], s/p left neck incisional biopsy with partial removal LN with melanoma [**9-23**] Social History: lives alone, former taxi driver Family History: NC Physical Exam: Afebrile, VSS NAD, alert, oriented x 3, though occasionally confused during conversation (baseline) Eyes - injected bilaterally Nose - no gross drainage Oc/op - no trismus, mobile tongue Neck-soft, flat with flap well perfused and cap refill < 2 secs. Suture and staple lines clean, dry and intact. Chest-Staple line clean, dry and intact. No evidence of erythema or drainage. Regular rate and rhythm. No murmurs, gallops or rubs. Left thigh incision site almost completely healed. Neuro exam nonfocal except for clear evidence of deficit in distribution of [**Female First Name (ambig) **]. [**Last Name (un) **]. nerve (drooping edge of left mouth) along with mild left dysmetria. Pertinent Results: [**2156-4-8**] 06:15AM BLOOD WBC-12.8* RBC-3.52* Hgb-11.0* Hct-34.0* MCV-97 MCH-31.4 MCHC-32.5 RDW-13.8 Plt Ct-546* [**2156-4-7**] 04:50AM BLOOD Glucose-131* UreaN-12 Creat-0.8 Na-143 K-3.8 Cl-104 HCO3-28 AnGap-15 [**2156-4-4**] 10:05AM BLOOD ALT-12 AST-19 CK(CPK)-186* AlkPhos-51 TotBili-0.6 [**2156-4-7**] 04:50AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.3 [**2156-3-30**] 04:23PM BLOOD Glucose-107* Lactate-3.8* Na-137 K-5.1 Cl-101 calHCO3-27 CT ([**4-4**]): Moderately sized Left cerebellar subacute, >24hrs old subacute infarction in approx [**12-20**] of cerebellum with slight effacement of the 4th ventricle. No ICH. NO midline shift CTA/CTV ([**4-5**]): No evidence of arterial dissection Echo ([**4-6**]): No evidence of patent foramen ovale. Changes consistent with hypertension. Brief Hospital Course: [**3-30**]-> Patient tolerated procedure without unexpected intra-operative complications. For [**Hospital1 2824**] details, please see operative note. Patient was extubated in the OR and transferred to the PACU in stable condition. In the PACU, the patient developed mild respiratory distress subsequent to vomiting 70 ccs of bilious fluid. Given that and pt.'s continuing lack of a gag reflex and responsiveness, pt. was reintubated and transferred to the ICU. [**3-31**]-> Pt. was kept intubated due to continuing thick secretions and suspected aspiration pneumonia. Pt. placed on Levaquin and Flagyl. Drains (JP x 6) kept in place. Pt. bolused overnight due to one episode of systolic hypotension into the 80s that resolved. [**4-1**]-> Pt. was extubated successfully but due to tenuous clinical status, kept in the ICU overnight. Drains (JP x 6) kept in place. [**4-2**]-> Pt. transferred to floor. Speech and swallow consulted and video swallow done. Pt. kept NPO. [**4-3**]-> Antibiotics changed to Cefipime. PT consulted. Ct head done due to their recommendation given atypical deconditioning in patient. Subacute left cerebellar infarct seen. [**4-4**]->Pt. transferred to neurology service for stroke care and workup. Neurology Service (4/19~[**4-7**]) Patient was transferred to neurology service on [**4-4**] after being found to be unsteady on his feet s/p extubation after total thyroidectomy surgery. Patient has L facial droop plus mild L dysmetria but otherwise much improving in his dysarthria and dysphagia. Imaging including CTA of head and neck shows L cerebellar infarct most likely kinking of vessel during surgery. His vessels were all patent. Patient also had echocardiogram which shows mild LVH but preserved EF and no thrombus. Patient was initially fed through Dobhoff given concern for aspiration but repeat speech and swallow evaluation showed that he was swallowing safely hence he was started on diet on [**4-6**] and Dobhoff was removed. Patient reports to feel improved and given that stroke work-up was completed, he is returning to the ENT service prior to discharge. Patient should continue [**Month/Year (2) **] 325mg daily. No need for statin right now given that LDL is 100 and patient is not diabetic in the setting of provoked stroke. Patient should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] as outpatient - already scheduled for [**2156-5-18**] at [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. [**4-7**]-> Dobhoff removed from patient one day after placement due to pt. passing speech and swallow. Pt. returned to po medications. [**4-8**]-> Pt. had no significant events overnight. Screened for rehab. [**4-9**]-> Pt. has had no significant events overnight. His JP drain and staples were removed. Patient was discharged to acute care facility with discharge instructions that request his white blood cell count to be checked every other day while in the extended care facility to make sure it is not increasing. Currently, it is 14.7. Patient has had extensive workup for elevated WBC already that is negative including chest x-ray (resolved pneumonia), urinalysis, wound checks, etc. No source has been identified and patient remains afebrile and clinically asymptomatic. He is being discharged on antibiotics for a previous suspected pneumonia and will finish his full course. Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a day: As needed. 3. Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime. 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal once a day as needed for shortness of breath or wheezing. 6. Medications Please continue all home medications as directed by your primary care [**Provider Number 79350**]. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: 1. Metastatic melanoma, left neck. 2. Thyroid carcinoma. 3. Left cerebellar infarct. Discharge Condition: Stable - L facial droop Discharge Instructions: Call or return to hospital for muscle weakness, numbness, tingling around your mouth/lips/fingers, trouble swallowing, fever (> 101.5) or chills, redness, swelling, discharge from wound, chest pain, shortness of breath or anything else that is troubling you. Avoid strenuous activity. OK to shower 24 hours after surgery; do not soak incision until follow up appointment, at least. Take medications as prescribed. Resume all home medications. Do not drive or drink alcohol while taking narcotic pain medications. Follow up per instructions from Dr. [**Last Name (STitle) 1837**]. Followup Instructions: Please followup with Dr. [**Last Name (STitle) 1837**] in 2 weeks. Call ([**Telephone/Fax (1) 26106**] to make an appointment. Please followup with endocrinology for radioactive iodine treatment and management of your synthroid dosage. An appointment is below: Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2156-5-18**] 1:30 Please followup with neurology given your cerebellar infarct. An appointment is below: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2156-5-18**] 2:30 [**Hospital Ward Name 23**] Clinical Center Floor 8 Completed by:[**2156-4-9**]

[ "250.00", "198.89", "997.02", "507.0", "434.91", "193", "997.5", "172.4", "E878.6", "401.9", "600.00" ]

icd9cm

[ [ [] ] ]

[ "40.41", "06.4", "86.74", "26.31" ]

icd9pcs

[ [ [] ] ]

7419, 7491

3192, 6579

401, 613

7620, 7646

2381, 3169

8277, 9029

1659, 1663

6602, 7396

7512, 7599

7670, 8254

1678, 2362

281, 363

641, 1294

1316, 1593

1609, 1643

75,354

100,286

42216

Discharge summary

report

Admission Date: [**2200-11-16**] Discharge Date: [**2200-12-4**] Date of Birth: [**2175-8-19**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p Found down Major Surgical or Invasive Procedure: [**2200-11-17**] 1. Decompressive fasciotomy right buttock, a with debridement of muscle. 2. Decompressive fasciotomy right thigh. 3. Application of large vac sponge to right thigh. 4. Decompressive fasciotomy left thigh without debridement. 5. Decompressive fasciotomy left buttock without debridement. 6. Application vac sponge left leg. [**2200-11-19**] I&D right hip and application of vacuum-assisted closure sponge left thigh. [**2200-11-25**] I&D and vac change left thigh wound [**2200-11-27**] I&D and primary closure of left thigh wound History of Present Illness: 25M directly transferred from OSH after being found down for unknown duration (hours) while intoxicated now w/ LE compartment syndrome w/ rhabdomyolysis and oliguria. At OSH, found to have potassium of 6.9, creatinine 3.8, CK >20,000. Ortho was consulted at OSH and compartment pressures were measured ~50 (L lateral?) w/ diastolic 78 and possibly also involving the R gluteal region. Pt received kayexelate 90mg and 3 doses of 10mg insulin w/ amps of D50 for hyperkalemia and was reportedly given 8L crystalloid (NS). He is transferred here for possible fasciotomy and further management. He c/o R gluteal and entire L thigh pain with weakness in R foot and L hip. He denies any other associated symptoms. Past Medical History: Anxiety/Depression Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: Vitals: 95.6F 104 140/77 19 97% 2L NC GEN: A&O, shivering HEENT: No scleral icterus, mucus membranes moist CV: tachycardic, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: RLE: gluteal muscle tense, soft thigh/calf, diminished motor at foot, cool toes but 2+palp DP, PT, Fem [**Name (NI) **]: tense thigh, soft calf, motor intact at foot/toes, cool toes but 2+palp DP, PT, Fem Brief Hospital Course: Mr [**Known lastname **] was admitted on [**2200-11-16**] after being found unconscious in his home for an unknown duration of time (likely >12hrs). The patient was brought to an OSH and found to have a potassium of 6.9, creatinine 3.8, CK >20,000. The orthopedic service was consulted at OSH and compartment pressures were measured and found to be elevated. Pt received Kayexalate 90mg and 3 doses of 10mg insulin w/ amps of D50 for hyperkalemia and was reportedly given 8L crystalloid (NS). He was then transferred to [**Hospital1 18**] for further workup and management. ICU course: On admission to the trauma ICU, a left sided IJ dialysis catheter was placed for temporary dialysis access. He was taken to the operating room by orthopedics for bilateral decompressive fasciotomies of b/l gluteal and thigh compartments. VAC dressings were placed. Postoperatively he received 4 U of PRBC for dropping HCT in setting of copious VAC output, hypotension, tachycardia with good results. He was dialyzed on HD1. On HD2 he was taken back to OR for washout, debridement and VAC change. He was successfully extubated later that day. Per nephrology recommendations the patient did not undergo hemodialysis on HD2. He remained oliguric. The patient was transfused and additional unit of PRBC for falling HCT during the day (22 from 28 preop). He was started on a Dilaudid PCA for pain control. He received 2 U of PRBC overnight since the response to the first unit had not been adequate. His HCT was again 22.4 and 2 additional U of PRBC were given on HD3. On HD4 he was taken back to the operating room by Ortho for washout and closure of the RLE wound and VAC re-placement in the [**Hospital1 **]. Postoperatively he remained intubated for acute desaturation and was hypoxemia. A CXR showed bilateral pleural effusions, greater on the right. A bronchoscopy was also performed. On HD5 the patient was able to be extubated and CXR showed slight improvement in b/l pleural effusions. The patient received HD. His HCT remained stable at 23.2. The patient was deemed ready for transfer to the regular surgical floor. Floor course: Upon transfer out of the ICU he continued to progress slowly. His acute kidney injury continued to warrant close monitoring and hemodialysis treatments 3-4x/week. His BUN/Cr were followed closely remaining quite elevated until [**12-4**] when it was down to 5.6 after peaking at 10.3 on [**11-24**]. His temporary dialysis line was removed due to fever and elevated white blood. Once his fevers defervesced a right tunneled catheter for dialysis was placed without any complications. He has received several treatments since that time with most recent on [**2200-12-3**] where his pre-dialysis creatinine was 8.8 and as noted previously on [**12-4**] was 5.6 and he is making urine (total of 300 cc's for 24 hours on [**12-3**]). His electrolytes in general were abnormal due to his [**Last Name (un) **] and have begun to show signs of return to normal. It is expected that he will only require hemodialysis for another 1 possibly 2 weeks if he continues to show signs of improving kidney function. It should also be noted that he has received several rounds of blood transfusions for falling HCT with lowest value of 17.9 on [**2200-11-25**]. His HCT's since that time have ranged between 23-24. For a very short period he was given weekly Epogen but this was stopped per recommendations of Renal on [**2200-12-3**]. On [**2200-11-27**] he was taken back to the operating room by orthoepdics for irrigation and debridement down to and inclusive of muscle of 40 x 10 cm wound for a total of 400 sq cm, and staged primary closure. There were no complications. His staples were removed by Orthopedics on [**12-3**] and he will follow up in [**2-27**] weeks in their outpatient clinic. In the meantime he is receiving DVT prophylaxis with Heparin SQ, orthopedics is asking that once he is discharged from rehab that he be started on Aspirin 325 mg daily for a total 2 weeks. He is also being treated for a wound cellulitis per recomendations by ortho - total 7 day course. It is important that on his HD days that he receives this medication after dialysis treatment. He was followed by Physical and Occupational therapy and has been recommended for acute rhab after his hospital stay. Medications on Admission: -xanax 1mg TID -prozac 20mg [**Hospital1 **] Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 1,000 unit/mL Solution Sig: 2,000-8,000 Injection PRN (as needed) as needed for dialysis. 8. alprazolam 0.25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day) as needed for anxiety. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000 units Injection PRN (as needed) as needed for line flush: Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 13. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 14. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO Q 8H (Every 8 Hours) as needed for pain. 16. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): stop date [**2200-12-8**]. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP) Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 20. Ondansetron 4 mg IV Q6H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: s/p Found down w/Rhabdomyolosis 1. Compartment syndrome right gluteal muscle. 2. Compartment syndrome left thigh and left gluteal region. 3. Acute Kidney Injury requiring CVVH followed by HD 4. Hyperkalemia 5. Hyponatremia 6. Hypocalcemia 7. Wound cellulitis 8. Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after being found down for an unknown length of time. You were found to have damage to your muscles as a result of this which lead to compartment syndrome in both of your legs as well as acute injury to your kidneys The orthopedic doctors are recommending that after you are discharged from rehab that you take Aspirin 325 mg daily for 2 weeks and then stop at the end of those 2 weeks. They are recommending this medication as a preventative measure for developing blood clots. Followup Instructions: *Your acute kidney failure will be managed by the renal doctors at the [**Name5 (PTitle) **] facility* Department: ORTHOPEDICS When: THURSDAY [**2200-12-11**] at 9:20 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2200-12-11**] at 9:40 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SURGICAL SPECIALTIES When: MONDAY [**2200-12-15**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2200-12-4**]

[ "790.4", "E879.1", "682.9", "729.72", "305.00", "276.69", "276.1", "736.79", "300.4", "998.12", "998.59", "E878.8", "584.5", "511.9", "276.7", "787.91", "287.5", "285.1", "728.88", "288.60", "996.62", "275.41", "276.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "83.45", "38.95", "33.24", "86.59" ]

icd9pcs

[ [ [] ] ]

8849, 8896

2269, 6586

319, 871

9225, 9225

9946, 10976

1672, 1689

6682, 8826

8917, 9204

6612, 6659

9408, 9923

1704, 2246

265, 281

899, 1613

9240, 9384

1635, 1656